Orthodontia A Textbook and Treatise on Malocclusion giving Technic of Treatment and Appliances With Illustrations by Edward Canning, D. D. S. Professor of Orthodontia in the Colorado College of Dental Surgery Published by The Dental Specialty Company 1638 California Street Denver, Colorado Copyright, 1919 Edward Canning The Brock-Haffner Press Denver, Colorado Preface RTHODONTIA, or the straightening of irregular teeth, is the most alluring field of endeavor in the whole art of dentistry, itself the one profession which is entering upon the most hopeful and prosperous phase of its history. The public has been educated to the need of dentistry, and along with this general education comes the knowledge that teeth can be, and should be, straightened if the individual is to enjoy beauty and health. Orthodontia has a most wonderful future before it because it is that branch of dentistry that has been most neglected in the past. Many dentists throughout the country have made a specialty of this branch of dentistry and nearly all find their time more than occupied in this highly paid and appreciated work. The man who can intelligently transpose into a symmetrical curve irregular teeth that greatly mar the appearance, and that dentist who at the same time can establish normal occlusion with the proper power of mastication in the young patient, is decidedly a benefactor of mankind and his services will always be in demand. Obviously all people with irregularities of teeth are not in reach of specialists and probably never will be. They live in or near small towns and cannot possibly journey to distant cities for treatment; therefore some dentist located near them must do the work, if it is to be done at all, otherwise the patient is compelled to go through life greatly embarrassed and handicapped by this perversion of nature. It is really the duty of dentists thus situated to be able to handle satisfactorily ordinary cases of orthodontia, precisely as they are expected to handle other phases of dentistry. It is part of their duty to the public. We do not mean to infer by this that the man of limited experience can handle a case of mal- occlusion with the same ease and precision as one with larger ex- perience, or who is practicing orthodontia to the exclusion of other dentistry, but there is no reason why, given the proper apparatus scientifically developed, the average dentist should not do ortho- dontia work as successfully as he can make plates or bridges, crown teeth, or restore the contour of teeth with plastic materials. There is nothing in orthodontia inherently more difficult than the other branches of dentistry. Indeed, the general practitioner owes it to the community which he serves to make himself as proficient in orthodontia as he is in the other equally difficult branches of his profession. It is mainly for this purpose of helping the average dentist perform this duty to the public at a most remunerative fee that this book is written. TABLE OF CONTENTS CHAPTER I MALOCCLUSION Causes of Malocclusion-Mouth Breathing-Habits-Too Long Reten- tion of Deciduous Teeth-Premature Loss of Deciduous Teeth-Tardy Eruption of Permanent Teeth-Frenum Labium-Maleruption of Permanent Molars 11 DIAGNOSIS AND CLASSIFICATION CHAPTER II Classification of Malocclusion-Chart of Classification-Class One, Type A-Class One, Type B-Class One, Type C-Class One, Type D-Class Two, Type A-Class Two,' Type B-Class Three, Type A-Class Three, Type B 30 CHAPTER III THE AUTHOR'S REGULATING APPLIANCES Gold Appliances-Nickel Silver-Cable-Spring Arch A-Application of Cable-Spring Arch A for the Correction of Malocclusion-Expansion Arch B-Double Bar Expansion Arch C-Adjustment of Molar Clamp Bands-Interchangeability of Arches and Molar Clamp Bands- Ready-Made Anterior and Bicuspid Plain Bands-Band Material- Wrenches-Ligature-Wire Ligature-Grass Line Ligature-Rubber Ligature 43 SOLDERING TOOLS AND MAKING OF BANDS CHAPTER IV Forming Plain Bands-Forming Cuspid Bands-Special Tools and Solder -Band Forming Pliers-Band Soldering Pliers-Orthodontia Lamp- Band Driver-Wire Ligature Twister-Wire Ligature Bender- Curved Scissors-Wire Cutter-Silver Solder Flux-Soldering Flux- Soft Solder-Soft Solder Flux-Micrometer-Brown & Sharpe Gauge 63 CHAPTER V ANCHORAGE Intramaxillary Anchorage-Simple Anchorage-Reinforced or Stationary Anchorage-Intermaxillary Anchorage 72 CHAPTER VI CORRECTION OF PROTRUSION BY EXTRACTION IN CONFIRMED CASES OF MALOCCLUSION 77 9 CHAPTER VII TREATMENT OF MALOCCLUSION Age for Treatment-Separating of Teeth for Bands-Treatment Class One, Type A-Class One, Type B, Retruding Upper Incisors-Class One, Type C, Protrnding Upper Incisors-Class One, Type D, Bimax- illary Protrusion-Treatment for Prevention of Class Two and Class Three Cases in Unconfirmed Malocclusion. Class Two-Confirmed Malocclusion, Class Two, Type A-Correction of Class Two, Type A, without Extraction, Confirmed Malocclusion-Correction of Class Two, Type A, with Extraction, Confirmed Malocclusion-Class Two, Type B. Correction of Class Two, Tvne B, without Extraction, Con- firmed Malocclusion-Correction of Class Two, Type B, with Extrac- tion, Confirmed Malocclusion-Class Three, Confirmed Malocclu- sion-Correction of Class Three, Type A, without Extraction, Con- firmed Malocclusion-Correction of Class Three, Type A, with Ex- traction. Confirmed Molocclusion--Class Three, Type B, Correction of Class Three, Type B, without Extraction, Confirmed Malocclusion -Correction of Class Three, Type B. with Extraction, Confirmed Malocclusion-Method of Retaining Tooth Space During Tooth Movement-Treatment for Impacted Cuspids 81 CHAPTER VIII RETENTION Removable Retentions-Tntramaxillary Retention for Class Two, Type A or B, also for Class Three, Type A or B, when Eirst Bicuspids Have Been Extracted-Intermaxillary Retention for Class Two, Type A or B, also for Class Three, Type A or B, when Eirst Bicuspids Have Not Been Extracted 135 CHAPTER IX IMPRESSIONS AND CASTS Material for Impressions-Preparing the Teeth for Impressions-Im- pression Trays and Taking the Impressions-Removing the Impres- sion-Varnishing the Impression-Pouring the Model-Separating the Model-Trimming the Models-Marking the Occlusion-Study of Models 146 CHAPTER X PHOTOGRAPHY AND THE X-RAY IN ORTHODONTIA 153 CHAPTER XI FEES 159 10 CHAPTER I Malocclusion Since the object of moving teeth is to harmonize them with nature's plan, it is essential at the very start that we familiarize ourselves with this design. See Fig. 1. In normal occlu- sion, not only the teeth but the su- perior and infe- rior maxilla are normally posed, imparting to the features balanced proportions and facial lines best suited to that par- t i c u 1 a r face. There are, how- ever, exceptions to this rule; the teeth may be in normal occlusion and yet present a bimaxillary pro- trusion of the up- per and lower an- terior teeth, giv- i n g disfiguring prominence to the lips. Treatment of this exception is given under "Treatment of Malocclusion." In normal occlusion, with the exception of the lower central incisors and upper third molars, each tooth has two antagonists which are so arranged that the depressions of one set of teeth receive in a general way the eleva- tions of the opposing set. By this arrangement the depressions and eleva- tions not only interdigitate for natural support of each tooth, but form an irregular surface that greatly facilitates mastication and the grinding of food. Fig. 1 shows far better than words the position of the jaws and teeth when normally posed. Any deviation from this arrangement is termed malocclusion. Fig. 1. 11 12 ORTHODONTIA Causes of Malocclusion It is very necessary that the dentist should be familiar with certain con- ditions that are bound to cause irregularities during the eruption of the per- manent teeth. A very small correction at the beginning will often make the difference between regular and irregular teeth. Malocclusion may be inherited or acquired. Inherited, as the name im- plies, is a condition transmitted from the parents to offspring. It is not unusual to observe this inheritance ranging all the way from malrelation of the arches to the malposition of a single tooth. Notwithstanding this, some writers on the subject claim inherited malocclusion is impossible, and base their claims on the theory that no disease can be inherited, but that all disease is caused by environment. Starting with the wrong premise, it follows that their conclusions must necessarily be wrong. Malocclusion is not a disease in the right sense of that word, and cannot be classified as such, but is merely a deviation from position, and therefore can be inherited like any other re- semblance. If a child can resemble a parent; for instance, in color of eyes, tint of hair, shape of nose, general features, and even inflection of voice, besides in other ways too numerous to mention, why cannot it resemble the parent in irregular teeth? Irregular teeth cannot be classed as a disease any more than an irregular face can be classed as a disease. The lines of the face may be quite unprepossessing according to our standards of beauty and yet be a perfectly healthy face. Irregularities of a similar type are so often observed between parent and child, or even more remote ancestors, that doubt cannot exist as to the operation of inheritance when applied to mal- occlusion. Indeed the fact is so obvious that it is amazing how anyone could miss it and promulgate theories to the contrary. However, whether mal- occlusion has been acquired or inherited does not make any difference in the treatment of the case. Once malocclusion is present, the same mechan- ical appliances are used in either case. A permanent tooth erupting in malposition should be moved into its proper position as soon as it is sufficiently erupted for placing a band or other attachment on it. In the past, many dentists have advised patients to wait until the permanent teeth are erupted before having them regulated; in other words, to wait until the malocclusion is CONFIRMED. They could not have given worse advice had they tried. Teeth not only move much more easily at an early age, but are also much easier to retain ; that is, the time of reten- tion is much shortened. In the young patient two points are of vital im- portance ; first, the permanent first molar must be in normal relation ; and. second, all the permanent incisors must describe the proper curve, and the laterals must be sufficiently forward to accommodate the bicuspids and cuspids later to appear. If these points are early arranged it is strongly pre- sumptive that the buccal teeth will erupt in position. Indeed, most mal- occlusion could be prevented with a very little work at the right time, or before the irregular conditions become confirmed, by which is meant the presence of all the permanent teeth, the third molars excepted. MALOCCLUSION 13 Following are some of the most prevalent causes in producing mal- occlusion : Mouth-breathing. Habits. Too long retention of deciduous teeth. Premature loss of deciduous teeth. Tardy eruption of permanent teeth. Abnormal frenum labium. Maleruption of the permanent first molars. Mouth-Breathing-Mouth-breathing due to adenoids or other obstruc- tions in the nasal tract is recognized as a cause of malocclusion. Mouth- breathing also impairs the general health, therefore the conditions which cause it should be removed if for this reason alone. Should patients inflicted by mouth-breathing conclude to defer the regulation of teeth until some future time they should be advised, nevertheless, to have the obstructions to normal respiration removed at once. Mouth-breathing is usually asso- ciated with protrusion of the upper incisors, as shown in class two cases. It is also characterized by a high vault and constriction of the dental arches. What is known as a Gothic arch (a V-shaped arch characteristic of Gothic architecture) which is confined to the upper maxilla is almost a sure indica- tion that its possessor is a mouth-breather. Whatever the cause of mouth- breathing, a surgeon should be consulted and the cause removed before the correction of malocclusion is begun. We could not expect the correction of a case of malocclusion, which is very likely caused by mouth-breathing, to be permanent so long as the original conditions are still present. Habits-Occasionally young children acquire the bad habit of sucking the fingers, lips, or tongue. If the habit is persisted in during the eruption of the permanent anterior teeth, it is likely to deflect them from their normal positions. The irregularity thus caused will depend entirely on the direction of force applied against the permanent teeth. Lower lip and thumb sucking, the most common habits, will tip the lower incisors inward and the upper incisors outward, causing a protrusion of the upper incisors and a retrusion of the lower incisors. If the malposed teeth have been regulated and retained, and the patient still persists in sucking the fingers, lips, or tongue, it is obvious that the retainer cannot be removed until the habit has been given up; otherwise the teeth, by a continuation of the cause, will revert to their original position of malocclusion. The dentist must exercise his own in- genuity in directing means to overcome the trouble. Too Long Retention of Deciduous Teeth-Frequently deciduous teeth are kept for too long a time. The root does not absorb at the normal time and the tooth remains firmly imbedded in the process. If the permanent tooth erupts while the deciduous tooth is still present, of course the permanent tooth will be deflected from position, and an irregularity will occur. Extrac- tion of the temporary tooth is always indicated under such conditions. 14 ORTHODONTIA Fig. 2 shows a deciduous cuspid still present and firmly anchored while the permanent cuspid is erupt- ing in labial occlusion. This tooth should have been extracted. On the other hand a deciduous cuspid should never be extracted until signs of the eruption of the permanent tooth are in evidence. This can be told by the bulging tissue, or swell- ing over the submerged cuspid, or by the use of the X-Ray. Often the permanent cuspids are delayed in eruption and should the temporary tooth be taken out too soon, the space might, and probably would, be partly filled by other teeth moving into the space. This would, of course, cause malalignment of the permanent cuspids when they finally arrive. The point is, not to extract the temporary cuspid prematurely nor allow it to remain in position too long. Fig. 3 shows pho- tograph of a patient twenty-four years old with the decid- uous cuspid still in place. Had this tooth been extracted when the patient was twelve or thirteen years of age, its loss would have been premature and the space would have been partly closed. This tooth is holding the space for the per- manent tooth if it ever erupts, or for an artificial tooth when the temporary cuspid is finally lost. Fig. 4 shows the displacement of a permanent cuspid lingually, due to the retention too long of Fig. 2. BEFORE TREATMENT. Fig. 3. MALOCCLUSION 15 the deciduous cuspid. The large black circular spot indicates where the de- ciduous cuspid has just been extracted. Had this temporary tooth been ex- tracted at the proper time, the permanent cuspid would not have appeared in lingual occlusion, but in proper alignment with the other teeth. The rule is, Fig. 4. never to extract a temporary tooth until evidence is present of a new tooth coming in; nor should a temporary cuspid ever be extracted for the purpose of making room for the movement of a permanent lateral incisor or any other tooth. Local treatment of this character will in the end produce a worse condition of malocclusion than if nothing at all had been attempted. No case is difficult to regulate if the temporary cuspids are correctly in place, or if full space is present. Premature Loss of Deciduous Teeth and Especially Cuspids-The early loss of deciduous teeth is another great cause of acquired malocclusion. When any of the deciduous teeth are lost before their time, the space is usually monopolized in whole or in part by the permanent teeth already erupted, mov- ing into the space. The outlocked cus- pids present the most typical form of malocclusion caused by this early loss of the deciduous cuspid. See Fig. 5. It is easy to understand that if the permanent cuspids erupt normally Fig. 5. 16 ORTHODONTIA about the thirteenth year, and if the deciduous cuspids are lost from any cause a couple of years earlier, the permanent teeth posterior to the space will move forward and partly or wholly occupy the room intended for the permanent cuspids ; therefore, when the permanent cuspid does erupt, there is insufficient room for its accommodation. There is but one course to pursue in preventing this irregularity from occurring; the space must be kept open by some mechanical device adjusted at the time the deciduous cuspid is lost. One of the best devices for retaining the space is a vulcan- ized plate with a projection in the plate to fit snugly into the space, either on one or both sides. This is easily made and is an efficient retainer. See Fig. 6. When the rubber plate is used for re- tention, instead of allowing a flange of the plate to project into the space, an artificial tooth can be attached to the plate and the space held by this means. This will preserve the esthetic effect while awaiting the eruption of the per- manent cuspid. See Fig. 6. These plates are made like any other vulcanite plate, therefore a descrip- tion of the technic is unnecessary. An- other way of retain- ing this space is to band the teeth on either side of the space and then solder a bar between the two bands. See Fig. 7. 1 his device is, of course, cemented to the teeth, and is an efficient retainer. It must be remembered that this device is worn for some time awaiting the eruption of the per- manent cuspids, therefore it must be strongly made to insure stability. The technic of making this retention, as shown in Fig. 7, is as follows: Band the two teeth adjoining the space with .003 or .004 band mate- rial according to the method de- scribed for "Making Plain Bands." See Fig. 72. Take an impression in Fig. 6. Fig. 7. MALOCCLUSION 17 modeling compound with the bands on the teeth. Remove the impression and place the bands in the indentures of the modeling compound. Then flow up the model in plaster and remove the modeling compound. This places the bands on plaster teeth. After the model is sufficiently dry, the bar can be soldered with silver or gold solder to the two bands, directly across the space, or to the labial surface of the band, as shown in Fig. 7. After a retaining device is made, it is cleaned according to the method described under the head of "Making Plain Bands." Very often in placing a retaining device on the teeth it will be found that the bands are a little tight, requiring a few moments to work them into position. It is always better to allow the patient to wear the retaining device a few days before cementing. In a short time it will be found the device can be easily slipped off and on, by reason of the teeth and bands accommodating themselves to each other. As soon as the device can be readily slipped into position it is made fast by cementing. Have the teeth clean and the cement harden under dry conditions. Tn connection with retention in general, the patient should be instructed to come to the office at once should anything be broken in order that repair may be made before any movement takes place. Bands that are destined to remain on the teeth for any length of time should be festooned and kept always free from the gums, otherwise they will be a source of irritation to the soft tissues. Tardy Eruption of Permanent Teeth-Permanent teeth when delayed in eruption sometimes become impacted by other teeth moving into their po- sition. Should this impaction occur in either one of the bicuspids, no one of the arches A, B, or C, furnishes the principle in this region for opening between the teeth. Some mechanical principle on the order of a jack-screw is required where force can be exerted in opposite directions. Fig. 8 shows a case of malocclusion with scarcely any room for the second bicuspid. The teeth below anterior to the first molar have drifted distally owing to the non- eruption of the sec- ond bicuspid, and have, therefore, caused a shortening of the lower dental arch, giving the ap- pearance of protrud- ing upper incisors. The first molars are in their normal rela- tion. In order to cor- rect this condition, the first bicuspid must be moved forward until space is made for the sec- ond bicuspid. The Fig. 8. 18 ORTHODONTIA circular marks on the lower cast indicate the position of the second bicuspid which is now trying unsuccessfully to erupt. The appliance for this work con- sists of plain bands on the molar and bicuspid with tubes soldered to the buc- cal surfaces. Fig. 8. The nuts and screw are adjusted to the bands outside the mouth and are placed on the teeth together. The bands are cemented to the teeth to prevent slipping or turning on the teeth when force is applied. By turning either one of the nuts a screw power is applied which must move the point of least resistance, which in this case will be the bicuspid and cuspid; the first and second molars furnishing the anchorage, or resistance. Sometimes Fig. 9. in turning a nut both nuts will revolve. Should this occur, one of the nuts can be held with a second wrench or pliers. The appliance here shown is only to create space for the second bicuspid and not for aligning the anterior teeth. That phase of the correction is accomplished with the ex- pansion arch and is a subsequent movement. Fig. 9 shows these jack-screws in operation from both the buccal and lingual aspects. This application of the double screw makes a powerful separator. The same device can also be used for obtaining increased space by lateral movement of anterior teeth. See Fig. 10. Fig. 11 shows the application of the principle in moving a cuspid for- ward. Both cuspids and first molar are banded, the cuspids with plain bands having tubes soldered to their labial surfaces, while the ordinary clamp-band is used for the molar. By turning the forward nut on the alignment wire the cuspid is carried mesially. The posterior nut on the MALOCCLUSION 19 alignment wire acts as anchorage to pre- vent the threaded wire from slipping distally when force is applied. The first and second molars provide the neces- sary resistance for the movement. Fig. 10. Fig. 11. 20 ORTHODONTIA Fig. 12 shows a jack-screw used for the same purposes as shown in Figs. 8 and 9. Fig. 12. Frenum Labium-The presence of the frenum labium passing between the teeth, as shown in Fig. 14, is also the cause of a large number of cases of malocclusion. Instead of this muscle terminating on the labial aspect of the gums, it passes directly between the two central incisors and is the cause of the separation of these teeth. If the two centrals are separated to any degree, an unsightly condition is caused by the space and also more or less irregularity of the rest of the anterior teeth, due to the fact that the space will not permit the other teeth to occupy their full mesio- distal position in the arch. It avails nothing to move these teeth together without removing the cord, because as soon as the teeth are released from retention, the action of the cord will open the space again. Where the space is due to the presence of this cord, no amount of retention will suffice to keep the teeth in position if the frenum has not been removed. The drawing of the teeth together is a very simple matter in most instances, whether or not the cord has been dissected out. The trouble is not in mov- ing the teeth together, but in keeping them there after the artificial reten- tion has been removed. The writer has drawn centrals together which were separated by the frenum labium, without removing it, and retained the centrals for a year pending the eruption of the lateral incisors. After the laterals were well erupted the retention was removed, whereupon the power of this cord was so great that the centrals and laterals were both moved, on both sides, and the space re-created. Therefore, it can be clearly seen that it is quite useless to draw the centrals together and expect permanent results without removing the frenum labium. The removal of this cord is a very simple operation if conducted in the following manner: The field is first prepared by painting with iodine. A small piece of cotton is rolled in the fingers into a ball about the size of a small pin head. This is dipped into phenol and pressed firmly against the tissue where the point of a hypo- dermic needle is to be inserted. This acts as a local anaesthetic and renders the penetration of the point of the needle well nigh painless. It is im- portant that the small ball of cotton, saturated with phenol and held with the pliers, be pressed firmly to the tissue, leaving an indenture in it. The mere application of the phenol to the gum without pressure would not carry the full effect of the phenol. Use a local anaesthetic and insert the needle into the soft tissue on the lingual surface % inch or less back of the neck of the two centrals and in a line with the center of the space; the soft tissue here is thick and gives an easy entrance to the point of the needle, and also conducts the anaesthetic very nicely. The effect of the MALOCCLUSION 21 anaesthetic will be principally along the lingual tissue, but some of the effect will be noticed in the space between the centrals. The point can then be withdrawn and entered between the teeth without any additional dis- comfort to the patient, and the effect of the anaesthetic carried through to the labial surface. The point can again be withdrawn and reinserted in the gum on the labial surface. This will insure complete insensibility of the tissue for the removal of the frenum labium. When a sufficient area, lingual, labial, and in between the teeth, has been rendered insensible to pain, the cord is dissected out only where it passes between the centrals. This is done with a fissure bur of the proper size. Care must be observed that this bur is not large enough to come in contact with the mesial sur- face of the teeth, otherwise an injury might be done them. The bur is held when revolving at right angles to the incisal edges and forced down to the bony process. Do not be afraid of injuring the process; even if it is slightly burred no harm will be done. This burring leaves the soft tissue in a loose spongy mass, which can be easily removed by the use of Black's right and left gingival margin trimmers. See Fig. 13. With these marginal trimmers the frenum labium and all other soft tissue can be com- pletely removed, and the process bared. It is only necessary to remove that portion of the cord that passes directly between the centrals. Dissecting out the cord either lingually or labially beyond this point is unnecessary. When the frenum has been removed, cauterize the wound with phenol; this acts as a disinfectant and also as a caustic; and, further, prevents any possible reuniting of the frenum. The mere cutting, or severance, of this cord, as with a lance, is perfectly useless ; the ends will reunite and its function be re-established as if nothing had been done. The bringing of the centrals together can be accomplished in several ways. Should the teeth be turned on their axes, as they often are, as well as separated, it is of course necessary to rotate them as they are drawn together. This can be done as follows: Place bands on both centrals and solder small spurs, or tubes, to the lingual sur- face of each band. Molar clamp bands are placed on the first or second molars, and an A, B or C arch, in accordance with the object to be obtained, adjusted. The centrals are rotated by ligating from the lingual spurs or tubes to the arch, as shown in Fig. 14. At the same time the teeth can be drawn together by ligating from tubes or spurs which have also been soldered to the labial surface. F'S- D. 22 ORTHODONTIA It is always best, in drawing teeth to- gether with liga- tures, to have some kind of attachment soldered to each band, designed for holding ligatures se- curely in place; otherwise, as the teeth move, the liga- tures may slip up- ward unde r the gums, or come off entirely. As a rule, centrals should al- ways be banded for this operation, and an arch should be used for control of the labio-lingual position of the centrals or other anterior teeth. The controlling liga- tures designed to pull the centrals together should be placed as high on the bands as possible ; so when force is exerted, the teeth will be moved in a perpendicular plane. Occasionally it is demanded that only one central be moved laterally, therefore anchorage must be secured in some other manner than by ligating to the opposite central. This anchorage can be secured very readily by employ- ing the C arch and molar clamp bands. With this arch the individual move- ment can be controlled, as resistance is taken from the standard which connects the upper and lower bars of the arch, as in Fig. 15. With this device centrals can be moved without tipping, or straightened into an up- right position if they have already been tipped. The cut shows clearly how this can be done. The upper ligature furnishes the power for moving the left central to the right. This ligature is hooked over the spur D and tied around the standard G. In order to control the perpendicular position of the tooth, if necessary, another ligature can be passed from spur C and tied around standard H. The same application can be made to the opposite central. We think that a moment's study of the ligatures over the pins C and 1) will show how the left central can be moved into an upright position. In other words, either one or both centrals can be moved directly toward each other by this method, each tooth being made to occupy its full mesio- distal position in the dental arch, closing the space. Sometimes separation occurs with more or less of protrusion. The treatment in such cases is Fig. 14. MALOCCLUSION 23 to retract the anterior teeth until the space or spaces are closed. This is very easy to accomplish by using the cable spring arch with its contractive feature. By simply turning the arch in the right direction, distal pressure is placed on the incisors which speedily closes the spaces between all anterior teeth. Fig. 14 shows the cable spring arch in position in conjunction with molar bands for this movement; notches are cut in the labial seam of the bands on the centrals for holding the arch in position. Occasionally cases Fig. 15. are found with separated centrals and no irregularity of other anterior teeth, nor does any protrusion exist. Therefore, there is no way of filling the space without causing separation between the laterals and centrals. If this type of malocclusion is confirmed, by which is meant the presence of all the other permanent teeth, nothing can be done, as there is no available material to use. Had separation such as this been corrected at the time of eruption of the incisors or before the eruption of the permanent cuspids, the space at that time could have been easily closed and thus a condition fore- stalled that later on cannot be corrected. 