PRACTICAL ORTHODONTIA PRACTICAL 
ORTHODONTIA 
BY 
MARTIN DEWEY, D. D.S., M. D. 
* \ K 
Professor of Dental Anatomy and Orthodontia, Kansas City Dental 
College; President of The Dewey School of Orthodontia 
THIRD REVISED EDITION 
ST. LOUIS 
C. V. MOSBY COMPANY 
1917 Copyright, 1916, 1917, By C. V. Mosby Company 
Press of 
C. V. Mosby Company 
St. Louis ro 
EDWARD H. ANGLE, M. D., D. D. S. 
IN RECOGNITION OF THE INSPIRATION AND HELP 
DERIVED FROM HIM 
IN MY EARLY DAYS IN ORTHODONTIA 
THIS VOLUME IS RESPECTFULLY DEDICATED 
BY THE AUTHOR PREFACE TO THIRD EDITION 
Since the first edition of this work was published in 1914, ortho- 
dontia has made many advances, and the author has endeavored to 
bring this third edition up to date. While the arrangement of the 
text remains practically the same as in the first edition, several new 
chapters and about four hundred new illustrations have been added. 
At its seventeenth annual meeting the American Society of Orthodon- 
tists adopted a new terminology, which differs from that used in the 
first edition of this work. The new terminology has been used through- 
out this edition in conjunction with the old in order to enable the 
student and the general practitioner to become familiar with the new. 
Many notable advances have been made in regulating appliances 
with the result that the old expansion arch still remains the standard. 
However, in place of the labial alignment wire, Dr. Lloyd S. Lourie 
and Dr. John V. Mershon have introduced the lingual alignment wire, 
which makes a very inconspicuous appliance and deserves a place 
in orthodontia. More and more attention is being given to the 
correction of the teeth by the use of delicate appliances. The bodily 
movement of the teeth is also receiving more consideration than 
formerly. It has been shown that such movement can be accomplished 
with very delicate appliances; all that is necessary being an appliance 
that gives a two-point contact, and if the pressure is constant and in 
the right direction, the movement will be accomplished. The author 
has endeavored to show only such appliances as have proved valuable, 
or that have some feature recommending their use above all other 
appliances in particular cases. 
The author is indebted to Dr. Oren A. Oliver, Professor of Ortho- 
dontia in the Dental Department of the Vanderbilt University, for a 
well illustrated description of the technique of facial cast construction. 
The chapter on facial deformities will be found of value, and the 
author desires to express his gratitude to Dr. B. E. Lischer, Professor 
of Orthodontics in the Dental Department of Washington University, 
for the many beautiful illustrations contained in this chapter. For 
the technique for duplication of models and the illustrations thereof, 
the author wishes to thank Dr. J. A. C. Hoggan, Professor of Ortho- 
dontia, School of Dentistry, Medical College of Virginia. PREFACE 
The science of orthodontia is indebted to Dr. Lourie and Dr. Mershon 
for the technique of the lingual arch, which, in the author's opinion, is 
one of the greatest advances made in recent years. The chapter on 
Ihe use of the x-ray in orthodontia has been written by Dr. James 
David McCoy, Professor of Orthodontia and Radiography, College of 
Dentistry, University of Southern California. Dr. Joseph D. Eby, of 
Atlanta, Ga., has furnished much of the material and illustrations 
for the chapter on the removable regulating appliance. The author 
also wishes to express his indebtedness to Dr. A. E. Suggett for a 
description of the use of the .0225 alignment wire. The chapter on 
malocclusion and nasal deformities is also a valuable addition to the 
work. Illustrations have been secured from numerous sources, to all 
of which recognition has been given. 
This book is an endeavor to furnish a text of practical value to 
orthodontists, to students in dental colleges, and to teachers, and it is 
hoped that to these it will be of service. M. D. 
25 East Washington Street, Chicago. 
PREFACE TO SECOND EDITION 
The rapid exhaustion of the first edition of "Practical Orthodontia'' 
has rendered it necessary to prepare a new edition, and has enabled 
the author to make a few additions and the necessary corrections in 
the text that were overlooked in preparing the first edition. The 
favorable reception given this book among the teachers and the pro- 
fession has been most gratifying. M. D. 
PREFACE TO FIRST EDITION 
Believing that there should be a book more suited to the needs of 
Ihe student of orthodontia than any which we now have, the author 
has attempted to include in this volume certain principles which he 
has found to partially fulfill, at least, the needs of his students. 
Occlusion being the basis of orthodontia, much space has been 
devoted to the different forces of occlusion, and there has also been 
added a table giving the occlusion of each of the inclined planes of the 
teeth. 
Classification has been based on the mesio-distal relation of the teeth, 
and since Angle's plan of nomenclature appears to be the one most PREFACE 
universally used, it has been adhered to. Under classification certain 
types have been included which are so different as to require a different 
technique in treatment. 
Causes of malocclusion have been taken up under different headings 
and described. 
Under appliances, the author has confined his discussion to those 
which have proven their worth and which he believes will be success- 
ful in the greatest number of cases. The principles of retention have 
been carefully explained, for undoubtedly much unnecessary trouble 
has resulted in the past by not taking into consideration the principles 
involved. 
It has been the aim of the author to confine his discussion to the 
practical side of the question rather than to the historical features. 
Very little has been said about art as related to orthodontia. Neither 
has he dwelt upon the histological side of tooth movement or the de- 
velopment of bone, as these subjects should be taught by the chair 
of histology. Mention has been made of only such appliances as 
would be in keeping with physiological tooth movement and bone 
growth. The author has purposely omitted any reference to the dis- 
puted question of opening the suture as an aid to orthodontic treat- 
ment. These questions are still unsettled and therefore should not 
be incorporated in a work of this kind to confuse the student. Since a 
great many methods pertaining to orthodontia have been advanced 
by different authorities in the past, and as priority is often a matter 
of dispute, the author has not attempted to give credit for everything; 
neither does he claim originality for anything contained herein. While 
he has done certain things and advanced certain theories which were 
new to him at one time, others have done the same twenty years ago. 
Lastly, this book is not supposed to be the final solution of all things 
pertaining to orthodontia, but is intended for those interested in the 
subject who may be helped as a result of some of the author's experi- 
ence gained during a period of twelve years as a teacher of ortho- 
dontia. M. D. CONTENTS 
Chapter I 
OCCLUSION 
Occlusion of the Teeth-Table Showing Occlusion of Inclined Planes 17 
Chapter II 
FORCES OF OCCLUSION 
Definition-Line of Occlusion-Classification of Forces of Occlusion-Normal 
Cell Metabolism-Muscular Pressure-Force of the Inclined Plane- 
Normal Approximal Contact-Harmony in the Size of the Arches- 
Normal Atmospheric Pressure 28 
Chapter III 
MALOCCLUSION 
Positions of Malocclusion, or Malpositions of the Teeth-Classification of 
Malocclusion, or Malrelation of the Arches-Neutroclusion, or Class I- 
Neutroclusion, or Class I, Mutilated Cases-Types of Neutroclusion, or 
Class I-Neutroclusion With Bunched Anterior Teeth, or Class I, Type 1 
-Neutroclusion With Labioversion of Upper Incisors, or Class I, Type 
2-Neutroclusion With Linguoversion of Upper Anterior Teeth, or 
Class I, Type 3-Distoclusion, or Class II-Distoclusion With Labio- 
versio.n of Upper Incisors, or Class II, Division 1-Distoclusion With 
Linguoversion of Upper Anterior Teeth, or Class II, Division 2-Mesio- 
clusion, or Class III-Class III, Type 1-Class III, Type 2-Class 
III, Type 3-Unilateral Mesioclusion, or Class III, Subdivision-Uni- 
lateral Mesioclusion and Distoclusion-Malformation of the Jaws and 
Their Processes, and Abnormal Relation of the Mandible to the Maxillae 
-Malocclusion and Facial Deformities 41 
Chapter IV 
ETIOLOGY OF MALOCCLUSION 
General or Constitutional Causes-Local Causes-Inherited, Congenital and 
Acquired Causes-Inherited Causes-Congenital Causes-Acquired 
Causes-Early Loss of the Deciduous Teeth-Tardy Eruption of the 
Permanent Teeth-Early Loss of the Permanent Teeth-The Loss of the 
Mesio-Distal Diameter of the Teeth-Improper Restoration-Mouth- 
breathing-Enlarged Tonsils-Habits-Sore Teeth 117 CONTENTS 
Chapter V 
REGULATING APPLIANCES 
Principles of Regulating Appliances-Requirements of Regulating Appli- 
ances-Efficiency-Durability-Cleanliness and Antisepsis-Simplicity 
-Fixed and Removable Appliances-Fixed Appliances-Removable Ap- 
pliances-Technique for Making Regulating Appliances-Bands-Com- 
position of Appliances-Gold-Band Technique-Direct Band Technique 
-Indirect Band Technique-Soldering Technique-Adjusting Clamp 
Bands-Ligatures-Rubber Ligatures-Wire Ligatures-Fixed Regulat- 
ing Appliances-Alignment Wires or Expansion Arches-Attachments 
for the Alignment Wire of Expansion Arch-Application of the Labial 
Expansion Arch-Loop Labial Alignment Wires-Lingual Arches, or 
Alignment Wires--Appliances for the Bodily Movement of Teeth-The 
Lingual Arch Used in Connection With the Labial Arch 157 
Chapter VI 
ANCHORAGE 
Intramaxillary Anchorage - Intermaxillary Anchorage - Extramaxillary 
Anchorage 230 
Chapter VII 
RETENTION OF TEETH 
Forces of Retention-Mechanical Forces-Passive Mechanical Forces- 
Active Mechanical Force-Intramaxillary Retention-Intermaxillary 
Retention-Extramaxillary Retention-Natural Forces-Force of the 
Inclined Plane--Harmony in the Size of the Arches-Normal Muscular 
Pressure-Normal Aproximal Contact-Normal Cell Metabolism-Nor- 
mal Atmospheric Pressure-Summary of Forces of Retention-Mechan- 
ical Forces of Retention-Simple Passive Intramaxillary Retention- 
Simple Compound Intramaxillary Retention-Stationary Intramaxillary 
Retention-Reciprocal Intramaxillary Retention-Compound Reciprocal 
Retention-Intermaxillary Retention-Active Primary Intermaxillary 
Retention-Reciprocal Intermaxillary Retention-Passive Reciprocal 
Simple Intermaxillary Retention-Plane and Spur Retention-Passive 
Reciprocal Stationary Intermaxillary Retention-Active Reciprocal In- 
termaxillary Retention-Compound Active Reciprocal Intermaxillary 
Retention-Extramaxillary Retention 250 
Chapter VIII 
IMPRESSIONS AND MODELS 
Preliminary Consideration of Cases-Taking the Impression-Varnishing 
the Impression-Pouring the Model-Separating the Model-Trimming 
the Model-Modeling Compound to Study Models-Duplicating Ortho- 
dontia Models-Photographs 269 CONTENTS 
Chapter IX 
USE OF THE X-RAY IN ORTHODONTIA 
The Question of Technique-Seating the Patient-Indications for the Use of 
the X-ray by the Orthodontist 310 
Chapter X 
TREATMENT OF CASES • 
Neutroclusion, or Class I-Mutilated Cases of Class I-Bilateral Distoclusion 
With Labioversion, or Class II, Division 1-Unilateral Distoclusion 
With Protruding Teeth, or Class II, Division 1, Subdivision-Bilateral 
Distoclusion With Retruding Anterior Teeth, or Class II, Division 2- 
Unilateral Distoclusion With Retruding Teeth, or Class II, Division 2, 
Subdivision-Bilateral Mesioclusion, or Class III-Unilateral Mesio- 
clusion, or Class III, Subdivision 325 
Chapter XI 
MALOCCLUSION AND NASAL DEFORMITIES 
Relationship Between Malocclusion and Nasal Deformities-Mouth-breathing 
-Development of Nasal and Oral Cavities-Methods of Treatment-Appli- 
ances Used in. Treatment 435 
Chapter XII 
REMOVABLE REGULATING APPLIANCES 
Definition-Early Types of Appliances-Coffin's Split-spring Plate-Jackson 
System of Removable Appliances-Instruments-Materials-Models- 
Full and Partial Spring Clasps-Base or Body Wires-Finger Springs- 
Lower Jackson Appliance-Anchorage-Valuable Features of Removable 
Appliances 451 PRACTICAL ORTHODONTIA 
CHAPTER I 
OCCLUSION 
Orthodontia is the science that has for its object the correction of 
malocclusion of the teeth. 
Malocclusion is a deviation from the normal to such an extent as to 
interfere with the functions of the teeth. 
Normal occlusion is the relation of the inclined planes of the teeth as 
intended by nature. 
Occlusion is the relation of the inclined planes of the teeth. 
As orthodontia is the science that deals with the malocclusion of 
the teeth, it necessarily follows that a study of this subject includes 
a thorough understanding of the teeth as arranged by nature (Fig. 
1). Each one of the teeth has a definite position in the dental arch, 
not only with the teeth of each individual arch, but also with those 
of the opposing arch (Fig. 2). To recognize malocclusion it is neces- 
sary that we be familiar with normal occlusion. Not only has each 
tooth a definite and positive relation with a tooth of the opposite 
arch, but each inclined plane of each cusp has a certain relation with 
the inclined plane of some other cusp. By a study of the anatomy of 
the teeth, we find each cusp to be made up and bounded by marginal 
ridges and developmental ridges and grooves. These ridges and 
grooves also separate the cusps into definite inclined planes. The oc- 
clusal inclined planes of the teeth are named from the surfaces to- 
ward which they face, and their names are derived from a combina- 
tion of the four terms, mesial, distal, buccal, and lingual (Fig. 3). In 
studying the arrangement of the teeth, we find that the lower teeth 
are set one inclined plane in advance of the upper teeth. This is 
made possible because the lower central incisor is narrower than the 
upper central incisor. When we reach the upper canine, we find that 
the upper canine occludes with the lower canine and a portion of 
the lower first premolar. Passing from the buccal to the lingual, we 
17 18 
PRACTICAL ORTHODONTIA 
find that the upper teeth are one-half of a cusp to the buccal of the 
lower teeth (Fig. 4) ; that is, the lingual cusps of the upper molars 
and premolars occlude between the buccal and lingual cusps of the 
5ecret^m Apert urn ] 
Fig. 1. 
Normal occlusion of teeth. (Summa.) 
lower molars and premolars (Fig. 5). The buccal cusps of the lower 
molars and premolars occlude between the buccal and lingual cusps 
of the upper molars and premolars. By studying Figs. 1, 2, 4 and 5 OCCLUSION 
19 
Fig. 2. 
Normal occlusion (Aztec skull). (Ketcham.) 20 
PRACTICAL ORTHODONTIA. 
some idea can be gained of their arrangement. Probably a much 
better idea can be obtained by studying the diagram shown in Fig. 6. 
□BUCCAL 
MESIAL 
DISTAL 
LINGUAL? 
M.B.I nclines KUndines D.B.Indines D.LIndines 
> Fig. 3. 
Showing occlusal inclined planes of the cusps. 
It becomes apparent that the inclined planes of the teeth are neces- 
sarily arranged diagonally to the mesio-distal relation of the arches. 
. Fig. 4. 
Buccal and lingual relation of molars. 
They are named mesio-buccal, mesio-lingual, disto-buccal and disto- 
lingual. A point to be remembered in studying the occlusion of the OCCLUSION 
21 
Fig. 5. 
Shows relation of lingual cusps of upper molar to lower 
BUCCAL 
DISTAL 
A 
rfESI"^ 
^LINGUA^ 
Disto-Bucco I 
Inclines 
Mesio-Buccol 
Inclines 
Disto-Liwquol 
Inclines 
Mesio-liHquol 
Inclines 
Fig. 6. 
Shows relation of cusps and inclined planes. Upper cusps, square; lower cusps, 
round. Note position of mesio-lingual cusp of upper molar and disto-buccal cusp 
of lower. 22 
PRACTICAL ORTHODONTIA 
teeth is that the mesio-buccal cusp of the upper first molar occludes 
in the buccal groove of the lower first molar. This arrangement is 
found on all of the molar teeth. The mesio-lingual cusps of the lipper 
molars occlude in the central fossae of the corresponding lower 
molars. The mesio-lingual cusp of the upper molar is surrounded 
by the four cusps of the corresponding lower molar. The disto-buccal cusp 
of the lower molar occludes in the corresponding central fossa of the 
BUCCAL 
DISTAL 
.MESIAL 
LINGUAL 
Fig. 7. 
Upper and lower molar, showing mesio-lingual cusp in central fossa of lower 
molar. Initial letters of cusps and inclines used ; e. g., M.B.I.-D.B.C. refers to mesio- 
buccal incline of disto-buccal cusp. 
upper molar, which makes the disto-buccal cusps of the lower molars 
surrounded by the four cusps of the corresponding upper molars. 
However, in the case of the lower first molar, which has a disto-buccal 
and distal cusp, the arrangement is a little different; but ordinarily 
we consider the disto-buccal and distal cusp as one cusp. Another 
point to remember is that the lingual surfaces of the lingual cusps 
of the lower molars and premolars are also without occlusion. OCCLUSION 
23 
The occlusion of the inclined planes of the upper teeth with the 
lower is given in the following table. The left-hand column contains 
cusps of the upper teeth, while the right-hand column refers to the 
lower teeth. By reading the left-hand column first we are given the 
occlusion of the upper teeth with the lower, and by reading the right- 
hand column first we are given the occlusion of the lower teeth with 
the upper. It is necessary that they who expect to treat malocclusion 
must know the relation of the inclined planes of each cusp or it will 
'be absolutely impossible to diagnose and treat correctly malocclusion 
of the teeth. 
Table Showing Occlusion of Inclined Planes. 
UPPER TEETH 
LOWER TEETH 
The occlusal lingual third of the 
upper first (central) incisor. 
occludes 
with 
'the labial occlusal third of the 
lower first (central) incisor and 
the mesio-labial half of the oc- 
clusal surface of the lower sec- 
,ond (lateral) incisor. 
<the disto-labial occlusal surface 
of the lower, second (lateral) 
incisor and the mesio-labial in- 
cline of the lower canine (cus- 
pid). 
The occlusal lingual third of the 
upper second (lateral) incisor. 
occludes 
with 
The mesio-lingual (inclined plane j 
of the upper canine (cuspid). | 
occludes 
with 
I the disto-buccal inclined plane of 
I the lower canine (cuspid). 
The disto-lingual inclined plane 
of the upper canine (cuspid) 
occludes 
with 
("the mesio-buccal inclined plane 
1 of the buccal cusp of the lower 
I first premolar (bicuspid). 
The mesio-lingual inclined planer 
of the buccal cusp of the upper 
first premolar (bicuspid)....! 
occludes 
with 
The disto-buccal inclined plane of 
1 the buccal cusp of the lower 
[^first premolar (bicuspid). 
The disto-lingual inclined planer 
of the buccal cusp of the upper' 
first premolar (bicuspid)....! 
occludes 
with 
The mesio-buccal inclined plane 
J of the buccal cusp of the lower 
[second premolar (bicuspid). 
The mesio-buccal inclined planei 
of the lingual cusp of the up-1 
per first premolar (bicuspid). I 
occludes 
with 
The disto-lingual inclined plane 
' of the buccal cusp of the lower 
[first remolar (bicuspid). 
The mesio-lingual inclined plane 
of the lingual cusp of the up- 
per first premolar (bicuspid) . 
J 
occludes 
with 
The disto-buccal inclined plane 
of the lingual cusp of the lower 
first premolar (bicuspid). (This 
cusp is often underdeveloped.) 24 
PRACTICAL ORTHODONTIA 
The disto-buccal inclined plane> 
of the lingual cusp of the up- 
per first premolar (bicuspid). I 
UPPER TEETH 
rthe mesio-lingual inclined plane 
I of the buccal cusp of the lower 
[second premolar (bicuspid). 
LOWER TEETH 
occludes 
with 
The disto-lingual inclined plane' 
of the lingual cusp of the up- 
per first premolar (bicuspid). 
occludes 
with 
rthe mesio-buccal inclined plane 
' of the lingual cusp of the lower 
[second premolar (bicuspid). 
The mesio-lingual inclined planer 
of the buccal cusp of the upper I 
second premolar (bicuspid)..] 
occludes 
with 
rthe disto-buccal inclined plane 
' of the buccal cusp of the lower 
[second premolar (bicuspid). 
The disto-lingual inclined planer 
of the buccal cusp of the upper 
second premolar (bicuspid).. 
occludes 
with 
The mesio-buccal inclined plane 
of the mesio-buccal cusp of the 
lower first molar. 
The mesio-buccal inclined plane'] 
of the lingual cusp of the up-' 
per second premolar (bicuspid) I 
occludes 
with 
rthe disto-lingual inclined plane 
of the buccal cusp of the lower 
[second premolar (bicuspid). 
The mesio-lingual inclined plane' 
of the lingual cusp of the up- 
per second premolar (bicuspid) 
occludes 
with 
fthe disto-buccal inclined plane 
of the lingual cusp of the lower 
[second premolar (bicuspid). 
The disto-buccal inclined plane' 
of the lingual cusp of the up- 
per second premolar (bicuspid) I 
rthe mesio-lingual inclined plane 
J of the mesio-buccal cusp of the 
[lower first molar. 
occludes 
with 
The disto-lingual (inclined plane' 
of the lingual cusp of the up- 
per second premolar (bicuspid) 
fthe mesio-buccal inclined plane 
of the mesio-lingual cusp of the 
flower first molar. 
occludes 
with 
The mesio-lingual inclined plane''] 
of the mesio-buccal cusp of' 
the upper first molar J 
rthe disto-buccal inclined plane 
of the mesio-buccal cusp of the 
[lower first molar. 
occludes 
with 
The disto-lingual inclined planer 
of the mesio-buccal cusp of 
the upper first molar J 
rthe mesio-buccal inclined plane 
of the disto-buccal cusp of the 
[lower first molar. 
occludes 
with 
The mesio-buccal inclined plane^ 
of the mesio-lingual cusp of 
the upper first molar J 
occludes 
with 
rthe disto-lingual inclined plane 
of the mesio-buccal cusp of the 
[lower first molar. 
The mesio-lingual inclined planer 
of the mesio-lingual cusp of' 
the upper first molar J 
occludes 
with 
'The disto-buccal inclined plane 
of the mesio-lingual cusp of the 
lower first molar. 
The disto-buccal inclined plane' 
of the mesio-lingual cusp of 
the upper first molar 
occludes 
with 
rthe mesio-lingual inclined plane 
' of the disto-buccal cusp of the 
[lower first molar. OCCLUSION 
25 
UPPER TEETH 
The mesio-lingual inclined plane'] 
of the mesio-lingual cusp of I 
the upper first molar I 
LOWER TEETH 
occludes 
with 
rthe mesio-buccal inclined plane 
of the disto-buccal cusp of the 
Jower first molar. 
The mesio-lingual inclined plane> 
of the disto-buccal cusp of 
the upper first molar 
occludes 
with 
rthe disto-buccal inclined plane 
I of the disto-buccal cusp of the 
I lower first molar. 
The disto-lingual inclined plane'] 
of the disto-buccal cusp of' 
the upper first molar I 
occludes 
with 
(the mesio-buccal inclined plane 
of the mesio-buccal cusp of the 
(lower second molar. 
The mesio-buccal inclined plane> 
of the disto-lingual cusp of' 
the upper first molar j 
occludes 
with 
(the disto-lingual inclined plane 
of the disto-buccal cusp of the 
(lower first molar. 
The mesio-lingual inclined plane'] 
of the disto-lingual cusp of' 
the upper first molar I 
occludes 
with 
(the disto-buccal inclined plane 
' of the disto-lingual cusp of the 
(lower first molar. 
The disto-buccal inclined plane'] 
of the disto-lingual cusp of' 
the upper first molar J 
occludes 
with 
(the mesio-lingual inclined plane 
of the mesio-buccal cusp of the 
flower second molar. 
The disto-lingual inclined plane'] 
of the disto-lingual cusp of 
the upper first molar J 
occludes 
with 
(the mesio-buccal inclined plane 
of the mesio-lingual cusp of the 
Jower second molar. 
The mesio-lingual inclined planer 
of the mesio-buccal cusp of । 
the upper second molar I 
(the disto-buccal inclined plane 
' of the mesio-buccal cusp of the 
(lower second molar. 
occludes 
with 
The disto-lingual inclined plane> 
of the mesio-lingual cusp of' 
the upper second molar I 
(the mesio-buccal inclined plane 
' of the disto-buccal cusp of the 
(lower second molar. 
occludes 
with 
The mesio-buccal inclined planer 
of the mesio-lingual cusp of 
the upper second molar 
occludes 
with 
(the disto-lingual inclined plane 
1 of the mesio-buccal cusp of the 
(lower second molar. 
The mesio-lingual inclined plane^ 
of the mesio-lingual cusp of । 
the upper second molar I 
occludes 
with 
'the disto-buccal inclined plane 
of the mesio-lingual cusp of the 
lower second molar. 
The disto-buccal inclined planeA 
of the mesio-lingual cusp of I 
the upper second molar I 
occludes 
with 
'the mesio-lingual inclined plane 
of the disto-buccal cusp of the 
lower second molar. 
The disto-lingual inclined planeS 
of the mesio-lingual cusp of' 
the upper second molar I 
occludes 
with 
'the mesio-buccal inclined plane 
of the disto-lingual cusp of the 
lower second molar. 26 
PRACTICAL ORTHODONTIA 
UPPER TEETH 
LOWER TEETH 
The mesio-lingual inclined plane\ 
of the disto-buccal cusp of I 
the upper second molar I 
occludes 
with 
rthe disto-buccal inclined plane 
of the disto-buccal cusp of the 
flower second molar. 
The disto-lingual inclined planer 
of the disto-buccal cusp of 
the upper second molar I 
occludes 
with 
The mesio-buccal inclined plane 
of the mesio-buccal cusp of the 
flower third molar. 
The mesio-buccal inclined planer 
of the disto-lingual cusp of I 
the upper second molar J 
occludes 
with 
The disto-lingual inclined plane 
of the disto-buccal cusp of the 
I lower second molar. 
The mesio-lingual inclined plane> 
of the disto-lingual cusp of 
the upper second molar I 
occludes 
with 
rthe disto-buccal inclined plane 
J of the disto-lingual cusp of the 
I lower second molar. 
The disto-buccal inclined plane> 
of the disto-lingual cusp of 
the upper second molar 
occludes 
with 
The mesio-lingual inclined plane 
1 of the mesio-buccal cusp of the 
lower third molar. 
The disto-lingual inclined plane 
of the disto-lingual cusp of. 
the upper second molar 
occludes 
with 
The mesio-buccal inclined plane 
' of the mesio-lingual cusp of the 
I lower third molar. 
The mesio-lingual inclined plane' 
of the mesio-buccal cusp of 
the upper third molar 
The disto-buccal inclined plane 
of the mesio-buccal cusp of the 
flower third molar. 
occludes 
with 
The disto-lingual inclined plane 
of the mesio-buccal cusp of< 
the upper third molar 
rthe mesio-buccal inclined plane 
' of the disto-buccal cusp of the 
flower third molar. 
occludes 
with 
The mesio-buccal inclined planer 
of the mesio-lingual cusp of1 
the upper third molar I 
rthe disto-lingual inclined plane 
of the mesio-buccal cusp of the 
i lower third molar. 
occludes 
with 
The mesio-lingual inclined plane' 
of the mesio-lingual cusp of 
the tipper third molar 
occludes 
with 
rthe disto-buccal inclined plane 
{ of the mesio-lingual cusp of the 
I lower third molar. 
The disto-buccal inclined plane' 
of the mesio-lingual cusp of 
the upper third molar J 
occludes 
with 
The mesio-lingual inclined plane 
of the disto-buccal cusp of the 
flower third molar. 
The disto-lingual inclined planer 
of the mesio-lingual cusp of I 
-the upper third molar J 
occludes 
with 
'the mesio-buccal inclined plane 
of the disto-lingual cusp of the 
flower third molar. 
The mesio-lingual inclined plane 
of the disto-buccal cusp of 
the upper third molar..'. 
occludes 
with 
'the disto-buccal inclined plane 
of the disto-buccal cusp of the 
lower third molar. OCCLUSION 
27 
UPPER TEETH 
LOWER TEETH 
The disto-lingual inclined plane^ 
of the disto-buccal cusp of 
the upper third molar I 
occludes 
with 
•' nothing. 
The mesio-buccal inclined planer 
of the disto-lingual cusp of 
the upper third molar I 
occludes 
with 
'the disto-lingual inclined plane 
of the disto-buccal cusp of the 
lower third molar. 
The mesio-lingual inclined planer 
of the disto-lingual cusp of 
the upper third molar I 
occludes 
with 
'the disto-buccal inclined plane 
of the disto-lingual cusp of the 
lower third molar. 
The disto-buccal inclined plane^ 
of the disto-lingual cusp of 
the upper third molar 
occludes 
with 
nothing. 
The disto-lingual inclined plane> 
of the disto-lingual cusp of 
the upper third molar ] 
occludes 
with 
nothing. 
NOTE-The author prefers the terms first and second incisors to those of central and 
lateral as it is in keeping with first and second molars, etc. The terms canines and premolars 
are also more scientific and descriptive than cuspids and bicuspids. To avoid confusion both 
terms are given in the table. 
The tip of the lingual cusp of the upper premolar does not occlude 
between the lower premolars but occludes in the distal portion of the 
central fossa of the lower first premolar. The tip of the lingual cusp 
of the upper second premolar occludes in the distal portion of the 
central fossa of the lower second premolar. 
The upper premolars are so placed in the upper arch that a line 
drawn through the buccal and lingual cusps of the right premolars 
would also touch the buccal and lingual cusps of the corresponding 
teeth on the left side. 
The lower premolars are so placed that lines drawn through the 
buccal and lingual cusps of the right and left teeth would cross at 
almost a right angle at a point distal to the teeth. CHAPTER 11 
FORCES OF OCCLUSION 
It has been shown that each cusp has a definite relation to the op- 
posing cusp, which relation we have termed "occlusion." Each 
tooth is held in a proper position by what we call "forces of occlu- 
sion." 
Definition.-Forces of occlusion are those factors that cause teeth 
to assume and maintain their position in the line of occlusion. 
Line of Occlusion.-The line of occlusion is that line with which, 
in form and position according to type, the teeth must be in harmony 
if in normal occlusion (Angle). The line of occlusion can also be 
defined as the line of the greatest occlusal contact. As each tooth 
begins to make its appearance from the dental crypt and gum it is 
guided to a certain position in the dental arch. If all of the forces 
of occlusion are acting normally, the tooth will take its proper posi- 
tion, and if the same forces of occlusion act normally during the time 
that the entire dental apparatus is forming, all of the teeth will be 
in their proper positions. However, should one of the forces of oc- 
clusion become abnormal the result will be malocclusion. The failure 
of any one of the teeth to take the proper position in the line of oc- 
clusion will influence some other tooth or teeth and malocclusion will 
result. 
Classification of Forces of Occlusion 
There are six forces of occlusion, as follows: 
1. Normal cell metabolism. 
2. Muscular pressure. 
3. Force of the inclined plane. 
4. Normal approximal contact. 
5. Harmony in the size of the arches. 
6. Atmospheric pressure. 
Normal Cell Metabolism.-That normal cell metabolism is given 
first, does not necessarily mean that it is the most important force, 
for we cannot have any one of the forces abnormal and still have 
normal occlusion of the teeth. These forces are given as nearly as 
28 FORCES OF OCCLUSION 
29 
Fig. 8. 
Half of the superior maxilla, showing the growth downward and forward of the 
alveolar process and palate. (After Noyes.) 30 
PRACTICAL ORTHODONTIA 
possible in the order that they make their appearance during the 
time the dental apparatus is developing. 
Normal cell metabolism may be defined as the proper physiologic 
development of the cells that have to do with the eruption of the 
teeth and the development of the surrounding parts. If a child is 
developing normally (Fig. 8), we will have calcifications at the end 
of the tooth germ, causing an increase in the length of the root and 
absorption of the bone forming the dental crypt, and the develop- 
ment of the peridental membrane. In fact, it is the cell activity of 
that particular region which causes the tooth to erupt. Therefore, 
cell metabolism is the first force which causes the teeth to assume 
the proper position in the dental arch. 
Fig. 9. 
Malocclusion of central produced by abnormal locking of inclined planes. 
Muscular Pressure.-It also generally follows that teeth, when they 
first erupt, do not always occupy their proper position. They may 
be too far to the buccal or lingual side of the arch. However, the 
second force of occlusion, muscular pressure, aids the tooth to take 
very nearly the proper position in regard to the buccal and lingual 
relation to the line of occlusion. Should the central incisor erupt 
too far toward the lingual, the pressure of the tongue will force it 
labially. Should it be too far toward the labial, the pressure of the 
lips will force it lingually. As a result of the activity of the muscles 
of the cheeks and tongue, we find that each one of the deciduous teeth FORCES OF OCCLUSION 
31 
is caused to assume a position in the arch in response to those forces. 
Therefore, muscular pressure is the second force that has an action 
Fig. 10. 
The position of first molars at this age easily permits of abnormal locking of cusps. 
Fig. 11. 
Left side of model shown in Fig. 10. 
upon the teeth that causes them to take their proper position. If 
everything is developing normally, from this time on the other four 32 
PRACTICAL ORTHODONTIA 
forces of occlusion act so nearly together that it is almost impossible 
to say which exerts an influence first or which is the most important. 
Force of the Inclined Plane.-The author is inclined to believe that 
Fig. 12. 
Abnormal locking of first molars will produce other malocclusions as age advances. 
Fig. 13. 
Showing abnormal approximal contacts of teeth and the influence of one tooth on 
the others. 
the third force, or the force of the inclined plane, is the next one to 
be an important factor as the teeth erupt. The force of muscular 
pressure has caused the upper and lower teeth to be placed in an FORCES OF OCCLUSION 
33 
arch which is about the shape of the tongue and which corresponds 
with the range of the activity of the muscles of the cheek and lip. 
Fig. 14. 
Fig. 15. 
Showing abnormal locking of teeth and abnormal approximal contacts. The 
upper right second premolar (bicuspid) and upper left canine (cuspid) are crowded 
lingually because of abnormal approximal contact. 
As the upper and lower teeth approach each other, we find that the 
inclined planes of the cusps of the occlusal surface come in contact, 34 
PRACTICAL ORTHODONTIA 
act in the nature of a wedge, and force the teeth to such a position 
that the cusps of the lower teeth will fall in the grooves and sulci of 
Fig. 16. 
Fig. 17. 
Shows malocclusion resulting from missing left upper second premolar (bicuspid), 
resulting in inharmoriy in size of arches. 
the upper teeth and the cusps of the upper teeth will fall in the fossae 
and grooves of the lower teeth (Fig. 9). It has been shown that the FORCES OF OCCLUSION 
35 
mesio-lingual cusp of the upper molar occludes in the central fossa 
of the corresponding lower molar; also that the buccal cusps of the 
upper molars and premolars are buccal to the lower molars and pre- 
molars. Seldom do we find each cusp occupying its proper position 
when the cusps of the teeth first come in contact; but owing to the 
act of mastication, the cusps force themselves into the proper place, 
provided that they have started in the right direction (Fig. 10). 
However, should one cusp be locked on the wrong incline it becomes 
a factor in producing malocclusion (Fig. 12), and instead of a normal 
occlusion of the teeth there will be malocclusion. The force of the 
Fig. 18. 
Malocclusion produced by missing lateral. 
inclined plane is active, from the teeth in one arch to the teeth in 
the opposite arch. 
We have stated that the forces of occlusion are closely related, and 
this is especially true in regard to the force of the inclined plane and 
that of muscular pressure. Muscular pressure has been defined as 
the force exerted by the muscles of the lips and cheeks upon the 
teeth. This action is derived from the muscles of respiration, degluti- 
tion and expression. These groups of muscles exert a direct force 
upon the teeth, which is different from the force exerted upon the 
teeth by the muscles of mastication. The muscles of mastication exert 
force on the teeth only through the medium of the inclined planes, 36 
PRACTICAL ORTHODONTIA. 
and it is this action of the muscles of mastication which causes the 
force of the inclined plane to be an active force. Therefore, in study- 
ing the forces of occlusion we must ever bear in mind the intimate 
relation that exists between the one and the others. 
Normal Approximal Contact.-The force of the approximal contact 
is the force that the approximating surfaces of the teeth of one arch 
exert on the approximating teeth of the same arch. It is different 
from the forces of the inclined plane, as it acts only upon approxi- 
mating teeth. For a number of years we failed to realize that there 
were certain cases in which the force of the inclined plane would be 
normal but the force of the approximal contact abnormal, resulting 
in troublesome types of malocclusion, the treatment of which can only 
be successfully accomplished by recognizing the relation of the ap- 
Fig. 19. 
Fig. 20. 
Showing missing lower second premolar (bicuspid). 
proximal contact points (Fig. 13). After one tooth in either arch 
erupts, it has a guiding influence on the approximating tooth, helping 
to produce either normal occlusion or malocclusion. If two teeth 
have erupted and the space remains between them for the third tooth, 
the third tooth is influenced by the approximating tooth on its mesial 
and distal side (Figs. 14 and 15). The force of the approximal con- 
tact is probably more important in the eruption of the permanent 
teeth than it is in the eruption of the deciduous teeth. It therefore 
becomes necessary that the normal approximal contact of the decidu- 
ous teeth must be maintained in order that the permanent teeth will 
erupt in their proper position in the dental arch. A great many cases 
of malocclusion are produced in the permanent teeth because this con- 
dition has been overlooked. FORCES OF OCCLUSION 
37 
Harmony in the Size of the Arches.-"Harmony in the size of the 
arches" means that the teeth in the upper arch and the teeth in the 
lower arch are so arranged that when in normal occlusion, each one 
occupying the proper position in the line of occlusion, the line of 
greatest occlusal contact will be the same in both arches. If there 
is one more tooth in the lower than in the upper arch (Figs. 16, 17, 
and 18), it necessarily will produce inharmony in the size of the 
arches, resulting in malocclusion. Likewise, if there is a missing tooth 
in the lower arch, malocclusion of the upper arch will result (Figs. 
Fig. 21. 
Inharmony in size of upper and lower teeth. (Hawley.) 
19 and 20). Malocclusion may be produced by inharmony in the size 
of the arches when the inharmony is the result of the decay of the 
teeth, causing destruction of the approximal contact. Inharmony in 
the size of the arches may be the result of inharmony in the size of 
the teeth. One or more teeth may be too large or too small. Cases 
are on record where the lower incisors are too large for the upper in- 
cisors, thereby making the establishment of normal occlusion and a 
normal overbite impossible, on account of the abnormal approximal 
contact. In other cases it has been found that the upper incisors 
would be too large as compared with the lower incisors. Sometimes 38 
PRACTICAL ORTHODONTIA 
the inharmony in the size of the teeth may be in the premolars or 
canines. In those cases where the inharmony as to size exists in the 
incisor region, the molars and premolars may be in normal relation 
with each other and the occlusion of the lateral halves may be normal. 
In some cases it is possible to establish a normal occlusion in the molar 
and premolar region with a normal relation of the inclined planes 
Fig. 22. 
Posterior portion of nasal cavity and sinuses. Note position of lingual cusp of upper 
molar. 
and normal approximal contact of the premolars and molars and have 
a compromise occlusion of the incisors. In these cases there may be 
a slight overlapping, a slight spacing, or a too short or too great 
overbite, which is the result of inharmony in the size of the arches 
and which must be considered as a force of occlusion that will always 
assert itself in some way. In some instances if there is an inharmony 
in the size of teeth it can be compensated by grinding the tooth so as FORCES OF OCCLUSION 
39 
to reduce the mesio-distal diameter and thereby establish new ap- 
proximal contacts and a harmony in the size of the arches. This 
inharmony in the size of the teeth was first called to my attention by 
Fig. 23. 
Typical case of malocclusion by mouth-breathing. 
Fig. 24-A. 
Fig. 24-B. 
Facial deformity associated with mouth-breathing-. 
Hawley and has later been proved by the work of Stanton, Rudolph 
Hanau, and Gilbert D. Fish. Their work proves that the forces of 
occlusion cannot be overlooked if we hope to establish normal oc- 
clusion. 40 
PRACTICAL ORTHODONTIA. 
So it will be seen that very often in the loss of one of the forces 
of occlusion a second one is also disturbed, finally causing an inhar- 
monious action of all of them. 
Normal Atmospheric Pressure.-Normal atmospheric pressure is 
that pressure produced in the nasal and oral cavities during normal 
respiration and deglutition. If the individual breathes through the 
nose, with each inspiration and expiration a pressure is exerted on 
all sides of the nasal cavity. Not only is a pressure exerted in the 
nasal cavity, but it is also produced in all of the nasal sinuses (Fig. 
22). As a result of atmospheric pressure the nasal cavity is developed 
to its proper size, consequently this pressure plays an important part 
in the development of the dental arch. In normal breathing, the 
proper action of the muscles of the lips, cheeks and tongue are pres- 
ent, which results in the proper muscular pressure; therefore, with 
the loss of normal breathing, muscular pressure is disturbed, causing 
two forces of occlusion to be perverted. Such resulting malocclusions 
as we find in Class II, Division 1, (Fig. 23) are primarily the result 
of disturbed atmospheric pressure and abnormal pressure of the 
cheeks, lips, and tongue (Fig. 24). Another very important phase of 
atmospheric pressure and muscular action takes place after we cease 
speaking-we close the lips and swallow; a vacuum is created in the 
oral cavity which in turn forces the tongue up against the roof of the 
mouth and exerts pressure upon the upper and lower teeth. In 
mouth-breathing the tongue exerts a pressure only on the lower arch 
and mostly upon the lower molars and premolars. Atmospheric pres- 
sure is an active force during the whole time that the individual is 
breathing. If at any time breathing becomes abnormal and the at- 
mospheric pressure is disturbed, malocclusion will result. Should 
children become mouth-breathers early, malocclusion will develop 
shortly after the mouth-breathing begins. Any of these forces of 
occlusion acting in the wrong direction then become forces of maloc- 
clusion. Acquired cases of malocclusion are simply the result of some 
condition that has resulted from one or more of the forces of occlusion 
that have been disturbed. Therefore, it becomes imperative that any 
effort toward the correction of malocclusion must be of such a nature 
that it will not only place the teeth in their proper position in the line 
of occlusion but, if they are expected to stay there, all six of the forces 
of occlusion must be normal and remain normal. CHAPTER III 
MALOCCLUSION 
Malocclusion is the deviation from normal occlusion to such an ex- 
tent as to interfere with the proper functions of the teeth. 
Malocclusion may be divided into four groups: First, positions of 
individual teeth that deal with the relation of the tooth to the ap- 
proximating teeth, the line of occlusion, and the median line of the 
face. Lischer terms this group "malpositions of the individual 
teeth.'' The second group is the relation of one arch to the other, 
malrelation of the arches," which is based on the antero-posterior 
relation or the mesio-distal relation of the lower dental arch to the 
upper. Third, we have "malposition of the mandible," which is based 
on the relation that the mandible bears to the face and cranium, es- 
pecially the relation that the condyle bears to the glenoid fossa. The 
fourth division includes "malformation of the jaws and processes," 
which includes deformities of the mandible and maxilife. 
Positions of Malocclusion, or Malpositions of the Teeth 
"Positions of Malocclusion" deal with the individual teeth or the 
relation of the teeth of one arch to the approximating teeth of the 
same arch. The positions of malocclusion may be defined as the rela- 
tion of the individual teeth to the line of occlusion and the median 
line of the face. 
Tn order to be perfectly clear on this subject, we might again state 
that the line of occlusion is that line with which, in form and position 
according to type, the teeth must be in harmony if in normal occlu- 
sion (Angle). 
There are seven distinct positions of malocclusion (Fig. 25), named 
from the position which the teeth occupy to the line of occlusion and to the 
median line of the face. The line of occlusion is divided into the 
right and left half by the median line of the face. 
A tooth that is too near the median line of the face or too far to- 
ward the middle of the arch is said to be in mesial occlusion or mesio- 
version* 
* Lischer has suggested the use of the ending "version" to apply to the malposition of the 
teeth, which ending is less confusing than occlusion, the latter term being limited by Lischer to 
refer to the malrelation of the arches. 
41 42 
PRACTICAL ORTHODONTIA 
One that is too far in the opposite direction or toward the posterior 
portion of the arch is in distal, occlusion, or distoversion. 
A tooth that is too far toward the' lips or cheeks is in labial or buccal 
occlusion, or labioversion or buccoversion.. Labial occlusion or labiover- 
sion is applied to the six anterior teeth and buccal occlusion, or buccover- 
sion, to the posterior teeth. 
A tooth that is too far to the lingual side of the line of occlusion is said 
to be in lingual occlusion, or linguoversion. 
One that is too short, that is, that has not erupted far enough to reach 
the plane of occlusion, is in infra-occlusion, or infraversion. 
One that has grown too long is in siupra-ocelusion, or supraversion. 
Fig. 25. 
Positions of malocclusion. Heavy black lines indicate normal position. Dotted lines 
indicate positions of malocclusion. 
La. O.-Labial occlusion. 
L. O.-Lingual occlusion. 
T. O.-Torsi-occlusion. 
D. O.-Distal occlusion. 
M. O.-Mesial occlusion. 
B. O.-Buccal occlusion. 
M. La. O.-Mesio-labial occlusion. 
A tooth that does not occupy a proper axis in the line of occlusion is 
said to be in t^si^oedusion, or torsiversion, that is, rotated on its axis. 
Lischer suggests the term transversion for teeth that are transposed; 
for example, when the canine is between the premolars. Ue also uses the 
term perversion for impacted teeth. 
We also have various combinations of these positions, for a tooth may be 
too far mesial and also rotated; it would then be in torsi-mesial occlusion. 
Likewise, it may be in any of the other four positions. A tooth may be in 
mesial occlusion, or me sio version, not erupted far enough and also ro- 
tated, in which case it would be in mesio-torsi-infra-occlusion, or mesio- 
torsi-infraversion. Various combinations will result from various posi- MALOCCLUSION 
43 
tions of the teeth. A tooth may be too far mesial, may be rotated, may be 
in infra-occlusion, or infraversion, and also occupy a labial position, in 
which case it is spoken of as being in mesio-labio-torsi-infra-occlusion, or 
as being in mesio-labio-torsi-infraversion. 
Fig. 26-A. 
Fig. 26-B. 
Upper and lower molars and premolars are in lingual occlusion. Lateral incisors are 
in linguo-torsi-occlusion. 
With the seven primary positions of malocclusion it is possible for 
a tooth to occupy four of them at one time. To move a tooth into the 
proper position, it would necessarily have to be moved in four dif- 
ferent directions. So positions of malocclusion while comparatively 
simple offer various complications in treatment (Fig. 26). 44 
PRACTICAL ORTHODON TIA 
Classification of Malocclusion, or Malrelation of the Arches 
Classes of malocclusion deal with the relation of the lower teeth 
to the upper. Of course, the positions of malocclusion have some re- 
lation in the formation of the class, the principal one being the mesial 
and distal (anterior and posterior) relation of the arches. We have 
Fig. 27. 
Diagram A illustrates normal arch relationship. In Diagram H, the parallelogram 
a, 1), c, d, illustrates arch malrelation in bilateral mesioclusion, and b, y, their relation 
in bilateral distoclusion. (Lischer.) 
Fig. 28. 
Diagrams illustrating arch malrelations in unilateral distoclusion and unilateral mesio- 
clusion. (Lischer.) 
shown in the study of normal occlusion that the mesia-buccal cusp of 
the upper first molar occludes in the buccal groove of the lower first 
molar. Also, the mesimlingual cusp of the upper first molar falls into 
the central fossa of the lower first molar. The upper canine occludes 
between the~iuwer canine and the lower first premolar. The relation MALOCCLUSION 
45 
Fig. 29. 
Neutroclusion, or Class 1 (Angle), showing normal mesio-distal (antero-posterior) 
relation of arches. 
Fig. 30. 
Another type of Class I, or normal mesio-distal (antero-posterior) relation of arches. 46 
PRACTICAL ORTHODONTIA 
of the mesio-buccal cusp of the upper first molar to the buccal groove 
has been called by Angle the ''Key.jtp Occlusion.'' Other cusps are 
just as important, but we must select some definite points and keep 
them in mind in deciding whether the teeth occupy a proper mesio- 
distal relation to the opposing teeth. We must take into considera- 
tion more than one tooth in order that we may decide whether the 
dental arches occupy their proper mesio-distal (antero-posterior) re- 
lation to each other, for classification of malocclusion depends upon 
whether the arches occupy a normal mesio-distal relation or are too 
far forward or too far back. As the lower teeth are the movable 
arch, we speak of them as being in normal mesio-distal (antero-pos- 
terior) relation to the upper arch, or as being in distal (posterior) 
relation to the upper arch, or as being in mesial (anterior) relation to 
the upper arch. Following this plan, malocclusion of the arches can 
therefore be divided into three general classes. By three classes, we 
mean that in all cases of malocclusion the lower arch must either be 
normal mesio-distally, or the lower arch distal (posterior) or mesial 
(anterior) to the upper. Therefore, one group of cases would in- 
clude those in which there is a distal (posterior) relation of the 
lower arch to the upper, and another group would include those in 
which the lower teeth are mesial (anterior) to the upper, while still 
another group would include all of those cases in which the lower 
arch is neither mesial (anterior) nor distal (posterior), but is normal 
in these relations. 
The mesio-distal relation of the arches can be illustrated by the 
use of curves or arches that represent the upper and lower dental 
arch. In Fig. 28 b-c represents the upper arch and a-d the lower 
arch. The Diagram A represents the normal mesio-distal (antero- 
posterior) relation of the arches. The lines a to b and c to d repre- 
sent the normal relation of the lower arch to the upper. In Diagram 
B the lines a to b and c to d represent what would happen if the lower 
arch was moved forward or mesially. The lines b to y and c to w 
represent the relations of the lower arch to the upper if a distal or 
backward movement was to take place. Cases of malocclusion that 
involve the mesial or distal malposition of the arches are spoken of 
as bilateral cases. In some instances the lower arch is shifted for- 
ward or backward on one side only. Diagram A, Fig. 28, shows the 
change in the lines a to b in the distal or backward movement of the 
lower arch on one side as compared with the normal relations as 
shown in Diagram A, Fig. 27. Diagram B, Fig. 28, to show the 
change that would occur in the mesial or forward movement of one MALOCCLUSION 
47 
Fig. 31. 
Fig. 32. 
Normal mesio-distal relation of arches with lingual occlusion of right upper molars 
and premolars (bicuspids) to lowers. Neutroclusion, or Class I, case. 48 
PRACTICAL ORTHODONTIA 
side of the arch, compare the lines a to 6 (Diagram B, Fig. 28) with 
the same lines in Diagram A, Fig. 27. Cases of malocclusion which 
are mesial or distal on one side only are called unilateral cases. The 
malrelation of the arches is therefore based on the mesio-distal or 
antero-posterior relation of the lower to the upper. If both sides of 
the lower arch are distal to the upper, we speak of it as a bilateral dis- 
tal occlusion of the lower arch. If one side only of the lower is distal 
to the normal relation of the upper we call such a case a unilateral 
distal occlusion of the lower arch. On the other hand, if the lower 
arch is mesial to the upper arch on both sides, we refer to it as a 
Fig. 33. 
Abnormal mesio-distal relation of first permanent molars with normal mesio-distal 
(antero-posterior) relation of arches. Neutroclusion, or Class I, ease. 
bilateral mesial occlusion. If the lower arch is mesial on one side 
only it is referred to as a unilateral mesial occlusion of the lower 
arch. 
As a result of this plan of classification, all cases of malocclusion 
will fall in one of the three groups that have been mentioned, which are 
based on the mesio-distal relation of the arches. Various efforts have 
been made to apply some short term to these groups of malocclusion 
so that it would be simple and easy to designate each case of maloc- 
clusion to its proper group. Angle used the numerals I, II, and III, 
which is a satisfactory way to designate the groups for one who has MALOCCLUSION 
49 
Fig. 34. 
Upper left second premolar impacted by the drifting of molars mesially, due to 
early loss of deciduous molar. Arch relations normal mesio-distally (antero-posterior). 
Neutroclusion, or Class I, case. 
Fig. 35. 
Showing position of impacted premolar (bicuspid). 
first learned the characteristics of each group. Better and more de- 
scriptive terms have been suggested by Lischer, which are neutro- 
clusion, distoclusion, and mesioclusion. The relation of the two set 
of terms is shown below. 
Lischek 
Class I is the same as Neutroclusion 
Class II is the same as Distoclusion 
\ Class III is the same as Mesioclusion 
Angle 50 
PRACTICAL ORTHODONTIA 
Fig. 36. 
Mutilated case of Neutroclusion, or Class I. 
Fig. 37. 
Class I, Type 1, case. Neutroclusion with bunched anterior teeth, or Complex Neu- 
troclusion (Lischer). MALOCCLUSION 
51 
Believing, from experience with students, that Lischer's terms are 
more descriptive, the author would suggest their general use; and 
throughout this work they will be used in conjunction with Angle's 
numerals. 
Neutroclusion, or Class I 
Neutroclusion, or Class 1, cases are those which present a normal 
mesio-distal relation of the arches (Figs. 29 and 30). The anterior 
teeth may occupy any of the seven positions of malocclusion, although 
the majority of neutroclusion, or Class I, cases show bunching of the 
Fig. 38. 
Class I, Type 2 case. Normal mesio-distal relation of arches. Protrusion (labial oc- 
clusion) of superior incisors. Neutroclusion with labioversion of upper incisors. 
anterior teeth. Some of the teeth are in torsi-lingual occlusion, while 
others may be in labial occlusion. There is usually a narrowing of 
the upper and lower arches, which would mean that the molars and 
premolars are in lingual occlusion. The one outstanding feature that 
is normal, regarding the teeth in this class, is that there must be a 
normal mesio-distal relation of the arches as indicated by the occlusal 
relation of the upper and lower first molars. If all of the teeth are 
present, it will be equivalent to saying that we have a normal mesio- 
distal relation of the molars. One or both sides of the molars may be 
in lingual occlusion, or linguoversion (Figs. 31 and 32). It must also 52 
PRACTICAL ORTHODONTIA 
be remembered that a normal mesio-distal relation of the arches does 
not necessarily imply a normal mesio-distal relation of the molars. 
Fig. 39. 
Fig. 40. 
Class I, Type 3 case. Normal mesio-distal relation of arches with lingual occlusion 
of upper incisors to lowers. Also slight mesial occlusion of lower incisors caused by 
abnormal force of the inclined planes of anterior teeth. Neutroclusion with linguover- 
sion of upper anterior teeth. 
Owing to the early loss of the deciduous molar, as shown in Fig. 33, 
the first permanent molar on the right side has drifted mesially, while MALOCCLUSION 
53 
all of the other teeth have a normal mesio-distal relation to each 
other, which shows a normal mesio-distal relation of the arches. Fig. 
34 shows a case of an older patient, also caused by the drifting of the 
upper molar forward as a result of the loss of the deciduous molar. 
Fig. 35 shows the occlusal view of the case. Again there is a normal 
relation of the arches, but not of the molars. Therefore, both of these 
cases (Figs. 33 and 34) are neutroclusion, or Class I, cases. 
Neutroclusion, or Class I, Mutilated Cases.-If any of the teeth 
have been extracted or are missing, we shall often find in these cases 
a normal mesio-distal relation of arches, and not necessarily a normal 
mesio-distal relation of the molars and remaining teeth (Fig. 33). In 
classifying cases where there is a normal mesio-distal relation of the 
Fig. 41. 
Class I, Type 3 case. Neutroclusion with linguoversion of upper anterior teeth. 
arches and some of the teeth have been lost by extraction, we have 
to resolve the condition to what it would have been before the loss 
of the tooth, whether it is a premature loss of a deciduous tooth or 
the loss of a permanent tooth. Such cases as have been described 
above are spoken of and classified as Class I, mutilated (Fig. 36). 
Types of Neutroclusion, or Class I.-Class I presents several dif- 
ferent types that demand special mention because they present char- 
acteristics that demand special treatment. For convenience we have 
designated them as Types 1, 2, and 3 of Class I. 
Neutroclusion With Bunched Anterior Teeth, or Class I, Type 1.- 
These cases are characterized by a normal mesio-distal relation of the 54 
PRACTICAL ORTHODONTIA 
Fig. 42. 
Class II, Division 1 case. Bilaterally distal (posterior) relation of lower arch. Nar- 
row upper arch. Protruding superior anterior teeth. Distoclusion with labioversion of 
upper anterior teeth. 
Fig. 43. 
Class II, Division 1 case. Bilaterally distal relation of lower arch. Bilateral disto- 
clusion with labioversion of upper anterior teeth. MALOCCLUSION 
55 
arches (Figs. 29 and 30). All of the teeth are in lingual occlusion, 
except that in certain cases we find some or all of the canines in labial 
occlusion (Fig. 37). The upper and lower molars and premolars are 
in lingual occlusion and demand expansion. The upper molars and 
premolars may be in lingual occlusion to the lower molars and pre- 
molars on one or both sides. 
There is a condition of the teeth that might be described as ''bunched." 
These cases may be called complex neutroclusion. 
Neutroclusion with Labioversion of Upper Incisors, or Class I, 
Type 2.-Cases belonging to this type are characterized by a normal 
mesio-distal relation of the arches, protruding upper anterior teeth 
Fig. 4 4. 
Fig. 45. 
Class II, Division 1 case. Malocclusion shown in Fig. 43. Short upper lip, abnormal 
muscular pressure, mouth-breathing. 
(Fig. 38), bunched lower anterior teeth and narrow upper and lower 
arches. The upper and lower molars and premolars usually occupy 
the proper bucco-lingual relation to each other. The patient is or 
lias been at some time a mouth-breather, or has a lip-habit. 
Neutroclusion with Linguo version of Upper Anterior Teeth, or 
Class I, Type 3.-Here we find a normal mesio-distal relation of the 
arches (Fig. 39). The upper incisors are in lingual occlusion to the 
lower (Fig. 40), with bunching of the upper anterior teeth and lack 
of development in the premaxillary region. The teeth of the lower 
arch may be bunched or occupy a nearly normal approximal relation 
to each other (Fig. 41). The lower lip appears prominent because 56 
PRACTICAL ORTHODONTIA 
Fig. 46. 
Fig. 47. 
Class II, Division 2 case. Bilaterally distal (posterior) relation of lower arch. 
Retruding or bunched upper incisors. Distoclusion with linguoversion of upper in- 
cisors. MALOCCLUSION 
57 
the upper lip is underdeveloped as a result of the position of the 
upper teeth. 
Any of these types of Class I may be complicated by mutilations. 
Distoclusion, or Class II 
Distoclusion, or Class II, cases of malocclusion are those that are 
characterized by a distal (posterior) relation of the lower arch. Class 
II cases are divided into Division 1 (Angle), or distoclusion, with labi- 
oversion of the upper anterior teeth (Lischer) ; and Class II, Division 
2 (Angle), or distoclusion with linguoversion of the upper anterior 
teeth (Lischer). 
Distoclusion With Labioversion of Upper Incisors, or Class II, 
Division 1.-Division 1 cases are those that are characterized by a dis- 
tal relation of the lower arch to the upper, the width of a premolar 
(Figs. 42 and 43). Instead of the mesio-buccal cusp of the upper first 
molar occupying a mesio-distal relation corresponding to the buccal 
groove of the lower first molar, we find it occupying a mesio-distal re- 
lation corresponding to the buccal embrasure between the lower first 
molar and lower second premolar. The other characteristics of Class 
II, Division 1, are as follows: A narrow upper arch, protruding an- 
terior teeth, a mandible that is deficient, an underdeveloped or re- 
ceding chin, abnormal muscular pressure, a short upper lip and 
mouth-breathing (Figs. 44 and 45). Mouth-breathing has disturbed 
the other forces of occlusion, especially muscular pressure, which has 
resulted in allowing the upper anterior teeth to protrude in the upper 
arch and in permitting them to remain in an undeveloped condition 
bucco-lingually. The underdeveloped mandible and the receding chin 
are the result of the distal occlusion of the lower teeth and the abnor- 
mal action of the muscles. 
Distoclusion With Linguoversion of Upper Anterior Teeth, or Class 
II, Division 2.-Class II, Division 2 (Figs. 46 and 47) is characterized 
by the distal relation of the lower arch to the same extent as in Di- 
vision 1. The other characteristics are directly the opposite. We 
have an upper arch that is nearly normal in width with retruding and 
bunched anterior teeth. The mandible is more nearly normally de- 
veloped and the chin is not receding. We have normal pressure of 
the lips and cheeks and normal action of the tongue and normal 
breathing. The difference between Division 1, Class II, and Division 
2, Class II, is the difference between normal and abnormal muscular 
pressure. In order to more clearly enumerate the differences between 58 
PRACTICAL ORTHODONTIA 
Fig. 48. 
Fig. 49. 
Class II, Division 1, Subdivision. Unilaterally distal (posterior) relation of lower 
arch (left side of lower, distal; right side, normal). Protruding superior anterior 
teeth. Unilateral distoclusion with labioversion of upper anterior teeth. MALOCCLUSION 
59 
Division 1 and Division 2, they are given in tabulated form o.ppositc 
each other in the following table: 
Class II. 
division 1. 
Bilaterally distal relation of the 
lower arch. 
Protruding anterior upper teeth. 
Narrow upper arch. 
Undersized chin. 
Undersized mandible. 
Abnormal muscular pressure. 
Abnormal atmospheric pressure. 
Mouth-breathing. 
Subdivision of Class II, Division 1. 
Unilaterally distal with the same 
characteristics as Division 1. 
One side of the lower arch is in 
normal mesio-distal relation to 
the upper. 
DIVISION 2. 
Bilaterally distal relation of the 
lower arch. 
Retruding and bunched upper an- 
terior teeth. 
Upper arch nearly normal in width. 
Normal-sized chin. 
Normal-sized mandible. 
Normal muscular pressure. 
Normal atmospheric pressure. 
Normal breathing. 
Subdivision of Class II, Division 2. 
Unilaterally distal with the same 
characteristics as Division 2. 
One side of the arch is in normal 
mesio-distal relation to the upper. 
Both Division 1 and Division 2 of Class II sometimes show a distal 
relation of the lower arch present on one side only. It may be on 
either the right or the left side according as the etiological factors 
have been present. These cases of Division 1 and Division 2 are 
therefore called subdivisions, or unilateral distoclusions, and are 
named as Class II, Division 1, Subdivision; or Class II, Division 2, 
Subdivision; or just reversing them and saying Subdivision of Di- 
vision 1 of Class II, or Subdivision of Division 2 of Class II. These 
subdivisions are spoken of as being unilaterally distal. The other 
characteristics are exactly the same as found in Division 1 and Di- 
vision 2 (as shown in table). For example, a subdivision of Division 
1, Class II (Figs. 48 and 49) would be a case in which we had a nor- 
mal mesio-distal relation of the arches on one side, with a distal rela- 
tion of the lower arch on the other, a narrow upper arch, protruding 
anterior teeth, an underdeveloped mandible, a receding chin, abnor- 
mal muscular pressure and abnormal breathing. A subdivision of 
Division 2 of Class II (Figs. 50 and 51) would be a case in which the 
lower arch was distal on one side, on the other side normal mesio- 
distally, an upper arch nearly normal in width, retruding and 
bunched upper incisors, a mandible of nearly normal size, a normal 
chin, normal muscular pressure, normal atmospheric pressure and 60 
PRACTICAL ORTHODONTIA 
Fig. 50. 
Fig. 51. 
Class II, Division 2, Subdivision. Unilaterally distal relation of lower arch. Right 
side, normal; left side, distal. Bunched superior anterior teeth. Unilateral disto- 
clusion with linguoversion of upper incisors. MALOCCLUSION 
61 
Fig. 52. 
Fig. 53. 
Class II, Division 2, Subdivision. Unilaterally distal relation of lower arch. Left 
side normal; right side, distal. Normal lip pressure is bunching anterior teeth. Uni- 
lateral distoclusion with bunching upper anterior teeth. 62 
PRACTICAL ORTHODONTIA 
normal breathing. It does not matter, so far as the classification is 
concerned, whether the right or left side in these subdivision cases is 
normal or abnormal mesio-distally (Figs. 52 and 53). 
Mesioclusion, or Class III 
Mesioclusion, or Class 111, cases are those that are characterized by 
the mesial relation of the lower arch to the upper arch the width of 
one premolar (Fig. 54). The mesio-buccal cusp of the upper first 
molar occupies a mesio-distal relation which corresponds to the buccal 
embrasure between the lower first and second molars. 
Fig. 54. 
Class III. Mesial (anterior) relation of lower arch. Mesioclusion. 
Class III presents a division and subdivision, which is a bilateral 
mesioclusion and a unilateral mesioclusion, and also three types. 
Class III, Type 1.-These cases present a mesial relation of the 
lower arch to the upper (Figs. 55 and 56). The teeth in each arch 
present an even alignment, with practically no torsi-occlusion in 
either arch. Each dental arch is very nearly the correct shape, and 
if viewed separately from the occlusal view, the true condition of the 
malocclusion would not suggest itself (Figs. 57 and 58). There is an 
appearance of the lower arch having moved forward from a normal MALOCCLUSION 
63 
occlusion to one that is mesial. The lip pressure is normal and we 
have normal breathing. 
Fig. 55. 
Fig. 56. 
Class III, Type 1. Bilaterally mesial (anterior) relation of lower arch with fairly even 
alignment of the upper and lower teeth. Bilateral mesioclusion. 
Class III, Type 2.-The lower arch is mesial to the upper the width 
of one premolar. The upper teeth are in good alignment with little 64 
PRACTICAL ORTHODONTIA 
torsi-occlusion (Figs. 59 and 60). The lower incisors are bunched 
and in lingual relation to the upper. The patient is a normal breather 
with normal lip habits. This type presents less facial deformity than 
Fig. 57. 
Fig. 58. 
Class III, Type 1. Showing even alignment of teeth in each arch. Bilateral mesio- 
clusion with even alignment of the teeth. 
any of the other types of Class III, or mesioclusion, because the lower 
anterior teeth are bunched and there is little overdevelopment of the 
mandible. MALOCCLUSION 
65 
Fig. 59. 
Fig. 60. 
Class III, Type 2. Bilaterally mesial relation of lower arch. Bunched lower anterior 
teeth. Bilateral mesioclusion with bunched lower anterior teeth. 66 
PRACTICAL ORTHODONTIA 
Class III, Type 3.-The lower arch is mesial to the upper the width 
ot one premolar (Fig. 61). The upper arch is underdeveloped and 
Fig. 61, 
Class III. 1 ype 3. Bilaterally mesial relation of lower arch. Bunched upper an- 
terior teeth. Small upper arch. Lower teeth in fair alignment. Bilateral mesioclusion 
with bunched upper anterior teeth. 
the anterior teeth bunched and in lingual occlusion to the lower. The 
lower teeth are in fairly good alignment. 
The facial deformity is very marked in these cases owing to the over- 
development of the mandible and the underdeveloped premaxilhe. MALOCCLUSION 
67 
Fig. 62. 
Fig. 63. 
Class ITT, Subdivision. Unilaterally mesial relation of lower arch. Right side, normal; 
left side, mesial, unilateral mesioclusion. 68 
PRACTICAL ORTHODONTIA 
Unilateral Mesioclusion, or Class III, Subdivision.-These cases are 
characterized by a mesial relation of the arch on one side and a normal 
relation, mesio-distal on the other (Figs. 62, 63 and 64). The positions 
of the anterior teeth may resemble any of the types described under the 
division. Owing to one side of the arch being in normal mesio-distal 
relation and the other in mesial relation, there is a tendency for 
a cross-bite to be present in the region of the incisors, which produces 
a great amount of abrasion of the incisal edge of the incisors. Subdi- 
vision cases of Class III also cause an abnormal relation in the median 
line of the upper and lower arches. 
Fig. 64. 
Front view of Class III, Subdivision, or unilateral mesioclusion. 
Unilateral Mesioclusion and Distoclusion.-There are some cases that 
are mesial on one side and distal on the other. This type of cases has 
been incorrectly called "Class IV." The case shown (Figs. 65 and 
66) is of that type. The etiologic factors are not understood in regard 
to these cases. After a careful examination of this case, the author is 
convinced that the trouble was entirely with the relation of the teeth 
and not with the relation of the condyle to the glenoid fossa. There may 
be some cases in which the mandible may be overdeveloped on one side, 
or the condyle may occupy an anterior relation to the glenoid fossa on 
one side; but it is more probable that the deformity is in the arches and 
not in the mandible. MALOCCLUSION 
69 
Fig. 65. 
