Ideal Arch Form* Georce C. Cuuck, D.DS. Long Beach, California A great deal has been written in orthodontic literature about the shape of the normal dental arch of man. We orthodontists have always been in- terested in arch form and are familiar with the different types of normal arches usually referred to as being square, round, oval, tapering, etc. We also know that the shape of the dental arch is influenced by the mechanics of the movements of the jaw and we note the influence of these forces upon the arch by comparing the models taken immediately after active treatment with those taken a year or so after all retainers have been removed. We refer to such changes as settling. This settling is but the working out of the individual ideal arch form by the forces of occlusion and by the associated structures involved in the functioning of the denture. These forces aid in creating the final ideal arch form in our treated cases if we have closely approximated the normal arch form or they greatly assist in undoing our work if proper arch form has not been attained. I am going to show two treated cases in which arch form was neglected because we concentrated our efforts on correcting the mesio-distal relations and on the straightening of the crowded anterior teeth. Figures 1 and 2. ‘A great many cases show finished arches which ate far too wide in the anterior region as compared with the molar area, With the edgewise arch appliance, arch form becomes the basis of our plan of treatment, because in the use of this appliance we predetermine the arch form and create an ideal archwire to which we move the teeth. This keeps the arch form constantly before us while we are executing all of the other tooth movements necessary for the treatment of the case. For this reason the ideal alignment arch assumes a very important place in our plan of treatment. It is quite noticeable in the study of those completed cases which have stood up after the removal of all retainers, that the arch form is especially pleasing to the eye and is in harmony with the type of the individual, while those cases which have relapsed will usually reveal that poor arch form was established during treatment, The latter cases also show an excessive widen- ing in the anterior part of the denture due to our concentration in treatment upon the crowded anterior teeth. Many of these cases exhibit an arch form *Read before the Ninth Annual Meeting of the Edward H. Angle Society of Orthodontia, Chicago, October 2ist, 1933, 312 THE ANGLE ORTHODONTISTin the molar area that is even narrower than before treatment was started. This is especially true of our ribbon arch work where no ideal arch plan was created before treatment was instigated. A careful study of successfully treated cases and also untreated normal occlusions reveals certain features of arch form that need special considera- tion when we are forming our ideal archwires. The first point to be considered is the position that the cuspid teeth should occupy in the arch. I feel that in many cases we have been placing these teeth in a far too prominent a location and this has led to that full, square appearance so characteristic of many of our treated cases. Concerning arch form Dr. Angle says: “It will be noted that there is a straight line from the labial ridge of the cuspid to the center of the mesial labial ridge of the first molar. This line is always straight, regardless of the degree or form of the curve of the anterior part of the dental arch.” I be- lieve that in our effort to create our ideal alignment arches according to this pattern we have over-emphasized this straight line, thereby placing our cus- pids in a far too prominent position in the arch, especially in the lower arch. When lower cuspids are retained in this position the cuspids are apt to be the only teeth that are in occlusion during lateral movements of the jaw and because of this the patient will limit the movement of the jaw during mastication to an up-and-down movement. If the cuspids of both dentures are kept in a less conspicuous position and have the proper axial inclinations they will glide past each other with no more force of occlusion upon them than there is on the other teeth on that side of the arch during the lateral excursion of the jaw. In all cases which have remained in good occlusion following the retention period, along with such normal cases as we have been able to study, there seems to be a definite step-out from the labial ridge of the cuspid to the buccal surface of the first bicuspid at the level of the brackets. This is more pronounced in the lower arch than in the upper. This question was discussed in a paper by Dr. Ralph Waldron which appeared in the International Journal of Orthodontia in December, 1931. In this article there are a number of photographs of surveys of normal occlusions all of which show that when we make our alignment arch straight back from the cuspid to the molar we either pinch lingually the first bicuspids or move labially the cuspids. This is what happens in most cases when we are widen- ing the teeth out to an arch form that results in the very toothy appearance before mentioned. We have taken a number of models of normal occlusions and have cut the teeth off at the level of the brackets. We have fitted arches to these THE GLE ORTHODONTIST 313models at this level and have