24 ORTHODONTIA Maleruption of the Permanent First Molars-The maleruption of the permanent first molars is by all odds the most serious irregularity that can occur in the eruption of the permanent teeth. The effect of their malposi- tion not only causes local disorder, but also affects the position of every tooth in the entire jaw. Nothing can be right if the first molars are not right Therefore, the very first point to note, when a case presents for considera- tion, is the position of the permanent first molars. If they are not in nor- mal mesio-distal relation to each other, irregularity must sooner or later develop, as surely as effect follows cause. This may be laid down as a general rule that WHEN THE FIRST MOLARS ARE NOT IN NORMAL MESIO-DISTAL RELATION, IT IS ALWAYS THE FIRST MOLAR THAT MUST BE MOVED DISTALLY, BY WHICH MOVEMENT PROPER RE- LATION IS ESTABLISHED WITH THE OPPOSITE MOLAR. Of all teeth in the human jaw, it is the lower first molars that most often erupt in their true positions; and if the remainder of the permanent teeth would erupt in occlusion with this base, facial deformity would scarcely exist, so far as caused by the teeth. Class Three, or protrusion of the lower jaw, would be the only facial defect. There will be apparent exceptions to this rule, due to the shape of the superior and inferior maxillary bones. They may be overdeveloped or underdeveloped, or not proportioned one to the other; or the teeth of one jaw may not be proportioned in size to the teeth of the other jaw. These are conditions of a special nature and do not affect the rule. Teeth depend on one another for mechanical support in taking position, and the deciduous teeth, especially the deciduous second molars and the cuspids, play a vital part in forming the regularity of the permanent dental arch. When the deciduous second molars and cuspids are in normal occlu- sion, and can be preserved intact until the permanent teeth destined to take their place erupt, there is little danger of these permanent teeth coming in irregular. If the upper and lower first permanent molars are in their normal relation to each other, the bicuspids, in nearly every instance, will erupt in normal occlusion, if their eruption is not too long delayed. The flat surfaces of the bicuspids do not permit of much torsion. The incisors are much more likely to be twisted than any of the buccal teeth. The shape of the anterior teeth in itself tends to irregularity; the roots are round and are, therefore, more easily turned by unfavorable forces than the roots of the molars and bicuspids; besides, the edges of the crowns are thin and rounded, allowing the teeth to slip by each other in response to pressure. The incisors, how- ever, often erupt irregularly even when room is present for their reception, showing the trouble to be inherited, or congenital. The incisors may erupt in all sorts of malpositions, either for lack of space or inherent reasons, while the form of malocclusion seen in the buccal teeth is usually mesial to normal. MALOCCLUSION 25 1 he deciduous sec- ond molars exercise a very vital influence over the erupting six-year molars. The deciduous molars must be in normal occlusion, or rest as- sured the permanent molars will not be in normal occlusion. Figs. 16 and 17 show a right and left view of the same case. The molars marked with a straight line are the deciduous second molars. On the left, the first bi- cuspid is making its appearance, while the right view shows the remnant of the broken down crown of the deciduous molar, and also, in the center, the buccal cusp of the erupting first bicuspid. Notice the close sympathy in occlusion between the permanent and deciduous molars on each side. The deciduous molars are mesial to normal, and as a natural result the permanent molars are also mesial to normal. The malposition of the upper first molars as they now stand will surely re- sult in protrusion of the upper teeth after the remainder of the permanent teeth have erupted, if the position of these mo- lars is not corrected in time. If the de- ciduous molars are in normal relation, but the distal sur- face of the second molar is shortened by caries, the perma- nent first molars will not erupt in proper relation to each other. There is a well known disposi- tion for posterior Fig. 16. Fig. 17. 26 ORTHODONTIA teeth to drift forward if a space exists in front of them. This is precisely what the erupting first molar will do if the contact point of the decid- uous molar is missing. Fig. 18 shows a case with the decidu- ous second molars in normal occlusion. Note how the distal aspect of the deciduous upper molar projects posteriorly. In this case the second deciduous molar is in normal occlusion and well preserved and is do- ing its full duty in guiding the six-year molar into normal oc- clusion. Should any of the de- ciduous molars in Fig. 18 have their mesio-distal diameter lessened through caries, it should be fully restored by suitable filling before the eruption of the six-year molars. This would insure their original shape and, therefore, the normal position of the permanent first molars. However, in the great majority of cases we do not see the patient at this early age, or before the eruption of the permanent first molars, therefore if the six-year molars erupt in malocclusion, the harm is done before we see them. Occasionally, however, a young patient appears at the dental office for fillings before the eruption of the six-year molars. The dentist can take advantage of this opportunity to observe the relation of the upper and lower deciduous molars. If the upper second deciduous molar is found, for example, to be mesial to the lower second molar, a molar clamp band or a plain band, with incline plane soldered to the distal surface of the band, can be adjusted to the upper second deciduous molar. (See Fig. 19.) The incline plane of this band will force distally the permanent first molar as it erupts and bring it into normal mesio-distal relation with the lower tooth. This principle can, of course, be used on the lower molars as well as on the upper. Notice the black crown in the radiograph, of the erupting six-year molar below. (Fig. 20.) The tooth is gliding upward along the distal root of the deciduous molar and will eventually take position in the dental arch accord- ing to the position of the deciduous molar. Should the second deciduous molar be in Class Two or Three, the first permanent molars, as we have stated before, will also be in the same class. It is easy to understand, for example, how one of the bands with in- clined plane placed on the lower deciduous molar would deflect distally the erupting first permanent molar. Had one of these bands with inclined planes been placed on the Fig. 18. Fig. 19. MALOCCLUSION 27 upper second de- ciduous molar as shown in Fig. 21 before the erup- tion of the six- year molar, the six-ye ar molar would have erupt- ed in normal oc- clusion with the lower molar in- stead of being me- sial to it. Plain molar clamp Lands with incline plane soldered to the distal surface can be used in place of the clamp band. The whitecrown of the permanent second molar be- low is also clearly shown in the ra- Fig. 20. diograph. As time goes on and the tooth erupts, it will be driven inexorably forward against the first molar. Thus it will be seen that the position of the second permanent molar is regulated by the first, and the first molar by the decidu- ous second molar. To say that a molar can retrude, or in other words acquire a position distal to normal, is not borne out by the facts. Molars never move backward but always for- ward in response to the forces that lengthen and broaden the maxillary bones during development. If permanent molars had the power of trav- eling distally as well as in the Fig. 21 28 ORTHODONTIA opposite direction, spaces would often be found between them, but as a mat- ter of fact the contact points of molars are invariably together, requiring separation before bands can be easily slipped between them. Again, it is very common to find the permanent second molars occupying the space of the first molar when this latter tooth for some reason has been extracted. That molars move for- ward but never backward in maloc- clusion is not merely a theory but is a conclusion based upon the examina- tion of hundreds of models from all sec- tions of the country sent to the author for advice, and is a scientific fact as well established as any other scientific fact in that it explains all known phenomena, and there are no real exceptions to this Figs. 22 and 23 show a case of marked protrusion of the upper jaw. Facial lines will not be corrected by moving the lower jaw forward, but by moving the upper jaw backward. To move the lower jaw forward into normal occlusion with the upper would result in bi- maxillary protru- sion. The lower mo- lars are now in their normal mesio-distal relation. We are aware that it is common prac- tice, in confirmed cases of malocclu- sion, such as shown in Figs. 22 and 23, to harmonize occlusion between the arches principally by mov- Fig. 22. rule that have come under the author's notice Fig. 23. MALOCCLUSION 29 ing forward the lower jaw. The movement is accomplished by the reciprocal action of Intermaxillary Anchorage. This anchorage will also broaden the anterior portion of the upper arch at the same time the lower teeth are carried forward, but does not move distally the upper molars. The upper arch cannot be moved distally as a whole by taking anchorage from the lower arch. The lower arch moves forward while the molars above remain practically stationary. In many cases fairly good results in facial lines are obtained by this method if the protrusion is not too marked, simply because any sort of harmony between the lips presents a better appearance than the original protrusion of the upper teeth. To establish balanced facial lines in this case the upper teeth must be moved backward the width of a bicuspid tooth or its equivalent (by which we mean the extraction of a bicuspid tooth) ; and not the lower teeth forward, which were normally posed. The paramount consideration in this case as in all others of a similar nature is, will the teeth STAY in their new positions after the retaining de- vice has been removed? Right here is where the real difficulty is likely to develop. Our experience and the experience of other men has shown us that in many cases where the en masse movement of the lower teeth has taken place, they will gradually assume their former relation to the teeth of the upper arch, or nearly so. It may take some time for the re- version to establish the old relation between the upper and lower arch but eventually it occurs, causing the upper teeth to protrude again. We have set forth the rule that the molars of either the upper or lower jaw, if they move from normal at all, will move inexorably forward and never backward. We expect this statement to be opposed by some, and especially those who have for years been moving the molars forward. However, we have made the statement after an examination of hundreds of models and feel confident that the rule is true and will sooner or later be so accepted in the minds of all reflecting men. Many patients with irregular anterior teeth appear for treatment between the ages of seven and ten, or just prior to the eruption of the bicuspids. An examination of the mouth reveals the fact that the anterior teeth are not only irregular, but that the first permanent molars are also in malocclusion, the disto-buccal cusp occupying the position intended for the mesio-buccal cusp. (See Figs. 16 and 17.) Merely to correct the position of the anterior teeth without moving the upper six-year molar distally into normal occlusion with the lowers would only temporarily improve conditions, as a protrusion of the upper teeth or its equivalent would occur when the remainder of the permanent teeth erupted. CHAPTER II Diagnosis and Classification The first permanent molars are selected as the points from which to determine the classification of any given case. They are the points of diagnosis. By correctly diagnosing the case and assigning it to its proper class, the treatment is automatically indicated in a general way. The six- year molars, on account of being the first permanent teeth to erupt, act as the basis of position on which all other teeth are aligned. If they are not right, nothing can be right. Solely through their position the mesio-distal relation of the dental arches is determined; and at once, upon their eruption. If they are not in normal relation none of the other teeth can possibly be in normal relation. The six-year molars are the largest and strongest teeth in the jaw, they also have the great advantage of erupting in an unobstructed field, by which is meant a field clear from the obstructions of deciduous teeth. Room, there- fore, is always present for their accommodation. When we consider that all the other permanent teeth along the buccal surface erupt after them, and take their mesio-distal position from the position of these six-year molars, it is easy to understand the dominating influence of these molars upon the mesio- distal position of the two dental arches. We have frequently observed dentists trying to obtain harmony of the arch when the six-year molars were not in their mesio-distal relations. No amount of buccal expansion can compensate when distal movement is needed. A traveler might as well try to arrive at a point east by going north. Since the position of the first molars, therefore, furnishes the diagnostic points for determining the relation of the two arches, or in other words, their classification ; if the points of the mesio- buccal cusps of the upper first molars, fall in the buccal grooves of the lower first molars (normal occlusion), the dental arches as a whole are in their normal mesio-distal relation, and the case is in class 1. Should these cusps and grooves not coincide as stated, the case belongs in class 2 or 3 according to the position of the first molars. When this occurs, the protruding upper or lower arch must be moved distally until the six-year molars are in correct occlusion with the first molars of the opposite jaw. Class 2 and 3 are always distinguished by protruding upper or lower teeth. Should these cases be confirmed, on account of the patient's age, and the movement of the arch in the desired direction be practically impossible, the equivalent of the move- ment must be obtained by extraction as shown in the chapter on extraction. It will be found when facial lines have been destroyed through protrusion that the first molars belonging to the protruding jaw are in mesial occlusion when compared to the corresponding molars of the opposite jaw. (Excep- tions, Types C and D, class 1.) When the first molars are not in correct mesio-distal relation, the abnormality is due to their forward position and 30 DIAGNOSIS AND CLASSIFICATION 31 never to a distal one. It is quite impossible for any of the first molars to move in a distal direction, when all the force of the erupting second and third molars is exerted toward the front for enlargement of the jaw. It is clear that molars cannot move distally when these strong forces are pushing the first molars in an opposite direction. The dentist is cautioned not to confound retrusion of the anterior teeth with retrusion of the entire arch. It will be found that if the arch suspected of retruding has each tooth placed in its proper position, and the curvatures of the arch as a whole are correct; facial lines, when the protrusion of the opposite jaw has been re- duced, will be correct, and that result is all that is necessary. There may be cases where, for instance, the upper arch on account of the size of the teeth is obviously entirely too small for the lower arch, or the lower for the upper, or either one or both of the dental arches may lack bone develop- ment, or there may be defects in the conformation of the bones in which the teeth are set, but these are anomalies and therefore do not conflict with the rule as laid down. Since teeth can assume nearly any position of malocclusion, their correction is greatly simplified by dividing into classes and the classes into types. Types of the same class can usually be treated by the same mechanical principle. Some writers who have classified maloc- clusion use the lower arch only in its re- lation to the upper for determining the class. The lower arch is simply moved backward or forward into occlu- sion with the upper teeth, regardless of the fact that the up- per teeth may be protruding and nothing whatever the matter with the lower arch. (See Fig. 24.) If cases of protruding upper teeth were actually corrected in accordance with this classification, the result would show bimaxillary protrusion, or protrusion of BOTH the jaws although the teeth were in normal occlusion. Obviously, the upper teeth in a case of this description should have been moved distally, and the lower teeth allowed to remain where they were. Classification based on the movement of the lower teeth only must always be incomplete and in the majority of cases of malocclusion entirely wrong. We think we are well within the limits in stat- ing there are probably forty cases of protruding upper incisors to one of lower Fig. 24, 32 ORTHODONTIA protrusion; in fact, the mesio-distal position of the lower first molars is nearly always correct, or as 1 to 40; therefore, in not one of these 40 cases should the lower teeth have been moved forward. Besides, when it is necessary to move the lower molars it is always distally and never forward. This point we have explained at length in other parts of this book. The first molars are always in sympathy with facial lines. Mesial occlusion of the upper first mo- lars when compared to the lower, means protrusion of the upper dental arch, and mesial occlusion of the lower molars to the upper is sure to cause pro- trusion of the lower teeth. In both cases the protrusion will be in propor- tion to the mesial advancement of the molars. Classification of Malocclusion Class 1. All first molars in normal mesio-distal rela- tion. Four types distinguished by the po- sition of the anterior teeth. Type A. Irregularities of the anterior teeth, due to overlapping, torsion, or constriction in the region of the bicuspids. Type B. Retruding upper anterior teeth. Type C. Protruding upper anterior teeth. Type D. Bimaxillary protrusion, or protrusion of both upper and lower anterior teeth. Class 2. Upper first molars mesial to normal in rela- tion to the lower first molars. Protruding- upper incisors. Type A. Mesial on both sides. Type B. Mesial on one side, normal on opposite side. Class 3. Lower first molars mesial to normal in re- lation to upper first molars. Protruding- lower incisors. Type A. Mesial on both sides. Type B. Mesial on one side, normal on opposite side. Fig. 25. CHART of CLASSIFICATION LINE OF DIAGNOSIS LINE OF DIAGNOSIS CLASS - 1 CLASS - 2 A CLASS-2 B CLASS -3 A CLASS -3 B Fig. 25. DIAGNOSIS AND CLASSIFICATION 35 All First Molars in Normal Mesio-Distal Relations CLASS ONE Type A Description Permanent first molars in normal mesio-distal r e 1 a- tions on both sides, with more or less ir- regularity of the an- terior teeth, and of- ten constriction in region of bicuspids. Facial lines very good but will be im- proved with move- ment of irregular teeth into normal position. (See Figs. 26 and 27.) Fig. 26. Treatment Expansion of ei- ther one or both arches, usually in the bicuspid and in- cisor region. Ex- traction of teeth, or mesio-distal move- ment of first molar not indicated. Fig. 27. 36 ORTHODONTIA CLASS ONE All First Molars in Normal Mesio-Distal Relation Type B Description Permanent first molars in normal mesio-distal relation on both sides, with facial lines destroyed by the retrusion of upper anterior teeth. (See Fig. 28.) Treatment Labial movement of upper incisors over the lowers with necessary movement of other irregular teeth, to establish normal occlusion. Ex- traction of teeth, or mesio-distal movement of the molars not indi- cated. Fig. 28. DIAGNOSIS AND CLASSIFICATION 37 CLASS ONE All First Molars in Normal Mesio-Distal Relation Type C Description Permanent first molars in normal mesio-distal relation on both sides, with remainder of buccal teeth usually in normal mesio-distal rela- tion. Usually no constriction of arch in bicuspid region but marked protrusion of upper anterior teeth. (See Fig. 29.) Treatment Extraction of upper right and left first bicuspids. Movement of six an- terior teeth distally to close the space caused by extraction. Distal movement of the permanent first molars not indicated. Fig. 29. 38 ORTHODONTIA CLASS ONE All First Molars in Normal Mesio-Distal Relation Type D Description Permanent first molars in normal mesio-distal relation. Remainder of the buccal teeth usually in normal mesio-distal relation. May be con- striction of arches above or below in region of bicuspids. Facial lines destroyed by the protrusion of the upper and lower anterior teeth ; in other words, bixamillary protrusion. (See Fig. 30.) Treatment Extraction of upper and lower right and left first bicuspids. Distal movement of upper and lower six anterior teeth until space caused by extraction is closed. Distal move- ment of the permanent first molars not indicated. Fig. 30. DIAGNOSIS AND CLASSIFICATION 39 CLASS TWO-TYPE A Confirmed Malocclusion DESCRIPTION Upper Arch Upper first molars mesial to lower first molars on both sides, resulting in protrusion of the upper anterior teeth. Upper arch may also be constricted with more or less ir- regularity of individual teeth. Lower Arch Lower first molars in normal mesio-distal position. Lower arch may have retrusion of the anterior teeth and also constriction of the lateral halves. How- ever, the lower arch is usually normal in the arrangement of teeth. (See Figs. 31 and 32.) Fig. 31. TREATMENT Upper Arch Extraction of upper right and left first bi- cuspids. Retraction of upper anterior teeth until space caused by extraction is closed. Expansion of the upper arch, if indicated, and also the aligning of ir- regular teeth, if pres- ent. Correction of con- firmed cases in any way other than by ex- traction not recom- mended. Lower Arch Expansion of the lower arch, if indi- cated; and also the aligning of irregular teeth, if present. Fig. 32. 40 ORTHODONTIA CLASS TWO-TYPE B Confirmed Malocclusion DESCRIPTION Upper Arch Upper first molar mesial to lower first molar o n one side, while the upper first molar on the opposite side is in normal mesio- distal relation with the lower first molar, re- sulting in more or less protrusion of the up- per incisors. Constriction of upper arch may be present with some irregularity of teeth. Lower Arch Lower first molars in normal mesio-distal position. Lower an- terior teeth may re- trude and also the lat- eral halves be con- stricted with more or less irregularity of teeth. However, the teeth in the lower arch usually normal. (See Figs. 33 and 34.) Fig. 33. TREATMENT Upper Arch Extraction of upper first bicuspid on af- fected side. Retraction of the upper anterior teeth until the space caused by extraction is closed. Expansion of the up- per arch, if indicated ; and also the correction of irregular teeth, if present. Lower Arch The expansion of lower arch, if indi- cated; and also the correction of irregular teeth, if present. Low- er arch usually normal in the arrangement of teeth. Correction of confirmed cases in any other way than by extraction not recommended. Fig. 34. DIAGNOSIS AND CLASSIFICATION 41 CLASS THREE-TYPE A Confirmed Malocclusion DESCRIPTION Lower Arch Lower first molars mesial to upper first molars on both sides, causing pro- trusion of the lower incisors. Lower in- cisors may have an end-to-end bite with upper incisors, or occlude labially to the upper incisors. Upper Arch Upper first molars in normal mesio- distal position. Upper arch is usually constricted throughout its entire length owing to lingual occlusion with the lower arch. (See Figs. 35 and 36.) Fig. 35. TREATMENT Lower Arch Extraction of lower right and left first bicuspids. Retraction of lower anterior teeth until the space caused by extrac- tion is closed. Expansion of lower arch if indicated, and also the correction of irregular teeth, if present. Upper Arch Expansion of the whole upper arch is usually indicated. Correction of irregu- lar teeth should they be present. Cor- rection of confirmed cases in any other way than by extraction not recom- mended. Fig. 36. 42 ORTHODONTIA CLASS THREE-TYPE B Confirmed Malocclusion DESCRIPTION Lower Arch Lower first molar mesial to upper first molar on one side, while the lower first molar of the opposite side is in normal mesio-distal relation with the upper first molar, causing more or less protrusion of the lower incisors. Lower incisors usually have an end-to-end bite with the upper incisors on the affected side, but may bite labially to the upper. Upper Arch Upper first molars in normal mesio-distal position. Upper arch is usually constricted on the affected side owing to lingual occlu- sion with the lower arch. (See Figs. 37 and 38.) Fig. 37. TREATMENT Lower Arch Extraction of lower bicuspid on the af- fected side. Retraction of the lower an- terior teeth until the space caused by ex- traction is closed. Expansion of lower arch, if indicated; and also the correction of irregular teeth, if present. Upper Arch Expansion of the upper arch either on one or both sides, if indicated. Correction of irregular teeth, if present. Correction of confirmed cases in any other way than by extraction not recommended. Fig. 38. CHAPTER III The Author's Regulating Appliances The appliances that follow are manufactured in either gold or nickel silver. Gold Appliances Since the dentist is familiar with the properties of gold, it is unnecessary to say anything further on the point, except that the gold used in these appli- ances is from a special formula in order to secure the best temper and strength according to the use for which it is intended. Nickel Silver Nickel silver is an alloy that has all the qualities that are necessary for the regulating appliance. It is true that in some mouths it will tarnish. This, however, can be overcome by occasional cleaning with a brush and pumice. Indeed gold in the form of a regulating appliance, when used in the mouth, must also occasionally be cleaned to remove a certain amount of discolora- tion that in the course of time settles upon it, owing to the fact that most patients do not use a tooth brush sufficiently to keep the gold in a state of brightness. No matter whether the appliance is formed of gold or nickel silver, to be kept bright, it will need the attention of the dentist. Nickel silver is a high fusing metal ; and, like gold, it can be procured either hard or soft in temper, and can be soldered as easily as gold. It is also malleable and ductile and can be rolled into very thin strips or drawn into small wire. So far as strength is concerned, it is far superior to any alloy of gold. The .002, or 40 gauge, band material has all the strength necessary for forming plain bands around the anterior teeth. Thickness, of course, is a disadvantage when passing between the teeth. These thin bands are also quite stiff when formed and can be driven upon the teeth, with ordinary care, without disfiguring the band. Nickel silver is also a slow conductor of heat, therefore much of the soldering in the way of spurs, etc., can be done by holding the wire in the fingers when making an attachment, then cutting off the superfluous ends. The only superiority that gold possesses over nickel silver is the fact that it is subject to less discoloration in the mouth. 