Unilaterally mesial and distal relation of lower. Incorrectly called Class IV. Uni- 
lateral mesioclusion and distoclusion. 70 
PRACTICAL ORTHODONTIA 
Fig. 66. 
Occlusal view of case, with lower arch unilaterally mesial and distal. 
Malformation of the Jaws and Their Processes, and Abnormal Relation 
of the Mandible to the Maxillae 
In the study of malocclusions, we find some conditions that can be 
accurately described only by taking into consideration the relation of 
the mandible to the face and cranium. We then speak of those condi- 
tions as "malposition of the mandible." Some of these conditions in- 
clude an entire malposition of the mandible as shown by the relation MALOCCLUSION 
71 
Fig. 67. 
Mandibular retroversion. The bilateral distoclusion is merely a symptom. (Lischer.) 
Fig. 68. 
Profile of case shown in Fig. 67. (Lischer.) 72 
PRACTICAL ORTHODONTIA 
of the glenoid fossa to the condyle. Others may be a relative condition 
only, which may be complicated by lack of development in the body of 
the mandible that gives the appearance of a misplaced mandible. In 
those cases where we find an anterior position of mandible, Federspiel 
has suggested the term mandibular anteversion. He has also suggested 
the term mandibular retroversion for those cases in which the mandible 
is distal. Figs. 67 and 68 show a case taken from Lischer's practice 
which he describes as mandibular retroversion of which the distoclu- 
sion is only a symptom. There are cases on record that show a mesial 
relation of condyle to the glenoid fossa. 
Fig. 69. 
Right side of skull with mesioclusion, or Class III ; also showing a malformation of the 
mandible. 
In considering the malformations of the mandible and the maxilla, 
it is hard to determine which is the cause and which is the effect. Cer- 
tain types of malocclusion will produce an overdevelopment or an un- 
derdevelopment of the mandible, while certain others will have a 
similar effect on the maxilla. However, in considering these facial de- 
formities, we are compelled to recognize the malformation of the parts. 
The close relation existing between the malposition of the arches and 
the malformation of the jaws is shown in Figs. 69 and 70. It will be 
observed in this case that the position of the condyle is normal, as MALOCCLUSION 
73 
nearly as it is possible to determine. A greater malformation of the 
mandible in a case reported by Lischer is shown in Figs. 71 and 72. 
This condition he has termed mandible curvature. 
Deformities of the jaws may present themselves as developments, 
for which the terms macro- and micro- serve admirably. If it is an over- 
development of the mandible it is called macroman-dibular. Such a 
case is shown in Figs. 72 and 73. The teeth are in mesioclusion with 
little torsiversion of either the upper or the lower. The profile shows 
the overdevelopment of the mandible very plainly. We also find cases 
Fig. 70. 
Left side of skull with mesioclusion and malformation of the mandible. 
in which the mandible is underdeveloped, which is described as microman- 
dibular development. Figs. 74 and 75 show such a condition. 
An overdevelopment of the maxillae is termed macromaxillary devel- 
opment, while an underdeveloped maxillae is a micromaxillary develop- 
ment. An extreme case of underdevelopment of the maxillae and there- 
fore maxillary micrognathia, is shown in Figs. 76 and 77. 
In considering the malrelations of the jaws and the maldevelopment 
of the body of the mandible, the maxillae, and their processes, we must 
be careful not to confuse one with the other. An overdevelopment of 
the mandible might be mistaken for a mandibular anteversion. The 74 
PRACTICAL ORTHODON TIA 
Fig. 71. 
Mandibular curvature. (Lischer.) 
Fig. 72. 
Profile of case shown in Fig. 71. (Lischer.) MALOCCLUSION 
75 
Fig. 73-A. 
Macromandibular development. Note the symmetrical, well-developed upper arch • the 
bilateral mesioclusion is merely a symptom of the lower jaw deformity. (Lischer.) 
Fig. 73-B. 
Profile of case shown in Fig. 73-A. The mandible is too long and its angle too obtuse. 
(Lischer.) 76 
PRACTICAL ORTHODONTIA 
author is of the opinion that the cases shown in Figs. 69, 70, 72, and 73 
are abnormal developments of the mandible and not mesial posi- 
tions of the condyle. Care must also be observed in studying cases 
that present an underdevelopment of the mandible, so as not to confuse 
them with retroversion of the mandible which is quite a rare condition. 
Fig. 78 shows a case of distoclusion with underdevelopment of the 
mandible in which the condyle occupies a normal relation to the glenoid 
fossa and is therefore not a case of retroversion of the mandible. 
In the study of the mesial and distal relations of the lower arch, we 
must use every means at our command to prove that so-called disto- 
clusions are not mesial occlusions of some of the upper teeth. Figs. 33 
and 34 show cases in which the upper molars have drifted forward. By 
observing the malrelation of the approximating teeth and the arch re- 
lations as shown by the teeth that are in normal position, a correct 
diagnosis can be made. However, in some cases a correct diagnosis of 
the conditions is more difficult. Fig. 79 is the left side of a skull that 
presents a normal mesio-distal relation of the arches. The occlusion 
appears to have been practically normal before the teeth were lost. 
The condyle appears in the normal position and the mandible is also 
normal. Fig. 80, the right side of the same skull, shows what may be 
called a distoclusion or a distal relation of the lower arch on the right 
side. However, in examining the occlusional view' of the skull (Fig. 
81), it will be observed that the upper teeth on the right side occupy 
an anterior position in the skull as compared with those on the left side. 
By comparing the relation of the first molars to the bases of the 
zygomatic arches, the difference in the relation of the two sides can be 
seen. Just what would cause this abnormal development, we have no 
way of determining at the present time in this case. 
In examining a large number of skulls, the author has found none 
that shows a distal relation of the condyle, although this condition 
may exist. In considering the positions of the condyle, it is well to re- 
member the relation that exists between the shape of the teeth and 
the shape of the condyle and glenoid fossa.. As a result of malocclu- 
sion and of the movements of the mandible, the shape of the condyle 
will change, but the change in shape will always be in keeping with 
the occlusion and be limited by the ligaments that form the temporo- 
mandibular articulation. In studying the malpositions of the mandi- 
ble, the anatomy of the parts must be kept in mind and the normal 
relation of the condyle as shown in Fig. 82. 
In considering the classification of malocclusions in the order of 
their frequency, we find that malpositions of the teeth are first in MALOCCLUSION 
77 
Fig. 74. 
Micromandibular development. Note the torso-linguoversion of the upper lateral 
incisors, encroaching on the cuspid spaces. The upper incisors are not in labioversion. 
(Lischer.) 
Fig. 75. 
Profile of case shown in Fig. 74. The mandible is too short in body and rami. (Lischer.) 78 
PRACTICAL ORTHODONTIA 
Fig. 7 6. 
Micromaxillary development. Note the marked arrest of development, complicated by 
deficiency in the number of teeth. (Lischer.) 
Fig. 77. 
Profile of case shown in Fig. 76. (Fischer.) MALOCCLUSION 
79 
Fig. 78. 
"Class II skull." Lower arch distal. Distoclusion. 
Fig. 79. 
Fig. 80. 
Skull showing normal mesio-distal relation of arches. Right side shown in Fig. 80. 
(Hellman.) 
Left side of skull shown in Fig. 79, showing what appears to be distoclusion but is 
a mesial relation of the upper teeth. (Hellman.) 80 
PRACTICAL ORTHODONTIA 
Fig. 81. 
Occlusal view of skull shown in Figs. 78 and 79. 
Pig 82. 
Normal skull. 
number, then we find malrelations of the arches, third, malformations 
of the jaw s and processes, and last in number and frecjuency of occur- 
rence, malpositions of the mandible. MALOCCLUSION 
81 
Malocclusion and Facial Deformities 
The close relation between malocclusion and the development of 
the face must always be considered in the classification. In fact, we 
may state that there is an equally important relation existing be- 
Fig. 83. 
Evolution of the Profile. (A) Infancy; (B) Maturity: (C) Senility. (Lischer.) 
Fig. 84. 
Cephalic Index. (A) Negro, index, 70, dolychocephalic; (B) European, index, 80, 
mesocephalic; (C) Samoyed, index 85, brachycephalic. (Lischer, after Tyler.) 
tween normal occlusion and normal development of the face. Various 
writers have agreed that the teeth play a greater part in the produc- 
tion of beauty in the face than any other organs or parts of the face. 
It would be very difficult to conceive of a really ugly face if the teeth 
were in normal occlusion, or of a really beautiful face if the teeth 
were in decided positions of malocclusion. However, there are a 82 
PRACTICAL ORTHODONTIA 
great many factors that enter into the development of the face, and it 
is very difficult to make a set and fast rule by which to judge either 
facial deformity or facial beauty. 
We must recognize in the beginning the relation that the head 
forms will have on the facial outlines of the patients, as wrell as the 
influence that age will have on the development of the facial profile. 
The various changes that occur in the mandible as the individual 
grows older, and which are shown in textbooks as being the result of 
age, are familar to all. The evolution of the profile is illustrated in 
Fig. 83. 
The principle changes that are observed from infancy to old age 
are the result of changes occurring in the dentition. In the child, we 
Fig. 85. 
Facial Index. (A) Negro; (B) Caucasian. (Lischer, after Camper.) 
find the lower part of the face short until the teeth begin to erupt and 
then we notice the increase in length that is observed in the adult. 
With the loss of the teeth, the face again shortens and we find the 
characteristics of old age. 
The shape of the face will also be influenced to a certain extent by 
the shape of the cranium and the cranium can be classified according 
to a plan used by anthropologists. The cephalic index is employed, 
which is the relation of the length of the cranium from forehead to 
the back as compared with the width on the head between the ears. 
The length is made to represent 100, and the breadth is made to rep- 
resent a fraction of that measurement. When the head is broad there 
will be a tendency for the cranium to become more rounded, and as a MALOCCLUSION 
83 
rule the face will also be more rounded than in the narrow cranium. 
The cranium is classified, according to the cephalic index, when the 
breadth across the cranium from the ears is more than eighty per cent 
of the length as the brachycephalic; when the breadth is less than 
seventy-five per cent of the length it is classed as dolychocephalic; 
and when the breadth is between seventy-five and eighty per cent of 
the length, it is termed mesocephalic (Fig. 84). 
Racial characteristics are also seen in the study of the facial pro- 
file, and the various facial angles as found in different races are 
shown in Fig. 85, which is made after the Dutch anatomist, Camper. 
By studying A in Fig. 85 it will be seen that the angle of the mouth 
Fig. 86. 
Gnathic Index. (A) Prognathic ; (B) Mesognathic; (C) Orthognathic. (Lischer, after 
Flower.) 
and nose diverges away from a straight line, while B approaches the 
straight line. 
The projection of the teeth and the lower part of the face is also in- 
fluenced by the race, and the amount of that protrusion can be studied 
by the gnathic index. The three distinct variations of facial protrusion 
or projection of the teeth and the lower part of the face are represented 
in Fig. 86. Fig. 86A shows a skull with a great protrusion of the teeth, 
and is therefore termed prognathic ; Fig. 86B shows one with less pro- 
trusion but still far from a straight line, and is termed mesognathic; 
while Fig. 866* shows a face that closely approaches the straight lines, 
and is therefore termed orthognathic. It must be remembered that race 84 
PRACTICAL ORTHODONTIA 
Swiss, Basle. Index 64. 
Norwegian, Aamot. Index 75. 
German, Baden. Index 83. 
Hungarian, Thorda. Index 88.5. 
Fig. 87. 
Illustrating the relation between face-form and head-form. (Lischer, after Ripley.) 
Lapp, Scandinavia. Index 94. 
French, Savoy. Index 96. MALOCCLUSION 
85 
Teutonic type (Norway). Pure blond. 
Alpine type (Austria). Blue eyes, brown hair. Index 88. 
Mediterranean type (Palmero, Sicily). Pure brunet. Index 77. 
Fig. 88. 
The three European racial types. (Lischer, after Ripley.) 86 
PRACTICAL ORTHODONTIA 
will influence the various facial angles, and malocclusion may cause 
facial deformities that will resemble the various conditions that have 
been mentioned. 
The racial characteristics that can be clearly seen in the various 
races can also be followed to a lesser extent in the different nations. 
It is a well-known fact that people of different localities have facial 
developments that distinguish them from people of other localities. 
Fig. 89. 
Principal features in the face, the relations of which may be altered by orthodontic 
treatment. Front view, (a) Mentolabial sulcus, (b) angle (angulus oris), (c) upper 
lip, (cl) cheek (bucca), (e) nasolabial sulcus, (f) tip (apex nasi), (g) base (basis 
nasi), (h) frontal eminence, (i) root radix nasi), (j) dorsum (dorsum nasi), (k) ala 
(ala nasi), (I) nostril (nares), (m) philtrum, (n) aperture (rima oris), (o) lower lip, 
(p) chin (mentum). (Lischer.) 
Fig. 87 shows various head and face forms as found in some of the na- 
tions of Europe. Fig. 88 represents the different facial characteris- 
tics as found in some of the blond and brunette races. Owing to the 
mixing of races we find the various racial characteristics blended to- 
gether so that it will not always be easy to pick out the pure types. 
This blending of races and nations often produces types that do not 
resemble either of the parents. Consequently it becomes necessary to MALOCCLUSION 
87 
study each face as a law unto itself, and in order to do so it is im- 
perative that we have some idea of what constitutes a normal face. 
In the first place, it is very difficult to define a beautiful face, as 
beauty is to a certain extent a question of education. What one per- 
son would consider beautiful would not be so considered by others, 
and this is equally true in the study of faces. However, there are 
certain anatomic factors that enter into the human face which must 
Fig. 90. 
Principal features of the face. Side view. (a) Mentolabial sulcus, (b) angle 
(angulus oris), (c) upper lip, (d) cheek (bucca), (e) nasolabial sulcus, (/) tip (apex 
nasi), (g) base (basis nasi), (h) frontal eminence, (i) root (radrix nasi), (k) ala 
(ala nasi), (Z) nostril (nares), (m) philtrum, (n) aperture (rima oris), (o) lower 
lip, (p) chin (mentum). (Lischer.) 
be considered and which go toward the formation of a pleasing face. 
In studying a face, we should do so from at least two views, the front 
and the profile. In some instances we find faces that present a pleas- 
ing outline if viewed from the front, but when viewed from the side, 
some part of the face is out of harmony with some other part. This 
is often true in the study of faces associated with malocclusion of the 
teeth. 88 
PRACTICAL ORTHODONTIA 
The principal parts of the face are shown in Fig. 89. The mento- 
labial sulcus (a) is located between the lower lip and the chin. The de- 
velopment of this sulcus is greatly influenced by the position of the roots 
of the lower teeth. The angle of the mouth, angulus oris (a), is in- 
fluenced by the position of the anterior teeth and also by the width of the 
arch in the canine region. In cases of malocclusion where the arches are 
narrow and the canines in lingual occlusion, the angles of the mouth will 
be close together and the lips more or less wrinkled. The angles of the 
mouth will also be greatly influenced by breathing, depending upon 
whether the patient is a normal breather or a mouth-breather. The posi- 
Fig. 91. 
Facial cast of boy nine years of age, with normal occlusion. (Parsons.) 
tion and development of the upper lip (c) depends upon the teeth and 
breathing. There are certain lip habits that will produce malocclusions, 
and the action of the lip itself may produce its overdevelopment, which 
will cause an unpleasing expression of the face. The upper lip of mouth- 
breathers is very short and thin, owing to the lack of use that it receives 
in such individuals. The cheek, bucca (d), may be influenced by the 
amount of fat present and exerts some pressure on the teeth, in turn 
counteracted by the tongue. In a few cases the author has seen the cheek 
so full of adipose tissue that it would exert sufficient pressure on the 
teeth to narrow the dental arches. The naso-labial sulcus (e) is formed 
by the junction of the cheek, the lip, and the nose. The development of MALOCCLUSION 
89 
this region will be changed by the abnormal development of any of the 
parts mentioned. The canine tooth also takes part in the development of 
the naso-labial sulcus, and in individuals who have lost the canine the 
sulcus becomes more noticeable. 
The development of the tip of the nose (apex nasi) depends upon the 
normal development of the nasal septum and premaxillary bones, as well 
as of the nasal cartilages. The tip of the nose will also be influenced by 
mouth-breathing, and it is exposed to all kinds of injuries resulting from 
physical violence, it may be displaced and thus may have an unpleasing 
effect on the rest of the face. The base of the nose (g) depends upon 
nasal breathing for its proper development. In mouth-breathers the 
base of the nose remains narrow, the skin is tightly drawn, and we have 
a very unpleasing appearance. The frontal eminence is a very noticeable 
Fig. 92. 
Models showing the occlusion of the teeth of Fig. 91. (Parsons.) 
part of the face but is not influenced by the teeth. It may, however, be 
taken as an indication as to what the development of the face should have 
been in those patients who have decided malformations of the teeth and 
jaws. The root of the nose (i), located at the base of the frontal bone, 
depends for its development upon normal breathing, and also upon the 
proper development of the frontal sinus with which it is closely asso- 
ciated. The dorsum of the nose (J) may present a variety of shapes, rang- 
ing from pug to Roman, and may also be influenced by racial characteris- 
tics. Like the tip of the nose, it is subject to injury, which may change 
its shape. Abnormal developments that influence the development of the 
septum will also play some part in shaping the dorsum of the nose. The 
ala nasi, or ala, of the nose (fc) is largely influenced by environment. In 
persons who have been mouth-breathers we find that the ala is not de- 90 
PRACTICAL ORTHODONTIA 
veloped normally, and it remains thin and flabby. This thinness and 
flabbiness of the ala has been thought by some to be a contributing 
factor toward continued mouth-breathing, owing to the fact that the ala 
is not sufficiently developed to prevent the atmospheric pressure from 
shutting off the nasal tract. In normal breathers the ala is well developed 
and gives a strong expression to the face. The nostril (Z) depends upon 
the development of the surrounding parts for its shape. The philtrum 
(n) plays a great part in the beauty of the face and is dependent upon 
the position of the teeth for its shape. The development of the nose, the 
development of the lips, and in fact the development of all of the parts 
around the oral cavity will influence the philtrum. The aperture of the 
Fig. 93. 
Normal type of face with normal occlusion. (Fischer.) 
mouth (n) will be of a size and shape in keeping with the lips. In some 
individuals we find an aperture that is quite small and the dental arches 
large, while in others the reverse may be true. The lower lip (o) is a 
great factor in the beauty of the face. No part of the face adds so much 
to the expression as do the lips, and the lower lip is equally as important 
as the upper. In fact, in some respects the lower lip is more of a factor 
in producing malocclusion of the teeth than is the upper; In lip habits, 
we find that the lower lip is the one that does the most harm. Mouth- 
breathers, as a rule, have thick lower lips, which are held between the. 
lower and the upper anterior teeth, with the result that the upper an- 
terior teeth are forced outward. In mesioclusion cases, the lower lips 
play a great part in forcing the lower incisors lingually if the patient is MALOCCLUSION 
91 
a normal breather. The lower lip covers the lower anterior teeth and 
overlaps the incisal third of the upper incisors, therefore exerting a 
direct pressure on the labial surfaces of the upper teeth in the normal 
breather. The chin (p) has long been recognized as an important factor 
in the development of the face, and people have been classified ac- 
cording to the development of the chin as having strong or weak 
characters. As the chin is the anterior part of the mandible it will 
be more or less affected by everything that affects the mandible. In 
cases of distoclusion with mouth-breathing, the chin is greatly under- 
developed, while in cases of mesioclusion the chin will be overdevel- 
oped. In unilateral cases of malocclusion, in cases in which there is 
Fig. 94. 
Prominent chin, with normal denture. (Lischer.) 
an unequal development of the two sides of the mandible, we find 
that the chin may be deflected to one side or the other. In cases of 
neutroclusion, characterized by underdevelopment of the dental arch, 
the chin will suffer in development because the mandible will be 
small. 
Fig. 90 shows a profile of the face with the same anatomical mark- 
ings as are found in the front view of Fig. 89. This profile, as well as 
the front view, probably gives the artist's conception of what he con- 
siders a normal face should be. The two views also show the necessity 
of having both a front and a side view of each patient. The front 
view is a very good face and shows each of the parts normally de- 
veloped. Some might object to the size of the mouth, but from an 92 
PRACTICAL ORTHODONTIA 
anatomic standpoint the author considers that the mouth is of the 
proper size and that the face is nearly normal. The profile view, from 
an anatomic standpoint, is not as good, as the lower part of the face 
is too weak. The mandible, the chin, and the lower lip are too reced- 
ing for a face that has a normal set of teeth, and if the teeth are re- 
ceiving proper use, and the subject has normal breathing. However, 
Fig. 90 only shows how difficult it is to select a definite type of beauty 
or of face to please everyone. 
It is equally as difficult to decide just what the normal face is, for 
we have shown that racial characteristics enter into the question to 
such an extent that we are unable to choose a standard type. It is 
Fig. 95. 
Receding chin, with normal denture. (Lischer.) 
conceded that the best balanced faces are those that have all of the 
teeth present and the teeth in normal occlusion. However, in exam- 
ining people with normal occlusions we find that the faces differ in 
varying degrees and that all are not equally beautiful. 
What might be considered beautiful by one person would not be 
so considered by another. The African negro is probably considered 
beautiful among his own people, but he would not satisfy the sense 
of the beautiful in the European. Also certain developments that are 
in harmony in one face would be out of harmony in another. Some 
faces are in balance with pug noses, other faces look well with Roman 
noses, but to reverse the noses on the respective faces would be to 
create very unpleasing facial expressions. MALOCCLUSION 
93 
In order to arrive at any conception of what a face should be, it is 
necessary to study a large number of faces of various types. Fig. 91 
shows the facial cast of a boy of nine, which may be considered to be 
nearly normal. The forehead, the nose, the lips, and the chin, all show 
that the boy is a normal breather and in order to have the develop- 
ment of the face that he has that he possesses a nearly normal occlu- 
sion of the teeth. The occlusion of the teeth is shown in Fig. 92. In 
comparing this face with the one shown in Fig. 90, the author prefers 
Fig. 96-A. 
Fig. 96-B. 
Photographs of 12 year old patient before treatment. (Tanzey.) 
the face of the boy to the artist's conception, since his idea of a normal 
face is based on the anatomic parts that as a whole go to make up the 
face. Some of us might claim tliat the mouth and lower part of the 
face in Fig. 91 is too heavy, but it must be remembered that a boy 
at the age of nine has his permanent incisors, that the arches should 
be wide, and that the mouth should be full. 
Angle has stated that the best harmony and the best balance of the 
face will be found in those individuals who have normal occlusion of 
the teeth. The author believes this to be true, but it does not prove 94 
PRACTICAL ORTHODONTIA 
that all individuals with normal occlusions will look alike. Fig. 93 
shows another type of face that has normal occlusion of the teeth. It 
will be observed that this type of face closely approaches the type 
shown in Fig. 91. 
Fig. 94 shows a type of face that possesses a prominent chin and 
normal occlusion of the teeth. The development of the chin and 
mandible in this type of face is, in the author's opinion, the result of 
use. We find this type of chin in individuals who are public speakers, 
actors, lawyers, and others who have used the muscles of speech to a 
great extent. In fact, it has been said by anatomists that the de- 
velopment of the chin in man has been the result of speech. The ob- 
Fig. 97. 
Showing models of case shown in Fig. 96 when dismissed after 21 months of treatment, 
including the retention. (Tanzey.) 
servation of the author is in keeping with this statement, and the type 
of face shown in Fig. 94 is such as is found in those who are normal 
breathers and also public speakers. It would be impossible to have 
the development of the chin to the extent as shown in an individual 
who is a mouth-breather. The use of the teeth as organs of mastica- 
tion has also played a part in the formation of the face shown in 
Fig. 94. 
Fig. 95 illustrates the type of face with a receding or weak chin, 
but which has a normal occlusion. With these individuals, the teeth 
are in normal positions but the functions of the teeth have been neg- 
lected to such an extent that the supporting structures have never 
developed. These patients are normal breathers, and the maxillae MALOCCLUSION 
95 
have developed enough so that normal breathing is possible. The 
mandible and chin have not developed because of the lack of use in 
mastication, and the muscles of speech have also been inactive. Peo- 
ple of this type are not forcible speakers, for if they were the chin 
would develop to the proper size. The lack of proper development 
is seen in the mento-labial sulcus and the mental eminence. The nor- 
mal occlusion of the teeth and the normal respiration give the upper 
and lower lip a good expression, but the weakness is in the mandible 
and chin. 
In studying facial development associated with malocclusion, we 
Fig. 98. 
Fig. 99. 
Facial casts of patient with neutroclusion, who was mouth-breather. (Parsons.) 
find that certain types of malocclusion always give certain types of 
facial deformity. With a certain malocclusion, there is always a cer- 
tain action of the muscles, a certain manner of breathing and a cer- 
tain action of the teeth in mastication, so that the facial development 
associated with malocclusion is always easily understood and recog- 
nized. In other words, if given a model of a case of malocclusion, it 
is possible in a great number of cases to describe or draw the type 
of face that the patient possesses. 
Cases of neutroclusion, with underdevelopment of the arches, al- 
ways show a lack of development in the anterior part of the face. 96 
PRACTICAL ORTHODONTIA 
There is a pinched expression around the mouth, too short a distance 
between the corners of the mouth, and the lips present a wrinkled ap- 
pearance as if there was too much material in the lips and they were 
wrinkling. The alae of the nose are more or less underdeveloped, are 
too close together, and the mouth seems too small for the face. This, 
in brief, is the facial expression if the patient is a normal breather. 
Such a type is shown in Fig. 96. Note the pinched expression of the 
lips and mouth, and this is what is always found in this type of 
malocclusion as shown in Fig. 97. 
We find a characteristic facial deformity in those patients who are 
mouth-breathers and who still have a normal mesio-distal relation of 
the arches. Such a face is shown in Figs. 98 and 99. The short upper 
Fig. 100. 
Models of patient shown in Figs. 98 and 99. Neutroclusion. Patient was mouth- 
breather, with abnormal lip action. (Parsons.) 
lip is characteristic, the lower lip is often tucked in and rests against 
the lower teeth, and owing to the fact that the pressure of the tongue 
is abnormal, or rather absent, the lower teeth are forced lingually 
by the action on the lower lip. The edges of the upper incisors rest 
against the lower lip, and they are forced labially. The mandible 
and chin may be underdeveloped. The cusps of the teeth are gen- 
erally long and well developed, which accounts for the fact that the 
arches are in normal mesio-distal relation when the patient is a 
mouth-breather. 
The facial deformities that are present in neutroclusion are very 
similar, but the development of the lips may be different and will 
change the facial type to a certain extent. Fig. 101 shows the facial MALOCCLUSION 
97 
development of a boy ten years of age. The upper lip is not func- 
tionating as it should and does not meet the lower lip, as a result of 
which the mouth is open and the face has the so-called idiotic stare. 
The lower lip is also abnormal in action and falls away from the upper 
teeth. The lower lip when occupying its proper position should cover 
the lower teeth and part of the upper teeth. It will be observed that 
the upper and the lower lip are thickened, and associated with this 
type of thick lips is an abnormal action of the glands of the lips. The 
saliva is viscid and stringy. The mucous glands of the lips are often 
closed and abnormal, which accounts for the thickness of both the 
Fig. 101. 
Showing abnormal function of the lips due to malposition of the incisors. (Lischer.) 
upper and the lower lips. If the lips were used properly, the action 
would have a beneficial result on the mucous glands, and the lips 
would become thinner. The facial expression of this patient is made 
more objectionable by the spacing of the upper teeth, which in this 
type of lips is generally the result of abnormal frenum. Observe in 
this case that the lower lip does not rest against the upper teeth as in 
Fig. 102. This face shows an abnormal development of the lips, which 
may be found in cases of neutroclusion with labioversion of the an- 
terior teeth or may be present in distoclusion cases. Such lips are 
characteristic of mouth-breathers who have a comparatively normal 98 
PRACTICAL ORTHODONTIA 
action of the mucous glands and are therefore not thickened as is seen 
in Fig. 101. In Fig. 102, the lower lip lies in contact with the upper 
teeth, which accounts for some of the protrusion of the upper teeth. 
As the upper lip is short it exerts no restraining influence on the upper 
teeth, which are forced outward by 'the lower lip. The irritation of 
the lower lip against the upper teeth has been responsible for the 
thickening of the lip, which cause is different from that which pro- 
duces the condition in Fig. 101. 
Certain types of malocclusion are sure to produce certain facial 
Fig. 102. 
Shows malformation of the lips; note especially the extreme deficiency of the upper 
lip; female 13 years old. (Lischer.) 
deformities. In cases of neutroclusion with linguoversion of the upper 
incisors (Class I cases with the upper incisors in lingual relation to 
the lowers), as shown in Fig. 103, we find that the lower lip is very 
prominent and that the upper lip is underdeveloped because of the 
lingual relation of the upper anterior teeth. The facial development 
is shown in Fig. 104. These cases very much resemble mesioclusion, 
or Class III, cases, and this is still more true when the upper incisors 
are in such a position that the patient cannot close the jaw and make 
the molars occlude without allowing the mandible to be pushed for- MALOCCLUSION 
99 
Fig. 103. 
Neutroclusion complicated by linguoversion of the upper incisors, age eleven. (Lischer.) 
Fig. 104. 
Facial deformity of case shown in Fig. 103. (Lischer.) 100 
PRACTICAL ORTHODONTIA 
ward. The author has seen cases of this type where, if the patient 
closed the jaws naturally, the upper and lower incisors would oc- 
clude edge to edge. It was impossible for the patient to retract the 
mandible sufficiently to bring the lower incisors behind the upper in- 
cisors which therefore made it necessary for the patient to protrude 
the mandible in order that the molars might be brought together. As 
a result of this, the mandible would be protruded, which would pro- 
duce a condition similar to anteversion of the mandible. Of course, 
the forward movement of the mandible is only for the purpose of mas- 
tication, and at least in a number of cases seen by the author, there 
had not been any change in the temporo-mandibular articulation that 
Fig. 105-A. 
Fig. 105-B. 
Neutroclusion, or Class I, with lingual relation of the upper incisors to lower. 
would keep the mandible forward. The facial deformity in such a 
case is shown in Fig. 105. Notice the heavy appearance of the lower 
part of the face, the prominent chin, the thick lower lip, and the 
greater fullness of the upper lip than is seen in Fig. 104. The differ- 
ence in the appearance of the upper lip in the faces is shown in Figs. 
104 and 105 is that in Fig. 104 there is more linguoversion or lingual 
position of the upper incisors than there is in Fig. 105. In Fig. 105, the 
upper incisors are lingual slightly, but not enough but that it is 
necessary for the patient to protrude the mandible when the molars 
are brought together. 
In those cases on neutroclusion complicated by linguoversion of the 
upper and lower anterior teeth (Class I with bunched anterior teeth), MALOCCLUSION 
101 
we have a facial deformity that consists of a lack of development 
around the lips (Figs. 106 and 107). These patients may be normal 
breathers, as was the patient from which Fig. 107 was made. The 
action of the lips is normal, but owing to the lack of development in 
the incisal regions of the upper and lower arch, the lips are sunken, 
they have not the proper contour, and a similar appearance exists as 
is found upon the extraction of some of the anterior teeth. 
Fig. 106. 
Neutroclusion complicated by linguoversion of the anterior teeth, age twelve. (Lischer.) 
Neutroclusion, or Class I, cases present many combinations of mal- 
occlusion of the anterior teeth, and as a result of which we find an 
almost endless variety of facial deformities. A rather common con- 
dition of the teeth is shown in Fig. 108, in which we have a normal 
mesio-distal relation of the arches with infraversion or lack of occlu- 102 
PRACTICAL ORTHODONTIA 
Fig. 107. 
Facial deformity of case shown in Fig. 106. (Lischer.) 
Fig. 108. 
Neutroclusion complicated by infraversion of the anterior teeth, age sixteen. (Lischer.) MALOCCLUSION 
103 
sion of the upper anterior teeth. These cases may be the result of 
abnormal habits of the tongue or lips; they may be the result of the 
elongation of the molars at the time of the eruption of the second 
molars; or they may be associated with deformities of the maxilla 
and mandible as the result of rickets, and there may be some glan- 
dular disturbance of the ductless glands. Whatever the etiologic 
factors are, the facial deformity is always well marked and is similar 
to that shown in Fig. 109. 
In neutroclusion, or Class I cases, and when the patients are 
mouth-breathers, we find abnormal action of the lips, protruding 
Fig. 109. 
Facial deformity of neutroclusion complicated by infraversion of anterior teeth. 
(Lischer.) 
upper anterior teeth, an underdeveloped chin, a narrow upper arch, 
and lack of development of the nose-all of which has an unpleasing 
influence upon the face (Fig. 110). 
To one familiar with the effects of malocclusion upon the face, it 
would be easy to conceive of the malocclusion present with the facial 
deformity as shown in Fig. 110. The abnormal action of the lips has 
had an influence upon the teeth until at the present time the malocclu- 
sion is so great that the lips cannot be closed over the teeth, which 
will allow the malocclusion to become more pronounced. The lack 
of normal action of the muscles of mastication and the resulting lack 104 
PRACTICAL ORTHODONTIA 
of use has allowed the mandible to remain underdeveloped. The 
upper arch is narrow, as is also the nasal cavities in these cases 
(Fig. Hl). 
Another type of facial deformity that is not found as often as those 
that have been mentioned is shown in Fig. 112. These cases call for 
very careful study in regard to etiology and treatment. The mal- 
occlusion consists of a prominence of the upper and lower teeth, 
which is generally associated with narrow arches. Early lack of de- 
velopment of the osseous systems and lack of development of the 
Fig. 110. 
Facial deformity of case shown in Fig-. 111. (Lischer.) 
mandible and maxillae have played a part in the lack of development 
of the face. 
In considering facial deformities as related to malocclusion, we have 
so far only spoken of those cases that have a normal mesio-distal re- 
lation of the arches. It is to be expected that as soon as we come to 
those cases that have abnormal relations of the arches that the condi- 
tions will become more marked and the facial deformities greater. 
Fig. 113 shows a decided facial deformity, protruding upper anterior 
teeth, short thick upper lip, and a thick lower lip. Mouth-breathing 
is present, which accounts for most of the facial deformity. The 
malocclusion associated with the facial deformity shown in Fig. 113 MALOCCLUSION 
105 
is shown in Fig. 114. The distal relation of the lower arch can be 
readily seen, and the protruding upper incisors that are the result of 
abnormal lip action are very apparent. The lower lip has pushed the 
upper teeth outward, causing spaces between all of them. The ex- 
treme deformity in this case has been the result of abnormal action 
of the lips, and not so much the result of the distal relation of the 
lower arch. In proof of this Fig. 115 shows another case of distal 
Fig. 111. 
Neutroclusion complicated by labioversion of the upper incisors, female, age sixteen. 
(Lischer.) 
relation of the lower arch, and the distal relation is as great as it is in 
the previous case. By comparing Fig. 115 with Fig. 114 it will be 
seen that each lower arch is equally distal. The difference in the 
facial outlines, as well as the different actions of the lips, can be seen 
by comparing Fig. 116 with Fig. 113. The facial deformity present 
in the distal relation of the lower arch is very much the same, and 
differs only as the action of the muscles differs, and as to whether 106 
PRACTICAL ORTHODONTIA 
the patient, is a normal or an abnormal breather. In those patients 
who are able to close the lips and breathe through the nose, we find 
that the upper lip is longer and that the chin is better developed as 
a result of the normal breathing and normal lip action. The greatest 
deformity is lack of development in the region of the lower incisors, 
which results in an abnormal mento-labial sulcus. Such a facial de- 
formity is shown in Fig. 117. 
Lischer shows a facial deformity that is due to a "malposition of 
the mandible; the distoclusion of the lower arch is merely a symp- 
Fig. 112. 
Facial type of neutroclusion complicated by labioversion of the upper and lower an- 
terior teeth. (Lischer.) 
tom." This is shown in Fig. 118. It will be noticed that the lips are 
closed, which indicates that the patient is at least able to breathe 
through the nose part of the time. The chin is not so well developed 
as the chin of the patient shown in Fig. 117. 
Patients suffering from distoclusions or distal relation of the lower 
arch soon become cognizant of their facial deformity and often try to 
conceal it by holding the mandible in a false position. 
The malocclusion in Fig. 119 is a case of complete distal relation 
of the lower arch, with some protrusion of the upper anterior teeth. 
The result of the malocclusion upon the facial lines is shown in Figs. MALOCCLUSION 
107 
Fig. 113. 
Showing adenoid appearance. (Duckworth.) 
Fig. 114. 
< Showing abnormal relation of molars and extreme protrusion of the upper incisors. 
(Duckworth.) 108 
PRACTICAL ORTHODONTIA 
Fig. 115. 
Distoclusion with labioversion of upper incisors. (Barr.) 
Fig. 116. 
Facial development of case shown in Fig. 115. (Barr.) MALOCCLUSION 
109 
120 and 121. The underdevelopment of the mandible is very notice- 
able, as is the receding upper lip. In fact, the entire lower part of 
the face is greatly underdeveloped, and the face has the appearance 
of distoversion of the mandible or a distal relation of the mandible. 
There is no direct evidence to prove that the mandible is any farther 
distal than it should be, but the chin is greatly receding regardless of 
the position of the mandible. The patient early recognized the facial 
deformity and acquired the habit of holding the mandible forward 
as is shown in Figs. 122 and 123. This position was the position of the 
Fig\ 117. 
Shows malrelation of the lower lip to the upper, and abnormal mento-labial sulcus, due 
to distal relation of the lower arch; male 14 years old. (Lischer.) 
mandible while speaking and during all of the hours of the day ex- 
cept when masticating. The effect on the facial lines by changing 
the position of the mandible can be readily seen by comparing Figs. 
120 and 121 with Figs. 122 and 123. 
The facial deformity accompanying mesioclusion, or Class III, cases 
is very well understood. It is one of the facial deformities with which 
the public has been familiar for some time. The overdevelopment of 
the mandible that accompanies these cases has been described by 
various names and has been thought to be the result of a great many 
conditions that have played no influence on it whatever. The facial 110 
PRACTICAL ORTHODONTIA 
deformity is very similar in all of these cases, the principal differ- 
ences being in the extent of the overdevelopment of the mandible and 
in the variation in the angle of the ramus. Fig. 124 shows what may 
be considered a typical case of such a deformity. Another similar 
condition is shown in Fig. 125. A greater number of these conditions 
could be shown, but they are so similar that it would only be more 
or less a repetition. Other cases of this type can be found in the 
chapter on Classification and Treatment. 
Fig. 118. 
Deformity due to malposition of the mandible; the distoclusion of the lower arch is 
merely a symptom; male 11 years old. (Lischer.) 
Facial deformities accompanying maldevelopment of the parts are 
often more noticeable than those that have resulted from malocclu- 
sion. Ankylosis of the mandible, which may be the result of accident 
or disease, by limiting the movement of the mandible contributes to 
the underdevelopment of the same. Such a condition is shown in Fig. 
126. It has long been known that use has played a great part in the 
development of the mandible, and that lack of use has had the oppo- 
site result. This is shown in the above case. The effect of use when 
there is a unilateral limitation of movement is shown in Fig. 127 
causing a very unpleasing unilateral facial development. MALOCCLUSION 
111 
Fig. 119. 
Distoclusion, or Class II. (Parsons.) 
Facial views of patient with mandible in masticating position. (Parsons.) 
Fig. 120. 
Fig. 121. 
Mandible protruding to overcome facial deformity present, and shown in Figs. 120 and 
121. (Parsons.) 
Fig. 122. 
Fig. 123. 112 
PRACTICAL ORTHODONTIA 
Fig. 124. 
Mesioclusion, or Class III, with macromandibular development. (Fernald.) 
Fig. 125. 
Facial deformity in mesioclusion, or Class III, case. (Parsons.) MALOCCLUSION 
113 
Fig. 126. 
Facial deformity due to close ankylosis at 5 years, which resulted from an injury at 
3 years. (Blair.) 
Fig. 127. 
Facial deformity produced by lack of use. (Blair.) 
Abnormal congenital development of the maxilla and mandible pro- 
duces a number of facial deformities, harelip and cleft palate being 
the most common. The entire absence of the mandible has been re- 
ported by some writers. A case of extreme facial deformity shown 
by Blair is reproduced in Fig. 128. 114 
PRACTICAL ORTHODONTIA 
Malocclusions therefore produce so many different facial deformi- 
ties, that it is only to be expected that a great many people who seek 
the services of an orthodontist, do so with a view of having the ap- 
pearance of the face improved. As a diagnostic aid, Lischer has made 
several suggestions, which are here shown. 
In neutroclusion cases, in which we have a lack of development of 
the alveolar process with a greatly crowded condition of the teeth, by 
placing wax under the lips as shown in Fig. 129 it is possible to give some 
idea of what the change will be in the face. Fig. 130, a and 6, shows the 
appearance of the lips before and after the placing of the wax. In disto- 
Fig. 128. 
Retraction of the mandible accompanying a branchial fistula of the first clefts. (Blair.) 
elusion cases with protruding anterior teeth, such as we find in Fig. 131-u, 
the mandible can be protruded until the teeth are brought into the posi- 
tion shown in Fig. 131-6, which is a position assuming a normal mesio- 
distal relation of the arches. The facial deformity is shown in Fig. 132-u, 
and the resulting change produced by the forward movement of the 
mandible is shown in Fig. 132-6. 
The resulting changes produced by the treatment of mesioclusion cases 
cannot so easily be demonstrated, owing to the fact that it is impossible 
for the patient to retrude the mandible sufficiently far to show any im- 
provement. MALOCCLUSION 
115 
Fig. 129. 
Shows Lischer's method for estimating in advance the probable effect of an orthodontic 
treatment; compare with Fig. 130. (Lischer.) 
Fig. 130. 
Photographs of the patient before and after the use of the wax model shown in Fig. 
129-0. (Lischer.) 116 
PRACTICAL ORTHODONTIA 
Fig. 131. 
Method employed in distoclusions ; compare with Fig. 132 a and b. (Lischer.) 
Fig. 132. 
Photographs of patient shown in Fig. 131 a and b; note change in profile in b. (Lischer.) CHAPTER IV 
ETIOLOGY OF MALOCCLUSION 
Etiologic factors of malocclusion may be divided into two groups, 
based upon the time in which the factor occurs and the manner of the 
occurrence. As to time, they are divided into inherited, congenital, 
and acquired. As to manner, into local and general. General causes 
are also called constitutional. 
General or Constitutional Causes 
General or constitutional causes of malocclusion include those that 
affect the general functions or metabolism of the individual to such 
an extent as to interfere with the development of the teeth or the sur- 
rounding structures supporting the teeth. There are a number of 
diseases that affect the general health of the individual to such an ex- 
tent as to interfere with the normal forces of occlusion and therefore 
produce malocclusion. There are more general diseases that affect 
the development of the complete dental apparatus one way or an- 
other than was formerly supposed to exist. There are a few that pro- 
duce conditions that are known to have a direct bearing upon maloc- 
clusion. First would be included all of those diseases of childhood 
that are accompanied with high temperatures. Scarlet fever, measles, 
chicken-pox and similar diseases are known to exert a deleterious effect 
upon the epithelial structures. They affect the formation of the 
enamel of the teeth to such an extent as to produce atrophy of the 
enamel organ, thereby causing a tooth that is faulty in shape, which 
in turn destroys the force of the inclined plane or the approximal 
contact. Syphilis has long been considered as a disease that produces 
atrophy of the enamel organ, and there is little doubt but that it does 
produce certain forms of crowns, which have been referred to as 
"Hutchinson's teeth," but there are also a great many other diseases 
that produce the same kind of crowns. In some cases, the general dis- 
turbance may be so great as to destroy the tooth germ entirely, which 
would then produce a cause of malocclusion, namely, missing teeth. 
Rickets is another general disease that produces a great many cases 
of malocclusion. Rickets is a disease of malnutrition characterized 
by faulty bone formation. As a result of the faulty bone formation 
117 118 
PRACTICAL ORTHODONTIA 
proper support is not provided for the teeth. The teeth being sup- 
ported by a faulty calcified alveolar process, have not enough support 
to prevent them from assuming a position of malocclusion under the 
stress of mastication. The muscles of mastication exert force upon 
the bone which results in deformity of the bone. The body of the bone, 
as well as the alveolar process, is abnormal and the pull of the muscles 
of mastication causes the mandible to straighten out at the angle, 
which results in an elongated and deformed mandible Blair consid- 
ers such deformities of the mandible as a sure indication of early 
rickets. The alveolar process is greatly thickened, as shown in Fig. 
134, and this thickening of the alveolar process can be seen as thick 
ridges in the living individual. The gums are thick and more or less 
inflamed. In those cases where a thick alveolar ridge is encountered 
the practitioner should be careful in making promises as to what the 
Fig. 133. 
Skull of opossum that suffered from rickets. (Bebb's Collection.) 
final outcome of the case will be; for in rickets the teeth can be moved, 
but they will move to some position of malocclusion under the stress 
of mastication just as easily as they move with an appliance. Rickets 
has been described as a disease of childhood, but it may also make its 
appearance in the middle-aged, and several cases have been reported 
in pregnant women and in nursing mothers. It is plain to be seen 
that if the mother was rickety the teeth of the child would be doubly 
affected. With rickets, the deciduous teeth erupt late, and there is a 
general deformity of the skull and jaws in the more extreme cases. 
However, children may have rickets and the disease not be diagnosed 
as a general disturbance and still the disease will be the cause of ex- 
treme malocclusions. We have stated that the deciduous teeth are erupted 
late and the conditions with regard to malocclusion are made worse, ETIOLOGY OF MALOCCLUSION 
119 
owing to the fact that the deciduous teeth are lost early. The roots 
are absorbed without any apparent reason. With regard to the per- 
manent teeth, they erupt late, and if the disease is rather marked, 
owing to the deformed jaws and processes, they take extreme posi- 
tions of malocclusion. The upper arch is always narrow and con- 
tracted with a tendency to the formation of thick ridges in the palate 
located to the lingual side of the molars and premolars. The lower 
dental arch is usually wide in the molar and premolar region, with the 
crowns of the teeth turned in and the apices of the roots turned buc- 
Fig. 134. 
Superior maxilla of ape that died from rickets. (Bebb's Collection.) 
cally. Rickets may be present for only a short time, but this will be 
long enough to disturb some of the forces of occlusion, which will 
cause the malocclusion to start, and the case will then be made worse 
by other conditions that develop later in life. It must be reniem- 
bered that, as rickets is a disease of malnutrition, it is found in the 
two extremes of society-the rich and the poor. The great middle 
class who have sufficient of the coarser foods and are able to live in 
good surroundings are free from rickets as compared with the poor 
who have to live in the poor surroundings and with the rich who have 
sufficient food but food of the improper kind. It is from this latter 120 
PRACTICAL ORTHODONTIA 
Fig. 135. 
Fig. 136. 
Malocclusion in which there was a history of rickets. ETIOLOGY OF MALOCCLUSION 
121 
class that most of the orthodontic cases are seen in private prac- 
tice with rickets. It must also be remembered that we may find the 
disease in varying degrees of severity, and as a result of this the dis- 
ease will produce different types of malocclusion depending upon the 
other causes that may be present. 
It has long been recognized that the early loss of the deciduous 
teeth would produce malocclusions, and as this is one of the conditions 
that is always present in rickets, we have little doubt that rickets has 
produced many cases of malocclusion in which this primary cause has 
never been recognized. The predisposing factors in the production of 
malocclusion are made more manifest, when we remember that the 
late eruption of the permanent teeth always causes malocclusion and 
that it is also one of the results of rickets. Patients who are rickety 
are also prone to be mouth-breathers and to suffer with enlarged ton- 
sils and adenoids. In fact, the hypertrophy of lymphoid tissue is an- 
other link of the chain of conditions that is found in rickets and an- 
other of the conditions that produces malocclusion. Figs. 135 and 136 
show a case of malocclusion in which there was a history of rickets, 
and the malocclusion is typical of those conditions. The upper arch 
is narrow, with thick gums and alveolar processes, wide lower arch in 
the region of the molars and permolars. The facial development of 
the patient showed a deformed mandible; one in which the angle was 
made obtuse by the action of the muscles of mastication. In treating 
this case the teeth moved very easily, and in retention they moved to 
new positions of malocclusion just as easily. More will be said in re- 
gard to these conditions under treatment. 
Tuberculosis also produces conditions that affect the teeth, but they 
are not so severe as those produced by rickets and the results are al- 
most directly opposite. A child suffering from tuberculosis will erupt 
the deciduous and permanent teeth early. After a deciduous tooth 
takes its place, the root will not be absorbed as it should and the per- 
manent tooth will take a position somewhere to the side of it. How- 
ever, the deformity caused by the prolonged retention of a deciduous 
tooth does not produce the harm that the early loss of the deciduous 
tooth would produce. 
The reason why these two constitutional diseases should act as they 
do has not been fully explained, but a great many who confine their 
practice to the diseases of children have tabulated the conditions as 
herein mentioned. 
Another constitutional condition producing malocclusion is the faulty 
development of the child, which may be the result of several conditions. 122 
PRACTICAL ORTHODONTIA 
Under the head of faulty development may be considered conditions 
that arise from faulty cell metabolism or improper growth of the 
youngster which may be the result of conditions that are acquired 
or congenital. In fact, it has been suggested by some writers that 
even hereditary influences may cause an ill effect upon the develop- 
ment of the child, which will result in malocclusion. This does not 
mean that the malocclusion of the teeth themselves is an inherited 
condition but that owing to imperfect germ cells or germ cells that 
are below par the child will develop and possess a physical organism 
which is not capable of withstanding the influences surrounding him, 
with the result that he develops improperly or poorly and as a further 
result, malocclusions of the teeth are present. In these conditions 
malocclusion is not only present but there is a lowered physical state 
of the entire individual, in fact, the child is below normal in every 
respect. From a biologic standpoint this condition may be com- 
pared with what would take place if we were to plant a seed of a 
plant that did not have the proper quality. In other words, if we 
should select the seed from a plant that had grown in an environment 
that rendered the plant below normal, we would expect the next 
generation of those plants raised from that same seed to be of a poor 
physical quality. As a result of this faulty cell metabolism, faulty 
development may be the result of the union of germ cells that do not 
possess as much vitality as is ordinarily possessed by germ cells that 
are said to be one hundred per cent perfect. Therefore, a great many 
constitutional conditions that would affect the general metabolism of 
the individual may be the result of unhealthy germ cells or rather 
are produced by the union of germ cells that are below par. As a re- 
sult of this we may say that certain types of malocclusion or certain 
constitutional conditions that will influence malocclusion have their 
beginning with the union of the germ cells. In other words, we would 
not expect a child who was the result of the union of two germ cells 
that were below par to develop in the same physical manner as a child 
who was the result of a union of healthy germ cells. Therefore, the 
child from the germ cells that are below par will develop all manner 
of physical ailments and show abnormal and retarded development 
in every respect, and of course among these will be the maldevelop- 
ment of his teeth and their supporting structures. 
Another factor that influences the development of malocclusion, 
because it influences the cell metabolism, is the condition that may 
be said to be congenital. In other words, if during pregnancy the 
mother is below par, improperly fed and improperly nourished, it will ETIOLOGY OF MALOCCLUSION 
123 
affect the development of the child to such an extent that the child 
will also be poorly developed and poorly nourished. It is a well- 
known fact that the calcification of the deciduous teeth, and certain 
of the permanent teeth, begins before birth. Therefore, if before 
birth, the mother is poorly nourished we would expect improper cal- 
cification of the deciduous teeth and some of the permanent teeth and 
improper calcification of the mandible and the maxilla as well as the 
disturbance of other general organs. 
It is a well-known fact that children born of mothers who have 
been forced to do a large amount of physical labor during pregnancy, 
who are overworked and underfed, give birth to children who show 
physical imperfections in a great many respects. While some of these 
physical conditions may be apparent, there are other conditions that 
pass unnoticed but that play a deleterious influence later in the life 
of the child, and this influence may make itself apparent by the pro- 
duction of deformities in the teeth and jaws. Certain constitutional 
conditions that may be said to be congenital have been acquired from 
the mother during pregnancy and they play a very important part in 
the development of malocclusion, although the malocclusions may not 
make their appearance until much later in the life of the child. It 
must also be remembered that the child who has been improperly 
nourished during embryonic life will also be subjected to a greater 
degree to the influences of environment, and will be more susceptible 
to disease than the child who developed from the embryo that was 
properly nourished. As a result of this, we shall find that some con- 
ditions will produce malocclusions in one child, while a similar condi- 
tion would be thrown off and have no apparent effect on another 
child. It must, therefore, be remembered in studying the etiologic 
factors of malocclusion that a great many cases that are obscure as to 
the cause really have their beginning in the embryonic period and 
are the result of constitutional conditions that developed during the 
embryonic life of the child. Cell metabolism or faulty development 
plays a much greater part than has been supposed. The long period 
of time during which it can act, and is in an active state, and every 
angle of the physical and embryologic development of the child make 
it a factor to which more attention must be given, one which must be 
recognized to a greater extent than heretofore. We might therefore 
divide constitutional conditions into three periods. Constitutional 
conditions or developments that are the result of conditions of health 
transmitted by the germ cells or are the result of the physical vitality 
of the germ cells at the time of fertilization; constitutional conditions 124 
PRACTICAL ORTHODONTIA 
that may arise during the congenital period and that are the result 
of environment or physical conditions in which the mother lived; and 
last, constitutional conditions that are the result of environment in 
which the child lives. The third factor plays a great part in the pro- 
duction of malocclusion, and of course will play a part depending to a 
certain extent upon the other two factors. 
However, it is a well-known fact that children may have developed 
normally as the result of hereditary influences, as a result of the trans- 
mitted physical conditions of the germ cells, and during the congenital 
or prenatal period, but that they will develop malocclusions as a re- 
sult of the environment in which they live. These environments pro- 
duce malocclusions as constitutional disturbances, owing to the fact 
that the environment affects the entire physical condition of these 
youngsters. As a result of these environments in which the child 
lives and as a result of constitutional conditions that are produced 
thereby, we may say that a certain number of malocclusions are the 
result of civilization. 
One of the greatest factors in the production of malocclusion today, 
acting in a constitutional manner, is the effect of food and diet upon 
the teeth directly and upon the constitution as a whole. In order for 
the osseous structures or calcified tissues to develop, the children 
must have the proper kind of food, and a large number of civilized 
youngsters do not have the proper kind of food. The children of the 
better class of people or the rich people are particularly liable to be 
affected in this manner because the child is very likely to eat food 
containing a large amount of starch and sugars, a large amount of 
meat, and food that contains very little of calcified tissue-builders. 
Foods should be used that contain lime, salts, and similar substances, 
such as are at present in whole-wheat bread and also present to a 
large extent in certain vegetables and vegetable fibers. As a result 
of improper diet, the osseous structures of the individual will not be 
properly developed, on account of the fact that the eating of this im- 
proper food does not require the proper usage of the jaws. It is a 
well-known fact that for any organ to be developed it must be used, 
and this is equally true in regard to the teeth and their supporting 
structures. The child is not receiving the food that requires the 
proper mastication, so the teeth are not used and pressure is not 
brought to bear upon the teeth, and therefore no pressure is trans- 
mitted to the alveolar process and the structures supporting the 
teeth. ETIOLOGY OF MALOCCLUSION 
125 
As the teeth are not properly used, they have not the proper cir- 
culation to their parts and therefore not the proper development. 
Associated with the improper usage of the teeth or lack of use will 
also be a lack of action brought to bear on the muscles surrounding 
the teeth and jaws. As a result of disuse there is a lack of muscular 
development, a lack of the stimulating influences produced by mus- 
cular activity, and the entire face and jaws of the child do not de- 
velop properly because of this lack of function. We see a great many 
children who have perfectly normal deciduous teeth as far as the 
shape of the teeth and the shape of the arches are concerned, and 
everything indicates if they would live properly and in the proper en- 
vironment that they would have normal permanent dentition. How- 
ever, without any apparent reason, so far as we can find direct 
pathologic factors, the child does not develop, its face does not de- 
velop, and the dental apparatus is not developed sufficient to accommo- 
date the permanent teeth. This lack of dental development is the 
result of faulty cell metabolism and the lack of growth that is pro- 
duced by the lack of use. We maintain that this is the result of the 
lack of use, because in the early life of the child he had the physical 
development that produced a normal set of deciduous teeth. Every- 
thing indicates that he started out along a normal path of develop- 
ment but that for some reason, between the time of eruption of the 
deciduous teeth and the eruption of the permanent teeth, something 
has gone wrong in nature's plan and the permanent dentition has not 
developed to a normal shape and size. This something that has gone 
wrong is in the majority of cases the result of the environment in 
which he lives, the lack of use to which the teeth have been put, the 
lack of function of the muscles of mastication, and a general lack of 
development that has been produced by lack of use. In other words, 
the malocclusion has been the result of the environment in which he 
lives, and that environment has affected the constitutional develop- 
ment or conditions of the youngster to such an extent that malocclu- 
sions are present. We find that malocclusions make their appearance 
in different races provided that the races live in such an environment 
as we have described. We find that malocclusions are present among 
the civilized Indians who are living in luxury, among the negroes 
who are living as white people live, so we can safely say that racial 
characteristics are neither a preventive of malocclusion nor a producer 
of it. Many malocclusions are the result of the environment in which 
the individual lives, the result of disuse that affects the constitutional 
development, and thereby produces the malocclusion. 126 
PRACTICAL ORTHODONTIA 
In examining skulls of ancient races, such as the one shown in Fig. 
137, which is the skull of an old Indian, we find the teeth well de- 
veloped, the jaws well developed, and a large amount of wear shown 
in the teeth. If the modern individual used his teeth in such a man- 
ner as the semi-savage used his, a large amount of malocclusion that 
is the result of environment and lack of use would disappear and 
normal occlusions would be much more common in the civilized man 
than they are at present. It must be remembered then that a large 
number of the obscure cases of malocclusion have their origin and 
Fig. 137. 
Showing well-developed jaws and wear of teeth as a result of use. 
faulty cell metabolism in a faulty development and that this faulty 
development may reach far back into the period that may be said 
to be the period of environment in which the child lives, to be a 
congenital condition that has been acquired during embryonic life, or 
even to be a constitutional condition that may be produced by the phys- 
ical nature or condition of the germ cells. Constitutional conditions 
as the cause of malocclusion must have a much greater study than 
they have received in time past. 
Another factor that is the cause of faulty developments and that ETIOLOGY OF MALOCCLUSION 
127 
plays a part in the development of malocclusion is disease of the duct- 
less glands of which very little is known. It is known that diseases 
of the pituitary bodies have a tendency to produce overdevelopment 
and are especially liable to produce overdevelopment of the mandible. 
Not only will it produce overdevelopment of the mandible but it will 
affect the development of the other bones of the face to a certain ex- 
tent, but the overdevelopment of the mandible is more apparent, be- 
cause in the development of that bone we have the malocclusion pro- 
duced directly. A great many cases of so-called mesioclusion, or 
Class 111, have been the result of the development of the mandible, 
which really are conditions arising from overgrowth of that bone, and 
therefore are a macromandibular development. Diseases of the thy- 
roid will produce a lack of development of the osseous structure and 
very probably a great many of our patients who show a lack of osse- 
ous development are children who are suffering from thyroid diseases. 
In a prognosis of these conditions it is well to be on our guard and 
not to make too positive a statement as to what can be done in the 
treatment of malocclusion, for very often the malocclusion is the re- 
sult of the constitutional condition that may at the present time be be- 
yond the control of even internal or general medicine. The known 
facts at present seem to indicate that a larger number of malocclusions 
are produced by constitutional conditions and that instead of maloc- 
clusion being purely a local proposition as the result of disturbed me- 
chanical factors, as was formerly supposed, we have to admit that a 
great many malocclusions are the result of disturbed cell metabolism, 
which is now considered as the first and most important force of occlu- 
sion. Furthermore, if normal cell metabolism cannot be established, 
the malocclusion will be more or less permanent. 
Another constitutional factor that plays a great part in the produc- 
tion of malocclusion, which has been referred to indirectly, is that 
which is the result of early feeding of the youngster. We refer par- 
ticularly to the prevalence of malocclusion in bottle-fed babies as com- 
pared with the children who are breast-fed. Bottle-fed babies are 
probably improperly nourished, owing to the fact that the modified 
milk that they receive does not contain some of the elements that are 
present in mother's milk, even though chemical analysis would seem 
to indicate that it is the same. In the investigations made by Hell- 
man, extending over a number of years, he has found that malocclu- 
sions in bottle-fed children are much more numerous than malocclusion 
in normally fed children. Therefore, malocclusion, instead of being 
the condition that may arise during the few years of child life, is prob- 128 
PRACTICAL ORTHODONTIA 
ably the result of conditions that extend over the entire developmental 
period of the youngster, beginning with the germ cells, and extend- 
ing over a period of time until the death of the individual. In other 
words, there is no period in the life of the individual, when he is exist- 
ing either as a single cell or as a complete organism, that the consti- 
tutional conditions cannot be manifested, and there is no period dur- 
ing that time when constitutional conditions may not occur that will 
produce malocclusion of the teeth. 
Local Causes 
Local causes of malocclusion are those that act directly within the 
oral cavity and its parts. They include such conditions as affect the 
Fig. 138. 
Showing nasopharynx, hard and soft palate, and location of adenoids shown at X. ETIOLOGY OF MALOCCLUSION 
129 
teeth and surrounding structures. At first it would seem easy to sep- 
arate local from constitutional causes and a number of those con- 
ditions are easily separable. However, there are other condi- 
tions that may be said to be both local and constitutional, and it is 
hard to determine which may have been the primary cause. In dis- 
cussing constitutional causes, we stated that rickets caused an early 
loss of the deciduous teeth and the tardy eruptions of the permanent 
teeth. These two things would act locally while the cause of them 
would be constitutional. But, as before stated, these local conditions 
are the result of a constitutional condition. Mouth-breathing has long 
been given as a local cause of malocclusion because it disturbs the mus- 
cular and atmospheric pressure and acts directly upon the surround- 
ing structures. The majority of cases of mouth-breathing are caused 
by hypertrophy of the lymphoid tissue located in the naso-pharynx, 
also known as the pharyngeal tonsil (see Fig. 138). Therefore the real 
cause of the mouth-breathing is the adenoids, which may be the result 
of a constitutional condition or of the environment in which the child 
is living. The local disturbance is the direct cause of the malocclu- 
sion, but the factor that caused the adenoids may have been over- 
looked. When we look at some causes in this light, we are forced to 
admit that the line between the local and constitutional causes blends 
together to such an extent as to be almost inseparable. However, the 
majority of malocclusions are surely the result of local disturbances 
or the result of environment. As there are a great number of local 
causes, this subject will be discussed more thoroughly later. We will 
now take up a different plan of classification of causes. 
Inherited, Congenital and Acquired Causes 
The causes of malocclusion may be divided again into three groups, 
according to the time in which they originate or according to the time 
of origin. They are hereditary, or inherited, congenital, and acquired. 
Inherited Causes.-An inherited condition is one that is transmit- 
ted from the parent to the child. An inherited malocclusion would be 
one that was present in the parent and transmitted to the offspring. 
Owing to the fact that much has been written on the inheritance of 
malocclusion, it will be necessary to review some of the theories for 
and against, as advocated by authorities formerly and at the present 
time. The evidence may be divided into biologic and clinical. From 
the standpoint of biology, anatomy, histology and embryology, there 
is no evidence that malocclusion is ever inherited. The author has 130 
PRACTICAL ORTHODONTIA 
seen but few cases of malocclusion that were not the result of some 
congenital or acquired cause. A child inherits a great many things 
from its parents. It inherits a great many characteristics. A child 
with white parents is white; a child with negro parents is a negro; a 
bird hatched from a duck egg will be a duck and one from a chicken 
egg will be a chicken. A child also inherits certain conditions that 
have been the result of the working of environment upon the human 
race for a great number of years. A child inherits a certain number 
of things that make up the dental apparatus. The teeth are so ar- 
ranged as to be in normal occlusion. Any deviation from normal oc- 
clusion is the result of some acquired or congenital condition. It is a 
well-known fact that characteristics that arise spontaneously and that 
are spoken of as variations are not as a rule transmitted unless they 
are a decided advantage to the offspring. Any variation that is not 
impressed upon the germ cell will not be transmitted. Each individ- 
ual germ cell possesses a certain amount of chromatin that presides 
over inheritance. In order that a child may inherit malocclusion, the 
malocclusion must be impressed upon the chromatin of the germ cell. 
We have no evidence that such a thing can occur. After the union of 
the male and female pronucleus, the embryo develops as a separate 
organism in which is contained the sum total of all the characteristics 
carried by the male and female germ cell. The offspring may resem- 
ble one or the other of the parents, or may be a blending of the two; 
if a blending of the two, the offspring will not exactly resemble either 
parent. The author does not feel that any other condition can occur, 
as no other conditions except those above mentioned can be found 
anywhere in biology. On the other hand those who advocate the in- 
heritance of malocclusion, and a certain number of men do, maintain 
that certain types of malocclusion are transmitted. 
One type is called family traits. They refer to such conditions as 
the protruding of the lower teeth, or Class III cases, or protrusion of 
the upper teeth, or Class II, Division 1. We do find Class II, Division 
1 cases in parents, uncles and aunts, and sometimes in several of the 
children, but it has not been the result of inheritance. These cases 
have been produced because each one of those individual children 
and each one of their parents, uncles and aunts who have Class II, 
Division 1, have lived in exactly the same environment and the same 
pathologic conditions have been acquired as a result of those en- 
vironments, which have disturbed the forces of occlusion so as to pro- 
duce that particular type of malocclusion. Therefore, such conditions 
as are grouped under the head of family traits by other authors are ETIOLOGY OF MALOCCLUSION 
131 
not the result of the transmission of the malocclusion, but the result of 
acquired conditions that are the same in each individual. 
Certain constitutional diseases may also produce malocclusion in 
the child that are the same as those present in the parent. Rickets is 
one of the diseases that often affects both the child and the parent, 
and because the child has the same malocclusion as the parent the mal- 
occlusion is charged to inheritance when it is the result of disease. A 
certain type of malocclusion that is prevalent in one of the royal fam- 
ilies of Europe has often been attributed to inheritance when clinical 
facts indicate that the entire family has suffered from rickets. 
Certain forms of malocclusion are sometimes found in different 
members of the same family and the cause of the condition may often 
be obscure. However, because we cannot locate the trouble, does not 
prove that the malocclusion is inherited. The author has seen three 
cousins in three different families who had very peculiar malocclu- 
sions, all very similar, and nothing could be found that should pro- 
duce such a condition. The author has seen all of these cases under 
treatment, and the treatment of all has been very slow and unsatis- 
factory, which would indicate some constitutional condition was play- 
ing an important part in the production of the malocclusion. The 
malocclusions are not present in any of the male cousins of the fam- 
ily. Unfortunately, from a scientific standpoint, the three families 
are small, which reduces the law of average so much as to make it 
useless. 
Cases with the same type of malocclusion may be present in chil- 
dren of the same family and inherited factors may be thought to be 
the cause of these conditions, but at the present time, we have not suf- 
ficient knowledge to prove that they are the result of inheritance. 
Figs. 139 and 140 are those of sisters that present very similar maloc- 
clusions. Figs. 141 and 142 represent the right sides of the same cases. 
The cause of these eases may be difficult to determine, but it probably 
was the same constitutional condition or the same acquired factors in 
each case, and not the result of inheritance. 
We find another class of conditions mentioned by those who advo- 
cate the inheritance of malocclusion, which class has been called the 
intermarriage of races or the mixing of types. They maintain that 
a certain number of malocclusions that are very often found are 
the result of the marriage of parents who are of different physical 
size. For instance, they say that a child will often inherit the teeth 
of a large father and the jaws of a small mother, resulting in a condi- 
tion in which the teeth are too large for the jaws. No explanation has 132 
PRACTICAL ORTHODONTIA 
ever been made as to how such a condition could occur. To any one 
who is familiar with the development of the teeth and jaws it becomes 
absolutely impossible to accept such a doctrine. The child's teeth are 
not formed from one group of cells and the jaws from another, but 
both come from the branchial skeleton, and up to a certain time it is 
impossible to say which cell is going to develop into a tooth and which 
Fig. 139. 
Fig. 140. 
Fig. 141. 
Fig. 142. 