found that we need an additional bend to carry the archwire out from the cuspid to the first bicuspid. This is also necessary if we are to have the correct contact established between the cuspid and the first bicuspid. When the archwire is formed in a straight line it carries the contact point of the cuspid too far to the buccal aspect of the first bicuspid. Figure 1 In Fig. 3 we have a model of a normal occlusion with the teeth cut off at the level of the brackets and to this we have fitted archwires. On the left side of the archwire we have made the usual arch form running in a straight line from the cuspid bend to the molar; on the right side we have made an additional bend between the cuspid and the first bicuspid. It will be noted how this latter modification maintains the cuspid in its proper position, while on the left side it can be seen that the cuspid would be moved considerably to the labial to conform to the archwire, thereby causing it to be placed in far too prominent a position. We also see how this would upset the relation- ship of the contact points of the cuspid and first bicuspid teeth. The same need for a slight bend between the cuspid and first bicuspid 314 THE ANGLE ORTHODONTISTis noted if the maxillary archwire is to harmonize with this denture form. We found this not to be as pronounced a bend as is necessary in the mandi- bular archwire. When this additional bend is made in the archwite of a case under treatment it aids the contact surface adjustment of the cuspids and bicuspids and results in immediate improvement in the appearance of the case, Figure 2 ‘The second point I wish to discuss is the relationship between the maxil- lary and the mandibular archwires. Quoting from Dr. Strang’s Text-Book of Orthodontia: “When the two ideal, typal alignment arches are finished the mandibular should conform to the type of the maxillary and lie generally parallel to the latter but in lingual relationship to it as illustrated in Figure 188.” Fig. 4. We have taken some models of normal occlusions and have carefully adapted archwires to the labial surfaces at the level of the brackets in each denture, Placing these archwires in relationship to one another on a flat surface we find that they do not parallel each other but tend to approach one another in the molar region. This is due to the fact that when these arch- wires are in position in the mouth they are separated from one another in the anterior region by the thickness of the maxillary incisors at the bracket level, while in the molar region the bracket areas are in almost a vertical plane due to the vertical inclinations of the buccal surfaces of the molars. Fig. 5. This is an important consideration in forming our ideal arches as we know that any disharmony in molar relationship immediately leads to other changes in the relationship of one dental arch to the other. If alignment = ORTHODONTIST 7.arches are made to parallel one another at all parts the tendency will be to either overexpand the maxillary molars or to contract the mandibular molars. It is necessary, then, that we construct the maxillary archwire first and keep a record of its form so that when the mandibular archwire is formed it may be compared to this pattern and made in harmony with it in form, width and symmetry. Figure 3 ‘A study of normal occlusions reveals that few are symmetrical; that most normal occlusions present a certain amount of asymmetry of arch form. I believe it beyond our present ability to work out the asymmetry for any given case. Such detail of arch form is worked out for us during the reten- tion period by the normal forces which act upon the denture while it is functioning. Because of this it seems a better plan to form our ideal align- ment arches symmetrically. The technique of bending the ideal alignment arch, as given to us by Dr. Angle, is well understood by this group. This technique of archwire bending has been presented several times by members of this society and has been added to until a fairly standard method is in use by most of us. In spite of this standardization it will be found that, given one set of measure- ments of a denture, each of us will construct differently shaped archwires for the same mouth. This difference will be so great as to be alarming when we consider that there is probably but one best arch form for any given case. This wide difference in results is due to the fact that in our present method of forming an ideal alignment arch we have no plan to guide us; we do it 316 THE ANGLE ORTHODONTISTempirically, with our supposedly trained eyes. For this reason, in the work which has been given our profession on the subject of arch predetermination, we have sought for some plan which would serve as a guide in creating our ideal alignment arches for a given case. One of the earliest attempts at arch predetermination was that of Dr. Bonwill. Since then many systems have been worked out, each becoming Figure 4 more complicated and requiring such elaborate instruments in their use as to make them prohibitive in our daily practices. None of these methods have yet been considered general and universal. One group takes as a basis of calculation, the dimensions within the dentures, and the process consists of metric methods (ratios) and graphic methods with various and sundry curves; the other methods are based on occlusion