43 44 ORTHODONTIA Cable-Spring Arch "A" Fig. 39. Actual Size. Cable-Spring Arch A-non-oxidizable, with a non-oxidizable wire stiffener. Fig. 39 shows cable-spring arch "A" before being curved around the teeth. The arch is long enough to reach to the second molars, should the molar clamp bands be placed on these teeth. The entire arch is non-oxidizable, the nut in the median line being solid 18 carat gold, and the spring portion 22 carat rolled plate, which is a guard against discoloration, and is equivalent to solid gold wire. An alloy has been used for the core of the wire from which the arch is made, because more resiliency and toughness is secured by the special alloy than any carat of gold can give. Extending through each end of the arch, as shown in the cut, is a small wire from the same material as composes the arch. This wire fits closely the interior of the arch, and adds greatly to the spring and strength of the arch when in the mouth. The stiffener is removable, and can, therefore, be taken out at any time and straightened, if necessary, or a new one inserted. This, however, is rarely necessary. Fig. 40 shows the cable-spring arch "A" and molar clamp bands (en- larged). The arch and bands are in the right position for placing on the lower teeth. The constricted, or smaller, opening of the bands "S" always goes toward the gingival, whether the bands are used above or below. The bolts are threaded externally to engage threaded collars soldered to the band for the purpose of clamping the band to the tooth, and are also threaded for a short distance within the tube of the bolt, with right and left threads as shown in E and D, for engaging the right and left halves of the arch, A and B. B represents the right wind and A the left wind, co-operating with E, the right threads, and D, the left threads. It will be seen by this that all left threads are on the left side, and the right threads on the right cide. With this arrangement the arch is turned upward for contraction, or exerting distal pressure against the incisors; and downward for enlargement, or expansion anteriorly. AUTHOR'S REGULATING APPLIANCES 45 Should the bands and arch, as shown in Fig. 40, be employed above ; the right band should be placed on the upper left molar, and the left band on the right molar. This will bring the constricted portion of the band S toward the gingival; and by changing the bolts in the bands, all left threads will be on the left side and the right threads on the right side, consequently the arch would still be turned upward for contraction and downward for ex- pansion. If the dentist is using several of the cable-spring arches at the Fig. 40. Cable-Spring Arch A Enlarged. same time, by having them all turn one way to shorten and in the opposite direction to lengthen, confusion is eliminated when it becomes necessary to turn the arch. If he wishes to contract the arch either above or below, he knows it is turned upward; if he wishes to expand, it is turned downward. If the bands and arch shown in Fig. 40 were used above, placing the right band on the upper left molar and the left band on the upper right molar, without changing the bolts, the right threads of the arch would be on the left side ; therefore, the arch would be turned upward for expansion and downward for contraction, or in the opposite direction than if the right 46 ORTHODONTIA and left threads were on their respective sides. The arch would, of course, work just as well, but it is desirable to turn the arch always in the same direc- tion for the same movement, as it avoids confusion. "F" Fig. 40 shows the connecting collar joining the right and left halves of the arch, and "C" is the square which engages the wrench "G". This collar does not turn upon the arch, but is tightly swaged to the two halves of the arch ; consequently when the nut is turned, both sides of the arch are turned at the same time, which screws the arch forward or backward through the bolts of the molar clamp bands "E" and "D". Since the spiral spring turns on its own axis, it can be turned while in a curve, or surrounding the teeth, as shown in Fig. 40, as easily as when in a straight length. If the arch were a solid wire, adjustment could not be made from the center, as it could not be turned on its own axis. Application of the Cable-Spring Arch "A" for the Correction of Malocclusion The Cable-Spring Arch is indicated for the correction of malocclusion in Class One ; or, in other words, where all the permanent first molars are in normal relation. The arch is also indicated for the closing of spaces between the anterior teeth, by exerting a retractive force, and in the movement of the anterior teeth distally to close the spaces caused by extraction of the first bicuspid, as in reducing cases of protrusion. This arch is not intended for expansion in the region of the molars, the lateral spring not being active enough for this purpose. We do not wish to be understood by this that the arch has no s.pring in the region of the molars ; only here, expansion can be accomplished more quickly by the solid wire arch. For correcting a case of malocclusion where buccal movement of the molars is desired, and also alignment of the anterior teeth, the stiff arch B and the Cable-Spring Arch A can frequently be used in conjunction to great advantage by exchanging them during the process of tooth movement. As stated elsewhere in this book, the molar clamp bands are interchangeable with any of the arches, therefore one arch can be substituted for another without removing the molar clamp-bands from the teeth. With this convenience, arches may be exchanged several times during the treatment of a case, and the arch best suited for the movement in hand be kept constantly employed. It is quite impossible to expect one mechanical principle to solve all the problems pre- sented by irregular teeth in the same arch, but by employing several prin- ciples when necessary much quicker progress is made; and when these changes can be so quickly accomplished it is, of course, to the interest of all to make them. It hastens the completion of the case. Fig. 41 shows an enlarged view of a very irregular set of teeth. This case belongs to Class One, therefore the molars are not to be moved. For the correction of this case, and others more or less like it, the Spiral Spring Arch is superior to any form of stiff or solid arch. The object here is to move outwardly to their proper positions all of the teeth anterior to the AUTHOR'S REGULATING APPLIANCES 47 first molars. Grass-line or rubber ligatures are used in connection with the Cable-Spring Arch. With grass-line or rubber the spiral arch cannot be abused, as force placed on the arch with a knot cannot be drawn tight enough to do the arch any harm. With this arch a ligature only needs to be tight enough to spring the arch a little in the direction of the tooth to be moved. Notice the arch ("B", Fig. 104). The grass-line ligature at this point has Fig. 41 48 ORTHODONTIA sprung the arch only a little lingually, which is all that is necessary. Wire ligature No. 30 could, of course, be employed at "B", Fig. 104, to exert about the same tension as shown with the grass-line without doing any harm to the arch ; but if a wire ligature were used and turned with a pair of pliers until the arch touched the lateral, a kink, or sharp bend, would be placed in the arch, and its elasticity at this point destroyed. In other words, the spiral arch can be abused with wire, but not with grass-line or rubber. Notice how the four incisors in Fig. 41 are ligated. The centrals and laterals marked "B" are to be rotated to the left and at the same time car- ried in a labial direction. The central marked "C" is rotated to the right, and the lateral "D" moved straight forward. When the knots in the grass- line ligatures are pulled tight, the arch is sprung lingually, as shown by the dotted outline, and with its tendency to assume its original position con- stant tension is kept on the ligatures. Spurs could be used on the lingual surfaces of these four incisor bands instead of tubes. The bicuspids show double, or staple, spurs soldered to the lingual surface of these bands through which the ligatures pass. Experience has shown that it is nearly always necessary to band bicuspids with spurs on the lingual surface to prevent ligatures from working under the gums. There is often a strong tempta- tion to ligate bicuspids, especially long ones, without banding, but in the end it will usually be found that bands, for the reason stated, would have been best. The ready-made plain gold bands, as shown in Fig. 58, are notched, and this notch can be turned lingually in place of the tube, if the operator prefers the notch. When the incisors in torsion are sufficiently rotated, the direction of force can be changed at any time to exercise a straight forward pull, as shown in the lateral "D". Little or no turning of the arch, either forward or backward, is required in the regulation of this case. The circle of the arch where it now stands is sufficiently large to admit the aligning of the anterior teeth. Being sprung with ligatures toward the teeth does not in the least diminish the size of the original circle. In using the spring arch for expanding or broadening the circle an- teriorly, care must be exercised that the arch is not tight around the teeth, and is therefore in reality constricting, when it is the desire to create more room. It is manifestly impossible to expand with a contracting force. The arch when in position for ligatures, as shown in Fig. 41, must not exercise any distal force at all. The arch should pass around the anterior teeth without exerting tension, either in a lingual or labial direction; or, in other words, it should pass around the teeth in a neutral manner. As stated before, it is the reaction of the arch when sprung toward the mal- posed teeth with ligatures that furnishes the necessary force for tooth movement. It may be necessary at some time during the •movement to shorten or lengthen slightly the arch by turning with a wrench at the median line. This, of course, must depend on the judgment of the operator. AUTHOR'S REGULATING APPLIANCES 49 Fig. 42. Fig. 42 shows a labial view of the same model with the arch ligated to the teeth. The two bands encircling the central incisors have a notch cut in the seam of the bands. These notches hold the arch nicely in place and are, therefore, important. Notches on the lateral bands for this pur- pose are unnecessary. The caps on the cuspids have several points on the labial surface. Any of these points can be bent slightly outward, and the arch passed above or below them, either for holding the arch in position in this region or to have the arch exercise a downward or upward pressure. All these caps and plain bands are cemented to the teeth. It is seldom necessary to band a tooth merely for the purpose of gain- ing a notch. Nearly always one or more of the anterior teeth require plain bands, and these bands can supply the notch. Many of the simpler cases arise where bands on any of the incisors or cuspids are unnecessary, the malposed teeth being in such a position that the grass-line holds it in the desired position on the teeth without bands. In these cases the arch is satisfactorily held in its labial position after the ligatures are tied around it. If an arch has a tendency to work toward the gums, between visits of the patient, place one or two notched bands on the teeth. It is not neces- sary to remove the arch for this purpose, as it can always be lifted out of the road of adjustment of a band, and then lifted into the notches. Under the head of "Ligatures" it is pointed out that grass-line in the ORTHODONTIA 50 course of time will discolor a 22-K gold arch where it comes in contact with it. This discoloration, however, does not penetrate the metal, and can be instantly removed by pumice and engine brush at necessary intervals with- out removing the ligature or arch. The cable-spring arch when placed on the teeth according to directions is turned upward for making smaller, and downward for increasing the size, whether it is employed on the upper or lower teeth. Since Figs. 41 and 42 present both a labial and occlusal view of the same case and show bands on all the incisors and bicuspids, and the manner in which ligatures are applied to produce the various movements, it may be considered as the Master Case. The adjustment of the Cable-Spring Arch to other cases in Class One should be conducted according to the principle and technic shown in this case of malocclusion. Some combina- tion of these parts will be found competent when applied to any case where the first molars are in normal relation to each other. Expansion Arch "B" Fig. 43 shows the flat expansion arch B. This arch, on account of being flat, is very springy, and is much more easily sprung toward the tooth with ligatures than a round arch. Often arches in use re- quire reshaping from time to time, to meet the changing condition of the circle as described by the teeth. It will be found that these flat arches can be rebent satisfactorily with the fingers alone to meet all necessary changes, and as easily shaped in the region of the hooks as in any other part of the flat surface. The "B" arch is provided with intermaxillary hooks "A". These hooks are flush with both the inner and anterior surfaces of the bar, and are never in the way, whether or not they are in use. All nuts used on the stiff arches are friction-nuts, as in "C". One end of the nut is slit to a depth of one-third of its length, and the two halves pressed together with pliers, before running on the bar. The split ends, when run upon the arch, are forced apart and exert a constant tension on the threads of the arch. The split friction-nut when thus adapted will stay wherever placed. Progress cannot be made in regulating a case of mal- occlusion, if the action of the cheeks or other forces can turn the nuts on the bar. The molar clamp bands are interchangeable with all arches. One arch can be substituted for another without removing the bands from the teeth. This is a great convenience. Fig. 43. AUTHOR'S REGULATING APPLIANCES 51 Double Bar Expansion Arch "C" Two sizes of the double expansion arch are made; the larger one for the upper teeth is designated "C"-a (Fig. 44), while the one for the lower teeth, which is somewhat smaller, is known as "C"-b (Fig. 45). In some cases where the incisors are short, the smaller arch should be used above. This is a matter that must be determined by the dentist. However, in most cases the larger arch is used above and the smaller one below. Fig. 47 shows a front view, and Fig. 46 a side view of the double ex- pansion arch in position, and also the spring attachment for the elongation of cuspid teeth. "C", Fig. 44, shows the split frictional nut. These nuts are employed on all the solid stiff arches. With this arch the roots of the incisors can not only be easily tipped forward into a perpendicular plane, but can be moved forward en masse in an upright position by turning the power nut "L", Fig. 46, back against the bolt of the molar clamp band. When the arch is adjusted, the lower bar "B" comes in contact with the incisal edges, while the upper bar "A" stands away from the gingival as shown in the cross-section. Fig. 48. With the arch in position the upper bar is sprung lingually by twist- ing No. 26 ligature wire around it. The ligature wires should go under the free margins of the gums on the lingual surface or around the necks of the incisors. This prevents the wire from working down the lingual incline of the tooth and becoming loose. The upper bar being ligated, as shown in "C", Fig. 47, the apex of the root is tipped forward and the reaction is on the lower bar, which holds the lower por- tion of the tooth from advancing. It is easy to understand that if the upper bar, as shown in the cross-section, Fig. 48, is sprung Fig. 44. Arch "C"-a. Fig. 45. Arch "C"-b. Fig. 46. 52 ORTHODONTIA towards the teeth, and the resistance is on the incisal edges, the end of the root must be tipped forward. After teeth are tipped in a perpendicular plane, they can be carried forward in an upright position by turning the nut "L" against the anchorage "N", Fig. 46. Greater tipping movement in the arch can be secured at any time by grasping the arch with a pair of pliers at the junction of the cross standard "E" and the up- per bar "A", Fig. 44, and bend- ing the lower bar "B" in a lingual direction. This, of course, must be done with the arch out of the mouth. The slot in the nut "C", Fig. 44, prevents the nut from turning by the action of the cheeks, lips, etc. With the spring attachment, cuspids can be elongated simultaneously with the aligning of the incisors. The device for this purpose is shown in Fig. ±7, "D". This spring slips over the intermaxillary hook "E", Fig. 4d, and the end of the hook is then bent at a right angle, "F", Fig. 47. This bend pre- vents the spring from slipping off. The spring can be adjusted to the hook while the arch is in the mouth, but it is more convenient to do this before placing on the teeth. The springs are made right and left, and the enlarged cut, Fig. 47, shows exactly how they are placed on the hook. The cuspid elongating springs "D", Fig. 47, can also be attached to the intermaxillary hooks by simply ligating the short end of the spring, with No. 30 ligature wire, to the upright standard "E". The idea is clearly shown in* Fig. 49. This really holds the spring in place better than bending the hooks, and is easier to adjust. Fig. 47. Fig. 48. Fig. 49. AUTHOR'S REGULATING APPLIANCES 53 Fig. 50. Fig. 51. Fig. 50 shows another form of the double expansion Arch C known as "C"-d. This arch can be cut with an ordinary pair of cutting pliers (see Fig. 88) as shown in Fig. 51, and one or more of the lower sections bent lingually for operation against a single tooth as shown in "B", Fig. 51, where it works exactly like Arch "C"-a as already described. Note the recession "C" for the accommodation of the frenum labium. In order to secure anchorage to the partly erupted cuspid, a gold cap is cemented to the tooth (Fig. 52). Some cuspids are very pointed, and in such cases the end of the tooth can project through the hole in the cap, as shown in Fig. 52, "K". This gives the cap additional anchorage to the tooth. These cus- pid caps are made in three sizes - small, medium and large. The tooth must first be cleaned before cementing a cap, and the cement allowed to harden free from moisture. When the cement is hard, one of the points "J" is bent outward, and the long lever of the spring "G" lifted over the point. The point can be bent back over the lever, which practically places the lever in a tube. This spring will elongate a cuspid quickly without further attention. The hooks "G", Fig. 50, can be used for intermaxillary rubbers and for the springs at the same time without one interfering with the other. Fig. 52. 54 ORTHODONTIA Adjustment of Molar Clamp-Bands The molar clamp-bands are made in two styles, S and T, with three sizes, small, medium and large, in each style. (Fig. 53 shows Style S enlarged.) Each size is also made upper right and upper left, and lower right and lower left. It will be noticed that the band Style S, Fig. 54, is slightly funnel-shaped; that is, one opening of the band is smaller than the other. The smaller open- ing of the band, whether used above or below, right or left, always goes toward the gingival. Since the smaller opening of the band necessarily passes over the tooth first, the band must be opened widely for this purpose. The bands which go on the right side either above or below have the interior of the bolts threaded right, Fig. 40; while those which go on the left have the interior threaded left. Fig. 54 shows a molar clamp band for upper right. The edge of the band marked S goes toward the gingival. With this arrangement, the right threads of the Cable-Spring Arch A are always on the right side, whether above or below, while the left threads of the arch are, of course, on the left side. In other words, all left threads, whether in the bands or arch, go on the left side, while the right threads are on the right side. With the bands placed as described, the arch is turned upward, either above or below, for shortening, or contraction, and downward for lengthening, or expansion. Right and left threads may be distinguished by turning the arch into the bolts. Fig. 55 shows style "T" molar clamp-band. This band is not funnel-shaped, but is, as the cut shows, a straight band, the occlusal edges of which have three spear-shaped points that are bent over the occlusal surfaces after the band has been tightened around the tooth. These points do not interfere with occlusion, and prevent the band from slipping toward the gingival. This style "T" band is also made in rights and lefts upper and lower in three sizes, the same directions for adjustment applying as in band "S". As a rule dentists do not give the necessary attention to the adjustment of the molar clamp-bands. These bands must be placed on the teeth in the right position as shown in Fig. 56. The bolt must be parallel with the buccal surface. Fig. 57 shows the position of a band before tightening the bolt. As the screw is applied, the square end of the bolt will swing toward the cheek and be on a line with the buccal surfaces of the teeth when the band is finally tightened, as shown in Fig. 56. If the anterior end of the bolt points diagonally toward the cheek, the position is wrong; and consequently none of the arches can readily pass through the bolt, simply because the delivery end of the bolt is not on the same line as the arch. Fig. 53. Enlarged Fig. 54 Fig. 55. AUTHOR'S REGULATING APPLIANCES 55 Notwithstanding the fact that the molar bands are made in three sizes, occasionally a tooth will be found that requires a band between the two sizes. Should such a condition occur, unsolder the unthreaded collar and cut off the required length from the end of the band, resoldering the tube in place. The distal end of the tube must be inclined upward from the band so the bolt and tube will align when the band is circled around the tooth. The right pitch of the tube to be resoldered can be seen by observing the collar on the opposite end of the band. The tube can be held when soldering, by pliers or a piece of wire of the right size slipped through the tube. Nickel silver from which the bands are made is a high fusing alloy and any karat of solder can be used without danger of melting the end of the band. Another way of making a molar clamp-band smaller is to cut the band in the center, fuse a small piece of solder on one of the ends, then overlap the ends the desired distance and fuse together, as shown in A and B, Fig. 70. Fig. 56. Fig. 57. Fig. 56 shows a molar clamp-band adjusted to the tooth with about one- sixteenth of an inch between the ends of the band after it is tightened. It is 56 ORTHODONTIA obvious that if the band is a trifle large, the two collars will be drawn to- gether during the process of tightening and a loose band result. A molar clamp-band should be tightened a little at each visit of the patient until the operator is assured all stretch has been removed, and the band is tight. If the band is cemented to the tooth, the cement should be allowed to harden under dry conditions ; if it becomes incorporated with the saliva, the cement in a short time will decompose and afford a first-class medium for the recep- tion of bacteria, and consequent marking or decay of the tooth will result. If the band is not cemented, it can be removed about once a month and the tooth cleaned. This cleaning can be done on some occasion when it has been necessary to remove all the ligatures ; at that time the arch can be removed, the molar clamp-bands loosened and slipped off and the tooth cleaned. In- deed, the arch and ligatures should be removed every four or five weeks and all the teeth and appliances cleaned. If the removed parts are boiled for a moment in equal parts of hydrochloric acid and water, and then polished by pumice and engine brush, the metal will be restored to original brightness. So far as our experience goes we have never seen a marked molar when this method has been pursued, something that we cannot say of the cemented molar band. Interchangeability of Arches and Molar Clamp-Bands In this system, any of the arches can be used equally well on the same molar clamp-band. The cable-spring arch "A" screws into the band, while the stiff arches slip through the bolt of the band without engaging the threads in the bolt. This is due to the fact that the threaded portion of the stiff arches is smaller in diameter than the spiral spring arch. With this interchangeability the spiral spring arch can be unscrewed from the molar bands while in the mouth, and any of the stiff arches substituted without changing the molar clamp-bands. This is very convenient, as it frequently happens that one arch must be substituted for another in order to get quickly the desired tooth movement. AUTHOR'S REGULATING APPLIANCES 57 Ready-Made Anterior and Bicuspid Plain Bands These bands are made of 22-K gold, and also from nickel silver, and are so shaped that they fit accurately any of the bicuspid or anterior teeth, either upper or lower. With the twelve sizes (see Fig. 58), an accurate fit can always be secured to any of the anterior or bicuspid teeth. They are a great time-saver and convenience, allowing the dentist to band any number of teeth at a sitting, provided the separa- tion of the teeth has been previously secured. Each band has a small tube on the lingual surface of the gingival border, through which ligature may be passed, or hooked over, as shown in "B", Fig. 67. Either the wire, rubber, or grass-line ligature can be passed through the tube, or hooked over the tube, as shown in "B", Fig. 67. The labial surface of these bands has a notch cut in the seam for the purpose of supporting the arch should it be necessary. Should the notch not be required, or in the road, it can be ground off quickly with a stone. These bands will fit as well if the tube is placed on the labial surface in place of the lingual. The edge of the band on which the tube is soldered al- ways goes toward the gingival, either above or below. They are made from metal .003 thick and 5/32 wide. The writer in his practice uses them exclu- sively. It is only occasionally that a band will have to be made to fit some malformed tooth. It is quite impossible to measure teeth and expect to pick out one of these bands to fit the measure. It would be largely an accident if it should fit. In order to insure a good fit the band must be tried on the tooth itself, and for this reason an assortment is necessary. Fig. 59 shows a numbered steel mandrel on which these bands are made. This mandrel is very convenient for determining the size of the bands, for the re-forming of bands that have become bent, and for the truing up and salvage of bands that have been used on the teeth. Fig. 58. Fig. 59. Actual size. 58 ORTHODONTIA Band Material Band material for the purpose of forming plain bands around the teeth is shown in three sizes (Fig. 60)-light .002, medium .003, and heavy .004. This material is made from a special formula of nickel-silver, and also 22 karat gold. It is 5/32 inch in width and 24 inches long. The light and medium are most com- monly used, and especial- ly the light, as it passes readily between the teeth and does not require as much separation as the other sizes. The heavy material is used to band the molars, being entirely too heavy and thick for anterior teeth. The dentist will find it convenient to have the three sizes. Nickel-silver has a high fusing point, therefore, any grade of silver or gold solder can be used in joining bands without danger of melting the material. The technic for making plain bands from this material is given under the head of "Making Plain Bands." Fig. 60. Wrenches Fig. 61. Fig. 61 shows a double-end wrench for turning the bolts on molar or bicuspid bands, and also the nut in the median line of the Cable-Spring Arch "A". Fig. 62. The single end wrench (Fig. 62) is used for turning the nuts on the arches C-a, C-b, and B. Fig. 63 illustrates a wrench on the principle of a watch key, which is convenient in turning quickly the nut of the molar clamp-band and bicuspid clamp-band when the arch is not through the bolt of the band. Fig. 63. AUTHOR'S REGULATING APPLIANCES 59 Three kinds of ligatures are used for the movement of teeth ; namely, wire, grass-line and rubber. Each one of these ligatures has its special held of usefulness. The function of the ligature is the conveyance of power from the tooth to the anchorage or arch, precisely as a belt conveys power between the motor and lathe. The machines can only be effective accordingly as the belt co-ordinates their functions. A ligature that is constantly slipping from a tooth or becoming deranged cannot be effective. For a ligature to give results it must exercise practically constant tension and in the right direction, and also be found in place at each visit of the patient. That ligatures should function in an effective manner is of such importance in the movement of teeth that the operator should have this point in view in the beginning when the appliance is assembled within the mouth. Ligatures Wire Ligature The wire ligature is in two sizes, Nos. 26 and 30 (Fig. 64). 1 hese two sizes are sufficient for ligatures to move the teeth or for use in separating the teeth for bands. Brass, dead soft, really makes the best metal ligature. It contours readily to spurs and can be twisted around the arch for exercising force, without breaking. The wire can also be further short- ened by retwisting at a sub- sequent visit of the patient. This is an advantage that no other ligature possesses. Brass in the form of a liga- ture is quite free from discoloration while in the mouth, usually assuming a bright, clean appearance; nevertheless, a wire composed of any metal must not be left too long undisturbed in contact with the tooth, as it may mark the enamel. The tooth must be cleaned every week or so with a bristle-brush and pumice, under the wire, to prevent marking the tooth. It is unnecessary to remove the wires for this cleaning. Ligature wire is not used with the Cable-Spring Arch A, but only on the solid wire arches B and C. Rubber and grass-line ligature are indicated for the Cable-Spring Arch A. One method of twisting ligature is shown on the upper arch G and the lower arch H, Fig. 65. When the ligature wire is in position for twisting around the arch it is first given two or three loose turns with the hand, and the long ends cut off within one-quarter of an inch of the arch ; in order to give the desired trac- tion on the tooth, the wire is then twisted with a pair of ordinary pliers as shown in Fig. 78, or with the special twisting pliers as shown in Fig. 84. These special twisting pliers are much better for this work than the ordinary pliers because they hold the wire in the center of the beaks without slip- Fig. 64. Showing Short Section of Ligature Wire 60 ORTHODONTIA ping, and therefore the wire is always true with the center, which produces a smooth even twist. When sufficient tension has been placed upon the tooth by twisting the ligature, the wire is again cut off, leaving an end one- eighth of an inch long, that is bent under the arch so as not to scratch or irritate the patient's lips or cheeks. In twisting ligature wire there is one special point to remember, THE WIRE SHOULD ALWAYS BE TURNED TOWARD THE RIGHT, therefore the operator knows at once, when there is occasion to loosen or retwist the wire, in what direction to turn it for the desired purpose. Fig. 65. Another method of twisting the ligature around the arch is to hold the strands of the wire in the two hands for this purpose. The wire should be about nine inches long, the twist is made by pulling the wire to exert tension on the tooth and giving one full turn of the wire around the arch. The wire is then cut off, leaving one-eighth of an inch of strands ; and one of the strands is bent under the arch and the other over the arch. By this method the ligature is not loosened by the process of bending, which occurs to some extent in the first method. AUTHOR'S REGULATING APPLIANCES 61 This ligature can be secured in three sizes, light, medium and heavy. The medium is the best size, although occasions where one of the other sizes can be used to better advantage occur frequently. A dentist engaged in the regulation of teeth should have three kinds of ligature and each size of the three kinds, as there is no way of knowing in advance which size or material will answer the purpose best. One of the advantages of grass-line as a ligature is its shrinking properties when sub- jected to moisture or the saliva of the mouth. By this shortening tendency, a steady trac- tion is kept on the tooth. Another advantage possessed by the grass-line is that it can be used without bands in rotation of teeth, for instance, as shown in A, Fig. 67. A tooth can be rotated in either direction by reversing the loop. D, Fig. 67, shows the grass-line ligature passed through the tube of a band for rotation. With a little experience in the use of this grass-line the dentist will find that many teeth in torsion can be rotated without bands on them. This, of course, is de- sirable when it can be done. Grass-line, however, has one undesirable feature, it ab- sorbs the fluids of the mouth, and in about a week in most cases presents a bad appear- a n c e, necessi- tating a change. It will also dis- color to some extent a gold arch immediately where it passes over it. This discoloration can be easily removed with a brush and pumice whenever necessary; but notwithstanding the two defects, it still remains a valuable ligature in the movement of teeth. Grass-Line Ligature Fig. 66. Fig. 67. 62 ORTHODONTIA Rubber Ligature This special rubber ligature is valuable for any movement of a tooth and especially for the rotation of teeth (see Fig. 68). It can be used to great advantage where constant force is required for several weeks. This rubber, if good at the time of employing it, deteriorates very slowly in the mouth, it also holds elasticity for weeks; in fact, the rubber remains in work- ing order four or five weeks without change. It is easy to apply by pulling it between the teeth, nor has it ends like the wire, which on becoming deranged will scratch the patient's lips or cheeks. The whole success of using this rubber depends upon tying the proper knot. The knot adopted for tying this ligature is known as the sailor's square knot (see Fig. 69). By observing the knot as shown in Fig. 69, anyone can tie it. The directions are as follows: When the rubber is in posi- tion ; that is, one strand of the rubber over the arch and the other under, the strand held in the left hand is brought under and over the right strand. When the knot has been pulled tight to exercise the desired amount of force, the strand in the left hand is brought over and under the one on the right. In tying the second knot the operator must take a very short grip on the rubber close up to the knot, and stretch the rubber until its elasticity is taken from it; it must be stretched almost to the breaking point. When the rubber is released, the knot swells on itself and will not come untied. Before any of these knots are tied, the rub- ber must be wet with the saliva of the patient, as it is impossible to tie the rubber without this lubricant. If the rubber is tied according to the above directions there need be no question about the knot holding. If it does not hold, the rubber has not been tied according to directions. Ten or fifteen minutes' practice outside the mouth is suf- ficient to acquire this technic. Fig. 68. Fig. 69. CHAPTER IV Soldering, Tools, and Making of Bands As the soldering done on appliances is of a delicate nature, it is essential that an orthodontia blow-lamp be used. With this blow-lamp both hands of the operator remain free for con- trol of the work. The flame of the lamp can be regulated to the exact size and point desired. Many devices have been constructed for holding tubes, spurs, etc., in position while being soldered, but with a little ex- perience the soldering for these small parts can be done much more easily and better by holding the parts in the fingers, or some suitable instrument that does not consume much heat (see Fig. 70). The special formula of nickel-silver from which the author's appliances are made is a high fusing alloy and conducts heat very slowly; therefore, in soldering a spur on a band, for example, quite a short piece of the wire can be held in the fingers while attaching with solder to the band (Fig. 71). The spurs are soldered to the band in a long piece and afterwards cut off to the desired length. Tubes, of course, cannot be held in the fingers, but by passing a suitable discarded instrument through them, or a wire of the right size, they can be held in contact with the band and soldered at any angle (see Fig. 70). With a little experience the operator soon becomes proficient in this free-hand soldering. The parts are held steadily in the flame and in contact with each other at the moment the solder flows, by allowing the fingers of the hand, as shown in the cuts, to touch each other. In soldering a spur, the solder is first fused on the end of the wire; while in soldering a tube to be united to a band, the solder should first be fused to the band at the desired point. Any karat of gold solder can be used on this metal composing the band material, as the fusing point is considerably higher than pure gold. However, 18-karat solder answers all requirements. If gold band material is employed, the karat of solder must be below the fusing point of the karat of gold used. The solder chiefly used for joining Fig. 70. 