Similar types of malocclusion in members of the same family. Claimed by some to be 
inherited. (Zentler.) 
cell is going to develop into the jaws or bone supporting the teeth. 
The size of the child's teeth was determined at the time of the fertili- 
zation of the ovum. From that time on until the eruption of the per- 
manent teeth, if the child leads a perfectly normal life, and is not in- 
fluenced by any other acquired cause or constitutional disease, the 
arches will be large enough for the teeth. The size of the teeth, that ETIOLOGY OF MALOCCLUSION 
133 
is, the enamel of the teeth, will not be changed unless there is an 
actual destruction or atrophy of the enamel organ. However, the size 
of the bone or the jaw supporting the teeth depends upon the environ- 
ment of the individual, and there are a number of conditions that will 
Fig. 143. 
Supernumerary teeth, congenital cause of malocclusion. 
Fig. 144. 
Supernumerary teeth, congenital cause of malocclusion. 
retard the development of the jaws and produce malocclusion of the 
teeth. The author has never seen a case of malocclusion that has been 
the result of such inherited conditions as have just been mentioned, 134 
PRACTICAL ORTHODONTIA 
nor has he ever had an opportunity to inspect a case in which the mal- 
occlusion of a parent was transmitted to the offspring. 
Congenital Causes.-Congenital conditions are those that occur in 
the embryo before birth. There has been some dispute as to the mean- 
ing of inherited and congenital conditions. Some writers have used 
the terms synonymously. It may be said that all inherited conditions 
are congenital, but congenital conditions are not always inherited. In 
other words, there are some congenital deformities of the parents that 
will not be transmitted to the offspring. 
The most frequent congenital conditions that have to do with mal- 
clusion of the teeth are harelip and cleft palate. Harelip and cleft 
palate occur in a certain number of cases in each community, that is, 
they occur as "the result of average." If a thousand cases were ex- 
amined in one community, a thousand individuals in another commu- 
nity, and a thousand in the third, we would find about the same num- 
ber of harelips and cleft palates in all three communities. We would 
find just as many cases of harelip and cleft palate in one family as we 
would in another. At certain times the average may run up and at 
others it will be diminished. We may find a few cases where the par- 
ents and some of the children in the same family have harelips, but 
after that there might be generations and generations in which these 
deformities would not again appear. Harelip and cleft palate are 
simply improper unions of the premaxillae with the maxillary bud, and 
these conditions exist in all individuals at some time in embryonic 
life. Some disturbance that occurred during the intra-uterine life pro- 
duces a failure of union of these parts. It has been observed that the 
majority of harelip and cleft palate cases occur in the first-born 
children, and very seldom are these conditions seen in children born 
afterward. Some authorities maintain that it is caused by improper 
stress that has forced the maxillary and premaxillary bones apart and 
prevented them from uniting. 
Another congenital condition is supernumerary (Figs. 143 and 144) 
and missing teeth (Figs. 145, 146 and 147). We find the supernumer- 
ary tooth germ present before birth and in the majority of missing 
teeth germs are absent at birth. A few cases of missing teeth will be 
found that result from accident or disease after the birth of the child, 
in which case the condition would not be congenital. The lateral (Fig. 
148) incisors and premolars are most frequently absent. 
Abnormal development and attachment of the frenum labium (Fig. 
149) is also congenital, although in a great many cases this condition 
does not assert itself until some time after birth. ETIOLOGY OF MALOCCLUSION 
135 
Fig. 145. 
Fig. 146. 
Missing tooth (upper second premolar), congenital cause of malocclusion. 136 
PRACTICAL ORTHODONTIA 
In examining a large number of newly born children with reference 
to the attachment of the frenum labium, it has been found that the fre- 
num is always attached at a point close to the gingival border of the 
gum. It is also large and thick. The lower frenum, as well as the up- 
Fig. 147. 
Congenital missing upper second premolar. 
Fig. 148. 
Missing lateral incisor, congenital cause of malocclusion. 
per frenum, may be well developed. As the child grows older and the 
deciduous teeth erupt, we find that, in the majority of cases, the teeth 
and alveolar process grow downward or gingivally away from the 
attachment of the frenum, with the result that the attachment of the ETIOLOGY OF MALOCCLUSION 
137 
frenum is at a more apical point compared with the gingival border 
than it was at birth. There is also a tendency for the frenum to de- 
crease in size. The frenum is large and attached close to the gingival 
border at birth, but as the teeth erupt it becomes attached at a point 
farther from the gingival border, because the teeth and alveolar proc- 
ess grow away from it. In abnormal cases, the attachment of the fre- 
num continues to grow downward or gingivally with the gingival 
growth of the teeth and process, with the result that the attachment 
is always between the teeth and causes a space to exist between the 
incisors. We find some cases in which the deciduous teeth will be 
normal and the attachment of the frenum during the time the decidu- 
ous incisors are present will also be normal. However, with the erup- 
Fig. 149. 
Abnormal frenum labium, congenital cause of malocclusion. 
tion of the permanent teeth, and the growth of the alveolar process, 
the attachment of the frenum grows gingivally as the permanent teeth 
erupt. This results in the appearance of an abnormal frenum in a 
case that has been previously normal. 
The frenum may be abnormal in the upper or lower lip, but the ma- 
jority of abnormal frenums are found in the upper lip. In a few 
instances we have seen the frenum abnormal in the lower lip and the 
upper lip presented a normal condition. Associated and with abnor- 
mal frenums, may be a thickened and abnormal lip. The lip presents 
the appearance of having too much tissue in it and produces a very 
bad facial deformity, besides the deformity produced by the maloc- 
clusion. In some cases, the frenum will be too short, which will retard 
the action of the lip, and it will be impossible for the patient to use 138 
PRACTICAL ORTHODONTIA 
the lip as he should or to raise the lip in smiling to give the proper 
facial expression. 
Fig. 150. 
Fig. 151. 
Result of oversized tongue, which may be congenital. 
Other congenital conditions may be large or oversized tongue (Figs. 
150 and 151), or undersized tongue-, although the latter condition oc- ETIOLOGY OF MALOCCLUSION 
139 
curs very rarely and complete data in any great number of these cases 
have not yet been worked out. 
In considering inherited, congenital, and acquired causes of maloc- 
clusion, the time of the appearance of the factors that produce the mal- 
occlusion must be kept in mind. The individual is the result of the 
union of the male and female germ cells and everything that is inher- 
ited is present in the germ cells at the time of the union. After the 
union of the male and female germ cells and while the individual is 
in utero the congenital conditions make their appearance, some of 
which are the result of inherited conditions and some are the result of 
environment upon the mother. Such congenital conditions as are nor- 
mal are always inherited, but a great many of the abnormal congeni- 
tal conditions are the result of environment. After the birth of the 
individual, the acquired conditions arise which may aid in the normal 
development of the person, or which may so affect the body as to pro- 
duce pathologic conditions or developments. The effect of inherited, 
Male germ cell - 
Inheritance 
Female germ cell 
-Congenital - 
-Acquired 
Birth 
Death 
Fig. 152. 
Diagram showing time in life when inherited, congenital, and acquired factors are 
active. 
Fertilization 
congenital and acquired conditions on the growth of the body may be 
shown by a diagram in Fig. 152. The first part of the diagram with 
the two lines represents the male and female germ cells, which carry 
all of the characteristics that will be transmitted. As the two lines 
come together at fertilization, we have the beginning of a new indi- 
vidual who has all of the characteristics that can be transmitted, and 
who is now living under a congenital condition that may be normal, or 
that may be abnormal. The environment of the mother will influence 
the growth of the embryo and a great many constitutional conditions 
are begun at this time that will later develop into malocclusions. At 
birth, the individual is thrown upon his own resources, and environ- 
ment affects him more than it did during the congenital and inherited 
periods. From birth to death conditions may arise that will have a 
bearing on the production of malocclusion. As a result of the study 
of this chart, it will be seen that acquired factors are more responsible 140 
PRACTICAL ORTHODONTIA 
Fig. 153. 
Malocclusion produced by early loss of deciduous incisors. 
Fig. 154. 
Early loss of deciduous lateral has allowed upper central to drift toward the right side. 
Lower lateral is nearly in contact with deciduous molar. ETIOLOGY OF MALOCCLUSION 
141 
for the production of malocclusions than any of the other factors, but 
it must be remembered that a large number of constitutional condi- 
tions are the result of congenital conditions that do not manifest them- 
Fig. 155. 
Upper canine out of line because of early loss of deciduous canine. 
Fig. 156. 
Lower canine crowded labially because of contracted arch due to early loss of deciduous 
canine. 142 
PRACTICAL ORTHODONTIA 
selves until after birth. Such things as faulty development or cell 
metabolism, as a result of an improper environment of the mother, and 
improper nutrition of the embryo that results from improper health 
of the mother, must always be considered in the study of acquired 
causes. 
Acquired Causes.-Acquired causes of malocclusion are those that 
occur after the birth of the individual. They are the result of the en- 
vironment in which the individual lives. Acquired causes may be 
either local or constitutional. The majority of conditions that pro- 
duce malocclusion of the teeth come under the head of acquired causes. 
Fig. 157. 
Early loss of deciduous molar has allowed permanent molar to drift forward. 
Early Loss of the Deciduous Teeth 
The early loss of the deciduous teeth may be constitutional, as, for 
instance, when it is associated with rickets; or it may be local when 
associated with decay, or early extraction. Malocclusion is bound to 
develop regardless of whether the deciduous tooth has been lost as a 
result of local or constitutional conditions. The early loss of a decid- 
uous incisor, above or below, will produce a lack of development in 
the region of the incisors (Fig. 153). The loss of the force of the ap- 
proximating teeth will permit them to drift together. The early loss 
of a deciduous lateral incisor will allow the central to drift toward ETIOLOGY OF MALOCCLUSION 
143 
the canine and close the space, which will result in an impacted per- 
manent lateral. The early loss of an upper or lower deciduous canine 
will permit the incisor to drift toward the side from which the tooth is 
missing (Fig. 154) until very often the lateral incisor comes in con- 
tact with the first deciduous molar. As a result, the dental arch will 
be too small to accommodate the permanent canine, which will appear 
Fig. 158. 
Fig. 159, 
The upper molars have taken a mesial position as a result of the early loss of the 
deciduous molar and the premolar is impacted as shown in Fig. 159. 
as in Figs. 155 and 156. The loss of a deciduous molar will permit the 
permanent molar to drift forward (Fig. 157). This will result in an 
abnormal mesio-distal relation of the first permanent molar and will 144 
PRACTICAL ORTHODONTIA 
Fig. 160. 
Loss of permanent molar, acquired cause of malocclusion. 
Fig. 161. 
Loss of lower first molar. ETIOLOGY OF MALOCCLUSION 
145 
also often result in impaction of the premolar when it attempts to 
erupt (Figs. 158 and 159). Given the loss of any of the deciduous 
teeth, it is possible to describe the malocclusion that will result in a 
few years from that time. 
Tardy Eruption of the Permanent Teeth 
Tardy eruption of the permanent teeth is an acquired character- 
istic that is very often the result of a constitutional disease, as rickets; 
or it may be the result of a poor physical development that prevents 
the proper calcification and eruption of the teeth. If the deciduous 
teeth have been lost, either as the result of constitutional disease or as 
a result of local cause, the space that remains vacant by the non-erup- 
tion of the permanent tooth will be closed by other teeth drifting to- 
ward each other, because of the loss of the approximal contact. The 
longer the permanent teeth are delayed in eruption the more compli- 
cated becomes the malocclusion. 
Early Loss of the Permanent Teeth 
Early loss of the permanent teeth produces a large percentage of 
malocclusions found in adults, and malocclusion will result from the 
loss of any permanent teeth at an advanced age. The early loss of the 
first permanent molar (Figs. 160 and 161) produces a malocclusion 
which is very difficult to treat, which does a great amount of damage 
to the occlusion of the teeth. It destroys the masticating appara- 
tus of the patient, and which is a predisposing factor to pyorrhea. 
Malocclusion is sure to result irrespective of the age at which the first 
molar is lost; neither does it make any difference whether the lower 
and upper molars are lost on the same side or on opposite sides (Fig. 
162) ; nor whether one or all of them are lost. The malocclusion will 
result, and result in such a positive manner that it is possible to fore- 
tell what is going to take place by knowing the time at which the 
molar is lost. Some authors have advocated the extraction of the 
first permanent molar for the correction and prevention of malocclu- 
sion, explaining that the second molar would move forward and take 
the position occupied by the first molar. This is a false theory, and 
one that has caused no end of trouble. Loss of the lower first molar 
permits the lower second molars to tip forward half the width of a 
tooth (Fig. 163), and the teeth anterior to the lower first molar will 
drop back half of the distance (Fig. 164), which will destroy the 
occlusion on that side of the mouth. In addition to this malocclusion 146 
PRACTICAL ORTHODONTIA 
Fig. 162. 
Loss of lower and upper first molars. 
Fig. 163. 
Loss of lower first molar at early age. ETIOLOGY OF MALOCCLUSION 
147 
there will occur an overlapping of the upper anterior teeth and the 
lower incisors will drop distally (Fig. 165) so far as to occlude against 
the gingival of the upper teeth. The facial deformity that is pro- 
duced is one in which the chin is too close to the nose (Fig. 166). The 
Fig. 164. 
Malocclusion produced by loss of permanent lower molar. 
Fig. 165. 
Excessive over-bite produced as a result of extraction of lower permanent molars. 148 
PRACTICAL ORTHODONTIA 
loss of both lower first molars would simply make the malocclusion 
more pronounced and the facial deformity more noticeable. The loss 
of all four first molars would produce a very similar type of maloc- 
clusion, destroy the approximal contact of all of the teeth and ruin 
their masticating efficiency, bringing about an inharmonious expres- 
sion of the face. The reason that the loss of all four first molars de- 
stroys the approximal contact point and the facial expression, with 
a tremendous loss of masticating efficiency, is because the upper and 
lower first molars have entirely different shapes and are different 
in mesio-distal diameters, and the teeth mesial and distal to them 
tip as the teeth drift together. 
Fig. 166. 
Facial deformity caused by loss of lower first molar in Fig. 163. 
The Loss of the Mesio-Distal Diameter of the Teeth 
Malocclusion will result in the premature loss of the deciduous or 
permanent teeth, because the approximal contact of that arch has 
been destroyed, which results in a mesio-distal shortening of that par- 
ticular lateral half. The loss of the mesio-distal diameter of the lateral half 
of the arch is not so great as the loss of the entire tooth. The loss of 
the mesio-distal diameter of the tooth is generally the result of caries 
with improper treatment of the same. A large number of malocclu- 
sions are produced because of the loss or decrease of the mesio-distal 
diameter of the deciduous molars. It is a well-known fact that the ETIOLOGY OF MALOCCLUSION 
149 
deciduous molars are wider mesio-distally than the premolars. This 
has caused many to believe wrongfully that it is possible to allow the 
mesio-distal diameter of the deciduous tooth to become less than nor- 
mal without producing any serious effect. This is not true. The loss 
of a mesio-distal diameter of a deciduous molar as a result of caries 
will always result in the displacement of the first permanent molar. 
If the loss is still greater it will result in the impaction of the pre- 
molar. Therefore, to avoid the loss of the mesio-distal diameter of 
deciduous teeth it becomes necessary that the treatment be such as 
will retain the original diameter. They should be filled with some 
substance that will maintain this mesio-distal diameter. The tooth 
must be restored to the original shape, size, and proper contour. It 
very often follows, in mesial or distal approximal cavities that have 
been present for some time in molars and premolars, that the teeth 
have drifted together, destroying the mesio-distal diameter of the 
tooth and the mesio-distal length of the arch. As a result of the loss 
of the mesio-distal diameter of the teeth, the cusps will not occlude 
properly and there will be inharmony in the size of the arches. 
Improper Restoration 
We have mentioned the loss of the approximal contact of the de- 
ciduous teeth which destroys the mesio-distal diameter of the teeth, 
and the same can be said of conditions found in the permanent teeth. 
We should also call attention to improper restorations of the teeth. 
Very often such restorations are not properly made so as to replace 
the mesio-distal diameter, and fillings and inlays do not always have 
the properly shaped approximal contact point. The force of the ap- 
proximal contact point is one of the normal forces of occlusion, and 
failure to properly restore contact is a cause of malocclusion. The 
occlusal surfaces of the teeth are not always properly restored, there- 
by destroying the force of the inclined plane. A great many cases 
of malocclusion are the direct result of improper restoration of the 
teeth as well as improper occlusal surfaces of crowns and bridges. 
Mouth-Breathing 
Mouth-breathing has long been recognized as a cause of malocclu- 
sion, and is generally the result of adenoids. There are other con- 
ditions that cause mouth-breathing, but the large percentage in chil- 
dren is produced by adenoids. Adenoids may be defined as the hyper- 
trophy of the lymphoid tissue located in the naso-pharynx. Lym- 150 
PRACTICAL ORTHODONTIA 
phoid tissue is present in all children and becomes the cause of mouth- 
breathing only when it is infected and congested to such an extent 
that it extends downward and forward until it comes in contact with 
the soft palate and closes the naso-pharynx. In some children this 
congested condition becomes sufficient to produce an obstruction of 
the nasal tract when lying down only. The mass of lymphoid tissue 
mentioned above is only a part of a continuous ring that encircles the 
pharynx, and is known as the ring of Waldeyer. Owing to the ease 
with which this ring of lymphoid tissue becomes infected it is also 
known as the vicious circle. The enlargement of the mass of lym- 
phoid tissue in the naso-pharynx posterior and above the soft palate, 
can only be seen by the use of reflected light and a pharyngeal mir- 
Fig. 167. 
Fig. 168. 
Facial deformity caused by mouth-breathing. 
ror. However, the clinical picture of the patient is enough to prove 
the presence of adenoids to one familiar with the conditions. The 
patient has a ' ' vacant stare ' ' which is better described as follows: 
the upper lip is short; the external nares undeveloped; lack of de- 
velopment through the nasal region; antral cavities are undeveloped, 
which gives a narrow face; mandible underdeveloped; poorly devel- 
oped chin. The eyes often appear large and staring, which is the 
result of lack of development of the nasal regions. Figs. 167 and 168 
show the appearance of a patient who is a mouth-breather as the re- 
sult of adenoids. Patients suffering from this condition all present 
the same picture. Figs. 169 and 170 show a case somewhat older. As ETIOLOGY OF MALOCCLUSION 
151 
these patients grow older, the condition becomes more marked and 
in adults the deformity is great (Figs. 171 and 172). 
Owing to mouth-breathing, air does not pass through the nasal 
cavities, and as a result no atmospheric pressure is exerted upon the 
Fig. 169. 
Fig. 170. 
Facial deformity of older patient caused by mouth-breathing. 
Fig. 171. 
Fig. 172. 
Facial deformity caused by mouth-breathing. 
walls of the nose. The relation of the bony walls of the nose is shown 
in Fig. 173, made from an embryo at birth. At this age the maxillary 
sinus is not seen and the roof of the mouth is nearly straight. The 152 
PRACTICAL ORTHODONTIA 
inferior turbinated bone lies close to the floor of the nose. If the child 
breathes normally, the nasal cavity will develop, the floor of the nose 
will be carried downward and the septum will have room to grow. 
The growth of the nasal cavity affects the growth of the maxillary 
bone, and likewise anything which affects the growth of the maxil- 
lary bone will influence the oral cavity. Fig. 174 shows the maxillary 
bones, and it will be seen that about three-fourths of the lateral walls 
and four-fifths of the floor of the nose is made up of the superior max- 
illary bones. It is therefore easy to understand how the lack of develop- 
Fig. 173. 
Shape and relation of nasal cavity and roof of mouth at birth. Note absence of 
maxillary sinus. 
ment of the nasal cavity will influence the maxillary bone and how the 
lack of growth of the maxillary bone will influence the nasal cavity. As the 
child grows, the nasal cavity increases in size and grows downward 
and outward until in the adult we find conditions as shown in Figs. 
22 and 175, the force of atmospheric pressure acting as a force to 
cause the normal development of the nasal and oral cavities. Mus- ETIOLOGY OF MALOCCLUSION 
153 
cular pressure also plays an important part. In normal breathers, the 
mandible is held in place by atmospheric pressure. When the mouth 
is closed, one usually swallows, which brings the tongue up against 
the roof of the mouth and causes it to fill the whole of the oral cavity. 
As result of the tongue occupying this position, pressure is exerted 
on the lingual sides of the upper and lower teeth, which forces them 
buccally. In mouth-breathing, the tongue does not exert any force 
on the upper teeth, which allows the upper arch to remain undevel- 
oped, and it is therefore spoken of as a narrow arch. The tongue 
Fig. 174. 
Maxillary bones, showing large amount of nasal cavity formed by maxillary bones. 
lies in the lower part of the oral cavity and does not touch the lower 
anterior teeth. The mandible drops downward as a result of the loss 
of atmospheric pressure and the muscles that depress the mandible 
hold the mandible from developing forward, owing to the weight 
that they exert on the anterior part. As the mouth is held open, the 
molars are separated enough to allow the lower molars to lock distal 
to the upper molars. If mouth-breathing occurs early in life, we find 
the deciduous teeth as shown in Fig. 176, which makes distoclu- 
sion with labioversion of the upper anterior teeth, or Class II, Divi- 
sion 1, the prevailing type. If mouth-breathing occurs after the lock- 154 
PRACTICAL ORTHODONTIA 
ing of the first molars, and the cusps of the teeth are long, we find 
such cases as are shown in Fig. 38. 
As the action of the muscles is abnormal, the upper lip does not 
Fig. 175. 
Relation of nasal and oral cavities in the adult. Compare with Fig. 173. 
exert pressure on the upper anterior teeth, thus allowing them to 
protrude. With the open mouth and parted lips, the lower lip drops 
back against the lower teeth and then the upper portion of the lower 
lip exerts pressure on the lingual surface of the upper teeth, as shown ETIOLOGY OF MALOCCLUSION 
155 
in Fig. 177. The irritation of the upper teeth causes the lower lip 
to become thicker, which in turn causes the upper teeth to protrude 
farther. 
Enlarged Tonsils 
Associated with the enlargement of the lymphoid tissue in the naso- 
pharynx is the enlargement of the lymphoid tissue in the oral phar- 
ynx, commonly called tonsils. These masses of tissue are located on 
the right and left sides of the oral pharynx at the base of the tongue, 
Fig. 176. 
Malocclusion of deciduous teeth caused by mouth-breathing. 
Fig. 177. 
Showing abnormal muscular pressure associated with mouth-breathing. (Pollock.) 156 
PRACTICAL ORTHODONTIA 
between the anterior and posterior pillars of the fauces. The tonsils 
often become inflamed and are the source of much annoyance. As 
they are enclosed in a capsule and contain a considerable amount of 
connective tissue, the tonsils are quite painful when they become in- 
flamed, in which respect they differ from adenoids. Many times the 
tonsil becomes chronically inflamed, and when in that state often is 
the beginning of mesioclusion, or Class III cases. Owing to the in- 
flamed tonsil, the child protrudes the mandible, which produces more 
space between the pillars of the fauces and consequently relieves the 
pressure on the inflamed tonsil. As a result of the protruded man- 
dible the teeth are locked in an abnormal position. As a muscular 
action that moved the mandible forward is relinquished, the mandible 
drops back to its normal position, but as the teeth are locked in an 
abnormal relation they remain in that position and malocclusion re- 
sults. 
Habits 
Habits of childhood produce a few types of malocclusion. Thumb- 
sucking and finger-sucking have long occupied a place among the 
etiologic factors of malocclusion, but they do not produce as many 
malocclusions as was formerly supposed. There are a few cases that 
are produced by lip-biting and lip-sucking, also others which are 
produced by tongue habits. This type of cases becomes very trouble- 
some to treat unless it is possible to break the patient of the habit. 
Sore Teeth 
Very often the decay of a deciduous tooth will cause the child to 
masticate in such a manner as to miss that tooth, with the result that 
the mandible will be thrown to one side. This will permit some of 
the teeth to lock abnormally when they are erupting and thus furnish 
the starting point of a severe malocclusion. 
In certain cases, other conditions will be found to play a part in 
the production of malocclusion. Each case must be studied carefully 
and every effort made to find the etiologic factor that has been re- 
sponsible for the deformity. CHAPTER V 
REGULATING APPLIANCES 
Principles of Regulating- Appliances 
Regulating appliances are mechanical devices for the purpose of 
exerting force upon malposed teeth, in turn creating cell activity and 
thereby causing the teeth to assume a proper position in the line of 
occlusion. It is necessary that the operator has a proper conception 
of what the regulating appliance is for. The appliance must be 
viewed from three distinct angles. First, it is a mechanical device 
for exerting force upon malposed teeth, which is the necessary fea- 
ture. If the appliance is mechanically imperfect and does not exert 
the pressure upon the proper teeth, failure will result. The second 
and equally important point is the purpose of the appliance, which 
is to exert force upon the malposed teeth to "create cell activity," 
after which, if the cell activity occurs, the teeth, as a result of the 
force of the appliance and the cell activity, assume a proper position 
in the dental arch. The mere exertion of force upon the teeth is not 
enough to cause them to assume the position in the line of occlusion 
that they should occupy. It is true that teeth have been moved and 
can be moved by the application of a great amount of force and such 
movement occurs too often, but the movement is not physiologic and 
those who use such methods are not practicing orthodontia. They 
are only moving teeth and causing much suffering to their patients. 
Requirements of Regulating Appliances 
In the definition of appliances, we state what the appliance is for 
and what it must do, which are the essential features of any appli- 
ance. However, there are requirements that appliances must possess 
and some appliances are better suited to do certain things and correct 
certain types of malocclusion than others. 
Efficiency.-Efficiency might be named as the first essential feature, 
which means that the appliance should do the work for which it was 
devised. This may seem like an extravagant statement, yet formerly 
appliances have been invented that were not suited to do the work 
157 158 
PRACTICAL ORTHODONTIA 
intended. It is possible to exert force on teeth with very crude and 
unscientific devices and accomplish some results. However, when we 
speak of efficiency, we mean that the appliance should accomplish the 
desired results without waste of time or energy. The appliance 
should be so made that it will follow certain mechanical principles 
that have been proved effective in other devices. There must be some 
means of attaching the appliance to the teeth to be moved so that it 
will be possible to exert the required amount of force and in the 
proper direction. The appliance must be attached to some point that 
is known as the anchor tooth, or we may say that the appliance must 
possess sufficient anchorage. As anchorage is one of the essential 
features in the efficiency of appliances, it will be described under a 
separate heading. 
Durability.-The appliance must be so constructed that it will be 
capable of use during the entire operation. It should be of such ma- 
terial that it will be little affected by the fluids of the mouth, and of 
such design that force can be exerted upon any or all of the teeth 
at the same or in opposite directions. By having such an appliance it 
is not necessary to subject the patient to the fitting of several differ- 
ent appliances before the case is completed. It saves much time for 
the operator and accomplishes the result in the shortest possible time. 
Cleanliness and Antisepsis are properties which go together to a 
certain extent. It must be possible for the patient to keep the teeth 
clean, which can only be accomplished when the appliance is con- 
structed with that idea in view. For example, round appliances are 
more easily cleaned than flat appliances, for there is not so much of 
the appliance in contact with the teeth. All bands must be cemented 
on to prevent anything getting between the teeth and the bands. 
The use of cement is for prophylactic measures. In regard to aseptic 
appliances, the material out of which the appliances are constructed 
plays an important part. Some alloy that contains an amount of 
copper or zinc is more aseptic than gold or platinum. The use of some 
of the non-corrosive alloys offers the advantage of being aseptic and 
at the same time presenting a good appearance in the mouth. 
Simplicity is another characteristic that must always be considered. 
All mechanical devices are more useful as they approach simplicity. 
In fact, the only perfect mechanical devices we have are those that 
have eliminated all superfluous parts until nothing remains that does 
not perform some definite function. The tendency in modern regulat- 
ing appliances is to eliminate all parts that do not add greatly to the 
value of the appliance. Appliances should be constructed so as to REGULATING APPLIANCES 
159 
get the greatest number of principles without increasing the bulk. 
Many devices constructed in former years have failed because sim- 
plicity was neglected. 
Inconspicuousness is a feature that is considered only for the satis- 
faction of the patient. This essential is one that the patient is always 
considering and often the success of the practitioner will depend upon 
his ability to make the appliance inconspicuous. If cleanliness, asep- 
tic properties and simplicity have been considered as they should be, 
inconspicuousness will generally follow. Still, many appliances that 
are conspicuous in the hands of some operators look well and are little 
seen when used by others. Experience has shown that the expansion 
arch, which is the most universal fixed appliance, can be made incon- 
spicuous if properly applied and at the same time will be just as 
efficient as if it were used otherwise. In no case must efficiency be 
sacrificed for inconspicuousness, as when we are often requested by 
the patient to place the appliance lingual to the teeth. Experience 
has proved that a lingual appliance is less conspicuous than a labial 
appliance, but in using a lingual appliance, the operator must be able 
to accomplish results with it that will be equally as effective as the 
labial appliance. Efficiency must not be sacrificed for ineonspicuous- 
ness. 
Fixed and Removable Appliances 
Regulating appliances are divided into fixed and removable. Fixed 
appliances are those that are placed on the teeth in such a manner 
that they can only be removed by the operator. Removable appli- 
ances are those that are attached to the teeth in such a manner that 
they can be removed by the patient. 
Fixed Appliances have the advantage of firm attachment both to 
the moving teeth and to the anchor teeth. As it is firmly attached, 
the appliance can be of smaller size than if of the removable variety. 
The fixed appliances may be divided into the labial and lingual 
arches. The labial arch, when used as an ordinary expansion arch, 
is very conspicuous and less cleanly than the removable appliance. 
The same objection holds true in regard to the pin-and-tube appli- 
ance, the ribbon arch, and the Robinson appliance. The lingual 
arches are very inconspicuous and cleanly and offer many advantages 
that are not possessed by the labial arch. They have firm attach- 
ments and cause little inconvenience to the patients. 
Removable Appliances are recommended because of the fact that 
they can be removed by the patient and the appliance and teeth thor- 160 
PRACTICAL ORTHODONTIA 
oughly cleaned after each meal. They are less conspicuous than the 
fixed labial appliances, but have the disadvantage that they are not 
securely attached to the moving teeth or to the anchor teeth, which 
limits their use in some of the complicated cases of malocclusion. The 
simpler forms of malocclusion can be treated with the removable ap- 
pliance, but there are a large number of cases in which the results 
obtained by the fixed appliance are better than the author has ever 
seen from the treatment of similar cases by the removable appliance. 
One of the great advantages of the removable appliance, namely, that 
the patient can remove it, becomes a disadvantage in the mouths of 
some patients. 
Technique for Making Regulating Appliances 
Various forms of fixed devices have been placed on the market and 
used at different times, some of which have become obsolete. It is 
the author's intention to consider only those that have a place in 
modern orthodontia, those that he has found of advantage and those 
that are employed by the majority of men who are devoting their 
entire time to the practice of orthodontia. 
Bands 
Bands form one of the principal parts of the fixed appliance. Bands 
are divided into plain and clamp (Figs. 178 and 210). A plain band 
is made by pinching or burnishing a piece of metal around the tooth 
to be banded or around a model of the same and soldering the ends 
Fig. 178. 
Plain, or Magill, bands. 
together. The size of the band is not adjustable. They are made and 
used on all of the teeth, but the best fitting bands are made on the 
six anterior teeth. 
Which form of plain band was first used, or the inventor of same, 
has never been known. They did not meet with universal use until 
the introduction of cement. The use and making of the plain band 
as employed today was introduced by Magill, and is known in litera- 
ture as the "Magill band." REGULATING APPLIANCES 
161 
Composition of Appliances.-The band may be made out of various 
materials, namely, gold, gold and platinum, iridio-platinum, German 
or nickel silver, and aluminum-bronze. There are several alloys on 
the market sold under various names which are said to possess certain 
desirable qualities. These alloys are probably aluminum-bronze. The 
"non-corrosive material" sold by some manufacturers makes a very 
desirable material. Each one of the various materials used for plain 
bands has its advantages and disadvantages. 
Gold, which was probably used first, is recommended for its ease 
of manipulation and for its color. It does not tarnish easily in the 
mouth, although in some instances it does discolor greatly. One of 
the disadvantages of gold is the lack of strength when rolled thin 
enough to permit its use without causing great separation of the 
teeth. Also, if appliances are attached to gold bands and considerable 
force exerted upon the appliances the gold will tear. Still, the great- 
est disadvantage to the use of gold is that it possesses no antiseptic 
property. Alloys of gold to form what is known as clasp metal have 
been used which eliminate some of the first objections, but the last 
one still remains. Gold and platinum material, composed of equal 
parts of gold and platinum, makes an alloy that is strong, can be rolled 
thin and has a nice appearance, discolors in some mouths, and is not 
antiseptic, that is, does not retard the growth of microorganisms. On 
account of the last-named objection it is little used by the author. 
Iridio-platinum is a material much used by some practitioners, and is 
very strong even when rolled thin. It is seldom necessary to use it 
more than .005 or 36 gauge and some cases will possess sufficient 
strength when used .003 or 40 gauge. It melts at a high degree of 
temperature and can be soldered with pure gold. This leaves little 
danger of the opening of the solder-joint when other solder attach- 
ments are being made to the band. Also, the joint will not open under 
stress as sometimes happens when a low karat solder is used. Iridio- 
platinum discolors in some mouths and like the other noble metals 
does not retard the growth of microorganisms. A tooth that is in 
contact with an iridio-platinum appliance is very liable to decay; in 
fact it seems as if the tooth is more apt to decay than not. As a re- 
sult of the use of this material, many caries have been caused that 
would not have been produced otherwise. 
German or nickel silver has been used in the past in the making of 
appliances to a greater extent than any other material. Various 
metals are used in alloying of the material, generally some percentage 
of nickel, copper, tin or zinc being employed, each manufacturer 162 
PRACTICAL ORTHODONTIA 
having his own combinations. The great advantage of German silver 
lies in its strength, as it is much stronger than gold, and even when 
rolled thin and made pliable by annealing, it will not stretch. It can 
be soldered with a high karat solder, as the melting-point is higher 
than low karat golds. It takes a high polish and in some mouths 
holds the color well. German silver can be easily gold-plated, but in 
those mouths where discoloration occurs the plate does not last long. 
It always corrodes and is affected by the fluids of the mouth. Pits 
will form in the bands and in some cases after six months to a year 
deep pits will form, which, finally perforate the band. This limits 
the tinieMuring jvhich a German silver band can be left in the mouths 
of some patients. In spite of all these objections German silver has 
an advantage that is not possessed by the metals above mentioned, 
namely, its antiseptic properties. This metal will discolor and the 
teeth become blatd^buV there is less liability of the occurrence of 
decay than if the appliance was not there. The author much prefers, 
to a metal that invites caries, one that discolors but that can be kept 
clean with a reasonable amount of care, and one that retards the 
growth of microorganisms and decay. 
The objectionable characteristic of German silver-its tendency to 
discolor-was taken up by a number of manufacturers with the re- 
sult that several metals were placed on the market that probably 
should be called aluminum-bronze. The author has never employed 
aluminum-bronze under that name, but for the past six years has 
used the non-corrosive metal as sold by the various dealers, and he 
finds that it has all of the advantages of German silver: is germicidal, 
easy to work, can be made extremely pliable but is slightly more dif- 
ficult to solder. The metal is more yellow than German silver and 
in some mouths turns the color of gold. It will discolor to no greater 
extent' than gold, gold and platinum or iridio-platinum. In some 
mouths the bands have a tendency to pit, but this is a slight objec- 
tion, which is more than offset by the germicidal action. 
Most of the materials above mentioned can be bought in any suit- 
able width and thickness. Gauge 36 or .005 is the most ideal thick- 
ness for all purposes. For the molar bands^a thicker gauge may be 
used and for the anterior teeth one that is thinner may be employed. 
Whatever material is employed must be well annealed before be- 
ing used. 
Band Technique.-Bands can be made by the direct or indirect meth- 
ods. The direct method consists in making the band over the tooth by 
pinching and burnishing a piece of metal to fit the tooth and then sol- REGULATING APPLIANCES 
163 
Fig. 179. 
Angle's band-forming pliers. 
Fig. 180. 
Angle's soldering pliers. 
dering the ends of the band together. These bands are classified as 
pinch bands, which are made by pinching the end of the material to- 
gether and then soldering the pinched ends; or lap bands, which have 
the end of the material lapped over and soldered together. The in- 
direct method consists of making the band over some form of model, 164 
PRACTICAL ORTHODONTIA 
which may be a plaster model or a metal model. Metal models are 
made out of low fusing metals, Babbitt and Malotte's metal and such, 
or from amalgam. 
Direct Band Technique.-The seam of the band that is the soldered 
joint, can be placed on the lingual or labial side of the tooth. This 
is decided by the occlusion of the teeth and what other attachments 
are to be placed on the band. It is more convenient to make the 
seam on the labial side, and unless there is some very good reason 
for not doing so, that side is always chosen. 
In making a band for the upper incisor, it is seldom necessary to 
separate the teeth previous to making the band. By using a 38 
gauge material it can generally be passed between the teeth. A piece 
of band material slightly longer than is needed for the band is passed 
between the teeth and the lingual portion is burnished close to the 
tooth. Traction is made on the free ends of the band material and 
while this is being done the labial portion is made to conform to the 
tooth by plier beaks, the edges of which come close together. For 
that purpose there are several forms of pliers on the market, known 
as band-forming pliers. Those designed by Angle are shown in Fig. 
179. Case and Pullen have also designed excellent band-forming 
pliers. After the band has been pinched so as to conform close to 
the teeth at all points, it is soldered by holding the material with a 
pair of soldering pliers, made of some material that conducts heat 
poorly, and the points are bent at right angles (Fig. 180) so as to 
conduct little heat away from the band. A little flux is placed on 
the inside of the seam (or joint), and when heated to the proper de- 
gree, a piece of solder in wire form is touched to the seam. The use 
of a solder, either silver or gold, in wire form will be found to be a 
great convenience, and is used as shown in Fig. 181. In making these 
bands it is necessary to have a blowpipe which can be at all times un- 
der the absolute control of the operator and still leave both hands 
free. After giving every blowpipe and method a fair trial, the author 
has reached the conclusion that the best results can be secured with 
the Herpath or Lane pipe, the air supply coming from the mouth 
blowpipe. There is no objection to compressed air, but the author has 
secured better control over his flame in the "old-fashioned way." 
Plain bands on the incisors should be placed as far gingivally as pos- 
sible without infringing upon the gums. As a rule the author does 
not festoon the band, but leaves it the same width the entire cir- 
cumference, as it makes a stronger band. Any band is only as strong 
as its weakest point. Some orthodontists trim the band so that it REGULATING APPLIANCES 
165 
follows the gum line on all sides of the tooth. Others trim it on the 
approximal side so that it will not interfere with the approximal con- 
tact, which makes a neat but very weak band. Various attachments 
are placed on the bands for various purposes. 
In making the direct band with lap seam, some measure of the 
tooth is made at the point of greatest circumference. This measure- 
ment can be easily made by using the thin copper strips that are used 
in measuring teeth for crowns and are on the market as the Hollings- 
worth copper strip. One of these strips is pinched around the tooth 
in the same manner that the pinch band is. made, and a strip of band 
material is cut a suitable length sufficiently longer than the measure- 
Fig. 181. 
Using solder in wire form. 
ment to enable one to properly lap the ends. The ends are then 
soldered together. 
Mershon recently demonstrated to the author the following tech- 
nique for making lap bands for the anterior teeth. A piece of band 
material is carefully worked around the teeth and the ends drawn 
with the fingers while the band material is burnished on the lingual 
side. The material is then removed and the mesial and distal por- 
tions of the band material that will be over the mesial and distal 
contact points, or the points of greatest convexity, is made concave 166 
PRACTICAL ORTHODONTIA 
by using contouring pliers that have one concave and one convex 
beak. The band material is again passed around the tooth to be 
banded, and it will be found that the band material now fits the tooth 
closely on the mesial and distal sides, owing to the concavity that has 
been produced by the use of the contouring pliers. The band is now 
tightly pinched by the band-forming pliers and removed. One end 
of the band material is now cut off at one of the pinch marks. The 
other end is straightened out and cut off sufficiently far from the 
pinch mark to leave enough lap to solder. The ends are then soldered 
together with a high-fusing solder, and should it be desired to make 
any other attachments to the band in the region of the seam, they 
can be made by using a lower fusing solder or by holding the seam 
together with a pair of soldering pliers while the piece is soldered 
to the band. If any attachment is to be made to a band that will re- 
quire the exertion of much force on the attachment, either from oc- 
Fig. 182. 
Impression for indirect band-making, showing pieces of metal between teeth and ap- 
proximating teeth filled with moldine. (Schroeder.) 
elusion or from the appliance, it is an advantage to make the attach- 
ment on the lap seam, as this is the strongest part of the band. 
Indirect Band Technique.-The first step in indirect band-making 
is to secure an impression from which to make the model of the tooth. 
A plaster impression of the tooth to be banded is obtained, and it 
will necessarily include the approximating teeth. The approximating 
teeth are filled with moldine, and the moldine is built up on the 
mesial and distal side of the impression of the tooth to be banded and 
around the buccal and lingual gingival margin in such a manner as 
to increase the length of the crown of the tooth when the metal 
model is made (Fig. 182). This building of moldine around the gin- 
gival margin of the impression makes possible a metal tooth that has 
the gingival margin exposed so that the band can be fitted. The fill- 
ing of the approximating teeth with moldine eliminates them from the 
metal models and leaves only the tooth to be worked on, without the REGULATING APPLIANCES 
167 
interference of any approximating teeth. If a model is to be obtained 
of the anterior teeth, incisors, and canines, an ordinary plaster im- 
pression is obtained of the mouth, and in removing the impression, it 
is broken in as few pieces as possible. The impression is waxed to- 
gether and every other tooth filled with moldine, and then the im- 
pression is poured with Melotte's metal. The plaster impression is 
carefully removed from the metal model, care being taken to avoid 
breaking the impression into many pieces. The moldine is removed 
from the impression of the teeth, the impression is again placed to- 
gether, and moldine is placed in the impression of those teeth from 
which the metal models were made the first time. The impression is 
again poured full of Melotte's metal and we now have a model of the 
remaining anterior teeth. We now have all of the anterior teeth re- 
produced in metal, bands can be made over them, the necessary at- 
Fig. 183. 
Metal models of single teeth. Models of anterior teeth made with strip of metal 
between teeth. (Schroeder.) 
tachments made, and the appliance tried on the model. The metal 
molars and a part of the anterior teeth will be on one model, which 
will enable the operator to make and adjust all appliances over the 
models (Fig. 183). This plan of making a metal model was shown the 
author by Dr. Hoggan. 
Amalgam models are made from copper amalgam by taking an 
impression of the tooth in modeling compound. Separating wires are 
placed on the mesial and distal side of the tooth in order to produce 
enough separation so that a piece of German silver or thin copper 
can be roughly fitted around the tooth and the ends soldered to- 
gether (Fig. 184). The mesial and distal gingival borders are fes- 
tooned so as not to interfere with the gum, and the buccal and lingual 
portions of the band must come well gingivally on the buccal and 
lingual side of the tooth. This gives us a band of German silver or 
copper that is slightly larger than the tooth and about twice the 168 
PRACTICAL ORTHODONTIA 
Fig. 184. 
Thin copper band trimmed 
to festoon of gum. 
Fig. 185. 
Impression of tooth in 
compound. 
Fig. 186. 
Impression with celluloid 
strip wrapped around it. 
Fig. 187. 
Impression invested in plaster. 
Fig. 189. 
Band soldered with lap 
joint. 
Fig. 188. 
Copper amalgam model 
of tooth. 
Fig. 190. 
Band swedged. 
Fig. 191. 
Cusp swedged for band. 
Fig. 192. 
Band with cusp soldered 
and cut out for occlusion. 
Fig. 193. 
Crown with tube and lug. 
(Coston.) REGULATING APPLIANCES 
169 
length of the crown of the tooth. This band is to serve as an impres- 
sion tray and is filled with modeling compound and forced over the 
tooth (Fig. 185). This gives us an impression of the crown of the 
tooth that is as accurate as is possible to obtain. In order to increase 
the length of the gingival portion of the impression and to give a 
base to the amalgam tooth, a piece of celluloid is wrapped around the 
impression (Fig. 186). This impression is then invested in plaster in 
order to give a firm base in which to pack the copper amalgam (Fig. 
187). Copper amalgam is then packed into the impression, and after 
it is hard the plaster is broken apart and the metal tooth removed 
(Fig. 188). Around this metal tooth a band is made, with either a 
lap joint or a pinch joint. The lap joint is the better, owing to the 
fact that this band is to be swaged, as are all bands that are made 
over single metal teeth. The band is fitted to the metal tooth and 
placed in a crown and bridge swager of the plunger type. A rubber 
disk, moldine or warm modeling compound may be used as the swag- 
ing material. The band, after being swaged, is shown in Fig. 190. 
On deciduous molars and teeth that are badly broken down, a cusp 
Fig. 194. 
Plaster model for use in indirect band-making. (Mershon.) 
(Fig. 191) can be swaged over the amalgam tooth and attached to the 
band, which will give a crown that will offer more adhesion to the 
cement and afford better protection to the tooth. If, after cementing 
the band in place, the cusp portion interferes with the occlusion, the 
interfering parts can be ground off, leaving the band as shown in 
Fig. 192. Fig. 193 shows the buccal tube attached to the band. It 
will be noticed that there is a small piece of wire soldered on the 
lingual side of the band, which is for the purpose of catching an in- 
strument under the band to remove the band from the tooth, in case 
the band is put on the tooth before being cemented. These swaged 170 
PRACTICAL ORTHODONTIA 
bands fit more accurately than bands made by any other method. 
They go on the teeth with a snap and are very difficult to remove even 
if not cemented on the teeth. Bands that are made over metal models 
Fig. 195. 
Model with tooth trimmed for indirect band technique. (Mershon.) 
Fig. 196. 
Buccal view of model for indirect band technique. (Mershon.) 
Fig. 197. 
Wire measurement of tooth shown in Figs. 195 and 196. (Mershon.) 
can also be adapted by the use of a horn mallet in the same manner 
that metal plates are worked over a metal die. Bands can also be 
made by the indirect method over plaster teeth. A modeling com- REGULATING APPLIANCES 
171 
pound impression is taken of the teeth on one side only in order to 
avoid drawing of the compound. A model so made is shown in 
Fig. 194. With a small saw, the teeth on the proximal sides of the 
tooth to be banded are cut away and the model trimmed as shown in 
Figs. 195 and 196. A wire measure is then taken of the plaster tooth 
as shown in Figs. 195 and 196. This measure is taken at the point 
Fig. 198. 
Wire measurement laid on band material. (Mershon.) 
of greatest circumference and is twisted tight around the tooth, and 
then the ends are pulled and given one-quarter or one-half more of a 
turn. The wire measure is then removed and cut as shown in Fig. 197. 
The measure is then laid on a piece of band material as shown in Fig. 
198, the ends of the band material having been cut on a bias. The 
wire measure is placed on the wide portion of the band material and 
a scratch is made at the end of the wire measure. The band material 
Fig. 199-A. 
Band material with ends lapped. 
(Mershon.) 
Fig. 199-B. 
Band soldered. (Mershon.) 
is cut about 8-100 of an inch longer than needed, so as to allow for 
the overlapping ends. The ends are overlapped far enough to cover 
up the scratch on the band material, for it is desired that the band 
be made slightly smaller than the measurement. Fig. 199-A shows the 
end of the strip of band material overlapped preparatory to solder- 
ing. Fig. 199-B shows the edges of the band material soldered together. 172 
PRACTICAL ORTHODONTIA 
The band is then shaped to the tooth. In attempting to place it on 
the tooth, it will be found to be too small, owing to the fact that the 
occlusal part was made smaller than the measure. By carefully 
noting where the band binds, it can be removed and pinched with 
the band-stretching pliers and again tried on the tooth. The band 
will now go on farther than it did before it was stretched. By re- 
peating the trying on and stretching process, the band can be made 
Fig. 200. 
Mershon's band-stretching pliers. (Mershon.) 
to fit the plaster tooth very accurately. The gingival edges on the 
mesial and distal portions are trimmed to avoid injury to the gum 
tissue. The stretching pliers are shown in Fig. 200. After the band 
has been stretched and trimmed, it will fit the convexities of the tooth 
Fig. 201. 
Band cut to show effect of contouring- and stretching. (Mershon.) 
very accurately. If a band so shaped is cut opposite to the seam, the 
band material will have assumed a shape as shown in Fig. 201. 
In making a band after the above technique, the seam on the band 
for the lower molar is placed on the buccal side, and on the band for 
the upper molar is placed on the lingual side. This is because of the 
convexity of the respective surfaces of the upper and lower molars. 
After the band has been fitted to the model, whatever attachment is REGULATING APPLIANCES 
173 
necessary is placed on the band. Fig. 202 shows a half round spur 
that is placed on the band for use with the removable lingual align- 
ment wire. If a buccal tube is required, it can also be used. Owing 
Fig. 202. 
Band with half-round tube attached. (Mershon.) 
to the fact that the band is made with a lap seam that is soldered with 
a high fusing solder, the tubes or any other attachment can be made 
Fig. 203. 
Fig. 204. 
Band fitted to model of upper molar. (Mershon.) 
directly over the soldered seam. Any possibility of opening up of the 
seam can be avoided by holding the lap ends of the seam with a pair 
of soldering pliers the end of which are bent at right angles. 174 
PRACTICAL ORTHODONTIA 
Fig. 203 shows the lingual side of a band fitted to the model of the 
upper molar. Notice how the lingual side follows the convexity of 
the lingual surface of the upper molar. Fig. 204 shows the occlusal 
view of the same tooth. 
Soldering Technique.-A small spur is soldered on the band for 
rotating teeth and is made as follows: 
The spur should be attached at a point far enough gingivally so 
that the ligature will pass above the gum and below the approximal 
contact point, and slightly to the side toward which the tooth is to 
be rotated. A piece of wire of 18 or 20 gauge is selected and the end 
Fig. 205. 
Manner of holding wire to make spur on plain band. 
filed to an angle of 45 degrees. The band is held in the pliers and the 
solder flowed at the point to which the spur is to be attached. This 
is done by heating the band and touching it with the wire-solder when 
it reaches the proper heat. A little flux is placed on the wire and 
then by holding the piece as shown in Fig. 205 the wire is soldered 
to the band. The wire is then cut off making a spur about one and a 
half times as long as the thickness of the ligature-wire, or ligature 
that is to be used. In place of the spur, Brady has suggested the use 
of small tubes soldered well toward the gingival portion of the band, 
through which the ligature is passed. When threaded through the REGULATING APPLIANCES 
175 
tube, the ligature will be prevented from coming if it should in any 
way become loose on account of the teeth moving a great deal be- 
tween visits. Care must be taken in soldering the tube to the band to 
prevent the solder from flowing into the tube and closing it. It is 
held and soldered to the band as shown in Fig. 206. The plain band 
is also used with the perpendicular tube is employed in the bodily 
movement of teeth as suggested by Angle. In those cases the seam of 
the band is generally made on the lingual side as a matter of con- 
venience. 
The making of the canine band is more difficult owing to the pointed 
Fig. 206. 
Manner of holding small tube on ligature wire while soldering same to band. 
shape of the tooth. A piece of the band material is placed between 
the teeth and traction is made on the material. It will be seen that 
the occlusal portion of the material on the lingual side stands away 
from the tooth. While traction is being made on the ends of the band 
material, the lingual portion of the material is pinched with the band- 
forming pliers, making a pinch as shown in Fig. 207. The material 
is then removed from the tooth and flux applied to the lingual portion 
of the pinched band material and heat applied and touched with the 
solder at the proper time. It will now be found that the lingual por- 
tion of the material fits the canine accurately. The mesial and distal 176 
PRACTICAL ORTHODONTIA 
part of the band material that will be against the convexity of the 
mesial and distal portion of the tooth should be made convex, after 
the method suggested by Mershon, by using a pair of contouring 
pliers that have a concave and convex beak. After the mesial and 
distal sides are made concave, with the concavity toward the center 
of the band, the material is placed around the canine and the pinch 
is made on the labial side. If a pinch band is to be made, it is soldered 
in the usual manner, and if lapped, the same technique is employed as 
described in the description of making incisor bands. 
In making plain bands for the premolars and molars, it is best to 
slightly separate those teeth, which enables us to get the material be- 
tween the teeth more easily and also to secure a better fit, which is 
greatly to be desired, for it will require long experience before one 
is able to make a plain band on the molars and premolars that will in 
any manner nearly approach the neatness of the anterior bands. The 
Fig. 207. 
Band pinched on lingual and labial sides. 
best method of producing separation is to take a piece of ligature 
wire of about 26 gauge and pass it between the teeth gingivally to 
the proximal contact point and bring the end occlusally to the contact 
point and twist the ends together. The twisting of the ends exerts 
pressure upon the teeth and slightly separates them. One of these 
wires should be placed on the mesial and distal side of the tooth to be 
banded. Some have suggested the tying of silk ligature or traction 
cable in the same manner as the wire ligature is placed, but the 
author does not like it so well, for it becomes filthy and often makes 
the proximal gum tissue sore. The wire ligature will produce suf- 
ficient space in twenty-four hours, but no harm will result if left a 
longer time. In making a band for a molar or premolar, the mate- 
rial is passed around the tooth and the pinch is made at the mesio- 
buccal angle so as to bring the seam as near the proximal contact as 
possible. This places the soldered part of the band out of the way 
of the cheek. As the gingival part of the permanent molars and pre- REGULATING APPLIANCES 
177 
molars is of a smaller diameter than that part at the contact points, 
care must be exercised not to pinch the band too tight at the gingival 
portion or it will be imposible to get the band on the tooth after it 
is soldered. After the band is soldered it is then placed on the tooth, 
and if made for the premolar, the mesial and distal occlusal margins 
are burnished into the mesial and distal parts of the central fossa. 
If made for a molar, the disto-occlusal part is burnished into the 
distal part of the central fossa of the lower molars and into the distal 
part of the disto-lingual fossa of the upper molars. This prevents the 
band from being forced too far gingivally, should the cement become 
loosened between visits. It will usually be necessary to make a pinch 
on the linguo-occlusal margin of the upper molars so that the band will 
fit the convexity of the lingual surface. A pinch is often made on the 
buccal side of the lower molar for the same purpose. 
When this band is made to be used as an anchor band with the 
expansion arch, the band is placed on the tooth after it has been 
burnished and the pinches soldered, and a scratch is made on the 
Fig-. 208. 
Plain molar bands with tubes. 
Fig. 209. 
Plain band with lingual bar. 
buccal side showing the proper direction in which the tube is to be 
placed. The seam of the band is held with a pair of pliers, the point 
of which has a groove of sufficient width to straddle the seam, and 
possesses a slide on the handle that holds the beaks together. With 
this form of pliers the band can be securely held, and should there 
be enough heat on the band to melt the solder, the seam will not open. 
Solder is flowed on the buccal tube that is to be attached to the 
band, flux is placed on the band, and the tube soldered to the band at 
the proper place and in the proper direction. A band of this kind 
is shown in Fig. 208. 
It is much easier to make a plain band for the deciduous molars, 
because the gingival margin of the teeth presents a diameter nearly 
as great as any other part. The band can be pinched tight around the 
tooth, and any free portion of the band that exists around the occlusal 
portion can be burnished and pinched to the tooth. All pinches are 
united with solder as was done in the canine bands. Plain bands on 178 
PRACTICAL ORTHODONTIA 
molars possess the advantage that they do not present any sharp por- 
tion on the lingual side, which is a great advantage in the case of 
children. In those cases in which the permanent molar region re- 
quires expanding and the bands are placed on the second deciduous 
molars, a lingual bar is soldered to the band to engage the first per- 
manent molar and the first deciduous molar. This style of attachment 
is shown in Fig. 209. 
Plain molar and premolar bands are also used in retaining appli- 
ances. 
Adjusting' Clamp Bands.-Clamp bands are made adjustable by 
means of a screw attachment. There are two kinds of^glamp bands, 
those with the clamping device on the lingual side and those with the 
clamping device on the buccal side, as shown in Fig. 210. Each style 
of band has advantages-that will be taken up separately. Clamp 
bands are made out of German silver, "non-corrosive" metal "alumi- 
num-bronze," gold and platinum, and iridio-platinum. The author 
Fig-. 210. 
Clamp bands with clamping- device on buccal and lingual sides. 
prefers the band made out of a "non-corrosive" alloy that contains 
some copper. 
The clamp band with the clamping device on the lingual side, which 
was and is a part of the "Angle appliances," makes the strongest and 
best fitting clamp band known. It is adjustable to all cases and by 
changing the angle and position of the tube, which is in no way a 
part of the clamping device, has a universal use. It is now made by 
different manufacturers in two forms, contoured and non-contoured. 
In order that a contoured band be of the greatest service it must be 
made for the right and left upper molars and for the right and left 
lower molars. A band that is contoured is also usually festooned, 
which weakens the device. In other words, ease of adaptability is 
obtained at the expense of strength, but in most cases the contoured 
band is strong enough. The non-contoured band is universal-can be 
used on either the upper or the lower molars. It is contoured by the 
operator so as to fit the individual tooth. If the band is to be placed 
on the right upper molar, the screw should be bent so as to conform REGULATING APPLIANCES. 
179 
to the convexity of the lingual surface and the band contoured to the 
shape of the tooth. The gingival portion of the band should be con- 
toured toward the center of the tooth so that the band will hug the 
tooth and pass under the gum and not infringe on the gum tissue. 
The band should be placed about two-thirds of the way on the tooth 
and then tightened enough to make it conform to the tooth, which 
also makes the gingival portion hug the tooth closely. At this stage 
of the operation never tighten the band to its fullest extent or it will 
surely be ruined. Now loosen the band and push it on the rest of 
the way. If there is any pain in putting on a clamp band, the tech- 
nique is wrong, or the band is so wide that it is infringing upon the 
gum tissue. If the band is too wide it should be trimmed slightly on 
both the occlusal and the gingival side, taking off a small portion 
around the entire band. Never trim the band only in the proximal 
part, for if that is done the band will be weakest at that point and 
probably tear. The object of trimming the band on both the occlusal 
and the gingival parts is to cause the screw to always pull from the 
middle of the band and to make the band draw evenly around the 
tooth. These bands are made of a material that is thin and tough 
enough so that they will stretch over the greatest convexity and pull 
into the concavities of the mesial and distal gingival parts. As the 
final tightening proceeds, the band is burnished to the teeth at all 
parts that can be reached with a burnisher. 
In adjusting a clamp band, with the screw on the lingual side, care 
must be taken that the screw lies close to the lingual surfaces of the 
teeth. Also the flat side of the nut must always be toward the tongue; 
never leave the screw and nut projecting into the mouth. Greater 
care should be exercised in having the screw and nut in the proper 
place than in getting the tube to occupy its proper position, for the 
tube can be unsoldered and placed at the required position, while the 
screw cannot be so treated. If the screw is placed as suggested, it 
will produce little annoyance to the patient. A band placed on the 
teeth as described will stay without cement, but cement is used as a 
prophylactic measure only. A clamp band that depends upon the 
cement to hold it on the tooth is a poorly fitted or constructed band. 
The second form of clamp band is one that has the clamping device 
on the buccal side. The idea of such a band is to avoid having any- 
thing on the lingual side to annoy the tongue. The angle of the tube 
cannot be changed, thus limiting the use of the band in a great num- 
ber of cases. 180 
PRACTICAL ORTHODONTIA 
One form of this band is shown in Fig. 211. This type of band has 
been improved by Rogers by placing a locking device on the arch and 
band in such a manner as to add no extra bulk to the band, yet to lock 
securely the arch in the tube of the band. Fig. 212 illustrates such a 
band. In Fig. 212, a shows the screw tube on the band that has the 
mesial end of the outside of the nut threaded (6) to receive the nut (d), 
Fig. 211. 
Band with clamping device and tube combined on buccal side. (Lukens.) 
Fig. 212. 
"Arlox" band designed by Dr. F. C. Rogers. 
which is large enough to slip over the nut (c), which is the nut on the 
alignment wire, and to screw on to the threads on the tube shown at b. 
Ligatures 
Ligatures constitute one of the important parts of the fixed appli- 
ance. Ligatures are of four kinds-wire, rubber, catgut, and silk, or 
grass-line. Of the last there are several kinds of ligatures on the mar- 
ket made by different manufacturers that are very nearly the same. REGULATING APPLIANCES 
181 
They are made of a material that shortens under the action of moist- 
ure and continues to exert force on the teeth for a considerable length 
of time. The disadvantage of this ligature is that it becomes very 
filthy owing to the fact that it absorbs the fluids of the mouth. Great 
care must be taken to keep it away from the gum tissue, because in- 
flammation will result if it should come in contact with the tissue at 
any point. These ligatures are found very useful in rotating teeth, 
for they can be used without a plain band. A loop is made and the 
ligature is doubled around the tooth, and then both ends are pulled 
tight and passed between the teeth and tied around the arch. Fig. 
Fig. 213. 
Left central shows method of looping silk ligature to rotate distal corner of teeth 
labially. Right central shows how the ligature is then tied to arch to rotate distal 
corner labially. 
213 shows the manner of looping the ligature around the tooth, while 
the right central shows the manner of pulling the ligature between 
the teeth and tying it around the arch. Just before pulling the liga- 
ture tight around the tooth, J. Lowe Young has recommended that one 
of the ends of the ligature be passed through the loop, making a wrap 
that will prevent the loop from loosing as the ends are being tied 
around the alignment wire. 
Rubber Ligatures are really rubber bands. They have the greatest 
use in intermaxillary anchorage. If used on single teeth with intra- 
maxillary anchorage, they exert too much force. These ligatures can 182 
PRACTICAL ORTHODONTIA 
be secured prepared for this purpose, or can be made by cutting pure 
gum rubber tubing (Fig. 214) the desired length and thickness. The 
length of the ligature can be varied by cutting straight across or on 
the bias. Fig. 215 shows a length of the rubber tubing and several 
ligatures all different lengths cut from the same tube. 
Wire Ligatures, as introduced by Angle, are very useful with the 
fixed regulating appliance that exerts both spring and screw force. 
The wire ligatures are generally of a tenacious variety of brass, 
although German silver, and iridio-platinum have been used by some. 
The requirements of a good wire ligature are: softness, so that it will 
be easily adaptable, and strength, so that it will not stretch when 
Fig. 214. 
Rubber tubing from which ligatures of different sizes may be cut. 
Fig. 215. 
Three lengths of rubber ligatures cut from tubing shown in Fig. 214. 
stress is placed on it. They are made in several sizes in order that 
they can be easily passed through the approximal space between the 
contact points and the gum. A ligature that is passed around the 
tooth and twisted, as shown in Fig. 216, is called a plain ligature. The 
wire that is on the distal side of the tooth should always be placed 
gingivally to the arch, as there is greater danger that the distal side 
slips off than there is that the mesial side does. If there is a great 
tendency for the ligature to slip off the tooth, the wire should be 
passed between the teeth on the mesial side of the tooth toward the 
lingual; brought toward the labial on the distal side of the tooth, 
occlusally to the arch; through on the mesial side, occlusally to the 
arch ; and then out on the distal, gingivally to the arch. This makes REGULATING APPLIANCES 
183 
a wrapping of the wire around the tooth that grips it tight, besides 
the two ends that pass over the arch. This plan of applying the liga- 
ture is shown in Fig. 217. When the wire ligature is used to rotate a 
tooth, a plain band that has a tube or spur soldered on it must be em- 
Fig. 216. 
Showing plain wire ligature. 
Fig. 217. 
Wire wrapped around teeth before being put over arch to prevent ligature from 
slipping off. 184 
PRACTICAL ORTHODONTIA 
ployed. Then the ligature is passed between the teeth above the arch, 
passed around the spur on the occlusal side and next brought through 
the approximal space below the arch. The reason for crossing the lig- 
ature on the lingual side is that it grips the spur more securely. If . a 
tube is used on the band instead of the spur, there would be no need of 
crossing the ligature. 
When twisting a wire ligature it should always be toward the right, 
the same as a nut is tightened. This will be found very convenient, 
Fig. 218. 
Wire wrapped around arch in front of spur to prevent wire from slipping over spur. 
as it will not be necessary to look which way the ligature is twisted 
each time it is tightened. 
Where spurs have been placed on the arch to prevent the ligature 
from slipping, the ligature should be passed below the occlusal side of 
the arch and the end brought up over the gingival portion, which makes 
one turn around the arch, and the end then passed between the 
teeth in the usual manner. This wrap (Fig. 218) around the arch pre- 
vents the ligature from slipping over the spur should the teeth move 
and the ligature become very loose. The manner of making spurs on 
the arches will be considered with arches. 
Fixed Regulating Appliances 
The main part of the fixed regulating appliance consists of some 
form of the screw or spring lever. The force is the screw force and 
the force of the spring. The two forces have been combined in the ex- 
pansion arch. REGULATING APPLIANCES 
185 
The jack-screw, which was the first appliance placed on the mar- 
ket and constructed so that it could be used on different cases, has 
been made in many different forms. The best jack-screw consists of 
three pieces-screw, nut and tube. The object of the tube is to cover 
up the free end of the screw so that it will not (Fig. 219) annoy the 
Fig. 219. 
Angle's jack-screw. 
tongue, and it also affords attachment for one end of the appliance. 
There are many different ways of attaching the screw to the teeth that 
are to be moved. The kind of anchorage that is used will determine 
what form of attachment is to be made. The advantage of the jack- 
Fig. 220. 
Angle's traction screw. 
screw lies in the amount of force that can be exerted, the control of 
the force, and the firm manner in which it can be attached to the 
teeth. The disadvantage lies in the limited application of the device. 
The jack-screw exerts force only in one direction, and when a number 
Fig. 221. 
Lourie's ligature jack. 
of different tooth movements have to be made, it becomes necessary 
to use many combinations of jack-screws, making the appliance very 
complicated and bunglesome. The traction screw is only a modifica- 
tion of the jack-screw and is used for pulling (Fig. 220). It is very 
seldom that either of these appliances is used, as the improvement of 186 
PRACTICAL ORTHODONTIA 
the expansion arch and the use of the intermaxillary anchorage makes 
it possible to treat cases more easily with the arch than with the jack- 
screw and traction screw. 
A very ingenious and useful form of jack has been devised by Lou- 
rie, which is known as the "ligature jack." It embodies the principle 
of the traction cable, and the appliance is so constructed that the force 
Fig. 222. 
Ligature jack used with stationary anchorage. (Lourie.) 
of the silk ligature or traction cable is exerted between two points. It 
can be used for the expansion of the arch by pitting it against teeth 
on the opposite side of the arch or for moving a single tooth by the 
employment of stationary anchorage. Tt consists of a piece of heavy 
tubing (Fig. 221-a) of 19-gauge which has a longitudinal (&) 22- 
Fig. 223. 
Ligature jack used to relieve impaction of third molar. (Lourie.) 
gauge slot cut in it and a piece of 19-gauge wire (c) to which has been sol- 
dered a spur of 22-gauge wire (d). A 22-gauge spur (e) is also soldered to 
the end of the tubing. A piece of traction cable (/) is tied between 
the spurs d and e, and as a result of the contraction of the cable, force 
is exerted on the tooth to be moved. The construction of the ligature 
jack for use with stationary anchorage is shown in Fig 222. The 
appliance can be employed for elevating and straightening a molar, 
as shown in Fig. 223. As a reciprocal appliance for the widening of REGULATING APPLIANCES 
187 
the arch it can be attached to the deciduous canines, as shown in Fig. 
224. This principle can be used with the alignment wire in length- 
ening the lateral halves of the arch and can be made curved to fit the 
anterior part of the arch in the incisal regions. The author is of the 
opinion that it is one of the most useful principles that has been given 
to us in the construction of appliances. It requires very little atten- 
tion, and moves the teeth with no pain. 
Fig. 224. 
Ligature jack employed to widen upper arch. (Lourie.) 
Alignment Wires or Expansion Arches 
One of the principal fixed regulating appliances employed is the 
alignment wire, which has been called the expansion arch. For some 
time this type of appliance consisted of a threaded arch, as shown in 
Fig. 225, which was employed for expanding the arch-hence the 
name expansion arch. It was found in the treatment of malocclusions 
that it was sometimes necessary to contract the dental arch, and with 
the advent of intermaxillary anchorage that it was desirable to move 
the teeth forward and backward with the expansion arch, so Lischer 
suggested that the appliance be called "alignment wire," as it was 
more descriptive and less confusing. For instance, we might contract 
the dental arch with the expansion arch, which is a statement that ap- 
pears rather contradictory; however, if we say that we contracted 
the dental arch with the alignment wire, the statement is not confus- 
ing. 