itself. In the first group we have the work of Bonwill, Campion, Pont and Williams; in the other, we have Stanton, Gilpatrick, Johnson and others. None of the ratios set forth by these methods can serve to establish in certain manner the dimensions of a normal arch. Knowing this, however, a study of the Bonwill method as adapted to orthodontia by Hawley revealed a much smaller variation when applied to our cases than we were subjecting them to with our present technique. For this reason we believe we can use to advantage the Bonwill-Hawley method as an aid in our present technique of constructing ideal alignment arches THE ANGLE ORTHODONTIST 317I wish to say at this point that we are not advocating the Bonwill- Hawley arch as a diagnostic method of arch predetermination but only as an aid in constructing a symmetrically formed alignment arch up to a certain point in its formation, from which it may be altered to give the required form using all the guides to type at our disposal while at the same time maintaining the symmetry of the alignment archwire. Figure 5 I will now show the method of constructing this Bonwill-Hawley pattern and how it may be applied to the technique of forming symmetrical alignment archwires. Fig. 6. Take as an example any case and, using the combined widths of the central, lateral and cuspid as a radius, draw a circle A. H.C. Measure the radius upon the circumference of the circle at H. and J., marking the distal points of the cuspids. From C., the end of the diameter of the circle, drawn through A. and B., draw the lines C. D. and C. E. through H. and J., ex- tending them indefinitely. Draw a tangent to the cirle at A., cutting these lines at D. and E., forming the equilateral triangle C.D. E. Take one side of this triangle as the radius of a circle passing through A with the center I, upon the extension of the line A.C. From A., mark off six times the radius of the circle, whose center is I., upon the circumference and draw the inscribed triangle A. F. G. Draw the lines F. J. and GH. We have now an arch based upon and arranged with an equilateral triangle but proportional to the widths of the three front teeth, or the radius A. B, This figure when placed ‘on the model passes through the cutting edges of the teeth. 318 THE ANGLE ORTHODONTISTFigure 7 THE ANGLE ORTHODONTISTFigs. 7, 8, 9, and 10 are of models of treated and untreated normal occlusions. A Bonwill-Hawley chart was made for each case and conforming with these charts we constructed archwires and superimposed them upon the models. Fig. 11 shows two cases in which proper arch width was not attained during treatment as indicated by superimposed Bonwill-Hawley charts. ne Figure 8 Fig. 12 shows a case before and after treatment. There is an interesting history attached to this case. Following active treatment retainers were wom and a cuspid to cuspid retainer was kept in place for five years. A model taken at this time shows that during the retention period there was a fourth of an inch increase in width in the molar area. I believe this widening should have been accomplished during active treatment and would have been if ideal arch form had been carefully considered. 320 THE ANGLE ORTHODONTISTThe three archwires in the illustration are all the same and conform to a Bonwill-Hawley chart created for the case. You will note how the tooth position closely approaches the predetermined arch -form in the final model. We have yet to find a normal mouth in our practices where an archwire was constructed according to this plan that did not follow very closely through the cutting edges of the teeth regardless of the size of the mouth, Figure 9 However, the ideal alignment arches which we create for our cases are not placed upon the cutting edges of the teeth which the lines of this chart alone locate. Hence Fig. 13 was prepared to illustrate the relationship that our alignment arch bears to this chart. In this we see an archwire, formed over the Bonwill-Hawley chart, superimposed on the model. We also have placed an alignment arch, with its brackets in position, on this model. Now it will be seen that if we are to create a chart to be used as a guide for the THE ANGLE ORTHODONTIST 321construction of an alignment arch we must add to the measurements of the central, lateral and cuspid in order to create an archwire large enough to assume the desired relationship to the denture instead of one that conforms ‘to the cutting edges of the teeth. This additional measurement consists of the width of the bracket, the width of the band and the necessary amount Figure 10 required to catry the archwire from the cutting edge of the incisor to its labial surface. The total of these measurements is approximately .125” or % inch for the central, lateral and cuspid of each side. It is also to be noted in Fig. 13 that the anterior section of the ideal alignment arch is closer to the Bonwill-Hawley arch than are its buccal sec- tions. For this reason, in forming the alignment arch with this pattern as a basis, the anterior section is formed within the pattern while the buccal sections are formed on the outside of the pattern. 