63 64 ORTHODONTIA parts composed of nickel-silver, is silver solder. This silver solder is much cheaper than gold solder and for strength of union answers all purposes. Borax of a creamy consistency is the flux. The soldering flux paste (see Fig. 89). is better than straight borax mixed with water, as it does not expand and dislodge the sol- der when heat is ap- plied. The operator should bear in mind that only a little flux and solder is neces- sary in joining spurs or tubes to plain bands. In re- soldering a collar to the end of a molar clamp - band o n e - eighth inch square of silver solder is used. These tubes are elevated or cocked up on their distal end and there should be enough solder to fill under the elevated end of the tube (Fig. 70, A and B). In making attachments to bands with solder, the thin metal should be heated only enough to cause the solder to flow evenly; overheating has a tendency to weaken the thin material. Hard solder must never be applied to any of the arches, as the heat required to melt the solder would draw the spring entirely out of the arch. When necessary to make attachments of any description to one of the arches, it must be done with soft solder, using zinc chloride as a flux (see Fig. 91). With a piece of soft solder placed in position and held over the fine point of the flame, the solder can be fused without at all impairing the integrity of the arch. Very little heat is required to flow soft solder. The flame should be very small; the smaller the flame the less danger of draw- ing the spring from the arch. Fig. 71 Forming Plain Bands These bands must be formed to the teeth themselves ; they cannot be shaped on plaster teeth and then transferred to the natural teeth with any degree of accuracy. In banding an upper incisor, for example, cut off from the coil about one inch and a half of the material; and anneal. The piece is then bent in the form of a loop and the ends held together by fusing a very small piece of solder between them (A, Fig. 72). The loop is passed around the tooth to be banded and drawn tight from the labial surface with the thumb and finger, and burnished until it conforms to the lingual surface of the tooth. With the forming pliers, as shown in Fig. 78. the band is drawn and pinched around the labial surface, as in B. SOLDERING TOOLS AND MAKING OF BANDS 65 The object of first soldering the band into the form of a loop here becomes apparent; with the ends held parallel to each other by means of this solder, the two sides can be brought evenly together. If the ends of the loop were not joined be- fore pinching, one side of the band might draw up- ward and the other down- ward and fail to approxi- mate each other correctly, as shown in E. To make a well fitting band, the jaws of the form- ing pliers must come closely together; the joint will then look as shown in F. If the jaws of the pliers do not ap- proximate each other close- ly, the joint will appear as shown in D. The band in this case will not fit the tooth properly because it does not present a continuous surface on the inner side. When the band has been pinched to the tooth, it can be removed by an instrument with the point bent at right angle; the upper edge of the band is caught by this hook and by alternating from lingual to the labial edge, the band can be gently worked off without changing its form. The superfluous ends are caught with the soldering pliers close up to the band, and a thin coat of borax painted over the joint on the inside; the band is passed into the flame and the borax melted, after which a small piece of solder is placed in position and fused into the joint. The solder should be guided into the joint at the moment of fusing by a piece of spur wire or pointed instrument. Nearly all plain bands require a short spur on the lingual surface, for keeping ligatures in position. These spurs are attached by holding the band at the superfluous end with the soldering pliers, flowing a piece of solder on the end of the spur-wire and making the union by touching the wire to the band at the moment of fusing. The parts can be held steadily in contact by allowing the fingers of the hands to touch each other lightly. In affixing the spur-wires to a band for rotation, it is better that they incline to form a hook as shown in B and C, Fig. 72; this obviates all possibility of the ligature wire slipping off. After soldering, the spur-wire is cut to the desired length and the superfluous end of the band also removed. Both the spur and the union of the band are then smoothly ground, so they will not abrade the soft tissue with which they come in contact. The band is cleaned by boiling for a moment in a test tube, in dilute hydrochloric acid (equal parts acid and water). The band is then polished to its original brightness with an engine brush and pumice. Fig. 72. 66 ORTHODONTIA Fig. 73 shows five bands (enlarged) for incisor teeth with tube and various spurs soldered to the lingual surface of these bands. Some spurs are straight and some in the form of hooks, so that the ligature will not slip off when the tooth is rotated. Also one band is shown with a double spur; which, when used on a bicuspid, pre- vents the ligature from working into the gums. Both parts of the dou- ble spur are soldered on at the same time by using spur wire in "U" form as shown in Fig. 74. Fig. 75 shows the method in which the single spurs are all soldered on in a long- piece and then cut off after the union is made with the band. Fig. 73. Fig. 74. Fig. 75. Forming Cuspid Bands On account of the cone-like form of the cuspid teeth, they are the most difficult to band. It is sometimes impossible to make a well fitting band by pinching on the one side only. When this condition occurs, two pinches are necessary, one on the lingual and one on the labial surface. The band is made in the following manner: A piece of band material about two inches long is cut from the coil and an- nealed to a dull red, bent double and the end of the fold pressed tightly together with the pliers, making a double thickness of the material. The folded end of the piece is grasped diagonally with the pliers and the ends opened; this gives the piece a V-shaped outline as in A, Fig. 76. The joint is united with a small piece of solder, only enough being used to fill the joint. The two ends of the band are now brought together in the form of a loop and held by soldering, as in B. The loop is passed around the tooth and the mode of procedure is the same in pinching, soldering, cleaning, etc., as just described in forming plain bands. Fig. 76. SOLDERING TOOLS AND MAKING OF BANDS 67 C shows a cuspid band with only one joint necessary, and a spur for rota- tion soldered to the same. C and D show completed bands with the spur wire and joints untrimmed. It is difficult to form a plain band of any sort around partly erupted cuspids, owing to the fact that the lingual surface of the tooth has erupted but a short distance through the gums. A much better method in cases of this description is to use a gold cap. These caps are made in three sizes, small, medium and large (see Fig. 77). They will fit accurately any cuspid of normal shape. These caps do not pass between the adjoining teeth like a band, but come in contact with the tooth on the labial and lingual surface only and are held in position by ce- ment. The points J on the labial surface of the cap can be bent outward for engaging springs, ligatures, etc. In cases where the cuspid has a long point it will enter through the hole as shown in the cut K. This allows the cap to fit any kind of point on the cuspid. Fig. 77 also shows a pin-head sold- ered to the cervical edge of the cap. This pin-head is used to attach intramaxillary or intermaxillary rubbers for the distal movement of the tooth. Fig. 77. Special Tools and Solders Before beginning the correction of malocclusion, it is important that the dentist have a few special tools for uniting bands with solder, twisting ligature wires, and also for pinching plain bands around the teeth. There are other tools or instruments all more or less indispensable for the accurate despatch of the work. Band Forming Pliers These pliers are necessary for pinching bands around a tooth. The beaks must be thin, in order to pass readily to a tooth in lingual occlusion Fig. 78. ORTHODONTIA 68 without interference from adjoin- ing teeth. The beaks of the pliers must also come close together in order to make a sharp joint for soldering. (See Figs. 78 and 79.) Fig. 79. Band Soldering Pliers For soldering bands, pliers with the points bent at right angles (see Fig. 80) are also indispensable for good work. The points grasping the seam permit the flame to pass entirely around the joint, the solder therefore flowing easily with little expenditure of heat. It is quite impossible for solder to flow quickly and easily if the device that holds the two sides of the band together consume much heat. Fig. 80. Orthodontia Lamp The soldering of Orthodontia bands requires a small pointed flame that can be adjusted to the requirements of the work. The blow-lamp as shown in Fig. 81 answers fully all requirements. It also can be used for other sorts of soldering; such as making crowns, bridges, etc., as well as in Orthodontia work. Band Driver The band driver (see Fig. 82) in conjunction with the wooden mallet is employed for tapping or forcing the plain band into position. The chisel Fig. 81. end is placed against the edge of the band and by a series of light blows the band is quickly forced to the required position on the tooth. A wooden mallet is much better than a metal mallet for this purpose. (See Fig. 83.) Fig. 82. Wire Ligature Twisters Fig. 83 A wire ligature can be twisted around the arch with the forming pliers as shown in Fig. 78; but a much better instrument for this purpose is shown in Fig. 84. ith this twisting plier One-half Size. SOLDERING TOOLS AND MAKING OF BANDS 69 the wire is held firmly in the center of the beaks without slipping. The wire thus held turns true with the center and makes a smooth even twist. Fig. 84. Wire Ligature Bender Vv hen the wire ligature has been twisted around the arch, it is necessary to bend the twisted end up or down around the arch, so that it will not come in contact with the patient's lips or cheeks. The twisted ends of ligature must not slip while being turned over. Fig. 85 shows an instrument used for this purpose so convenient that it should be found in every orthodontist's equipment. Fig. 85. Curved Scissors A pair of strong, curved scissors (see Fig. 86), with cutting points, are necessary for cutting wire liga- ture when ligated to the teeth. The points of the scissors can be inserted between the arch and tooth and the wire severed. They can also be used for cutting grass-line or rubber ligature, although for cutting grass-line a lance with tapering point and curved blade is better. (See Fig. 87.) The point of the lance is inserted under the ligature and by pulling outward the grass-line is more easily severed perhaps than in any other way. Fig. 86. Fig. 87. 70 ORTHODONTIA Wire Cutter A better way for remov- ing a wire ligature from an arch is to use the wire-cut- ters as shown in Fig. 88; with this cutter both strands of the twisted end of the wire can be smoothly cut off on the labial side of the arch. Fig. 88. Silver Solder Unless the material composing the appliance is made from gold, silver solder is used for joining the various parts together, with borax as the flux. Silver solder must not be used on gold, for when heated sufficiently to flow, the solder will eat a hole in the gold and especially in the thin gold bands. Gold solder can be used on gold or nickel silver appliances, one as well as the other, but silver solder cannot be used on gold for the reasons above stated. Soldering Flux Fig. 89 shows a bottle of soldering flux for either silver or gold soldering. This prepara- tion is much better than borax mixed with water, as it does not expand and puff up when heat is applied. Fig. 89. Soft Solder Occasionally soft solder is used in attaching spurs or tubes to arches. Silver or gold solder could not be used without drawing the spring or temper from the arch. Very little heat is required to flow soft solder and it holds for all ordinary purposes. (See Fig. 90.) Fig. 90. Soft Solder Flux As with gold and silver solder, soft solder must also have a flux before it will flow. Fig. 91 shows Soft Solder Flux in bottle. Fig. 91. SOLDERING TOOLS AND MAKING OF BANDS 71 Fig. 92 shows a micrometer used to measure plate or wire, and registers in thousandths of an inch. Fig. 92. Fig. 93 shows the Brown & Sharpe Gauge usually used by dentists and dental depots in measuring plate and wire, but it does not measure in thousandths of an inch like the micrometer gauge. The follow- ing table gives the reading in thousandths of an inch of the Brown & Sharpe Gauge. Fig. 93. American Standard Brown & Sharpe Gauge Gauge 0-.325 Gauge 1-.289 Gauge 2-.257 Gauge 3-.229 Gauge 4-.204 Gauge 5-.182 Gauge 6-.162 Gauge 7-. 144 Gauge 8-.128 Gauge 9-.114 Gauge 10-.102 Gauge 11-.091 Gauge 12-.081 Gauge 13-.072 Gauge 14-.064 Gauge 15-.057 Gauge 16-.051 Gauge 17-.045 Gauge 18-.040 Gauge 19-.036 Gauge 20-.032 Gauge 21-.028 Gauge 22-.025 Gauge 23-.022 Gauge 24-.020 Gauge 25-.018 Gauge 26-.016 Gauge 27-.014 Gauge 28-.013 Gauge 29-.012 Gauge 30-.01002 Gauge 31-.00893 Gauge 32-.00795 Gauge 33-.00708 Gauge 34-.0063 Gauge 35-.OO561 Gauge 36-.005 Gauge 37-.00445 Gauge 38-.00396 Gauge 39-.00353 Gauge 40-.00314 Gauge 41-.00280 Gauge 42-.00249 Gauge 43-.00222 Gauge 44-.00197 Gauge 45-.00176 CHAPTER V Anchorage 1 he application of Orthodontia appliances to any given case must be based upon the principles of anchorage. The term anchorage may be de- scribed as that point of resistance from which force is applied for orthodontic correction. It is a well known principle in physics that, in all application of force, action and reaction are equal and in opposite directions. This is as true in the regulation of teeth as in the application of force outside the oral cavity. In other words, by anchorage we mean the base from which force is applied. Anchorage may be considered under two heads ; first, intramaxil- lary anchorage; second, intermaxillary anchorage. By intramaxillary anchor- age is meant anchorage from the same jaw as the teeth to be moved. By intermaxillary anchorage is meant anchorage taken from the opposite jaw to the teeth to be moved. Intramaxillary anchorage is divided into three kinds: (a) simple; (b) re- inforced, or stationary; (c) reciprocal. By simple anchorage we mean an- chorage in which the anchor tooth, on ac- count of its size and position in the den- tal arc h, naturally offers more resis- tance than the tooth or teeth to be moved; and will, therefore, remain practically in posi- tion against the force employed. The simple anchorage is well shown in Fig. 94. The two first molars act as the anchorage for closing the spaces between the anterior teeth. The natural resist- ance of the first mo- lars in this move- ment is further in- Fig. 94. 72 ANCHORAGE 73 creased by the resistance of the bicuspids and cuspids on each side. B shows the notches in the labial surfaces of the band on the centrals to prevent the cable-spring arch from slipping up or down. Force is brought into action by turning the arch for contraction. Reinforced, or sta- tionary anchorage, is the combining to- gether of the resist- ing force of several teeth against the tooth or teeth to be moved. Fig. 95 shows two forms of reinforced anchor- age. On the right a bicuspid has been extracted with the object of retracting the cuspid until it takes the place of the first bicuspid. The movement is produced by the in- tramaxillary rubber F, and the contraction of the cable-spring arch to move lingually the anterior teeth. The case belongs in class Two B. As can be seen in the cut, anchor- age is secured on the right side by combining the resistance of three teeth by means of a bar soldered to the bands on bicuspid and molar. The left side shows another form of reinforced anchorage, which consists of banding several teeth and soldering the bands together. It should be remembered that either one of the two anchorages shown in Fig. 95 renders the resist- ance of the teeth much greater than their resistance separately without the reinforcement. Fig. 96 shows another case of reinforced anchorage. In this case buccal movement of the first molar and two bicuspids on the left side only is de- sired. The molar is first moved against the resistance of the five teeth on the opposite side ; when this has been accomplished, the second bicuspid is banded and moved in the same manner as the molar; and lastly the first bicuspid. These teeth can be moved very quickly one at a time without dis- turbing the anchorage on the opposite side. The outward spring of the Arch B acts constantly, and the desired amount of force can be imparted by straightening it out as shown in "B". The method of constructing the rein- forced anchorage is shown under the head of "Retention." In reciprocal anchorage one tooth is employed against another for move- ment in opposite directions. This anchorage can be best shown in the applica- tion of the expansion arch as shown in Fig. 97. The operator should never Fig. 95. 74 ORTHODONTIA Fig. 96. overlook the use of this anchorage, as it is ideal when both points are to be moved in opposite directions. The same principle as shown on the bicuspids can, of course, be applied to any of the buccal teeth either singly or collectively by use of the expansion arch. Intermaxillary an- chorage is the op- posing of teeth in one jaw to teeth to be moved in the op- posite jaw. It may be reciprocal inter- maxillary anchor- age, or stationary Fig. 97. ANCHORAGE 75 intermaxillary anchorage according to the object desired. In reciprocal intermaxillary anchorage the teeth are moved in both jaws, as shown in Fig. 98. The principle will apply to one tooth in each jaw as well as to the arches as a whole. The force used in intermaxillary anchorage is rubber bands of suitable length passing from the upper to the lower stiff arch. Fig. 98 represents a class Three case, or protrusion of the lower teeth. The stiff arches are here adjusted for moving the lower teeth in a posterior direction and the upper teeth forward. The contraction of the rubber bands forces the arches in opposite directions. By changing the rubber band from the hook on the arch below to the hook on the arch above and also Fig. 98. changing the rubber band from the upper to the lower molar, the force would be reversed; that is, the upper arch would be moved in a posterior direction, and the lower arch forward. Fig. 99 shows the same case with the first bicuspids extracted; although we are using precisely the same appliance, it is working on the principle of stationary intermaxillary anchorage. All the upper teeth now act as anchorage for the movement distally of the six lower anterior teeth. It will be noticed in the cut that the nut "D" on the lower arch is moved forward in order that the arch may slip distally in response to the contraction of the rubber band. Fig. 100 shows another form of stationary intermaxillary anchorage in which the teeth of the lower jaw are all united for resistance against the distal movement of the upper first 76 ORTHODONTIA m o 1 a r. f h e teeth below are rendered s t a - tionary by the nut on the ex- pansion arch abutting on the nut of the molar clamp band, and also by ligating the anterior teeth to the arch. It can be clearly seen that by this method none of the lower teeth can be moved for- w a r d unless they all move. In fact, every tooth anterior to the first molar and including the first molar is furnishing resistance for the distal movement of the tooth to be moved, which is the upper first molar. It will be noticed that the nut on the upper arch is also in contact with the nut of the molar clamp-band; but the anterior portion of the arch is not in contact with the incisors, as is the case with the arch below; therefore, the whole contraction of the rubber band is a force operating against the upper first molar. Occipital and oc- clusal anchorage are also sometimes named; but these anchorages are rare- ly used now, as the work done from these anchorages is better done with the four anchorages al- readv described. Fig. 99. Fig. 100. CHAPTER VI Correction of Protrusion by Extraction in Confirmed Cases of Malocclusion There is a time in the history of every case when protruding upper incisors could have been prevented by proper treatment, and permanent teeth erupting subsequently would have assumed normal mesio-distal relations with the lower arch. In incipient protrusion of the upper incisors, we find the six-year molars, shortly after their eruption, advanced, in whole or in part, the distance of a cusp either on one or both sides with the intervening deciduous molars and cuspids still present. Nothing could be easier at this stage of the trouble than the movement distally of the advanced molar into normal relation with the lower and prevent the protrusion that would be inevitable when all the permanent teeth had erupted. This condition can be named "Unconfirmed Protrusion," and treatment at this early age is most easy with permanent results. It is, in fact, preventive orthodontia. Should this condition of malocclusion not be corrected in its beginning or unconfirmed stage, the remainder of the permanent teeth as they erupt will also take an advanced position in their relation to the lower teeth, and we are confronted by protrusion of the upper incisors, which varies accord- ing to the advancement of the six-year molars. After the permanent teeth have all erupted (third molars excepted), the condition can be called "Con- firmed Protrusion." When the case has progressed into the confirmed stage, it is, for several mechanical reasons, exceedingly difficult to restore normal occlusion, and from inherent causes the teeth will not remain in their new positions, when finally released from retention or artificial re- straint. The new positions are not permanent when thrown on their own resources for retention. We have heard much about the interlocking of cusps and teeth being sufficient in themselves to retain regulated teeth ; but when we consider that at all times, except during a voluntary movement of the jaws, such as mastication, the occlusal planes of the teeth are one-eighth of an inch or more apart, it would seem that this form of retention has been greatly over-estimated. It is, at best, only active an hour or two each day, while during the other twenty-three hours, more or less, the teeth are not to- gether at all. There is a wide difference both in dentistry and medicine between treating successfully an incipient, or unconfirmed, condition and the same trouble that is chronic, or confirmed. The first may respond instantly to treatment with a permanent cure, while the latter may not respond at all, or only temporarily, making surgical interference necessary for permanent results. 77 78 ORTHODONTIA Surgical interference in confirmed cases of protruding upper incisors, is not only permissible, but absolutely demanded if we would have perma- nence and facial harmony as a result of treatment. We all understand perfectly that to save teeth is the most important mission of the dentist or Orthodontist, but if in an effort to save one tooth, he impairs the vitality and stability of many others, his treatment is evi- dently not based on the final welfare of his patient. In the last analysis, when everything is summed up, he has done more injury than good. This is precisely what happens in endeavoring to reduce protrusion of the upper teeth without extraction: the first bicuspids are temporarily saved at the expense of all the other teeth in the mouth. In correcting malocclusion of this protruding type, three great objects must be kept constantly in view, namely: First. Satisfactory masticating surfaces. Second. Restoration of facial harmony. Third. Permanence. The last, of course, is the most important, as without permanence the other desirable results would be but temporary. The treatment, therefore, must always take into consideration as the most important factor, the question whether the moved teeth will stay in their corrected positions when finally thrown on their own resources. It has taken some years to prove to me that the correction of these confirmed cases of protruding upper incisors is an impossibility without ex- traction. Give the teeth time enough and they will partly, or wholly, relapse into their old positions of malocclusion. The real difficulty is not in moving the teeth into occlusion, but in the inherent disposition of the whole upper arch to resume its original lines when no longer subjected to restraint. One of the arguments that has constituted an important plank in the Orthodontia platform for a number of years, but which now begins to show signs of decay, is the interdict against extraction under any circumstances. If the teeth are all present they must be moved into harmonious relation regardless of mal-position; and if all are not present, room must be made and an artificial tooth inserted, regardless of the age of the patient, or whether the conditions are confirmed or unconfirmed. In other words. Orthodontia, unlike other things in this world, is limited by no laws, me- chanical, physical, biological, or anything else under the shining sun. The aftermath as to injury of tissue in these extensive distal or mesial move- ments seems never to have received consideration. This treatment without extraction would be ideal if biological laws, over which at present we have no control, did not manifest displeasure in loose teeth, pyorrhea alveolaris, gingivitis, recession of the gums, etc., all caused by the long continued pull of the intermaxillary rubbers in com- bination with the long wearing of molar clamp bands. The erosion of teeth from the long wearing of bands should in itself be a strong and suf- ficient reason why the work should not be attempted without extraction. Without extraction, years must elapse before the teeth are finally relieved CORRECTION OF PROTRUSION 79 of all bands, and then what? In time a relapse. And again, to say the relations between the tooth and the walls of the alveoli can be disturbed at any age and to any degree without injury, is not conceivable. Nature builds the tooth into the process thoroughly but once, and if its adhesive- ness is long placed under strain and to too great an extent, the tooth be- comes loose, and never again regains its adamantine stability in the bone. The true cause of Orthodontia is not interested in brilliant technic at the expense of the patient, but is interested in what can be done and stay done without injury to tooth structure or other tissues. Orthodontia is still very young and is in a state of progress or evolution. It is as beneficial for us to know what cannot be done, as what can be done. We will consider a case of true protrusion of the upper incisors ; that is, the lower jaw and teeth are normally posed while the upper teeth are advanced the whole width of a biscupid tooth on each side. To correct this case in an ideal manner, the whole upper arch without extraction should be carried distally into occlusion with the lower teeth without changing the position of the lower teeth at all. The force generally used to accomplish this purpose consists of rubber bands, suitably adapted, passing diagonally from the upper to the lower teeth. With this power, the upper teeth are moved distally in sections, or en masse ; but since these rubber bands are reciprocal in their action, and the lower teeth are more easily moved for- ward than the upper are backward, we are confronted by the principal movement taking place in the lower jaw, which to begin with was normally posed. Therefore, when occlusion is established, we have bimaxillary protrusion. It is cpiite impossible to move the upper jaw backward, either in sections or en masse, without at the same time moving the lower jaw forward. In connection with this movement of the lower teeth by intermaxillary rubbers, it is much more than probable that the lower teeth are not moved forward through the process, but that the condyle in the Glenoid Fossa is merely distorted, which, when released from retention, slips back into its old location and carries the lower teeth with it. This temporo-mandibular joint is undoubtedly the point of least resistance when force is applied to the lower arch. The length of time required to do this work in confirmed cases varies from three to five years, and some of its disadvantages are as follows: Loose teeth (permanently) from long pressure. Chronic gingivitis, from long pressure and bands. Recession of gums from long wearing of bands. Tipping of molars from diagonal force of intermaxillary anchorage. Three to five years of impaired mastication. General annoyance to the patient for same length of time. Eroded teeth from long wearing of bands. Ultimate relapse when retention is removed. This may seem like a pretty severe arraignment, but it has the re- deeming feature of being true. And the truth is what we are after. 