Alignment wires may be classified into the labial and the lingual 
alignment wires or arches. Of the labial alignment wires we have the 
threaded arches that are made in one, two, or three pieces. The one- 188 
PRACTICAL ORTHODONTIA 
piece alignment wire, or arch, is the most used. The three-piece arch 
was recommended for use with the pin attachment for bodily tooth 
movement. We also have the plain labial alignment wires, one type 
of which has been called the loop appliance, because the appliance 
possesses a number of loops for the purpose of increasing the efficiency 
of the expansive or contractive force. 
Lingual alignment wires, or arches, are placed on the lingual side of 
the teeth and can be divided into the fixed and the removable. The 
fixed lingual alignment wire is soldered directly to the molar bands, 
and the force for moving the teeth is obtained by pinching and bend- 
ing the alignment wire. The removable lingual alignment wires are 
attached to the anchor bands by some form of a locking device that 
Fig. 225. 
Expansion arch with different forms of nuts. 
will permit the removal of the alignment wire from the anchor bands. 
Lingual alignment wires are generally used without any threads, 
although threaded lingual arches have been employed by some. The 
use of the thread greatly increases the bulk of the appliance, and the 
making of the appliance more bulky defeats one of the good qualities 
of the lingual alignment wire, which is lack of bulk. 
The expansion arch (Fig. 225) has been evolved from several forms 
of appliances until at the present time it embodies several principles 
in a single appliance. It is possible to do anything with the expan- 
sion arch that can be done with any other appliance, and to do it 
easier and quicker and with less pain than is possible with some 
others. It is possible to move a tooth in any direction except that of 
depressing it in the socket, which movement is even maintained by REGULATING APPLIANCES 
189 
some. The expansion arch, or alignment wire, can be used with any of 
the three forms of anchorage. Crude forms of the alignment wire were 
used by practitioners for a number of years, but it was not employed 
as a universal appliance until the writings of Angle were given to the 
profession. The present form of the alignment wire can be traced to 
the plain arch of Angle, which was a part of his device for the treat- 
ment of prominent upper anterior teeth. Case employed forms of the 
alignment wire in the construction of his contouring appliance. Ains- 
worth likewise used another form of the arch in his appliance, which 
has been known as the "Ainsworth appliance." The Ainsworth appli- 
ance, as originally made, was limited to the expansion of the teeth 
and not adopted to the various tooth movements as was the Angle 
arch. As stated before, the plain arch that was used in the retraction 
of the upper anterior teeth, may be said to be the forerunner of the 
modern alignment wire. In the plain arch, we have a long spring, 
which is an ideal appliance for exerting force upon the lateral halves 
of the arches by means of reciprocal anchorage. With occipital anch- 
orage, it was possible to accomplish good results in a certain number 
of cases, namely, distoclusion with protruding incisors, or Class II, 
Division 1. However, these results were not ideal, and in the treat- 
ment of neutroclusion, or Class I, cases with its various types, and 
distoclusion with retruding anterior teeth, or Class II, Division 2, and 
mesioclusion, or Class III, cases, various combinations of appliances 
were used and the results were not always ideal. By threading the 
ends of the plain round arch and putting on the nut, we have an appli- 
ance that combines the force of the spring lever and the jack-screw. 
Then with the improvement of intermaxillary anchorage, it became 
possible to accomplish better results than had ever been accomplished 
before. With the proper adjustment of the arch and the addition of 
a few devices for the movement of the roots of the teeth, the results 
that can be accomplished are only limited by the ability of the op- 
erator. 
The expansion arch, or alignment wire, as designed by Angle, pos- 
sesses a patented nut with a friction sleeve, as shown in Fig. 225, which 
slips in the end of the tube on the molar band. The round end of the 
nut fitting in the tube prevents the cheeks from working the nut loose. 
In order to be of any benefit the round end of the nut must fit the tube 
closely. Another feature of some of the Angle arches is the making 
of a small rib into which notches can be filed (Fig. 226), which pre- 
vents the ligatures from slipping on the arch. Owing to the fact that 
the rib on the arch interferes with the even spring of the wire and in 190 
PRACTICAL ORTHODONTIA 
a great many cases greatly irritates the lips, the ribbed arch is not 
used in the author's practice. The ribbed arch was designed to allow 
the placing of a notch in the rib for the purpose of engaging the liga- 
ture so that it would not slip. The rib greatly interfered with the- 
spring of the arch, and the Lourie spur-forming plier was designed 
for the purpose of making a spur on the arch without taking the arch 
out of the mouth. This form of pliers has strong beaks, which grasp 
the alignment wire firmly, while a short lever that moves a sharp 
chisel is pushed down on the alignment wire, cutting a small delicate 
spur in the wire without injuring the alignment wire. 
Other arches are made by different manufacturers and various forms 
of nuts have been designed in such a manner that the cheeks will not 
work them loose. Lock nuts are placed on the arch; others are made 
with specially designed nuts to prevent them from working loose. 
Fig-. 226. 
Angle's ribbed expansion arch. 
Some nuts are made six and eight sided in order that the angles will 
not be so sharp against the cheek. Various other details to accom- 
plish certain results have been added by orthodontists in the past, but 
they have always produced complications that, in the author's opinion, 
have often defeated the end sought. Alignment wires, or expansion 
arches, are made from various materials. German silver has been 
more widely used in the making of arches than any other material. 
It is capable of being tempered so as to give the necessary spring. 
Attachments to German silver arches must be made with soft solder, 
for the use of silver or gold solder will destroy the temper. As it is 
antiseptic, German silver saves a great many teeth from decay, which 
would occur if gold or some other noble metal were used. The objec- 
tion has been made that they discolor. The author much prefers an 
appliance that demands care in order to keep it clean than one that 
invites decay. Gold and platinum came into great favor a few years regulating appliances 
191 
ago, recommended by its color and by the fact that it possessed more 
spring than German silver and could be used in a smaller gauge. Also, 
attachments can be made to it with hard solder without destroying 
the temper. In a great many mouths it discolors more than German 
silver, and the great disadvantage is the absence of any antiseptic 
property. Iridio-platinum is also used and has the same advantages 
and disadvantages that gold and platinum has. One of the recent 
metals or alloys to be used is aluminum-bronze, which the author be- 
lieves more nearly approaches the ideal. It has all of the advantages 
of German silver and many of the advantages of gold and platinum, ex- 
Fig. 227. 
The Lourie spur pliers. 
eept that it cannot be soldered with hard solder without destroying 
the temper. The color is better in a higher percentage of mouths than 
any other metal. It can be made very tough and springy, and arches 
of small gauge can be used. 
Iridio-platinum, because of its stiffness, makes a very desirable ma- 
terial for the construction of the fixed lingual arch. It is also tough 
and works nicely with the wire-stretching pliers, which are necessary 
for the use of the fixed lingual alignment wire. An alloy of iridio- 
platinum containing about 16 per cent of iridium is best for use with 
the wire-stretching pliers. Nineteen gauge is generally employed. 192 
PRACTICAL ORTHODONTIA 
Gold and platinum, elastic gold, and high-fusing clasp metal are em- 
ployed in the construction of the removable lingual arch because they 
are slightly more elastic than is iridio-platinum. These are also gen- 
erally used in 19 gauge. 
Sixteen-gauge is employed more in the threaded labial arches. 
Arches of 18-gauge are often used on the deciduous teeth and in neutro- 
clusion, or Class I, cases where only intramaxillary anchorage is 
used. If a smaller gauge than 18 of any metal is used there is great 
danger that the small diameter of the arch cuts into the cheek. Arches 
of very small gauge have been introduced by Angle under the name 
of "The New Angle Appliances," and the ribbon arch. Small gauge 
arches are also used by Robinson in the Robinson appliance. These 
have some advantages and some disadvantages. However, they have 
been used successfully. The 16-gauge arch will long be the standard 
size, for it can be universally used. It possesses the required spring 
and strength, without taking up too much room. 
Attachments for the Alignment Wire of Expansion Arch.-It will 
often be found necessary to make three attachments to the expansion 
arch for various purposes: first, a spur to prevent the ligature from 
slipping on the arch and to control the direction in which the force is 
exerted; second, an intermaxillary hook for use in intermaxillary 
anchorage, and third, a finger extension, or spur, for the movement of 
the teeth. 
Spurs to prevent the ligatures from slipping on arches made of Ger- 
man silver or aluminum-bronze must be attached with soft solder. On 
the gold and platinum and iridio-platinum arches these spurs can be 
attached with gold solder. The spurs can be made out of ligature 
wire, a tube or a wire heavier than ligature wire. There is little need 
that the spur be higher than the diameter of the ligature that it is to 
hold on the arch. The simple spur (Fig. 228-A) is made by flowing a 
little solder on the end of the ligature wire and then soldering to the 
arch. Soft solder requires the use of a soft solder flux. A saturated 
solution of zinc chloride makes the best that the author has tried. This 
simple spur is of little practical value, for if much force is to be exerted 
on the ligature it will tear off. The half-loop spur (Fig. 228-Z)) is made 
by bending a piece of the ligature wire so that it will half encircle the 
arch. Soft solder is flowed in the bend, the wire is held in the proper 
position on the arch, heat is applied, and the wire soldered to the arch. 
The ends of the wire are cut off leaving the spur. If this spur is soldered 
to the noble metal arch with hard solder, it will be strong enough, pro- 
vided that the spur has been so placed that the ligature pulls from the REGULATING APPLIANCES 
193 
entire length of the spur and not against one end. In those cases where 
it is necessary to open space for an impacted tooth, e. g., a second pre- 
molar, a strong spur is necessary. This is best made by wrapping a 
Fig. 228. 
Forms of soft-solder spurs. A, simple spur; B, wire-twisted before flowing soft- 
solder; C, spur made by flowing soft-solder over B; D, half-loop spur. 
wire twice around the arch (Fig. 228-7?) at the proper place and flow- 
ing solder entirely around the arch (Fig. 228-C). The ends are then 
trimmed and filed close, which makes a spur that is neat and capable 
of withstanding all the force necessary. This spur can be made as neat 
and strong as a tube, and much quicker. In using a tube for a spur, 
a piece of tubing is selected with an inside gauge the same as the gauge 
Fig. 229. 
A, sheath- or intermaxillary-hook made by soldering wire to tube and soft-solder- 
ing tube to arch. B, Intermaxillary-hook made twisting ligature wire around arch to 
which it is then fastened with soft-solder. 
of the arch. A piece is cut from the tube of sufficient length to afford 
solder attachment that will be strong enough to withstand the force, 
the nut removed from the arch and the tube slipped to the desired posi- 194 
PRACTICAL ORTHODONTIA 
tion on the arch, which has previously had flux placed on it. A small 
piece of solder is laid on the arch at one end of the tube. The other 
end of the tube is then heated and the solder "pulled" through the 
tube. Split tubes that can be placed on the arch without removing the 
nut are obtainable, but they are not so strong. 
The second attachment to be placed on the expansion arch is the 
sheath-, intermaxillary-, or tube-hook. These different terms are synony- 
mous, and the hooks consist of some form of attachment for the rubber 
ligatures when intermaxillary anchorage is used. Sometimes hooks are 
placed on the arches to engage a rubber ligature not used with inter- 
maxillary anchorage, in which case the term intermaxillary-hook would 
be wrong. The standard form of sheath-hook consists of a piece of 
wire soldered to a small tube and bent in the form of a hook, as shown 
in Fig. 229-A. The tube is slipped over the arch and attached in the 
same manner that a tube is soldered to the arch, as described on page 
193. Various forms of hooks have been made, but one that is simple 
serves the purpose as well as one of peculiar pattern. Hooks can be 
made by wrapping a wire around the arch and bending the ends in a 
hook, then soldering it so as to attach the wire to the arch, and strength- 
ening the wire in the hook portion (Fig 229-B). This hook is neat and 
strong and can be made without taking the nut off the arch. Very 
often the hooks can be placed on the arch so as to serve the purpose 
of the spur also. When gold and platinum or iridio-platinum arches 
are used, a piece of wire of suitable gauge can be soldered to the arch 
direct, with hard solder, and then bent into a hook. 
The third form of attachment to the arch is spurs for the bodily move- 
ment of the teeth, or spurs to move the apex more than the crown, or to 
depress teeth. 
As these spurs must withstand considerable force, it is necessary that 
they be firmly attached to the arch. With gold and platinum and iridio- 
platinum arches the spur can be soldered directly to the arch. The 
spur should be so placed that it will occupy a central axis of the tooth 
mesio-distally. The tooth is attached to the arch and held in such a 
manner that it will occupy a perpendicular relation to the spur. If the 
apex is to move more than the crown, the spur is so bent as to exert 
that manner of force. When German silver or aluminum-bronze is 
used, hard solder cannot be employed or the temper of the arch will 
be destroyed. In that case the wire is soldered to a tube (Fig. 230-A) 
that is the right size to slip over the arch. The tube is placed at the 
proper position on the arch and pinched slightly with a wire cutter. 
The pinching of the tube with the wire cutter makes the tube fit tightly REGULATING APPLIANCES 
195 
to the arch so that it will not turn and slip while the arch is being re- 
moved from the mouth and placed over the flame to be soldered. The 
tube-spur is soldered by placing flux and solder at one end of the tube 
and gently heating the other end to pull the solder through the tube 
(Fig. 230-B). 
Fig. 230. 
A, spur used to depress prominent canines ; B, spur used in bodily movement of teeth. 
Application of the Labial Expansion Arch.-As the labial expansion 
arch, with the bands and ligatures that go with it, is the most widely 
used of all appliances, it becomes necessary that the principles of apply- 
ing the arch be fully understood. In the hands of the skilled, or in the 
hands of those who properly adjust it, it becomes a valuable appliance- 
Fig. 231. 
Case in which anterior teeth only need moving. 
so valuable that it is the only form of appliance that is needed, with the 
occasional use of the traction screw. 
It must be remembered that the arch embodies two forms of meehani- 196 
PRACTICAL ORTHODONTIA 
cal devices-the screw and the spring lever; therefore we have an enor- 
mous amount of mechanical force at our disposal. 
In using the expansion arch, or alignment wire, one must be familiar 
with the various forms of anchorage in order to obtain the best results. 
In applying the alignment wire, or expansion arch, to move the anterior 
teeth forward, we depend upon simple anchorage obtained from the 
molar teeth that have been fitted with bands. The tubes on the molar 
band must be so placed and the sides of the arch aligned so that the 
tube and arch will be parallel to each other before the arch is placed 
in the tube. If this is not done, the molars will be rotated by the spring 
of the arch if the arch is not parallel to the tube. In moving the an- 
Fig. 232. 
Showing relation of screws on band close to premolars and expansion arch without 
any expansion. 
terior teeth forward, if that is the only movement that is to be made, as 
seen in Fig. 231, the sides of the arch are only as wide as the tubes on 
the molar band (Fig. 232). It is unnecessary to spring the arch to get 
it in the tubes. The side of the arch lies close to the teeth so as to avoid 
any irritation to the cheeks. The anterior portion of the arch stands 
slightly away from the teeth. In applying the arch to this class of 
cases, one side of the arch is placed in the tube on the molar band and 
the position noted. If the arch is too long, the nut is turned forward 
until the arch is the proper size, and if the end projects through the 
tube, the end of the arch is cut off so that it will be covered by the tube REGULATING APPLIANCES 
197 
and not irritate the cheek. The arch is again placed in the tube on the 
same side only, and if the tube on the band is properly placed, the side 
of the arch will lie close to the teeth. The position of the canine is 
noted, a small scratch is made opposite it and the arch is removed. A 
bend is made in the arch opposite the canine in order that the anterior 
part will lay close to the anterior teeth. This bend should be made so 
that it will cause the anterior part of the arch to occupy the proper posi- 
tion to the six anterior teeth. It may be necessary to try the arch sev- 
eral times before the anterior part occupies the place intended. With 
the same end of the arch in the same tube and holding the arch in the 
proper position to the anterior teeth, the position of the opposite canine 
is noted and marked on the arch. The arch is removed, and the bend 
made in the canine region where marked so that the side of the arch 
occupies the proper relation to the tube. The side of the arch that was 
first fitted on the teeth is again placed into the tube and all positions of 
the arch noted. The side that was bent last should not be put into the 
tube until the nut has been placed at the proper position, the end cut 
off at the proper length, and the side so bent that the end of the arch 
lies parallel to the tube, when the anterior portion of the arch is held 
in position with the fingers. This shows that there is no spring in the 
arch that will be exerted upon the molars. After it appears that the 
arch is properly aligned, insert the side that was fitted last into the 
tube, leaving the other side out, and notice what position the arch occu- 
pies to the tube when free. It should lie parallel and in exact relation 
to the tube, which shows there is no spring on that side. Now both sides 
of the arch can be placed in the tube and it should go into place with- 
out binding. 
If the arch is to be applied to a case that requires expansion in the 
molar region, the same procedure is followed in the fitting of the arch, 
except that the arch is left wider in the canine region and the sides of 
the arch are so bent that they are parallel to the tubes but stand buccal 
to the tubes before the ends are inserted into them. Fig. 233 shows how 
the ends of the arch must be parallel to the tubes. If the arch and tube 
are not parallel the molar will be rotated by the spring of the arch. 
Very often this is taken advantage of when the molars are in torsi-oc- 
clusion, or torsiversion. If the arch and tube occupy the relation shown 
in Fig. 234, the mesio-buccal angle of the molar would be moved buc- 
cally. If they occupy the relation shown in Fig. 235, the disto-buccal 
angle would be turned buccally. If they occupy the relation shown in 
Fig. 236, before the arch is placed in the tube, the mesial portion of the 
tooth would be rotated lingually. If the tube and arch occupy the rela- 198 
PRACTICAL ORTHODONTIA 
Fig. 233. 
Position of arch to expand molar without rotating same. 
Fig. 234. 
Left side shows relation of tube and arch to rotate mesio-buccal angle of molar. REGULATING APPLIANCES 
199 
tion shown to each other in Fig. 237, when the arch is placed in the tube, 
the molar would be rotated in the center. Other forms of application 
will be shown in the treatment of cases. 
Fig. 235. 
Arch adjusted to rotate distal angle of molar buccally. 
Fig. 236. 
Position of arch to rotate mesio-buccal angle of molar lingually. 200 
PRACTICAL ORTHODONTIA 
Fig. 237. 
Position of arch and tube to rotate mesial angle of molar lingually and distal angle 
buccally. 
Loop Labial Alignment Wires 
The labial wire is used also without threaded ends for various tooth 
movements and has become known as the loop appliance. Loops have 
long been used in conjunction with other forms of forces. They were 
employed by Ainsworth many years ago in what has been known as the 
Ainsworth appliance. This appliance consisted in the use of labial 
Fig. 238. 
Fig. 239. 
Loop appliance and case on which it was used. REGULATING APPLIANCES 
201 
arches that were attached to the anchor bands by vertical tubes for the 
purpose of expanding the arches. They were also held in place by vari- 
ous forms of locking devices. In some cases, loops were made in the 
labial arches, and in others, the ends of the labial arches were only bent 
at right angles and placed in the perpendicular tubes on the anchor 
bands. The use of loops was also early employed by Barnes and Pullen. 
Loops have been used much more extensively within the last few years, 
and are used with appliances that are designed to move teeth bodily, 
and also with the plain wire ligatures. The advantage of the loop appli- 
ance is the ease with which it can be constructed, owing to the fact that 
no threads or nuts are required. In the absence of threads and nuts, the 
tissues also take more kindly to the appliance. The loop also gives a 
greater range of elasticity, and can be made to accomplish practically 
Fig. 240. 
Loop used in conjunction with pins and tubes. (Pullen.) 
everything that can be done with the screw; however, it must be remem- 
bered that the spring force of the loop is not so positive as the screw 
force but that it acts over a greater range. The loop can be used in the 
treatment of simple cases or of those that are more complicated. Fig. 
238 shows a simple case of malocclusion, which was treated by the use 
of the loop appliance shown in Fig. 239. Plain bands were placed on 
the molars for anchorage, and perpendicular tubes were soldered on 
the buccal surface of the molar bands, as can be seen by studying the 
appliance shown in Fig. 239. The end of the labial wire was bent gin- 
givally to form a lock similar to the lock that has been described by 
Young, and used by others. A loop was made in the labial wire about 
the region of the first deciduous molar for the purpose of exerting the 202 
PRACTICAL ORTHODONTIA 
force necessary to move the incisor forward, which was in lingual oc- 
clusion. 
Another use of the loop in a simple appliance is shown in Fig. 240, 
which was used not as an expanding force but as a contractile force for 
the purpose of moving the lateral toward the centrals. 
The loop appliance can be used in more complicated cases and is ex- 
tremely valuable in cases of expansion, as shown in Figs. 241 and 242. 
The front view shows a loop in the lower wire in the region of the cen- 
tral incisors, which is for the purpose of exerting an expansive force in 
the anterior part of the dental arch. By opening the loop, the canine 
parts of the wire will be carried labially or rather buccally. In open- 
Fig. 241. 
Fig. 242. 
The application of the loop alignment wire in neutroclusion. 
ing a loop of this character, it must be opened on both sides so that the 
labial wire may be kept straight. Owing to the fact that more expan- 
sion is required in the upper dental arch than in the lower, a loop is 
made in the upper alignment wire in the region of the upper canines. 
By turning this loop gingivally and by having it press against the 
canines, it can be made to exert a downward pressure on the prominent 
canines if desired. By opening the superior canine loops the wire is 
increased in size and room is made for the placement of the teeth. In 
Fig. 242 it will be seen that the lower wire has a loop turned gingivally, 
which is directly in front of the parallel tube on the molar band. This 
loop serves the double purpose of preventing the labial wire from slip- 
ping distally through the tube and also of providing a means of in- 
creasing the length of the lateral halves of the labial arch. Care must REGULATING APPLIANCES 
203 
be observed with these labial loops that are turned gingivally that they 
are so bent that they do not impinge upon the gum tissue. The upper 
labial loop alignment wire is attached to the anchor tube by means of 
a perpendicular tube soldered on the band. The distal end of the wire 
is bent to form a lock. As the labial wire rests at the occlusal part of 
the band, the appliance must be bent gingivally to give the wire a posi- 
Fig. 24?. 
Occlusal view of loop alignment wire. 
Fig. 244. 
Loop alignment wire used in combination with threaded section of arch on lower 
teeth for making space to accommodate the premolar. 
tion suitable for the attachment of wire ligatures. It will also be ob- 
served that a loop is made in the labial wire at the region of the pre- 
molars, which serves the purpose of a spur to. prevent the tipping of 
the premolars that are ligated tight to the perpendicular part of the 
loop. The occlusal view of the appliance is shown in Fig. 243. 
The loop appliance can be used in various combinations, and different 
attachments can be made for various tooth movements. Fig. 244 shows 204 
PRACTICAL ORTHODONTIA 
the application of the loop appliance to a case that presents several com- 
plications of adjustment. The occlusal view of the lower model shows 
that the lower left premolar is impacted and deflected to the lingual. 
Loop alignment wire showing use of spur on upper lateral and combination of loop 
appliance with threaded arch. 
Fig. 245. 
Fig. 246. 
Fig. 247. 
Loop used in conjunction with threaded arch and pins and tubes. (Pullen.) 
The lower appliance is a combination of the screw labial wire and the 
loop labial wire. The screw is used on the left side for the purpose of 
moving the anterior teeth forward to make room for the impacted tooth. REGULATING APPLIANCES 
205 
On the right side the loop is attached to the molar band by means of 
a perpendicular spur in a perpendicular tube. This attachment permits 
a bucco-lingual hinge between the band and appliance, and avoids a 
tendency of the right molar to be rotated as the anterior teeth are car- 
ried forward and over by the screw on the left side. The occlusal view 
of the upper model shows to what extent the upper right canine is in 
lingual occlusion and the apical movement that is necessary for the 
upper lateral incisor. Figs. 245 and 246 show the adjustments of the 
appliances with the expansion spur on the upper labial arch to control 
the apical movement of the lateral incisor. 
The loop is used also in other combinations and with other forms of 
the screw, one type of which is shown in Fig. 247, after Pullen. Further 
descriptions of the various combinations will be found under the head 
of bodily tooth movements. 
Lingual Arches, or Alignment Wires 
Lingual arches, or alignment wires, are distinguished from labial 
arches by the fact that they are placed on the inside of the dental arch 
or on the lingual side of the teeth. Who was the first to make use of 
the lingual arch as a regulating appliance is not known to the author. 
Crude forms of lingual appliances have been offered by certain manu- 
facturers for some time. The Jackson crib appliance, or the Jackson re- 
movable appliance, is a lingual appliance that possesses many virtues 
and is described in another chapter. Lingual arches or wires were also 
used for some years as retaining appliances, but the use of the lingual 
arch as a regulating appliance, as described in this chapter, belongs to 
Lourie and Mershon, the technique of each being slightly different. 
The use of the lingual arch as described by Lourie was evolved from 
the lingual wire as used in retention by various practitioners for a 
number of years, and was brought to a highly efficient point because of 
the many valuable features that it possesses. The ease with which the 
appliance moves teeth, the inconspicuousness of the appliance, along 
with the mechanical principles involved also influenced Mershon in per- 
fecting his technique. 
Lingual arches may be divided into the fixed and the removable, or 
those that are soldered to the anchor bands and those that have some 
form of attachment to the anchor bands that permits of their removal. 
Both types are not to be removed by the patient, and in that sense are 
fixed. The lingual arch that is soldered is the type that has been evolved 206 
PRACTICAL ORTHODONTIA 
by Lourie, and the one with removable attachments to the anchor bands 
has been used by Mershon. 
The lingual arch soldered to the anchor bands was developed from 
the retaining wire and was utilized by the employment of the principle 
of stretching wire with the wire stretchers, as first practiced by Angle. 
The soldered lingual arch is best used by having plain bands on the 
anchor teeth, which are selected according to the requirements of the 
case. Fig. 248 shows the plain bands upon the second deciduous molars 
to which the lingual wire is soldered. The technique of making this 
appliance consists in making the plain bands, placing them on the teeth, 
and taking a good modeling compound impression. The bands are 
placed in the impression, and a model is made that has the bands in 
position on the anchor teeth. The lingual wire is then fitted to the model 
and soldered in place to the bands. The lingual arch is shaped to give 
Fig. 248. 
Ungual arch soldered to molar bands. (Lourie.) 
the desired tooth movement. In Fig. 248 expansion was required in the 
canine region, and the arch is placed against the lateral halves of the 
dental arch and the required force is exerted by use of the wire stretchers. 
The wire stretchers, as designed -by Angle, are shown in Fig. 249, and 
are a heavy pair of pliers with short round beaks for the purpose of 
pinching the wire and thereby increasing its length. A pair of pliers 
for the same purpose, but much smaller, as designed by Lourie, is shown 
in Fig. 250. 
In considering the lingual arch it is well to think of it as being com- 
posed of the incisal section, which is that part extending from one canine 
to the other, and the premolar and molar sections, which are the right 
and left parts that are distal to the canines. By pinching the wire in 
the incisal section, as shown adjusted in Fig. 248, the canines will be 
expanded and the premolar or molar section will be carried buccally. REGULATING APPLIANCES 
207 
The expansion of the molars can be increased by bending the wire 
buccally distal to the canine bends, by means of the Bogue pliers as 
shown in Fig. 251. When bending the premolar section of the lingual 
arch buccally in the premolar region, there will be a rotation of the 
distal corner of the molar buccally unless another slight bend or offset 
is made lingually to counteract that tendency. The occlusal relation of 
the soldered lingual arch can also be changed by the use of the modified 
How pliers, shown in Fig. 252. 
Fig. 249. 
Angle wire-stretching pliers. 
Fig. 250. 
Lourie wire-stretching pliers. 
The lingual arch can also be bent with the stretching pliers at the 
time the pinch is being made. This makes what may be termed a ' ' dead 
bend, as pinching the wire at the time it is bent prevents the occurrence 
of any backward spring, as is often the case when bends are made with 
the pliers as shown in Figs. 251 and 252. 
The position of the lingual arch will vary according to the type of 
tooth movement that is to be desired. Fig. 253 shows the soldered 208 
PRACTICAL ORTHODONTIA 
lingual arch on the upper and lower teeth. In the lower dental appar- 
atus the lingual wire is so adjusted that the pressure can be brought to 
bear on the lateral halves of the dental arch and on the incisors by 
pinching and lengthening the wire. The lingual wire on the upper 
Fig. 251. 
Bogue pliers. 
Fig. 252. 
Modified How pliers. 
teeth is adjusted for the purpose of expanding the right half of the 
dental arch that was in lingual occlusion to the lower teeth. It will be 
seen that the lingual wire on the left side rests against all of the teeth, 
but on the right side, the only tooth which is receiving any force 
Fig. 253. 
Lingual arches showing different styles of application. (Lourie.) REGULATING APPLIANCES 
209 
at the present time is the molar to which the lingual wire is attached. 
Spurs are soldered to the upper lingual wire at such a point that they 
engage the mesial portion of the canine. These spurs can be bent dis- 
tally and can be made to keep the deciduous canines against the decidu- 
ous molars. 
In his technique, Mershon employs a form of attachment that enables 
the operator to remove the lingual arch or wire and bend it outside of 
the mouth in order to get the necessary force on the teeth. A plain band 
is fitted to the anchor tooth, the technique of making which, according to 
Fig. 254. 
Fig. 255. 
Bands with half-round tubes for use with Mershon's lingual alignment wire. 
(Mershon.) 
Mershon, is described on page 171. To the lingual side of the anchor 
band is soldered a half-round tube, which is about .10 inch in length, 
as shown in Figs. 254 and 255. These bands, which are made over 
models in Figs. 194, 195 and 196, are then placed on a full model of 
the dental apparatus, as shown in Fig. 256. The construction of the 
lingual arch is begun by soldering a half-round spur .9 inch in length 
on a piece of 19-gauge wire. The premolar section of the arch extends 
forward to the region of the mesial surface of the first premolar or 210 
PRACTICAL ORTHODONTIA 
thereabouts. It is bent to fit the irregularities of the lingual surfaces 
of the teeth, as they occupy positions of malocclusion, as shown in Fig. 
257. After the premolar sections are fitted, the next step is to fit the 
incisor section, as shown in Fig. 258. This section is also bent to follow 
the teeth as they set in positions of malocclusion and is made long 
enough so that the distal ends will touch the mesial ends of the pre- 
molar sections. The incisal section is fitted to the lingual surfaces of 
the teeth at a point slightly occlusal to the gingival marginal ridge. 
Fig. 256. 
Bands placed on model of mouth. (Mershon.) 
Fig. 257. 
Model showing construction of premolar section of lingual wire. (Mershon.) 
The ends of the premolar sections and the incisal sections should meet 
so as to form a square end-to-end joint, as shown in Fig. 259. 
This technique of making a lingual arch in three sections is employed 
because the lingual wire is easier to adapt in three pieces than it is to 
handle it as a single piece in attempting to make it conform to the irregu- 
larities of the teeth. The appearance of the different sections is shown 
in Fig. 260. In order to prevent the arch from being displaced and to REGULATING APPLIANCES 
211 
keep the half-round spur in the half-round tube, a piece of wire of 
about 22-gauge is soldered to the lingual arch mesial to the half-round 
spur, as shown on the right side of Fig. 261. This lock is a modification 
of what has been known in literature for the last few years as the 
Fig. 258. 
Incisal section of lingual arch fitted 
to teeth. (Mershon.) 
Fig. 259. 
Incisal and premolar, section in place 
ready for soldering. (Mershon.) 
Fig. 260. 
Incisal and premolar sections removed 
from model. (Mershon.) 
Fig. 261. 
Sections of lingual wire soldered together, 
showing locking device. (Mershon.) 
Fig. 262. 
Lock for use with perpendicular tube on molar band. (Burrill.) 
Young-Angle lock, though similar locks were used by Barnes a great 
many years previously. The locking devices that are soldered only on 
one end are easily bent and consequently irritate the tongue. To avoid 
that trouble, Burrill has devised a lock soldered to each side of the spur 
that contains a coiled spring. This greatly increases the stability of 
the lock, which is shown in Fig. 262. 212 
PRACTICAL ORTHODONTIA 
The completed lingual arch is shown in place in Fig. 263, which also 
shows that one of the locks is bent under the half-round tube to prevent 
it from coming out, and that the lock of the left side has not been bent 
into position. 
Fig. 263. 
Completed lingual arch in position on model. (Mershon.) 
Fig. 264. 
Calipers suggested by Dr. C. A. Hawley. 
Fig. 265. 
Hawley's calipers used in the measurement of lingual arch between molars. 
(Mershon.) REGULATING APPLIANCES 
213 
Owing to the accuracy with wdiich the half-round spurs fit the half- 
round tubes and to the large amount of elasticity that is obtained from 
this type of appliance, great care must be observed in adjusting it cor- 
rectly in order to avoid unnecessary pain and discomfort to the patient 
and also to avoid the displacement of the molar teeth. The spurs are 
placed in the half-round tubes without any pressure at first. When 
the appliance is removed for bending in order that pressure may be 
exerted on the teeth, a careful measurement is made of the distance 
between the half-round spurs by using a pair of calipers, as shown in 
Fig. 264. These calipers were suggested by Hawley for measuring the 
mesio-distal diameters of teeth, and are very useful in adjusting the 
lingual arch. After the measurement has been obtained, the calipers are 
set at that point and the changes are made in the bends of the arch to 
exert force on the irregular teeth, after which the distance between the 
molars is checked up with the calipers, as shown in Fig. 265. 
Fig. 266. 
Extension spring soldered on lingual arch to increase action on tooth. (Mershon.) 
To increase the pressure on one or more teeth and to give a longer 
range of elasticity than is possible with the plain lingual arch, exten- 
sion spurs are soldered on the wire, as shown in Fig. 266. These spurs 
are generally placed on the gingival side of the lingual wire and are 
made from spring gold, which exerts a delicate but positive force on 
the teeth. 
Appliances for the Bodily Movement of Teeth 
Appliances designed for the bodily movement of teeth have been used 
for many years. One of the early types has been described by Case 
under the name of the contouring appliance. Since that time different 
types have been placed on the market that possess more or less value. 
The principle embodied in all types of appliances for the bodily move- 
ment of teeth, or the movement of the apex more than the crown, or 214 
PRACTICAL ORTHODONTIA 
the movement of the crown in one direction and the root in the other, 
is that of two-point attachment. 
Case's appliance consists of two arches or wires that are so attached 
to the teeth that one will exert force at one point in one direction and 
the other will exert force at another point in the opposite direction. 
An appliance for the bodily movement of teeth has been suggested by 
Angle, and called the pin and tube appliance. It consists of small gauge 
tubes soldered to bands that are placed on the teeth to be moved. The 
alignment wire is of small gauge, .03 inch in diameter, which gives great 
elasticity. The small pins that engage the tubes on the bands are 
Fig. 267. 
Angle's pin and tube appliance. (Ketcham.) 
soldered to the alignment wire with hard solder, and care must be em- 
ployed to avoid overheating of the parts. If too much solder is used, 
the pin will not properly engage the tube. A catch is made on the 
gingival end of the pin to engage the gingival part of the tube. The band 
should be sufficiently wider than the length of the tube so that there will 
be enough width of band occlusally to the tube for the arch to lie on, 
thus keeping it from contact with the tooth. Fig. 267 shows the Angle 
appliance in place on the teeth. To enable the parallel tubes to be used 
with the perpendicular tubes on the molar bands, the arch is made in 
three sections-the screw sections and the middle section. The screw 
sections and the middle section have telescoping ends, as shown in 
Fig. 267. REGULATING APPLIANCES 
215 
The use of the pin and tube in conjunction with a small labial wire 
of .0225 inch has been described by Suggett,* as follows: 
"Take a piece of wire, of platinum-gold, about six inches long, and 
with pliers (Fig. 268) bend the end as shown in Fig. 269. Then place 
this right angle in the left molar tube, and after getting the length of 
the loop, make a scratch on the wire to indicate where the next pin 
should be soldered (Fig. 270). Pins 3-16 inch long, cut from the same 
Fig. 268. 
Sharp-nosed pliers for bending .0225 wire. (Suggett.) 
.0225 wire, with a small sliver of 16 gold solder melted to one end, 
should be at hand ready for use. Dip the end of this pin in flux, and 
solder it to the wire as indicated by the scratch. A jig, or any other 
mechanical apparatus, is absolutely unnecessary, unless the operator is 
rather shaky. The jig was thought to be necessary when using the stiff 
Fig. 269. 
After first bend is made in wire. (Suggett.) 
Fig. 270. 
Second step. (Suggett.) 
.030 wire, which was too rigid to bend and adjust if the pin was not 
absolutely in the correct position. In making the loop just distal to the 
cuspid, shape it so that it will act as a hook for the intermaxillary an- 
chorage. Either do this, or solder a small piece of wire for this purpose. 
Make your next loop and get your measurement for the next pin, as 
before, but provide for the rotation of the centrals and laterals as shown 
* Suggett, A. H. : The use of .0225 Alignment Wire, International Journal of 
Orthodontia, February, 1917, vol. iii, p. 105. 216 
PRACTICAL ORTHODONTIA 
in Figs. 271 and 272, where the loop rests on the mesial corner of these 
teeth. After boiling the appliance and slightly bending the pins so 
that they will bind in the tubes, and shaping it to as near an ideal curve 
as practicable, it is ready to slip in place. There is no need of adjust- 
ing it again for several months, and possibly not at all, for there are 
Fig. 271. 
Fig. 272. 
Fig. 273. 
Adjustment of .0225 alignment wire. (Suggett.) 
Fig. 274. 
Upper alignment wire .0225 adjusted to upper arch. (Suggett.) 
the hooks for intermaxillary anchorage, the spring for the necessary ex- 
pansion, and the upward spring necessary to carry the incisors upward 
and reduce the excessive overbite, as shown in Fig. 272. In attaching 
the lower, the close bite of the molars presents another problem. The 
pins and tubes are indicated, but it is an ideal place for the Robinson REGULATING APPLIANCES 
217 
attachment, which requires less vertical room (Fig. 272). The molar 
bands are fitted just as the upper molar bands were, with lingual spurs 
to carry out the deciduous molars. All the other teeth on the lower 
arch are banded and tubed, and the wire and tubes adjusted just the 
same as on the upper, except for the Robinson attachment on the molars, 
and that the wire is not sprung in to attach to the right lateral, but a 
rubber is looped over it until it is a little nearer the line, when the pin 
can be slipped into the tube and the root movement is made in unison 
with the others (Fig. 273). A hook for intermaxillary anchorage is 
soldered on the wire just anterior to the molar attachment, and this arch 
wire is ready to slip into place (Fig. 272). Fig. 274 shows the occlusal 
view of the upper." 
The use of small gauge wire for the bodily movement of teeth was 
advocated by Robinson* and described in clinics and in papers that he 
Fig. 275. 
One style of Robinson's .022 alignment wire. 
gave before various societies. In a recent article he described the va- 
rious forms of appliances that can be used for the bodily movement of 
teeth, as follows: 
"The appliance was first made with short, split, round tubing soldered 
to the labial surfaces of the incisor bands near the gingival line. The 
arch made of .022 inch wire was threaded at its ends, which were placed 
in tubes on the molar bands. The arch wire was engaged in the short 
split tubes, and at the points where it emerged, was bent sharply to- 
ward the incisal edge. It was allowed to extend nearly to the cutting 
edge, and was then bent at right angles and passed to the next tooth, 
when it was bent at right angles again toward the gingival line. When 
it reached the line of the split tubing, it was bent again at right angles 
* Robinson, R. D.: A System of Positive and Painless Tooth Movement, International 
Journal of Orthodontia, October, 1915, vol. i, p. 397. 218 
PRACTICAL ORTHODONTIA 
and passed through the next tubing and so on for each tooth (Fig. 275). 
By proper bending of the wire, pressure could be brought to bear on 
the incisal ends of the teeth in the lingual direction, and at the same 
time it would pull labially on the gingival portion of the tooth. In this 
way the apices of the roots were moved labially, and the incisal ends 
lingually. The appliance as described, did very good work in certain 
instances, but its usefulness was restricted to a very small percentage 
of cases. The things of greatest interest learned were the length of 
time such an appliance would continue its pressure, and the absence of 
all soreness. After this, came the thought that better control could be 
secured if the rotation of the arch wire in the tubing could be prevented. 
To this end square split tubing was secured, and a square wire used, 
Fig. 276. 
Robinson's blocks and seals for use with the .022 alignment wire. 
but a new difficulty immediately arose. When the wire was made into 
loops, it was found that no two loops had the same resistance, for a 
square wire bent in the direction of one side will not have the same 
resistance as though it is bent in the direction of a corner, and all the 
different angles between the flat side and the corner give different re- 
sults. A triangular wire was then tried, then a flat wire with a groove 
on one side to provide means for locking into a suitable form milled from 
solid metal and soldered to the tooth bands, but they all presented diffi- 
culties. Then came the idea of squaring a round wire just at the points 
where it was to be locked to the bands. When a wire small enough to 
give just the right delicate resilience required for the work was squared, 
the squared portion was too small to handle, and when it was made large REGULATING APPLIANCES 
219 
enough to handle, it was too stiff to give the results desired. After a 
period of study, came the idea of using hollow square blocks soldered 
on the arch wire at the places where the attachments were to be made 
(Fig. 276). That was the first real step in developing the present ap- 
pliance. The ability to lock the arch wire itself into the seats without 
soldering on attachments was at first held by the essayist to be a nec- 
Fig. 277. 
Robinson's appliance adjusted to upper arch. 
Fig. 278. 
Robinson's interlocking slat. 
essity, but after once preparing an arch in this way, it developed that 
the technique is so simple as to bother no one. The possibility of making 
an error in alignment in soldering the block to the arch is practically 
nil, and the advantage gained is so great that there can be no question 
that the use of the round wire and the soldered blocks will be accepted 220 
PRACTICAL ORTHODONTIA 
as more desirable than the use of the angular wire. Iridio-platinum 
seats into which the blocks accurately fitted, were constructed and 
soldered to the tooth bands. When the blocks were soldered to the arch 
wire and locked into the seats by bending their, edges,lithe attachment 
between the arch wire and tooth was rigid (Fig. 277). The appliance 
was first published in this form, and much good work was done with it 
as it was then used, but a serious fault developed. When the seat was 
made thin enough to bend over and lock the block in place, it was so 
frail that it often became loose under continued pressure and the stress 
of mastication, allowing the block and arch wire to slip, and thus the 
force was not applied as it should have been. 
"The attachment between the tooth and the arch was then made by 
an interlocking seat (Fig. 278-a) and block (Fig. 278-6), the former 
being soldered to the tooth band, and the latter to the arch wire. The 
seat consists of a flat oblong base and two flat parallel walls rising at right 
angles to the base. The walls are rounded at the top, and each is pierced 
near the top with a small hole, the two holes being in alignment. The 
seat is made of platinum-gold and is .022 inch thick. The distance be- 
tween the walls or across the base of the seat is .040 inch. 
"The block is of platinum-gold, but harder than the seat, and is .040 
inch thick and shaped to fit inside the walls of the seat above described, 
except that it is .005 inch greater in elevation than the side walls of the 
seat, which provides means for its being forced into the seat, with a 
pair of pliers, when there is stress on the arch wire to which it is soldered. 
The block (Fig. 278-6) is pierced by two holes, the larger runs longitudi- 
nally and its bore is equal to the diameter of the arch wire used, or .020 
inch. The smaller hole is through the transverse diameter of the block 
near the top and is in the exact place to be brought into alignment with 
the two holes in the seat walls when the block is forced into place in the 
seat. The block is locked into the seat by placing a delicate pin through 
the seat walls and the block (Fig. 278-d). When so locked, no play is 
possible. The two parts are made to fit to the minutest fraction of an 
inch, and as they have three flat walls in apposition, and are locked 
firmly together, they do not permit of any play whatever. The molar 
and anterior attachments are alike, except that the molars are the 
longer (Fig. 278-c). 
"The technic of construction is very simple. The tooth bands are first 
constructed, and to their labial surfaces are soldered the seats (Fig. 279). 
No necessity exists for getting them into alignment with each other, or 
of getting them at exactly right angles to the long axes of the teeth. If 
they be placed somewhere nearly at right angles it will be sufficient. REGULATING APPLIANCES 
221 
After the bands with the seats attached have been cemented to the teeth, 
the arch wire is prepared as follows: A piece of arch wire is selected 
and enough blocks to correspond with the number of tooth bands are 
threaded on the wire; a molar block being first and last with the an- 
terior blocks between. One of the molar blocks is now soldered to the 
wire. The block is next introduced into the seat in the mouth and the 
arch wire is bent in such a way as to bring it to lie through the next 
seat. If there is to be any change made in the relative position of the 
molar and the first tooth to be engaged, anterior to it, a loop should 
be made in the wire in such a position that it will lie near, without 
touching, the gum, and then bring the wire to lie through the next seat. 
When this has been done, bring forward the next block on the wire until 
it is approximately in the proper place to go into the seat. Next, with 
a pair of crimping pliers having a delicate projection in one beak, crimp 
Fig. 279. 
Showing construction of Robinson's appliance. 
the block on the wire; now the block may be forced into the seat and 
if not in its proper place on the wire, it can be forced into place by 
grasping the ends of the seat and block in a pair of pliers and bringing 
force to bear. As they are exactly the same length, the block must go to 
its proper place. The arch wire is now removed from the mouth and 
the block soldered, there being little danger of displacing the block on 
the wire because after crimping the block, force must be used to change 
its position on the wire. Each block is, in its turn, brought to its proper 
place and soldered in a like manner, loops being formed wherever neces- 
sary. After the last block has been soldered, any remaining portion of 
the wire is cut off. It will now be found that when the arch is placed 
in position each block will lie passively in its seat (Fig. 280). When 
the work required of the arch wire has been determined, it is bent into 
the necessary form and is then replaced in the mouth and each block 
is forced into its corresponding seat and locked there." 222 
PRACTICAL ORTHODONTIA 
The bodily movement of teeth by the use of a seat and flat arch has 
lately been described by Angle under the trade name of the "ribbon 
arch". It has features very similar to Robinson's appliances in that 
it makes use of a seat that is termed a bracket, an enlarged view of which 
is shown in Fig. 281. The ribbon arch fits into the bracket, as shown 
Fig. 280. 
Robinson's alignment wire with blocks in seats. 
in Fig. 282. A small hole in the bracket admits of the passage of a 
small pin, which locks the arch in place. The pin is made with a small 
head that engages the ribbon arch and does not pass through the arch 
at all. The bracket is made on the band, and the band is fitted to the 
teeth by pinching the strip of band material that carries the bracket 
around the tooth, and then it is soldered. It is needless to say that the 
seam of the band is always made on the lingual side. Fig. 283 shows 
Fig. 281. 
Angle's bracket band. 
Fig. 282. 
Ribbon arch in bracket of Angle band. 
how the appliance appears when adjusted in the mouth. In the correc- 
tion of torsiversion, the appliance is employed as shown in Fig. 284. The 
ribbon arch is a one-piece arch, the ends of which are flattened and fit 
into curved tubes on the molars' bands, as shown in Fig. 285. This 
gives a greater degree of stability and prevents the alignment wire or 
ribbon arch from turning in the tube. The buccal tube is also curved to REGULATING APPLIANCES 
223 
Fig. 283. 
Angle's ribbon arch adjusted to the teeth. 
Fig. 284. 
Angle's ribbon arch adjusted to correct torsiversion. 
Fig. 285. 
Ribbon arch and brackets adjusted for the 
treatment of distoclusion. 
Fig. 286. 
Ribbon arches and brackets adjusted for 
treatment of mesioclusion. 224 
PRACTICAL ORTHODONTIA 
follow the convexity of the buccal surface of the molar, which places 
the distal end of the tube out of the way of the cheek much better than 
does a straight tube. The bracket can be turned toward the occlusal or 
towards the gingival part of the tooth, depending upon what is to be 
done and upon how the appliance is to be used. In Fig. 285 the appli- 
ance is adjusted in a case of distoclusion, and in Fig. 286 in a case of 
mesioclusion. 
Flat arches with flat or oval tubes for the bodily movement of molars 
are also in use, one style of which is shown in Fig. 287. Another style of 
molar band that can be used with any form of attachment, either for 
the bodily movement of teeth or otherwise, has been designed by Brady, 
and is shown in Fig. 288. 
Fig. 287.. 
Julius Aderer's clamp band for bodily 
movement of molars. 
Fig. 288. 
Brady's clamp band for anchorage and use 
with alignment wires. 
The Lingual Arch Used in Connection With the Labial Arch 
The type of appliance that possesses many advantages over the ma- 
jority of other appliances is the lingual arch or wire supplemented with 
the labial arch or wire for use in some kinds of cases. The use of the 
labial and lingual arch produces the bodily movement of the teeth, and 
in most instances this movement can be produced without the use of 
any bands, which make the appliance much less conspicuous than it 
would be otherwise. There are various combinations of the labial and 
lingual appliances, one of the earliest forms being that shown in Fig. 
289. Bands are placed on the first molars and the lingual arch is fitted 
to the lingual surfaces of the teeth. In a great many cases the lingual 
arch is not fitted at the gingival border of the teeth as shown in this 
figure. The lingual arch exerts an outward pressure on the teeth at 
the gingival portion. On the buccal surface of the bands are soldered 
molar tubes, which receive the labial appliance, as shown in Fig. 290. 
This labial wire carries extension spurs, which rest against the labial 
surfaces of the incisors at such points as it is desired to bring pressure. 
If it is desired to continue wearing the labial wire at night as a re tain- REGULATING APPLIANCES 
225 
Fig. 289. 
Early form of labial and lingual arch. (Lourie.) 
Fig. 290. 
Front view of labial arch in combination with lingual. (Lourie.) 
Fig. 291. 
Modeling compound form to maintain shape of labial arch when not on teeth. 
(Lourie.) 226 
PRACTICAL ORTHODONTIA 
ing appliance, it can be removed in the daytime and placed on a model- 
ing compound form, as shown in Fig. 291. As long as the labial wire 
fits the form accurately, it will exert the proper force on the teeth when 
it is replaced. Should the labial wire become bent, the patient is in- 
structed to have it readjusted by the orthodontist. 
The combination of the lingual arch with the labial arch has many 
advantages in the bodily movement of teeth. Fig. 292 shows the adjust- 
ment of the lingual arch with bands on the molars. The lingual arch 
can be made to serve the purpose of expanding the dental arch and at 
the same time acting as an anchorage, while the labial arch is producing 
the bodily movement of the lateral incisors and the distal movement of 
the canines, as well as the depression and rotation of the canine. 
Fig. 292. 
Lingual arch adjusted with buccal tubes on molar bands to receive labial arch. 
(Lourie.) 
The molar bands carry buccal tubes, to which is fitted the labial arch, 
shown in Fig. 293. Bands are placed on the lateral incisors, which 
carry small perpendicular tubes of 22-gauge on the inside. At the 
proper point on the labial arch, which has been fitted above the gingival 
margin of the teeth to make it less conspicuous, is soldered 22-gauge 
spurs of spring gold, the ends of which are bent so as to pass into the 
tube from occlusal edge. This gives a greater length of spur and thereby 
increases its elasticity, and the bent occlusal end enables the tooth to 
be rotated by bending the horizontal part of the bend. The extension 
levers soldered to the labial arch just in front of the screw on the labial 
arch have their anterior ends bent at right angles, which are received 
into tubes on bands that have been placed on the canines. A side view 
of the appliance is shown in Fig. 294. The labial arch is fastened in 
position by means of a traction cable that is tied around the distal end REGULATING APPLIANCES 
227 
Fig. 293. 
Labial wire with spring extensions for use 
with lingual arch. (Lourie.) 
Fig. 294. 
Labial wire with extensions 
to canines. (Lourie.) 
Fig. 295. 
Labial and lingual arch in combination. (Lourie.) 
Fig. 296. 
Labial and lingual arch in combination showing spring extensions for canines. 
(Lourie.) 
of the tube and in front of the nut. Should the appliance exert enough 
force to make the teeth sore, instruction is given to cut the string and 
remove the appliance. 228 
PRACTICAL ORTHODONTIA 
Another form of the lingual and labial arch in combination is shown 
in Figs. 295 and 296. Spurs have been soldered to the lingual arch to 
engage the gingival part of the upper lateral incisors, thereby exerting 
force nearer the neck of the tooth; and they can also be made to exert 
a downward pressure if the tooth is in infra-occlusion. 
A more recent adoption of the combination of the labial arch with 
the lingual is seen in Figs. 297 and 298. Fig. 297 shows the bands on the 
Fig. 297. 
Labial wire applied gingivally to avoid conspicuousness. (Lourie.) 
Fig. 298. 
Labial wire with spring extensions. (Lourie.) 
first molars to which the lingual arch has been soldered. The lingual 
arch is placed gingivally to the free margin of the gum and lies far 
enough toward the apical portion of the teeth so that there is no chance 
that the lingual wire will hold food against the tissue. Spur extensions 
are soldered at suitable points on the lingual wire to exert pressure on 
the desired teeth. These spurs are so bent that they will not impinge on 
the gum tissue and will still exert force against the necks of the teeth. REGULATING APPLIANCES 
229 
By pinching these spurs between the beaks of the wire stretchers they 
can be lengthened, and force can be exerted upon the individual teeth 
without disturbing any of the other teeth. Tubes are soldered on the 
buccal surfaces of the molar bands for the purpose of carrying the labial 
arch. This arch is made from 17-gauge iridio-platinum to which is 
soldered 22-gauge elastic gold extension spurs for the purpose of exert- 
ing force on the cutting edge of the incisors and producing a bodily 
tooth movement. 
Fig. 299. 
View of labial wire in use showing inconspicuousness. (Lourie.) 
The combination of the labial and lingual arches makes an appliance 
that renders any form of tooth movement possible and one that is less 
conspicuous than any other type of appliance that is capable of pro- 
ducing as wide a range of movement. Fig. 299 shows that the extension 
spurs are the only part of the appliance that is visible. Other uses of 
the lingual arch with its combinations will be shown in the treatment 
of cases. CHAPTER VI 
ANCHORAGE 
Anchorage, which may be defined as the resistance used to overcome 
an applied force, is one of the most important requirements of a regu- 
lating appliance. In orthodontia, the applied force is exerted by the 
regulating appliance upon the teeth that are in malocclusion and in turn 
there must be a reaction that must be resisted. As action and reaction 
are equal, the anchorage must be strong enough to withstand this ap- 
plied force. 
Anchorage is first classified according to the source of origin into three 
groups-intramaxillary, intermaxillary, and extramaxillary. 
Intramaxillary anchorage is that form where the resistance neces- 
sary to overcome the force required to move the malposed tooth is ob- 
tained from a point located in the same arch. 
Intermaxillary anchorage is that form where the resistance necessary 
to overcome the force required to move the malposed tooth is obtained 
from a point in the opposite arch. 
Extramaxillary anchorage is that form where the resistance necessary 
to overcome the force required to move the malposed tooth is obtained 
from a point outside the mouth. 
Intramaxillary and intermaxillary anchorage may be divided or classi- 
fied according to the number of teeth used from which the resistance is 
obtained. If but one tooth is used, it is called single anchorage. If two 
or more teeth are used as points of resistance, it is termed reenforced 
or compound anchorage. Intramaxillary and intermaxillary anchorage 
may also be divided with reference to the manner in which the resist- 
ance is obtained: into simple, stationary, and reciprocal. 
With these definitions and plans, the following diagram has been con- 
structed to show the various combinations of anchorage: 
Of these various anchorages, intramaxillary is probably the oldest 
variety that we have. According to the literature on the subject, extra- 
maxillary anchorage was the next form to be used; while intermaxillary 
anchorage as used today belongs to modern orthodontia. 
230 ANCHORAGE 
231 
Single, or primary 
Compound, or reenforced 
Simple 
Stationary .. 
Reciprocal .. 
f Single, or primary 
I Compound, or reenforced 
Intramaxillary . 
Simple primary 
Simple compound 
Stationary primary 
Stationary compound 
Single, or primary 
Compound, or reenforced 
Simple 
Stationary .. 
Reciprocal .. 
Intermaxillary 
Compound 
Simple primary 
Simple compound 
Stationary compound 
Occipital 
Facial 
Cervical 
Extramaxillary 
Intramaxillary Anchorage.-Intramaxillary anchorage is that form 
of anchorage in which the resistance necessary to overcome the malposed 
tooth or teeth is derived from a tooth or teeth located in the same arch. 
Intramaxillary anchorage is divided into simple, stationary, and re- 
ciprocal. 
Simple Intramaxillary Anchorage is subdivided into primary, or 
single, and reenforced, or compound, and reciprocal intramaxillary an- 
chorage into primary and compound. Stationary intramaxillary anchor- 
age may be divided in the same manner. 232 
PRACTICAL ORTHODONTIA 
Simple Primary, or Single, Intramaxillary Anchorage is that form in 
which the resistance necessary to overcome the malposed tooth is derived 
from a larger tooth or one more favorably located. Fig. 300 shows a 
lateral incisor that has force exerted upon it by means of an appliance 
attached by primary, or single, simple intramaxillary anchorage. The 
molar, being the largest tooth and more favorably located, overcomes the 
force necessary to produce movement of the incisor. No other teeth are 
employed to overcome the force, nor is the appliance so constructed as to 
aid the anchor tooth. 
Reenforced, or Compound, Simple Intramaxillary Anchorage is that 
form in which the force necessary to produce movement of the malposed 
teeth is overcome by two or more teeth, larger or more favorably located. 
Fig. 300. 
Plain bands on lateral and molar teeth with jack-screw, showing simple primary 
intramaxillary anchorage. 
Fig. 301 shows where attachment is made to the molars and premolars to 
move the premolar on the opposite side.* 
In simple anchorage, either primary or reenforced, if sufficient force 
is brought to bear upon the anchor tooth it will tip as the attachment is 
made in a hinge manner. If a rubber band is stretched over two separated 
teeth with the object in view of drawing one toward the other, we would 
have simple anchorage, provided that one tooth is larger and more favor- 
ably located. In simple anchorage one of the teeth is generally in normal 
occlusion and the other in malocclusion, for it is intended to hold the 
anchor tooth still and move the malposed tooth. Sometimes simple an- 
chorage is secured from the molars that are in normal mesio-distal rela- 
tion with the idea of moving the anterior teeth mesially, in which case 
♦Reenforced simple intramaxillary anchorage is also called compound simple intra- 
maxillary anchorage. anchorage 
233 
the molars are not disturbed mesio-distally; yet another force may be 
exerted to move them buccally. The force that moves them buccally does 
not prevent them from being used as simple anchorage in providing a 
point from which force is exerted upon the incisors. Therefore several 
forces may be active on the anchor teeth at one time. 
One of the disadvantages of simple anchorage is that the appliance 
cannot be assembled or constructed so as to increase the stability of the 
anchor tooth. Care must be exercised not to place too much force on the 
anchor tooth or it will be displaced, much to the chagrin of the operator. 
The great number of cases in which the anchor tooth was displaced, made 
Fig. 301. 
Reenforced simple intramaxillary anchorge. Plain bands on premolar with bar on 
right premolar band to reenforce it. 
it necessary to devise some form of attachment that would be more rigid 
and fixed. So after many attempts stationary anchorage was evolved and 
described by Angle. 
Stationary Anchorage is that form in which the appliance is so con- 
structed and attached to the anchor tooth that if the anchor tooth moves 
at all, it will move bodily through the process. It has been stated that with 
the use of simple anchorage there is danger of moving the anchor tooth. 
There is not one tooth in the mouth that is entirely immovable, as the 
spring of the alveolar process and the peridental membrane allows the 
teeth to be moved; so it is logical to expect that a tooth will often move 
slightly when used as an anchor tooth. If this movement occurs in simple 
anchorage it is a tipping movement, but in stationary anchorage the 
''appliance is so attached to the anchor tooth" that a tipping movement 
is impossible. Not only must the appliance be attached to the anchor 234 
PRACTICAL ORTHODONTIA 
tooth in such a manner as to eliminate any "hinge" movement, but all 
parts of the appliance must be so constructed as to prevent any tipping 
or springing between the parts. As the early regulating appliances were 
some form of a jack-screw for pushing or a traction screw for pulling, 
the problems of simple and stationary anchorage were worked out with 
these appliances. Therefore they are figured in the illustrations accom- 
panying this text although they are only occasionally used now. Station- 
ary anchorage was developed and perfected as a matter of necessity, for 
it dates back to the time when extraction played a large part in the regu- 
lation of teeth. In Class II. Division 1 cases (distoclusion cases with pro- 
truding upper incisors), it was at one time the approved treatment to 
extract the upper first premolar and to move the canine and incisors dis- 
tally. Great force was required to move the canine distally and with 
Fig. 302. 
Showing plain band on canine and clamp band on molar. The long tube on molar 
band prevents molar from tipping, hence if it moves it must move bodily, as shown 
by the dotted outline. The canine will tip. 
simple anchorage the molar was displaced. Even reenforced simple an- 
chorage was not sufficient to provide enough resistance to overcome the 
force necessary to "move" the malposed teeth. 
In order to have stationary anchorage, there are two things that must 
be secured, viz., rigidity and stability of the appliance. The appliance 
must be made from some material that will not bend under the necessary 
force, and the parts must be accurately fixed together and attached to 
the tooth in such a manner as to prohibit any movement between the 
tooth and the appliance. A molar band is placed on the anchor tooth 
to which the appliance is rigidly attached. These are the things that 
make stationary anchorage. Fig. 302 shows the manner in which the ANCHORAGE 
235 
traction screw is used with stationary anchorage. The long tube that is 
soldered to the molar band in which the traction screw fits accurately, 
prevents any tipping of the parts. The right-angle end of the screw 
is attached to the canine by engaging the tube, which is placed so as to 
make a hinge joint when the force is placed on the canine. In order for 
the molar to tip, the canine end of the appliance would have to move 
Fig. 303. 
Primary reciprocal intramaxillary anchorage. 
gingivally, which could not occur unless the canine is depressed in the 
alveolus. 
Fig. 302 shows single stationary intramaxillary anchorage. If a band 
was placed also on the premolar and the tube of the traction screw was 
soldered to the premolar band and the molar band, we would then have 
compound stationary intramaxillary anchorage. 
Reciprocal Anchorage is that form in which the force necessary to 
move a malposed tooth is derived from another malposed tooth, with the 
Fig. 304. 
Another form of primary reciprocal anchorage. The centrals will be the teeth to move. 
idea that both be made to assume a proper position in the line of occlusion. 
Fig. 303 shows two canines in lingual occlusion. A jack-screw placed 
between them would exert pressure in such a manner as to move both of 
them buccally. One of the canines may move more easily than the other, 
in which case some other means must be employed to increase the resist- 
ance of the easily moving tooth. These things will be mentioned later. 236 
PRACTICAL ORTHODONTIA 
A rubber band placed around the central incisors that are separated gives 
us reciprocal anchorage. Reciprocal anchorage is divided into primary, 
or single, and compound. It may also be divided into simple and sta- 
tionary. 
Fig. 305. 
Compound reciprocal intramaxillary anchorage. 
Fig. 305. 
The of the expansion arch generally embodies compound reciprocal intramaxillary 
anchorage. 
Primary, or Single, Reciprocal Intramaxillary Anchorage is that form 
in which the appliance is attached to but one malposed tooth on each side 
with the object in view of moving only those teeth to which the appliance 
is attached Fig. 303). A wire passed around the teeth, as shown in Fig. 
304, is primary, or single, reciprocal anchorage. ANCHORAGE 
237 
Compound Reciprocal Intramaxillary Anchorage is that form in which 
the appliance is so constructed that other teeth are moved besides the one 
to which the appliance is attached. Fig. 305 shows a jack-screw attached 
to a band on the second premolar with a lingual bar soldered to the band 
Fig. 307-A. 
Fig. 307-B. 
Removable appliances employing compound reciprocal intramaxillary anchorage. 
resting against the molar, premolar and canine, which will move the 
teeth on each side buccally. The appliance used is exactly the same as 
shown in Fig. 303, yet several teeth are being moved when only two 
were moved with primary, or single, reciprocal intramaxillary anchor- 238 
PRACTICAL ORTHODONTIA 
age. The author has used the same appliance in most of the anchorages 
described to show that anchorage does not depend upon certain appli- 
ances. Different appliances can be constructed and used with these an- 
chorages to meet the requirements of the cases. 
Fig. 308-A. 
Fig. 308-B. 
Removable appliance employing compound reciprocal intramaxillary anchorage. 
Compound reciprocal intramaxillary anchorage is the form employed 
when the expansion arch is used, as shown in Fig. 306. It is also the 
anchorage employed in the use of the regulating appliance shown in 
Figs. 307A, 307B, 308A, 308B, 309, 310A, and 310B. In fact, it is used 
in nearly all cases of malocclusion. To be exact, the use of the expansion ANCHORAGE 
239 
arch as shown in Fig. 306 evolves simple compound reciprocal intra- 
maxillary anchorage. 
Reciprocal anchorage is further divided into simple reciprocal and 
stationary reciprocal. 
Fig. 310-A. 
Fig. 309. 
Fig. 310-B. 
Canning's spiral arch which employs compound reciprocal intramaxillary anchorage. 
Simple Reciprocal Intramaxillary Anchorage, either primary or com- 
pound, is where the attachment is made to the anchor tooth or teeth in 
such a manner that the teeth can tip. Fig. 311 shows an expansion arch 
or spring attached to two canines with the object in view of moving them 240 
PRACTICAL ORTHODONTIA 
buccally. The tubes are so placed that the teeth will tip because there 
is a hinge motion possible between the arch and the tube on the band. 
Stationary Reciprocal Intramaxillary Anchorage, either primary or 
compound, is that form in which the appliance is attached to the anchor 
teeth in such a manner that they will be moved bodily through the proc- 
ess. Figs. 312 and 313 illustrate the same small expansion arch as shown 
in Fig. 311, which is again attached to two canines, but the tube is so 
placed on the bands and the end of the arch bent in such a way that the 
canines are moved bodily. In cases where the molars are to be moved 
bodily, an arch with a square end and a tube that is square on the inside 
make stationary reciprocal anchorage on the molars with the expansion 
arch (Fig. 314). 
Fig. 311. 
Simple reciprocal intramaxillary anchorage that allows anchor teeth to tip. 
The use of the ordinary expansion arch with round ends and the wire 
ligatures embodies simple compound reciprocal intramaxillary anchor- 
age. This is the most generally used form of anchorage. 
Intermaxillary Anchorage.-Intermaxillary anchorage has been de- 
fined as that form in which the resistance necessary to overcome the mal- 
posed tooth or teeth is derived from a tooth or teeth located in the oppo- 
site arch. In other words, the malposed tooth and the anchorage are in 
different arches. Intermaxillary anchorage is the newest form that we 
have and has done more to eliminate the extraction of teeth than any 
other. It offers many combinations and is the least understood of any 
of the anchorages by the majority of practitioners. ANCHORAGE 
241 
In regard to the number of teeth moved, intermaxillary anchorage is 
divided into primary and compound, and in regard to the manner of 
movement, into simple, stationary and reciprocal. 
Primary Simple Intermaxillary Anchorage is employed when a tooth 
in one arch is used to overcome the force necessary to move a tooth in 
Fig. 312. 
Fig. 313. 
Stationary reciprocal intramaxillary anchorage. Anchor teeth must move bodily. 
the opposite arch. It is employed in moving teeth that are in infra-oc- 
clusion. An example is shown in Fig. 315, where the canine is in infra- 
occlusion and the anchorage is obtained from the lower premolar. 242 
PRACTICAL ORTHODONTIA 
Compound Simple Intermaxillary Anchorage is that form in which 
one or more teeth in one arch are moved by force derived from teeth in 
the opposite arch. This is shown in Fig. 316, in which case the central 
incisors in infra-occlusion and the force is derived from the lower teeth. 
Primary Reciprocal Intermaxillary Anchorage is that form in which 
the force necessary to move a malposed tooth in one arch is derived from 
a malposed tooth in the opposite arch, the force causing both to assume 
a proper position in the line of occlusion. An upper and lower canine 
that are in infra-occlusion, as shown in Fig. 317, is an example of this 
r ig. 314. 
The square tube and arch used on molars make stationary anchorage on the molars. 
Oval buccal tube shown above, square buccal tube below. 
anchorage. Such cases as illustrated here are seldom seen, as there is 
generally some other malocclusion present demanding treatment at the 
same time. 