322 THE ANGLE ORTHODONTISTHaving constructed a Bonwill-Hawley chart from the measurements of the central, lateral and cuspid teeth, we will now proceed to construct our ideal alignment archwire using this chart as a guide. Where the correspond- ing teeth in a denture differ in size it is well to select the average measure- Figure 11 Figure 12 ment. This one measurement is carefully transferred to the record card and is used as the measurement for both centrals. Next, one-sixteenth of an inch is marked off on the card before adding the lateral measurements so that the central and lateral measurements will be separated by this extra sixteenth of an inch. The measurement of the average of the two laterals is then added to the record card. Again, one-sixteenth of an inch is marked off and placed THE ANGLE ORTHODONTIST 323between the lateral and cuspid measurements. Next to this one-sixteent mark on the record card is added the measurements of the cuspid, bicuspic and first molar. The importance of adding these additional amounts in tl manner indicated so that they lie between the central and lateral, and tl lateral and cuspid measurements, is best shown in illustrations. In Fig. 1 Figure 13 the section of archwire had the measurements of the teeth transferred to consecutively without any allowance being made for the fact that the arct wire must follow a larger circle, situated far to the labial from the cuttin edges of these teeth. When the archwire was bent to the contour of the arc form and placed in the brackets we note that the distal cuspid mark ha been brought forward into the cuspid bracket. In Fig. 15 we see a sectio of archwire to which the additional one-sixteenth of an inch had been adde between the measurements of the central and lateral and the lateral an cuspid. We now find that the distal cuspid mark falls opposite the en brasure between the cuspid and bicuspid teeth, just where it should b found. In the lower arch, one-eighth of an inch is added between the later: and cuspid mark only. Having the measurements on our record card our next step is to transfe these measurements accurately to the archwire. First transfer the media line to the wire and then, with a pair of dividers, check the ends of the arck wire to see that they are at equal distance from this median line. Next trans fer to the wire the center point of the one-sixteenth of an inch space, whic 324 THE ANGLE ORTHODONTIS:Figure 14 Figure 13 THE ANGLE ORTHODONTIST 325was added between the central and lateral. With a pair of dividers the same distance may be marked off on the other side (right or left) of the archwire. We next transfer the mid-point of the one-sixteenth of an inch, which was added between the lateral and cuspid marks, and again, with the dividers, transfer this measurement to the opposite side of the wire. The distal cuspid Figure 16 mark and the molar mark are now transferred to the wire. These two mark: are transferred to the other end of the archwire by means of the dividers It is absolutely necessary that each and all of these marks on respectiv sides be at equal distances from the median line if we are to keep our arch wire balanced and symmetrical during its formation. With a Bonwill-Hawley chart before us as a guide it is a simple matter to bend the arch from cuspic to cuspid making it conform to the inner surface of this true curve. If the bend which we have put into the archwire is irregular it may be readily altered to conform to the pattern as shown in Fig. 16, A. In Fig. 16, B w see that the two cuspid bends have been made equal to each other. In Fig 16, C the bends between the cuspids and the laterals have been placed in the 326 THE ANGLE ORTHODONTIS”archwire and are equal to each other. Fig, 16, D shows the first step of the central-lateral bend and Fig. 16, E, the second step of the central-lateral bend. In Fig. 16, F are noted the slight bends necessary to carry the arch- wire from the labial surface of the cuspid to the buccal surface of the first ‘bicuspid. This also deflects it to the outside surface of the Bonwill-Hawley Figure 17 chart. In Fig. 17 we see the archwire with its final molar bends and note its relation to the lower archwire. In this illustration we also see the square archwires with straight sides which are a fair example of what we have been constructing in the past. The mandibular chart from which the mandibular archwire is formed is not based upon measurements taken from the mandibular teeth but is pat- teed after the maxillary chart of the case in question. It is constructed inside of the maxillary chart, using the same center for the primary circle but a radius that is one-eighth inch shorter than that used for the maxillary. ‘The lines for the buccal segments are also drawn one-eighth inch from the corresponding lines of the maxillary chart. ‘The mandibular archwire is bent to conform to this smaller chart from cuspid to cuspid mark. It then passes outside of the lines of the buccal seg- ments and gradually approaches the maxillary chart in the region of the first molars where it runs parallel to it. That is its general outline. Of course the cuspid bends and the step-out bends from the cuspids to the first bicuspids are made in their regular order during the bending of the archwire. We believe this method to be a simple guide to arch form with much less variation from normal than our past method of determination has had. It also shortens the time of making the ideal alignment archwire and aids in keeping it symmetrical in the process of formation. Security Building THE ANGLE ORTHODONTIST 327