80 ORTHODONTIA Now let us consider results where extraction is used in these confirmed cases of protrusion: Length of time of treatment, three to six months. Retention of the simplest kind, six months, and very often not any; pressure of the lips being sufficient. No marking or erosion from long wearing of bands. No pyorrhea alveolaris or gingivitis from the same cause. No tipping of molars. No recession of gums from bands. General annoyance and impaired mastication, only three to six months as compared to three to five years. No disposition at all for the six anterior teeth to move forward when retention is removed. Facial lines precisely as good as if all the upper teeth could have been moved back and held. Dr. Case (of Chicago) has long ago said, that where the lower jaw was normally posed with protruding upper incisors, the extraction of the first upper bicuspids was demanded in order to secure correct facial outlines. This is absolutely true, and I will go Dr. Case one better, and say that without extraction permanent retention is impossible in the great majority of cases. CHAPTER VII Treatment of Malocclusion Age for Treatment The question, "What is the best age for correcting malocclusion of the teeth?'' is constantly being asked. This question can be answered in a most definite manner by stating that the best time for beginning treatment is just as soon as the permanent malposed teeth are sufficiently erupted for placing bands on them. Every year or every additional month even, that elapses after this ideal time, makes the movement just so much harder and also lengthens the period of retention. If irregular teeth are corrected, say at the age of seven or eight years, the movement is much easier than if the patient were twelve or thirteen years of age. Irregular teeth should be moved into the desired position while the process is comparatively soft and yielding. Besides, these young people are really better patients to work on than older ones. As a rule they are very careful to carry out all instructions given them. The early correction of the molars and incisors forestalls more complicated irregular- ities that are sure to develop upon the eruption of the other permanent teeth. The most favorable time for tooth regulation is after the eruption of the six-year molars, and incisors, and while the deciduous molars and cuspids are still present. With these teeth in their proper relation in both the upper and lower jaw, and space for the permanent cuspids and bicuspids still to erupt, the chances are largely in favor of these teeth coming in correctly. If they do not, their correction is easily accomplished. It is the "stitch in time that saves nine." If the children of this country could have skillful Orthodontic attention from the age of six until the eruption of all the permanent teeth with the exception of the third molars, there would scarcely be such a thing as irregular teeth. The great trouble at the present time is that usually we do not see the patient until all the per- manent teeth have erupted, and consequently the malocclusion is confirmed. The correction then, in these confirmed cases, becomes long and laborious compared with correction at the earlier age. In fact, it may be laid down as a rule, the older the patient the longer time required for tooth movement and retention. Some corrections of malposed teeth, in older patients, can never be held in place except by retention of a permanent nature. In the years gone by it was a customary thing for dentists to instruct patients to wait until all the teeth had erupted, before having anything done. Worse advice could not have been given. Once more we repeat, treatment of mal- posed teeth should be begun just as soon as suitable attachments can be made to the teeth. 81 82 ORTHODONTIA Separation of Teeth for Bands Before undertaking to band a tooth, ascertain if the band material will pass between the teeth without requiring much force; if much force is required, the teeth must be separated. This can easily be done as follows: A piece of soft ligature wire of suitable size is passed between the teeth at the junction of the gum. It is sometimes difficult to force the soft ligature wire through the inter-proximate space. W hen this trouble arises, the end of the wire can be stiffened by drawing it between the thumb and some round-handled instrument; the wire can also be pointed to facilitate its passage through. W hen the wire is passed through the inter-proximate space, the lingual end is carried over the occlusal surface and the two ends twisted together, (Fig. 101, between the molars), at first loosely by the hands, and then with the pliers. By this means the wire is put on tension and exercises a wedging force. The short twisted end of the wire can be bent in- to the embrasure. This system of gaining space can be used on any of the teeth, provided the proper sized wire is selected. Ligature wire No. 26 is preferable for the molars and bicuspids and No. 30 for the in- cisors. It will be found, as a rule, that within twenty-four hours after the wire has been placed as described, the band material, or clamp bands will pass readily into position. Occasionally it may be necessary to tighten the lig- ature wire by additional twisting, at the next visit of the patient. This is an infallible means of gaining space for orthodontia bands ; it not only does the work efficiently, but is absolutely painless to the patient. In twisting a wire for separation, the twist should always be made to the right; when it is necessary to remove the wire, turn to the left. If this rule is not followed, the wire may be broken between the teeth by additional tightening when the intention is to loosen. It is annoying to remove a wire thus broken off. This rule should be followed whenever wire is to be tightened whether in separating or in ligatures. Fig. 101. TREATMENT OF MALOCCLUSION 83 Let it be remembered, the first step toward the banding of any tooth, or the adjusting of molar clamp bands, is to gain space (if it does not al- ready exist), to admit of the material passing easily between the teeth. As shown in the classification of malocclusion, four types are possible in Class One, and in all the types the first molars are in their normal mesio- distal relation. As a rule, the molars will not require expansion or buccal movement, the correction being limited to alignment of anterior teeth and often more or less buccal movement of the bicuspids, in order that they may coincide in circle with the broad- ened arch in front, after the malposed teeth have been moved into place. It is quite useless to expect cuspids and in- cisors to remain in place after correction (no matter how long they Treatment Class One-Type "A" Fig. 102. are retained) if constric- tion still exists in the re-i gion of the bicuspids. It may be laid down as a rule, that a tooth will not remain in its corrected position unless it has full room between the adjoin- ing teeth. In other words, the natural contact points of the tooth must be in easy relation with the contact points of adjoin- ing teeth. This is espe- cially true of cuspids. If a cuspid is, for example, in labial occlusion, or too prominent, there is a ten- dency to discontinue its lingual movement as soon Fig. 103. 84 ORTHODONTIA as it seems to be aligned labially with the other teeth. Now, unless the broadest mesio-distal aspect of the cuspid has easy room between the contact points of the bicuspid and lateral, it will again be crowded out of alignment when released from retention. Unless the tooth has free room, the distal and mesial curves of the lingual surface become inclined planes over which the adjoining teeth, with their tendency to come together, will slide, displacing, more or less, the cuspid. Outlooked cuspids are very common to this class, hence observance of this fact is important. Figs. 102 and 103 show a right and left view of a case of malocclusion where the molars are in normal relation with overlapping anterior teeth, hence it belongs to Class One, Type A. A great majority of the Class One cases belong to Type A, and the treatment consists in expansion until all the malposed teeth have full space within the arch. For this movement, the Cable-Spring arch is chiefly used, although it may be supplemented with one of the stiff arches for some particular movement of an individual tooth, where the spring arch does not embody the necessary principle for obtaining the desired result; such as, tipping the apex of a root forward or in a lateral direction. As stated before, all arches are interchangeable with the molar clamp bands ; hence arches can be changed in a few moments, as it is un- necessary to remove the bands from the molars to make the change. Figs. 104 and 105 show occlusal views of the same case of malocclusion with appliance adjusted for the regulation of the teeth. Fig. 104 shows the cuspids about where they should be, consequently the bicuspids and incisors are aligned on the present position of these cuspids. In order to move the bicuspids buccally on a line with the cus- pids and first molars, it is best to band the bicuspids with the .003, or m edi u m , band material, sol- dering a spur, or tube, to the lingual surface of each band, for holding the liga- ture in place. Liga- tures on the bicus- pids will work under the gums if a band with a spur is not used to prevent it. These bands are shown on the bicus- pids in Fig. 41. The lateral incisors are Fig. 104. TREATMENT OF MALOCCLUSION 85 both banded, and the grass-line ligature is adjusted for rotation, and at the same time labial movement; without bands on these laterals it would be impossible to prevent the ligatures from slipping off. The centrals can also be ligated with the grass-line without bands, as in this particular case they will hold the ligatures if placed around their necks. However, if these cen- trals were so formed lingually that a ligature would not remain in position between visits of the patient, bands must be placed on them similar to the laterals, and in addition notches must be cut in the seam on the labial surface through which the arch can pass. These notches lend the arch additional support which may as well be taken advantage of, although the points in the gold caps (Fig. 106) are sufficient for the purpose. With the four in- cisors and bicuspids ligated to the arch, expansion of the malposed teeth is accomplished. As the laterals move forward, the arch can occasionally be turned downward for enlargement, as the circle in front must be wider when the laterals are finally in position. Since the general movement here is one of expansion, in order to make room for the malposed teeth, care must be ob- served that the spring arch is not a trifle too short, therefore producing a con- striction, or distal tension. Let the operator bear in mind that the spring arch, in a way, works on the same principle as a rubber band fastened to the molars and stretched around the anterior teeth. If the rubber were more or less taut, it would be folly to expect enlargement of the arch, as the force would be for contraction. When the arch spring is adjusted in this case, either to the upper or lower teeth, it should pass around the incisors in a neutral manner. We hope this point is clear. For the movement of the laterals labially and the bicuspids buccally, as in Fig. 104, anchorage is taken from the first molars and the two cuspids ; also, in the beginning, from the central incisors. By keeping the arch slightly sprung toward the malposed teeth with ligatures, and occasionally enlarging it by turning downward at the median line, the teeth are brought into alignment. The arch can be turned under the ligatures as well as if no ligatures were attached to it. In adjusting this spring arch, the square of the gold nut should fall between the centrals. This can be exactly located after one or two trials by turning one end of the arch into the bolt a little, before screwing both ends in together. In adjusting the arch it is screwed in as far as possible with the fingers before using the wrench. 86 ORTHODONTIA Fig. 105 represents the lower arch of the same case. All that has been said regarding the adjustment of the cable-spring arch to the upper teeth applies below. This lower dental arch must also be expanded anterior to the first molars to correspond to the expansion above. Both jaws are ex- panded simultaneously. Fig. 105. The bicuspids are banded as explained for the upper bicuspids, as shown in Fig. 41. Since the lower cuspids are fully erupted, instead of using caps on them as on the upper, bands with notches cut in the seam on the labial surface are used to support the arch. These cuspids are ligated with grass-line for rotation "H", while the laterals have the line simply passed around them for labial movement "C". The two centrals are also to be ligated, the right one in the same manner as the laterals for forward move- ment ; and the left central, for rotation. The technic of rotating teeth with- out bands is shown in Fig. 67. The lower incisors, as a rule, are much easier to work on without bands than the upper incisors, on account of length and favorable inclination. However, it must be borne in mind that if re- sults cannot be obtained when bands are omitted, a band should be quickly TREATMENT OF MALOCCLUSION 87 placed on the tooth. It is, of course, desirable to keep bands off the teeth as much as possible, but not at the expense of prolonging the work. The lower arch is turned in the same direction for expansion as the upper arch-namely, downward. The lower arch will require considerable expansion forward to make room for six anterior teeth. The arch must be turned once around every ten days or so for expansion. Fig. 106. Since the lateral halves of the spring incorporate the principle of a right and left-handed thread, the arch moves with twice the rapidity of an ordinary screw. When the wrench is applied to the nut in the median line, both ends of the arch turn through the bolts of the molar clamp bands at the same time. Fig. 106 gives a side view of this case with the appliance mounted on the teeth. This view shows clearly the points of the gold cap "A" above. Since this cuspid requires elongating, it is easy to understand that if the arch were ligated in front and then carried up over the top point, force would be brought immediately into play for the elongation of the tooth. The notch in the plain band on the lower cuspid "G" is also clearly shown. 88 ORTHODONTIA Fig. 107 shows a front view of the case. Here both caps with their restraining points are shown, and also the notches in both the lower cuspid bands to prevent the arch from working downward into the soft tissues. Fig. 107. Class One. Type B.-Retruding Upper Incisors This form of malocclusion is not of infrequent occurrence, embracing one or more of the incisors. The cuspids, of course, are outlocked, with insufficient room within the line of occlusion for their accommodation. The mesio-distal position of the lower arch as a whole is normal, as shown in Figs. 108 and 109. The first phase of the movement in the case shown, is carrying the four incisors directly forward over the lower teeth, paying no attention to the cuspids at this stage. The solid arch "B" and molar clamp-bands are used, the molar clamp-bands going on the first molars. In moving the anterior teeth forward with the arch, the molar bands should always be placed on the most anterior molar, in order to increase anchorage by the additional resist- ance of the second molar when the distal thrust is put upon the arch. The rule is this: When anterior teeth are to be retracted by intramaxillary anchorage, the molar bands should be adjusted to the most posterior molar; and when the anterior teeth are to be moved forward, the molar band should be placed on the most anterior molar. By this method the resisting force TREATMENT OF MALOCCLUSION 89 of two molars is always present. In moving the up- per incisors over the lowers as shown in the cut. Fig. 110, many dentists open the bite by placing crowns on the pos- terior teeth, the ob- ject of this being to avoid interference with the lower in- cisors as the upper incisors move for- ward. This greatly impairs the process of mastication on ac- count of the occlusal surfaces of the teeth being held apart when the jaws are closed, and is very annoying to the pa- Fig. 108. tient as well. A mo- ment's consideration will show that this procedure is unnec- essary, in fact the upper teeth can b e moved over without opening the bite, as quickly as when the bite is opened, and this un- necessary discomfort to the patient is en- t i r e 1 y eliminated. The reason is this: during all the time the jaws are at rest, or, in other words, except when actually engaged in the proc- ess of mastication, the incisal and oc- clusal surfaces of the Fig. 109. 90 ORTHODONTIA opposing teeth are one-eighth of an inch or more apart; therefore, retruding teeth have twenty-three hours, more or less, free from interference, when they can move forward in response to ligatures just as well as if the bite were held constantly open. Take, for in- stance, the case as shown, Fig. 110. Just what is the technic after the ap- pliance is adjusted to the teeth ? Simply this, the incisors are ligated with No. 26 wire on tension. The wire is tightened at suitable intervals and the nut on the arch is also turned occasionally to force the anterior part of the arch labially. In due course of time this combined for- ward action on the incisors will move them close up to the lower incisors; in fact, the labial and lingual surfaces will begin to bear heavily on each other, the patient being unable to bring the occlusal sur- faces of the buccal teeth c|uite together. The upper incisors are by this time naturally more or less loose from movement. At this stage of the proceed- ings, the operator must assure himself that the molar clamp-bands are tight around the molars and will not slip, otherwise there would be leakage of power at this point when the lifting over Fig. 110. Fig. 111. TREATMENT OF MALOCCLUSION 91 force is applied. At this critical time, take off all the old ligatures around the incisors, and re-ligate them tightly with No. 26 wire, and in addition throw the arch forward by turning the nuts. Two or three repetitions of this treatment will produce an end-to-end bite of the incisors, after which it is only a short time until the lingual surface of the upper incisors begins to pass downward over the labial surface of the lowers. While the incisors are biting end to end, the buccal teeth cannot occlude, but this condition is of short duration. In adjusting the upper arch, it is obvious that it must be placed high enough to escape the lower teeth during mastication. On account of the quick and positive pressure that must be placed on the incisors at the crit- ical time of lifting them over, the solid wire arch "B" is employed. The carrying forward of the incisors as described, will create sufficient room for the' cuspids. If the- operator is of the opinion that of their own accord they will assume, by natural eruption, their position in the arch, he may await developments in this particular. However, it is extremely doubtful if they will naturally align themselves in place ; and in order to complete the regulation without delay, he had better elongate them by a suitable appliance. This can be done quite easily by cementing a cap on each cuspid (see Fig. 110), and so bending the arch that it exerts a down- ward pressure on the points of the cuspid caps. Figs. 46 and 163 also show other methods of elongating cuspids or incisors. Occasionally cases of upper retrusion present themselves for treat- ment before the eruption of the second molars; therefore intermaxil- lary anchorage is employed, as it is doubtful whether the first molars only would stand the backward thrust without being moved. Fig. Ill shows how intermaxillary anchorage is used under such circumstances. Resistance for the forward movement is secured from the lower jaw and the upper first molars. Power is applied for moving the upper incisors forward by turning the nut on the upper arch. All of the incisors above are, of course, ligated with ligature wire No. 26. The backward thrust of this movement against the upper first molars is equalized by the rubber band passing from the hooks below and over the distal end of the upper molar clamp bands. The tension of the equalizing power can be increased or diminished according to the length and size of the rubber bands. As a rule, a slight rubber only is re- quired, and in many cases can be omitted entirely. The operator can judge of this matter as the case proceeds. When the intermaxillary rubber is used, there is no danger of rotating the molar. The expansion arch "B" passing through the bolt is sufficient to prevent any tendency of this kind Fig. 112 shows a case with the two upper laterals in lingual occlusion with the lower teeth. This case can be corrected very easily with the cable- spring arch A and molar clamp bands adapted in the usual manner. Here the arch has anchorage not only from the molars on each side, but from the two centrals as well. This anchorage is sufficient for moving the upper laterals over the lower teeth. In this case the bite does not need to be opened for the same reason as explained above. The two laterals are banded 92 ORTHODONTIA and grass-line em- ployed for the liga- ture. As shown in the cut, the centrals are banded with notches cut in the seams of the band for supporting the flexible arch. Fig. 112. Class One, Type "C"-Protruding Upper Incisors Protruding upper incisors are an unusual condition in Class One (Figs. 113 and 114). As all the buccal teeth are already in normal occlusion, the only possible treatment is the extraction of the upper first bicus- pids on both sides ; then by retracting the six upper an- terior teeth until the spaces caused by extraction are closed, facial lines will be corrected. The most prac- ticable manner to accomplish the dis- tal movement o f these protruding teeth is by using Fig. 113. TREATMENT OF MALOCCLUSION 93 the Cable - Spring Arch, and reinforced anchorage, supple- mented by a rubber band, passing from a hook soldered to the labial surface of the cuspid band and hooked over the dis- tal end of the bolt of the molar clamp band, as shown in Fig. 115. As shown in Fig. 115, and completely in Fig. 116, the cus- pids offer most of the resistance to the movement, hence this independent power is applied di- rectly to them. The movement distally of the incisors is ex- tremely easy, when not held in check bv Fig. 114. the more stubborn cuspids. 1'he occa- sional shortening of the arch will retract the incisors and also exert additional force on the cuspids. "B", Fig. 115, shows the labial surface of the anterior bands, notched for holding the arch in place. In order that the an- chorage shall be as strong as possible, it is reinforced. Molar clamp bands are placed on the second molars, and plain bands on the second Fig. 115 94 ORTHODONTIA bicuspids. These two bands are united by soldering a wire on the lingual surface. A neater and stronger way, however, is to contour a thin strip of gold, 36 gauge, along the lingual surface, and flow a strong body of solder over the same as shown in "C" and "D." This reinforced anchor- age greatly increases the resistance of the two molars and bicuspids on each side, and also prevents the second molar from rotating when force Fi£. 116. is applied. In this movement, or others similar to it, there need be no fear that the point of the cuspid will be tipped at a distal angle. Such will not be the case. The roots of the incisors are being carried distally at the same time, which keeps the roots of the cuspids in an upright position. Besides, the arch, though the teeth are moving, is holding them all in their proper circle, and the contact points are, therefore, never lost. If, for any reason, such as the loss of teeth, or unerupted teeth, suf- ficient anchorage cannot be secured, intermaxillary anchorage can be em- ployed, as shown and explained in Fig. 135. Retention where bicuspids have been extracted is shown under the head of "Retention." TREATMENT OF MALOCCLUSION 95 Class One, Type "D"-Bimaxillary Protrusion This type differs from Type C in that both the upper and lower ante- rior teeth protrude, im- parting to the patient's features that character- istic negroid expression of protruding upper and lower lips. This type is shown in Figs. 117 and 118 without appliances, and also in Fig. 119 with appliances adjusted for treatment. In treating bimaxillary protrusion, exactly the same appliance and method is pursued on both the upper and lower teeth as shown with re- inforced anchorage (Fig. 115). Fig. H7. Fig. 119 shows a buc- cal view of bimaxillary protrusion with both the upper and lower first bicuspids extract- ed. and the appliance in operation, including the rubber bands passing from the cuspid to mo- lar, as an independent means of retracting the cuspids and thereby hastening the comple- tion of the case. Since the molars and bicuspids are in normal occlusion, the only pos- sible way of correcting the facial lines above and below is the ex- traction of the right and left upper and low- er first bicuspids and Fig. 118. 96 ORTHODONTIA retracting the six anterior teeth in both jaws until the spaces caused by extraction are closed. This treatment will harmonize satisfactorily the lips with the rest of the features, and make a great improvement in the facial appearance of the patient. There is little or no disposition of anterior teeth which have been moved distally, after the extraction of bicuspids, to show a tendency to move forward again after being retained for a few months. Fig. 119. I'he retention, after the correction of bimaxillary protrusion, is shown under the head of "Retention," and termed intramaxillary retention. Another method of correcting bimaxillary protrusion is by intermaxil- lary force. This method is slower than the one just described as only one set of teeth can be regulated at a time. In other words, the correction of the teeth of one jaw must be completed before the correction of the op- posite jaw is begun. This intermaxillary method must be used when, on account of unerupted or missing teeth, sufficient anchorage cannot be se- cured from the posterior teeth to withstand the direct distal pull. The appliances used are exactly the same as for reducing protrusion of the incisors in Class Two and Class Three cases, where extraction of the first bicuspids has taken place. In reducing bimaxillary protrusion by in- termaxillary force, the posterior molars designed for anchorage are banded TREATMENT OF MALOCCLUSION 97 with molar clamp bands, both above and below, and the lower first bicuspids ex- tracted (not the upper bi- cuspids a t this time). " B " arches are adjusted to the upper and lower teeth, as shown i n Fig. 120. The upper incis- ors are li- gated with wire to the arch "H". Ligation o f the lower incisors, although shown in cut, is unnecessary. Nut "C" of the upper arch is turned back against the bolt of the molar clamp band, while below, the nut "D" is one-eighth of an inch or so from the bolt. This ar- rangement of nuts and ligature wires above converts all the teeth of the upper jaw into anchorage for the movement distally of the six anterior lower teeth. The position of nut "D" permits the lower arch to slip back in response to the pull of the rubber bands, carrying the anterior teeth with it. The rubber on tension is clearly shown in the cut. The lower teeth, on account of the upper teeth overlapping them, must be moved distally first. When this movement is completed, molar clamp bands are removed, the anchor teeth cleaned, and the nut "D" screwed on the distal end of the arch after the arch has been passed through the bolt of the band. The arch and molar bands are adjusted outside of the mouth and are all placed on the lower teeth together, otherwise difficulty would be found in starting nut "D" on the end of the arch after the arch was in the mouth. By this arrangement the arch binds all the lower teeth to- gether, and the nut can always be turned to take up lost motion or any slight separation that might possibly occur between some of the teeth. The cor- rection of the lower teeth now being completed, the first bicuspids above are extracted and intermaxillary force employed for retraction of the upper anterior teeth, as shown in Fig. 121. In the figure it will be noticed that the upper nut "C" is moved away from the bolt. It is the upper teeth that Fig. 120. 98 ORTHODONTIA are being moved dis- tally in this second phase of the oper- ation, while in the first phase it was the lower teeth. The reten- tion for bi- m a x i 11 a ry protrusion is accom plished by intramax- illary reten- tion, and is shown under the head of "Retention." When sufficient anchorage can be obtained (which is usually possible), the first method shown, where the Cable-Spring Arch with reinforced an- chorage is used, is by far the best method, as distal movement of both jaws can be conducted at the same time. Besides, the spring arches are less harsh in the mouth, and do not interfere with the action of the jaws during mastication. In retraction of the anterior teeth, where extraction of the first bicuspids has been followed, it may be laid down as a rule that the anchor bands should be placed on the most posterior teeth, whether the force employed for tooth movement is intermaxillary or intramaxillary. Fig. 121. TREATMENT OF MALOCCLUSION 99 TREATMENT FOR PREVENTION OF CLASS TWO AND CLASS THREE CASES IN UNCONFIRMED MALOCCLUSION Since confirmed and unconfirmed malocclusion are terms which fre- quently occur under the head of "Treatment of Cases," the terms are defined as follows: By confirmed malocclusion we mean malocclusion in which all the permanent teeth in each jaw are present, whether the third molars have, or have not, erupted. By unconfirmed malocclusion we mean malocclusion in which the twelve-year molars have not yet erupted, and the distance between the six-year molars and the permanent lateral incisors is usually occupied by the deciduous molars and cuspids. The treatment of unconfirmed malocclusion has reference exclusively to the distal movement of the permanent first molars in any of the types of Class Two or Three. Other irregularities may exist in the central or lateral incisors which can be corrected in the usual manner; but the first permanent molars, as we have stated before, must be in normal occlusion, otherwise the whole dental arch is deranged. By moving the first permanent molars distally before the eruption of the second molars, bicuspids and cuspids, room is created for their reception when they erupt, and mesio-distal malocclusion in this region entirely prevented ; or in other words, protrusion of either the upper or lower teeth will not occur. In the treatment of unconfirmed cases, anchorage can not be secured from the permanent incisors for moving one or both the molars distally. Anchorage taken from the incisors, on account of insufficient resistance, would most likely result in the forward movement of the incisors rather than the displacement of the molars distally; therefore, if the upper molars are to be moved, the whole lower arch is employed for anchorage, in the following manner: Molar bands are placed on the up- per and lower perma- nent first molars and the stiff arch B shaped and placed in position on both den- tal arches. The nuts on the arch above are so adjusted that the anterior portion of the arch does NOT COME IN CONTACT with the incisors, standing slightly in advance of these teeth as shown in Fig. 122. Fig. 122. 