Compound Reciprocal Intermaxillary Anchorage is that form in which 
two or more malposed teeth of one arch are pitted against two or more 
teeth in the opposite arch for the purpose of causing both to assume a 
proper position in the line of occlusion. This form of anchorage could 
be used when the six anterior teeth of the upper and lower arch are in 
infra-occlusion, as illustrated in Fig. 318. However, it is very seldom ANCHORAGE 
243 
that we find such conditions that demand an equal movement of the 
upper and lower anterior teeth. The most frequent use of compound 
reciprocal intermaxillary anchorage is in the treatment of Class II, or 
distoclusion, and III, or mesioclusion cases, and according to the early 
literature on the subject, this was the manner in which it was employed. 
It also appears to have been used in this way by Baker and later called 
"Baker Anchorage" by Angle. When all of the teeth in one arch are 
pitted against all of the teeth in the opposing arch, with the object in 
view of moving the teeth in both arches, this form of anchorage is the 
Fig. 315. 
Primary simple intermaxillary 
anchorage. 
Fig. 316. 
Compound simple intermaxillary 
anchorage. 
Fig. 317. 
Primary reciprocal intermaxillary 
anchorage. 
Fig. 318. 
Compound reciprocal intermaxillary 
anchorage. 
one usually employed, as shown in Figs. 319 and 320. It is possible to 
use compound reciprocal intermaxillary anchorage by pitting a certain 
number of the teeth in one arch against a certain number of teeth in 
the opposing arch. This does not mean that the same kind of teeth in 
one arch are pitted against the same kind of teeth in the other. In Fig. 
321 is shown a case in which it was necessary to move the superior in- 
cisors distally and the lower premolars, canines and incisors mesially. 
This was accomplished by using compound reciprocal intermaxillary 
anchorage, the application of which is described in Chapter X. This 244 
PRACTICAL ORTHODONTIA 
Fig. 319. 
Fig. 320. 
Compound reciprocal intermaxillary anchorage used with expansion arches. ANCHORAGE 
245 
form of intermaxillary anchorage should also be called simple, the teeth 
being attached in such a manner as to permit tipping. 
Stationary Intermaxillary Anchorage is that form in which the at- 
tachment is made to the anchor teeth in one arch in such a manner that 
if they move at all they must be dragged bodily through the process, the 
anchor teeth and the moving teeth being in different arches. This form 
of anchorage is obtained by constructing and applying the appliance 
in such a manner as to make tipping impossible and is the outgrowth of 
simple compound reciprocal intermaxillary anchorage. It was found in 
the treatment of certain cases that the lower teeth moved forward more 
Fig. 321. 
An ideal case for the use of compound reciprocal intermaxillary anchorage. 
rapidly than the upper teeth moved distally. In order to stop the move- 
ment of the lower teeth it becomes necessary to make them stationary, 
which was done by the proper construction and attachment of the appli- 
ance. This greatly increased the movement of the upper teeth, while 
the lower teeth remained immovable. If bands are placed on the upper 
and lower molars and the arches applied with intermaxillary rubbers, as 
shown in Fig. 319, we would have compound reciprocal intermaxillary 
anchorage of the simple form. This form of anchorage would permit 
a tipping of the upper and lower teeth, which would make it simple 
anchorage. As stated before, the upper teeth would not move as rapidly 246 
PRACTICAL ORTHODONTIA 
as the lower and by bending the anterior part of the lower arch gingivally, 
also placing wires around the anterior lower teeth, which would spring 
the arch upward to its proper position, a backward force would be ex- 
erted upon the lower molar that would overcome the forward pull of 
the intermaxillary rubbers. The tipping stress exerted upon the lower 
molars by the bent arch and the wires on the lower anterior teeth spring- 
ing the anterior portion upward, converts the anchorage into a stationary 
one on the lower teeth. The upper teeth can still tip. The manner of 
bending the arch and wiring it is shown in Fig. 322. 
As soon as the lower appliance is adjusted, as shown in Fig. 322, the 
anchorage is no longer reciprocal as the lower molars stop tipping. By 
making the attachment on the lower arch, as shown in Fig. 585, the 
lower anterior teeth are also prevented from tipping and must move 
bodily. This forms stationary attachment to the lower teeth. 
Fig-. 322. 
Showing manner of bending lower arch down and then springing upward to make 
lower molars stationary. Dotted line indicates position that lower arch will occupy 
when sprung upward. 
It is very seldom that the teeth of both arches are moved bodily to 
the same extent. What generally occurs is that the teeth of one arch 
are made rigid by the attachment of the appliance so as to prevent move- 
ment and the teeth of the other arch are so attached to the appliance 
that they will move bodily. This would then be only another form of 
compound stationary intermaxillary anchorage. An example of the 
stationary attachment of teeth in both arches is seen in Fig. 285, which 
is a Class II, Division 1 (distoclusion, with labioversion of the upper 
anterior teeth) case. It has been found that the best results in these 
cases are obtained by not moving the upper molars and canines distally, ANCHORAGE 
247 
and moving the entire lower arch or teeth mesially the entire distance 
necessary to establish normal occlusion. Also, the best facial results and 
masticating apparatus are obtained by moving the lower teeth bodily. 
Bands are placed on the upper and lower molars. The upper arch is 
Fig. 323. 
Occipital extramaxillary anchorage. (Angle.) 
Fig? 324. 
Occipital extramaxillary anchorage. (Angle.) 248 
PRACTICAL ORTHODONTIA 
ligated to all of the upper teeth in such a manner as to prevent the upper 
molars from tipping. If the anterior portion of the upper expansion 
arch cannot move occlusally, the molars cannot tip. The lower expansion 
arch is also wired to the lower teeth so as to prevent tipping of the 
molars; to prevent tipping of the incisors, spurs are placed on the lower 
arch and the incisors wired to them in such a manner as to hold the 
teeth perpendicular with the spurs, as shown in Fig. 528. The advan- 
tage of stationary compound intermaxillary anchorage whether used re- 
ciprocally or not is very great and is the last form of intermaxillary an- 
chorage to be introduced. 
Fig. 325. 
Cervical anchorage. (Carl Case.) 
Extramaxillary Anchorage.-Extramaxillary anchorage is that form 
in which the resistance necessary to overcome the malposed tooth or 
teeth is derived from some source outside the oral cavity. It offers the 
most immovable base that can be obtained. The principal objection is 
the appearance of the appliance. There are three types of extramaxillary 
anchorage-occipital, facial and cervical. 
Occipital Anchorage is where the force necessary to overcome the mal- 
poscd tooth is derived from the occipital region. This is one of the oldest 
forms of anchorage of which we have a record. It was first used with 
an ordinary night-cap and was improved and modified by various means 
until we find the most ideal form as designed by Angle (See Figs. 323 
and 324). ANCHORAGE 
249 
Facial Anchorage is where force necessary to overcome the malposed 
teeth is derived from the facial bones. This anchorage was introduced 
by V. E. Barnes and consists of a device which rests against the molar 
bones and forehead. 
Cervical Anchorage was introduced and first applied, to the author's 
knowledge, by Carl Case (Fig. 325), and is that form in which the force 
necessary to overcome the malposed teeth is derived from the cervical 
vertebras (Fig. 325). Occipital anchorage was used in those cases that 
demanded a distal movement of the anterior teeth. It was used on the 
superior anterior teeth, as shown by Fig. 323, and by means of the chin 
cap (Fig. 324) the pressure was exerted on the mandible. It was also 
used to exert pressure on the lower anterior teeth, but there was a tend- 
ency to elongate the lower anterior teeth. It was to overcome this tend- 
ency to elongate the lower anterior teeth that cervical anchorage was 
devised. Facial anchorage was devised to move the teeth mesially, and 
is valuable in those cases that demand the forward movement of the upper 
and lower molars. If one is able to use the various other anchorages as 
they should be used, there is little need for extramaxillary anchorage. 
Owing to the fact that reciprocal anchorage utilizes all of the force ex- 
erted on the malposed teeth, it is the most useful form of anchorage. 
With intermaxillary anchorage in the various compound, reciprocal, and 
stationary forms, we are able to get tooth movement in any particular 
direction desired. Simple anchorage is the easiest to obtain but not 
always sufficient for the needs of the case. Stationary anchorage re- 
quires a greater understanding of mechanics than any other form. The 
principal and most useful forms of anchorage will be considered in the 
chapter on treatment of cases. CHAPTER VII 
RETENTION OF TEETH 
It has been said that the problem of modern orthodontia is one of re- 
tention. With the modern regulating appliances it becomes cpiite easy 
to regulate teeth, but to keep them in their new position has been dif- 
ficult. 
Forces of Retention 
Retention is the application of force to maintain teeth in their proper 
position in the line of occlusion. Not only must the teeth be retained 
in position in the line of occlusion, but they must often have force ex- 
erted upon them to assist them in assuming different angles and lengths 
than are present immediately after the regulating appliance is removed. 
It has been said that retention is the application of force to maintain 
and produce normal occlusion. It must be remembered that teeth are 
not held rigid in the dental apparatus but are constantly moving under 
the stress of mastication; also that they are held in position by the forces 
of occlusion and are constantly changing positions during the growth 
of the individual. Therefore the force exerted upon the teeth during 
retention must be exerted with that idea in view. 
The forces of retention are mechanical and natural. 
Mechanical Forces 
Mechanical forces are those that are exerted by artificial devices. They 
exert force until the natural forces can establish themselves, for it must 
be remembered that all cases of malocclusion are the result of interference 
with some of the forces of occlusion. In other words, some one of the 
natural forces of retention has not been active. 
Mechanical forces are divided into active and passive. 
Passive Mechanical Forces are those that antagonize the backward 
tendency of the teeth only, and do not exert any force, simply resisting 
the efforts of the teeth to return to their former position. Angle has 
said that teeth should be retained against their backward tendency only. 
This backward tendency of the teeth can be prevented by the use of 
passive force. 
250 RETENTION OF TEETH 
251 
Active Mechanical Force is obtained by the use of an appliance that 
possesses some force in itself, and a constant force is being exerted by 
the retaining appliance equal to that exerted by the backward tendency 
of the teeth. The advantage of such a force enables us to use a more 
delicate appliance, gives us a chance to regulate the force exerted upon 
the teeth, and permits the teeth to move under the stress of mastication, 
as a result of which they assume normal positions more readily, by the 
natural forces of retention or occlusion being able to exert themselves. 
Besides being divided into active and passive forces, mechanical ap- 
pliances are divided into intramaxillary, intermaxillary, and extramax- 
illary. 
Intramaxillary Retention is where the mechanical force necessary to 
overcome the backward tendency of the teeth in one arch is derived from 
a tooth or teeth in the same arch. It may be either active or passive. 
Intermaxillary Retention is where the force necessary to overcome 
the backward tendency of the teeth is derived from teeth in the opposite 
arch. It may be active or passive. 
Extramaxillary Retention is where the force necessary to overcome 
the backward tendency of the teeth is derived from some source outside 
of the oral cavity. This is always an active force. 
Intramaxillary retention is divided into simple, reciprocal and station- 
ary. Reciprocal is further divided into primary and compound. Sta- 
tionary should not be used as it holds the teeth too rigid. 
Intermaxillary retention is also divided into simple, reciprocal and 
stationary. Reciprocal is again divided into primary and compound. 
Extramaxillary retention is divided into occipital, cervical and facial. 
No form of extramaxillary retention is often used. 
With this outline of mechanical retention we will take up the prin- 
ciples of the natural forces, which, it must be remembered, are the final 
solution to the retention of teeth. 
Natural Forces 
The natural forces of retention are the same as the forces of occlusion, 
as follows: 
1. The force of the inclined plane. 
2. Harmony in the size of the arches. 
3. Normal muscular pressure. 
4. Normal approximal contact. 
5. Normal cell metabolism. 
6. Normal atmospheric pressure. 252 
PRACTICAL ORTHODONTIA 
Taking the forces more in the order given above than in their order 
of importance, for it is hard to say which is the most important, we will 
begin with one with which all are familiar, viz., the "Normal relation 
of the inclined plane." 
Force of the Inclined Plane.-Since so much has been written on this 
as a force of occlusion, it will be unnecessary here to go into details. 
However, the author wishes to caution the reader again that the lingual 
cusps are as important as are the buccal cusps. We must keep in mind 
the various shapes of the teeth, especially the lower premolars; also the 
position that they occupy in the arch. 
Fig. 326 shows the different shapes of the lower second premolars. 
They are illustrations made from a skull and model in the author's pos- 
session. The lower second premolar with three cusps is not so rare as 
might be supposed and each cusp has a definite occlusion. 
Fig. 326. 
Different shapes of lower premolars, which must be considered in retention. 
We must also take into consideration the fact that the lower premolars 
do not occupy the same angle of inclination as do the upper premolars 
(Fig. 327). A line drawn through the buccal and lingual cusps of the 
upper premolars would not be parallel to one passing through the lower 
premolars. The line from the lower premolars would cross with the 
apex of the angle to the lingual of the teeth. It is the author's opinion 
that in a great many cases, the lingual cusp of the lower first premolar 
has been too far mesially in the attempt to get it parallel with the upper. 
This change has invited the distal surface of the lower canine to turn 
buccally. These things we must watch, for the influence of the inclined 
planes in holding the teeth is well understood. We can even determine 
at the beginning of the case by observing the length of the cusps whether 
we will have any difficulty whatsoever in getting the natural forces of RETENTION OF TEETH 
253 
occlusion to assert themselves. Also, in speaking of the length of the 
cusps in relation to the forces of the inclined planes as a factor in re- 
tention, we should not forget the importance of the length of the cusps. 
In order that we may not have undue trouble in getting the teeth to re- 
main where we desire them, and in order that the forces of the inclined 
planes be exercised to their fullest capacity, we must be sure that the 
length of the overbite be no greater than the length of the buccal cusps 
of the molars and premolars. In other words, when the anterior teeth 
are edge to edge, the tips of the buccal cusps should just touch. By study- 
ing a great many models, we shall find when the cases are retained that 
we do not always have that condition, and in those cases in which it does 
occur, experience will prove that they are the ones in which we have 
our best results; they are the ones from which we have been able to re- 
move the retaining appliance early. If the length of the overbite is not 
the same as the length of the buccal cusps of the molars and premolars, 
Fig. 327. 
Showing the different angles that the lower and upper premolars occupy in the arch. 
we must so adjust the retaining appliance that the teeth will be forced 
to assume the normal position. Great care must be exercised in making 
the retaining appliance so as to assist and permit the overbite of the teeth 
to become normal. In this class of cases, the importance of the active 
mechanical retaining appliance becomes apparent. The force of the 
inclined plane with reference to the overbite and as a factor in retention, 
will be again taken up in conjunction with the approximal contact point. 
Harmony in the Size of the Arches.-In speaking of harmony in the 
size of the arches in retention, very little need be said, for if the reader is 
familiar with normal occlusion, he should understand the importance 
of this force of retention. However, in order that the reader may better 
appreciate this condition, the author will call attention to several cases 
in which this one factor has been neglected. It is true that harmony in 
the size of the arches cannot be disturbed without throwing out some 
other force to a certain extent. The importance of keeping the proper 254 
PRACTICAL ORTHODONTIA 
mesio-distal relation of the teeth in all cases, in order that we may have 
the proper size of each arch, is as important in the deciduous as in the 
Fig. 328. 
Fig. 329. 
Inharmony in size of arches produced by extraction, making the establishment of 
normal occlusion impossible, also interfering with retention. RETENTION OF TEETH 
255 
permanent teeth. The evils of extraction are so apparent that it is hardly 
necessary to mention them. Aside from destroying the facial contour 
and expression of the patient, extraction renders the establishment of 
normal occlusion impossible, because it forever destroys the possibility 
of again having harmony in the size of the arches. Owing to the fact 
that no two teeth in both arches are exactly the same size, the arches 
would not be of equal size should any of the teeth be extracted. There- 
fore, when in a "fit of wisdom" some one takes out different teeth in 
opposite arches, normal occlusion becomes a thing impossible for that 
patient without artificial substitutes. The case shown in Figs. 328 and 
329 is one of this kind. Fig. 330 shows a case with a lower second molar 
Fig. 330. 
Inharmony of arches produced by the prolonged retention of lower second premolar. 
retained too long. An x-ray showed that the premolar is absent. The 
normal relation of the teeth can be seen in the models, but the molars did 
not remain as shown. Because the lower molar was held distally at the 
time of the eruption of the upper second molar, the first molar was car- 
ried forward as it should have been and now the lower is distal to nor- 
mal, not because there was not proper locking of the molar cusps, but 
because of the inharmony in the size of the arches. In the latter case, 
regardless of how long mechanical retention would be employed, normal 
occlusion of all of the teeth could not be maintained when the retainer 
was removed, because of the missing natural force of retention. This 
brings us to the important fact that all fillings and artificial substitutes 256 
PRACTICAL ORTHODONTIA 
should have the proper mesio-distal diameter as well as the proper in- 
clined plane and normal approximal contact. In fact, if one force is 
missing, some of the others will soon be thrown out of balance. 
Normal Muscular Pressure.-The importance of normal muscular 
pressure is well shown in any case in which the patient is a mouth- 
breather. Of course, some of the deformity that we see in those cases 
is the result of abnormal atmospheric pressure. Nevertheless we must 
have the harmonious action of the lips and tongue in order that normal 
occlusion may be maintained. The great amount of deformity that we 
find in cleft palates is the result of the muscular pressure that has no 
constraining influence. Likewise, in abnormal frenums, we see the 
effect of abnormal muscular action caused by the abnormal attachment 
of the frenum. We also find eases of large tongues that produce maloc- 
clusions. These cases must be treated with the object in view of getting 
the teeth in such a position that when they are retained the muscular 
pressure will be normal. Cases that are tire result of tongue and lip 
habits are very difficult to retain because these habits destroy the normal 
muscular relations. 
The importance of the action of the various muscles as a factor in 
producing and maintaining the proper relation of the teeth has long 
been a recognized fact. It is one that has also been improperly under- 
stood. It should be remembered that we have but four pair of muscles 
of mastication. They are all attached in the region of the ramus, that 
is, they are inserted into some portion of the ramus or angle; none of 
them are inserted forward into the body of the bone. Therefore, all of 
the force that they exert on the body of the mandible must be transmitted 
through the teeth during mastication. If we have malocclusion, we shall 
not find the proper development of the body of the mandible because of 
the improper stimulation as a result of the improper muscular force. 
This is especially true in Class II and III cases. 
The muscles of expression play an important part in maintaining oc- 
clusion and their action is almost entirely confined to the eight anterior 
teeth. This is easily understood when we consider that all of the muscles 
of expression, except the levator menti, are inserted into the obicularis 
oris; therefore, the result of their action would be apparent at the point 
of insertion or in the region of the anterior teeth. All of the muscles 
of expression acting normally will maintain normal occlusion while any 
of them acting abnormally will produce malocclusion. When we con- 
sider that it is necessary to have the sum total of the muscles of expres- 
sion, levators and depressors of the mandible, in order to maintain normal 
occlusion, and that any group of any muscle acting abnormally will pro- RETENTION OF TEETH 
257 
duce malocclusion, we readily see what a large part muscular action plays 
in retention. 
Normal Approximal Contact.-The force of the approximal contact 
differs from the force of the inclined plane in several respects. First, 
the inclined plane of the tooth acts on the occluding incline of the tooth 
in the opposite arch, while the approximal contact acts on the adjoining 
tooth in the same arch; also, the inclined plane is an active force while 
the approximal contact is a passive force; that is, we see the result or 
the lack of it through other forces. For example, we may consider the 
blocks of stone in a masonic arch; as long as they are in their proper 
place the passive force that they exert to hold up the structure above them 
is great. If one of them be removed or displaced the entire arch will 
collapse because of the absence of the force exerted by the approximal 
contact. A simpler example would be the staves of a barrel. Here the 
pressure of the staves is balanced by the force of the hoops. Both are 
passive, yet if one stave is removed or broken the entire barrel will fall 
to pieces. The hoops and staves of a barrel occupy very much the same 
relation to each other that the approximal contact of the teeth and the 
muscular pressure bear to normal occlusion. 
The example that the author has cited above, in trying to show what 
is meant in regard to the passive force of the approximal contact of the 
teeth, may be further shown with billiard balls, or any spheres of the 
same size. As the approximal contact of the teeth is but a point, the 
example of the sphere may be better. If you take three spheres and 
have them touching each other, lying in a straight line, you will be able 
to apply great pressure from the opposite sides of them providing this 
pressure is also in a straight line; the spheres will occupy the same 
relative position and will not move. However, if you deflect the line 
of the application of your force but slightly, one or all of the spheres 
will be moved from the position. Likewise, if the teeth are so arranged 
in the dental arch that the approximal contact points are normal, each 
tooth will remain in its proper position and the proper shape of the 
arch will be maintained. All of the active forces that are brought to 
bear on the teeth and arches will be resisted by the passive force of 
the approximal contact points of the various teeth. Many cases have 
resulted in failure when all other things were as near normal as was 
possible under the circumstances. A position that needs watching is 
that of the canines, especially the lower, for if they are not placed so 
that the approximal contact is correct, we shall soon find them slipping 
out of place and the entire arch collapsing, as a result of which the nor- 
mal occlusion will soon be destroyed. As may be imagined, those teeth 258 
PRACTICAL ORTHODONTIA 
that are not well supported by the inclined planes require a greater 
amount of watching than do the premolar or molar series. This brings 
us to the fact that there is a definite relation existing between the in- 
clined planes and the width of the approximal contact. 
Normal Cell Metabolism.-If the cell metabolism is normal, we shall 
have the proper development of the peridental membrane and alveolar 
process. It is evident that the teeth are supported by the above named 
structures and in the majority of cases the alveolar process develops to 
support the teeth accordingly as the forces are applied. Of course, the 
peridental membrane is that "membrane which covers the root of the 
tooth occlusally to the enamel, the fibers of which pass from the cemen- 
tum into the connective tissue supporting the epithelium, into the fibrous 
mass of gum, into the periosteum, into the cementum of the adjoining 
tooth, and into the alveolar wall." This shows that the peridental mem- 
brane not only supports the tooth but also supports the soft tissue 
around the tooth and some of its cellular elements form the bone of 
the alveolar wall. This places the peridental membrane as the prime 
factor that has to do with the permanent retention of the tooth. If all 
of the other forces are normal the peridental membrane will do its part 
and a normal alveolus will result and the tooth will be permanently 
retained. Unfortunately we often find conditions that arise and make 
the end we wish to obtain impossible-sometimes the result of condi- 
tions that we cannot govern and at other times the result of our care- 
lessness. Factors that we cannot control are those that arise in cases 
of lowered vitality, especially rickets, which disturb the normal cell 
metabolism. In such cases, the bone formed will be of such faulty 
structure that the teeth will not remain where placed. Those that we 
can govern are those that arise when we tamper with some of the forces 
mentioned, or when we so construct our retaining appliance that the 
natural forces cannot do their work. One of the most common mistakes 
is to make an appliance so that the teeth will be held rigid: one that will 
support the teeth in every direction and not allow any of the force 
of mastication to fall on the teeth; constructing mechanical retainers 
so as to interfere with the proper approximal contact of the teeth; or 
holding the teeth so that the influence of the inclined planes becomes 
inactive. In order that the peridental membrane may perform its 
proper function, in order that the osteoblasts may deposit and build 
bone as they should, it is necessary for the teeth to be used as they 
should. In other words, the proper force must be brought to bear on 
the teeth at all times. RETENTION OF TEETH 
259 
Normal Atmospheric Pressure.-Another force that is difficult to 
classify, yet one that must be taken into consideration in the retention 
of teeth, is the force of the atmosphere in respiration and deglutition. 
The air as it passes through the nasal cavity, filling all of the sinuses 
as it does, exerts a wonderful pressure in the course of a year. The 
pressure may be slight with each breath, but when this force is added 
or subtracted, during the growing period of the child's life a great 
difference will be noted. Also, with each act of swallowing we have the 
pressure of the tongue and lips plus the pressue of the air as a factor 
that plays an important part in the retention of teeth. In order to 
get the advantage of the forces we must be sure that we have a normal 
nasal tract as well as a normal occlusion. Retention will be a failure 
unless the child is receiving its supply of oxygen in the proper manner. 
Summary of Forces of Retention 
In summing up these forces of retention, the author wishes to im- 
press upon the readers their importance as grouped together in certain 
cases. Beginning with the last one, normal atmospheric pressure, we 
find that it is very closely associated with normal muscular pressure- 
so closely that if one is faulty the other is sure to be. If the nasal tracts 
are closed or not properly developed, abnormal muscular pressure will 
result, caused by abnormal breathing. In case of enlarged tonsils, we 
see the evil effect of long enforced voluntary muscular action, as the 
child endeavors to relieve the pressure and render breathing freer. It 
would be useless to expect retention to be a success as long as this ab- 
normal pressure of the muscles and forced mouth-breathing are con- 
tinued. No matter how long mechanical retention is employed, failure 
would be the final result. 
As the cells of the peridental membrane respond to any force that is 
brought to bear upon the teeth, it is evident that any of the forces of 
occlusion that are wrong will also exert some evil influence upon the 
cellular elements, and the development of the tissue will be faulty. 
Attention has already been called to the length of the overbite as com- 
pared with the length of the buccal cusps, of the molars and premolars. 
In the normal denture, the length of the overbite should be the same as 
the length of the buccal cusps. This is the condition as found in the 
teeth before abrasion and wear have taken place. As man advances in 
age, and as the teeth are worn down, we find that the wear of the molars 
and premolars corresponds with that of the anterior teeth. This per- 
mits the "end-to-end" bite as described by A. H. Thompson. It also 260 
PRACTICAL ORTHODONTIA 
accounts for the mistakes made by some who thought, because they 
found this end-to-end bite, that we had no normal occlusion. The author 
has shown that the teeth are retained by the inclined plane and the 
harmony in the size of the arches. As the cusp and the overbite are 
worn off, it is plain to all that the force exerted by the inclined plane 
becomes less and less. The harmony in the size of the arches is main- 
tained and the approximal contact becomes more important. In fact, 
as the influence of the inclined plane is lost, the approximal contact 
becomes more important until it is exerting more force in maintaining 
normal occlusion than the inclined plane exerts. It would then be safe 
to say that the teeth are guided and held in place in early life by the 
inclined plane. When the dental apparatus becomes complete, the 
approximal contact becomes an important factor and as the force of the 
inclined plane is lost, it (approximal contact) becomes the greatest force 
that holds the teeth where they belong. 
As the length of the cusp decreases the width of the approximal con- 
tact increases. This change can be followed in the study of the human 
denture and in the study of evolution. In a well-formed dental appa- 
ratus-one which has not been long used-we find that the approximal 
contact is but a point; also that it is some distance from the occlusal 
surface of the teeth. As the cusps and cutting edge of the teeth are 
worn off, the occlusal surface becomes near the approximal contact point 
until finally the contact point is close to, and later at, the occlusal sur- 
face. After the teeth become worn off to a greater extent, the contact 
point is reached; it is worn down and a greater surface of the teeth is 
in contact than was the case early in life. Instead of having but a point 
in contact, we have a surface. When the teeth have been in a position 
of malocclusion for some time, the approximal contact point becomes 
worn abnormally. As a result of this, it becomes extremely difficult to 
keep them in their proper position. That is why it has been found so 
difficult to make teeth, which have occupied positions of torsi-occlusion, 
retain their proper position in adults. It is not because of the age of 
the patient but because of the abnormal approximal contacts. There- 
fore, the relative importance of the inclined plane and the interproximal 
contact as a factor in retention changes during the lifetime of the in- 
dividual. 
The natural forces of retention must always be considered in the con- 
struction of the mechanical retaining appliance. The mechanical device 
is only to aid nature and nothing must be done that will interfere with 
the forces of occlusion. With this view in mind we will pass to the 
consideration of mechanical devices. RETENTION OF TEETH 
261 
Mechanical Forces of Retention 
Simple Passive Intramaxillary Retention-The first form of me- 
chanical retention used was simple passive intramaxillary. In this form, 
we take advantage of some tooth that has not been moved to hold a tooth 
that has been moved. We depend upon the large and favorably located 
teeth to retain the ones that have been moved. It does not require much 
force to prevent a tooth from returning to its old position; therefore, as 
a rule, the retaining appliance can be made very simple. It may be a 
band and spur, as shown in Fig. 331. In making use of the band and 
spur, as far as the principle is concerned, it makes no difference whether 
the band is placed on the tooth that has been moved or on the firm tooth. 
The advantage of this form of retention is the ease with which it can 
be constructed. Having a firm tooth as a base, no mechanical construc- 
tion of the appliance is needed to assist in retention. Simple passive 
intramaxillary retention is seldom used, for in most cases of malocclu- 
sion it becomes necessary to move so many teeth that there are none 
Fig. 331. 
Simple passive intramaxillary retention. 
that have not been moved that can be utilized as the base for retention. 
Simple Compound Intramaxillary Retention.-Compound retention 
of this variety is where a number of teeth that have been moved are 
retained by one or more teeth that have not moved. This is the style of 
retention used in cases resulting from lip habits, where the superior an- 
terior teeth have been forced outward without disturbing the canines. 
After the four anterior teeth have been placed in their proper position, 
bands are placed on the canines with a wire running labial to the incisors, 
soldered to the canine bands, which will prevent the superior anterior 
teeth from again retruding. This form of device is simple compound 
intramaxillary retention. 
In some cases, where there is a great tendency for the corrected tooth 
to return to the old position, the retainer is made in such a manner that 
it will exert an active force. This is accomplished by having the spur 
made from some material that possesses spring, and so made and ad- 262 
PRACTICAL ORTHODONTIA 
justed that a spring force will be exerted upon the malposed tooth to 
overcome the backward tendency. 
Stationary Intramaxillary Retention can be produced but is not de- 
sirable. Tn those cases in which the teeth are held rigid, it has been 
found that the normal cell metabolism is interfered with to such an 
extent that the teeth do not become firm. Therefore, every effort should 
be made to allow the teeth to respond to the forces of mastication as much 
as possible. 
Reciprocal Intramaxillary Retention is used in those cases that have 
been regulated with reciprocal anchorage. It is the pitting of the back- 
Fig. 332. 
Simple primary reciprocal intramaxillary retention. 
ward tendency of one tooth that has been moved against the backward 
tendency of another tooth that has also been moved. The simplest form 
of this principle is shown in Fig. 332, where two central incisors have 
been moved toward each other. By passing the ligature wire around 
them, one is made to retain the other. This is primary reciprocal re- 
tention of the passive variety-primary, because the appliance is hold- 
ing only the teeth to which it is attached; passive, because there is no 
spring or pull in the ligature, which only occurs as the teeth try to re- 
turn to their old position. 
Compound Reciprocal Retention is where the backward tendency of 
two or more teeth is overcome by the backward tendency of two or more RETENTION OF TEETH 
263 
other teeth, which are trying to return in an opposite direction. Fur- 
thermore, the appliance is so constructed that it is attached to less teeth 
than the number that are being retained. With this form of appliance 
we have the greatest working efficiency. Compound reciprocal retention 
is used in the active and passive form. Compound passive reciprocal 
intramaxillary retention is often employed in retaining the six anterior 
teeth. An example is shown in Fig. 333, in which the six anterior teeth 
have been moved. All of the teeth have been moved from positions of 
lingual occlusion. By placing bands on the canines and soldering a 
wire on the lingual sides of the bands so that it will engage the lingual 
surface of the incisors, the six teeth are retained by the one appliance. 
Fig. 333. 
Compound reciprocal intramaxlllary retention ; lingual bar. 
The lingual tendency of the canines is overcome by each other and the 
backward tendency of the incisors is also overcome by the same appli- 
ance, which justifies the use of the term compound reciprocal intramax- 
illary retention. As there is no spring to the appliance, it only exerts 
force as the teeth try to return, being called passive retention. This 
principle can be carried further, and by placing bands on the molars 
and canines and soldering a wire on the lingual side of these bands, the 
retainer can be made to retain all of the teeth in the arch, if they have 
all been in lingual occlusion. 
In using the lingual retainer just described on all of the teeth in one 
arch, it has been found that the force of the teeth may be greater than 264 
PRACTICAL ORTHODONTIA 
the passive force exerted by the appliance. As a result, the arch would 
contract and the teeth would assume a position of malocclusion, much 
to the chagrin of the operator. To avoid this, active compound recip- 
rocal intramaxillary retention was devised, which consists in making 
the lingual retaining wire out of some material that has a spring, and 
which is so constructed that the pressure of the spring can be regulated. 
If the teeth are exerting more force than is exerted by the retaining 
wire, the wire is removed from the small open tubes holding it in place 
and more spring given to the lingual wire, which makes the appliance 
of sufficient strength to hold the teeth (Fig. 334). By making an ap- 
pliance of this kind we are able to have one of smaller bulk and have 
absolute control over the teeth at all times. There are other forms of 
Fig. 334. 
Simple compound reciprocal intramaxillary retention, with removable lingual bar. 
retaining devices that utilize this principle, which are fully described 
in the chapter on treatment. 
Intermaxillary Retention is where the force necessary to overcome 
the backward tendency of the teeth in one arch is derived from some 
teeth in the opposite arch. This form is primary and compound, active 
and passive, also simple and stationary. Primary passive intermaxillary 
retention is where the backward tendency of one tooth in one arch is 
overcome by a tooth in the other. The most common form of this re- 
tention is when the loss of the upper second deciduous molar makes it 
necessary to hold the upper first molar distally. This form of retention 
can be taken advantage of by cementing a pin on the occlusal surface 
of the lower second deciduous molar so as to engage the mesio-occlusal RETENTION OF TEETH 
265 
surface of the upper first molar. The favorable location of one tooth 
to the other makes possible this form of retention. 
Active Primary Intermaxillary Retention is where the force neces- 
sary to overcome the backward tendency of a tooth in one arch is ob- 
tained from a tooth in the opposite arch. An example of this is shown 
in Fig. 335 in which a canine, which was in infra-occlusion, has been 
brought to the proper position. In order to retain it there a rubber 
band is attached to the lower first premolar. 
Reciprocal Intermaxillary Retention is where the backward tendency 
of the teeth in one arch is overcome by the backward tendency of the 
Fig. 335. 
Retention of superior canine, which was moved from infra-occlusion retained by 
rubber band from lower premolar, which makes active primary simple intermaxillary 
retention. 
teeth in the opposite arch. This may be primary or compound, but in 
most eases is compound. It may be used either active or passive. 
Passive Reciprocal Simple Intermaxillary Retention is where the 
backward tendency of the teeth in one arch is overcome by the back- 
ward tendency of the teeth in the other arch, the appliance being so 
constructed and attached that the teeth will be tipped if sufficient force 
is exerted upon the appliance. The appliance is made so that it exerts 
force upon the teeth only as they try to return to their old positions. 
Should the appliance become bent or the teeth slip slightly no force 
will be. exerted, which will regain what has been lost. Passive inter- 
maxillary retention has been used for some time in the retention of 266 
PRACTICAL ORTHODONTIA 
Class II, Division 1 cases, or in fact in any class of cases in which the 
mesio-distal relation of the teeth has been changed. 
Plane and Spur Retention.-A form that was much used was de- 
scribed by Angle and has been known as the "plane and spur." It 
consists of a band fitted to an upper and lower tooth, generally to the 
first molars, which have been chosen on account of their size and strength. 
Fig. 33 6. 
Plane and spur, which is passive reciprocal intermaxillary retention. (Angle.) 
A plane is soldered on the buccal surface of the upper band (Fig. 336) 
and a spur on the buccal surface of the lower band for the purpose, in 
Class II, of engaging the anterior part of the plane on the upper molar 
band. This retainer antagonizes the backward tendency of the teeth, 
but the disadvantages lie in its principle: First, it depends only upon 
the firm location of the molar teeth to supply the resistance necessary 
Upper molar 
.Clamp band 
-with plane 
-Clamp band 
- with spur 
Lower 1st. molar 
Fig. 337. 
Shows how force of passive retention in Class II tends to tip upper and lower molars. 
to prevent the backward tendency of the teeth; second, there is no at- 
tachment or construction of the appliance that will give the teeth any 
assistance; and, third, the force is entirely passive, that is, if the teeth 
drop backward the least bit, there is no way of regaining the movement 
lost. It very often happens that the teeth to which this appliance is 
attached will be tipped, as shown in Fig. 337. This allows the teeth RETENTION OF TEETH 
267 
mesial and distal to the ones to which the appliance is attached to as- 
sume incorrect positions. Many different forms of the plane and spur 
have been used and attached to different teeth, but the principle has 
always remained the same. 
Passive Reciprocal Stationary Intermaxillary Retention is that form 
in which the teeth in one arch are made to overcome the backward ten- 
dency of the teeth in the other, the appliance being so attached that the 
teeth supporting it cannot tip at all. Figs. 338 and 339 illustrate very 
clearly what was intended to be done, but the great disadvantage was 
that it held the teeth too firm and for that reason this form of retention 
was used by the author only on one case. 
Fig. 338. 
Fig. 339. 
Showing passive reciprocal stationary intermaxillary retention, which is a very un- 
satisfactory form to use. 
Active Reciprocal Intermaxillary Retention is where the force neces- 
sary to retain the teeth that have been moved in one arch is derived 
from the teeth that have been moved in the opposite arch, and is of an 
active nature. Various forms of this principle are employed-e. g., 
primary, when a tooth in one arch is used to retain a tooth in another 
arch. This form is used when a canine in the upper arch, which has 
been moved from infra-occlusion, is used to retain a lower tooth moved 
from the same position, by placing a band on both teeth and connecting 
them by means of a light rubber ligature. Fig. 340 illustrates such a 
condition. 
Compound Active Reciprocal Intermaxillary Retention is used when 
the teeth of one arch are made to retain the teeth in the opposite arch, 268 
PRACTICAL ORTHODONTIA 
the teeth in both arches having been moved. This is the form of reten- 
tion used in the retaining of cases caused by tongue habits. The use 
of the rubber ligature that supplies the active force causes a better re- 
tention than the use of any other appliance. 
Compound active reciprocal intermaxillary is most useful in the re- 
tention of Class II, or distoclusion, and III, or mesioclusion, cases. One 
form is shown in Fig. 341. The details of construction are discussed 
Fig. 340. 
Active primary reciprocal intermaxillary retention used to retain canines that have 
been in infraversion. 
in Chapter X, under treatment of Class II, or distoclusion, and III, or 
mesioclusion, cases. The chief advantages of this form of retention are 
that it prevents the tipping of the molars and can be so adjusted as to 
aid the settling of the inclined planes of the teeth. The use of this form 
of retention has displaced all others in the author's practice for Class 
Upper ist. molar 
clamp 
v band 
Plain 
Band 
'Spurfor ruober 
on Lower 1st. molar 
Fig. 341. 
Compound active reciprocal intermaxillary retention used in Class II, Division I cases. 
(See also Fig. 536.) 
II, or distoclusion, and III, or mesioclusion, cases. It will be consid- 
ered further in the treatment of cases. 
Extramaxillary Retention is that form in which the force necessary 
to retain the teeth is derived from some source external to the oral 
cavity. It is derived from the occipital, cervical or facial region and is 
very little used. The author has never had occasion to make use of any 
of these forms. CHAPTER VIII 
IMPRESSIONS AND MODELS 
Preliminary Consideration of Cases.-One of the essential things in 
the treatment of eases is a thorough understanding of the conditions. 
The case must be studied with the object in view of learning the cause 
of the malocclusion. The history of the case should be gone into in order 
to learn whether nasal obstructions, constitutional conditions or habits 
have played a prominent part in the production of the malocclusions. 
Very little should be said in regard to the prognosis of the case until 
after the condition has been studied from models made from good im- 
pressions. 
It is very necessary that an orthodontist should be able to take the im- 
pression skillfully and without annoying or agitating the patient. Many 
patients have been frightened away from the operator because of the 
crude manner in which he obtained the impression. 
Taking the Impression.-In order that we may obtain the best im- 
pression possible-for without a good impression we cannot have a 
good model-plaster must be used. The advantages of plaster are so 
apparent that it is hardly necessary to mention them here. It is the only 
material that will give an accurate reproduction of the condition as it 
exists. The more pronounced the malocclusion the greater the need 
of plaster. In the hands of the skilled operator it is no more objection- 
able to the patient than modeling compound. Modeling compound has 
a place in dentistry, but not in orthodontia, for the making of record 
models. Modeling compound impressions can be used for study models 
and for models to be used in the construction of appliances, lingual 
arches, and retainers. The teeth should be carefully cleaned, and the 
mucus removed from the teeth and gums as thoroughly as possible. A 
tray larger than the dental arch should be selected, being perfectly 
smooth on the inside and having high walls, as shown in Fig. 342. One 
with a quarter of an inch between the teeth, alveolar process and the 
edge of the tray is preferable. The tray should be of a material that 
will permit bending so that it can be shaped to the dental arch. The 
tray must be placed in the mouth and the cheeks and lips pulled over 
it, which enables the operator to observe how it fits and the patient to 
269 270 
PRACTICAL ORTHODONTIA 
become familiar with the sensation. If the patient has a tendency to 
gag or is frightened, the impression must not be taken until all fear is 
allayed, and a tray should be selected that will not produce nausea. 
When about to take the impression, the patient is carefully protected 
Fig. 342. 
Plaster trays. 
with a suitable towel or large apron. It is unnecessary to distribute 
debris of plaster upon the clothes of the patient, or to allow it to ac- 
cumulate upon the floor of the operating room. All that is needed is an 
ordinary towel with the corners pinned up to make a pocket into which IMPRESSIONS AND MODELS 
271 
the excess pieces of plaster are dropped when the impression is being 
taken. 
A quick-setting plaster should be chosen so that it will not be neces- 
sary to keep the material in the patient's mouth very long. A small 
plaster bowl (Fig. 343) holding the required amount of water is used, 
and the use of salt depends upon the rapidity with which the plaster 
sets and the ability of the operator to work rapidly. 
The plaster is slowly sifted into the water until the water will take 
no more plaster. Then it is carefully removed from the bowl and placed 
in the tray, as shown in Fig. 344. A liberal amount of plaster should 
be inserted around the buccal and labial parts of the tray, but none 
should be placed in the palatal part. The tray is placed in the mouth 
Fig. 343. 
Piaster bowl, which must be smooth inside, so that hard plaster can be removed. 
and the part of plaster that has been placed on the labial part and handle 
of the tray, is carefully worked under the lip and cheek. This is done to 
be certain that no air is caught between the lip and impression. After 
the plaster has been placed under the lip, care must be taken that the 
impression tray is in the proper position-not too far distally or mesi- 
ally, nor too far to the buccal, and straight with the median line of the 
face. If, in forcing the upper tray into place, some of the plaster is 
forced over the palatal part of the tray, it should be removed at once 
with a mouth mirror. In taking the lower impression, just before the 
tray is forced down and after the plaster has been placed under the lip, 
the patient should be instructed to raise the tongue, and while the tongue 
is raised, the tray is forced down. This insures a good impression of 
the lingual part of the mouth. Also, the fingers should be passed back 272 
PRACTICAL ORTHODONTIA 
Fig. 34 4. Manner of placing plaster in trays so that excess can be worked under lips. IMPRESSIONS AND MODELS 
273 
to the disto-buccal part of the tray and the cheek forced buccally; for 
often the cheek is caught under the heel of the impression tray, thus 
spoiling the accuracy of the impression. 
The tray is held firmly until the plaster begins to set and then pieces 
of cotton or bibulous paper can be used to wipe the saliva out of the 
mouth and to remove the loose pieces of plaster. After the plaster 
is hard enough to hold the tray in place, the part of plaster on the 
outside of the tray is removed. Any part that breaks off below the 
border of the tray should be saved, others are thrown into the pocket 
made by pinning the towel at the corners. After all pieces of the 
plaster have been broken away from the tray, the tray is then re- 
moved, leaving the impression intact in the mouth. With a sharp 
knife, using a chisel stroke, grooves should be made in the impres- 
sion over the canine eminences, as that is the most convenient way 
to break the impression. These grooves should be made narrow with 
straight walls, as the straight walls are necessary to use as a fulcrum 
for the knife blade in breaking away the plaster. The positions of 
the teeth should be fixed in mind, and the lip pulled out of the way 
so as to get an idea of the anatomy of the parts, and the grooves cut 
through the plaster only far enough to permit it to break. The blade 
of the knife is placed in the groove and one piece is pried out. Whether 
the center piece or the side pieces are broken away first depends upon 
the position of the teeth. In breaking the buccal parts away, the 
thumb should be placed against the anterior end of the broken plaster 
and the finger placed along the buccal side of the same so as to pro- 
tect the cheek. After the buccal and labial parts have been removed, 
the palatal part is then taken out. Occasionally an upper impression 
can be taken out in three or four pieces, but a greater number would 
not spoil the value of the impression. In removing the lower, the 
same procedure is followed. The lingual part is broken as near the 
median line as possible by pushing lingually on one side of it from 
about the region of the first molar. In removing the pieces, those 
from the right side should be laid on the right side of a blotter or 
piece of clean paper and those from the left side, on the left side of 
the blotter, and all the other pieces placed in their respective relations 
on the paper. The pieces of the impression must be laid away until 
they are dry and then placed together and held by sticky wax. In 
putting these impressions together, the small pieces of the right side 
must be stuck to the large pieces of the right side, and so on, and then 
the right and left parts of the impression put together. If trouble 
is encountered in getting the halves of the impression to stay together, 274 
PRACTICAL ORTHODONTIA 
they can be braced by sticking a match across the back with sticky 
wax. Figs. 345 and 346 show the upper and lower impressions as 
they are removed from the mouth. Fig. 347 shows the appearance 
of the upper and lower after they are put together. 
Fig. 345. 
Fig. 346. 
Impressions removed from mouth, 345, upper impression ; 346, lower impression. 
Fig. 347. 
Impressions put together with sticky wax. 
Varnishing the Impression.-The impression is then coated with a 
separating medium. The author has obtained the best results from 
the use of shellac and sandarac varnishes, as recommended by Angle. 
The consistency of the varnishes can be learned only from experience. IMPRESSIONS AND MODELS 
275 
Alcohol must be added to the varnishes from time to time to keep 
them thin enough. One coat of shellac is placed on the impression 
with a fine brush from a solution so thin that all of the shellac will 
soak into the impression. If this first application leaves a coating on 
the impression, the varnish is too thick and the impression will not 
produce a good model. The object of this coat is to fill all of the 
pores in the impression, color the impression for a certain distance, 
and act as a filler for the next coat. The second coat is applied only 
after the first is thoroughly dry, and at least three hours should 
elapse after the first coat is put on before the second is applied. This 
second coat should cover the entire surface of the impression, and is 
Fig. 348. 
Impression poured before being turned over on glass slab. 
taken from the same bottle as the first. The purpose of the second 
coat of shellac is to fix a gloss on the impression. After this second 
coat it would be possible to separate the impression from the model, 
if it was poured then. However, in order that the teeth may have a 
better gloss and that the impression may be separated more readily, 
a coat of very thin sandarac is placed in the impression of the teeth 
and the rough parts of the impression. Care must be taken not to 
get any of the sandarac on the gingival margins of the teeth. After 
the last coat of varnish is dry, the impression is ready to pour. 
Pouring the Model.-The plaster used for the model should be one 
that will be reasonably hard and must not set too slowly. The plaster 276 
PRACTICAL ORTHODONTIA 
is carefully sifted into the water so as to avoid bubbles. When the 
water has taken up all of the plaster, the mixture is placed in the im- 
pression of the teeth with a fine brush. In filling the impression, be- 
gin at one side at the last tooth or heel and fill from there entirely 
Fig. 349. 
Impression turned over and placed on glass slab. 
Fig. 350. 
Impression removed from glass slab, showing square corners. 
around the impression. The plaster is carefully placed in the teeth 
so as to expel any air bubbles that may occur in their cusps. After 
the teeth have been filled with the brush, the remaining part of the 
impression can be filled with the spatula, and a large amount of IMPRESSIONS AND MODELS 
277 
plaster should be placed on the impression, as shown in Fig. 348. By 
this time, the plaster should be hard enough to support the weight 
of the impression and also stiff enough so that it will not run out when 
turned upside down. The impression is now turned upside down on 
the glass slab, as shown in Fig. 349, and the plaster pulled up around 
Fig. 351. 
Plaster trimmed away from border of impression previous to separation. 
Fig. 352. 
Occlusal surface of impression trimmed to show discoloration from shellac varnish. 
the impression. The disto-buccal corners of the plaster must be left 
square, as shown in Fig. 350, for the reason that they represent the 
corners of the finished model. 
Separating the Model.-After the plaster has become hard the im- 
pression can then be separated from the model. The plaster is 278 
PRACTICAL ORTHODONTIA 
trimmed away from the edge of the impression until the border can 
be seen plainly. Fig. 351 shows the preliminary trimming and Fig. 
352 the manner of trimming the occlusal portion until the stain of the 
Fig. 353. 
Grooves cut into impression before separation. 
shellac can be seen. A groove is then cut into the impression as near 
the gingival portion of the teeth as possible so that it will extend 
from the right distal corner to the left distal corner (Fig. 353). Then 
grooves are cut parallel to the long axis of the teeth and at right 
angles to the first groove. These grooves are carefully cut into the 
Fig. 354. 
A to C represents height of model; A to B, the anatomical portion of model; 
C to B equals one-third of distance from A to B ; A to B equals three-fourths of height 
of model. 
impression until the stain from the shellac shows. The pieces are 
then pried off by prying toward the occlusal surface. No piece of 
impression larger than a tooth should be removed at one time. When IMPRESSTONS AND MODELS 
279 
prying off the impression, care must be taken not to break off the 
teeth. 
Trimming the Model.-After the impression is removed, the model 
Fig-. 355. A group of instruments used in trimming the model. 280 
PRACTICAL ORTHODONTIA 
is then ready to be trimmed. The part of the model representing the 
teeth and alveolar process is known as the anatomic portion. The 
rest of the model is known as the base or art portion. In handling the 
Fig. 356. 
Plaster plane, used in trimming the model. 
Fig. 357. 
Taking measurement from the median line to a point distal to the molars. 
model, the anatomic portion should not be touched with the fingers. 
The anatomic portion of the model is measured in the highest 
part and that length represents three-fourths of the height of the IMPRESSIONS AND MODELS 
281 
completed model. Therefore, the art portion of the model is one- 
third of the height of the anatomic portion. These measurements 
can better be understood by referring to Fig. 354. After these meas- 
Fig. 358. 
Model with base and back trimmed. Back must be at right angles to base. 
Fig. 359 
Sides trimmed at right angles to base. 
urements have been obtained, the art portion of the model is marked on 
all sides and then the base is trimmed to the line. The lower model 282 
PRACTICAL ORTHODONTIA 
should always be trimmed first. The base should be finished smooth 
before any side is trimmed. 
In order to properly trim the art portion of the model, it is neces 
sary to have a small square, a pair of compasses, one or two sharp 
Fig. 360. 
Appearance of base of model after the anterior corners have been established and the 
front marked with compasses. 
Fig. 361. 
Distal corners of model trimmed at right angles to mesial corners. 
strong knives Fig. 355 , and a plaster plane Fig. 356 . The plane 
will be found very difficult to manipulate at first but when used prop- 
erly it gives a finish that can be obtained in no other way. 
After the base has been trimmed and finished with the plane, a 
measurement is taken from the median line to a point distal to the IMPRESSIONS AND MODELS 
283 
molars (Fig. 357). This point distal to the molar establishes the dis- 
tal portion of the art portion of the model. It is trimmed straight 
across and at right angles to the base (Fig. 358'. The sides are then 
trimmed and form a straight line parallel with the lines of occlusion 
from the molars to the canine, being trimmed only close enough to 
the anatomy to get all of the overhanging edges (Fig. 359). Care 
Fig. 362. 
A. B. C are points on the arc of circle, the radius of which is the distance from 
A to C. F. G. H are points on circle, the radius of which is the distance from A to C. 
El to E2 and DI to D2 are trimmed at right angles to lines running from C to E and 
A to D, which are one-fourth of distance A. B, C. The arc H. G. F is centrally located 
between D2 and E2. The different parts of the model should be trimmed in the fol- 
lowing order: (1) The base; (2) the back from D to E; (3) the sides A to E and 
C to D : (4) the front A. B. C; (5) the corners DI. D2 and El. E2; (6) the arc F. G. H. 
must be taken to hold the knife at right angles to the base, for the 
side must be trimmed at right angles to the base. Very often the 
sides are trimmed so close to the anatomic portion as to ruin some 
of the anatomy and greatly mar the beauty of the model. The an- 
terior part of the model is now trimmed. A mark is made on the side 284 
PRACTICAL ORTHODONTIA 
in the region of the canine to represent the corners, as shown in Fig. 
360. After these corners are established, the compasses are placed on 
each mark and the distance between the two points represents the 
Fig. 363. 
Base of completed lower model. Front trimmed round. 
Fig. 364. 
Base of completed upper model. Front trimmed to a point. 
radius of a circle. The anterior part of the lower model is then 
trimmed to represent the arc of a circle, the radius of which is the 
distance from one canine point to the other. Then the distal corners IMPRESSIONS AND MODELS 
285 
of the model are trimmed at right angles to a line passing from the 
canine point to the opposite distal point (Fig. 361). The distal cor- 
ners are trimmed so as to be one-fourth the length of the arc of the 
circle that forms the front of the art portion of the lower model 
(Fig. 362). The distal part of the base of model is divided into 
fourths, and two-fourths are used in making a curve as shown in 
Figs. 362 and 363. This distal curve represents the arc of the circle, 
the radius of which is the distance from one canine point to the other. 
Fig. 365. 
Method of obtaining the measurements for the anatomic and art portions of the 
upper model. Measure the anatomic portion of upper model, which is three-fourths 
of height of completed model. Then add one-third of distance from A to B, set square 
and make mark at C. Place upper model on lower model and measure from C on 
upper to C on lower, with teeth in occlusion. Make a scratch all around upper model 
with square, as shown by dotted line. 
The curve in the front and the curve in the back are then arcs of 
circles that have the same radius. The base of the model then ap- 
pears as shown in Figs. 362 and 363. Fig. 364 illustrates the base of 
an upper model, which is trimmed as follows: The anatomic por- 
tion is measured in the same manner as described above, and the 
height of the art portion established in the region of the median line. 
The anatomic and art portions of the upper model are obtained as 
shown in Fig. 365. Upon the upper model a line is circumscribed 286 
PRACTICAL ORTHODONTIA 
around its entire circumference, and the base is then trimmed. The 
distal line and sides are obtained in the same manner as in the lower 
model. The canine points are then fixed but the front of the upper 
model is made pointed, as shown in Fig. 365. The anterior angle is a 
point on the arc of a circle, the radius of which is the distance be- 
tween the canine points. The distal corners are trimmed the same as 
they were in the lower, except that they are made one-third of the 
length of the line from the canine point to the center of the model. 
The distal curve is obtained in the same manner. 
Models when trimmed this way are well balanced, and if care has 
been exercised all through the procedure, there is no necessity to 
apologize for their appearance. 
Modeling Compound to Study Models.-Study models can be made 
from modeling compound impressions at any time during the treat- 
Fig. 366. 
Modeling compound shaped for the tak- 
ing of impression from which study 
models are made. 
Fig. 367. 
Modeling compound impression for the 
making of study models. 
ment of the case. They are made for the purpose of comparing the 
progress of treatment with the original model made at the beginning 
of the case. They can be made by taking an impression of the teeth, 
using a tray in the usual manner, and taking an impression of each 
arch separately. They can also be made by having the patient bite 
into a piece of soft modeling compound, which is shaped as shown 
in Fig. 366. This piece of soft modeling compound is placed in the 
mouth in such a position as to include the posterior teeth, and the 
patient is instructed to close the mouth. The buccal and labial parts 
of the modeling compound are worked around the teeth, up under the 
lips, and the patient is instructed to close the lips while the cheeks 
are manipulated in such a manner as to work the impression material 
well toward the gingival border of the teeth. The lips are held apart, IMPRESSIONS AND MODELS 
287 
and the modeling compound is chilled by having cold water sprayed 
on it while the patient leans over the cuspidor. After the buccal and 
labial parts have been chilled, the mouth is opened by the pulling of 
the lower teeth from the impression by the patient, and while the im- 
pression is still in place on the upper teeth cold water is sprayed on 
the palatal part of the impression. By chilling the palatal part after 
the lower teeth have been removed from the impression, and while 
the upper teeth are in place, any great amount of warpage is pre- 
vented and the impression will be fairly accurate, although not so 
accurate as a plaster impression would be. The appearance of the 
impression upon removal is shown in Fig. 367. These study impres- 
sions can be made in a few minutes with the appliance in place, and 
serve as a valuable means of checking up the treatment or retention. 
Fig. 368. 
Study model made from modeling compound impression. (Lourie.) 
In pouring the study impressions, the models should be poured so that 
there will be an extension to the distal of the molars on the upper 
and lower models to act as a guide in placing the models in the correct 
position. These guides on the posterior parts of the models are ex- 
tremely valuable in cases in which the anterior teeth are in infra- 
occlusion. The appearance of the study model is shown in Fig. 368. 
Duplicating Orthodontia Models. - Very often one desires to make 
a duplicate from the original model. In order to do this it is neces- 
sary to use some process that will injure the original model but little 
and still give a reproduction or duplicate that will be accurate. Sev- 
eral processes have been devised, all of which are more or less similar. 
The plan described by Hoggan* is as simple as any and requires as 
* Hoggan, J. A. C.: Duplicating- Orthodontia Models, International Journal of Orthodontia, 
July, 1915, vol. i, p. 357. 288 
PRACTICAL ORTHODONTIA 
little special equipment or material as any process. It is as follows: 
"Flake glue (Fig. 369) is prepared in thin chips about one-thirty- 
second inch in thickness. It is the glue that is used for duplicating 
plaster decorations on ceilings and .statuary. The ordinary variety of 
glue is not suitable for this purpose. A tin dish about 8 inches long, 
4 inches wide and 3 inches deep (Fig. 370) is the right size to contain 
two models and sufficient glue. An ordinary double boiler, the inside 
Fig. 369. 
Flake glue. (Hoggan.) 
portion to contain about two quarts, completes the necessary appar- 
atus. The inside portion of double boiler is filled with flake glue, and 
sufficient cold water is then added to cover. This is allowed to stand 
until the glue becomes softened, usually about thirty minutes. Half 
of the water is then removed from the glue. Water is placed in the 
outer boiler, the two parts of the boiler put together and placed over 
the flame. It is allowed to heat until the water in the inside boiler 
rises to the top of the glue. The double boiler is then removed from IMPRESSIONS AND MODELS 
289 
the flame and the whole mass is allowed to stand until liquid, after 
which the inside boiler is lifted out of the hot water in the lower por- 
tion, and the glue allowed to stand until a scum begins to form on the 
Fig. 370. 
Tin dish with models placed in bottom ready to be poured with glue. (Hoggan.) 
Fig. 371. 
Glue impression after models have been removed. (Hoggan.) 
surface, when it is ready to pour. The models to be duplicated are 
first thinly coated with vaseline and placed in a tin dish with teeth 290 
PRACTICAL ORTHODONTIA 
Original. 
Fig. 372. 
Duplicate. 
Original. 
Fig. 373. 
Duplicate. 
Original. 
Fig. 374. 
Duplicate. 
Original and duplicate models. (Hoggan.) IMPRESSIONS AND MODELS 
291 
presenting upward (Fig. 370) and the glue poured over them. The 
secret of the success of this process is to make the mass of glue liquid 
at the lowest possible temperature, then to pour it over the models at 
the moment in which it is still liquid, but beyond which it would con- 
geal. If models have a tendency to rise in liquid glue, they may be 
cemented to the bottom of the pan with a little sticky wax. This is 
allowed to stand in a cool place for at least twelve hours, after which 
congealed glue is removed from the pan and the models are carefully 
lifted out by springing the glue aside. The glue impression is now 
ready to pour (Fig. 371) with Plaster of Paris. These models may be 
Original. 
Fig. 375. 
Duplicate. 
Original and duplicate models. (Hoggan.) 
Original. 
Original and duplicate models. (Hoggan.) 
Fig. 376. 
Duplicate. 
removed from the impression in ten minutes but are set aside for an 
hour to allow the surface of the model to set, it being softer than 
ordinary models for the depth of one-quarter inch. Figs. 372 to 376 
show models removed from the glue impression. The models are 
then retouched, and if desired several sets can be reproduced from 
the same glue impression." 
Photographs.-A valuable adjunct to the records as supplied by 
models is the use of photographs of the patient, and facial casts. 292 
PRACTICAL ORTHODONTIA 
There are advantages in both the photograph and the cast. In taking 
photographs of patients, a side view and a front view should be se- 
cured. The side view should be a full profile, which sometimes is 
rather difficult to get owing to the fact that the photographers do not 
Fig. 377. 
Showing abnormal facial outline due to 
mouth-breathing. (Parsons.) 
Fig. 378. 
Showing fairly normal outline due to 
forced normal breathing. (Parsons.) 
Fig. 379. 
Showing fairly normal profile due to 
forced normal breathing. (Parsons.) 
Fig. 380. 
Showing abnormal profile due to mouth- 
breathing and distoclusion (Parsons.) IMPRESSIONS AND MODELS 
293 
always pose the patient so as to give the best results. Photographs 
which show the proper poses are shown in Figs. 377, 378, 379, and 380. 
With those patients who are mouth-breathers it is sometimes well to 
take a front view showing the lips closed and one showing them 
parted, as shown in Figs. 377 and 378. The profile taken in the same 
manner is also shown in Figs. 379 and 380. The photographs can be 
easily obtained without any discomfort to the patient, and for that 
reason they have been much used during the last few years. They are 
not so satisfactory in some other respects as facial casts. 
Facial Casts.-Facial casts show the different facial developments 
better than does the photograph and are especially desirable in those 
patients who have unequal developments in the two parts of the face. 
Facial casts are divided into the full cast and the profile; we also have 
partial facial casts and the full facial cast with the dental insert. 
Profile Cast.-The technique of making the profile cast will be given 
first, as it is probably the more easily made. The patient is placed 
in a comfortable position in the chair, or better still lies on a table. 
A piece of soft lead wire, or fuse wire, is made to fit the facial profile 
by starting with the wire at the top of the cranium and adapting it 
To the anatomic curves along the median line of the face, along the 
nose, upper lip, lower lip, chin and neck, as shown in Fig. 381. When 
this is done, the wire is carefully removed and laid on a piece of heavy 
cardboard and pushed down sufficiently hard to make an indentation 
in the cardboard, and the outline of the wire is carefully marked on 
the cardboard with a pencil. The cardboard is then cut out to fit the 
face, as shown in Fig. 382. This cardboard must fit the facial profile 
carefully, for it will serve as a means of limiting the plaster to the 
part of the face that is to be included in the facial cast, and will pre- 
vent annoyance to the patient from the spreading of the plaster over 
more of the face than is necessary. The side of the face that is to be 
included in the profile is then coated with thin vaseline, which has 
been liquefied by placing the jar of vaseline in warm water. The 
vaseline should not be completely liquid but should possess enough 
body so that it may be applied with the aid of a shaving brush. The 
vaseline is placed over all parts of the face that are to be included 
in the profile cast, including the hair, eyebrows, eyelashes, the ear, 
the nasal opening, mouth, cheeks, lips and neck. Especial care must 
be taken to paint sufficient vaseline on the hair and eyebrows so that 
they will not adhere to the cast. The eyelashes must also have 
enough vaseline on them so that they will pull free from the facial 
impression. If there is any fine hair on the face it must also be care- 294 
PRACTICAL ORTHODONTIA 
Fig. 381. 
Adjustment of fuse wire to center of face. (Oliver.) 
Fig. 382. 
Cardboard trimmed to fit outline of face. (Oliver.) IMPRESSIONS AND MODELS 
295 
fully painted down with vaseline to avoid the discomfort to the pa- 
tient that will be experienced in the removal of the cast should the 
hair cling to the cast. A piece of cotton containing vaseline should 
be placed in the side of the nose that will be included in the impres- 
sion. A piece of cotton should also be placed in the opening of the 
external ear, and a piece of cotton saturated with vaseline should be 
placed behind the ear to prevent the plaster from filling the space be- 
hind the ear so closely as to prevent the removal of the cast from 
the ear. After the face and parts have been thoroughly covered with 
vaseline, the patient's head is turned so that the part of the face to 
be included in the impression is turned upward, and the piece of 
Fig. 383. 
Profile impression on face with cardboard removed. (Oliver.) 
cardboard is placed on the face to prevent the plaster from spreading- 
over the face beyond the desired area. The plaster is mixed in a 
large mixing-bowl, one that will hold at least two quarts of the mixed 
plaster. The first plaster that is placed on the face should not be 
thick enough or stiff enough to displace the parts and should be care- 
fully worked into the fine lines and concavities of the face. After this 
first thin layer of plaster has begun to set more plaster can be added 
to give the impression the desired thickness. In taking a facial pro- 
file cast, it is necessary to have an assistant who holds the cardboard 
form in place, and also one who assists in getting the plaster on the 
face, as the plaster must be laid on the face very rapidly so that it 296 
PRACTICAL ORTHODONTIA 
will not set in patches, or that part of it will not begin to set before 
the entire face is covered. It is often necessary to make a second 
mixture of plaster to strengthen the first that has been placed on the 
face. After the impression is set the cardboard can be removed, 
leaving the impression in place, as shown in Fig. 383. After the im- 
pression is thoroughly hardened, it is carefully lifted from the face. 
If sufficient vaseline has been placed on the hair, eyebrows, and eye- 
Fig. 384. 
Facial impression grooved for separation. (Oliver.) 
lashes, they will pull away from the impression without any discom- 
fort to the patient. Should the hair cling to the impression, it can 
be carefully worked loose by pushing the skin away from the cast 
with the fingers or a spatula. After the impression is removed, it 
should be thoroughly dried and then given a coat of shellac varnish, 
the same as is used in a plaster impression of the mouth. If there are 
any small air bubbles or other imperfections, they can then be filled IMPRESSIONS AND MODELS 
297 
Fig. 385. 
Front of profile cast. (Oliver.) 
Fig. 386. 
Back of profile cast. (Oliver.) 298 
PRACTICAL ORTHODONTIA 
up by the use of a brush with dry plaster and water. The coating of 
shellac will furnish a line of demarkation so that the plaster can be 
added only where it is desired. A second coating of shellac is then 
placed on the impression, and after it is dry a coating of sandarac 
varnish is applied. After the sandarac varnish is dry, the impression 
is ready to pour, which is done by mixing enough plaster to entirely 
fill the impression to about the thickness of half an inch. This mix- 
ture of plaster is poured in the impression and the impression turned 
from side to side to get the plaster into all of the fine lines and to 
distribute it equally inside the impression. Immediately, a second 
mixture is placed in the impression for the purpose of increasing the 
Fig. 387. 
Fuse wire used to get outline of face for partial facial cast. (Oliver.) 
thickness and of giving it more strength. After the cast has become 
hard, the impression can be removed in the same manner that a 
plaster impression is removed from the teeth. Deep grooves are cut 
in the impression, as shown in Fig. 384, until the discoloration of the 
shellac is seen. Care must be observed in removing the ear, lips, 
nose and eyebrows. After the impression has been removed, the cast 
can be trimmed to bring out the profile, and the imperfections can be 
remedied with the use of plaster and a brush. Fig. 385 shows the 
finished profile cast, front view. The back of the profile cast is com- 
pleted by cutting holes in the plaster, into which two corks are in- 
serted and pasted by placing some soft plaster around them. Screw- IMPRESSIONS AND MODELS 
299 
eyes can then be placed in the corks, and the cast hung up, if so de- 
sired (Fig. 386). 
Partial Facial Cast.-A partial facial cast includes only a part of 
the face and does not include the ears, or one ear, as does the profile 
cast. They are much easier to make as they are easy to remove and 
do not include the hair or eyes. They are made by taking a piece of 
cardboard and by cutting a hole in it large enough to include the 
chin, mouth, part of the cheeks, and the nose. Provision has to be 
made for the patient to breathe through the nose, and rubber tubes 
are placed in the nares through which the patient breathes. These 
tubes should not be so large as to distort the nose, yet they must be 
Fig. 388. 
Cardboard in place for the partial facial cast showing rubber tubes in nose. (Oliver.) 
large enough so that the patient can breathe through them with com- 
fort. The partial facial cast can also be extended so as to include the 
eyes, in which case the technique consists in taking a piece of fuse 
wire and in making an oval to include the parts of the face that are 
to be included in the cast. The fuse wire is shaped as shown in Fig. 
387. This piece of wire is then laid over the piece of cardboard and 
serves as a pattern for cutting the cardboard that fits over the face, 
as shown in Fig. 388. The position of the rubber tubes is also shown. 
In order that the end of the tube can be held away from the lip, a 
piece of string is fastened to it. The assistant can hold the rubber 300 
PRACTICAL ORTHODONTIA 
Fig. 389. 
Impression for partial facial cast showing position of tubes and cardboard. (Oliver.) 
Fig. 390. 
Partial facial cast. (Oliver.) IMPRESSIONS AND MODELS 
301 
tube out of the way while the plaster is being placed around the tube. 
Care must be observed not to displace the rubber tube or the breath- 
ing of the patient will be interfered with and the impression will be 
spoiled. The face is, of course, coated with vaseline in the same way 
as it was in the profile casts, and the plaster is applied to the face in 
the same manner. The appearance of the face covered with plaster, 
Fig. 391. 
Partial facial casts. (Parsons.) 
Fig. 392. 
Partial facial casts. (Parsons.) 302 
PRACTICAL ORTHODONTIA 
and the position of the rubber tubes and the cardboard, are shown 
in Fig. 389. The impression is varnished in the same way as was the 
impression of the facial profile, and poured and separated in the same 
manner. Fig. 390 shows the facial cast, front view, which does not 
include the ears. Fig. 391 shows the side view of a partial facial cast, 
and Fig. 392 the front views. 
Full Facial Cast.-In making a full facial cast the fuse wire is ad- 
justed to the face and cranium so as to include the ears and chin 
Fig. 393. 
Full facial cast with dental insert. (Oliver.) 
and as much of the cranium as is desired. It is generally necessary to 
include only that part of the cranium as far back as the ears. A piece 
of cardboard is then cut to fit the face and the face is covered with 
vaseline as in the other impressions. After the face has been covered 
with vaseline, the plaster is applied to the face in the same manner 
as in the profile, and when the first coat or layer of plaster has been 
reenforced, the facial impression is removed. In some instances the 
full facial impression can be removed in one piece, and in other cases 
it will be necessary to break it in order to free it from the posterior IMPRESSIONS AND MODELS 
303 
part of the mandible. The impression is varnished and poured and 
separated in the usual manner. 
Full Facial Cast With Dental Insert.-The full facial cast is also 
made with an insert of the teeth, an example of which is shown in 
Fig. 393. It will be observed that the teeth are shown in the full cast, 
and that they occupy the same relation in the cast that they occupy 
in the face. This makes possible the study of the teeth in relation to 
the face in a manner that has never before been possible without the 
insert cast. In making the dental insert, the face is coated with 
Fig. 394. 
Impression of teeth and face for the dental insert. (Oliver.) 
vaseline, and the rubber tubes are placed in the nose, as is shown 
in Fig. 388. It is not necessary to use a cardboard to control the 
plaster in making the dental insert. The patient holds the teeth to- 
gether, the lips are separated, and soft plaster is worked between the 
teeth and the cheeks as far distally as the last tooth. A good amount 
of plaster is placed in the oral vestibule so as to include all of the 
alveolar process on the buccal sides and on the labial side of the 
teeth, and thus give the necessary strength. After the oral vestibule 
is full of plaster, it is continued over the face, covering the chin, nose, 
and median part of the forehead. It is necessary to have the facial 304 
PRACTICAL ORTHODONTIA 
part of the dental insert impression cover the points mentioned on the 
face in order to have three points that are fixed for the placement 
of the insert in the facial impression. The appearance of the dental 
insert impression after the plaster has been placed over the chin, nose, 
and forehead is shown in Fig. 394. The impression is then varnished 
in the same manner as are the other facial impressions, and is shown in 
Fig. 395. The impression is poured, and after the removal of the 
dental insert cast, the facial parts are trimmed away, leaving only 
three points untrimmed, which are the tip of the nose, the center of 
Fig. 395. 
Facial and dental insert impression varnished. (Oliver.) 
the forehead, and the tip of the chin (Fig. 396). This trimming is 
done to allow the plaster that is poured in the full facial impression 
to flow around the dental insert at all points, except the three points 
mentioned and the part that is protected with wax, as is shown in 
Fig. 397. The part of wax that is shown in Fig. 397 is to prevent the 
plaster from flowing over the entire dental insert when it is placed in 
the facial impression and when the facial impression is poured. The 
wax protection is made by taking a piece of soft wax, molding it over 
the side of the dental insert, and then trimming it approximally. The IMPRESSIONS AND MODELS 
305 
Fig. 396. 
Dental insert cast ready to be placed in facial impression. (Oliver.) 
Fig. 397. 
Wax protection of side of dental insert to prevent plaster from flowing over 
teeth. (Oliver.) 306 
PRACTICAL ORTHODONTIA 
Fig. 398. 
Clamp for holding dental insert in facial impression. (Oliver.) 
Fig. 399. 
Dental insert in facial impression. (Oliver.) IMPRESSIONS AND MODELS 
307 
wax can then be warmed, and the dental insert with the wax in position 
is placed in the facial impression with the point of the nose, forehead, 
and chin in the proper relations, and the wax forced into the proper 
form and shape. The dental insert can then be removed and the wax 
added to or trimmed as desired. After the wax has been properly 
shaped, the next step is to hold the dental insert in the facial impres- 
sion in the proper place while the facial impression is poured. The 
dental insert is held in place by a clamp, as shown in Fig. 398, which 
Fig. 400. 
Facial cast with iron or wood in position for holding it. (Oliver.) 
consists of a steel bow that is threaded, large enough to encircle the 
outside of the facial impression. A steel cross-bar is used, which car- 
ries a central screw, with a slot in each end to receive the steel bow, 
and which is wide enough to accommodate the posterior width of the 
facial impression. The dental insert is placed in the facial impression 
and held in position by the clamp, as shown in Fig. 399. In order 308 
PRACTICAL ORTHODONTIA 
that the central set-screw may have a firm grip on the dental insert, 
it is well to make a hole in the back side of the dental insert into which 
a cork can be fitted. This cork gives a more secure hold for the 
set-screw than the plaster does, which might crumble under pressure 
and thereby allow the dental insert to become displaced. After the 
dental insert has been secured in place, the facial impression is filled 
with soft plaster, care being taken to work it around the dental in- 
sert in such a manner as to fill all of the space between the dental 
Fig. 401. 
Facial cast with wax insert in position. (Oliver.) 
insert and the walls of the facial impression. After the first layer 
of plaster is placed in the facial impression, a second layer is added 
to give the facial cast the proper thickness and strength. In order to 
provide some means to hold the facial cast, a piece of iron or strong- 
wood is imbedded in the cast at the time the second layer of plaster 
is placed in the impression, as shown in Fig. 400. The facial impres- 
sion is removed from the cast in the same manner as has been de- 
scribed in the other casts. The facial cast with the wax insert in 
position is shown in Fig. 401. Figs. 393 and 402 show a view of the IMPRESSIONS AND MODELS 
309 
facial cast with the dental insert in position. The value of the facial 
cast with the dental insert is that it gives the relation of the teeth to 
the face, and the different tooth movements can be observed with re- 
gard to the fixed positions of the face. 
Fig. 402. 
Front view of facial cast with dental insert in position. (Oliver.) 
Some men have objected to the facial cast because of the trouble 
necessary to make it. This objection is not well founded, for the facial 
impression can be made in a few minutes and is not a great annoyance 
to the patient. The facial cast with the dental insert has so many 
points of superiority over everything else as a matter of record that 
it is well worth anyone's time to master the necessary technique. CHAPTER IX 
USE OF THE X-RAY IN ORTHODONTIA 
By James David McCoy, D. D. S. 
It is no longer necessary to present an argument in favor of the use 
of the x-ray in any of the various branches of dentistry, as its merits 
and possibilities are now recognized by all open-minded and pro- 
gressive members of the dental profession. 
Orthodontists were among the first in the profession to recognize 
the valuable aid to be gained through the adoption of this agent as a 
regular part of office routine, and as a result, many of the uncer- 
tainties and perplexing situations incident to orthodontic practice 
have been clarified. 
That the orthodontist should maintain his own x-ray laboratory is 
no longer a debatable point. With it he is able to utilize the x-ray 
whenever the necessity for its use arises, without subjecting patients 
or himself to the inconvenience or added expense incident to referring 
them to a roentgenologist; and what is even more important, with it 
conveniently at hand, he will use it tvhenever indicated, instead- of limit- 
ing its use to cases of dire necessity. 
It is only logical, therefore, to assume that an essential part of the 
preparation of the student or practitioner, who is to undertake ortho- 
dontic procedures, will include the basic principles of radiography, 
which entails a knowledge of the nature of the x-ray, the electrophy- 
sics of its production, the intelligent handling of x-ray apparatus, the 
technique of radiography, the development of plates and films, the inter- 
pretation of radiographs, as well as a knowledge of the dangers aris- 
ing through the misuse of the x-ray. 
Taking it for granted that the reader is thus prepared, it will there- 
fore be unnecessary to discuss here any phases of the above enum- 
erated principles, other than touching upon a few practical suggestions 
in technique of special significance to the orthodontist. 
Owing to the fact that patients undergoing orthodontic treatment 
are usually children whose ages necessitate their being handled with 
tact and gentleness if confidence is maintained, precaution should be 
taken to rid every operation of fear or discomfort. Especially is this 
essential in making radiographs, for any considerable degree of move- 
310 USE OF THE X-RAY IN ORTHODONTIA 
311 
ment on the part of a patient will either curtail the value of the fin- 
ished radiograph, or perhaps render it useless. 
The Question of Technique 
To obtain a radiograph of any portion of the body, it is necessary 
to have a photographic or x-ray plate or film (properly prepared so as 
to exclude all light and moisture) placed in such a position that the 
x-rays may pass through the desired structures and register their 
shadows with the least amount of distortion possible upon the plate 
or film. 
In securing radiographs of the dental and oral structures, two gen- 
eral methods of procedure are open to us, each of which has its value 
and special indications. These are known as the "intra-oral" and 
"extra-oral" methods. 
With the first named, small films are used, which are placed within 
the mouth opposite the area to be radiographed, and held in position 
either by means of a film holder, or by the assistant, or better still, by 
the patient exerting slight pressure with the finger. This method is in- 
dicated when radiographs of small areas only are desired; as, for in- 
stance, two or three teeth, with the adjacent alveolar process. 
With the other method of procedure mentioned, namely, the extra- 
oral method, large plates or films are used, and the areas desired are 
brought in as close contact as possible with the plate, by pressing or 
resting the side or portion of the face in which the structures are lo- 
cated against it. The rays are then passed through the structures from 
the other side of the skull, in such a manner as to cause the shadows of 
the desired structures to be imposed upon the plate. By using this 
method, large areas may be radiographed, which in some instances, 
will embrace the lateral half of both the upper and lower jaws from the 
region of the lateral incisors anteriorly to the angle of the jaws pos- 
teriorly. and from the floor of the orbit above to the inferior margin of 
the mandible below. In fact, it is possible, by making several exposures, 
to obtain in detail a radiographic representation of the dental apparatus 
in toto, as well as its associated organs and structures, the nasal cavity, 
pneumatic sinuses, the maxilla, and mandible. 
In selecting a method of procedure for making radiographs of chil- 
dren, the child's comfort must be taken into consideration, and with 
this idea in mind, the author has found it an advantage to use the 
extra-oral method cpiite universally. In fact, he has used it in nearly 
all cases except where the region embracing the upper anterior teeth 312 
PRACTICAL ORTHODONTIA 
is under scrutiny. The wisdom of this course will be apparent to any- 
one who has experienced the discomfort of having intra-oral films 
placed lingually to the lower teeth, where the tissues are very sensi- 
tive, or has had them placed back in the molar region, against the 
palate, where they so frequently induce gagging. These unpleasant 
features are all eliminated by using the extra-oral method, and good 
radiographs of the structures desired can be secured on the larger 
plates. This statement should not be construed as a protest against 
the use of intra-oral films in dental radiography, for it is very often 
necessary to use such films with adult patients where a high degree of 
Fig. 403. 
The arrangement of the apparatus preparatory to seating the patient. (McCoy.) 
detail is essential in determining the condition about non-vital teeth, 
root canal fillings, etc. In orthodontic practice, however, where we 
are dealing with young subjects entirely, a sufficient degree of detail 
can be obtained in the majority of instances, using the extra-oral 
method to satisfy the needs of the operator. 
Seating the Patient 
In preparing the patient to be radiographed, it is important that a 
suitable chair be provided, which will afford ample support, not only 
for the head, but will make it possible for the patient to be sufficiently USE OF THE X-RAY IN ORTHODONTIA 
313 
Fig. 404. 
Position of patient's head for extra-oral exposure. (McCoy.) 
Fig. 405. 
Radiograph obtained from position shown in Fig. 404. (McCoy.) 314 
PRACTICAL ORTHODONTIA 
Fig. 406. 
Position of patient's head for extra-oral exposure. (McCoy.) 
Fig. 407. 
Radiograph obtained from extra-oral exposure to determine presence of permanent 
teeth. (McCoy.) USE OF THE X-RAY IN ORTHODONTIA 
315 
comfortable to remain quiet, without difficulty. For this purpose, the 
dental chair may be used, or if this is not convenient to the x-ray 
apparatus, the ordinary armchair with a headrest may be utilized. 
The author has found it an advantage to use the ordinary chair with a 
straight back and small arms, placed against the back of the dental chair 
(Fig. 403). The headrest of the dental chair is turned over and adjusted 
to the proper height, position and angle to support the patient's head. If 
the extra-oral method is being utilized, the headrest wings are flattened 
out to make a resting place for the plate. In this way, the patient's 
Fig. 408. 
Position of patient's head for intra-oral exposure of incisors. (McCoy.) 
head is afforded the firm support of the heavy dental chair, and the plate 
is held in an immobile state without difficulty and the operator can, by 
making a few changes in the position of the small chair, and by moving 
and readjusting the headrest, have radiographic access to any part of the 
dental structures (Figs. 404 to 408). The fact that this requires but a 
few moments, does not disarrange the office, or put the patient to dis- 
comfort, justifies the author in feeling that it is an excellent method for 
use in the dental office. Of course, it is necessary where this method is 
followed, to have the x-ray machine and accessory apparatus in the same 316 
PRACTICAL ORTHODONTIA 
Fig. 409. 
Radiograph to show space necessary for impacted premolar. (McCoy.) 
Fig. 410. 
Radiograph to show space necessary for impacted canine. (McCoy.) USE OF THE X-RAY IN ORTHODONTIA 
317 
room with the dental chair. Where this is not possible, it is an easy mat- 
ter to attach an adjustable headrest to the ordinary straightback chair, 
and by having the patient change positions in the chair, accomplish the 
same result. 
Indications for the Use of the X-ray by the Orthodontist 
The necessity for using the x-ray in orthodontic practice, varies with 
different patients, but generally speaking, may be summarized under ten 
different headings as follows: 
Fig. 411. 
Radiograph to show space necessary for impacted tooth. (McCoy.) 
1. As a means of determining the presence or absence of unerupted 
permanent teeth before treatment is started. 
The majority of patients requiring orthodontic treatment usually have 
a mixed dentition; that is, they usually have present in the mouth, the 
deciduous molars and cuspids. It is essential, therefore, to determine 
whether or not these deciduous teeth all have permanent successors. If 
the upper and lower incisors have erupted, information concerning the 
other permanent teeth is easily obtained, by making a radiograph of each 
side by the extra-oral method. Such radiographs are shown in Figs. 
405 and 407. 318 
PRACTICAL ORTHODONTIA 
Such radiographs give the operator a very adequate survey of these 
unerupted teeth, and leave no doubt as to their presence or absence. 
2. As a means of determining the approximate size of unerupted 
teeth, for which space must he made in the arches. 
Where the deciduous molars or cuspids have been lost prematurely, 
with the usual resultant loss of space in the arch involved, the radio- 
graph can be made to show quite accurately the amount of space which 
Fig. 412. 
Radiograph showing condition of unerupted second molar. < McCoy.) 
it will be necessary to establish, if adequate space is to be prepared for 
the unerupted teeth Figs. 409. 410. and 411 . 
3. To determine the state of development of unerupted teeth which 
are tardy in their eruption. 
Not infrequently permanent teeth fail to come through when expected. 
By utilizing the radiograph, their degree of development is easily deter- 
mined. and often the cause for their noneruption is determined. Steps 
can then be taken to open up spaces, and hold them until such a time USE OF THE X-RAY IN ORTHODONTIA 
319 
as the teeth involved progress in their development to the point of erup- 
tion (Fig. 412). 
4. To determine the approximate direction in zvhich teeth are erupting, 
and the relationship u'hich they will have to the line of occlusion when 
erupted. 
Where the deciduous teeth have been retained in the mouth longer than 
Fig. 413. 
Radiograph to show direction of erupting 
teeth. (McCoy.) 
Fig. 414. 
Radiograph to show location of canine 
to aid in making attachment. (McCoy.) 
Fig. 415. 
Radiograph to show location of lateral in- 
cisors and anomalous teeth. (McCoy.) 
Fig. 416. 
Same as Fig. 415 with attachment on 
lateral incisor. (McCoy.) 
their normal period, and where the roots of these teeth have not been en- 
tirely absorbed, the erupting permanent teeth will sometimes be deflected 
out of their normal course. It is an advantage to know the direction in 
which they are deflected, so that if retaining appliances are to be placed, 
they may be arranged in such a way, and in such a relationship to the 
erupting teeth that they will not interfere with them. In fact, it is some- 320 
PRACTICAL ORTHODONTIA 
Fig. 417. 
Radiograph to show conditions in tardy loss of deciduous tooth. (McCoy.) 
Fig. 418. 
Unerupted upper second bicuspid' retarded in its eruption by the presence of the 
deciduous second molar. (McCoy.) USE OF THE X-RAY IN ORTHODONTIA 
321 
times possible to construct the retainer in such a way that the tooth which 
is deflected out of its course may be guided towards its normal position, 
or moved there before the inclined planes of the opposing teeth become a 
factor in establishing it entirely out of its normal position (Fig. 413). 
5. As a guide where it is necessary to make attachments to unerupted 
teeth, to aid in their eruption. 
Fig. 419. 
Radiograph showing relation of incisor 
roots to canine. (McCoy.) 
Fig. 420. 
Radiograph showing relation of canines 
to centrals. (McCoy.) 
Fig. 421. 
Radiograph showing relation of perma- 
nent canine. (McCoy.) 
Fig. 422. 
Radiograph showing position of canine 
root. (McCoy.) 
While it is not often necessary to secure attachments to teeth lying be- 
neath the gingival tissues, the occasion for this sometimes arises, as shown 
in Figs. 414, 415, and 416. In such cases, radiographs should be made 
as a guide in securing the attachment. After the attachment is secured, 322 
PRACTICAL ORTHODONTIA 
others should be made to determine the direction in which force should 
be applied to accomplish the desired tooth movement. 
6. To determine the most opportune time for the extraction of the 
deciduous teeth. 
Where the deciduous tooth persists in the mouth, and shows no sign of 
being shed, it is an advantage to determine the extent of absorption of 
the roots, as well as the development of its successor, so that if extraction 
is resorted to, it can be done with the knowledge that the developing 
Fig. 423. 
Radiograph showing location of erupting lower third molars. (McCoy.) 
tooth will not be disturbed or injured, and that the successor has reached 
a degree of development which will insure its eruption within a reason- 
able time (Figs. 417 and 418). 
7. To observe the movement of the roots of teeth and their relation- 
ship to other roots and structures. 
In the bodily movement of teeth, and particularly of the incisors, it is 
important in young subjects that these roots do not encroach upon each 
other or upon other teeth; for instance, an unerupted cuspid. It is, USE OF THE X-RAY IN ORTHODONTIA 
323 
therefore, advisable, where any doubt exists, to determine the exact 
status of this relationship (Figs. 419 to 422). 
8. To determine the relationship of developing third molars to cer- 
tain recurrent malocclusions, and also as a precaution so that steps may 
be taken to prevent these teeth from becoming a cause of malocclusion 
during their eruption. 
The pressure exerted by developing lower third molars is often suffi- 
Fig. 424. 
Radiograph showing position of lower third molars. (McCoy.) 
ciently great to cause a crowding of the lower incisors and cuspids (Figs. 
423 and 424). This can be true, even though malocclusion has not ex- 
isted in this region previous to the development of the third molars. By 
making radiographs from time to time, of those patients who are of an 
age for development and erupting these teeth, the status of the develop- 
ing teeth can be determined and the necessary precautions taken to 
prevent the crowding of the incisors and cuspids. 
9. To observe non-vital teeth prior to tooth movement, to determine 324 
PRACTICAL ORTHODONTIA 
their fitness for movement or anchorage, and their state of health during 
the process of ortthodontic treatment. 
Where it is necessary to either move non-vital teeth, or utilize them 
as anchorage, it is essential to the patient's welfare and comfort to know 
that such teeth and their investing tissues are in a healthy condition. By 
determining this prior to instituting orthodontic treatment, much trou- 
ble both to the patient and operator can often be avoided (Fig. 425). 
Fig. 425. 
Radiograph to show condition of lower 
molar which is used for anchorage. (Mc- 
Coy.) 
Fig. 426. 
Radiograph showing anomalous tooth. 
(McCoy.) 
Fig. 427. 
Radiograph showing absence of lower centrals. (McCoy.) 
10. In cases where anomalous teeth are present, to differentiate be- 
tween anomalous and normal teeth. 
In a majority of instances, this can be done without the aid of the 
radiograph, unless the teeth in question have failed to erupt. Under such 
conditions, by utilizing accuracy in the technique of making the radio- 
graphs, little difficulty is encountered in determining the difference be- 
tween normal and anomalous teeth. (Examples are shown in Figs. 415, 
426 and 427.) CHAPTER X 
TREATMENT OF CASES 
Neutroclusion, or Class I 
Cases of neutroclusion, or Class I, present many different features. They 
resemble each other in that they have a normal mesio-distal relation of 
the arches. In other respects they may differ a great deal, as shown by 
the different types that were described under classification. 
Taking up the treatment of the simpler malocclusions of this class first, 
we shall consider the treatment of such cases as are shown in Fig 428. Tn 
Fig. 428. 
Neutroclusion, or Class I, case. Lingual occlusion of upper incisors to lower. 
this case, the arches are in normal mesio-distal relation. The upper in- 
cisors are in lingual relation to the lower. In fact, the upper teeth are 
lingual to their proper position and the lower incisors are labial. The 
patient is five and one-half years old. If the malocclusion is not correct- 
ed, it is certain that the permanent teeth will take the same position as 
shown by the deciduous teeth. The demand for treatment at this age is 
obvious. If this condition was allowed to exist until the eruption of 
the permanent teeth, the malocclusion would probably develop into a 
mesioclusion, or Class III, case. 
325 326 
PRACTICAL ORTHODONTIA 
Plain bands, made as described in Chapter V, were placed on the 
upper and lower canines. On the upper bands, a wire was soldered on 
the labial side, far enough labially to permit the incisors to be brought 
labially to their proper position. On the lingual side of the lower ca- 
nines a wire was soldered, far enough lingually to permit the lower teeth 
to be moved lingually. The appliances are shown in Fig 429. The 
Fig. 429. 
Appliance for moving upper incisors labially and lower incisors lingually. 
Fig. 430. 
Completed case of Fig. 429. 
upper and lower teeth were tied to the respective appliances by silk 
ligatures that exerted force on the teeth. In a few weeks the teeth were 
in the position shown in Fig. 430, and were retained for a short time by 
fastening them to the appliance by means of wire ligatures, which ex- 
erted a passive force. TREATMENT OF CASES 
327 
Figs. 431, 432, and 433 show a case of neutroclusion, or Class I, the 
upper central incisors and right lateral incisor being in lingual occlu- 
sion. The left lateral incisor is in torsi-occlusion. The lower incisors 
Fig. 431. 
Fig. 432. 
Side and front views of neutroclusion, or Class I, case. 
are slightly in labial occlusion. A space exists between the lower left 
lateral and canine, which shows the distance the lower anterior teeth 
are mesial. After studying the case carefully, the author came to the 328 
PRACTICAL ORTHODONTIA 
conclusion that the position of the lower teeth was the result of the mal- 
occlusion with the upper, and if the upper incisors were moved labial 
to the lower, the force of the upper teeth against the lower teeth would 
force the lower incisors lingually to their proper position. 
The upper teeth were treated by placing clamp bands on the first 
molars. The screw was so placed that it occupied the position shown in 
Fig. 435, which also shows the position of the tube on the molar band. 
The arch was bent and adjusted so as to stand away from the anterior 
teeth, as they are the only ones that have to be moved. On the upper 
left lateral incisor, a plain band was placed with a spur soldered near 
Fig. 433. 
Black line indicates position expansion arch should occupy to the upper teeth and 
gingival margin. 
the disto-gingivo-lingual angle. The position of the arch is shown in 
Figs. 434 and 435. Wire ligatures were then placed on the upper anter- 
ior teeth and twisted tightly. At first, the greatest force was placed on the 
central incisors so as to avoid too much pressure on the molars. After 
the central incisors started to move, force was placed on the lateral 
incisors. After the teeth had started to move, the three incisors, which 
are not rotated, were carried labially by tightening the nuts on the ex- 
pansion arch: that is, by screwing the nuts distally. The wire ligature 
on the left lateral incisor was tightened at each visit so as to correct 
the torsi-occlusion of the lateral, on which was placed a plain band with 
a spur. After the upper teeth were moved into the position shown in TREATMENT OF CASES 
329 
Fig. 436, the teeth were retained by passive retention, as shown in Fig. 
437. The retaining appliance was worn until the upper canine erupted, 
for it was necessary to retain the space for the permanent canine as the 
Fig. 434. 
Side view showing position of arch in premolar region. Band on left canine to 
rotate same. 
Fig. 435. 
Occlusal view of arch. Band was used on left lateral, but is not shown. 330 
PRACTICAL ORTHODONTIA 
deciduous canine was soon lost. The occlusion of the upper incisors with 
the lower teeth carried the lowers distally and closed the space between 
the lateral and canine, as shown in Fig. 438. This case was one belong- 
ing to the third type of Class I. 
Fig. 436. 
Fig. 437. 
Showing retention of Fig. 433. 
Fig. 439 shows another case of neutroclusion, or Class I, that is typical 
of a great many cases belonging to this class and is one of the first type. TREATMENT OF CASES 
331 
In order to treat this case, it will be necessary to expand both the upper 
and the lower arch. The upper arch is underdeveloped about equally on 
both sides, and therefore the teeth will all have to be moved equally with 
Fig. 438. 
Completed case of Fig. 433. Note how occlusion has driven lower anterior teeth 
distally and closed space between canine and premolar. 
Fig. 439. 
Neutroclusion, or Class I, case. Normal mesio-distal relation of arches. 332 
PRACTICAL ORTHODONTIA 
the exception of the upper canines, which will have to be depressed 
slightly. The front view (Fig. 439) shows that the median line of the 
upper and lower incisors is not a straight line. This is caused by the 
fact that the lower incisors have drifted to the right. The right lateral 
Fig. 440. 
Fig. 441. 
Occlusal view of appliances. Spurs on lower arch to move teeth toward left side. 
is distal to the canines and all of the lower incisors will have to be moved 
to the left. 
Ligature wires are twisted between the teeth, as described in Chapter 
V, so as to produce enough separation to permit putting on the molar TREATMENT OF CASES 
333 
bands. Clamp bands are placed on the upper and lower first molars, as 
shown in Figs. 440 and 441. The upper arch is adjusted in such a man- 
ner that it stands away from the second premolars slightly and a little 
farther away from the first premolars. A bend is made in the canine re- 
gion so that the arch lies below the tip of the canine. No effort is made 
to place the arch labially to the upper canines, for it would be too 
prominent and hold the lip out too far. The arch stands labially to the 
incisors, as shown in Fig 440. In order to exert force on the upper ca- 
nines to depress them, tube-spurs are soldered to the arch, as shown in 
Fig. 422. These spurs are bent to fit the labial convexity of the canine 
Fig. 442. 
Front view, showing spurs to depress canines. 
and by bending the spur with a pair of pliers, force is exerted on the 
canines to depress them. This pressure can be increased by putting a 
rubber wedge between the canine and wire spur. The molar bands are 
placed on the lower first molars and the arches adjusted, as shown in 
Fig. 440. Fig. 441 shows the shape of the lower alignment wire. The 
lower alignment wire is bent so as to assume a position labially to the lower 
right canine and bent with rather a sharp angle in the canine region. 
Owing to the fact that the lower incisor must be shifted to the left, soft 
solder wire spurs are placed on the arch at points shown in Fig. 442, and 
the ligatures placed so as to pull the teeth to the left. In order to in- 
crease the pull of the teeth toward the left side, the expansion arch, 334 
PRACTICAL ORTHODONTIA 
or alignment wire, is so adjusted that it stands away from the left canine 
region farther on the left side than it does on the right. 
The upper teeth were retained by placing bands on the upper lateral 
Fig. 443. 
Fig. 444. 
Occlusal view of retainers. Compound reciprocal intermaxillary retention. 
incisors and the first molars. The first molar bands are plain bands. A 
lingual wire was placed on the lingual side of the teeth to retain the ex- TREATMENT OF CASES 
335 
pansion of the arch. A spur was soldered on the labial side of the lateral 
incisor to make a downward pressure on the canine. The occlusal view 
of the retainer is shown in Figs. 443 and 444. The lower arch was re- 
tained by plain bands on the molars, left canine and right lateral. A lin- 
gual wire was used to retain the expansion of the teeth. A spur was sol- 
dered on the labial surface of the right lower lateral band to retain the 
canine. No band was placed on the lower right canine, for it was in 
infra-occlusion, and a band would have prevented it from elongating as 
it should. The front view of the retainer, which is a compound reciprocal 
retainer, is shown in Fig. 445. 
Figs. 446 and 447 is a case of neutroclusion, or Class I, in which there 
is bunching of the upper ad lower teeth. The front view of the case 
Fig. 445. 
Front view of retaining appliance. Spurs to hold and move upper canines occlusally. 
shows that the median line of the upper and lower teeth is not in balance. 
The upper teeth have drifted to the right and the lower teeth to the left. 
The occlusal view (Figs. 448, 449 and 450) shows the reason for the 
shifting of the median line. The position of the upper and lower canines 
is due to the early loss of the deciduous canines, which permitted the 
upper anterior teeth to drift to the right and the lower anterior teeth to 
the left. When the lower left canine erupted, it forced the lateral incisor 
lingually and took a labial position. After separating the molar teeth, 
clamp bands were placed on both the upper and the lower first molars. 
The arches were bent in the canine region to give the relations shown in 336 
PRACTICAL ORTHODONTIA 
Fig. 446. 
Fig. 447. 
Neutroclusion, or Class I, case. Largely due to early loss of deciduous teeth. TREATMENT OF CASES 
337 
Fig. 448. 
Occlusal view, showing spurs on arch and bend in arch on right side to move 
median line to the right. Dotted line shows position of arch before being placed in 
tube. 
Fig. 449. 
Shows how ligatures spring arch toward teeth. Dotted line represents position of arch 
before ligatures were placed on teeth. 338 
PRACTICAL ORTHODONTIA 
Figs. 448, 449 and 450. Owing to the infra-occlusion of the right upper 
canine, it was necessary to place a tube spur on the arch, as shown in Fig. 
451. It will be noticed that the spur is double, one part of which pro- 
jects gingivally and distally and rests on the labial surface of the canine 
and the other part projects occlusally and distally and is used for inter- 
maxillary anchorage. In adjusting the upper arch it is made to stand 
away from the canine and lateral left side, and spurs are soldered on the 
expansion arch in the position shown in Fig. 452. When the ligatures are 
placed on the anterior teeth, the arch will be sprung as shown by the 
dotted lines. It will now be seen that the placing of the wire ligatures, as 
Fig. 450. 
Shows relation of lower arch to teeth. Ligatures and spurs on lower arch to move 
teeth to left. 
shown by the lines, has pulled the upper arch to the right side. No liga- 
ture should be placed on the left lateral incisor until the other three in- 
cisors have been moved to the right far enough to give room to bring it 
through. In applying the wire ligatures on the incisors, the right lateral 
should be ligated first as it is the one that receives the greatest stress; if 
the centrals were ligated first and the lateral last, it would be found that 
the ligatures on the central were loose after the lateral was ligated. After 
the three incisors have begun to move, a wire can be placed on the left 
lateral and the gingival part of the tube-spur bent down on the canine. 
The lower expansion arch is applied the same as the upper arch except 
that the spring is reversed; that is, the right side of the arch takes its TREATMENT OF CASES 
339 
Fig. 451. 
Double spur on upper arch. Gingival spur to depress canine. Occlusal spur to engage 
intermaxillary rubber, as shown in 452. 
Fig. 452. . 
Intermaxillary rubber to assist in shifting median line of upper and lower arch. 340 
PRACTICAL ORTHODONTIA 
position away from the canine region and the spurs are soldered to the 
arch at the left side of the teeth that are to be moved. The position of 
the spurs can be seen by noting Figs. 450 and 451. On the right side 
of the lower arch is soldered a sheath-hook for the use of intermaxillary 
anchorage. The left canine, left lateral incisor and the centrals are 
ligated to the arch, which causes the arch to assume the position shown by 
the dotted lines. From the sheath-hook on the lower arch to the sheath- 
hook on the upper arch, an intermaxillary rubber is stretched and worn 
at night, which assists in shifting the median line. This use of the inter- 
maxillary anchorage was first described to the author by Angle. 
Fig. 453. 
Completed case. 
As a result of the treatment, the teeth were brought to their proper 
position and the median line of the upper and lower arches corrected, as 
shown in Fig. 453. The retention of the upper arch consisted of a plain 
band, which was placed on the left lateral with a spur on the lingual side 
that engaged the lingual side of the left central, and a spur on the mesial 
side of the lateral band bearing against the labial surface of the canine, 
gingivally to the greatest convexity: so. by bending the spur downward, 
pressure would be brought to bear on the canine that would cause it to 
assume the proper position in the arch, as it is in infra-oeclusion. TREATMENT OF CASES 
341 
Owing to the length of the cusps, it was impossible for the upper arch 
to change unless the left canine and lateral slipped out of the line and 
the lower teeth changed. Therefore, it was important that the lower arch 
be retained in order to make the upper stay. Bands were placed on the 
Fig. 454. 
Fig. 455. 
Neutroclusion, or Class I, case. Notice extreme linguoversion of upper lateral 
incisors. 342 
PRACTICAL ORTHODONTIA 
lower canine and the right lateral incisor. A wire was placed lingually 
connecting the two. On the labial side of the lateral band was soldered 
a spur, which engaged the labial surface of the right canine that had 
Fig. 456. 
Upper appliance ligated to teeth. 
Fig. 457. 
Dotted line on lower shows relation of heels of arch to tubes before arch is placed in 
molar bands. 
been moved from labial occlusion and was still in infra-ocelusion. A band 
intended for use in compound retention should never be placed on a TREATMENT OF CASES 
343 
tooth that is in infra-occlusion, for it prevents the tooth from taking its 
proper position in the arch. 
In removing the retaining appliances from a case of this kind, the upper 
should be removed first and the lower left a month or more longer. In 
any case, all of the retaining appliances should not be removed until all of 
the forces of occlusion have been established. 
The right and front view of the case illustrated in Figs. 454 and 455 
shows it to be one of neutroclusion, or Class I, as the arches are in normal 
mesio-distal relation. By looking at the right side and the front view 
it will be seen that the right lateral and central are in lingual occlusion. 
The occlusal view shows the right lateral in contact with the premolar. 
The entire upper arch needs to be expanded. Ligature wires were placed 
Fig. 458. 
Showing method of adjusting arch by beginning at one side and carefully adjusting 
same until molar on opposite side is reached. 
on the mesial and distal sides of the first molars and twisted to separate 
the teeth slightly so as to permit the placing of the molar bands. The 
molar bands were so placed that the tube lined buccally to the canine. 
While the canines are prominent, as the teeth now stand there is not suffi- 
cient room between them to accommodate the incisors. One side of the 
arch was placed in the tube on the molar band so as to obtain the proper 
length and alignment. The arch is allowed to stand away from the pre- 
molars and canine. In the region of the canine, the arch is bent at an 
angle, as shown in Fig. 458. This bend is made in one side only, and 
the arch is in one tube only at this time. The position of the anterior 
part of the arch to the anterior teeth is now noted, and the arch bent 
again in the region of the canine on the opposite side. The buccal part 344 
PRACTICAL ORTHODONTIA 
of the arch is now aligned with the tube. Up to this time, the arch has 
been placed in the tube on one side only. With the side of the arch in 
the tube that was first adjusted, the position of the other side is carefully 
noted. It should be observed how the angle of the arch compares with the 
Fig. 459. 
Plain bands with spurs were placed on the laterals, but are not shown on this 
model. Upper arch does not touch canines as those teeth must be expanded. Spur 
opposite right lateral is for bodily movement of same. 
Fig. 460. 
Front view of appliances. Right upper lateral incisor is ligated to arch after sufficient 
room has been made to allow it to move. TREATMENT OF CASES 
345 
angle of the tube before being placed in the tube. The arch should also 
stand buccally to the tube, for the molars require expanding and a slight 
amount of expansive force should now be given the arch. The arch can 
be made to stand bucally to the tube the width of a 16-gauge arch and 
will not exert enough expansive force to cause any pain. In adjusting 
the arch so as to produce expansion, the spring that produces the expan- 
sion must be derived from the anterior segment of the arch, and never 
from the heels or the distal corners, or the molars will rotate buccally. 
The position of the adjusted arch to the teeth is shown in Figs. 459 and 
460. The positions of the ends of the arch to the tubes before they are 
placed in the tubes are shown by the dotted lines. Bands are placed on 
the laterals with spurs so that they can be rotated and also to prevent 
Fig. 461. 
Cross section of arch and spur for bodily movement of teeth shown in Figs. 459 and 460. 
the ligatures from slipping off. A spur is soldered on the arch at a point 
directly labially to the mesial surface of the right lateral, as the tooth 
must be moved directly labially in order to get past the canine. After 
the premolars have been expanded slightly and the incisors moved la- 
bially, it will be necessary to place a tube-spur on the upper arch so as 
to move the apex of the right lateral forward. This spur rests against 
the incisal edge of the tooth, which prevents that part from moving, and 
by tightening the ligature the apex is brought forward. The position of 
the spur is shown in Figs. 459, 460 and 461. 
There is nothing unusual or new in the adjusting of the lower arch 
as the teeth need expanding slightly. The left lower canine must be 
banded so as to permit its rotation. 
The teeth of the upper and lower arch, having been expanded, are 
retained by compound reciprocal retention, so as to permit them to re- 346 
PRACTICAL ORTHODONTIA 
spond to the forces of occlusion. Bands are placed on the upper lateral 
incisors. A spur, long enough to engage the lingual surface of the cen- 
tral incisor, is soldered on the lingual side of each band. A long spur. 
Fig. 462. 
Fig. 463. 
Impressions made after retaining appliances were placed on teeth. 
extending back to the mesial portion of the upper first molar, is soldered 
on the labial surface of the lateral band. This long spur rests against the 
upper canine on the labial surface. Ligature wires, which have had a TREATMENT OF CASES 
347 
piece soldered to them as shown in Fig. 462, to prevent their slipping 
under the gum, are placed on the first and second premolars. This plan 
of soldering a wire on the ligature wire to prevent it from slipping under 
the gum was suggested to the author by Lourie. After the premolars have 
been ligated to the labial spur we have the retaining appliance, as shown 
in Fig. 462. The advantage of this form of retainer is that none of the 
teeth are held rigid, and by bending the spurs different amounts of force 
can be brought to bear on different teeth. The greatest tendency for the 
teeth to return to their former position is in the region of the first pre- 
molar, canine and lateral. This tendency is prevented by the use of the 
retaining appliance, which has been so constructed as to make possible the 
Fig. 464. 
Front view, showing long labial spur over canine. 
highest degree of compound active reciprocal retention. The lower teeth 
were retained by the device shown in Fig. 463. 
The case illustrated by Fig. 465 has a normal mesio-distal relation of 
the arches on both sides. The upper teeth on the right side, from the cen- 
tral to second molars, are in lingual occlusion, except the canine. This 
makes it necessary to expand or move the upper teeth on the right side 
farther than we shall move the same teeth on the left side. It will 
therefore be impossible to use reciprocal anchorage, which has to a cer- 
tain extent been employed in the former cases. In order to move the 
teeth that are in lingual occlusion to their proper position, we have the 348 
PRACTICAL ORTHODONTIA 
choice of several methods and anchorages. We can use reenforced simple 
anchorage, stationary anchorage, or intermaxillary anchorage. 
In using reenforced simple anchorage, the molar bands are adjusted 
to the first molars in the usual manner. The arch is placed in the tubes 
on the molar bands with expansion in the molar regions. If nothing else 
was now done, there would be an equal amount of force exerted on the 
molars of both sides, which is not desired. However, in order that the 
molar on the left side may have the advantage over the one on the right 
side, the screw on the left molar band is bent against the premolar, as in 
Figs. 466 and 467, and away from the premolar on the right side. This 
Fig. 465. 
Neutroclusion, or Class I, case. Upper molars and premolars on right side in 
linguoversion to lower. 
enlists two teeth on the left side against one on the right side. To further 
increase the anchorage on the left side, the first premolar and canine are 
ligated to the arch. This now makes reenforced simple anchorage, as a 
number of teeth on the left side are pitted against the tooth on the right 
side. Owing to the attachment of the peridental membrane and the al- 
veolar process, it will be impossible to move the right first molar without 
exerting some force on the second molar and second premolar. In fact, 
when expanding the first molar in cases of this kind, it is seldom neces- 
sary to attach to the second molar. In order to increase the buccal move- 
ment of the right molar, intermaxillary anchorage can be used by plac- TREATMENT OF CASES 
349 
ing a rubber ligature from the screw on the lingual side of the right 
upper molar band to the tube on the right lower molar band. This will 
make the rubber occupy the relation as shown in Fig. 469. If rubber 
Fig. 466. 
Showing arch before it is placed in tube. 
Fig. 467. 
Showing arch after having been placed in tubes. 350 
PRACTICAL ORTHODONTIA 
Fig. 468. 
Front view of arches in position. 
Fig. 469. 
Fig. 470. 
Fig. 469.-Rubber ligature from screw on lingual side of right upper molar band to tube 
on right lower molar band. 
Fig. 470.--Showing oval and square tubes for stationary anchorage of molars. TREATMENT OF CASES 
351 
ligatures of good quality are used, they will resist the stress of mastica- 
tion remarkably well. 
It has been stated that the molars and premolars on the right side 
could be moved by stationary anchorage. Stationary anchorage can be 
produced in several ways. One way is to use an oval tube; the arch is also 
Fig. 471. 
Fig. 472. 
Front and occlusal view of Fig. 465, showing retention. 
oval, which prevents the arch from turning in the tube (Fig. 470). This 
oval tube is used on the left side or the side that is to be made stationary. 
A square tube serving the same purpose has been devised by Kemple. I f 
the oval or square tube cannot be obtained, stationary anchorage can be 
produced by the use of the ordinary round tube and expansion arch in 352 
PRACTICAL ORTHODONTIA 
the following manner: The arch is adjusted to the teeth and bent to 
align with the tube as it should. On the left side the tube is pinched to 
the arch by means of heavy pliers or a wire cutter. Then the nut on the 
band is loosened and the band removed with the arch in the tube. The 
tube is then soldered to the arch by means of soft solder. Soldering the 
arch in the tube makes the tipping of the left molar impossible unless the 
arch twists. The twisting of the arch must be taken into consideration 
in any of the forms of anchorage that we have mentioned. Care must be 
exercised so as not to strain the anchor tooth. 
Another means of producing greater resistance on one side of the 
dental arch than we have on the other is to employ a perpendicular tube 
on one side, as shown in Fig. 473, and a horizontal tube, as shown in Fig. 
Fig. 473. 
Perpendicular tube to produce stationary 
anchorage on molar in unilateral buccal 
expansion. 
Fig. 474. 
Parallel tube to allow tipping of molar in 
unilateral buccal expansion. 
474. The perpendicular tube prevents the molar from moving unless it 
is carried bodily, and the horizontal tube allows tipping of the molar. 
After the upper arch was expanded to the proper size, and the teeth 
on the right side brought to their proper position, they w'ere retained by 
the retention as shown in Figs. 471 and 472. 
As there is nothing of particular interest about the lower arch, the 
treatment will not be considered here. 
By looking at the right and left sides of the ease shown in Fig. 475, 
it will be seen that on the right side there is a slight mesial tendency of 
the lower teeth, but they are not beyond the influence of the cusp, and the 
case is therefore classed as neutroclusion, or Class I. The left side shows 
a normal mesio-distal relation of the molars and the lower arch is short 
on that side owing to the early loss of the second deciduous molar, which TREATMENT OF CASES 
353 
has permitted the space intended for the second premolar to close. Look- 
ing at the front view of Fig. 475, and the left side of Fig. 475, it will be 
seen that the upper left incisor is in lingual occlusion to such an extent 
that it is lingual to the lower teeth. In order to get this tooth into its 
proper position, it is necessary to adjust the expansion arch in the same 
manner as described in other cases. The arch is adjusted so that it 
stands away from the teeth slightly, as a general expansion is needed. 
Fig. 475. 
Neutroclusion, or Class I, case. Impacted lower left second premolar and upper left 
lateral incisor in linguoversion to lower. 
The premolars are ligated to the arch, as are the incisors. A spur should 
be soldered to the arch directly in front of the left central incisor so as 
to prevent the central from drifting to the left as it is carried forward. 
After the arch is expanded slightly and the anterior teeth carried forward, 
a ligature is placed on the left lateral and it is carried labially over the 
lower anterior teeth. It has often been suggested that a gag or some 
device be put on the teeth to open the bite while the teeth are being car- 354 
PRACTICAL ORTHODONTIA 
ried from lingual to normal occlusion. The author has never found this 
necessary in his practice. The lower arch will have to be expanded in all 
regions. In addition to that, it will be necessary to carry the left pre- 
molar, canine and incisors forward to make room for the impacted sec- 
Fig. 476. 
Front view, showing upper and lower arches. 
Fig. 477. 
Spur and long ligature is shown on left side to move canine and premolar forward to 
make room for impacted second premolar. TREATMENT OF CASES 
355 
ond premolar. The lower expansion arch is adjusted so as to exert force 
on all of the teeth to carry them buccally and labially. The relation of 
the expansion arch to the teeth is shown in Fig. 476. The expansion 
arch must be made wide in the canine region, as it is necessary to expand 
the dental arch a great deal in order to make room for the incisors. The 
canines are moved bucally before any attempt is made to bring the lower 
right lateral forward. The mesial movement of the left premolar and 
canine is accomplished by the use of a long wire ligature that engages 
the premolar and canine, and is twisted in front of a spur that has been 
soldered to the arch directly mesially to the canine. This spur is at- 
tached by soft solder and is macle by twisting a ligature wire around 
the arch after the manner described in the making of spurs. Fig. 477 
illustrates how this long ligature is placed on the arch. It will also be 
Fig. 478. 
Fig. 479. 
Fig. 478.-Intermaxillary rubber placed distal to molar tube to prevent molar from 
moving distally, as the nut on arch is screwed distally to carry anterior teeth forward 
to make room for impacted premolar. 
Fig. 479.-Intermaxillary rubber placed on intermaxillary hook, which is mesial to 
nut on lower arch, for the purpose of moving lower teeth forward. No forward force is 
exerted on lower molar with this plan of attachment. 
seen that there is another ligature on the canine, used for expansion. 
After this long ligature is twisted tight around the premolar and canine, 
the teeth are carried forward by tightening the nut on the expansion arch. 
This gives the same movement to the teeth that would occur with a jack- 
screw. It must be remembered that as much force is being exerted 
upon the molar as upon the premolar, canine and anterior teeth. Very 
often the lower molar will be displaced distally, in which case it will be 
necessary to enlist intermaxillary anchorage in order to hold it in the 
proper position, or to restore it to its normal position if it has been dis- 
placed. In this instance intermaxillary anchorage will be used by plac- 
ing an intermaxillary-hook on the upper arch in the region of the 
upper canine, and adjusting a rubber from it to the distal portion of 
the tube on the lower molar band. (Fig. 478). Some have placed an 356 
PRACTICAL ORTHODONTIA 
intermaxillary-hook on the lower arch just in front of the nut on the left 
side and attached the rubber from the hook fastened to the upper arch I 
to the hook on the lower arch. This will prevent any forward pull upon 
the molar. Where the intermaxillary rubber is used from the upper hook 
to the distal portion of the lower band, the forward pull of the rubber 
is counteracted by the backward push of the nut on the expansion arch. | 
and if these forces are kept balanced the molar will not move at all. I 
Should the molar be moved distally before it is discovered that the ante- * 
Fig. 4S0. 
Front view of completed case shown in Fig. 475. 
rior teeth are causing the molar to be displaced, a rubber is used that is 
strong enough to pull the molar and lower anterior teeth forward. The 
different attachments for this use of intermaxillary anchorage are shown 
in Figs. 478 and 479. 
During the treatment of this case, the second left lower premolar came 
into position. The eruption of this tooth maintains the proper mesio-dis- 
tal relation of the lower teeth on the left side (Fig. 480 . The upper teeth 
were retained by placing a band on the upper lateral incisor with a spur 
on the labial side that embraced the central incisor and canine (Fig. 
481). Xo other retainer was placed on the upper teeth, for with the long TREATMENT OF CASES 
357 
cusps it was impossible for the upper arch to narrow unless the lower 
one did so first. The lower arch was retained by placing bands on the 
lower canines and by shaping a wire to fit the lingual surfaces of the 
lower molar. This lingual arch should be made of some material that 
Fig. 481. 
Upper impression was made before retaining appliance was placed on lateral. 
Fig. 482. 
Lower impression was made with retainer on teeth. Lingual bar extended to molars. 
possesses considerable spring. It is soldered to the lingual surface of the 
canine bands and occupies the position shown in Fig. 482. The narrow- 
ing of the lower molars is prevented by the spring of the lingual bar. and 
the pressure can be increased in a buccal direction by grasping the bar 
distal to the canine band with a pair of pliers and bending it outward. 358 
PRACTICAL ORTHODONTIA 
Lack of facial development produced by neutroclusion. (Tanzey.) 
Fig. 483. 
Fig. 484. 
Fig. 485. 
Malocclusion of patient shown in Figs. 483 
and 484. (Tanzey.) 
Fig. 486. 
Occlusion of teeth after treatment of case 
shown in Fig. 485. (Tanzey.) TREATMENT OF CASES 
359 
Neutroclusion, or Class I, cases present many varieties and produce 
various effects on the facial outlines, which have been considered in a 
previous chapter. Neutroclusion cases that have a bunching of the teeth 
as we have just described produce a lack of development of the dental 
region of the face, which is shown in Figs. 483 and 484. The position of 
the teeth is shown in Fig. 485. The proper treatment of the malocclusion 
resulted in the condition as shown in Fig. 486. The expansion of the 
arches is shown in Fig. 487. The result of the expansion of the arches 
and of the placing of the teeth in their proper positions produced the 
change in the face, which is shown in Figs. 488, 489 and 490. 
Fig. 487. 
Occlusal view before and after treatment. (Tanzey.) 
Mutilated Cases of Class 1, or neutroclusion, should be treated with 
a view of restoring normal occlusion as nearly as possible. This means 
that some artificial substitute should be placed on the teeth that will take 
the place of the missing teeth or tooth. Considerable has been written 
on ''Compromise Treatment,'' which means that, in those cases, that have 
been mutilated, some method is followed that will improve the occlusion 
but will not tend to produce normal occlusion. The compromise method 
should only be attempted by the experienced orthodontist. 360 
PRACTICAL ORTHODONTIA 
Fig. 488. 
Fig. 4S9. 
Fig. 490. 
Improved facial expression produced by the correction of the malocclusion present in 
Figs. 483 and 484. (Tanzey.) TREATMENT OF CASES 
361 
Fig. 491 shows a case that is complicated by extraction. The lower 
first and second molars and second premolars below were extracted. The 
third lower molars drifted slightly forward. Owing to the loss of the 
lower molars the lower anterior teeth drifted distally until the lower lip 
was caught under the upper anterior teeth and those teeth were forced 
forward. The general facial appearance of the patient would suggest 
distoclusion or Class II. but the mesio-distal relation of the arches shows 
it to be Class I. or neutroclusion. These cases become so extreme that 
they demand some sort of treatment, and it is to show that something can 
Fig. 491. 
A mutilated case of Class I, or neutroclusion. 
be done for these unfortunate patients that the author is describing this 
case. The lower anterior teeth occlude against the superior gums, lin- 
gually to the superior anterior teeth. This condition was causing a great 
amount of irritation, which could be corrected only by increasing the 
length of the molars and the premolars. 
In treating this case, it was impossible to attach bands on the lower 
molars for they were too loose, so it became necessary to use the lower 
first premolars for anchorage. This position of the lower teeth makes it 
necessary to move all of the lower teeth forward and this was done by the 362 
PRACTICAL ORTHODONTIA 
use of intermaxillary anchorage. In order that there will not be much 
upward pull on the premolars, a bar is soldered to the premolar band, 
as shown in Fig. 493, which extends backward as far as the position oc- 
Fig. 492. 
Showing upper appliance in place. 
Fig. 493. 
Showing lower appliance in place. 
cupied by a lower first molar. A tube to support the end of the arch was 
soldered on this bar. The distal end of the band was bent lingually so TREATMENT OF CASES 
363 
Fig. 494. 
Side view, showing intermaxillary rubbers. Compound reciprocal intermaxillary an- 
chorage. Note position of nuts on upper arch. 
Fig. 495. 
Front view, showing position of upper arch. 364 
PRACTICAL ORTHODONTIA 
as to form a "V," which engages the intermaxillary rubber. With this 
extension bar on the premolar, it is possible to use a regular size arch, 
which gives a greater range of spring and does not exert much upward 
pull on the premolars. 
The upper expansion arch was adjusted so that the anterior portion 
rested against the upper anterior teeth, buccally to the canines and pre- 
molars, as shown in Fig. 492. The nuts on the upper arch did not touch 
the tube on the upper molar band, for all of the force of the rubber liga- 
ture was to be exerted against the incisors. Wire ligatures were placed 
on the premolars and canines so as to move them buccally. 
Fig. 496. 
Completed result of case shown in Fig. 491. 
The backward pull of the intermaxillary rubbers against the upper 
anterior teeth was also reciprocated against the lower teeth. As the upper 
incisors moved distally faster than the lower teeth moved forward, when 
the upper anterior teeth had been moved to their proper position, and the 
dental arch widened the proper width, the nuts on the upper expansion 
arch were allowed to rest against the bands on the upper molars, so 
that all of the upper teeth were pitted against all of the lower teeth 
(Figs. 494 and 495). The continued use of the intermaxillary rubbers 
finally moved the lower teeth to their proper position. It was then 
necessary to restore the missing teeth. In this case a gold plate was TREATMENT OF CASES 
365 
used. The improvement of the facial outline was very pleasing. The 
improvement in the occlusion of the teeth is shown in Fig. 496. Cases 
of this type are not attractive to some operators, and many practition- 
ers go so far as to advise against treatment, but these unfortunate 
Fig. 497. 
Fig. 498. 
Front and side view of malocclusion caused by extraction of lower first molars. 366 
PRACTICAL ORTHODONTIA 
people have a right to some relief, and if properly handled, very sat- 
isfactory results can be obtained. 
The retention of the case consisted in placing an accurately fitting 
gold plate in the lower, which carried properly occluded artificial 
teeth with proper mesio-distal contact. This plate retained the lower 
teeth in their proper position. No retaining appliance was put on the 
upper teeth, as it was impossible for them to change their position 
owing to the position of the lower lip and the force of the muscular 
pressure. 
Common forms of neutroclusion, or Class I, cases are those that are 
mutilated as the result of the extraction of the first molars. These 
patients often give a history of a normal occlusion prior to the time 
of the extraction of the first molars. The change is often gradual and 
Fig. 499. 
Position of tube on molar band, which must be resoldered so as to assume position 
shown in 500. 
they are not aware of the trouble that is resulting until it is brought 
to their attention. In the case shown in Figs. 497 and 498, which was 
caused by the early loss of the lower first molars, the teeth gradually 
drifted together until the lower second molars and the premolars 
were in contact on both sides. As a result of this drifting, none of the 
teeth are in normal occlusion. The lower incisors are biting against 
the upper gums, and to remedy this condition the difficulty presented 
was to open the space for the missing teeth and to supply an artificial 
substitute. 
Very often, in these cases, it is necessary to open the space only far 
enough to supply a tooth half the size of the molar, as that is sufficient 
in some cases to open the bite far enough to prevent the lower teeth TREATMENT OF CASES 
367 
from striking the upper gums. However, it must be remembered that 
it is always necessary to move the lower anterior teeth, or rather the 
teeth anterior to the molars, into their proper position. If the proper 
space is not restored, it is because the second and third molars are 
not moved distally to their proper position, for the teeth anterior to 
them must always occupy the proper mesio-distal relation to the 
uppers. 
In treating these cases, it is necessary to move the molars distally 
and the teeth anterior to them mesially. Clamp bands are placed on 
the second molars, and owing to the tipping of these teeth it is al- 
ways necessary to solder the tube at a different angle from that which 
it occupies on the band as supplied by the manufacturers. Fig. 499 
shows the tipping that usually is encountered in these cases, and 
Fig. 500. 
Position of arch, which is sprung- up to tip molar backward. 
plainly illustrates the position that the tube assumes as the band is 
placed on the tooth. In Fig. 500 is shown the position to which the 
tube must be changed. In aligning the tube, the anterior part of the 
tube should be so placed that the anterior part of the arch rests 
apically to the gingival part of the teeth, as shown in Fig. 501. This 
position of the arch is necessary to give a backward and upward tip- 
ping of the molar, produced by springing the arch occlusally and 
wiring the anterior portion of the arch to the anterior teeth. The ef- 
fect of this action upon the molars is shown in Fig. 502. The side view 
of the appliance is shown in Fig. 503. Spurs are placed on the lower 
arch mesially to the canines for the purpose of using the long ligatures 
to bring the premolars and canines forward. The ligatures on the 
anterior teeth carry them forward as the nuts on the arch are tight- 368 
PRACTICAL ORTHODONTIA 
ened. The tightening of the nut exerts a backward force on the 
molars and a forward force on the anterior teeth. Under ordinary 
conditions the anterior teeth would move more rapidly than the molars, 
but it must be remembered that the molars have a tipping force 
exerted on them by the spring of the arch. If the molars do not move 
distally as fast as they should, and there is danger of moving the an- 
terior teeth too far, intermaxillary anchorage can be used, with the 
rubber running from the tube on the upper molar band to an inter- 
maxillary hook on the lower expansion arch opposite the canine. It 
would be necessary to adjust an alignment wire on the upper teeth, 
which was not used in this case, if intermaxillary anchorage was em- 
ployed. The upper arch required expansion only in the canine and 
premolar region, and this was accomplished by placing plain bands 
Fig. 501. 
Fig. 502. 
Fig. 501.-Showing gingival position of arch, which must be sprung occlusally, 
as shown by dotted line, and wired to anterior teeth to tip molar distally. 
Fig. 502.-Dotted tooth form illustrates result of action as outlined in occlusion. 
on the canines to which was soldered a lingual spur that rested against 
the upper first premolar. On the labial surface of the canine band 
was soldered a horizontal tube that received the 18-gauge wire that 
supplied the expansive force. The appliance is shown in Figs. 503, 
504 and 505. 
After the space has been provided, the retention will consist in re- 
storing the missing tooth by some means as indicated in crown and 
bridge work. The position of the anterior teeth can be retained by 
any of the retaining devices mentioned heretofore that meet the re- 
quirements of the case. 
In the treatment of mutilated cases, or other cases where there are 
missing teeth, one of the unsatisfactory problems is the replacing of 
the missing tooth with an artificial substitute. The replacement of TREATMENT OF CASES 
369 
Fig. 503. 
Appliance as first placed on molars. Side view. 
Fig. 504. 
Shows model with lower appliance in place. Small arch was placed on canines to 
expand upper arch in canine region. 370 
PRACTICAL ORTHODONTIA 
the missing tooth with the artificial tooth presents more problems 
than was at first imagined. In order for the replaced tooth to be of 
the greatest use, it must be so made as to present the proper mas- 
Fig. 505. 
Occlusal view of upper appliance to expand canines and premolars. 
Fig. 506. 
Model of lower teeth with appliance adjusted, showing how space has been made for 
extracted tooth. 
ticating surface and also to have the proper mesio-distal diameter. 
The fact that a great many methods make necessary the mutilation 
of the teeth to which the artificial tooth is attached, has caused many TREATMENT OF CASES 
371 
to try to avoid the use of artificial substitutes more than they have in 
times past. In those cases in which the first molars are lost early, it 
is possible to move the second molars forward in an upright position 
and to close the space and make the second molar take the place of the 
first. It is true that the second and first molars are not of the same 
shape, but by closing the space after the manner suggested, we avoid 
the necessity of mutilating the teeth for the attachment of artificial 
teeth and do not compel a young patient to go through life with some 
form of artificial tooth in his mouth. However, in the cases in which 
the remaining teeth are moved to close the vacant spaces, there must 
be a careful diagnosis, and the case must be selected that is suitable 
Fig. 507.' 
Made during treatment. Compare with Fig. 497. 
for such treatment. The case shown in Fig. 507 could be benefited 
only by opening the space, as the teeth posterior and anterior to the 
missing tooth had tipped to such an extent that the lower teeth were 
impinging against the upper gum. In young patients it is possible 
to bring the second molars forward and produce more satisfactory 
results where the first molars are missing than to attempt to maintain 
the space and insert an artificial substitute. 
In a great many cases of neutroclusion, it is possible to use the 
lingual wire, which makes an appliance that is less bulky and con- 
spicuous than the labial wire. 
Fig. 508 shows the front view of the model of a patient six years of 372 
PRACTICAL ORTHODONTIA 
age, with an underdeveloped upper and lower arch. Fig. 509 shows 
the occlusal view of the upper arch with a bunching of the deciduous 
incisors; a lack of development between the upper canines. There is 
also a crowding of the lower permanent incisors, which can be seen 
in Fig. 508. This crowding is the result of the lack of development 
of the lower arch, which in turn is also retarded by the lack of de- 
velopment of the upper arch. The lingual alignment wire was placed 
Fig. 508. 
Front view of case showing lack of development. (Lourie.) 
Fig. 509. 
Occlusal view showing lack of develop- 
ment of upper arch. (Lourie.) 
Fig. 510. 
Upper arch with lingual wire in place. 
Compare with Fig. 509 for amount of de- 
velopment obtained. (Lourie.) 
on the upper teeth, as shown in Fig. 510, with bands upon the deciduous 
molars. By pinching the lingual alignment wire in the incisal portion, 
the angles that rest against the deciduous canines are carried away 
from each other, resulting in expansion in the canine region, which 
will also cause some expansion of the molars. As the upper dental 
arch is widened, thereby giving more room for the lower arch, the 
lower arch developed and the teeth were forced buccally by the action TREATMENT OF CASES 
373 
of the tongue assisted by the force of the inclined plane of the lower 
teeth with the upper permanent and deciduous molars. In taking 
cases at this age it is not always necessary to place an appliance on 
both arches as the lingual arch is used only on the upper teeth. By 
pinching the lingual wire the development of the upper dental arch 
occurred, as is shown in Figs. 510 and 511, and the appliance is much 
less conspicuous than many other appliances would be and causes 
little annoyance to the patient. The use of the lingual alignment wire 
in neutroclusion cases offers many possibilities. 
Bilateral Distoclusion with Labioversion, or Class II, Division 1 
Bilateral distoclusion with labioversion, or Class II, Division 1, 
cases are those that are characterized by the distal relation of the 
lower arch, the width of one premolar. It is very seldom that we find 
Fig. 511. 
Front view showing development as result of use of lingual arch. Compare with Fig. 
508. (Lourie.) 
the lower teeth distal to a greater extent (Fig. 512). The upper arch 
is narrow, upper anterior teeth protruding, underdeveloped chin, un- 
derdeveloped mandible, short upper lip, thickened lower lip (Figs. 
513 and 514), abnormal muscular pressure, further complicated by 
abnormal breathing. In fact, long-continued mouth-breathing may be 
said to be responsible for all of the conditions found in Class II, Divi- 
sion 1. Mouth-breathing is usually caused by adenoids, for a full de- 
scription of whicIFsee Chapter IV. 
The first requirement in the treatment of these cases is to make 
certain that all nasal obstructions have been removed. It should be 
recalled that the nasal cavity in these patients is always undersized, 
which has been caused by the lack of proper development, as a result 
of mouth-breathing, and lack of atmospheric pressure brought about 374 
PRACTICAL ORTHODONTIA 
by disuse. The lack of development of the nasal cavity can be rem- 
edied only by widening the dental arch, which produces a transfor- 
mation in the bones forming the nasal cavity. It is often found that 
the nasal septum is deflected in a large percentage of these cases, 
which is due in part to the improper development of the bones that 
make up the nasal cavity. While it is a fact that these patients gen- 
erally seek relief for the malocclusion, still they will always be greatly 
benefited by the change that will occur in the nasal cavity as a result 
of the proper treatment of the malocclusion. 
Owing to the extreme facial deformity present in distoclusion with 
protruding superior anterior teeth, or Class II, Division 1, cases, the 
Fig. 512. 
Extreme distal (posterior) relation of lower arch. 
literature on orthodontia is full of these cases and of the different 
plans of treatment. In fact, the advancement of orthodontia may be 
traced through the advancement of the technique in the treatment of 
distoclusion cases, or Class II, Division 1, cases. Therefore, it will be 
appropriate to state briefly the different plans of treatment as prac- 
ticed in the past and at the present time. 
One of the first plans that we have any record of is one in which 
the case was treated by the extraction of some teeth. An upper pre- 
molar on each side was extracted; first, to establish harmony in the 
size of the arches, and second, to reduce the protrusion of the upper 
anterior teeth. This plan of treatment made the upper arch conform TREATMENT OF CASES 
375 
to the underdeveloped lower arch, improved the occlusion slightly, 
and changed the facial profile. Normal occlusion and normal facial 
outlines were not recognized by this plan. 
Fig. 513. 
Fig. 514. 
Class II, Division 1 case, caused by mouth-breathing. 
Fig. 515. 
Typical case of Class II, Division 1. 
Owing to the unsatisfactory facial results and the lack of normal 
occlusion, the next method of treatment to attract attention was the 376 
PRACTICAL ORTHODONTIA 
one introduced by Kingsley and known as "Jumping the bite." This 
plan has for its object: First, the establishment of the n'ormal rela- 
tion of the arches by reducing the protrusion of the superior anterior 
teeth; second, the forward movement of the mandible, which improves 
the facial outlines; and third, the establishing of normal occlusion of 
the teeth. 
It will be seen that the results that were hoped for in this plan of 
treatment were much more attractive than those that were obtained 
by the other method of procedure. The treatment, in brief, was to 
expand both the upper and the lower arches and reduce the protru- 
sion of the upper anterior teeth until both arches were of the same 
size and shape. Then the mandible was moved forward by muscular 
action until the teeth were in their proper mesio-distal relation. The 
. forward movement of the mandible remedied the deformity that re- 
sulted from the underdeveloped chin. The facial outlines and the oc- 
clusion of the teeth were much improved immediately following the 
completion of the treatment. However, the trouble was that great 
difficulty was encountered in getting the mandible to stay forward 
after it had been moved by muscular action. Various forms of re- 
taining appliances were devised and the hope for permanent results 
was based on the belief that the temporo-mandibular articulation 
would change, so as to keep the mandible in its new position, and also 
that the body of the mandible would change. Owing to the great 
tendency of the ligaments to pull the mandible back to its former 
position, the author has grave doubts as to the number of cases treated 
by this plan that could be said to be entirely successful. The two 
plans above mentioned were not wholly satisfactory and therefore 
orthodontists were constantly seeking something that would promise 
better results. 
With the use of intermaxillary anchorage, as described by Baker 
and used on a distoclusion, or Class II, Division 1 case, a new plan of 
treatment was given to orthodontia. With the use of intermaxillary 
anchorage, it became possible to move the upper teeth distally and the 
lower teeth mesially. The forward movement of the lower teeth was 
the great feature of intermaxillary anchorage. Up to that time there 
was no means of bringing about this condition, for the plan known as 
"Jumping the bite" moved the teeth only as the mandible was moved 
by muscular action. After Baker described the treatment of his case, 
Angle began the use of intermaxillary anchorage in distoclusion and 
mesioclusion cases. The following was accomplished: TREATMENT OF CASES 
377 
1. Establishment of the normal mesio-distal relation of the in- 
clined planes of the teeth. 