100 ORTHODONTIA The nuts on the arch below are also abutted against the bolts of the molar clamp bands, but unlike the upper arch the anterior portion of the lower arch comes in CONTACT with the incisors and is ligated to the arch with No. 26 wire. This arrangement of nuts and ligatures below secures resist- ance of all the lower teeth as anchorage ; in fact, none of the lower teeth can move unless they all move, which is not likely to occur. When the appliances are placed on the teeth as shown in the cut, a rubber band of the size to exert suitable tension is caught in the hook of the upper wire arch and hooked over the distal end of the bolt of the molar clamp band below. The whole contractive force of this intermaxillary rubber band is thus thrown against the band on the upper molars which causes them to move distally into occlusion with the lower molars. If the molar on only one side is to be moved backward, a rubber band on the affected side only is used, and the wire arch on the opposite side allowed to touch the incisors and cuspid. If the lower molars are to be moved distally the operation is reversed. In this case the upper wire arch comes in contact with the incisors, while the anterior portion of the lower arch stands slightly away from the teeth. The intermaxillary rubber band is passed from the hook on the lower arch to the hook formed by the bolt of the molar clamp band above. The nuts on the upper arch (Fig. 122) can be turned from time to time to keep the arch from touching the incisors and cuspids. If the distal movement of the first molars is undertaken at an early age, say eight or nine years, they will usually remain in the corrected posi- tion, by interlocking of cusps during the process of mastica- tion or other closing of the jaws. How- ever. should a doubt arise in the mind of the operator on this point, the molars can be retained by band- ing the same and also the adjoining tooth forward, and uniting the bands with a lingual or buccal bar soldered to them. The tech- nic for this retention can be found under the head of Reten- tion. After the mo- Fig. 123. TREATMENT OF MALOCCLUSION 101 lars have been moved distally it is well to allow the appliance to remain on the teeth for a few weeks until the molars are somewhat stabilized in their new position. Fig. 123 shows a side view of the same case as that shown in Fig. 122. It can be seen in this view also how the front portion of the upper arch stands away from the incisors. This position of the arch in front is abso- lutely necessary. 102 ORTHODONTIA CLASS TWO-CONFIRMED MALOCCLUSION Class Two is characterized by the upper first molars being in mesial occlusion to the corresponding molars below, either on one or both sides, re- sulting in protrusion of the up- per incisors. (See Fig. 124.) If the case is mesial on both sides it is Class Two Type A, as shown in Figs. 125 and 126, and if mesial on one side only the case is Class Two, Type B, as shown in Figs. 127 and 128. In Class Two, the lower arch is invariably normally posed; that is, the lower first molars have their correct mesio-distal position; consequently, if the remainder of the lower teeth are aligned on this base, the lower lip will be in harmony with the rest of the features (when the upper protrusion has been reduced). Harmony of the upper lip with the lower facial lines is obtained by two methods. The first method is based on the theory that inter- maxillary rubbers will move all the upper teeth backward and all the lower teeth forward into normal relation with each other, regardless of the fact that the lower first molars are in normal mesio- distal position, and should not be moved forward. Extraction is not used in this method. The second method extracts one or both of the upper first bi- cuspids, and moves backward the six anterior teeth until the space caused by the extraction is closed. In confirmed cases we regard the first method as quite impossible, and the retention of the teeth as still more impossible. By the second method, perfectly satisfactory masticating surfaces are obtained, correct facial lines result, and retention is easy. Fig. 124. TREATMENT OF MALOCCLUSION 103 Fig. 125. Fig. 126. 104 ORTHODONTIA Fig. 127. Fig. 128. TREATMENT OF MALOCCLUSION 105 CLASS TWO, TYPE A Correction of Class Two, Type A, Without Extraction Confirmed Malocclusion When the correction of Class Two "A" is undertaken without extrac- tion, reciprocal intermaxillary force or anchorage is employed. See Fig. 129. No other an- chorage com- bines the nec- essary prin- ciple for act- ing simultane- ously on the upper and lower teeth at the same time. The supposition has been cur- rent that this anchorage will move all the upper teeth back- ward and all the lower teeth forward, and normal occlusion and facial lines be thus established. In confirmed malocclusion this theory is not borne out by the facts. What occurs is this: The circle of the upper anterior teeth is broadened, due to the distal pressure of the arch, but no distal movement of the molars takes place. It is quite impossible by applying power across the labial surfaces of the incisors to move the second molars in a distal direction. The point at which power is applied and the distal teeth, the point to be moved (the second molar) are too far apart for the force to be transmitted in sufficient intensity to cause the desired movement. If the force is continued long enough the bicuspids will show a tendency to be squeezed out of their sockets while the molars are still in their original position. 'l'he principal action in establishing occlusion without extraction is the apparent movement of the lower teeth forward through the process. The movement of the lower teeth is not due to their movement through the process but to the distortion of the condyle in relation to the glenoid cavity. The Temporo-Mandibular Articulation is held in position principally by the various ligaments which surround it. All the tissue that in any way sus- tains the mandible in position is soft tissue, while the bone composing the Fig. 129. 106 ORTHODONTIA mandible is the most compact bone in the body, enamel excepted; therefore, when force is applied by intermaxillary anchorage to the lower second molar for the purpose of moving all the lower teeth forward, frequently the width of a bicuspid tooth, it is the soft tissues which yield and not the compact bone of the process. It has been said by some advocates of this method that the angle of the mandible is changed in a favorable direction by the applied force, throwing the lower teeth forward. Now the angle of the mandible is the strongest portion of the whole bone, and necessarily so, as it connects the body of the bone with the ascending ramus, the two planes of which are more or less at right angles with each other. The two Fig. 130. ends of this right angle are represented by the condyle and the incisors; the condyle representing the resistance ; and the teeth, or body of the bone, the power. Therefore, it is the angle that connects these two levers that receives the stress and impact of mastication, hence naturally the greater rigidity of the bone at this point. See Fig. 130. Again, how can the mandible be altered at the angle when one end terminates in a loose ball-and-socket joint, held entirely in position by soft tissue? The bending of this stubborn angle implies definite immovable anchorage, or at least anchorage stronger than the point to be moved or bent; precisely as in moving teeth - the anchorage must be stronger than the point to be moved. The only available anchorage to the mandible is through the teeth. Now, can the angle of TREATMENT OF MALOCCLUSION 107 the mandible be so changed by anchorage to the teeth that the angle can be thrown forward carrying the process and the teeth in it to normal oc- clusion, and all this after the patient has reached the age of confirmed malocclusion ? We think not. It has been pointed out in other parts of this book that there is not such a thing as retrusion of the lower molars with protrusion of the upper teeth. There may be retrusion and constriction of the lower anterior teeth, but the lower molars are always in their normal mesio-distal position in Class Two cases. If the bicuspids, cuspids, and incisors are all placed in their proper position in this class and type, using the first molars as the base of alignment, lower facial lines will be correct. In other words, the lower first molars in this type are always in their normal mesio-distal relation, although expansion may be necessary. The constant characteristics of this class are protruding upper incisors with lower jaw normal. The ideal movement would be to move backward all the upper teeth into normal occlusion with the lowers. This would es- tablish normal facial lines. The great difficulties attending a major move- ment of this character, in confirmed cases, cannot be overcome even when the teeth are moved in sections, as explained under the head of "Extraction." It would be necessary to employ occipital anchorage for the movement of a single arch, as intermaxillary anchorage operates on both jaws. The cor- rection of protruding upper incisors is now conducted almost entirely by the intermaxillary method; and, as stated before, nearly the whole move- ment is made by forcing the lower jaw forward; which, if the lower jaw were normally posed to begin with, produces protrusion of both the upper and lower incisors, or bimaxillary protrusion. The logic of this is in- escapable. Another great difficulty met with in endeavoring to correct this sort of malocclusion without extraction is the impossibility of having the teeth stay, no matter how long they have been retained. The temporo- mandibular articulation works on the principle of a ball and socket joint (see Fig. 130), and while with sufficient force it may be distorted from its natural position ; rest assured it will, when released from artificial restraint, slip back to its former position carrying the teeth with it. Nothing but constant restraint can prevent the ball and socket from centering them- selves. It is well to remember it is the mandible principally which has been moved forward and not the teeth through the process. Altogether, from the viewpoint of treatment and retention, we regard permanent results as quite impossible in confirmed cases where the conditions have not been modified through extraction. The method of treating Class Two, Type A, without extraction and by intermaxillary force is as follows: The molar clamp bands are placed on the first or second molars above and below, and the stiff arch B or C bent in the fingers to correspond ap- proximately with the curve of the anterior teeth. If expansion of the posterior teeth is desired, the lateral halves of the arch are opened out and therefore, when compressed and inserted into the tubes of the molar clamp bands, will exercise lateral expansion. 108 ORTHODONTIA As shown in the cut (Fig. 129), the nut on the lower arch is in contact with the bolt of the molar clamp band and the anterior teeth are ligated to the arch with No. 26 wire. With the nuts and wire placed as described the lower teeth must travel forward in a body. The nuts on the upper arch, unlike the lower one, must not come in contact with the molar bolt as shown in C, otherwise the arch could not slip backward, carrying the teeth with it, in response to the pull of the inter- maxillary rubbers. CLASS TWO, TYPE A Correction of Class Two, Type A, With Extraction Confirmed Malocclusion Correction of con- firmed Class Two- Type A cases by ex- traction is, in our judgment, far supe- rior in every way to the results obtained by endeavoring to move all the teeth without extraction. Roth plans of treat- ment are shown in order that the den- tist may be able to make an intelligent choice as to which of the two methods to pursue. Figs. 131 and 132 show a typical Class Two-Type A case of malocclusion. The upper molars on each side are advanced the width of a cusp; or, in other words, the upper first bicuspid is exactly where the cuspid should be located in relation to the lower arch. Two methods are employed in the reduction of protrusion of the upper teeth by extraction. First method: If the two molars and second bicuspids are present on both sides, they can be combined into stationary, or rein- forced anchorage, by placing molar clamp bands on the second molars and plain bands on the second bicuspids, and connecting the bands lingually by wire soldered from one band to the other, or by flowing solder over a strip of thin contoured gold, as shown in C-D, Fig. 133. The uniting thus of the three posterior teeth will furnish all the resistance necessarv for the distal movement of the incisors and cuspids. The Cable-Spring Arch Fig. 131. TREATMENT OF MALOCCLUSION 109 A is used for the re- traction of the teeth. In order to arrive at the most speedy re- sult, INTRAMAX- ILLARY force i s used in addition to the traction of the Cable - Spring Arch A. The arch is fully competent to execute the move- ment unaided, only more time will be required than when supplemented by in- tramaxillary force. This technic is true in any distal move- ment that involves the cuspids. Fig. 134 shows in- tramaxillary force applied to the cuspids. The cuspids are banded, and a hook soldered to the disto-labial surface of the band into which the rubber is caught, and passed over the dis- tal end of the bolt of the clamp band. Notches are cut in the seam of two or more bands to hold the flexible arch in position. When suf- ficient posterior an- chorage can be ob- tained and r e i n - forced, as shown in Fig. 133, it is the best method, as it entirely does away with rubber bands passing from one jaw to the other, as is the case when intermaxillary force is employed. The de- Fig. 132. Fig. 133. 110 ORTHODONTIA tails of moving the six anterior teeth distally by the Cable-Spring Arch and intramaxillary anchorage are clearly shown in the two cuts. This is the same technic as already described in Bimaxillary Protrusion, Class One-Type D, Fig. 134 and is repeated here because it is used far more frequently in Class Two- Type A. Fig. 135. TREATMENT OF MALOCCLUSION 111 I he second method employs the principle of intermaxillary force. In the application of this force, as shown in Fig. 135, the molar clamp bands can be placed on the first or second molars. All the lower teeth with the exception of the second molars act as resistance for the retraction of the up- per incisors and cuspids. The lower incisors are ligated with No. 26 wire. This ligation of the lower incisors greatly increases resistance, as no tooth can move forward unless they all move. The position of the two nuts on the upper and lower arches is important. The lower nut "D" abuts on the end of the molar clamp band bolt, while the upper nut "C" is turned sufficiently forward so it will at no time come in contact with the bolt of the upper band. The upper arch must be able to slip distally through the bolt in response to the pull of the rubbers. It is the arch above being able to slip distally that carries the anterior teeth in a posterior direction. The liga- tures "G" below, and the position of the nuts on the arch are very plainly shown in the cut. In the course of treatment, if the upper wire arch should work down toward the incisal edges, it can be slipped out of the mouth and be rebent in a gentle curve again to occupy the desired position in front. Care must be observed that the arch is never bent or kinked in such a manner that it cannot slip freely through the bolts. This is important. Since none of the teeth below or none of the posterior teeth above have been disturbed, intramaxillary retention is employed when the case is com- pleted. (See chapter on Retention.) Fig. 136 shows a completed Class Two-Type A case with first bicuspids extracted. It will be noticed that the interdigitation of the buccal teeth is prac- tically as good for mastication as if the teeth were in normal occlusion. The movement of the an- terior teeth was ac- complished as shown in Figs. 133 and 134, in five months' time, while the retention covered a period of six months. There is no disposition whatever of the teeth to move for- ward when the re- tention is removed, as usually happens when the conditions are not modified by the extraction of the first bicuspids. Fig. 136. 112 ORTHODONTIA Fig. 137 shows the use of intermaxillary anchorage F for moving distally the upper anterior teeth, combined with intramaxillary anchorage A for exercising additional force for distal movement of the cuspids, after the first bicuspids have been extracted. Fig. 137. TREATMENT OF MALOCCLUSION 113 CLASS TWO, TYPE B Correction of Class Two, Type B, Without Extraction Confirmed Malocclusion This class and type has only one upper side advanced, the first molars of the opposite side being in normal occlusion with the lower teeth. (See Figs. 138 and 139.) The correction of Class Two-Type B, with or without ex- traction, is conducted substantially in the same manner, and by the same methods as just described for Class Two-Type A. except if extraction is followed, it is con- fined to one side ONLY. Figs. 138 and 139 show the buccal teeth of the upper left side about nor- mal with those of the lower, while the upper right side is Fig. 138. advanced the width of a bicuspid tooth ; or, in other words, the upper right first bicuspid is exactly in the position the cus- pid should occupy; therefore, if the method of extraction were followed in this case, the upper right first bicuspid would be the only tooth extracted. Fig. 139. 114 ORTHODONTIA As shown in rig. 138, the upper right lateral half must be moved distally until normal occlusion is obtained with the lower teeth. The backward movement of the teeth must be conducted in sections; that is, the upper second molar is first moved back into normal occlusion with the lower second molar, and then the upper first molar is moved backward into nor- mal relations with the lower first molar, and so on, one tooth at a time, until all the buccal teeth on the upper right side, including the cuspid, have been moved backward into normal occlusion with the lower teeth. The dentist will bear in mind that the case of malocclusion as shown in the cut is CONFIRMED, and also that we are not recommending this method of treatment, but only explaining the best procedure should he decide to attempt the work without extraction. We have long reached the conviction that the movement from the viewpoint of permanent results is impracticable. However, we give the technic. Molar clamp bands are adjusted to the lower FIRST molars and a B arch bent to encircle the lower teeth. The anterior teeth are ligated with No. 26 wire to the arch, and the nuts on each side of the arch are turned back in contact with the bolts of the molar clamp bands. This arrangement binds all the lower teeth together as stationary anchorage, for the back- ward movement (one at a time), of the teeth on the right side above. Molar clamp bands are also adjusted to the SECOND molars above, and force applied by the use of an intermaxillary rubber band, on the right side ONLY. The same principle is employed in this confirmed case for moving the second molar distally, as in moving backward the permanent first molar in unconfirmed cases of malocclusion. The nuts on the upper arch are so adjusted that they abut against the bolt of the molar clamp band on the right side and also keep the front of the arch slightly away from the anterior teeth. (See Fig. 140.) With this adjust- ment of the arch and nuts, the full force of the rubber band is exerted against the tooth to be moved, which in this case is the upper right sec- ond molar. After the second molar is in place, the molar band is transferred to the Fig. 140. TREATMENT OF MALOCCLUSION 115 first molar, and the operation continued until all the buccal teeth are in normal occlusion with the lower teeth. The cuspid is moved distally by banding, and soldering a hook to the labial surface of the band, and passing a rubber from the hook to the distal end of the bolt on the lower clamp band, which in itself forms a hook. As the second molar is moved distally, the nut on the upper arch can be turned from time to time to keep the arch away from the front teeth. Retention for the corrected case, when done by this method, must be on the principle of intermaxillary retention, which is shown in the chapter on Retention. CLASS TWO, TYPE B Correction of Class Two, Type B, With Extraction Confirmed Malocclusion Now, let us con- sider the correction of the same case (Class Two - Type B), with the condi- tions modified by the extraction of the upper right first bi- cuspid. (See Figs. 141 and 142.) The case, after extrac- tion, may be cor- rected by either IN- TRA MAXILLARY anchorage or I N - TER MAXILLARY anchorage. The correction of the case by intra- maxillary anchorage will be first de- scribed. Molar clamp bands are adjusted to the upper second molars, and on the right side a plain band is made for the second bicuspid. The resistance of the three teeth on the right side is reinforced by a contoured bar of gold, attached to the lingual surface of the two bands (the technic for making this bar is fully explained in C-D, Fig. 133), or the teeth on the right side can be reinforced by soldering two bands to- gether as shown in Fig. 143. Either of the two anchorages, thus reinforced, will offer the necessary resistance for the distal movement of the right cuspid. The left side in this movement is not reinforced; only a clamp band, to co-operate with the Cable-Spring Arch, is adjusted to the second molar. The two cuspids are banded with plain bands and notches cut in the labial Fig. 141. 116 ORTHODONTIA seam of the bands, to prevent the arch, which passes through the notch of the bands, from working up or down. The band on the right cuspid has a hook soldered to the disto-labial surface of the band, which engages a rubber that is carried backward and hooked around the end of the bolt of the molar clamp band. (See Fig. 143.) This intramaxillary rubber will greatly hasten the retrac- tion of the cuspid as it has a direct pull on that tooth. The Cable-Spring Arch is, of course, shortened from time to time by turning, which retracts the incisors according to their position, and also acts on the right cuspid in con- junction with the in- tramaxillary rubber. The teeth on the left, as far forward as the lateral in- cisor. remain sta- Fig. 142. tionary, since they cannot move distally. The bicuspid should not be ex- tracted until the op- erator is ready to begin the movement, as the cuspid can be moved much more easily toward the open socket, than after the socket is filled with bone. This is a general rule and applies when- ever extraction is necessary. Fig. 144 shows a side view of the Fig. 143. TREATMENT OF MALOCCLUSION 117 Cable-Spring Arch with Intramaxillary Anchorage. It also shows clearly a notched band on the right central for supporting the flexible arch, and a gold cuspid cap with points on the labial surface for further sustaining the arch in this region. The cap has a spur soldered to its disto-labial surface to e n g a g e the retract- ive rubber band. These caps are in- dispensable when cus- p i d s cannot be banded due to the fact that they are only partly erupt- ed. They can also be used for elonga- tion of the tooth by lift- ing the arch over one of the points; the points can be bent outward o r inward. Some dentists are under the impression that if only one bicuspid is extracted in the dental arch, as in Fig. 144, the circle of the teeth in front, from cuspid to cuspid, will not de- scribe an equal curve after correction ; and therefore, the upper and lower median lines will fail to coincide. From this supposition we must dissent. Fig. 144. 118 ORTHODONTIA Figs. 145 and 146 show a right and left view of a case of malocclusion in Class Two-Type B. The upper right side is in normal relation with the lower teeth, while the upper left is mesial to the low- er. IT MAY BE LAID DOWN AS A GENERAL RULE, IN MALOCCLU- SION OF THIS TYPE, THAT AS THE UPPER FIRST MOLAR IS ADVANCED, THE MEDIAN LINE ABOVE WILL BE DEFLECTED TOWARDS THE OP- POSITE SIDE, as shown in Fig. 147. If the upper left first bicuspid (as shown in Fig. 146) were extracted, and the space caused by extraction closed by retracting the left cuspid and shifting the incisors to the left to make room for the right cuspid, the median line above would coincide with the median line below. Sometimes the upper and lower median lines, in this type of malocclu- sion, seem to be cor- rect, but this agree- ment is delusive, for it is caused by over- lapping or other ir- regularities of the anterior teeth. If the teeth in front, in these cases, were moved so each tooth would have its mesio-distal relation to adjoining teeth, the upper median line would not coincide with t h e true median line be- low, but would ap- pear much as shown Fig. 145 Fig. 146. TREATMENT OF MALOCCLUSION 119 in big. 147. Indeed, how could it be otherwise? In order to have the upper and lower median line correct, all the first molars must be in nor- mal occlusion. If one side of the upper dental arch is advanced the width of a bicuspid tooth, as shown in Fig. 146, and the opposite side normal, as shown in Fig. 145, there must log- ically be more tooth structure in front on one side of the curve than on the other. The incisors and cus- pids, therefore, will present an irregular curve rather than the normal ellipse, it is only by moving all the teeth on the affected side back- ward into normal oc- clusion with the op- posing teeth, or the equivalent (extract- ing a bicuspid), that the teeth in front will describe a uniform circle. All we have said in this connection about the upper teeth applies with equal force to the lower, when in Class Three- Type B. Fig. 147. 120 ORTHODONTIA Class Three Confirmed Malocclusion Class Three is characterized b y protrusion of t h e lower anterior teeth, caused by the lower first mo- lars being me- sial to the up- per first molars on one or both sides (see Fig. 148). The up- per dental arch in this class is always normal- ly posed; that is, the upper first molars are in normal me- sio-distal rela- tion ; therefore, treatment con- sists in moving backward the lower arch un- til it is in nor- m a 1 relation with the upper dental arch. If this movement were practicable, and normal occlusion could be thus obtained, facial lines would be satisfactory ; but since in confirmed cases of malocclusion, the en masse distal movement of the lower teeth is quite impossible, the equivalent of the distal movement is accomplished by the extraction of one or more of the first bicuspids below, accordingly as the lower first molars are advanced on one or both sides. It is, therefore, recommended that both types in this class be corrected by extraction, that being the only method by which perma- nent and satisfactory results can be obtained in these confirmed cases. How- ever. the method of correcting this class without extraction is also explained. Class Three has two types, A and B. In Type A, both the lower first molars are mesial to the upper first molars, resulting in protrusion of the Fig. 148. TREATMENT OF MALOCCLUSION 121 lower jaw. In Type B, only one lower first molar is mesial to the corre- sponding upper molar, the upper and lower first molars of the opposite side being in normal mesio-distal relation. This type of malocclusion is also ac- companied by protrusion of the lower jaw, but not to the extent of Class Three-Type A, where the lower first molars are advanced on both sides. Correction of Class Three, Type "A", Without Extraction Confirmed Malocclusion Class Three, 1 ype A, is shown in Figs. 149 and 150. It will be noticed in the right and left views of the two cuts, that the right and left lower first molars in their relation to the upper first molars are advanced on each side about the width of a bicuspid tooth. The remainder of the lower buccal teeth on each side are also advanced propor- tionately with the molars, causing pro- trusion of the lower jaw. The buccal teeth above are also in lingual occlusion to the lower teeth, which is a characteristic of this class. Expansion of the upper arch along its lateral halves is indicated. We will first outline the method employed to correct a Confirmed Class Three, Type A case, as shown in Figs. 149 and 150, without extraction. Fig. 151 shows Figs. 149 and 150 fitted with appliances. In Fig. 151 the inter- maxillary rubbers are so attached to the upper and lower arches that their force tends to draw backward the lower teeth and at the same time move forward the upper teeth. This anchorage can, therefore, be termed Recip- rocal Intermaxillary anchorage. The upper anterior teeth must be ligated to the arch with No. 26 wire as partly shown in H-I Fig. 151, in order that they may be carried forward in unison with the posterior teeth. The cut shows the lower incisors ligated with wire, as in G. This ligation, however, is unnecessary, as the lower arch is always pressed tightly against the in- cisors, in response to the pull of the rubbers. Expansion of the upper bicuspids, by ligating them to the arch with wire, can be conducted simultaneouslv with the mesio-distal movement of the Fig. 149. 