2. Widening of the upper arch and reducing the protrusion of the 
upper anterior teeth. 
3. Movement of the upper teeth distally and the lower teeth me- 
sially, bringing about the normal relation as described in paragraph 
one. 
4. Improvement of the facial outlines of the individual by so 
doing. 
5. Production of normal muscular action by making it possible 
for the individual to close the lips over the teeth. 
6. Making normal breathing possible because the patient could 
close the lips. 
More satisfactory results could be obtained with this plan of treat- 
ment than from any of the others mentioned. The great improvement 
was the result of having moved the lower teeth forward. However, 
normal occlusion was not always established by obtaining the proper 
relation of the inclined planes; for, in moving the upper teeth distally 
and the lower teeth mesially, a tipping of the teeth was produced, 
which was not desired. After the treatment of these cases it often 
occurred that the chin and mandible would be undersized. For this 
reason it was believed that better residts would be obtained if the 
plan of treatment was changed slightly, which resulted in the follow- 
ing plan, the object of which was to establish normal occlusion of the 
teeth; First, by widening the upper arch and retracting the protrud- 
ing upper anterior teeth; second, by moving the lower teeth forward 
the entire distance (do not move the upper molars distally) ; third, 
by making such anchorage and attachments as would prevent the 
lower teeth from tipping, which would bring them forward in an up- 
right position. As a result of this plan, the best facial outlines were 
obtained, the mandible was developed to its normal size, the muscular 
action became normal and the chin was developed. 
It has been shown in the majority of these Class II, Division 1 cases 
that the upper molars are not too far forward. Such being the case, 
a plan that would approach the ideal result must be one that will not 
move these teeth distally. Therefore, our efforts should be directed to- 
ward moving the lower teeth forward and developing the mandible. 
By examining a large number of these cases, by studying the facial 
outlines and the anatomy of the temporo-mandibular articulation, the 
author is convinced that the great deformity that we encounter in 
these cases in the mandibular region is the result of the underdevelop- 378 
PRACTICAL ORTHODONTIA 
ment of the mandible and is not the result of the distal location of 
the condyle. Therefore our treatment should be of such a nature as 
will produce a development of the mandible that can be brought about 
by the last-named plan. 
Distoclusion with protruding upper anterior teeth, or Class II, 
Division 1 cases are found at all ages-even in children who possess 
only deciduous teeth. It is the opinion of some that the condition may 
be congenital; but in most instances it is the result of some acquired 
pathologic condition, usually mouth-breathing, the mouth-breathing gen- 
erally being the result of adenoids. Treatment is indicated as soon as 
the malocclusion is discovered, for only complications can come by wait- 
ing. 
Fig. 516. 
Distoclusion with labioversion of anterior maxillary teeth. Class II, Division 1 case, 
Patient five years of age. 
Fig. 516 shows a case of distoclusion, or Class II, Division 1, at five 
years of age. This case gave a clear history of adenoids, the patient 
having been operated on one year previously. Plain bands were 
placed on the second deciduous molars, after wire had been placed be- 
tween them and the first deciduous molars to produce separation. An 
eighteen-gauge arch was used, as very little force was required to 
move the teeth. The upper arch was so adjusted that it rested against 
the superior anterior teeth and assumed a position away from the 
canines. The sheath-hooks were placed on the upper arch opposite 
the canines; the lugs on the upper arch were not allowed to rest 
against the tubes on the molar bands at the beginning of the treat- TREATMENT OF CASES 
379 
ment; wire ligatures were placed on the superior canines so as to pro- 
duce widening in the canine region. The position of the arch, liga- 
tures and lugs is shown in Figs. 517, 518 and 520. 
Fig. 517. 
Fig. 518. 
Front and side view of appliance used on Fig. 516. 380 
PRACTICAL ORTHODONTIA 
The lower arch was placed on the lower teeth with the anterior 
portion in close contact with the anterior teeth, with a slight space 
between the canines and the arch, as there is a demand for a slight 
expansion in the canine region; the lugs on the lower arch are against 
the tubes on the molar bands, for it is the intention to bring all of the 
Fig. 519. 
Fig. 520. 
Occlusal view of appliance used on case shown in Fig. 516. 
lower teeth forward. Owing to the ease with which the lower teeth 
move, the force of the intermaxillary ligature, which will depress the 
upper anterior teeth, will also start the lower teeth to moving for- 
ward. As the canines of the upper teeth are expanded, the pull of 
the intermaxillary rubbers will depress the anterior teeth without TREATMENT OF CASES 
381 
destroying the approximal contact of the teeth. After the upper an- 
terior teeth have been moved distally to their proper position, which 
is determined by the shape of the dental arch, the lugs on the expan- 
sion arch are allowed to rest against the molars and the expansion 
arch so changed in shape that it rests passive in contact with all of 
the teeth. All of the teeth are then ligated to the expansion arch 
so as to obtain as much resistance as possible, which is used as an- 
chorage in moving the lower teeth forward. The continued use of 
the rubber ligatures will move the lower teeth forward until they 
occupy the position shown in Fig. 521. The teeth were retained by 
Fig. 521. 
Finished result of Fig. 516. 
the use of passive intermaxillary retention, consisting of a band placed 
on the upper second deciduous molar with an inclined plane on the 
distal side of it, which engaged the distal portion of the lower second 
deciduous molar. This device was worn until the first molars began 
to erupt, and was then taken off. Bands were placed on the lower 
canines with a bar soldered to the lingual side to maintain the expan- 
sion in that region, but nothing was placed on the upper anterior 
teeth; for, if the lower teeth are held and lip pressure is normal, the 
upper teeth will remain normal. If the lip pressure is subnormal, re- 
taining appliances will hold the teeth mechanically only, and when 
removed the teeth will return to their former position regardless of 382 
PRACTICAL ORTHODONTIA 
how long the appliance was worn. Therefore, greater attention should 
be paid to the natural forces of retention than has formerly been 
done. 
Fig. 524 shows a typical case of distoclusion with protruding upper 
anterior teeth, or Class II, Division 1, at the age of seventeen years. 
Fig. 522. 
Plain band on uppei' molar with cast lug to hold lower molar forward. (Suggested 
by Brady.) 
The facial outline of the patient is shown in Figs. 525 and 526. The 
short upper lip, receding chin and underdeveloped mandible are char- 
acteristic of these cases. In order to improve the facial outline of the 
patient, it will be necessary to move the lower teeth forward, widen 
the upper arch, and reduce the protrusion of the upper anterior teeth. 
Fig. 523. 
Occlusal view of finished case. 
The best results will be obtained by moving the lower teeth forward 
bodily, which will cause a development of the mandible. 
Wire is placed around the approximal contact points of the first 
molars to produce a slight separation. After the wire has remained 
in place twenty-four hours or more, clamp-bands are placed on the TREATMENT OF CASES 
383 
Fig. 524. 
Distoclusion with labioversion of anterior maxillary teeth. Class II, Division 1. 
Patient seventeen years of age. 
Fig. 525. 
Fig. 526. 
Effect of mouth-breathing and distal relation of lower arch. Short upper lip, under- 
developed mandible. 384 
PRACTICAL ORTHODONTIA 
first molars, care being taken to have the screws lie close to the lin- 
gual surfaces of the premolars. If the tubes on the bands do not oc- 
cupy the proper position, they are removed and soldered so that the 
Fig. 527. 
Side view, showing intermaxillary anchorage. 
Fig. 528. 
Front view, showing intermaxillary anchorage. TREATMENT OF CASES 
385 
arch will occupy the proper relation to the teeth. The position of the 
upper expansion arch is shown in Fig. 527. It will be seen that the 
anterior part of the arch rests against the upper anterior teeth; that 
the arch stands away from the canines, for they must be expanded; 
and that the nuts are screwed forward in order not to touch the tubes 
Fig. 529. 
Fig. 530. 
Occlusal view of appliances. Upper arch rests against anterior teeth, nuts away from 
tubes. Lower anterior teeth ligated to arch and nuts against tubes. 386 
PRACTICAL ORTHODONTIA 
on the molar bands. These details must be observed carefully in or- 
der to secure the greatest benefit from the regulating appliance. At 
the beginning of the case, wire ligatures are placed on the upper 
canines and first premolars (Fig. 529), which makes reciprocal an- 
chorage between the two sides. Intermaxillary anchorage is used on 
this case, the lower arch having been adjusted as follows: The lower 
expansion arch is placed on the lower teeth so that it will occupy the 
position shown in Fig. 528. Slight expansion is indicated in the 
canine region, but the anterior part of the arch should rest against 
the lower anterior teeth, for they are to be carried forward only as 
the molars and premolars are carried forward by intermaxillary an- 
chorage (Fig. 530). The lower incisors may be prevented from tip- 
ping by soldering spurs on the arch, as shown in Fig. 461, and then 
ligating the teeth to the arch. The spur causes the tooth to maintain 
a perpendicular position. Should it be necessary to move the apex 
of the tooth faster than the crown, this can be accomplished by plac- 
ing a rubber between the tip of the spur and the tooth. 
After the upper teeth have been expanded and the anterior teeth 
brought to the proper position with each other, the nuts on the upper 
arch are allowed to touch the tubes on the upper molar bands so that 
the resistance of all of the upper teeth will be pitted against all of 
the lower teeth. 
It is an anatomic fact that more force is necessary to move the 
upper teeth distally than is required to move the lower teeth for- 
ward, and this knowledge aids us materially in the treatment of this 
class of cases. The continued use of intermaxillary anchorage will 
bring the lower teeth forward to their proper position, but they must 
not be moved rapidly. 
In the majority of distoclusion, or Class II, Division 1 cases, a con- 
dition exists that may be described as infra-occlusion of the lower 
molars. Some have called it supra-occlusion of the incisors, but after 
an examination of many patients and skulls, the author is convinced 
that the difficulty lies in the molar region; therefore, the best results 
will be obtained by some plan of treatment that will produce an 
elongation of the lower molars, and that is what results when the 
lower anterior teeth are ligated stationary to the arch. The position 
of the lower molar roots is such that the continuous pull of the rub- 
bers tends to elongate these teeth as they are being brought forward. 
If attempts are made to move them too fast, there will be too much 
elongation of the lower molars; therefore, it becomes important that TREATMENT OF CASES 
387 
we watch these cases carefully so as to keep the forces employed 
evenly balanced. 
Fig. 531 shows the case after the teeth had been moved to their 
proper position. The change in the mandible can be seen by compar- 
Fig. 531. 
Condition of teeth at the time active intermaxillary anchorage was employed. 
Fig. 532. 
Fig. 533. 
Changed facial results. 388 
PRACTICAL ORTHODONTIA 
ing Figs. 525 and 526 with Figs. 532 and 533, the latter having been 
made after treatment. The movement of the lower teeth forward has 
caused a lengthening of the mandible. 
The retention of the case consisted in placing bands on the upper 
canine and soldering a wire on the labial surface of the bands so as 
to rest against the labial portion of the teeth (Fig. 534). The wire is 
placed on the labial side in order to secure greater efficiency. A 
small spur is soldered on the disto-labial portion of the canine band 
(Figs. 535 and 536) to engage the intermaxillary rubber that will be 
used in retention. In order that this retaining appliance may be of 
Fig. 534. 
Retention of case shown in Fig. 524. 
any value, the wire extending from one canine to the other must be 
made of some material rigid enough to hold the canines labially, for, 
if they "collapse" all of the upper teeth will move to positions of 
malocclusion. The retainer is shown in Fig. 537. 
The lower teeth are retained by making plain bands for the first 
molars and canines. A wire is shaped to fit the lingual side of the 
teeth and is soldered to the lingual side of the bands that retain the 
teeth, as shown in Fig. 538. 
A spur is soldered on the mesio-occlusal angle of the molar bands 
to engage the intermaxillary ligature that is used for retention (Fig. TREATMENT OF CASES 
389 
536). The mesio-distal relation of the-teeth is retained by wearing 
the intermaxillary-rubbers. These rubbers must be strong enough to 
resist the backwarcT tendency of the teeth. This form is called active 
intermaxillary retention. It holds the lower teeth forward, and the 
constant pull of the rubber ligatures holds the lower molars in their 
Upper 1st. IDolar 
clamp 
s band 
Plain 
band 
Spur for rubber 
on Lower 1st. molar 
Fig. 535. 
Active intermaxillary retention used in case shown in Fig. 524. 
Fig. 536. 
Side view of retention used in case shown in Fig. 524. 
proper position and relation, as they have been moved from infra- 
occlusion. 
One of the difficulties with the form of retaining appliances, as 
shown in Figs. 537 and 538, is that the appliance is too rigid and fixed 
and does not permit the removal of the parts for the brushing of the 
teeth. To obviate this difficulty, Fernald has designed a lock for use 390 
PRACTICAL ORTHODONTIA 
with the lingual retaining wire, which makes it possible to remove the 
lingual wire. The lock consists of a triangular tube and a triangular 
spur that fits into the triangular tube. The tube is soldered to the 
band and the spur is soldered to the lingual wire. An enlarged model 
of the device is shown in Fig. 539. Plain bands are made for the 
Fig. 537. 
Fig. 538. 
Occlusion plan of retainer used on case shown in Fig. 524. TREATMENT OF CASES 
391 
molars to which the triangular split tube is soldered. Plain bands 
are made for the canines, which have a notch made on the lingual 
side into which the lingual arch rests. On the labial side of the 
Fig. 539. 
Model showing triangular spur and tube used with lingual wire. (Fernald.) 
canine bands is soldered a square tube perpendicular with the long 
axis of the tooth that is to receive the end of a square wire, as is shown 
in Fig. 540. This square wire resting in the square tube prevents the 
canines from rotating as a result of the pull of the intermaxillary 
Fig. 540. 
Square labial wire used to hold anterior teeth and prevent rotation of canines. 
(Fernald.) 
rubbers used in retention, and by changing the relation of the end of 
the wire as it enters the tube, a variety of movements of the canines 
can be accomplished, should it be so desired. A spur is soldered on 392 
PR AC TIC AL ORTHODONTIA 
the disto-labial angle of the canine band for the attachment of the in- 
termaxillary rubber. Fig. 541 shows the position of the lingual wire 
with the locks on the lingual sides of the molar bands and the lingual 
wire resting in the seat on the canine band. A removable retaining 
appliance for use in distoclusion cases has been designed by Beaser. 
The various parts of the appliance are shown in Figs. 542 and 543. 
The appliance may be made from any kind of material and consists 
of plain bands for the molars and canines. A 16-gauge vertical tube 
is soldered on the lingual surface of the molar bands and a slot cut 
into the tube from the occlusal end, large enough to permit a 20- 
Fig. 541. 
Position of lingual wire locked in molar tubes. (Fernald.) 
gauge wire to slip into it easily. The lingual wire is fitted to the 
lingual surface of the teeth on the model, and the end of the wire is 
cut off flush with the inner surface of the vertical tube. To the end 
of the lingual wire is soldered a piece of 16-gauge wire, which is cut 
off the same length as the vertical tube, and makes a "T" on the 
end of the lingual wire. This piece of 16-gauge wire fits in the vertical 
tube with the 20-gauge lingual wire lying in the slot and prevents 
the molars from rotating. Small hooks are soldered to the linguo- 
cervical border of the canine bands to engage the lingual wire and to 
hold it in place (Figs. 544 and 545). To prevent the outward ten- TREATMENT OF CASES 
393 
Fig. 542. 
Fig. 543. 
Removable retaining appliance in which all parts are separate. (Beaser.) 394 
PRACTICAL ORTHODONTIA 
deucy of the anterior teeth, a piece of 18-gauge tubing is soldered on 
the labial surface of the canine bands and a slot is cut into the tube 
mesially and distally from the cervical end about two-thirds of its 
length, large enough to permit the passage of a 20-gauge wire. This 
Fig. 544. 
Fig. 545. 
Removable retaining wire in position on models. (Beaser.) 
can best be accomplished by cutting the tube about half through for 
the desired length and then soldering to the band. A piece of 20- 
gauge wire is then cut the desired length, which is long enough to 
make a hook on each end after it is adjusted to the incisors and TREATMENT OF CASES 
395 
slipped in place in the notch in the tube on the canine band. To pre- 
vent rotation of the canine, an 18-gauge spur is soldered on the 20- 
gauge labial wire to pass into the 18-gauge tube on the canine band. 
Intermaxillary rubbers are adjusted from hooks that have been sol- 
Fig. 546. 
Fig. 547. 
Intermaxillary rubbers used with removable retaining appliance. (Beaser.) 396 
PRACTICAL ORTHODONTIA 
dered on the lower molar bands to the bent end of the 20-gauge wire 
in the incisors (Figs. 546 and 547). 
Distoclusion, or Class II, Division 1 cases can also be successfully 
treated by means of the lingual arch used in combination with the 
labial arch and spur extensions, thereby making an appliance that is 
Fig. 548. 
Fig. 549. 
Side and front views of distoclusion case. (Lourie.) 
not so conspicuous as when the regular labial arch is used. Figs. 548 
and 549 show a case of distoclusion with protruding upper anterior 
teeth. Fig. 550 shows the occlusal view of the upper model, which 
shows the expansion necessary in the canine and premolar region. 
Plain bands were adjusted to the upper molars, which carry buccal TREATMENT OF CASES 
397 
tubes as shown in Fig. 551. Fig. 551 is a study model that was made 
during treatment and shows the application of the lingual arch. The 
lingual arch was soldered to the lingual side of the molar bands, and 
by pinching the lingual wire with the wire-stretchers the dental arch 
was widened. The lingual arch was made of 19-gauge iridio-platinum 
Fig. 550. 
Occlusal view of case shown in Figs. 
548 and 549. (Lourie.) 
Fig. 551. 
Occlusal view of Fig. 550 with lingual 
arch in place. (Lourie.) 
Fig. 552. 
Labial wire with spur extensions which 
nake an inconspicuous appliance. (Lourie.) 
Fig. 553. 
Study model of case shown in Fig. 548 
made during treatment. (Louri^.) 
and rested against the premolars and canines but did not touch the 
incisors, as they were moved with the spurs on the labial arch. Fig. 
552 shows the labial arch with the spur extension, which rests against 
the incisors and carries them distally as the lingual arch widens the 
canine and premolar region. This appliance does not require any 398 
PRACTICAL ORTHODONTIA 
ligatures on the upper teeth and the only part that is visible is the 
small extension spurs on the labial arch. Intermaxillary anchorage 
is used in the usual manner to shift the mesio-distal relation of the 
Fig. 554. 
Photograph of patient wearing labial arch with spur extensions. (Lourie.) 
Fig. 555. 
Class II, Division 1, Subdivision case unilateral distoclusion with protruding upper 
anterior teeth. TREATMENT OF CASES 
399 
Fig. 556. 
Fig. 557. 
Facial outlines of Class II, Division 1, Subdivision. 
Fig. 558. 
Fig. 559. 
Showing facial outlines after development of mandible. 400 
PRACTICAL ORTHODONTIA 
arches. Fig. 553 is a study model made to show the mesio-distal re- 
lation of the arches, and shows clearly the progress of treatment. Fig. 
554 shows the small amount of the appliance that is visible in the 
patient's mouth. 
Unilateral Distoclusion with Protruding Anterior Teeth, or 
Class II, Division 1, Subdivision 
Unilateral Distoclusion, or Division 1, Subdivision, includes such 
cases as are distal on one side and normal mesio-distally on the other 
(Fig. 555). They present the same other symptoms as are found in 
the division. Subdivision cases are treated in very much the same 
manner as are those of the division. It is necessary to widen the up- 
per dental arch and to reduce the protrusion of the upper anterior 
teeth. This is done by adjusting the upper expansion arch in the 
same manner as is done in the division just described. The lower 
expansion arch is also adjusted as was done in the division. Inter- 
maxillary rubbers are placed on the appliance to reduce the protru- 
sion of the upper teeth and the upper canines are widened as they 
were in the case above mentioned. After the upper anterior teeth 
have been moved backward to the proper place, a light rubber is 
worn on the normal mesio-distal side, while on the abnormal side a 
strong rubber is employed to bring the lower forward on that side. 
It will be noted by studying the profile of the patient that the facial 
deformity is nearly the same as it is in the division. In fact, in the 
subdivision we find just as great a facial deformity and the mandible 
just as deficient (Figs. 558 and 559) on the average as we do in the 
division, which proves that the lack of development of the mandible 
is due entirely to the abnormal muscular pressure. 
After the teeth have been moved into the proper position, they are 
retained in the same manner as described in the division. It will be 
necessary to wear a retaining rubber ligature on the normal side for a 
while to hold back the retracted superior anterior teeth, until the 
pressure of the lip becomes normal. 
Bilateral Distoclusion with Retruding Anterior Teeth, or 
Class II, Division 2 
In the treatment of Class II, Division 2, we have a class of cases 
that are found in older patients than in Division 1. At least, the 
author has never seen a Class II, Division 2 case in as young a patient 
as is found in Class II, Division 1. The majority of cases and patients TREATMENT OF CASES 
401 
seen by the author during his practice, gave a history of having been 
mouth-breathers at one time, but probably there are other factors 
that also cause this condition of malocclusion. By far the greater 
number have had operations for adenoids or have been troubled with 
Fig. 560. 
Fig. 561. 
Class II, Division 2 case. Side views. Bilateral distoclusion with linguoversion of 
anterior maxillary teeth. 402 
PRACTICAL ORTHODONTIA 
nasal obstruction at some time. The author is of the opinion that 
these patients were mouth-breathers and that the abnormal muscular 
and atmospheric pressure has permitted the lower molars and teeth to 
assume a position distal to normal. The teeth have protruded, the 
tongue has been in the lower part of the mouth, and the lips have 
acted abnormally; then, as a result of an operation or change in en- 
vironment, normal breathing has become possible and the patient, 
conscious of the deformity, has closed the lips, with the result that 
the upper and lower lips have forced the upper anterior teeth back 
against the lower anterior teeth. With the tongue held in the upper 
Fig. 562. 
Bilateral distoclusion with linguoversion of anterior maxillary teeth, or Class II, 
Division 2. Front view. 
part of the mouth, the upper arch has developed to nearly the proper 
width, which was also stimulated by nasal breathing. As a result, 
Class II, Division 2, differs from Class II, Division 1, in every re- 
spect except in the distal relation of the lower dental arch. The up- 
per teeth are bunched and retruding, the upper arch nearly the nor- 
mal width, the mandible nearly normal in development, and the chin 
normal or well developed. These conditions have all been the result 
of normal muscular and atmospheric pressure. 
Remembering, then, the conditions that are present, the most suc- 
cessful plan of treatment would be one that would expand the upper 
arch in the canine and incisor region, expand the lower dental arch, TREATMENT OF CASES 
403 
and bring the lower teeth forward to their proper position. It will 
not be necessary to attempt to secure a development of the mandible 
(unless it is demanded), for in the majority of cases the chin and 
mandible are well developed. Therefore, there is less to do, and if 
properly handled, Division 2 is easier to treat than Division 1. How- 
ever, the author has observed that more difficulty arises in the treat- 
ment of Division 2 cases than in those of Division 1. The reader 
should be cautioned against thinking that these cases can be treated 
in a "slip-shod" manner. 
Owing to the fact that the upper anterior teeth must be moved 
labially (Figs 560, 561 and 562), it will be necessary to adjust the 
expansion arch in the same manner as if a case of Class I, or neutro- 
clusion were to be treated. The expansion arch is away from the 
superior anterior teeth, as shown in Fig. 563. Wire ligatures are 
placed on the anterior teeth and they are moved into the proper rela- 
tion with each other. The lower expansion arch, or alignment wire, 
is placed on the teeth, the dental arch is expanded and the teeth 
moved into their proper position. After the teeth in the upper arch 
have been moved into the position that they should occupy, after the 
upper arch has been expanded and the anterior teeth have moved 
labially, then, and not until then, should intermaxillary anchorage be 
used. If intermaxillary anchorage is used at the time the upper an- 
terior teeth are being moved, too much stress will be exerted on the 
upper molars and they will be pushed distally. After the anterior 
teeth have been moved, the expansion arch should be adjusted in 
such a manner as to rest against all of the teeth, and then all of the 
upper teeth should be wired to the alignment wire. This gives the 
resistance of the entire upper dental arch as anchorage to move the 
lower teeth forward. It may be necessary in some cases to place 
spurs on the lower expansion arch to prevent the tipping of the 
lower incisors. The lower teeth, having been moved forward into 
their proper position, are retained by both reciprocal and intermaxil- 
lary retention. 
The upper teeth are retained by placing bands on the first molars 
and canines. A lingual wire is soldered on the molar and canine 
bands, as shown in Figs. 569 and 570. A spur is soldered on the disto- 
labial angle of the canine band to hold the rubber that will be used 
as intermaxillary retention. It will be observed in the upper retainer 
that the wire is on the lingual side of the teeth in Division 2, while 
in Division 1 the appliance is placed on the labial side. 404 
PRACTICAL ORTHODONTIA 
Fig. 563. 
Fig. 564. 
Position of upper and lower appliances at the beginning of treatment. TREATMENT OF CASES 
405 
Fig. 565. 
Fig. 566. 
Views of the appliances as upper and lower dental arches are being expanded before 
intermaxillary anchorage is used. 406 
PRACTICAL ORTHODONTIA 
Fig. 567. 
Fig. 568. 
Showing use of intermaxillary anchorage after dental arches have been expanded to 
move lower teeth mesially (forward). TREATMENT OF CASES 
407 
Fig. 569. 
Fig. 570. 
Showing plan of retention for bilateral distoclusion, or Class II, Division 2. 408 
PRACTICAL ORTHODONTIA 
The lower teeth are retained by plain bands from the molars and 
canines and a wire is placed on the lingual side, as shown in Fig. 570. 
A spur is soldered on the mesio-bucco-occlusal angle of the lower 
molar band to engage the lower end of the rubber that is attached to 
the spur on the upper canine band. The pressure of the rubbers is 
diminished gradually by having the patient wear lighter rubbers dur- 
ing the period of retention. Figs. 572, 573, and 574 show the result 
of the treatment. 
Since the treatment is the same in all cases, the author feels that it 
is unnecessary to take up these cases here. 
Fig. 571. 
Showing active intermaxillary retention in bilateral distoclusion, or Class II, Division 2. 
Bilateral distoclusion cases with bunched anterior teeth, or Class 
II, Division 1, in young patients and in some types of older patients 
can be advantageously treated with the lingual arch, as suggested by 
Lourie and Mershon. The case here shown is taken from Lourie's 
practice. Fig. 575 shows the side view of the models of a patient 
six years of age. There is a distal relation of the lower arch to the 
upper. Fig. 576 shows the occlusal view of the case, and it can be 
seen that both the upper and the lower teeth require expansion in 
addition to the shifting of the occlusal relation, as shown in Fig. 575. TREATMENT OF CASES 
409 
Fig. 572. 
Fig, 573. 
Result of treatment of case shown in Figs. 560 and 561. 410 
PRACTICAL ORTHODONTIA 
Fig. 574. 
Front view of case shown in Fig. 562 after treatment. 
Fig. 575. 
Bilateral distoclusion. (Lourie.) 
Fig. 576. 
Occlusal view of bilateral distoclusion case. (Lourie.) TREATMENT OF CASES 
411 
Bands were fitted to the second lower deciduous molars and a lingual 
alignment wire of 19-gauge iridio-platinum was soldered to the bands, 
as is shown in Fig. 577. Plain bands were placed on the upper first 
molars and an alignment wire of 19-gauge iridio-platinum was ad- 
justed, as shown in Fig. 577. Tn order to better control the expansion 
of the deciduous canines above, spurs were soldered to the lingual 
Fig. 577. 
Lingual wires adjusted to case shown in Fig. 576. (Lourie.) 
Fig. 578. 
Study model of Fig. 576. Made during treatment. (Lourie.) 
arch, as can be seen in the illustration. These extension spurs could 
be bent and thereby better control the movement of the deciduous 
canines. On the buccal surface of the upper molar band there is at- 
tached an extension for the attachment of the intermaxillary rubber; 
the other end of the rubber is attached to a spur on the buccal sur- 
face of the lower molar bands. The buccal extension for the use of 
the intermaxillary anchorage is shown in Fig. 578, which also shows 412 
PRACTICAL ORTHODONTIA 
Fig. 579. 
Fig. 580. 
Mesioclusion, or Class III, case. A type often treated by extraction in former days. TREATMENT OF CASES 
413 
the changed occlusal relations. This appliance is entirely inconspic- 
uous, as no bands or ligatures were used on the anterior teeth and as 
there was nothing that could be seen on the labial or the anterior 
teeth. The very nature of the tooth movement required in disto- 
clusion cases with retruding anterior teeth, makes this appliance very 
desirable. Owing to the inconspicuousness of the lingual wire, both 
patients and parents are always greatly pleased with it. 
Unilateral Distoclusion with Retruding Teeth, or Class II, 
Division 2, Subdivision 
The treatment of the subdivision of Class II, Division 2, is the 
same as the treatment of the division; that is, the case is started in 
Fig. 581. 
Showing form of appliances used on cases similar to case shown in Fig. 580. (Angle.) 
the same way, but the intermaxillary ligature is only worn on the 
side that has an abnormal mesio-distal relation of the arches. There 
is no necessity of wearing the rubber on the normal side. 
Bilateral Mesioclusion, or Class III 
Mesioclusion, or Class III, includes those cases that have a mesial 
relation of the lower dental arch. As was shown under the classifica- 
tion of malocclusion, different types of mesioclusion, or Class III ex- 
ist, which fact makes possible different methods of treatment. While 
we should try to get normal occlusion and normal facial outlines in 
all cases, the different types will render necessary a different technique 
of treatment. Mesioclusion, or Class III, cases are more rare than 414 
PRACTICAL ORTHODONTIA 
any other class, or at least have been so in the author's practice. 
Therefore, it is impossible at the present time for the author to show 
finished results of all of the types, but the plan of treatment will be 
outlined. 
Figs. 579 and 580 show a mesioclusion, or Class III, case in which 
the upper teeth are in rather even alignment; the lower teeth are 
"bunched," and it will be noted that the lower first premolars have 
been extracted. When the teeth are in occlusion it will be seen that 
there is an end-to-end bite of the anterior teeth. 
Fig. 582. 
Mesioclusion, or Class III, case. Patient twelve years of age. 
This case recalls one of the common plans of treatment of this type 
of mesioclusion, or Class III, cases that was followed a few years 
ago; namely, the extraction of the lower first premolars and the distal 
movement of the canines and incisors until they were lingual to the 
upper teeth. The distal movement of the canines and anterior teeth 
was accomplished by the use of the traction screw and stationary 
anchorage. The appliance was arranged as shown in Fig. 581. This 
plan of treatment has not been a success and has since been discarded. 
Its application was only possible in that class of cases shown in Fig. 
579. At the present time the treatment for such a case would be as 
described for the following case (Fig. 582). TREATMENT OF CASES 
415 
Fig. 582. a mesicclusion. or a Class III case, is from a younger pa- 
tient than the one shown in Fig. 579, and is one that was treated with 
an intermaxillary anchorage. It will be seen that the lower teeth are 
mesial to the upper teeth the width of one premolar. The upper an- 
terior teeth are lingual to the lower teeth. 
Fig. 583. 
Mesioclusion, or Class III, case. Upper and lower appliances in place. 
The case demands the expansion of the upper arch and the distal 
movement of the lower teeth. 
After having placed wire on the mesial and distal side of the first 
molar to procure the necessary separation, clamp-bands are fitted to 
the teeth with the screw and the tube occupying the proper relation. 416 
PRACTICAL ORTHODONTIA 
The upper expansion arch is placed on the upper teeth, as shown in 
Fig. 583. Spurs may be soldered to the anterior part of the arch 
(Fig. 585) so as to hold the upper anterior teeth stationary or per- 
pendicular, thus giving more resistance to the upper teeth, which is 
Fig. 584. 
Position of lower arch, showing intermaxillary anchorage. 
needed to move the lower teeth distally. With all of the upper teeth 
ligated to the expansion arch, we have firm anchorage. However, 
the resistance of the upper teeth to forward movement can be in- 
creased by bending and springing the upper expansion arch. In ad- 
. Fig. 585. 
Spurs to produce bodily movement of anterior teeth and to make stationary anchor- 
age of teeth in upper arch to move lower teeth distally in Class III. 
justing the expansion arch on the upper teeth, the tubes are so 
aligned that the anterior portion of the arch occupies a position high 
on the gingival portion of the teeth, as shown in Fig. 586. Then, by 
springing the arch occlusally and wiring it to the teeth, a backward TREATMENT OF CASES 
417 
force is brought to bear on the upper molars (Fig. 586). If the arch 
should be left this way without any counteracting force, the upper 
molars would be tipped distally. However, in mesioclusion, or Class 
III, cases the upper molars are prevented from moving distally by the 
puli of the intermaxillary rubbers, which exert a forward pull on the 
upper teeth. As a result of the spring of the arch that exerts a back- 
Fig. 586. 
Position of arch high on gingival portion of teeth to make stationary anchorage on 
molars when arch is sprung down as shown in Fig. 587. 
Fig. 587. 
Upper arch bent occlusally and wired to make molars stationary. 
ward tipping on the molars, and the forward pull of the intermaxil- 
lary rubbers, the upper teeth remain stationary and become the an- 
chorage that moves the lower teeth. 
In adjusting the expansion arch to move the lower teeth distally, 
the anterior position of the arch does not rest against the lower an- 
terior teeth. This is because we desire to exert all of the force upon 418 
PRACTICAL ORTHODONTIA 
the lower molars and move them distally first. The position of the 
lower arch is shown in Fig. 583. No ligatures are placed on the lower 
anterior teeth, for all of the force is to be exerted on the lower molars. 
With all of the force exerted against the lower molars, they will be 
moved distally, and in the majority of cases the premolars will follow 
them. In the treatment of the case, as the molars move distally and a 
space is left between the molars and premolars, a wire ligature, as 
shown in Fig. 588, is placed around the first premolar and attached 
distally to the tube on the molar band. This ligature can be tightened 
and a stress exerted upon the premolars, which brings them toward 
Fig. 588. 
Application of ligature around premolars and distal end of molar tube to move 
premolars distally. 
the molar. Spurs may be placed on the arch slightly distally to the 
premolars, and each tooth ligated to the arch; then, by screwing the 
nut on the lower expansion arch forward to such position that it does 
not rest against the tube, the pull of the intermaxillary rubber moves 
the lower premolars distally. This application of the arch is shown 
in Fig. 589. As the molars and premolars move distally, it is then 
possible to place wires on the canines and expand in the canine re- 
gion. Spurs can be placed on the lower arch in such positions as to 
exert a distal pull on those teeth. After the teeth are moved into the 
proper position, the upper teeth are retained by placing plain bands 
on the molars and premolars, with a wire soldered to the lingual sur- TREATMENT OF CASES 
419 
Fig. 589. 
Spur soldered to arch to engage ligature that holds premolar to arch and causes it to 
move distally as a result of the intermaxillary anchorage. 
Fig. 590. 
Upper retainer for Mesioclusion, or Class UI. 420 
PRACTICAL ORTHODONTIA 
face of the bands. On the mesio-buccal angle of the molar bands 
(Fig. 590) a spur is soldered to engage the intermaxillary rubber to 
be used in retention. On the lower teeth plain bands are made for 
the molars and canines. A wire is placed on the labial side of the 
incisors and soldered to the labial surface of the canine bands, as 
shown in Fig. 591. A wire is soldered on the lingual side of the 
molars and canines. On the disto-labial angle of the canine band a 
spur is soldered, engaging the intermaxillary rubber that extends 
from the spur soldered to the upper molar bands. The wearing of 
the intermaxillary rubbers maintains the mesio-distal relation of the 
teeth. 
Fig. 591. 
Showing intermaxillary retention of mesioclusion, or Class III. 
In the treatment of mesioclusion, or Class III, cases, there is a 
great tendency to elongate the molars, both the upper and lower. 
However, the greater danger lies with the lower molars, owing to the 
manner in which the stress is brought to bear on those teeth. There- 
fore, the teeth must not be moved too fast, as the slow movement of 
the teeth prevents the elongation. 
Figs. 592 and 593 show another case of mesioclusion, or Class III, 
that was complicated by open-bite. An attempt had been made to 
correct the open-bite by extracting the second and third lower molars 
and by grinding off the occlusal surface of the lower first molars. The TREATMENT OF CASES 
421 
Fig. 592. 
Fig. 593. 
Mesioclusion, or Class III, case. Open-bite and narrow upper arch. 422 
PRACTICAL ORTHODONTIA 
lower molars are in buccal occlusion and the upper arch is slightly 
narrow. There is very little malocclusion of the upper teeth. The 
lower anterior teeth are slightly bunched and are inclining lingually. 
Fig. 594. 
Upper teeth ligated to make stationary anchorage in molar region. 
Fig. 595. 
Shows how arch was bent to move lower molars lingually. 
With the lingual inclination of the lower teeth it becomes necessary 
to move the apex of the teeth as well as the crowns, or the tipping 
will be more noticeable. TREATMENT OF CASES 
423 
The expansion arch was placed on the upper teeth, as shown in Fig. 
594, all of the teeth being ligated to the arch in order to make the 
upper teeth as rigid as possible. As the lower molars were in buccal 
occlusion, the expansion arch was adjusted with a spring to the lin- 
gual in the molar regions. The relation of the ends of the expansion 
arch to the molar bands is shown in Fig. 595. When the expansion 
Fig. 596. 
Ends of lower arch in tubes and ligated in place. 
Fig. 597. 
Showing spurs on lower arch to keep lower teeth upright. 
arch is inserted in the tubes on the molar bands, a lingual force will 
be exerted on the teeth that will narrow the distal portion of the 
dental arch. In putting the expansion arch in the tubes where a 
lingual force is exerted on the molars, it is always necessary to tie 
the arch in place, for the lingual spring will throw the arch out of the 424 
PRACTICAL ORTHODONTIA 
Fig. 598. 
Side view with intermaxillary anchorage. 
Fig. 599. 
Front view with intermaxillary anchorage. TREATMENT OF CASES 
425 
tubes. While the lower molars are being moved lingually, the inter- 
maxillary rubbers are worn from the hooks that were placed on the 
lower arch in the region of the canines to the tubes on the upper molar 
Fig. 600. 
Fig. 601. 
Result of treatment of case shown in Figs. 592 and 593. 426 
PRACTICAL ORTHODONTIA 
bands. After studying the case, it was decided to elongate the lower 
incisors in order to close the open-bite. Therefore, the lower expan- 
Fig. 602. 
Fig. 603. 
Showing effect of moving lower molars lingually. 602, before treatment; 603, after 
treatment. 
sion arch occupied a position along the incisal border of the teeth. 
Wire ligatures were placed around the teeth and twisted tightly to TREATMENT OF CASES 
427 
prevent them from slipping over the gingival marginal ridge of the 
teeth; then the ends of the wires were brought around the arch and 
twisted. This springs the expansion arch gingivally and exerts a 
force on the lower teeth so as to elongate them. In order to keep the 
lower teeth in their upright position and to move the apex of the 
teeth distally, spurs are soldered to the lower arch, as shown in Fig. 
597. The lower anterior teeth should be elongated to very nearly the 
desired length before they are ligated to the arch and spur; for, in 
order that the spur will be effective, it is necessary to use a plain 
ligature that will hold the tooth tightly to the spur. A small piece 
of rubber can then be placed under the gingival end of the spur, and 
the apex of the teeth will be carried lingually. Figs. 600 and 601 il- 
lustrate the side and front views of the case at the time the regulating 
appliance was removed and a retainer placed on the teeth. The rear 
view (Figs. 602 and 603) shows how much the region of the lower 
molars was narrowed. The retaining appliances are the same as those 
described in the previous case, with the addition of small spurs on the 
lingual side of the lower labial wire, which engage the approximal 
sides of the lower teeth. These spurs keep the teeth in their proper 
position, occluso-gingivally. Intermaxillary rubbers are worn to keep 
the teeth in their proper mesio-distal relation, extending from the 
spur on the upper first molars to the lower canines. 
For the purpose of producing a distal movement of the apices of 
the lower incisors in mesioclusion, or Class III, cases, the pin-and-tube 
appliance is very desirable, as the pins can be adjusted to produce an 
apical movement. In order to increase the action of the pin and to 
give it a greater range of elasticity, the pin can be extended and bent 
in the form of a hook (Fig. 604) and placed in the tube from the 
occlusal side. This application, which was suggested by Lourie, al- 
lows the labial arch to be out of sight, as it is entirely covered by the 
lip, which is a great advantage over the old form where the arch 
occupied a position near the occlusal edge of the teeth. Lingual 
arches can also be employed in a great many cases of mesioclusion 
and offer the same advantages that they do in other types of mal- 
occlusion, namely, delicacy and inconspicuousness. 
Fig. 605 is a case of mesioclusion in a patient of advanced age who 
was very sensitive in regard to having any appliances show. Plain 
bands were placed on the upper first molars carrying small tubes for 
the purpose of receiving the ends of the lingual arch, which was held 
in place by a lock similar to the others described in the construction 
of lingual arches. Plain bands were also placed on the lower molars 428 
PRACTICAL ORTHODONTIA 
Fig. 604. 
Spring extension to be used for apical movement in mesioclusion cases. (Lourie.) 
Fig. 605. 
Fig. 606. 
Fig. 607. 
Case of mesioclusion treated by the use of lingual arches. (Lourie.) TREATMENT OF CASES 
429 
and the lingual arch was soldered to the bands. On the buccal sur- 
face of the lower molar bands, was soldered an extension for the pur- 
pose of receiving the intermaxillary ligature. The extension is shown 
Fig. 608. 
Side view of unilateral mesioclusion, or Class III, Subdivision case. 
Fig. 609. 
Front view of Class III, Subdivision case. 430 
PRACTICAL ORTHODONTIA 
in Fig. 607. A small spur was soldered on the buccal surface of the 
upper molar band to engage the intermaxillary rubber that extended 
to the buccal extension of the lower molar. By pinching the upper 
lingual wire, the necessary expansion was produced. The change in 
the mesio-distal relation of the arches is shown by comparing Fig. 605 
with Fig. 606. This appliance can be made less bulky and less con- 
spicuous by attaching the intermaxillary rubber to the lingual arches, 
as Lourie is doing with later cases. 
Unilateral Mesioclusion, or Class III, Subdivision 
Figs. 608 and 609 show a case of the unilateral mesioclusion, or 
Subdivision of Class III. The dental arches are normal mesio-distally 
on one side, and mesial on the right. In looking at the front view of 
the case, it will be seen that the upper lateral incisors are in lingual 
occlusion. The palatal view (Figs. 610 and 611) shows great contrac- 
tion or rather lack of development of the upper dental arch, all of the 
molars and premolars being in lingual occlusion. 
In applying the expansion arch to the upper teeth, clamp bands 
are placed on the upper first molars after separation has been gained 
by the use of a ligature wire. The bands are so adjusted that the 
tubes will occupy a position that will enable the arch to lie near the 
gingival portion of the teeth. The expansion arch in the canine re- 
gion is left rather square, as shown in Fig. 610, as the canines must be 
moved buccally. Soft-solder spurs are placed on the arch buccally 
to the canines so that it will be possible to move these teeth directly 
buccally. Before the arch is placed in the tubes on the molar bands, 
the ends of the expansion arch should occupy a position to the tubes 
as shown in Fig. 614. If the distal part of the arch is farther buccally 
to the tube than is the mesial part, the tooth will be rotated. The 
canines and premolars are ligated to the arch and after the canines 
have been moved slightly, or enough to make some space, the ligatures 
are placed on the lateral and they are moved into position. 
Clamp-bands are placed on the lower first molars and the tubes are 
so placed that they will permit the arch to occupy a position near the 
gingival border of the teeth. As it is necessary to move the lower 
teeth on the right side distally, an intermaxillary-hook is soldered to 
the lower arch opposite the right canine. An intermaxillary d'look 
should also be placed on the left side of the arch opposite the canine, 
not to move the lower teeth distally, but to be used to reenforce the 
upper molar, for in moving the upper left lateral over the lower teeth TREATMENT OF CASES 
431 
Fig. 610. 
Occlusal view with upper arch adjusted. 
Fig. 611. 
Occlusal view with lower arch adjusted. 432 
PRACTICAL ORTHODONTIA 
Fig. 612. 
Fig. 613. 
Side views showing intermaxillary anchorage used on mesial side of lower. TREATMENT OE CASES 
433 
the upper molar is sometimes forced distally. With the intermaxil- 
lary-hook on the lower arch, an intermaxillary rubber can be used to 
prevent such occurrence. The anterior position of the lower ex- 
pansion arch stands away from the teeth/and the intermaxillary 
ligatures exert all of the force on the lower right molar. No rubber 
ligature is placed on the left side, unless it is necessary to reenforce 
the upper molar anchorage. After the lower molars begin to move 
distally, if a space is developed between the molars and premolars, 
ligatures should be put on those teeth to move them distally, after 
the manner described in the treatment of the full division. The au- 
thor does not consider it at all advisable, to allow the molars to be 
moved away from the premolars any distance; for it destroys the 
Fig. 614. 
Application of arch to expand molars without rotating same. 
approximal contact of the teeth, destroys the fibers of the peridental 
membrane that run from the cementum of one tooth to the cementum 
of the other, and makes retention more difficult. The lower right 
canine must also be moved in turn as the molars are moved. The 
author wishes it distinctly understood that he does not advocate 
starting all of the lower teeth on one side at once; but as soon as there 
has been sufficient tissue change around the molars so that they will 
start to move, the premolars and the canine must have force brought 
to bear on them in order that they will move distally together and 
hold the teeth in their proper approximal relations. After the molars, 
premolars and canines have been moved to their proper place, or 
nearly so, the anterior lower teeth can then be moved to the desired 
position. 434 
PRACTICAL ORTHODONTIA 
The retention of the upper teeth consists in the use of the plain 
bands on the first molars and canines with a lingual retaining wire 
soldered to the bands. On the mesio-buccal angle of the upper molar 
band, a spur is soldered that will engage a rubber ligature to be used 
for intermaxillary retention. The lower retainer in this case will 
consist of the same device as was used in the bilateral case (Fig. 591), 
except that on the lower right canine band a spur is soldered on the 
disto-labial angle to engage the intermaxillary rubber. 
As the teeth become locked by the inclined planes and the ap- 
proximal relation of the contact point, the wearing of the rubbers can 
be discontinued gradually. 
Since the treatment of any one case of the subdivision is very much 
the same as any other, these cases need not be discussed further here; 
however, it must be remembered that the cases of this particular type 
are generally progressive, and both the division and the subdivision 
should receive early attention. CHAPTER XI 
MALOCCLUSION AND NASAL DEFORMITIES 
It has long been recoginzed that there is a relation existing be- 
tween malocclusion of the teeth and deformities of the nasal cavity, 
but there has been some dispute in regard to what relation one has to 
the other and which is the causative factor and which is the effect. 
In considering the etiology of malocclusion, we have learned that a 
certain number of malocclusions are caused by mouth-breathing, 
which is produced by abnormal forces of occlusion that result from a 
disturbed function of the muscles and abnormal atmospheric pressure. 
It has also been observed that associated with certain types of maloc- 
clusion we almost invariably have certain types of nasal deformity. 
It has long been recognized that there are certain types of nasal de- 
formities associated with certain malocclusions that cannot be im- 
proved to any great extent, unless the treatment is associated with the 
correction of malocclusion. 
There are a certain number of individuals who are suffering from 
mouth-breathing in which the mouth-breathing has undoubtedly been 
caused by hypertrophy of the lymphoid tissue in the naso-pharynx, 
and upon removal of this lymphoid tissue the mouth-breathing still 
persists. This is because the abnormal action of the muscles and ab- 
normal atmospheric pressure during the time the individual has 
been a mouth-breather has produced a malocclusion and along with the 
malocclusion has been produced a deformity or abnormal develop- 
ment of the nasal cavity. We are then naturally confronted by the 
question as to what relation exists between malocclusion of the teeth 
and deformed nasal cavities, which is the causative factor and which 
is the effect, and what benefit can be expected to be derived from the 
correction of malocclusion so far as the deformed nasal cavity is con- 
cerned. Considering the relation between malocclusion and deformed 
nasal cavities, it is well to remember the anatomy of the parts con- 
cerned. It must be remembered that the nasal and oral cavity, as we 
find them in the adult, have at one time been a common cavity, which 
may be described from an embryologic standpoint as consisting of a 
single opening at the anterior end of the alimentary canal which is 
435 436 
PRACTICAL ORTHODONTIA 
known as a stomodium. We must also bear in mind the fact that in 
the early life of the individual, the nasal and oral cavities are one 
cavity without any separating structure, or, in other words, the hard 
and soft palate has not yet developed to separate the nasal from the 
oral cavity. 
In the development of the nasal and oral cavity, we find that the 
Fig. 615. 
Drawing showing embryonic de\ elopment 
of roof of mouth. (His.) 
Fig. 616. 
Cross section of developing nasal and oral 
cavity of embryo pig. (His.) 
Fig. 617. 
Cross section of developing- nasal cavity after the union of the palatal processes of the 
superior maxillse. (His.) 
first branchial arch and the fronto-nasal process play a very important 
part. The first branchial arch divides into two parts: one of which 
is known as the mandibular portion and is the lower part, and the 
upper part known as the maxillary portion which grows from the 
superior right and left side of the mandibular arch and finally unites 
with the frontal-nasal bud in that region that may be compared to MALOCCLUSION AND NASAL DEFORMITIES 
437 
the lip or alveolar border. From the inner posterior part of the first 
branchial arch there grows off a shelf or offshoot, which finally unites 
in the median line that forms the hard and soft palate. It is a forma- 
tion of the hard and soft palate that separates the nasal from the 
oral cavity. 
The development of these parts can be observed in Fig. 615, which 
is copied after His. Another structure or development that we must 
consider in relation to malocclusion and deformity of the nasal cavity 
is the development of the nasal septum, the turbinated body shown 
in Fig. 616. Growing downward from the base of the cranium or 
from the chondro-cranium we have a cartilaginous structure, or rather 
structures, which make up or contribute to what is known in later life 
as the nasal septum. Growing down from the horizontal plate of the 
ethmoid we have the perpendicular plate of the ethmoid, which grows 
downward into the nasal cavity toward the median line or the junc- 
tion of the hard palate. From the base of the sphenoid, we find an- 
other cartilaginous structure that grows forward, which is known as 
the cartilaginous vomer. It is later replaced by intramembranous 
bones developing on the right and left side of the cartilage. Asso- 
ciated with the perpendicular plate of the ethmoid and the vcmer we 
have a cartilage known as the triangular cartilage, which completes 
what is later known in life as the nasal septum. The downward 
growth of the perpendicular plate of the ethmoid and the vomer 
occurs regardless of the development of the lateral halves of the nasal 
cavity. It occurs regardless of the development of the floor of the 
nose and it is this factor that must be kept in mind in considering the 
relation of the deformity of the nasal cavity in relation to malocclu- 
sion. As the nasal septum grows downward from the chondro-cran- 
ium, the horizontal plate of the superior maxillary bone, which has 
been developed in the maxillary bud of the first branchial arch, 
grows toward the median line and the structures unite at the median 
line forming the floor of the nose, the nose being divided by the nasal 
septum into the right and left nares. The embryonic development of 
the nasal septum and the floor of the nose is shown in Fig. 617. Fig. 
618 is a posterior view of the maxillary bone and the mandible, show- 
ing the bony wall of the oral cavity and the nasal cavity as viewed 
from the posterior border. It will be seen that the hard palate or the 
roof of the mouth also forms the floor of the nose, that the right and 
the left half of the nares is made up by the perpendicular plate of the 
superior maxillary bone or the nasal process of the superior maxillary, 438 
PRACTICAL ORTHODONTIA 
while the superior lateral wall of the nose is made up of the lateral 
mass of the ethmoid. 
The horizontal plate of the ethmoid, assisted by a small part of the 
frontal and body of the sphenoid bone, forms the roof of the nose. 
It then gives us the nasal cavity completely surrounded by a bony 
structure and separated by the nasal septum. The nasal cavity is 
separated into the right and left nares by the nasal septum, which 
has grown downward from the perpendicular plate of the ethmoid, 
Fig. 618. 
Posterior view of nasal cavity showing bony cavity which contains the nasal septum. 
the body of the sphenoid, and which grows toward the roof of the 
mouth in the median line. The nasal septum is primarily of cartilag- 
inous origin and is replaced by an osseous structure. Physiologically 
the nasal septum has nothing to do with respiration. From an evolu- 
tionary standpoint the vomer was originally a tooth-bearing bone and 
has been walled off in the nasal cavity during the process of evolu- 
tion. MALOCCLUSION AND NASAL DEFORMITIES 
439 
As we study this question further, we find that the factors that 
effect the development of the lateral walls of the nasal cavity and the 
floor of the nasal cavity do not necessarily affect the septum. As a 
result of this, we find certain types of malocclusion in which the nasal 
cavity does not develop as rapidly as it should. The nasal septum 
will continue to grow downward and as it meets with resistance from 
the floor of the nose will become deflected. Fig. 619 is a diagram 
showing the various parts of the nasal septum, of which T C is a tri- 
angular cartilage, E is the perpendicular plate of the ethmoid, and V 
the vomer. It will be observed that the vomer grows downward and 
forward originally in cartilage, and is later replaced by intermem- 
Fig-. 619. 
Diagram of nasal septum. T.C., Triangular cartilage ; E., Perpendicular plate of eth- 
moid ; V., Vomer. 
branous bony development on both sides of the cartilage, and the car- 
tilage disappears. The vomer may thus be considered a double struc- 
ture composed of a right and a left side. The perpendicular plate of 
the ethmoid grows downward from the horizontal plate of the eth- 
moid and joins the vomer and the triangular cartilage. The ante- 
rior part of the nasal septum is completed by the triangular cartilage, 
which is also subject to a great many deformations that may be the 
result of abnormal development of the nasal cavity as the result of 
injury. An examination of Fig. 619 will show that the nasal septum is 
enclosed between two bony walls or surfaces, which are the roof of the 
nose and the floor of the nose. The distance between the floor of the 
nose and the roof of the nose is dependent upon the development of 440 
PRACTICAL ORTHODONTIA 
the lateral wall of the nose, the principal part of which is the superior 
maxillary bone. Therefore, if any condition arises that interferes 
with the growth of the superior maxillary bone, it necessarily will 
cause a shortening between the floor of the nose and the roof of the 
nose. The nasal septum will be compelled to occupy a smaller space 
than it was originally intended to occupy. 
It is also a fact that conditions that affect the development of the 
Fig. 620. 
Nasal septum enclosed in nasal cavity. 
lateral wall of the nose do not affect the nasal septum. Therefore, in 
a great many types of malocclusion we find that deflected nasal septi 
are the result of the lack of development of the lateral walls of 
the nasal cavity and the superior maxillary bone, which have resulted in 
a lack of distance between the roof of the nose and the floor of the nose. 
Fig. 620 shows a fetal skull at birth, and at this time the bony septum or 
nasal septum is enclosed in the bony walls of the nasal cavity. It will 
also be observed that the roof of the mouth is comparatively flat; that MALOCCLUSION AND NASAL DEFORMITIES 
441 
the alveolar process is close to the orbital cavity; and that there must 
be great increase in distance between the floor of the orbital cavity 
and the alveolar process as the individual develops. The inferior tur- 
binated bone is very close to the roof of the mouth or floor of the nose, 
Fig. 621. 
Nasal cavity of an adult. 
with the result that as the individual grows, the nasal cavity in- 
creases in length, especially between the inferior turbinated bone and 
the floor of the nose. 442 
PRACTICAL ORTHODONTIA 
As this floor of the nose is carried downward by the development of 
the lateral walls, space is made for the nasal septum, and if develop- 
ment goes on harmoniously we find that a development occurs in the 
adult that is the same as we find in Fig. 621. From above downward 
there is a tendency for the nasal septum to separate into two parts, 
showing the tendency for the organ to be developed into a right and a 
left part. 
Fig. 622. 
Showing double plates of nasal septum. 
Fig. 622 is the posterior part of Fig. 621 and it shows the shape of 
the roof of the mouth, which is a beautiful arch, by the development 
of the maxillary sinuses and the increased distance between the tur- 
binated bones and the floor of the nose. This skull may be considered 
as showing a normal development and as one in which there is a 
normal nasal cavity associated with what was a normal occlusion. In MALOCCLUSION AND NASAL DEFORMITIES 
443 
certain types of malocclusion, which may be neutroclusion, or Class 
I, complicated by lack of development of the dental arches, or which may 
be distoclusion complicated by labioversion of the upper incisors 
(Class II, Division 1), or in fact in any individual who is a mouth- 
breather, we are very apt to have an abnormal development of the 
nasal cavity because of the abnormal development of the superior 
maxillary bone. 
If the lateral walls of the nasal cavity do not grow downward 
rapidly enough, there will be a decrease in distance between the floor 
of the nose and the roof of the mouth, which will result in a de- 
flected septum. The removal of adenoids does not benefit this condi- 
tion, because the only thing that will restore the development of the 
nasal cavity to the proper size is the treatment of the malocclusion that 
will produce the proper growth of the superior maxillary bone and 
result in changes in the entire nasal cavity. It has long been recog- 
nized by the many authorities that the correction of the malocclu- 
sion has produced a beneficial result in the deformity or lack of de- 
velopment of the nasal cavity. This observation has led to several 
plans of treatment, some of which are based on the correction of mal- 
occlusion only with the resulting change in the nasal cavity, while 
other plans of treatment are based upon the correction of the mal- 
occlusion with the idea of improving the nasal cavity by changing the 
shape with mechanical interference. 
A number of cases, reported several years ago by Ketchum, showed 
that, in the treatment of malocclusion in patients who were mouth- 
breathers, the nasal cavity increased very materially in size and that 
deflected septi disappeared or improved during the process of treat- 
ment. Observations made in the author's practice have substanti- 
ated this fact, so that we can state that the correction of the malocclu- 
sion in the young individual, when the superior dental arch is not 
properly developed, will practically remove the deflected nasal sep- 
tum. It has also been observed that in older individuals who were 
suffering from nasal stenosis in which there was insufficient space in 
the nasal cavity, especially in a lateral direction, by an expansion of 
the dental arch an increased nasal space is produced and normal 
breathing becomes possible. 
By studying Figs. 618, 621, or 622 from a purely mechanical stand- 
point, it will be seen that any device or kind of treatment that will 
expand the dental arch and expand the alveolar process of the super- 
ior maxillary bone will necessarily produce some change in the width 
of the nasal cavity. The change in the width of the nasal cavity can 444 
PRACTICAL ORTHODONTIA 
be produced in several ways. It must be remembered that the teeth 
are embedded in the peridental membrane, which is a continuation 
of the muco-periosteum that covers the floor of the nose and the roof of 
the mouth, and which is made up of white inelastic fibers. By an 
expansion of the dental arch, stress is brought to bear upon the fibers 
of the peridental membrane, which in turn is transmitted to the per- 
iosteum covering the floor of the nose and roof of the mouth. This 
exerts an influence upon the floor of the nose to such an extent that 
the shape of the floor of the nose will be changed, and with individuals 
who have high narrow arches the roof of the mouth will be changed to 
one which is wide and broad. If the nasal cavity is examined in these 
individuals before treatment is begun, we will observe that either the 
nasal septum is deflected or there is a lack of width between the 
lateral walls of the nose. As the change occurs in the roof of the 
mouth and as the nasal cavity is again examined, it will be found 
that the nasal septum has straightened and that there has been an 
increase in width between the lateral walls of the nose. In other 
words, there has been a change in the roof of the mouth, in that the 
roof of the mouth has become wider and has come farther downward 
from the base of the cranium. 
Seme of this change in the roof of the mouth is the direct result 
of mechanical pressure, while more of it is the result of a growth pro- 
duced by mechanical stimulation, and the result of cell metabolism and 
changes in the structure as a result of natural growth. It must be 
remembered that the superior maxillary bone is a bone of environ- 
ment and responds to mechanical influences and stress; and that by 
changing the position of the teeth so as to change the stress upon the 
bone, the entire superior maxillary bone will be changed in the grow- 
ing individual. In fact, a great change will also occur in older indi- 
viduals, which has been observed in the author's practice. The cases 
that Ketcham reported and the cases observed in the author's prac- 
tice were changes that were produced by ordinary orthodontic treat- 
ment or that were the result of slow and gradual pressure upon the 
teeth without making any direct effort to change the shape of the 
maxillary bone as the result of direct mechanical pressure. 
A number of others have reported cases in which the superior 
maxillary bone has been changed in shape and in which the nasal 
cavity has been changed by exerting pressure upon the teeth and the 
superior maxillary bone with the idea of changing the shape of the 
roof of the mouth as a result of direct mechanical pressure. This 
treatment has been based upon the idea that by pressure the median MALOCCLUSION AND NASAL DEFORMITIES 
445 
suture between the right and left superior maxillary bone could be 
opened, and as the result of the opening of this suture a lateral expan- 
sion of the nasal cavity would occur. 
While the author has never followed this plan of treatment in active 
practice, nevertheless he is convinced that it is possible to open the 
intermaxillary suture by the construction of special appliances, and 
in fact, it may be done in some cases with any appliance. The author 
has done this experimentally upon dogs at different times without any 
seemingly ill effect upon the dogs and with the result that the bone 
has filled in the open suture and the nasal cavity has been increased 
in width. There is no question but what there are extreme cases of 
nasal stenosis, narrow dental arches with high palate, in which it is 
desirable to construct some style of appliance especially suited to 
widen the lateral halves of the superior maxillary bone, not so much 
with the idea of opening the median suture as with the idea of pro- 
ducing a bodily movement of the teeth and of carrying out the lateral 
halves of the superior maxillary bone as much as possible. This can 
be produced by constructing appliances that consist of bands placed 
upon the molars and the canine teeth, or upon the teeth of the two 
lateral halves of the arches, and then, by the use of alignment wires 
in such a manner that a direct buccal pressure is exerted upon the 
teeth, they are forced to move bodily thereby carrying the superior 
maxillary bone or alveolar process with them in a bodily direction. 
In younger individuals who have only the deciduous teeth, or decid- 
uous molars and permanent molars, the construction of an appliance 
for the purpose of producing bodily movement is very unsatisfactory 
if the appliance is attached directly to the teeth, because it will loosen 
the deciduous teeth. However, we find that the cases at this age are 
the most desirable for treatment. To overcome the difficulty encoun- 
tered with loose deciduous teeth, the use of the plate has been em- 
ployed to exert pressure upon the alveolar structures through the soft 
tissue. 
The old Coffin split plate presented some advantages in the treat- 
ment of these cases. The idea has later been modified by others, in- 
cluding a device that was published several years ago by Ottolengui, 
and a modification of a common split plate that is used at the present 
time by Richardson. As a result of the use of this appliance the pa- 
tients report a great improvement in the nasal breathing, improve- 
ment in speech, and individuals who before the treatment were able 
to breathe through their mouth only now breathe through their nose 
entirely during the day and night. 446 
PRACTICAL ORTHODONTIA 
The appliance, by exerting a gentle pressure on the soft tissues, car- 
ries the lateral halves of the superior maxillary bone laterally either 
by direct mechanical influence or by development. The roof of the 
mouth is changed, the nasal cavity increased in width, and the deflected 
nasal septum is straightened because of the increased room that is 
made for it. The author does not believe that the changes that occur 
in all of these cases are the direct result of mechanical pressure but 
that they are the result of mechanical stimulation of the cells, which 
produces a development that has been retarded, and consequently the 
parts assume a normal proportion in shape resulting in a normal de- 
velopment of the nasal cavity following the correction or treatment of 
malocclusion. 
Fig. 623. 
Model of upper arch, showing anchorage for split plate. (Richardson.) 
Fig. 623 shows a model of a young patient in which the only per- 
manent teeth present are the first permanent molars with a high 
narrow arch. These patients suffer from mouth-breathing and invar- 
iably show deflected nasal septi and nasal cavities that are below the 
normal width. The removal of adenoids or tonsils that are usually 
present does not improve the nasal breathing because of the deformed 
nasal cavity. The appliance is constructed by making bands upon the 
permanent molars and the deciduous teeth and by adjusting a lingual 
wire that extends from the canine to the molar. This wire should be 
at least a 16-gauge wire so as to be of sufficient size to enable the roof 
plate that is to be used to grasp the wire securely. After the appli- 
ance has been constructed, or rather after the band has been made for 
the molars and canines, the lingual wire is put in position as shown in 
Fig. 623. The roof plate is made in the ordinary manner by waxing 
up with base plate wax until it is of the desired thickness. A spring 
of some sort is embedded in the wax, as is shown in Fig. 624, and then 
the plate is vulcanized in the usual manner. MALOCCLUSION AND NASAL DEFORMITIES 
447 
This spring that is embedded in the roof plate must be made in the 
form of a "W," as shown in Fig. 624, in order to give it a greater 
range of elasticity and to enable it to be so adjusted as to exert a 
greater expansion either on the canines or the molars. If the spring 
is made in the form of a "W," it can be opened and greater pressure 
exerted on the canines than on the molars, or it can be opened in the 
Fig. 624. 
Roof plate with spring for expansion of upper arch. (Richardson.) 
posterior border in such a manner as to exert a greater pressure on 
the molars than on the canines. After the plate is vulcanized it is 
separated in the middle, as shown in Fig. 625, and then by opening 
with springs the desired amount of pressure can be produced upon 
the canines or molars. 
Fig. 625. 
Oral view of roof plate for expansion of arch. (Richardson.) 
Fig. 626 shows the palatal view of the plate, which is shaped to fit 
the soft tissue accurately so that pressure will be brought to bear upon 
the soft tissue aud be evenly distributed, and thus produce no sore- 
ness. A groove in the gingival border of the plate catches under the 
lingual wire extending from the canine to the molar and thereby holds 
it in position. The result produced by this plate is very gratifying 
because the loose deciduous molars are moved bodily, the roof of the 448 
PRACTICAL ORTHODONTIA 
mouth changes shape, and the nasal cavity increases in size. The re- 
sults from the use of this plate cannot be surpassed by any other form 
of appliance. The treatment produces a change in the shape of the 
roof of the mouth and in the shape of the superior maxillary bone 
and also produces a change in the nasal cavity. With the use of this 
plate no provision is made to exert pressure upon the anterior teeth 
Fig. 626. 
Palatal view of roof plate, showing groove for anchorage on lingual wire. 
(Richardson.) 
if they are protruding, and therefore the alignment wire must be used 
to exert pressure on the upper incisors in cases where some of the 
upper incisors have erupted. 
In younger patients where the permanent incisors have not erupted, 
the only kind of treatment necessary at this time is the widening of 
the superior dental arch, so far as the upper teeth are concerned. 
Fig. 627. 
Labial arch with spur extensions which can be used with roof plate shown in Fig. 624. 
Allowing the deciduous teeth to assume such positions as they will as- 
sume as the result of change in the atmospheric and muscular pres- 
sure, and the probabilities are that if sufficient change is made for the 
upper central incisors and if the individual is a normal breather at 
the time they erupt, they will take their normal position. If it is 
necessary to use an intermaxillary anchorage to correct the mesio- MALOCCLUSION AND NASAL DEFORMITIES 
449 
distal length of the arches with the use of this roof plate, intermaxil- 
lary hooks can be placed on the canine bands to be attached to the 
lower appliance in the usual manner. If the patient is more advanced 
in age and if it is desired to bring pressure upon the upper central 
Fig. 628. 
Showing nasal septum bent from before backward. 
incisors to correct a protrusion, this can be accomplished by soldering 
tubes upon the buccal surface of the molar bands that will receive a 
labial arch as illustrated in Fig. 627. 450 
PRACTICAL ORTHODONTIA 
By bending the labial arch gingivally as it leaves the buccal tube, it 
is carried far upon the gingival, and then by using finger spurs pressed 
against the protruding incisors the appliance is made very incon- 
spicuous. The use of the labial arch in no way interferes with the ac- 
tion of the roof plate. The appliance is as inconspicuous as any appli- 
ance that can be used. Intermaxillary anchorage should also be em- 
ployed, by having the spurs soldered on the canine bands and by hav- 
ing an intermaxillary hook attached on the labial arch. It would be 
more preferable in using intermaxillary anchorage to have the spurs 
attached to the canine band, because this would give a greater rigidity, 
and the intermaxillary rubber would not have a tendency to displace 
the labial arch as it would if they were attached to the labial arch. 