122 ORTHODONTIA arches. Also, any ir- regularities of the teeth, should they be present, can be corrected while the mesio-distal move- ment of the arches is in progress. Dur- ing the process of tooth movement, should the wire arches n o longer surround the teeth at the desired point, they can be slipped off and bent again to assume the re- quired position around the teeth. With the appliance adjusted as shown in Fig. 151 there is Fig. 150. nothing t o do but keep the various parts in working or- d e r, and await the de- sired move- ment of the teeth. Another method o f treating this case without e xtraction. would be to place the bands on the upper and lower second molars, and adjust the upper arch just as shown in the Fig. 151. TREATMENT OF MALOCCLUSION 123 cut, ligating it with No. 26 wire to the anterior teeth. The lower arch is also adjusted as shown in the cut, with the exception that the arch is not ligated in front. Nut D on the lower arch is turned distally until the an- terior portion of the arch stands slightly away from the incisors and cuspids, as shown in Fig. 140. The object of this position of the wire arches is to move distally the lower buccal teeth, one at a time; that is, one tooth on each side is moved at the same time, starting with the right and left second molars. By keeping the front portion of the lower wire arch slightly away from the teeth, the upper jaw is converted into stationary anchorage for the backward movement of the lower second molars. When these molars have been moved sufficiently, their bands are placed on the first molars and the operation repeated; and so on until the bicuspids have been moved distally. In the movement of the bicuspids, for engaging the arch, bi- cuspid clamp bands must be used, or plain bands with tubes soldered to their buccal surfaces. The cuspids are retracted by banding, and soldering a hook on the labial surface of each band. A rubber is then hooked to the band and carried to the upper clamp band, as shown in E, Fig. 151. (This rubber band would not be hooked to the arch, as shown in the cut, but to the band on the lower cuspid.) By this arrangement the cuspids are drawn backward by the resistance of the upper teeth. After the molars, bicuspids and cuspids have been moved backward, the nuts I) on the lower arch are turned forward until they no longer come in contact with the bolts of the molar clamp bands. The turning for- ward of the nuts permits the front portion of the wire arch to slip back in contact with the incisors. As the wire arch is pulled backward by the contraction of the intermaxillary rubbers, the incisors, of course, are car- ried back with it. The anchorage used in this latter method is Stationary Intermaxillary Anchorage, while that of the first method is Reciprocal In- termaxillary Anchorage. Although we have given in a general way the working details of cor- recting this class of malocclusion without extraction, for that reason it must not be thought we are in favor of the method. On the contrary, we are opposed to it. and believe the only practicable method in confirmed cases is that of extraction. The movement of the teeth of the lower jaw distally en masse is with- out a doubt the most difficult one in orthodontia. The lower jaw can be moved forward much more easily than backward. The condyle can be displaced forward in the glenoid fossa (temporarily) by force applied to the teeth; or even by a voluntary effort of the will, the lower front teeth may be made to protrude beyond the upper teeth. This goes to show the ease with which the mandible (but not the teeth in the mandible) can be moved forward. The movement of the mandible distally is an entirely different proposition. It cannot be moved voluntarily at all beyond the natural closing of the teeth, nor can it be moved backward to any extent when force is applied through the medium of intermaxillary rubbers, 124 ORTHODONTIA owing to the fact that the posterior surface of the condyle has consider- able bearing against the temporal bone (see Fig. 130). Besides, the cap- sular ligaments that surround the articulation are so arranged that they facilitate forward and rotary movement of the mandible, but not backward movement. In other words, the Temporo-Mandibular Articulation is so constructed that the mandible can move with ease in any direction except backward. CLASS THREE-TYPE A Correction of Class Three-Type A, With Extraction Confirmed Malocclusion The correction can be made in two ways, either by Stationary Inter- maxillary Anchorage, as shown in Fig. 152, or Intramaxillary Anchorage, as shown in Fig. 153. Clamp bands are usually placed on the upper first molars, although placing them on the second molars materially increases the resistance of the anchorage ; and an arch B adjusted to the upper teeth. The incisors are all ligated to the upper arch with No. 26 wire as partly shown in H, Fig. 152, and the nuts C adjusted to abut on the end of the molar clamp bands. All the teeth in the upper jaw are united for resistance by ligating the incisors to the arch, and having the nuts C rest against the bolt of the molar band. The combined resistance of the teeth in the upper jaw is so much greater than the resist- ance of the lower incisors and cuspids, which are the teeth to be moved, that the upper teeth, or anchorage, do not move at all. hence the term STATIONARY anchorage. It might be said here, however, that no anchor- age is really stationary a s the word im- plies, but only stationary i n the sense that Fig. 152. TREATMENT OF MALOCCLUSION 125 its resistance is greater, usually far greater, than the tooth or teeth to be moved, and is therefore, relatively speaking, immovable or stationary. Below, it is unimportant whether the clamp bands are placed on the first or second molars, as they support the ends of the arch only. When the bands are satisfactorily adjusted, an arch B is conformed to the lower teeth, making sure when the arch is finally in position that the nuts D are turned away from the bolt of the molar clamp band, as the arch must be able to slip backward through the bolts carrying the incisors and cuspids with it. If necessary the incisors and cuspids can be ligated to the arch, as shown in G. However, this is seldom necessary and should not be done except for some special reason. By observing the cut it will be seen that the intermaxillary rubbers pas£ from the lower to the upper wire arches ; and, therefore, while the stress of force is mainly exerted along a hori- zontal plane, there must necessarily be some force exerted along a per- pendicular plane as well; or, in other words, the direction of applied force tends to lift upward to some slight extent the anterior portion of the arch, and should teeth be ligated to it, they might possibly be elongated. As a rule, the lower arch should not be ligated in front for the sole pur- pose of holding it down against the uplift of the rubbers. If the arch works up too far toward the incisal edges, slip it out of the mouth and re- bend to conform to the desired position. Figs. 149 and 150 show the upper bicuspids and cuspids to be in lingual occlusion to the lower teeth. These teeth can be moved buccally by ligat- ing to the arch. The operator must determine whether or not it is neces- sary to band them for the movement. If expansion is desired in the region of the molars it can be obtained in the usual way with the expansion arch B. Lateral expansion above is conducted simultaneously with the distal movement of the lower teeth. As shown before in Figs. 115, 116, 119, 133, 134, 137, 143 and 144, we have found it advisable to place a direct force on the cuspids when neces- sary to retract them. They are the teeth which seem to furnish most of the resistance to the backward movement, consequently by applying this direct force their movement is accelerated. If this independent force were applied to the lower cuspids in Fig. 152 in addition to the pressure of the lower arch, the time of treatment would be considerably shortened. Should this supplemental force be employed, the molar clamp band must be placed on the second molar instead of the first, as shown in the cut. The band on the second molar would supply two molars and a bicuspid for anchor- age in place of one molar and bicuspid. This point must not be overlooked. Fig. 153 shows the same case as that shown in Fig. 152, undergoing correction without the intermaxillary rubbers. Two forms of intramax- 126 ORTHODONTIA i 11 ary force are here em- ployed ; name- ly, the Cable- Spring Arch and rubber bands. This is an efficient combinat ion for retracting the incisors a n d cuspids and does away with the in- termaxil lary rubber bands passing be- tween the jaws. Bands on the central incisors with notches in the seams of the bands and points on the gold cuspid caps will hold the flexible arch in position. Lateral expansion above can be obtained by placing molar clamp bands on the first or second molars and using expansion arch B in conjunction with them. The general alignment of the teeth above can also be made with this arch. The retention of Class Three, Type A, with or without extraction is illustrated and explained under the head of Retention. Fig. 153. TREATMENT OF MALOCCLUSION 127 Class Three-Type B Correction of Class Three-Type B Without Extraction Confirmed Malocclusion This type differs from the preceding type in that the lower first molars are mesial to the upper first molars on one side ONLY. On the opposite side the upper and lower first molars maintain their proper mesio-distal relation to each other. See Figs 154 and 155. This type is characterized by more or less protrusion of the lower in- cisors, but not to the extent of Type A, where the lower first molars are both mesial to the upper molars. Class Three-Type B occurs with less fre- quency than any other type here classified. In addition to the mesial occlusion of one lower half, there may also be irregularities of other teeth. Expansion of the upper arch is near- ly always necessary in the treatment of Class Three cases, regardless of whether the type is A or B, or whether or not extraction has been fol- lowed. The upper arch invariably has a constricted appearance throughout its entire length, and especially in the regions of the bicuspids and in- cisors. This constriction is caused largely by the displacement forward of the lower arch, permitting the up- per incisors and often the cuspids to bite inside the lower teeth. A good proportion of the cases, however, in either type of Class Three will have the lower incisors biting end to end with the upper incisors, as shown in Figs. 149 and 150. The treatment of Class Three-Type B cases WITHOUT extraction is pre- cisely the same as just shown and ex- plained for Class Three-Type A, wherein the text refers to the movement of teeth distally ONE AT A TIME. The only exception in the type now under consideration, Class Three-Type B, is that the lower teeth are moved on one side ONLY. Therefore, a repetition here of the technic is unnecessary. Fig. 154. Fig. 155. 128 ORTHODONTIA Intermaxillary Retention is employed for the retention of Class Three -Type B. In the chapter on Retention, Intermaxillary Retention is shown for the upper teeth. In Class Three this Retention would simply be RE- VERSED. Class Three-Type B Correction of Class Three-Type B With Extraction Confirmed Malocclusion 1'he treatment of Class Three-Type B WITH EXTRACTION is the same as already explained for Class Three-Type A, with the single ex- ception that only ONE bicuspid is extracted in this type instead of two bicuspids, as in Type A. Either form of anchorage can also be used as shown in Fig. 152 or Fig. 153. When the two forms of Intramaxillary Anchorage are used as shown in Fig. 153, the posterior teeth on the affected side can be reinforced as shown in Figs. 133 or 143. These Figures show reinforced anchorage for the upper teeth, but the same principle can, of course, be employed below when extraction of a bicuspid has taken place. Under Class Two-Type B WITH EXTRACTION, we have shown, Figs. 145, 146 and 147, that when a first bicuspid above was extracted on one side ONLY, the median line, after the anterior teeth had been retracted and the space closed, was improved. This is also true in Class Three - Tvpe B, WITH EXTRAC- TION, where the lower arch is con- cerned. The drawings (Figs. 156, 157 and 158), showing the occlusion of the low- er first molars with the upper and also sho w i n g the dis- placed median line below, will be found to be a substantially correct representa- tion of models in Class Three - Tvpe B. Fig. 156. TREATMENT OF MALOCCLUSION 129 Should the upper and lower median lines in this type appear to be about correct, it will be due to irregularities of some of the anterior teeth. If these malposed teeth were made to assume their normal contact points, the median line would be displaced to the right or left, according as to which side below was advanced. The median line after the correction of contact points would look much as shown in Fig. 156. It is only by moving distally and laterally the lower lateral half that is mesial to normal, or by extraction of the first bicuspid below on the affected side, and then moving distally and laterally the anterior teeth until Fig. 157. the space is closed, that the lower median line can be made to coincide with the upper. Figs. 156, 157 and 158 show three views of a Class Three-Type B case of confirmed malocclusion. If the left lower first bicuspid were extracted, and the cuspid moved distally into the place of the bicuspid, and the in- cisors also moved distally and toward the left, the median line between the lower central would coincide with the median line above. The retention of Class Three-Type B, WITH EXTRACTION, is ex- plained under the head of Retention. 130 ORTHODONTIA Fig. 158. TREATMENT OF MALOCCLUSION 131 METHOD OF RETAINING TOOTH SPACE DURING TOOTH MOVEMENT It occasionally happens in the treatment of orthodontia cases that it is desirable to maintain the space of the permanent tooth that has been lost through some cause, or the space of some permanent tooth that has failed to erupt. Fig. 159 shows a case where it is desired to broaden out the circle of the upper anterior teeth by intermaxillary anchorage. It is evident that if the force of this anchorage were exerted against the incisors to broaden the arch at this point, the first upper left bicuspid F might also be moved Fig. 159. more or less distally and partly close the space caused by the loss of the second bicuspid. In order to retain this space during the movement, the first bicuspid is banded and a wire soldered between the band on the bicuspid and the clamp band on the molar. This will retain the space exactly as if the second bicuspid were still present. On the right side of the same case the second bicuspid below is miss- ing (Fig. 160). It is evident that the lower first molar would be moved forward in response to the strain of the intermaxillary rubbers if the tooth were not reinforced against the movement, therefore the first lower bi- cuspid on the right is banded and a wire soldered between the band on the 132 ORTHODONTIA first molar and the band on the bicuspid. By this arrangement it can be seen that the first bicuspid above on the left cannot move distally nor can the first molar below move forward through the tension of the rubber bands. The lower arch, as seen in the cut E, is ligated with 26 wire, which converts the lower arch into stationary anchorage ; or, in other words, we have all the lower teeth below as anchorage for expanding the circle of the upper incisors. This principle of retaining space can be applied to any missing tooth. Fig. 160. Fig. 161 shows a case of an impacted cuspid in addition to other irreg- ularities of the upper teeth. An expansion arch C has been adjusted to the upper arch for the purpose of correcting the position of the anterior teeth, but the arch has nothing to do with the elongation of the impacted cuspid. In order to obtain attachment to the impacted cuspid it is necessary to remove the soft tissue overlying the tooth after a local anaesthetic has been applied. The soft tissue can be removed with a large round bur by the same technic as described for removing the frenum labium (page 20). Special effort should be made to uncover the lingual portion of the cuspid. Into this exposed part of the cuspid with a round bur. drill a hole not over TREATMENT FOR IMPACTED CUSPIDS TREATMENT OF MALOCCLUSION 133 one-thirty-second of an inch deep to accommodate a hook with roughened end that has been previously made of gold wire 20 gauge, as shown in I, Fig. 161. The roughened end is then cemented into the hole in the cuspid. Fig. 162 shows the hook in position without the arch on the teeth. Anchorage for elongating the tooth is secured in the following man- ner : Molar clamp bands and Arch B are adjusted to the lower teeth. This arch has three spurs made from 20 gauge wire and attached with soft solder to the arch as shown in Fig. 161, A, B and C. One spur is soldered directly under the Fig. 161. Fig. 162. 134 ORTHODONTIA cuspid which is to be elongated, and one spur C attached about one-half inch distally from spur B, while the other spur A is attached about one-half inch forward of spur B. The object of the three spurs is to enable the operator to change the direction of force at any time and direct the eruption of the cuspid. Erupted teeth can be elongated according to the method shown in Fig. 163. In this method the expansion Arch B is placed on the teeth below the incisal edges as shown in the dotted line A. A piece of grass- line is then tied securely around the neck of the tooth to be elongated and then tied around the arch which has been elevated enough to furnish sufficient downward pressure on the tooth. The impacted cuspid as shown in Fig. 161 can also be elongated by using the same principle, attaching the grass-line to the hook. Fig. 163. CHAPTER VIII Retention After teeth have been moved in any direction, there is a strong in- clination to return to their former positions of malocclusion; therefore, they must be held by some suitable mechanical device in their corrected positions until the process itself can hold them. The beginner, or the man with little experience in Orthodontia, must not make the mistake of thinking that the case is practically completed when the malposed teeth have been brought into the desired position, for retention plays as im- portant a part in the final results as the movement of the teeth. When a case of regulation has been completed, the models as the case stood originally become of vital importance. It is only through them that the original irregularities can be noted and the necessary restraining force applied to prevent the teeth from returning to their former positions of malocclusion. After the teeth have been moved into the desired position, the ap- pliance should be worn for a week or so longer in order that the teeth may become somewhat settled in their new position; when the appliance can be removed, the teeth cleaned, and the retainer made without much danger of the teeth changing position ; but it must be remembered that the retaining device must be quickly made and applied to the teeth after the regulating appliance has been removed. The retainer should go on the same day the appliance is removed, certainly not more than twenty-four hours should elapse between the change from regulator to retainer. In applying retention to a given case we only simplify the apparatus used in the regulation. In the following illustration we have shown those types most com- monly used, and each operator must call on his resourcefulness to modify these forms to meet the case. In Fig. 164 we have shown an enlarged view of a "V", or Gothic-shaped, arch. The movement for correction has been one of expansion and also rotation of the incisor "A". Several forms of retention are shown for cases such as this. In Fig. 165 the six anterior teeth are banded and the bands cemented to the teeth. Fig. 164. 135 136 ORTHODONTIA The teeth cannot move from this retention, and it is effective so far as that point is concerned. Its disadvantage consists in two thicknesses of material passing between the reeth and constantly holding them apart to that extent. It is not sanitary if worn for any great length of time, and is therefore liable to mark the teeth, or may even be the cause of caries. If any of the bands come in contact with the gums, a pyorrhea con- dition is likely to result. If the bands are carefully made and festooned to escape the soft tissues, this last objection can of course be avoided; however, if for any reason this banded retention is used, it must be inspected from time to time to insure sanitary conditions. Figs. 166 and 167 show a lingual and labial view of the same case. The two cuspids "B" and the right central "A" are banded and a lingual bar is attached with solder to the bands. The band on the central answers a double purpose, as it prevents this tooth from rotating, which it otherwise would do. Since these teeth have all been moved outward, there is a strong tendency for lingual re- action, which the lingual bar prevents. The method of mak- ing this bar is as follows: Band the three teeth with non-oxidizable bands, festooning the bands to escape the soft tissue. Then take an impression with modeling compound with the bands on the teeth. Remove the impression and place the bands back in their respective matrix and flow a model from suitable plaster. Some of the stone plasters are the best, as they become much harder than the plaster of paris, and do not consume so much heat in sol- dering. W hen the model is suffi- ciently dry, a strip of gold 1/16 of an inch wide and .005 thick, or gauge 36, is tacked with gold sol- der to one of the cuspid bands. By heating the gold strip to a dull red and following up with suitable in- strument. the strip is accurately and easily contoured to the lingual surface of the model. This strip for the lingual surface should be cut in a suitable curve. The contoured strip of gold can then be strengthened by flowing solder over it. The bar can be at- Fig. 165. Fig. 166. Fig. 167. RETENTION 137 tached to the remaining two bands during the process of flowing the solder. Very accurate adaptation can be made to the surfaces of teeth by this method. All retaining bands are cemented to the teeth. This form of retention is fairly reliable and is far more sanitary than the all-band reten- tion as shown in Fig. 165. Removable Retentions The dentist's attention is particularly called to the removable reten- tion here shown. No bands pass between the teeth when it is employed, nor does any part of it come in contact with the soft tissue as is generally the case when bands are used. This type of retention will hold teeth regardless of the direction from which they have been moved, as each tooth is held in a matrix of its own ; and perhaps most im- portant of all, each tooth has its individual movement and yet cannot leave its alignment. The device can be slipped off at any time and the teeth cleaned, which insures sanitary conditions. This removable retention is as easily made as any other kind of retention, and when accurately made will go into place without the least trouble. It may be claimed by some as an objection that if the patients can remove the retention at will, they will fail to wear it continuously and thereby permit the teeth to move out of alignment. It is conceivable that some half-witted patient might do this ; however, it is our experience that in practically every instance patients will carry out instructions. Fig. 168 shows a form of removable retention bar which can be employed on both the upper and lower teeth at the same time. This retention is quite ideal. The lingual and labial bar can be festooned to escape the soft tissues completely, and it can be removed each day and the teeth cleaned; besides, the contact points of the teeth are together and each tooth has individual movement and yet can- not escape from align- ment. Fig. 169 gives an occlu- sal view of the removable retainer and Fig. 170 gives a gingival view. Fig. 168. Fig. 169. 138 ORTHODONTIA 1 hese cuts are taken from an actual case. It is immaterial from which direc- tion the anterior teeth have been moved, this retention will hold each tooth in place. The technic for constructing this retention with the lingual and labial bar is as follows : An accu- rate impression is taken and a model run from some of the stone plasters. A strip of 24K gold % inch wide and 36 gauge thick is cut in a proper curve and then contoured to the lin- gual surface first and held in position during the proc- ess of contouring by clips "D" as shown in "A" or "F" (Fig. 171). The strip of gold can be contoured very easily as already ex- plained for Fig. 166, by holding with the clips and heating to a dull red with the Orthodontia lamp and following along behind the flame with an instru- ment shaped like a spatula. With this instrument the gold strip can be pressed into the embrasures between the teeth while it is still red, and adaptation se- cured. By annealing as described, all the spring is taken from the metal and it will lie close against the teeth throughout its entire length. 16K or 18K solder is then flowed over the con- toured strip of gold. Sufficient solder should be used to make a rigid bar, one that cannot be broken. The labial bar is made as out- lined for the lingual bar except that the Fig. 170. Fig. 171. RETENTION 139 strip may not be cut in a curve. The two bars now being held in position by the clips, the operator will assure himself that both bars are in close contact with the teeth throughout their entire length. If at any point either one of the bars appears not to be in close contact with the tooth, the bar can be reheated at the imperfect place and gently pushed until closer contact with the tooth is obtained. This can be done even though the bar has been covered with solder. When the contact points are satis- factory, the two halves are joined together. In almost all cases there is a natural path between the cuspids and first bicuspids through which 18 gauge iridio-platinum wire will pass (B Fig. 171). This wire is strongly attached with solder to the two bars. The wire which forms this connection must be of rigid material which does not become soft on heating. Solder can also be flowed over the connection. Occasionally it may happen that the natural path between the cuspid and bicuspid "B" is not sufficient to accommodate the 18 gauge wire. Should this occur, the path can be slightly enlarged with a separating stone without doing any practical harm to the teeth. How- ever, this is rarely necessary. This retention if necessary can be extended distally to the molars. All oxidization from heating can be removed from the completed device by boiling for a moment in equal parts hydrochloric acid and water. Do not put the final polish on the retainer until it has been tried on to the patient's teeth, as it may require slight grinding in certain places to escape contact with teeth of the opposite jaw. A small felt wheel 1% inches in diameter on the spindle of the motor with tripoli as the cutting grit will impart to the finished product a surface as smooth as glass. Another felt wheel carrying a very small amount of red rouge will give a bril- liant appearance to the gold. The inner surfaces of the bars, or those which come in contact with the teeth, are left just as they come from the model. Fig. 172 shows a lower labial and lingual view of the removable reten- tion, actual size as it appears on the pa- tient's teeth. Fig. 173 shows a lower labial and lingual view of the removable retention, slightly enlarged. As can be seen in both cuts the lingual and labial bars are not in contact with the gums at any point. Fig. 174 illustrates how the removable retention can be ex- tended along the lingual surface of the bicuspids for re- Fig. 172. 140 ORTHODONTIA tention of lateral expansion. "A" shows the edge of the labial bar which encircles the ante- rior teeth, including the cuspids. The lingual bar if neces- sary can be extended backward to include the molars, in which event the strip of gold must be con- toured into the lin- gual occlusal em- brasures of the teeth for support, other- wise there might be too much leverage on the unsupported end. The same tech- nic applies to the buccal surface if the labial bar is extended distally from the cuspids. In case both the lingual and labial bars are extended distally to the molars a cross section of iridio-platinum wire, gauge 18, can be passed over the occlusal surface between the molars and attached to the opposite bars with solder, as shown in "B", Fig. 171. This connecting wire can also be rein- forced by flowing solder over it. This retention may also be constructed with the lingual bar passing entirely around the distal surface of the most posterior molar and uniting with the bar on the buccal surface. Each tooth would then be held in a matrix and could not move in any direction. By contouring the strip of gold into the occlusal embrasures or connecting the two bars as shown in "B," Fig. 171, sufficient strength can always be obtained for posterior sup- port of this form of retention. The method of constructing this form of removable retention with posterior extensions is the same as already shown and explained for Fig. 171. Fig. 175 shows two laterals in torsion. This is a common form of malocclusion and after the teeth have been aligned, may be retained by the bar "C". The laterals are banded with gold banding material 36 gauge or .005 thick and an impression taken with the two bands on the teeth. The bands are returned to their indentures in the impression and the model run. The bands are Fig. 173. Fig. 174. RETENTION 141 now on the plaster teeth. A strip of soft gold is contoured to the labial sur- face with the ends projecting on to the cuspids "D" in accordance with the method described for Fig. 171. When the labial bar is satisfactorily adapted to the teeth, it is reinforced by flowing solder over the same. It can be noticed in the cut that the centrals are not quite in alignment in the uncorrected case. They are each a trifle in torsion. To hold them in the corrected position the bar "C" is not sufficient, therefore on the lingual surface of the lateral bands a short spur should be soldered with the end project- ing partly across the lingual surface of the adjoining central, as shown in Fig. 176. It can be readily understood that with the bar on the labial surface and the two spurs on the lingual surface, the centrals cannot rotate. 1 he lateral incisor bands are cemented to the teeth. Fig. 177 shows how a single tooth in torsion can be retained. The mal- posed tooth is banded and a contoured spur is soldered to the band with Fig. 175. Fig. 176. Fig. 177. Fig. 178. the end projecting on to the labial surface of the cuspid as shown in Fig. 178, and another spur attached to the lingual surface of the band with the spur projecting on the central incisor as shown in Fig. 176. It will be seen that the two contoured spurs resist the turning inclination of the lateral. If the lateral were in reverse torsion, the spurs would be reversed; that is, the labial spur would overlap the central incisor; and the lingual spur, the cuspid. To hold in its corrected position a tooth that has been rotated, it is absolutely necessary to employ the principle of the lingual and labial spurs. The contoured spurs are made by taking an impression with the band on the tooth, placing the band back in the impression and running up a model. A thin strip of gold is then tacked to the band with solder, and contoured to the surface of the adjoining tooth. The spurs are made strong and rigid by flowing solder over them. Fig. 179 shows the retention of a central incisor that has been moved directly outward. In this case both spurs are placed on the labial surface as shown in Fig. 180, as there is no inclination of the tooth to turn. Fig. 179. Fig. 180. 142 ORTHODONTIA For Class 2-Type A or B, also for Class 3-Type A or B, when First Bicuspids Have Been Extracted INTRAMAXILLARY RETENTION Fig. 181 shows an important kind of retention used in Class Two, Types "A" and "B" and Class Three, Types "A" and "B", when one or both first bicuspids in the same jaw have been extracted. The same retention as shown on the upper teeth in the cut can of course be used below if one or both of the lower first bicuspids have been extracted. Since the two mo- lars and second bi- cuspids above, as shown in the cut, have not been dis- turbed in retracting the six anterior teeth, they can be used as anchorage for retaining the anterior teeth. The retaining device is constructed as fol- lows : Band the two laterals with the seam of the band on the lingual surface, if tubes, as shown in the cut, are to be soldered to the labial surface of the band. Also place molar clamp bands on the first molars and clamp them in position. With the bands on the laterals and molars an impression is taken. Ihe bands on the laterals are carefully returned to their respective in- dentures in the impression. The molar clamp bands are also removed and this is done by giving the bolt sixteen quarter-turns. This is usually enough to enable the operator to slip the band from the tooth. W hen the molar band is removed from the tooth, the bolt can be turned back the sixteen quarter-turns, which makes the band practically the same size as when clamped on the molar and will make it fit its indenture in the impression. The molar and lateral incisor bands having been returned to the impression, a model is run ; and when separated, all the bands are found in their correct position on the plaster teeth. A soft wire 18 gauge is now passed around the teeth to determine approximately the proper length, and the ends of the wire threaded, as shown in the cut. The wire must project through the bolt of the molar clamp bands about % inch for the accommodation of the nut on the end of the wire. The retention is adapted to the teeth just as shown in the cut. The tubes are soldered to the bands on the lateral in- Fig. 181. RETENTION 143 cisors on the model after the wire is passed through them. In this way the alignment of the tubes and wire is perfect. A small piece of gold solder is used for the purpose, and some care must be taken that the solder does not How into the tubes, as the retaining wire must play easily through them. The nuts on the distal end of the wire are also adjusted to place while the retainer is still on the model. The retainer is transferred to the teeth as a whole, cementing all the bands in place. Should the retaining wire at any time become more or less loose, it can be tightened by turning the nuts on the distal end of the wire. If desired, a plain band with tube can be used on the molars in place of the clamp bands. An easier method of constructing this retention is to have the seam of the incisor bands on the labial surface, and notch them to contain the wire. (See Fig 181.) The notches can be strengthened by a little solder flowed against them. The retaining wire cannot escape from the notches, as the wire is always snug around the teeth. Experience has shown us that one of the most important objects to be kept in mind in the construction of any retaining device is that each tooth shall have individual movement and yet not be able to escape from alignment. With this principle in view the re- taining wire in Fig. 181 has not been soldered to the bands on the lateral incisors. INTERMAXILLARY RETENTION For Class 2-Type A or B, also for Class 3-Type A or B, When First Bicuspids Have Not Been Extracted Fig. 182 shows the application. This principle is employed when the upper teeth have been moved backward and the lower teeth forward. This retention can be constructed as follows: Bands .005 thick, or 36 gauge, are fitted to the upper cuspid teeth. An impression is then taken with these bands in place on the teeth, and after the impression is removed the bands are re- turned to their in- dentures and a model poured. After sep- arating the model from the impression a piece of soft gold wire .0 3 6, or 20 gauge, either flat or round, with a hook at each end is shaped to the curve of the anterior teeth, and soldered to the cuspid bands. Below, a gold band, .008 or 31 gauge, is placed on the first or second molar, with a hook soldered Fig. 182. 144 ORTHODONTIA to the mesio buccal surface of the band ; the hook in this position prevents the rotation of the anchor molar when the intermaxillary rubber is applied. Either a plain band as shown in the cut can be used or a molar clamp band. Should any of the lower anterior teeth have been moved from torsion, they would require retention as shown in Figs. 176 and 178 or some of the other forms of retention already shown. Intermaxillary retention prevents the lower arch from moving distally only; and the upper arch, mesially. What has been said regarding retention of the lower anterior teeth applies to the upper incisors as well. In case it is necessary to band one or more of the upper incisors to prevent rotation, the bands can be made and attached to the retaining wire at the same time as the cuspid bands. Fig. 183 is a reproduc- tion of a photograph of the patient's mouth showing one side of the upper portion of intermax- illary anchorage. In this case the lateral incisor instead of the cuspid is banded, as the lateral before straightening w a s in torsion and, there- fore, would have a tendency to resume its former position of malocclusion; the band soldered to the bar will prevent this movement of the tooth. The second bicuspid, as shown in the cut, is on the point of eruption while the second deciduous molar is still present. The deciduous molar, which has been holding the space for the bicuspid, was extracted immediately after the photograph was taken. We have spoken in other places in this book of moving distally the permanent first molars, in unconfirmed Class Two and Three cases. Fig. 184 shows a case in which the permanent first molars, before movement, were in contact with the second deciduous molars. The permanent molars have been moved distally on each side, as shown in the cut, and one permanent molar retained by banding the two molars and soldering a wire from one band to the other. This retention will prevent the molar from moving for- ward. The same retention can be used on the opposite side. This retention is made by banding the two molars and taking an impres- sion of the same with the two bands on the teeth, and pouring a model after Fig. 183. RETENTION 145 returning the bands to the impression. After separating the impression from the model, the bands are joined by attaching a wire with solder to each band. The bands are then cemented to the teeth. Fig. 184. CHAPTER IX Impressions and Casts Taking an impression of the teeth and their surrounding parts is seem- ingly such a simple operation as to require little description, and yet no other process in dentistry is so often poorly done. It is as necessary that an accurate model be made for Orthodontia as for a good artificial denture. In the latter instance every dentist is aware that an inaccurate impression will result in final failure. Models for orthodontic use with ill-defined teeth and cusps and perhaps the lateral halves deranged in their relation to each other, in carelessly assembling the pieces of the impression, with resulting incorrect occlusion, are very poor models for comparison. Judging from our own observation and the models constantly sent us for advice, dentists as a rule do not appreciate the importance of good models in this work. This is not intended to mean that the majority of dentists cannot make good models, but that they do seem to think that where Orthodontia is concerned any kind of model will answer the purpose. Those who entertain this view will discover, when too late, the value of a good model. It is, of course, obvious that after the teeth have been moved from their original position, the opportunity for taking another and better impression is lost forever. Since this matter of good models is so important in Orthodontia, it is thought advisable to outline the best method of securing them. Material for Impressions Models, to be of value and fulfill their purpose, must be practically accurate. Satisfactory impressions can be secured from either plaster or modeling compound. It was imagined at one time that plaster was the only substance from which a first-class impression could be secured. At the present writing it can hardly be said that this is correct. The manufac- ture and manipulation of compound has now been perfected to such a point that in most cases a reproduction of the teeth and their surrounding parts can now be taken with compound as satisfactorily as with plaster. Indeed, when we consider the expansion and contraction of plaster, and also take into account that the impression must be broken into pieces before it can be removed from the mouth, with the difficulty of joining the pieces nicely together, to say nothing of the minute pieces that arc frequently lost in the saliva, it does not seem to us that the plaster impression is any more accu- rate than the impression taken with modeling compound, which can be re- moved from the mouth in one piece. Fig. 185 shows upper and lower models made from modeling compound impressions. We do not think a better reproduction of the teeth and adjacent parts could be secured with plaster. 146 IMPRESSIONS AND CASTS 147 Preparing the Teeth for Impressions The teeth are first cleaned from all deposits ; if there are no apparent deposits, the teeth should nevertheless be gone over with pumice, to remove that characteristic slippery or greasy coating of mucin or other colorless constituents of the saliva. Plaster or modeling compound will not settle smoothly around the teeth with the coating present. If the teeth are cleaned just before taking the impres- sion, the plaster teeth, when 'shown on the model, will present a polished surface. Fig. 185. Impression Trays and Taking the Impression An impression tray with high walls is required in or- der to take the surrounding soft tissue as well as the teeth. Samples of these trays are shown in Figs. 186 and 187. In taking an im- pression with plaster or modeling compound, some of the material should be placed under the lip in order to get a clear imprint of the Fig. 186. 148 ORTHODONTIA frenum labium and frenum linguae, otherwise the lips will crowd the impression material away from the frenum when the tray is carried into place, and a very imperfect outline of these parts results. See Fig. 188. In using plaster, the palatine portion of the tray should be devoid of the ma- terial, as when the tray is carried upward into position, Fig. 187. the plaster will naturally squeeze upward over the vault of the tray. By this method superfluous plaster flowing backward onto the soft palate, gagging the patient, will be avoided in most instances. See Fig. 189. It oc- casionally happens that a patient can- not have plaster in- serted into the mouth without nau- sea. This can be overcome by spray- Fig. 188. IMPRESSIONS AND CASTS 149 ing the mucous membrane with a one-per-cent solution of cocaine hydro- chlorate, after which, in a few minutes, the impression can be taken with- out difficulty. Frequently the regulation is confined to one arch; neverthe- less casts must be made of both, other- wise the original relation of the arches would be lost when the case is completed. Besides, both casts are necessary for com- parative purposes during the progress of the work. An upper and lower cast pre- sent the whole picture in showing the relations of all the teeth, while one cast is but half the picture. Removing the Impression After removing the tray, a verticle V- shaped groove is made opposite each cuspid; some care must be taken that these grooves do not go quite through the plaster, as this would somewhat dam- age the impression. A hook scaler is a good instrument for cutting these grooves. See Fig. 190. By inserting a knife blade into one of these grooves and giving a sharp pry outward the labial piece is broken out; the buccal walls are fractured by a downward and backward pressure, using the thumb. The palatine portion can usually be dislodged from the roof of the mouth by gently working it back and forth. This leaves the impression in four pieces ; labial, palatine and two buccal. Should a greater number of pieces occur in the removal of the impression, with a little care they can be placed where they belong without impairing the value of the impression. See Fig. 191. If, upon the removal of the labial piece, the occlusal walls of the impression are found to be too thick to fracture easily, a V-shaped groove is also cut along the occlusal surface as shown in Fig. 190. The buccal pieces can then be easily brok- en off by a pry of the knife blade. When the impression has been removed from the mouth the pieces are held un- der gently flowing running water and all saliva and granu- lar particles washed away. Do not attempt to reunite the im- pression while the plaster is Fig. 189. Fig. 190. 150 ORTHODONTIA still wet. as this will ruin the sharp lines of the fracture. The impression is best assembled by placing the pieces back in the tray in which it was taken. Varnishing the Impression Shellac and sandarac are the best separating media. The impression, if taken in plaster, should dry an hour or so and then a coat of thin shellac applied with a camel's hair brush. Positively this fluid must not be thick ; it should flow like water. When the shellac has dried about an hour, the impression is given a coat of thin sandarac var- nish ; in order to obtain the best results, the im- pression should be var- nished within an hour aft- er taking, or before much of the water has evapo- rated from the plaster. If allowed to stand too long the varnish will penetrate the dry plaster instead of forming a smooth coat on the surface, and the model when separated will not possess the polished appearance it otherwise might have had. If either the shellac or sandarac varnish is unduly thick, the fine lines of the im- pression will be partly obliterated. If a modeling compound impression is taken, a coat of thin sandarac applied to the same will impart to the model a glossy surface. Not more than twenty-four hours should elapse, after pouring the model into a plaster impression, before separating the same. If allowed to stand too long, a chemical action takes place between the varnish and plaster that renders separation difficult, because the impression will stick to the model and can only be broken off in small pieces. The best results are obtained by separating the model as soon as the plaster is hard enough to admit of the operation. Fig. 191. Pouring the Model When the sandarac varnish is sufficiently dry, the model should be poured at once. Mix the plaster fairly thin and paint a coat of thin plaster in the indentures with a camel's hair brush. This painting acts as a guaran- tee against air bubbles in the deep depressions. As the plaster thickens, enough can be placed on the impression to form the base and the mass placed in a level position on a glass slab impression upward, and left to harden. IMPRESSIONS AND CASTS 151 Separating the Model When the model has hardened, the impression can be separated from it by paring off the occlusal surface until the brown shellac is visible. By a series of grooves cut along the inner and outer walls of the impression, until the shellac is again visible, the pieces can be broken off with a pry of the knife-blade. Haste should not enter into the separation of a model from the impression, otherwise teeth may be broken off which a little more care would have avoided. If air bubbles are discovered in the model they can be filled with thin plaster applied with a small pointed brush, after the spot has been thor- oughly dampened with water. Trimming the Models Trimming the base of a model appropriately adds greatly to the fin- ished appearance of the object. A person should follow some system in trimming the base in order that the lines and proportions of the whole col- lection of models will possess a uniform appearance. Fig. 192 shows an upper and lower model trimmed in about the right proportion. The base of the upper model has a straight line running from the center on each side to a point di- rectly over the cuspids and an- other straight line from the cus- pids to a point over the molars. The distal portion of the base is cut straight across to meet the buccal line and then the corner formed by the two lines is also trimmed. This work is best done with a plaster plane. Trimming the lower model dif- fers from the upper only in hav- ing one curved line from cuspid to cuspid instead of the two straight lines. Fig. 192. Marking the Occlusion Upon the completion of the models they can be compared to the pa- tient's teeth and occluded according to the bite. With a lead pencil a vertical line is drawn downward over the point of the mesio-buccal cusp of the upper permanent first molar on each side, allowing the lines to strike the lower teeth where they will. The original bite of the patient is thus es- tablished and a permanent record made of the same. It is also a good idea to draw a similar line through the cuspids. See Fig. 193. By placing these lines together at any time during the progress of the work, the original con- ditions can be ascertained. 152 ORTHODONTIA Study of Models A much more accurate conception of treatment can be determined by a study of models than of the teeth themselves. With the models the case can be looked over at leisure, the rela- tions of the lingual cusps as well as the buccal can be examined, and the two arches can be placed in any position for purposes of comparison. It is only through a study of the models that full information of the irregularities can be gained and an intelligent fee fixed. Fig. 193. CHAPTER X Photographs and the X-Ray in Orthodontia The use of the X-Ray in Orthodontia is invaluable in revealing the presence of permanent teeth that have been delayed in eruption. Without positive knowledge as to the presence and position or absence of the un- erupted teeth it is impossible to treat the case intelligently. For the purpose of illustrating the use of the X-Ray in Orthodontia a case is here shown of the upper and lower jaw which fully demonstrates the value of the X- Ray in this work. The radiograph in the following case is taken from a patient fifteen years old. Fig. 19 4 shows model of the upper teeth. The radio- graph (Fig. 195) clearly discloses that the roots of the temporary lateral and cuspid on the upper right side are nearly absorbed, without visible sign of the permanent lateral. The perma- nent cuspid on this same side has erupted distally to the temporary cuspid, in nearly the position the first bicuspid should occupy. No signs of either the first or second bicuspids can be discovered on the upper right side. The up- per left side shows the absorption of the lateral well advanced and only the permanent central, cuspid and molars present. There are no indications of bicuspids on this side. It therefore appears that the upper denture will lack the two permanent laterals and the four bicuspids. Fig. 196 shows the lower model of the same case. The right side in the lower jaw shows erupted the two permanent incisors and cuspid and also the molars; the second bicuspid can be seen pushing its way upward alongside the first molar. Only one tooth, the first bicuspid, is missing on this side. Fig. 194. 153 154 ORTHODONTIA The radiograph reveals on the left side, in this same lower jaw the two permanent incisors, cuspid and molars erupted, and the second bicus- pid deeply submerged, but no evidence of the first bicuspid ; therefore, the Upper Left Upper Right Lower Left Fig. 195. Lower Right right and left first bicuspids are missing in the lower jaw. It is not prob- able that any of these missing teeth either in the upper or lower jaw will ever appear. Fig. 196 shows the lower model with the appliance adjusted for the purpose of moving the right cuspid forward in contact with the lateral incisor. Some of the difficulties that permanent teeth encounter during eruption are shown in the radiograph, Fig. 197. The deciduous teeth may be retained too long or lost prematurely, which also greatly complicates normal dentition. That the permanent teeth have difficulty in assuming normal occlusion is evident. Go where we will malocclusion is there in abundance before us. Nor is it any respecter of persons; at least in the white race, the rich and the poor are treated verv much alike. PHOTOGRAPHY AND THE X-RAY 155 Fig. 196. Fig. 197. 156 ORTHODONTIA Photographs The correction of facial lines, as well as securing better relations of the teeth for mastication, are the objects aimed at in orthodontia; therefore, in those cases where facial lines are to be changed, due to the movement of teeth, two photographs of the patient should be taken before treatment is begun ; one showing a front, and the other a side view. These photographs preserve the original facial conditions; and, as the case pro- Fig. 198. PHOTOGRAPHY AND THE X-RAY 157 ceeds, are as important for purposes of comparison as the models them- selves. The upper and lower models of the case, in conjunction with the photographs, form a complete record of the original conditions. Figs. 198, 199, 200, 201, show photographs and models of the same case. On completion of the case new photographs and models are made and filed away with those taken before treatment. Fig. 199. Fig. 200. 158 ORTHODONTIA Fig. 201. CHAPTER XI Fees Two questions are continually being asked by dentists contemplating the correction of a case of malocclusion as follows: "How much time will be required to correct the case?" and "What should I ask as a fee?" With- out specific knowledge as to the extent of malocclusion or the ability of the operator these questions can be answered only in a general way. In our opinion any of the Class One cases, with the exception of Type D, should be corrected in from six to twelve months if the method is followed as laid down in the "Treatment of Malocclusion." There occasionally may be a case where the irregularity of the teeth is so great that more than a year will be required; however, these cases are few. A man who starts out to correct a case with a clear idea of what is to be done, who can also make the necessary bands or other attachments to be affixed to the teeth, and who will keep the appliance in working order, can correct Class One cases in an average time of eight months. This time, of course, does not include the period of retention. As a rule, teeth should be retained about twice the length of time that was required to move them. Retaining de- vices can usually be made delicate and inconspicuous; and it is immaterial if the patient wears them longer than actually necessary as long as they are occasionally inspected to guard against decay or the marking of teeth, caused by bands becoming loose. If removable retention is used it can gradually be discontinued by wearing it at night only and then every other night and so on, until the teeth are stabilized sufficiently to support them- selves. The correction of Class Two or Three cases where the conditions have been modified through extractions as recommended under the head of "Extraction" should be completed in from six to eight months. The re- traction of the anterior teeth in these classes does not take as long as the correction of many of the Class One cases. The retention is also propor- tionately shorter, a year being sufficient. However, as stated in treat- ment of Class One, a dentist should be in no hurry to remove the retention as long as it is doing no injury to the teeth. It is obviously far better that the retaining device should be left on the teeth longer than necessary than that it should be removed too soon. When a case of malocclusion presents for treatment at the dental of- fice, do not be too hasty in fixing the fee or stating the length of time re- quired for correction. The best method is to take modeling compound im- pressions of both the upper and lower teeth and make an appointment for the patient to return a week later. In the meantime models of the case can be run in plaster and the case studied more comprehensively from these 159 160 ORTHODONTIA models than from the mouth of the patient. From this study of the models a man of some experience can determine quite accurately the length of time necessary for treatment and also the fee, based on the length of time re- quired. It is usually necessary in a case undergoing active tooth regula- tion to see the patient once a week in order that the appliance may be kept in effective working order. Let us suppose we see a patient once every week for a year before the case is ready for retention. This will make fifty-two visits for the patient with an average of one hour for each visit. It the dentist considers his time worth five dollars an hour, the fee charged on this estimate would be two hundred and sixty dollars; and if ten dollars an hour is charged, the fee would be five hundred and twenty dollars. We think this system of estimating cost is fair to all parties con- cerned. Let the dentist first carefully decide the number of weeks neces- sary to correct the case, allowing one hour a week, and then multiply the number of weeks by his charges per hour. The dentist is cautioned not to accept cases of malocclusion for correction without a careful considera- tion of the work involved. If he makes an error in fixing his price it is nearly always in favor of the patient and consequently to his own finan- cial loss. It should be borne in mind that the treatment of malocclusion, from the time the case is begun to the time the retainer is removed, con- sumes many months and during all this time the dentist is responsible for the final results. It is not uncommon for a patient to appear with a broken retainer. When he does, the broken retainer must be repaired at once or even a new one made. This all takes time and must figure in the cost of the work. A case of malocclusion is never actually completed until the teeth stay in alignment after the retention has been removed. Since the treatment of malocclusion extends over several months of time the payments for the work naturally extend over the same time. We think the best plan is to ask the patient for one-half the amount for the case to begin the work, and the remaining one-half to be paid when the case is READY for retention, and not when the retention is REMOVED. This point should be clearly explained to the patient at the time arrange- ments for payment are made, otherwise there is likely to be a misunder- standing, the patient quite naturally assuming the case to be still unfin- ished as long as anything remains on the teeth. Of course, all patients cannot pay one-half the fee when the case is started but can make monthly payments. These monthly payments should be based on the computed time for correcting the case, not taking the time of retention into consideration. If the fee, for example, is to be three hundred dollars and the estimated time for correction one year, the monthly payments would be twenty-five dollars a month or a little more than six dollars for each visit of the patient, the first payment to be made at the time the work is begun. That the patient or the responsible guardian of the patient should clearly understand the amount to be charged for the correction of the case, the amount of payments, and the date of payments, and that the case will be considered finished when ready for retention and therefore the unpaid por- tion due at that time, is important. It avoids misunderstanding later on. FEES 161 When all this is clearly understood it is poor policy to allow the payments agreed on to lapse. If not checked in the beginning, they usually become worse as time goes on, and, furthermore, the attendance of the patient in keeping appointments gradually becomes unsatisfactory like the payments and the case drags along. If patients will not keep their part of the agree- ment financially, nor their appointments with fair regularity, the dentist will consult his own interests by quickly withdrawing his services from the case. People of this character will fritter away the operator's time and in the end blame him for not obtaining results for which they themselves are to blame. On the other hand the dentist also has a responsibility which he must be careful to observe. Each week the patient is entitled to have the appliance looked over, to be sure it is doing the work expected of it. If there are changes to be made they should be made at once and not put off to some other time; if the dentist expects promptness where patients are concerned it is only fair that he should be prompt with patients and not waste their time. In other words, let the dentist keep his part of the contract right up to date and then with a clear conscience see that the other party to the contract keeps his. In accepting a case of malocclusion for treatment the dentist should carefully look over the teeth and gums. If he discovers decay in teeth, or puffy or swollen gums which may later on develop into pyorrhetic condi- tions, he should state these facts to the patient, otherwise he may be blamed at a future time for having caused these conditions in moving the teeth. GENERAL INDEX A Abnormal frenum labium. 13, 20. appliances for, 21, 22, 23. removal of, 20. Anchorage, 72. intermaxillary, 29, 72, 74, 110, 111, 112, 115, 132. intramaxillary, 72, 88, 109, HO. Ill, 112, 115, 125. occipital and occlusal, 76. reciprocal intermaxillary. 75. reinforced, or stationary, 73, 93, 109, 116. simple, 72. stationary intermaxillary, 75, 93, 123, 124. Appliances, 43. Arch. Cable-Spring A. 44. double-bar expansion C. 51, 52, 53. expansion B, 50, 74. band, molar clamp, 54. band material, 58. cuspid caps, 53. for deciduous second molars, 26. for frenum labium, 21, 22, 23. for tardy eruption of permanent teeth. 18. ligatures, 59. of the author, 43. wrenches, 59. Arch, Cable-Spring A. 44. adjustment of, 44, 45. application of, 46. 73. 84 85. 86, 87. 88. 92. 93. 94. 96. 108, 109, 116. 117. 126. use with molar clamp-bands, 54. Arch B. 46. 50. 88. 90. 97, 99. 107. 108. 110, 112, 114, 121, 122, 124, 125, 132, 133. Arch C, 51. 52, 53. 107, 108. 133. Articulation, temporo - mandibular, 105, 106, 107, 123, 124. B Bands- cleaning of, 65. forming cuspid, 66. forming plain. 64. 65 . 66. molar clamp, adjustment of, 54, 55. alteration of. 55. notched. 49. 57. ready-made plain for anteriors and bi- cuspids. 48. 49. 57. 84. 86. 87. 88. 90. 93. 94. 96, 109. 110, 117. 126. separation of teeth for, 82. Band material, 58. c Caries. 26. Case. Dr. Case, 80. Casts, 146. Class One, 30. Type A. 35, 83. 84. Type B, 36, 88. Type C. 37. 92. Type D. 30. 95. with Arch A, 46. Class Two, 30. 99. 100. 102. Type A, 39, 100. corrected case. 111. with extraction. 108. without extraction, 105, 106. 107. Type B, 40, 73. 100. median line, 118, 119. with extraction, 115. without extraction, 113. Class Three. 24. 30, 75, 99. 100. Type A. 41, 120. with extraction, 124. without extraction, 121. Type B. 42, 119. 120. median line. 128, 129, 130. with extraction, 128. without extraction, 127. Classification, 30, 33. Confirmed malocclusion. 12. 100. 102. 113, 114, 115, 121, 124, 127, 128. defined. 99. 105, 108. Cuspids, impacted, 132. 133. Cuspid caps, 49, 52, 67, 84. 86, 87. 88. 90. 117, 126. D Deciduous second molars- appliance for, 26. influence of, 25, 26, 27. Diagnosis, 30. E Elongation of cuspid teeth, 51, 52, 117 134. Extraction. 30. 77. 78. 79. 80. 108, 115, 124 128. F Facial lines, 11. Fees, 159, 160, 161. First Molars, 24. Friction nuts, 50, 51, 52. 162 GENERAL INDEX-Continued G Gauge. Brown & Sharpe, 71. Gold. 43. Grass-line ligature, 47, 61. discolors arch, 49. with bands and without bands for ro- tation, 61, 84. H Habits, 13. I Impressions. 146. material for, 146. preparing teeth for, 147. removing, 149. trays, 147. varnishing, 150. Interchangeability of arches, 46. 50, 56. Intermaxillary rubbers, 53. L Ligatures, 48, 59. grass-line, 47. 61. rubber. 47, 62. wire, 51, 59. methods of twisting, 59, 60, 82. M Maleruption of the permanent first mo- lars. 13, 24. Malocclusion. 11. acquired, 12. causes of, 12. chart of, 34. classification of. 33. confirmed, 12 99. 100, 102, 113, 114, 115, 121, 124, 127, 128. defined, 99. 105, 108. cases of. 77, 78, 79, 80. inherited, 12. treatment of, 81. unconfirmed. 100. defined, 99. Mandrel for ready-made bands, 57. Median line. 118 119. 128, 129, 130. ' Micrometer, 71. Models, 150. marking occlusion, 151. pouring, 150. separating, 151. study of, 152. trimming, 151. Mouth-breathing, 13. N Nickel silver, 43, 63. O Occlusion. 11. normal, 11. marking the, 151. Opening bite. 89, 91. P Photographs, 153, 156, 157, 158. Premature loss of deciduous teeth. 13 15. R Radiographs, 27, 153, 154. Retention, 135, 136. construction of fixed appliances, 141. construction of removable appliances, 138, 139, 140. intermaxillary, 128, 143, 144. intramaxillary, 142. of first molars, 144. removable, 137, 138, 139. Root movement, 52. Rubber bands- intermaxillary, 73, 75, 90, 91. 97, 99, 122. 126. intramaxillary, 93, 94, 96, 116. Rubber ligature, 47. method of tying. 62. S Solder- silver, 64. hard, 64. soft, 64, 70. flux for soft, 70. Soldering, 63, 64. flux, 64, 70. of tubes and spurs, 63. T Tardy eruption of permanent teeth, 13, 17. Tipping incisors, 51. Too long retention of deciduous teeth, 13. Tools- band-driver, 68. band-forming pliers, 67. band-soldering pliers, 68. Brown & Sharpe gauge, 71. curved scissors, 69. 163 GENERAL INDEX-Continued Tools-Continued hard solder, 64. lancet. 69. micrometer, 71. orthodontia blow-pipe. 63, 68. silver solder, 64. soft solder, 64, 70. soft solder flux, 70. wire cutter, 70. wire ligature twisters, 68. wooden mallet, 68. Treatment, 81. age of. 81. Class One, Type A. 83. Class One, Type B. 88. Class One, Type C. 92. Class One. Type I), 95. Class Two, 102. Class Two. Type A. 105. 107. 108. Class Two, Type B- with extraction, 115. without extraction. 113, 114. Class Three, 120. Class Three, Type A- with extraction. 124. without extraction, 121. Class Three, Type B- with extraction, 128. without extraction, 127. for impacted cuspids, 132, 133. retaining tooth space. 131, 132. separation of teeth for hands, 82. U Unconfirmed malocclusion. 100. defined, 99. W Wire ligature, 59. bender, 69. cutter, 70. for separating teeth, 82. methods of twisting, 59, 60. twisters, 68. Wrenches- for Cable-Spring Arch A, 58. for arches B and C, 58. key wrench for molar clamp-band, 58. 164