The combination of the labial arch with the finger spur, as used by 
Lourie and employed in conjunction with the roof plate as used by 
Richardson, gives a very ideal appliance for the treatment of patients 
who suffer from deformed nasal cavities, narrow arches, high palates, 
in which it is desirous to move the teeth bodily by pressure on the 
alveolar precess, and produce as great a change in the nasal cavity 
as it is possible to produce. In the increase of width of the dental arch 
and in the increase of space in the nasal cavity, deflected septi are 
corrected provided that the deflection is from above downward. 
Such deflections as are shown in Fig. 628 are from the floor back- 
ward and are probably the result of traumatism. They are not correct- 
ed or benefited to any great extent by the correction of malocclusion. 
In beginning the treatment of a malocclusion it is very necessary to 
make a careful diagnosis of the malocclusion and a careful examina- 
tion of the nasal cavity in order to learn the exact condition of the 
nasal structures. Then the appliance must be selected with the idea 
of producing as nearly as possible the ideal results. While it is possi- 
ble to produce a great change in the nasal cavity, care must be taken 
not to promise the patient too much; and to remember that only cer- 
tain types of deflected nasal septi can be corrected. 
It is our belief that in the majority of cases in which there is a lack 
of width between the lateral walls of the nose, this can be changed by 
proper treatment; that the nasal cavity can be caused to increase to 
its proper size, and that a great benefit can be produced as far as 
respiration is concerned, provided that the proper treatment is insti- 
tuted. In a large number of nasal deformities there is nothing that 
offers as much benefit as the proper correction of the malocclusion 
with the idea of producing a normal nasal development. CHAPTER XII 
REMOVABLE REGULATING APPLIANCES 
Regulating appliances are mechanical devices for exerting force 
upon malposed teeth for the purpose of creating cell activity and 
thereby causing the teeth to assume a proper position in the line of 
occlusion. These appliances are divided into fixed and removable. 
The fixed appliance has been described in other chapters of this book. 
The removable appliances will be considered here because they pos- 
sess a great many advantages that are not possessed by the fixed 
appliances and embody mechanical principles that should be under- 
stood by all who are interested in the practice of orthodontia. 
The early types of removable regulating appliances were neces- 
sarily crude, although they possessed certain features which recom- 
mended them for use in the treatment of malocclusion. The very 
early appliance embodied some form of spring force which exerted a 
mild constant, painless pressure, but the purpose of this pressure was 
often defeated by the fact that the appliance was very unstable and 
very difficult to keep in position. It is through the work of Victor H. 
Jackson that removable regulating appliances have been brought up 
to their present standard. We can now say that it is practically pos- 
sible to treat any type of malocclusion with the removable regulating 
appliance that can be treated with a fixed appliance. 
A number of varieties of malocclusion can be more successfully and 
more easily treated from the patient's standpoint with the removable 
appliance than if treated with some of the fixed forms of appliances 
which are on the market. 
The early type of removable regulating appliance consisted of seme 
form of a plate, force being exerted by means of a spring. The Coffin 
split spring plate which is shown in Fig. 629 was this type of appli- 
ance and consisted of a split vulcanite plate covering the palate, 
touching only the lingual surfaces of the teeth and relying upon the 
lingual surfaces for expansion. It has the double loop spring of 18- 
gauge steel or piano wire which, when the plate was removed from 
the mouth, could be bent buccally, causing a spring force for the 
expansion of the arch when the plate was snapped back in position. 
451 452 
PRACTICAL ORTHODONTIA 
This plate was very satisfactory in accomplishing the expansion of 
the upper dental arch but was not so satisfactory if individual tooth 
movement was required. The plate also possessed very insecure 
anchorage and to overcome this insecure attachment Jackson's earli- 
est appliances consisted of the addition of wire clasps made to cross 
the occlusal surface of the interproximal occlusal groove and fitted to 
the bucco-cervical border, thereby giving a greater resistance and 
attachment to the removable appliance than was obtained with the 
plain vulcanite plate. 
Fig. 630-A shows the construction of a plate with encircling clasps 
around the molars, and Fig. 630-B shows the same construction of the 
plate with clasps encircling both the molars and premolars. The use 
of these clasps tended to eliminate the bulky portion of the plate over 
the occlusal surface of the teeth and rendered the appliance much 
Fig. 629. 
Type of Coffin's split spring plate. 
more cleanly and greatly increased its stability. After the clasp was 
employed for the use of the vulcanite plate, it was then used with an 
all-metal device and the clasp so constructed as to be,connected across 
the palate with wires from which springs were to be extended the 
same as in the vulcanite (Fig. 631). 
The original design of the Jackson all-metal removable appliances 
was limited to various tooth movements but the great range of these 
designs soon made it possible for a system to be perfected, governed 
by definite principles, and limited only by the ingenuity of the de- 
signer, for the correction of all classes of irregularities. 
The Jackson system of removable appliances reached a stage of 
perfection between 1899 and 1900, which resulted in their taking the 
lead among removable appliances. Having mastered the technique of 
these appliances, Jackson obtained the most beautiful results, and REMOVABLE REGULATING APPLIANCES 
453 
most operators, who realize the superior qualities of the spring force 
and elimination of the many objectionable features of the fixed type, 
have adopted the Jackson system. One great drawback in the use of 
removable appliances has been the impossibility of securing the 
Fig. 630. 
A shows partially encircling clasps around the molars, and B shows completely 
encircling clasps around the first bicuspids and first molars in a split spring plate. 
(Eby.) 
Fig. 631. 
A and B show all-metal device with clasps so constructed as to be connected across the 
palate with wires, from which springs are extended. (Eby.) 
Early forms of Jackson's removable appliances. 
cooperation of some patients. The fact that the removable appliance 
can be taken out of the mouth and the teeth cleansed has also been a 
disadvantage in the mouths of those patients who insist upon taking 
the appliance out and therefore interfering with the working of the 
appliance. However, these disadvantages have been gradually elim- 454 
PRACTICAL ORTHODONTIA 
inated and Jackson has designed these modern appliances so that it 
is easy for the operator to remove them, but practically impossible 
for the patient. These "removable-fixed" appliances designed by 
Jackson possess many advantages, but in those cases where the coop- 
eration of the patient can be secured, it is still possible to use the 
simpler form of the Jackson appliance. 
For the proper construction of the removable appliance it is neces- 
sary to have a certain number of instruments for the purpose of bend- 
ing the wire and making the part of the appliance so that it will do 
what it is intended to do. The instruments required are a short, 
straight-ended scissors, a combination punch and contouring pliers, 
Fig. 632. 
Instruments used in technique. (Eby.) 
straight flat-ended instrument for adaptation, a wire cutter, a long- 
nosed pair of pliers, a very small-ended round-nosed pliers, and par- 
allel pliers. These instruments are shown in Fig. 632. No pliers is 
better adapted to the contouring of plates and metal for the lingual 
surfaces of the anterior teeth than the S. S. W. pliers, No. 112. All 
other appliances which have been tried either undercontour or over- 
contour and crimp the strip, which will interfere with the metal being 
adapted to the convex surface of the tooth. The round-nosed plier is 
used for practically all wire bending and should be very small at the 
end in order to make the bending more accurate. The ends of these 
pliers can be made small by fastening them in a vise with the jaws of REMOVABLE REGULATING APPLIANCES 
455 
the pliers closed and with a strip of emery cloth uniformly reduce 
the exterior diameter of the point. The parallel pliers are used for the 
bending of the heavy wire. Side cutters, for cutting the wire, are 
indispensable. Fig. 633 shows a soldering equipment which consists 
of a brush burner and a one-pound pair of soldering coppers. These 
soldering irons should be pure copper as the composition metal iron 
will oxidize very rapidly, will pit, and will not control block tin accu- 
rately. Irons smaller than one pound to the pair, that is, one-half 
pound each, burn rapidly and do not hold heat long enough, and 
Fig. 633. 
Soldering equipment, consisting of a brush burner and a 1-pound pair of soldering 
coppers. (Eby.) 
larger irons are more cumbersome and clumsy and require too long a 
time to heat. The soldering flux is a saturated solution of zinc 
chloride and should be applied abundantly with a camel's-hair brush. 
This solution can be better made than that which is usually bought, by 
pouring hydrochloric acid (C. P.) slowly over the zinc globules. The 
zinc should remain in excess, as the free acid will attack the metals. 
This solution is put in a large vessel (Fig. 633) in order that the iron 
may be kept perfectly tinned by emerging the point after each 
heating. 456 
PRACTICAL ORTHODONTIA 
The first material to be mentioned for use in the construction of the 
Jackson appliance is Jackson's partial clasp metal, 36-gauge (Fig. 
634). This is a specially prepared, stiff material, not to be annealed, 
which responds to the contouring appliance, but is so resistant to 
bending that it will not yield to stress during insertion and removal 
of the appliance. This material is treated on one side to cause a 
tenacious attachment to the tin, and it is impossible to scale off the 
plates when made of this special metal. All substitutes, such as low 
carat gold, copper, platinoid, German silver, or brass of many forms, 
Fig. 634. 
Materials used in technique. (Eby.) 
cannot be used with as great success as can this metal. This metal 
possesses a gold surface for contact against the enamel. 
The wire used in making the Jackson removable appliance is an 
alloy of nickel silver, as springy as possible, and also bendable. The 
gauges required are Nos. 20 and 21 for clasps, 18, 19 and 20 for finger 
springs, and 10, 11 and 12 for connecting body wires. This material 
can be purchased at the supply houses. The solder must be purest 
block tin (Fig. 634). Manufactured market block tin, which abounds 
in arsenic and is slightly irritating, and the best tin procurable, is the REMOVABLE REGULATING APPLIANCES 
457 
tin used in making an alloy. Half and half solder should never be 
used. 
In the construction of the Jackson removable appliance, it is neces- 
sary that we have a perfect model showing all the anatomic outlines 
of the parts. These models should be made from plaster impressions, 
as it is necessary that all the surfaces of the teeth, including the lin- 
gual and buccal surfaces, be clearly outlined. The models should be 
made from the finest grade of plaster of Paris. When the very hard 
composition of modeling materials are used, or if the plaster of Paris 
is boiled in stearine or paraffin, the possibility of exercising exact 
technique is lost. 
Models should not only be made of plain plaster, but should be used 
moist. When the numerous parts are made over dry plaster surfaces 
they have to be removed, set aside, and assembled when all parts are 
finished. By this plan the desired accuracy is lost because the pro- 
gressive process of building one part upon another, from the first to 
the last, and if the parts first made are removed it is impossible to 
make allowance for the subsequent parts to fit over them accurately. 
If the model plaster is moistened, the individual parts have sufficient 
adherence to remain in position, allowing the advanced steps to be 
taken with accurate calculation of size. 
As soon as the design of the appliance has been determined the next 
step is the carving of the cervical border of the posterior teeth selected 
to bear the "partial clasp" lingually and the "spring clasp" buceally. 
Jackson has always emphasized this point, for the security of the 
anchorage depends upon the use of the cervical construction. Along 
the linguo-cervical borders of all posterior teeth which are to carry 
"partial clasps" a very thin, sharp-pointed instrument should be 
drawn to make a narrow groove to represent the natural space be- 
tween the cervix and the gingival border of the free margin of the 
gum. The instrument should be inserted at an angle of approximately 
35 degrees from the axis of the tooth to carve out the groove anatom- 
ically correct (Fig. 635). The bucco-cervical border of teeth to bear 
spring clasps must be brought out clearly by trimming away the 
slightest possible amount of outline of the margin of the gum. To do 
this the instrument should approach the surface at right angles from 
the axis of the tooth (Fig. 636). The surplus left between this line 
and the buccal surface can be carved away, thus opening a distinct 
outline of the bucco-cervical border to which the clasp is fitted (Fig. 
637). 458 
PRACTICAL ORTHODONTIA 
The next step is the construction of partial clasps. Partial clasps 
are made of partial clasp gold, a material especially prepared by Jack- 
son and mentioned in the former part of this chapter. The success of 
the attachment of the appliance depends greatly upon the adaptation 
of the partial clasp to the lingual surface constriction of the anchor 
teeth, held in position by spring clasps buccally. As these borders 
slide over the lingual surfaces during removal and insertion they 
would be bent outward if made of soft material, thus causing the 
apparatus to loosen. The strain will also cause a weak soldered con- 
Fig. 635. 
Carving model prior to fitting partial clasps. (Eby.) 
nection to loosen so that the "partial clasp" will peel off, leaving only 
a soldered surface in loose contact with the tooth. For these two prin- 
cipal reasons this material has no substitute and, being the first step 
in the construction, failure here will result in the complete failure of 
the appliance. Partial clasps are to be fitted to all the posterior teeth 
engaged in the arms of the appliance for anchorage. They must be 
fitted with perfect accuracy, well into the cervical constrictions, 
slightly beneath the free margin of the gums. However, they must 
not be carried far enough gingivally to interfere with the fibers of REMOVABLE REGULATING APPLIANCES 
459 
Fig. 636. 
Carving gingival surface of model prior to fitting of spring clasps. (Eby.) 
Fig-. 637. 
Carving- buccal surface of tooth prior to fitting spring clasp. (Eby.) 460 
PRACTICAL ORTHODONTIA 
the peridental membrane and produce irritation. The ends of the 
partial clasps should extend to the mesial and lingual aspects of the 
lingual surfaces but not into the proximal surfaces. If the ends pro- 
Fig. 638. 
Showing construction of partial clasp. 
(Eby.) 
Fig. 639. 
Contouring pliers used to contour partial 
clasp metal. (Eby.) 
Fig. 640. 
Pressing partial clasp into place. (Eby.) 
ject too far interproximally, they prevent the appliance from receding, 
wedge the teeth, and cause painful injury to the interproximal tissue. 
Partial clasps should extend towards the lingual cusps slightly occlus- REMOVABLE REGULATING APPLIANCES 
461 
ally to the point of greatest convexity on the lingual surface but not 
far enough to interfere with the occlusion (Fig. 638). 
The treated surface of the metal must be faced outwards, with the 
pure gold surface touching the model, and this especially treated sur- 
face can be readily distinguished by the color and finish. A wider 
strip should always be cut for the molars than for the premolars in 
order to keep the occlusal border on a straight line mesio-distally. 
The contouring pliers (Fig. 639) will conform the strips to the double 
curve of the gingival surface to any desired length. After trimming 
the cervical border to fit perfectly, the partial clasp should be carried 
to place, with the curve of the plate smaller than the surface curve 
of the lingual of the tooth and it then can be enlarged by pressing it 
into position where it will remain securely (Fig. 640). 
Spring clasps are divided into two forms-full and partial. The 
full spring clasp entirely circles the tooth, crossing from the lingual 
to the bucco-cervieal constriction over the interproximo-occlusal 
groove, with both ends attached in the solder. This design is typical 
of the removable appliance. The partial spring clasp partially encir- 
cles the tooth only, crosses only the mesial or distal interproximo-oc- 
clusal groove, traversing the bucco-cervical constriction, terminating 
in the opposite proximal side whence it is crossed for attachment lin- 
gually. This clasp is used both in the fixed-removable and removable 
type. Two spring clasps are employed on both sides of the arch to 
secure balance of attachment and are usually attached on the most 
anterior and most posterior teeth in the arms of the appliance. Spring 
clasps are made of 21-gauge or 22-gauge special alloy nickel silver 
wire. No. 21-gauge is generally indicated in all partial spring clasps 
and also in the full spring clasp excepting for especially large teeth. 
The wire should be cut into two and three-inch lengths and the bend- 
ing begun in the middle to permit a free holding for bending until the 
clasp is complete. The clasp wire should first be bent to the curve of 
the gum scallop on the buccal surface with the two ends pointing oc- 
clusally to the proximal side. 
After this, the second step is to bend this bucco-cervical portion into 
a second curve, the curve of the bucco-cervical constriction, mesio-dis- 
tally. For this it is necessary to use the brace of a rubber block to con- 
trol the bending accurately (Fig. 641). 
The third bend requires the greatest accuracy because it forms the 
angle between the buccal and occlusal surfaces. If this bend is too 
high, it causes the occlusal portion to interfere in occlusion. If it is 
bent too low, the bucco-cervical region will be too short on the teeth 462 
PRACTICAL ORTHODONTIA 
to reach the cervical constriction. The operator should possess a 
'medium-length left thumb nail so that it can grasp the wire accurately 
(Fig. 642), bringing off the wire so the end of the round-nose plier 
can pick up the exact point by running down over the surface of the 
Fig. 641. 
Bending clasp wire on rubber block. (Eby.) 
Fig. 642. 
Obtain measurement of occluso-gingival portion of clasp. (Eby.) 
thumb nail (Fig. 643). It is far better to continually underbend, trying 
to position frequently and in this way make continuous progress. By 
bending too far the work will be undone, started over again, and REMOVABLE REGULATING APPLIANCES 
463 
usually the part is ruined by inaccuracy and breaking by the crystal- 
lizing of the wire. 
In making full spring clasps, the mesial and distal portions should 
be carried across the occlusal surface together, for if one side is fin- 
Fig. 643. 
Bending clasp around round-nosed pliers. (Eby.) 
ished first, the clasp is liable to be warped. After fitting across the 
occlusal surfaces, the ends are bent downward to be curved around 
midway of the partial clasps for soldering. The mesial end should be 
Fig-. 644. 
Use of pins to hold partial clasps in position while soldering. (Eby.) 
bent to transverse the entire length of the partial clasp distally and 
vice, versa, so as to gain a strong "mechanical" attachment in the 
solder. If these ends are cut short they will pull out of the tin, 
which is caused by mild galvanic erosion which gradually makes in- 464 
PRACTICAL ORTHODONTIA 
gress between the wire and the tin, loosening the adhesion a short 
length around the wire at the point of entrance into the tin causing a 
short straight end to pull out. 
It is also important to extend the end of the spring clasp wires to 
rest against all portions of clasps not engaged (Fig. 644). If this is not 
done, the attraction of the molten tin as it is drawn over the partial 
clasps on the soldering iron is liable to pull them off or displace them 
slightly. After finishing the partial clasp and the spring clasp, the an- 
chorage or ' ' arms ' ' are completed. It is best to begin to unite the num- 
ber of small parts at this junction, reducing to one unit on each side the 
five or ten small parts, for it is very important to preserve them accu- 
rately as they are liable to be displaced during the advanced steps if 
Fig. 645. 
Partial clasps and spring clasps united 
with solder. (Eby.) 
Fig. 646. 
Body wire for anterior expansion. (Eby.) 
not united. The weight of the soldering iron against the lingual ends of 
the clasp is liable to elevate the bucco-cervical portion where the great- 
est accuracy is required. To prevent this, pins should be inserted to 
hold the clasp very securely in place (Fig. 644). The thinnest film of 
solder possible to make the attachment should be used to keep down 
the bulk of the appliance (Fig. 645). 
The next step is the construction of the "base wires" or "body 
wires" for the connection of the anchor arms across the palate in the 
upper end and in the sublingual region of the lower. The body wires 
are made of 12-gauge for average cases, although the gauge should 
range from 9 to 14, varying with the age, extent of development re- 
quired, and the control of bulk. The body wires should be made into 
a number of different designs, but the best plan to follow is to use REMOVABLE REGULATING APPLIANCES 
465 
the simplest form suited for the needs required. The simplest form of 
upper body wire is made for premolar and anterior expansion only 
(Fig. 646). This form is made by bending a piece of wire about six 
inches long into a U-shape to fit around the dome of the palate at the 
desired point across the molar region. Care must be taken, in de- 
termining the points, to bend the ends forward from the points of 
contact against the molars. If these angles are too high, they will in- 
terfere with the occlusion and impart bulk and bad finish. The meas- 
urements should be taken with a thumb-nail grasp, as before described, 
and should be low enough so that the outer curve of the wire will only 
touch, or, failing to touch, will approximate closely the linguo-cervical 
border of the molar. 
In all heavy wire bending, special care must be taken to calculate 
the position of the outer curves, and to do this the wire must be 
grasped in the pliers at a point the diameter of the wire away from 
the desired point of the bend, so as to make this allowance in the 
height of the curve. The palatal part of the wire should enter the 
sides about midway of the lingual surface of the distal teeth engaged 
in the appliance, and the ends should always extend forward or 
backward, as the case may be in the different designs, to about mid- 
way of the lingual surface of the tooth at the opposite end of the 
anchor arms. This will impart a round finish at the ends, which is 
lost if the end projects beyond the point. 
It is absolutely necessary for the side parts of the body .wires to ex- 
tend the full length of the anchor arms to render them rigid. Because 
the linguo-cervical borders of the molars are higher than the pre- 
molars, it will be found that as the side of the body wire extends for- 
ward, a space will be formed between the wire and the partial clasp 
on the premolar. It is in this space that the ends of the anterior ex- 
tension must be fitted and soldered, and the size of the space may be 
determined by the number of springs to be used (Fig. 646). 
Fig. 647 illustrates the body wire for premolar expansion and molar 
expansion on one side only. Fig. 648 illustrates a body wire for 
bicuspid and molar expansion on both sides. These are made by bend- 
ing the wire into the U-shape on the curve of the palate at the pos- 
terior region, and then the forward bends are made to be looped back 
parallel around the jaws of a round-nosed plier so that the end will 
terminate at the molar. Care must be taken to preserve the space at 
the bicuspid region for the anterior springs, and this last loop must 
not be higher than the cervical zone so the finished appliance will not 
interfere occlusally. 466 
PRACTICAL ORTHODONTIA 
The form of body wire found to be most effective for the premolar 
and molar expansion on both sides is shown in Fig. 649. This design 
contains less material than the one shown in Fig. 648 and responds 
to lines of lateral development with better effect. In constructing 
Fig. 647. 
Body wire for premolar and molar ex- 
pansion on one side only. (Eby.) 
Fig. 648. 
Body wire for expansion of both sides of 
upper arch. (Eby.) 
Fig. 649. 
Form of body wire used in premolar and molar expansion. Body wire attached with 
soft solder. (Eby.) 
this style of body wires, the wire is first bent into a U-shape to rest 
in the dome anterio-posteriorly with the ends pointing distally. The 
ends are then looped over the jaw of the round-nosed plier and 
brought forward, observing the same precautions as to position and REMOVABLE REGULATING APPLIANCES 
467 
terminating midway of the lingual surface of the teeth at the anterior 
end of the anchor arms. The body wires must not touch the soft tis- 
sues at any point. After construction, they may be held to position 
with moldine, and should be quickly tacked to place with a very light 
solder on both ends and both sides (Fig. 649). The finer bending of 
these heavy wires (Fig. 650) can be made to best advantage with the 
plier designed by Case (Fig. 651). Soldering the body wire to posi- 
tion completes the body and arm portions. 
All extensions and springs from these parts are known as "finger 
springs" or "fingers." Fingers are made of 18, 19 and 20-gauge 
wire, and are adjusted usually to the surface of the teeth opposite the 
Fig. 650. 
Base wire being bent with Case's bending 
pliers. (Eby.) 
Fig. 651. 
Case's wire-bending pliers. (Eby.) 
direction of motion. Fingers vary in design with every individual 
case. 
Careful comparison of a given irregularity with the normal and 
measurements to determine the extent and direction of the usual move- 
ment may show the path of movement towards the normal to be such 
that the arch may be corrected in segments, and the study of other 
conditions may show that all the teeth must move on individual paths. 
The effectiveness of the Jackson method is its great adaptability of 
design to meet various conditions with equal advantage and facility. 
Fig. 652 shows a condition caused by permanent extraction of the 
left deciduous cuspid, which, by breaking the proximal continuity of 468 
PRACTICAL ORTHODONTIA 
the arch, allowed the muscles to narrow the two posterior segments 
and drift the incisors lingually from the right canine at the center of 
the rotary axis. The molar expanding body wire is indicated for re- 
storing the two posterior segments to normal width. 
Fig. 652. 
Showing construction of finger spring to body wire. (Eby.) 
Fig. 653. 
Soldering finger spring to body wire. (Eby.) REMOVABLE REGULATING APPLIANCES 
469 
One lingual "finger" bent on the normal curve of the lingual sur- 
faces should be attached to the right arm of the appliance. By ren- 
dering this finger active with the right canine at the rotary center, the 
path of movement of each incisor will be determined by the radius 
Fig. 654. 
Finger spring used for depressing canine. (Eby.) 
Fig. 655. 
Appliance completely soldered. (Eby.) 
of the spring from the central axis of the point of contact at each 
tooth. The path of movement of the left lateral will be outward and 
to the right on a greater arc than that of the left central. The path 
of movement of the left central will be on a greater arc than that of 470 
PRACTICAL ORTHODONTIA 
the right central. The path of movement of the right central will be 
on a greater arc than that of the right lateral. By the pressure of this 
spring, each incisor will be moved along a different path toward its 
normal position, restoring normal incisal relations and concentrating 
the space gained for the left canine. 
The appliance is shown in Fig. 653 prepared for the finished solder- 
ing on the right side. The finger is held in position with moldine, 
and the spring clasps repinned into position to prevent them from 
slipping buccally. Zinc chloride is now applied to the entire side 
freely. The hot soldering iron is dipped continually in the flux before 
soldering to keep it well tinned and cleaned. Globules of pure block tin 
are carried on the iron and flowed well down into the crevices between 
the clasps and the body wire. Enough solder should be applied to 
slightly round off the exposed surface, to impart a smooth finish. 
Fig. 654 shows the buccal aspect of the left side finished. A buccal 
"finger" has been extended to press the canine into alignment after 
ample space is made for it. This illustration also shows how the 
spring clasp has been shifted to the second premolar and second molar 
on this side to prevent the need of two wires crossing the occlusion 
between the premolar and the canine. 
Fig. 655 illustrates the exposed aspect of a soldered appliance ready 
for removal from the model for the first time for polishing. It also 
shows the laterals collared with lugs, soldered to the lingual surfaces 
beneath which the "finger" snaps to be held securely in position. All 
of the posterior teeth are anchored against the labial movement of the 
incisors. The incisors and right posterior teeth are anchored against 
the left posterior teeth (ten anchor teeth against four teeth to be 
moved) which have moved lingually more on the right side. The ex- 
posed surface of the appliance removed from the model is shown in 
Fig. 656. 
After a sufficient amount of tin is added to the side of the arm, it 
should be melted along the full length at one time. This will cause it 
to harden in a uniform smooth surface which requires only a few 
strokes from a sand paper disc to prepare for the lathe polishing. The 
lingual side of an appliance requires very little attention in polish- 
ing. Sharp projections of the partial clasps extending too far inter- 
proximally should be cut away. When the solder runs around the 
ends of all the wires, completely enveloping them, it is cast against a 
strip of plaster representing the outline of the free margins of the 
gums. If this solder should touch the soft tissues, a slight compres- 
sion will be established as the appliance settles. This pressure will REMOVABLE REGULATING APPLIANCES 
471 
exclude the circulation from the capillary terminals and will de- 
vitalize strips of tissue which will resolve into a dense, white mass. 
To avoid this, the palatal side of the tin between the cervical border 
of the partial clasp and the body wire should be cut out to a reason- 
Fig. 656. 
Appliance removed from model. (Eby.) 
Fig. 657. 
Cutting out solder to prevent pressure on gingival gum tissue. (Eby.) 
able depth, forming a smooth, concave surface with a self-cleansing 
space between the appliance and the gum (Fig. 657). Great care 
should be taken in this step not to injure the cervical borders of the 
partial clasps, and they should be left projecting well up above the 472 
PRACTICAL ORTHODONTIA 
tin to enter the cervical constriction at the gum border. Fig. 658 illus- 
trates this, showing a cross section cut through the middle of the 
molar clasp. 
After excluding all sharp points to be found and rounding the ends 
of the finger springs, appliances are polished with the lathe. A felt 
wheel should be used and a stiff mixture of pumice to the exposed 
surface of the tin, which will make the tin very smooth. The lingual 
portion of the tin should be polished with bristle brush wheels with 
ample pumice. 
After removing all tool scrapings and pumice, a luster can be im- 
parted by washing off the pumice, drying the appliance and reapply- 
ing the same brush wheel with which the pumice was used, when the 
moist bristles and the slight amount of remaining pumice will impart 
a lasting finish. The final luster can also be made by prepared chalk 
paste on a camel 's-hair wheel. 
The construction of the lower removable Jackson appliance is very 
similar to the construction of the upper appliance. The posterior, 
Fig. 65S. 
Cross section of base wire and partial clasp, showing gingival extensions. (Eby.) 
side arm anchorages are to be made in the same manner, although all 
finger extensions are to be governed by the same various respective 
designs for the given conditions at hand. The body wires for lower 
appliances cannot vary under different conditions, however, because 
of the limited position which they occupy between the inner surface 
of the mandible and the tongue. 
After the side arm anchorages are completed, the first step in lower 
body wire bending is to bend the wire into a U-shape to fit closely 
around the lingual curves of the anterior segment of the arch with 
the ends pointing distally. In placing the anterior portion of this 
heavy wire, it must be so placed that the ends may be bent back upon 
themselves from points in the region of the most distal teeth engaged 
in the anchorage, running parallel with the lower portion forward, 
and terminating about midway of the most anterior anchored teeth 
engaged with spring clasps. 
If a straight loop is placed low enough in the sublingual region, it 
will interfere with the motion of the frenum linguae, which will cut REMOVABLE REGULATING APPLIANCES 
473 
into it in a very painful and damaging manner. If a straight loop is 
placed higher than this region, it is very difficult to bend the ends for- 
ward and keep the upper portion low enough to solder along the 
lingual surface of the posterior teeth without touching the lower por- 
tion of the wire which it parallels. This renders it very difficult to 
keep the solder from running between the wires and the adjustment is 
made more difficult in tightening, if the wires are very close together. 
In order to compromise between these conditions, it is necessary to 
bend the anterior end of the wire upward (Fig. 659). The best method 
of making this bend is to first bend the correct size and shape around 
the sublingual region, then by grasping the desired amount of the 
Fig. 659. 
Anterior end of lower wire bent occlus- 
ally. (Eby.) 
Fig. 660. 
Lingual base wire bent occlusally with 
heavy pliers. (Eby.) 
anterior portion between the jaws of the heavy parallel pliers, the 
bend can be made, retaining uniformly horizontal relations between 
the ends which point posteriorly (Fig. 660). That portion which is 
bent upward can be placed along the most prominent part of the 
ridge below the gum margin of the anterior teeth, allowing the ends 
to run backward at positions low enough for the looped parallel ends 
to fold back and rest no higher than the gingival borders of the pos- 
terior teeth with about one-eighth of an inch between them, thus re- 
ducing the bulk, permitting a thin bevel finish and not interfering 
with the tongue or pressing against the soft tissues (Fig. 661). The 
final bend should be made around the nose of the "round-nosed" 474 
PRACTICAL ORTHODONTIA 
pliers. Fig. 662 illustrates the completed lower body wire suspended 
in mouldine slightly away from the soft tissues. Note that the an- 
terior portion rests higher than the frenum linguae can reach, but at 
the same time low enough so as not to interfere with finger extension 
adjusted to the lingual surface of the anterior teeth. The body wire 
Fig. 661. 
Position of lingual body wire for lower 
appliance. (Eby.) 
Fig. 662. 
Lower body wire with ends bent an- 
teriorly held in place with moldine. 
(Eby.) 
Fig. 663. 
Completed lower appliance with finger springs attached. (Eby.) 
should be tacked to position with a very small amount of solder at 
the posterior ends leaving ample space between the arms and the up- 
per loops of the wire to form a groove into which is soldered the at- 
tachment ends of the finger springs. REMOVABLE REGULATING APPLIANCES 
475 
Fig. 663 illustrates the completed appliance for this case. It will 
be noted that the continuity of the arch has been broken, shown at 
present by the absence of the left first bicuspid. The normal diameter 
of this arch is reduced the amount of the mesio-distal diameter of 
this missing tooth. Under this condition, the history of the case may 
reveal the early loss of the deciduous molar with the resultant migra- 
tion of approximating teeth, causing impaction of the premolars. 
The environments of the teeth under the influence of the tongue lin- 
gually, the buccal and labial muscles, and the occlusal stress, have re- 
duced the size of this arch in certain segments which are normal and 
regular, insofar as relations between the teeth in these segments are 
concerned. If this missing tooth has been extracted merely to correct 
a buccally erupted canine, the same conditions exist from the correct- 
ive standpoint on the basis of normal occlusion. 
This is a case of neutroclusion, the left molars and second premolars 
having formed lingually, but they have not moved mesially. The an- 
terior teeth have moved lingually, proportionately greater at the left 
canine. The left molars and the second premolars are in correct rela- 
tion in one segment; the anterior teeth are in correct relation in the 
second segment; and the right posterior teeth are in correct relation 
in the third segment. The three teeth comprising the left segment 
are engaged with a full spring clasp on the first molars and two par- 
tial spring clasps on the proximal teeth soldered together on the buc- 
cal sides. 
There is more constriction on the left side than on the right side, 
indicating the need of a greater resistance for less expansion on the 
right side; therefore, the four posterior teeth are engaged on the 
right side with partial plates on the lingual surface, the first pre- 
molars bearing a partial clasp, but owing to the fact that the right 
second molar is not fully erupted, the spring wire is placed on the 
first molar. The right canine rests as the rotary center around which 
the anterior teeth have moved lingually. 
A finger spring is adapted to the curve of the lingual surfaces and 
soldered into the right arm of the appliance, terminating at the other 
end in the form of a hook looped around the distal proximal side of 
the left canine. These anterior teeth may be banded for lugs to be 
soldered to the lingual surfaces for this finger to snap beneath, or a 
second lingual finger may be adjusted to rest above the lower one 
for the purpose of holding it securely down to position under active 
pressure. When this lower spring is rendered active by bending it 
forward from the right side, each anterior tooth is moved in a dif- 476 
PRACTICAL ORTHODONTIA 
ferent arc toward its normal position. The finger affords the left 
canine a long radius through which it moves forward and outward to- 
ward a straight line across the arch opposite the right canine, to its 
correct position of angular prominence in the parabolic curve of the 
normal arch. 
The left lateral responds to the path of force applied on a shorter 
radius than the canine, the left central less than the left lateral, the 
right central less than the left central, and the right lateral less than 
the right central, and the right canine is only slightly turned. In this 
way the fingers may be so controlled as to guide each tooth in a seg- 
ment of a circle along entirely individual paths of movement towards 
their normal positions in the dental arch. 
By using the posterior loop of the body wire as rotary centers, a 
uniformly diffused expansion can be accomplished between the molars 
and premolars. If positive molar expansion is required, the middle 
of the anterior curve of the body wire is bent open as a rotary center. 
In this way individual tooth movement can always be perfectly con- 
trolled under a type of active anchorage which renders it impossible 
for unexpected secondary forces to cause warpage of arches of de- 
pressions, elongations, or other displacements of any serious nature. 
The removable appliance possesses valuable features for the correc- 
tion of irregularities of the deciduous teeth. The correction of mal- 
occlusions usually involves development across the posterior side of 
the subsequent anterior alignment. The gingival constrictions of de- 
ciduous teeth do not afford favorable undercuts for the spring clasp 
attachment for the simple removable appliance. It is, therefore, often 
necessary to use the fixed-removable attachment on the deciduous 
teeth. Even with this method, the technique of fitting simple bands to 
anterior and posterior anchor teeth on both sides can be very easily 
and effectively accomplished in the mouths of children between the 
age of five and seven, after which the bands are removed in a plaster 
impression ami the appliance finished out of the mouth. 
In the correction of malocclusions during those intermediate years 
between the loss of deciduous teeth and the eruption of permanent 
teeth the removable appliance possesses many valuable features. There 
is no more favorable time for the correction of malocclusion than dur- 
ing the period from seven to twelve years of age, or during that 
period when deciduous teeth are being lost and the permanent teeth 
are taking their position in the dental apparatus. 
Fig. 664 illustrates the lower arch with irregularities caused by the 
early loss of temporary incisors, which has caused the posterior sides REMOVABLE REGULATING APPLIANCES 
477 
to lose their stimulus and the lateral development has not been suffi- 
cient. If the case is allowed to remain in this condition, the permanent 
lateral incisors will be crowded out of the arch and forced to take 
positions of malocclusion. This removable appliance possesses full 
spring clasps for the second premolars with partial clasps on the 
first premolars soldered to the full spring clasps on the buccal sides. 
The body wire is made of the 13-gauge wire. Small hook-shaped ex- 
tensions engage the canines. In these two side arms exists a uniform 
degree of resistance, so that by the mild but constant stimulus of the 
spring force from the body wire there is produced the lateral develop- 
ment, restoring the normal width and concentrating the space for the 
normal eruption of the lateral incisors. If the centrals are spaced, 
new finger springs may be added at any time with which to draw them 
together. 
Fig. 664. 
Lower appliance constructed to produce 
expansion in incisor region. (Eby.) 
Fig. 665. 
Appliance constructed to exert pressure 
on central and laterals. (Eby.) 
Fig. 665 illustrates the removable appliance constructed to exert 
pressure upon the centrals and laterals which have taken abnormal 
positions. With this type of appliance the finger springs can be 
changed any number of times as the treatment progresses. 
Fig. 666 illustrates the anchorage engaging the permanent molars 
with the anterior portion of the appliance designed for the lateral ex- 
pansion of the arch so as to diffuse the space thus gained through the 
anterior segments of the arch. After the lateral development is ac- 
complished, the anterior extension may be replaced with " fingers" to 
perfectly align the incisors and in this progressive manner the ap- 
pliance can never be too complicated to be unnecessarily bulky and 
the different parts interfere with the work of each other. 478 
PRACTICAL ORTHODONTIA 
A great advantage of the Jackson appliance in cases at this age, as 
in many others, is the ease with which the appliance can be altered to 
meet the enlarged dimensions of the growing arch and still have the 
appliance so constructed as to not interfere with the eruption of 
teeth, for the appliance occupies a very small space in the oral cavity. 
The removable appliance possesses decided advantage over some fixed 
types because of the fact that it exerts a gradual spring force, and 
should the pressure be so great at any time as to cause inconvenience 
Fig. 666. 
Appliance with finger springs to distribute 
space in incisor region. (Eby.) 
Fig. 667. 
Appliance with labial bow to depress pro- 
truding anterior teeth. (Eby.) 
to the patient, the nurse or parent can remove the appliance and the 
child will avoid the inconvenience and soreness of teeth which often 
accompanies the fixed appliance where too much pressure is used and 
the patient is unable to remove it. However, to accomplish the great- 
est results with the removable appliance we must have the cooper- 
ation of the patient. This is not so difficult to obtain as would be 
imagined because of the fact that the appliance is quite inconspicuous, 
practically painless, and produces very little annoyance. GENERAL INDEX GENERAL INDEX 
A 
Abnormal development, cause of malocclusion, 134 
Abnormal frenum labium, 134, 256 
Abnormal relation of the mandible to the maxillae, 70 
Acquired causes of malocclusion, 129, 139, 142 
Adenoid appearance in patient, 107 
Adenoids, location of, illustrated, 128 
real cause of mouth-breathing, 129, 149 
Aderer's clamp band, 224 
Ainsworth appliance, 189, 200 
Alignment wire, 187, 285 (See Expansion Arch) 
.0225, use of, 215 
Aluminum-bronze, used in making appliances, 161, 191 
Amalgam models, 167 
Anatomic portion of model, 278, 280 
measurement of, 278, 282 
Anchorage: 
Baker, 243, 376 
cervical, 248, 249 
classification of, table showing, 231 
compound reciprocal intermaxillary, 242, 334, 363 
compound reciprocal intramaxillary, 237 
compound simple intermaxillary, 242, 243 
compound simple intramaxillary, 232 
compound stationary intramaxillary, 235 
definition of, 230 
extramaxillary, 230, 248 
facial, 249 
forms of, outline showing, 231 
intermaxillary, 230, 240, 249, 355, 376, 384, 403, 420, 430, 448 
intramaxillary, 230, 231 
occipital, 247, 248 
occipital extramaxillary anchorage, 247 
primary reciprocal intermaxillary, 242 
primary reciprocal intramaxillary, 236 
primary simple intermaxillary, 241, 243 
481 482 
GENERAL INDEX 
reciprocal, 235, 249 
reenforced simple intramaxillary, 232 
simple, disadvantages of, 233, 249 
simple compound reciprocal intermaxillary, 245 
simple compound reciprocal intramaxillary, 240 
simple intramaxillary, 231 
simple primary intramaxillary, 232 
simple reciprocal intramaxillary, 239 
single reciprocal intramaxillary, 236 
single intramaxillary, 232 
single stationary intramaxillary, 235 
stationary, 233, 242, 249 
stationary compound intermaxillary, 245 
stationary intermaxillary, 231 
stationary intramaxillary, 231 
stationary reciprocal intramaxillary, 240 
Angle's bracket band, 222 
classification of malocclusion, 48 
compared with Lischer's, 49 
expansion arch, or alignment wire, 189 
jack-screw, 185 
pin and tube appliance, 214 
ribbon arch, 222 
traction screw, 185 
Ankylosis of mandible, facial deformity due to, 110 
Antero-posterior relation of arches, 46 
Appliances. (See Regulating Appliances.) 
Approximal contact, normal, as force of occlusion, 36 
as force of retention, 257, 260 
Arch, Angle's ribbon, 222 
method of adjusting, 343 
Arches, malrelation of, 44 
mesio-distal relation of, 46 
normal mesio-distal relation of, 79 
Arlox band, Rogers, 180 
Art portion of model, measurement of, 278, 285 
Atmospheric pressure, normal, as force of occlusion, 28 
as force of retention, 259 
Atrophy of enamel organ, produced by syphilis, 81 
B 
Baker anchorage, 243, 376 
Bands, 160 
bracket, Angle, 222 
clamp, 160, 224 GENERAL INDEX 
483 
contoured and noncontoured, 156 
direct method of making, 162, 164 
indirect method of making, 162, 166 
Magill, 160 
plain, 160, 177 
technique for making, 162 
trimming of, 164, 179 
Band-forming pliers, Angle, 163 
Beauty, considered from orthodontic standpoint, 81, 92 
Beauty of face, part teeth play in, 81 
Bilateral mesioclusion, or Class III, cases, treatment of, 413 
Bilateral distoclusion with labioversion, treatment of, 373 
Bilateral distoclusion with labioversion of upper anterior teeth, 54 
Bilateral distoclusion with linguoversion of anterior maxillary teeth, 401 
Bilateral distoclusion with retruding anterior teeth, or Class II, Division 2, 400 
Bilateral mesioclusion with bunched upper anterior teeth, 66 
Bodily movement of teeth, 445 
appliances for, 213 
by seat and flat arch, 222 
Bone development, 436 
Brachycephalic, defined, 81, 83 
Brady's clamp hand, 224 
Buccal occlusion, definition of, 42 
Buccoversion, definition of, 42 
Burrill lock for lingual arches, 211 
c 
Calipers, Hawley, for measurement of lingual arch, 212 
Canning's spiral arch, 239 
Case's appliance for bodily movement of teeth, 214 
wire bending pliers, 467 
Cases, preliminary consideration of, 269 
treatment of, 325 
Casts, facial, valuable as records, 292, 293 
full facial, technique for making, 302 
full facial, with dental insert, 303 
partial facial, technique for making, 299 
profile, technique for making, 293 
Causes of malocclusion: 
abnormal development, 134 
abnormal frenum labium, 134, 256 
abnormal lip, 137 484 
GENERAL INDEX 
acquired, 138, 142 
cell metabolism, 123 
chicken-pox, indirect cause, 117 
children's diseases, indirect cause, 117 
cleft palate, 134, 256 
congenital, 134, 139 
disuse of teeth, 124 
ductless glands, diseases of, indirect cause, 127 
early loss of deciduous teeth, 142 
early loss of permanent teeth, 145 
enlarged tonsils, 155, 259 
environments, 124, 126, 129, 139 
faulty development, 121 
family traits, indirect cause, 130 
feeding of babies, improper, 127 
general or constitutional, 117 
habits, 156, 187, 256 
harelip, 134 
improper diet, 124 
improper restorations, 149 
inherited, 122, 129, 139 
intermarriage of races, 131 
local and constitutional, differentiation of, 128 
loss of mesio-distal diameter of teeth, 148 
measles, indirect cause, 117 
missing teeth, 117, 134 
mixing of types, 131 
mouth-breathing, 88, 129, 149 
oversized tongue, 138 
pituitary bodies, diseases of, indirect cause, 127 
racial characteristics, 125 
rickets, 117, 130 
scarlet-fever, indirect cause, 117 
sore teeth, 156 
supernumerary teeth, 134 
syphilis, indirect cause, 117 
tardy eruption of permanent teeth, 145 
thyroid glands, diseases of, indirect cause, 127 
tuberculosis, 121 
undersized tongue, 138 
Cell metabolism, faulty, as cause of malocclusion, 122 
normal, as force of occlusion, 28, 123, 127 
as force of retention, 258 
Cephalic index, 81, 83 
Cervical anchorage, 248, 249 
Chicken-pox, indirect cause of malocclusion, 117 
Chin cap, 247 GENERAL INDEX 
485 
Chin, development of, influenced by mouth-breathing, 91 
prominent, with normal denture, 91, 94 
receding, with normal denture, 92, 94 
Clamp bands, 160, 178 
Clamp bands, adjusting, 178 
Angle, 178 
Arlox, 180 
contoured, and noncontoured, 178 
Lukens, 180 
with clamping device on lingual side, 179 
with clamping device on buccal side, 179 
Class I, or neutroclusion, 45, 51 
treatment of, 325 
Class I, mutilated, or neutroclusion, 48, 53 
treatment of, 359 
Class I, term as used by Angle, 48 
Class I, Type 1, 45, 53 
Class I, Type 2, 51, 55 
Class I, Type 3, 52, 55 
Class II, or distoclusion, 57 
Class II, Division 1, or bilateral distoclusion with labioversion, 54, 57, 59 
treatment of, 373 
Class II, Division 1, Subdivision, or unilateral distoclusion with protruding 
teeth, 59 
treatment of, 400 
Class II, Division 2, or unilateral distoclusion with protruding anterior 
teeth, 57, 59 
treatment of, 400 
Class II, Division 2, Subdivision, or unilateral distoclusion with retruding 
teeth, 59, 60 
Class II skull, 79 
Class III, or mesioclusion, 49, 62 
Class III, Type 1, 62 
Class III, Type 2, 63, 65 
Class III, Type 3, 66 
treatment of, 311 
Class III, Subdivision, or unilateral mesioclusion, 68 
treatment of, 430 
"Class IV," incorrect name for cases, 68 
Classification of anchorage, table showing, 231 
of Angle's plan of nomenclature, 48 
of Lischer's plan of nomenclature, 49 
of forces of occlusion, 28 
of malocclusion, 44 486 
GENERAL INDEX 
Cleanliness of regulating appliances, 158 
Cleft palate, cause of malocclusion, 134, 256 
Cleft palate, facial deformity due to, 113 
Coffin split plate, 445 
Coffin split spring plate, 451 
Complex neutroclusion, 55 
Compound reciprocal intermaxillary anchorage, 242 
Compound reciprocal intramaxillary anchorage, 237 
Compound simple intermaxillary anchorage, 242, 243 
Compound simple intramaxillary anchorage, 232 
Compound stationary intramaxillary anchorage, 235 
Composition of appliances, 161 
Compromise treatment, 359 
Condyle, relation of, to glenoid fossa, 76 
Congenital causes of malocclusion, 134, 139 
Constitutional causes of malocclusion, 117 
Contouring appliance, Case, 213 
Cranium, classification of, 82 
Crowns, imperfect, cause of malocclusion, 149 
Cusps, occlusal, inclined planes of, 20 
relation of, to inclined planes, 21, 22 
D 
Deciduous teeth, early loss of, 142 
Dental insert, full facial cast with, 303 
Development, lack of, 372 
Diagnostic aids in correction of malocclusion, 114 
Distal occlusion, definition of, 42 
Disto-buccal cusps, 22 
Disto-buccal inclined planes, 17, 20 
Distoclusion cases, defined, 57 
Distoclusion, defined, 49 
or Class II, 49, 57, 373 
with labioversion of anterior teeth, treatment of, 378, 383 
with labioversion of upper incisors, 54, 57, 108 
with linguoversion of upper anterior teeth, 56, 57 
use of ribbon arch in treatment of, 223 
Disto-lingual cusps, 22 
Disto-lingual inclined planes, 20 
Distoversion, definition of, 42 
Disuse, cause of malocclusion, 124 GENERAL INDEX 
487 
Dolychocephalic index, defined, 81, 83 
Ductless glands, diseases of, indirect cause of malocclusion, 127 
Duplicating orthodontia models, 287 
Durability of regulating appliances, 158 
E 
Efficiency of regulating appliances, 157 
End to end bit, 259 
Environments, cause of malocclusion, 125, 129, 139 
Etiology of malocclusion. (See Causes.) 
Expansion arch. (See also Regulating Appliances.) 
Ainsworth's appliance, 189 
Angle's, with patented nut, 189 
Angle's ribbed, 189 
application of, 195 
attachments for, 192 
combinations used, 188 
construction of, materials used in, 190 
labial, 187, 195 
loop, labial, 200 
nuts for, different forms used, 188, 190 
sizes of, 192 
uses of, 189 
Extension spurs for lingual arches, 213 
Extramaxillary anchorage. (See Anchorage.) 
Extramaxillary retention. (See also Retention of Teeth), 251, 268 
F 
Face, front and side views necessary, 91 
normal type with normal occlusion, 90 
principal features of, 86 
Face-form and head-form, relation between, 84 
Facial anchorage, 249 
Facial casts, full, 302 
full, technique for making, 302 
full, with dental insert, 303 
objections to use of, 309 
partial, technique for making, 299 
showing normal occlusion, 88, 90 
valuable as records, 292, 293 
Facial deformities and malocclusion, relation between, 81 
Facial deformity accompanying mesioclusion, 109 
associated with mouth-breathing, 39 488 
GENERAL INDEX 
Facial development and malocclusion, 95 
lack of, produced by neutroclusion, 358 
Facial index, 82 
Family traits, inherited type of malocclusion, 130 
Faulty development of children, cause of malocclusion, 121, 126 
Feeding of babies, improper, cause of malocclusion, 127 
Fillings, imperfect, cause of malocclusion, 149 
Finger springs, 467 
Finger-sucking, cause of malocclusion, 156 
Fixed regulating appliances, 159, 184 
advantages of, 160 
Flake glue, for making duplicate models, 288 
Force of the inclined plane, as force of occlusion, 28, 32 
as force of retention, 252 
Forces of occlusion: 
classification of, 28 
definition of, 28 
force of the inclined plane, 32 
harmony in size of the arches, 37 
muscular pressure, 30 
normal approximal contact, 36 
normal atmospheric pressure, 40 
normal cell metabolism, 28 
Forces of retention. (See Retention of Teeth.) 
Frenum labium, abnormal, as cause of malocclusion, 134 
attachment of, cause of malocclusion, 134 
Full facial casts, technique for making, 302 
with dental insert, 303 
G 
General causes of malocclusion, 117 
German silver, used in making of appliances, 161, 190 
Glue impressions, for duplicating models, 289 
Gnathic index, for studying protrusion of teeth, 83 
Gold and platinum, used in making of appliances, 161, 190 
Grass-line ligature, 180 
H 
Habits of childhood, cause of malocclusion, 156, 256 
Harelip, cause of malocclusion, 134 
facial deformity due to, 113 GENERAL INDEX 
489 
Harmony in size of the arches, as force of occlusion, 28 
as force of retention, 253 
Hawley calipers for measurement of lingual arch, 212 
Head-form and face-form, relation between, 84 
Headgear and chin retractor, illustrated, 247 
Hooks, technique of making, 194 
Hutchinson teeth, 117 
I 
Impressions: 
duplicating orthodontia models, 287 
facial casts, 293 
methods of taking, 269 
modeling compound, for study models, 286 
modeling compound, not satisfactory, 269 
plaster used in taking of, 269, 271 
removing from mouth, 273 
trays for holding plaster, 269 
uniting, 273 
varnishing, 274 
Improper restorations, cause of malocclusion, 149 
Inclined planes of teeth, how named, 17 
diagram showing, 20, 21 
forces, of, 33, 182 
outline showing occlusion of, 23 
Inconspicuousness of regulating appliance, 159 
Infra-occlusion, definition of, 42 
Infraversion, definition of, 42 
Inharmony in size of arches, 37, 254 
Inherited causes of malocclusion, 129, 139 
family traits, 130 
intermarriage of races, 131 
mixing of types, 131 
Inlays, imperfect, cause of malocclusion, 149 
Intermaxillary anchorage. (See Anchorage.) 
Intermaxillary retention. (See Retention of Teeth.) 
Intermaxillary hook, 194 
Intramaxillary anchorage. (See Anchorage.) 
Intramaxillary retention. (See Retention of Teeth.) 
Iridio-platinum, used in making regulating appliances, 161, 191 
J 
Jack-screw: 
advantages and disadvantages in use of, 185 
Angle's, illustrated, 185 490 
GENERAL INDEX 
attachments of, 185 
attached to band, 237 
combinations of, 185 
traction screw, modification of, 185 
Jackson's all-metal removable appliances, 452 
crib appliance, 205 
partial clasp metal, 454 
removable-fixed appliances, 454 
system of removable appliances, 452 
Jumping-the-bit, 376 
K 
Key to occlusion, defined by Angle, 46 
L 
Labial and lingual arch in combination, with spring extensions, 227 
Labial arch, in combination with finger spur, 450 
used with lingual arch, 224 
Labial expansion arch, 187, 195 
Labial occlusion, definition of, 42 
Labial wire with spur extensions, 397 
Labioversion, definition of, 42 
Lap bands, 163, 165 
Large tongue, congenital cause of malocclusion, 138 
Ligature jack, Lourie, 185 
Ligatures, kinds of, 180 
rubber, 181 
silk or grass-line, 180 
wire, 182 
Line of occlusion, definition of, 28 
Lingual and labial arch in combination, with extension spring, 227 
Lingual arch, calipers for measurement of, 212 
cases of mesioclusion treated with, 428 
fixed, 205 
locking devices for holding spurs, 211 
Lourie's technique, 205 
Mershon's technique, 205 
removable, 205 
styles of application, 207 
use of, in cases of bilateral distoclusion, 408 
used with labial arch, 224 
Lingual occlusion, definition of, 42 
Linguoversion, definition of, 42 GENERAL INDEX 
491 
Linguo-torsi-occlusion, 43 
Lip, abnormal, cause of malocclusion, 137 
Lip-habits and malocclusion, 88 
Lip-sucking and lip-biting, causes of malocclusion, 156 
Lips, abnormal function of, due to malposition of incisors, 97 
development of, and malocclusion, 98, 103 
Lischer's classification of malocclusion, 41, 44, 49 
compared with Angle's, 49 
Lock for use with perpendicular tube on molar band, 211 
Lourie's ligature jack, 185 
Lourie's spur-forming pliers, 190, 191 
Lourie's technique for lingual arches, 205 
Loop appliance, application in neutroclusion, 202 
combinations of, 203 
with pins and tubes, 201 
with threaded arch, 204 
Loop labial alignment wire, 200 
Lukens clamp band, 180 
M 
Macromandibular development, 73, 75 
Macromaxillary development, 73 
Magill band, 160 
Malformations of the jaws and their processes, 70 
result of malocclusion, 70 
Malocclusion and facial deformities, relation between, 81 
Malocclusion and nasal deformities, 435 
Malocclusion, classification of, 44 
definition of, 17, 41 
diagram showing, 42 
division into groups, 41, 46, 48 
etiology of, 117. (See Causes.) 
Lischer's classification, 41, 44, 49 
compared with Angle's, 49 
positions of, 41 
produces abnormal jaw and process, 80 
Malocclusion, facial development in, 95 
Malposition of the mandible, 41, 70 
deformity due to, 110 
facial deformity in, 106 
Malpositions of the individual teeth, 41 
Malrelation of the arches, 41, 44 492 
GENERAL INDEX 
Mandible, abnormal relation to maxillae, 70 
ankylosis of, 110, 113 
curvature, 73 
malposition of, 70 
facial deformities due to maldevelopment of, 110 
facial deformities due to malposition of, 110 
Mandibular anteversion, defined, 72 
Mandibular retroversion, defined, 72 
Materials used in making bands, 160 
Maxilla, superior, illustrated, 29 
Maxillary bones, 152 
Measles, indirect cause of malocclusion, 117 
Measuring plaster models, 283 
Mechanical forces of retention. (See Retention of Teeth.) 
Mershon's technique for lingual arches, 205 
Mesial occlusion, definition of, 41, 42 
Mesio-buccal cusps, 22 
Mesio-buccal inclined planes, 21 
Mesioclusion cases, defined, 62 
Mesioclusion, defined, 49 
facial deformity in, 109, 112 
or Class III, 49, 62, 311 
treatment of, 413 
use of ribbon arch in treatment of, 223 
Mesioclusion with macromandibular development, 112 
Mesio-distal diameter of teeth, loss of, 148 
Mesio-distal relation of arches, 46 
Mesio-labio-torsi-infra-occlusion, 43 
Mesio-labio-torsi-infraversion, 43 
Mesio-torsi-infraversion, definition, 42 
Mesio-lingual cusps, 22 
Mesio-lingual inclined planes, 21 
Mesio-torsi-infra-occlusion, 42 
Mesioversion, definition of, 41 
Mesocephalic index, defined, 81, 83 
Mesognathic index, defined, 83 
Metal models, material used for, 164 
Micromandibular development, 73, 77 
Micromaxillary development, 73 
Mixing of types, inherited cause of malocclusion, 131 
Missing teeth, cause of malocclusion, 117, 134 GENERAL INDEX 
493 
Models, amalgam, 167 
duplicating, method of, 287 
instruments for trimming, 279, 280 
measuring, method of, 283 
metal, material for, 164 
pouring, 275 
separating, 277 
study, made from modeling compound, 286 
trimming, 279 
Modeling compound impressions, 269 
Modeling compound to study models, 286 
Molars, buccal and lingual relation of, 20 
Mouth, roof of, at birth, 152 
Mouth-breathers, facial deformities in, 96 
Mouth-breathing, 435 
Mouth-breathing, cause of malocclusion, 129, 149, 375 
facial deformity associated with, 39, 149, 155 
influence on development of nose, 89 
influence on mouth, 88 
typical case of, 39 
photographs, value of, 293 
Mouth, development of, influenced by mouth-breathing, 88 
roof of, 442 
Muscular pressure, as force of occlusion, 28, 30 
as force of retention, 256 
N 
Nasal and oral cavities, relation of, 152 
Nasal cavity, embryonic development of, 436 
posterior view of, 38 
Nasal deformities and malocclusion, 435 
Nasal septum, development of, 438 
Naso-labial sulcus, development of, influenced by mouth-breathing, 88 
Nasopharynx, illustrated, 128, 151 
Natural forces of retention. (See Retention of Teeth.) 
Neutroclusion, complex cases of, 55 
complicated by infraversion of anterior teeth, 102 
complicated by labioversion of upper and lower anterior teeth, 106 
complicated by linguoversion of upper incisors, 99 
definition of, 49 
facial deformities in, 95 
mutilated, case of, 50, 53 
with bunched anterior teeth, 45, 50, 53 
with labioversion of upper incisors, 51, 55 
with linguoversion of upper anterior teeth, 52, 55 494 
GENERAL INDEX 
Neutroclusion cases, defined, 51 
diagnostic aids in, 114 
Nickel silver, used in making of appliances, 161 
Nomenclature, Angle's, 48 
Lischer's, 49 
Non-corrosive material, used in making of appliances, 161 
Normal approximal contact, as force of occlusion, 28, 36 
as force of retention, 257 
Normal atmospheric pressure, as force of occlusion, 28, 40 
as force of retention, 259 
Normal cell metabolism, as force of occlusion, 28, 123, 127 
as force of retention, 258 
Normal muscular pressure, as force of occlusion, 28, 30 
as force of retention, 256 
Normal occlusion, definition of, 17 
skulls illustrating, 18, 19 
face showing, 90 
facial cast showing, 88 
Normal skull, 80 
Nose-breathing, effect on malocclusion, 40 
Nose, development of, influenced by mouth-breathing, 89 
O 
Occipital anchorage, 247, 248 
Occlusion: 
buccal, 42 
definition, 17 
distal, 42 
forces of, 28 
classification, 28 
definition, 28 
infra-, 42 
labial, 42 
line of, 30 
lingual, 42 
mesial, 41 
mesio-labio-torsi-infra-, 43 
mesio-torsi-infra-, 42 
normal, 17 
of inclined planes, 17, 23 
supra-, 42 
torsi-, 42 
torsi-mesial, 42 GENERAL INDEX 
495 
Orthodontia, definition of, 17 
Orthognathic index, defined, 83 
Ottolengui's modification of split plate, 445 
Oversized tongue, congenital cause of malocclusion, 138 
P 
Palate, hard and soft, illustrated, 128 
Partial clasps, used in Jackson's removable appliances, 458 
Partial facial cast, technique for making, 299 
Peridental membrane, 444 
Permanent teeth, early loss of, 145 
tardy eruption of, 145 
Perversion, definition of, 42 
Photographs, valuable as records, 291 
Pin and tube appliance, Angle, 214 
Pin and tube appliance, in mesioclusion, or Class HI cases, 427 
Pin and tube, used with .0225 wire, 215 
Pinch bands, 163 
Pituitary body, diseases of, indirect cause of malocclusion, 127 
Plane and spur retention, 266 
Plain bands, 160, 177 
Plaster bowl, 271 
plane, 280 
trays, 269 
used for taking impression, 269 
Plaster model for indirect band-making, 169 
Pliers, Angle's band-forming, 163 
Angle's soldering, 163 
Bogue, 207 
How, modified, 208 
Lourie's spur, 191 
Mershon's band-stretching, 172 
sharp-nosed, 215 
stretching, 207 
wire-bending, Case, 467 
Positions of malocclusion, 41 
Positions of teeth, normal, 42 
Pouring plaster models, 275 
Profile casts, technique for making, 293 
evolution of, 81, 83 
in infancy, 81 
in maturity, 81 
in senility, 81 
Prognathic index, defined, 83 496 
GENERAL INDEX 
R 
Racial characteristics, 83 
as cause of malocclusion, 125 
Racial types, European, 85 
Radiography in orthodontia. (See X-ray in Orthodontia.) 
Reciprocal anchorage, 235, 249 
Regulating appliances: 
composition of, 161 
definition of, 157, 451 
fixed, 159, 184, 451 
making of, technique, 160 
materials used in making, 160 
principles of, 157 
removable, 159, 451 
advantages of, 476, 478 
all-metal appliances, 452 
body wires, 464 
Coffin split spring plate, 451 
disadvantages in use of, 453 
early types, 451 
finger springs, 467 
instruments required for making, 454 
Jackson's system, 451 
lower appliance, construction of, 472 
materials used, 456 
partial clasps, 458 
plaster models, 457 
removable-fixed type, 454 
spring clasps, 461 
technique of construction, 457 
requirements of, 157 
antisepsis, 158 
cleanliness, 158 
durability, 158 
efficiency, 157 
inconspicuousness, 159 
simplicity, 158 
Removable appliances, 159, 389, 392, 451 
advantages and disadvantages of, 160, 451 
Removable retaining appliances, Beaser, 392 
Fernald, 389 
Removable-fixed appliances of Jackson, 454 
Retention, study models valuable in, 287 
Retention of teeth: 
definition of, 250 GENERAL INDEX 
497 
mechanical forces, 250 
active, 251, 387 
active primary intermaxillary retention, 263, 265 
active reciprocal intermaxillary retention, 263, 267 
compound active reciprocal intermaxillary retention, 264 
compound reciprocal intramaxillary retention, 263 
compound reciprocal passive intramaxillary retention, 263, 267 
extramaxillary retention, 251, 268 
intermaxillary retention, 251, 264, 355 
intramaxillary retention, 251 
passive retention, 250 
passive reciprocal simple intermaxillary retention, 265 
passive reciprocal stationary intermaxillary retention, 267 
plane and spur retention, 266 
primary passive intermaxillary retention, 264 
reciprocal intermaxillary retention, 265 
reciprocal intramaxillary retention, 262 
simple compound intramaxillary retention, 261 
simple passive intramaxillary retention, 261 
stationary intramaxillary retention, 262 
natural force, 251 
force of the inclined plane, 252 
harmony in the size of the arches, 253 
normal approximal contact, 257 
normal atmospheric pressure, 259 
normal cell metabolism, 258 
normal muscular pressure, 256 
summary of, 259 
Ribbon arch, Angle, 222 
Richardson's modification of split plate, 445 
Rickets, cause of malocclusion, 117, 142 
Robinson's .022 alignment wire appliance, 217 
Robinson's appliance, 192, 217 
Roof plate, in combination with labial arch and finger spur, 450 
Roof plate with spring for expansion of upper arch, 446 
Rubber ligatures, 181 
s 
Separating plaster models, 275 
Scarlet fever, indirect cause of malocclusion, 117 
Sheath-hook, 194 
Silk ligatures, 180 
Simplicity of regulating appliances, 158 
Sinuses, posterior view of, 38 
Soft-soldering, 174, 192 498 
GENERAL INDEX 
Soldering pliers, Angle, 163 
Soldering technique, 174 
Solder, in wire form, 164 
Sore teeth, cause of malocclusion, 156 
Spiral arch, Canning's, 239 
Split spring plate of Coffin, 451 
modifications of, 445 
Spring clasps, for Jackson's removable appliances, 461 
Spur extensions, labial wire with, 397 
Spur, triangular, and tube used with lingual wire, Fernald, 391 
Spurs: 
attachment of, 194 
extension, for lingual arches, 213 
extensions for labial and lingual arches, 227 
for bodily movement of teeth, 194, 416 
half-loop, 193 
half-round, 211 
locking devices for holding, 211 
making of, 174 
on lingual arches, 211 
soft solder, forms of, illustrated, 193 
soldering to bands, 173, 174 
to depress canines, 194 
to prevent ligature from slipping, 184, 192 
tubes used as, 193 
Stationary anchorage, 233, 242, 249, 350 
Study models, made from modeling compound, 287 
Supernumerary teeth, congenital cause of malocclusion, 134 
Supra-occlusion, 42 
Supraversion, definition of, 42 
Suture, opening of, aid to treatment, 445 
Syphilis, indirect cause of malocclusion, 117 
T 
Tardy eruption of permanent teeth, 145 
radiograph showing, 320 
Thyroid diseases, indirect cause of malocclusion, 127 
Thumb-sucking, cause of malocclusion, 156 
Tonsils, enlarged, effects of, 155, 259 
Torsi-mesial occlusion, 42 
Torsi-occlusion, 42 
Torsiversion, definition of, 42 GENERAL INDEX 
499 
Traction screw, use of, with stationary anchorage, 325 
Angle's illustrated, 185 
Transversion, definition of, 42 
Trays for taking plaster impression, 269 
Treatment, study models valuable in, 287 
Treatment of cases: 
of bilateral distoclusion with labioversion, or Class II, Division 1, 373 
of bilateral distoclusion with retruding anterior teeth, or Class II, Divi- 
sion 2, Subdivisions, 413 
of mesioclusion, or Class III, 413 
of neutroclusion, or Class I, 325 
of neutroclusion, or Class I, mutilated, 359 
of unilateral distoclusion with protruding anterior teeth, or Class II, 
Division 1, Subdivision, 400 
of unilateral distoclusion with retruding teeth, or Class II, Division 2, 
Subdivision, 413 
of unilateral mesioclusion, or Class III, Subdivision, 430 
Trimming plaster models, 279 
Tube, square, devised by Kemple, 351 
Tube-hook, 194 
Tuberculosis, indirect cause of malocclusion, 121 
u 
Undersized tongue, congenital cause of malocclusion, 138 
Unilateral distoclusion, defined, 68 
with bunching upper anterior teeth, 61 
with labioversion of upper anterior teeth, 49 
with linguoversion of upper incisors, 60 
Unilateral mesioclusion, defined, 68 
or Class III, subdivision, treatment of, 430 
w 
Wax models, used as diagnostic aids, 114 
Wire bending in making appliances, 465 
Wire-bending pliers, Case, 467 
Wire ligatures, 182 
Wire stretchers, Angle's, 206, 207 
Lourie's, 206, 207 
X 
X-ray in orthodontia: 
extra-oral method, most satisfactory, 311 
indications for use of, 317 500 
GENERAL INDEX 
intra-oral method not satisfactory, 311 
seating the patient, 312 
technique, 311 
value of, 310 
Y 
Young-Angle lock for lingual arches, 211