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History of Orthodontics
A glance at an exciting path, the oldest specialty
of dentistry has treaded so far…
Basavaraj Subhashchandra Phulari

BDS MDS FAGE FRSH

Formerly
Faculty, Department of Orthodontics and Dentofacial Orthopedics
Mauras College of Dentistry, Hospital and Oral Research Institute
Republic of Mauritius
Foreword
US Krishna Nayak
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History of Orthodontics (A glance at an exciting path, the oldest specialty of dentistry has treaded so far…)
First Edition: 2013

ISBN 978-93-5090-471-8
Printed at
Dedicated to
My Dear Parents
Subhashchandra and Shivalingamma Phulari
My Brothers
Sangamesh BE (USA), Jagadish BE (USA) and Manjunath BE (USA)

My Beloved Wife
Dr Rashmi GS, Reader (Oral Pathology)
and
My Sons
Yashas and Vrishank
Foreword
Humanity is passing through the most exciting period in the history of its
existence, because of rapid technological advancement and increase in the
research activities, there has been an enormous increase in the information
available which has led to better understanding of the respective subjects and
areas of specialization.
With the contemporary understanding of orthodontics, it is more apt and
important for everyone involved in the subject to be aware of how our
forefathers in the subject thought, how the subject evolved in different
countries, how new concepts evolved providing a trigger to each and everyone
to explore deeper into the subject and make learning more exciting and enjoyable.
Dr Basavaraj Subhashchandra Phulari has made sincere efforts to go into

the depth of each topic providing an exhaustive insight. I am convinced that it

will be a great learning experience for all the readers.
US Krishna Nayak
BDS MDS (Ortho) FFPA FICD FADI FWFO
Dean Academics, AB Shetty Memorial Institute of Dental Sciences
Karnataka, India
Past President, Indian Orthodontic Society
Past President, Indian Dental Association Head Office
Chairman, 8th Asia-Pacific Orthodontic Congress and 47th IOC
New Delhi, India
Chairman, 17th IOS PG Convention-2013
Editor, Asia Pacific, HEAL TALK-A Journal of Clinical Dentistry
President Elect, International College of Dentists
(India, Sri Lanka and Nepal Section)
Secretary, International College of Continuing Dental Education
(India Section).
Immediate Past Chairman, Pierre Fauchard Academy
(India Section)
Preface
Knowledge and understanding of the history of a scientific field can enable future practioners of that
field better to anticipate and respond to the challenges of rapid globalization and be better prepared to
mold our future.
Exposure to the history of our specialty helps us think, ask question and explore the concepts and
enable us to grasp what the subject is about and how it has evolved over the years.
History of Orthodontics is interesting and same time it is complex. This book is an attempt to glance
and take a note of important milestones in the exciting journey of this fascinating field. It is hoped that
the book would be useful to all the students of the faculty.
Extensive coverage of important events in the history of orthodontics that shaped what it is today.
Separate chapters dedicated to eminent inventors of the field—EH Angle, LF Andrew, James McNamara
and TM Graber.
Evolution of recent advances in orthodontics such as Invisalign and dental lasers are included.
Evolution of orthodontic materials, model analysis, cephalometrics and orthodontic appliances are
included. Exhaustive list of references is given for further reading.
Basavaraj Subhashchandra Phulari

basavarajsp@gmail.com
Acknowledgments
Writing history of the oldest specialty of dentistry and as fascinating as orthodontics at that, was a
herculean task. For writing history of any field, even it requires the author/historian to be present at
that specific time and place of the event that has taken place, which is practically not possible.
An event of today becomes history tomorrow. As we unravel and cherish the history of yester-
years, a new history would be shaping today. In the light of this practicality, I do agree that none of the
chapters in the book is directly written by me. I have drawn generously from the existing literature
about the subject in the form of various books, journal articles, research papers and thesis, etc. In many
of the chapters, literature about a specific event or person/researcher is kept as it appears in its
original literature so as to maintain authenticity and also not to inadvertently twist the history. Many
of the illustrations of the orthodontic appliances and photographs of eminent researchers used in this
book are facsimiles of the pictures that appear in the existing literature about the subject.
I hereby humbly acknowledge all the authors of various orthodontic books, articles, thesis, seminars, etc.,
whose works inspired the birth of this project. The list of the literature used for the preparation of this project is
given at the end of the book under the heading of suggested reading.
I also gratefully acknowledge all the professors, teachers and postgraduate students of the faculty from
various dental institutions in India and abroad who have contributed directly or indirectly to this exhaustive
piece of work.
My special thanks to my beloved wife, Dr Rashmi GS, Reader and Postgraduate Guide,
Department of Oral Pathology, Manubhai Patel Dental College and Hospital and Oral Research
Institute, Vadodara, Gujarat, India, for her valuable critical comments during the preparation of
the manuscript, editorial assistance and proofreading.
I take this wonderful opportunity to thank Dr Rajendrasinh Rathore, Chairman of Manubhai Patel
Dental College and Hospital and Oral Research Institute, Vadodara, for his inspirational support
during this endeavor and throughout my career. I also thank Dr Yashraj Rathore, Trustee, Manubhai
Patel Dental College and Hospital and Oral Research Institute, Vadodara, for encouraging me during
this project.
I owe a debt of gratitude to Professor (Dr) US Krishna Nayak, Dean Academics, AB Shetty Memorial
Institute of Dental Sciences, Mangalore, Karnataka, India, for his continuous encouragement in all my
endeavors and for providing foreword to this book.
I am indebted to Dr Anil Shah for all the help and encouragement I have received from him during
the formation of the Chapter 7—History of Dental Lasers and their Applications in Orthodontics in
the book.
I extend my heartfelt gratitude to Dr Padmaja Ankit Arora for helping me with important references
that were required for writing the chapters on TM Graber, James McNamara and Invisalign.
My heartfelt gratitude goes to Dr Poorya Naik, Assistant Professor, College of Dental Sciences,
Davengere, Karnataka, Dr Ramesh GC, Assistant Professor, Sharavati Dental College, Shimoga,
Karnataka, and Dr Sujay J, Assistant Professor, SJM Dental College, Chitradurga, Karnataka, who
have helped immensely in this endeavor. Exceptional efforts made the production of this book possible.
I extend my special thanks to Dr Hina Desai for comments and suggestions regarding chapter on
Dr TM Graber’s Contribution to Orthodontics.
xii History of Orthodontics
I will be failing in my duty if I do not mention the affection and support I have received from
Dr Syed Zakaullah, Chairman, Al Badar Dental College and Hospital, Gulbarga, Karnataka, who has
always provided that moral boost much needed during compilation of this book.
My heartfelt gratitude goes to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing
Director) and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P)
Ltd, New Delhi, India, whose exceptional efforts made the production of this book possible. I gratefully
acknowledge the contributions made by the talented professional staff at M/s Jaypee Brothers Medical
Publishers; in particular, I would like to thank Mr Venugopal V, Mr KK Raman and Mr Rajesh Sharma,
for their untiring efforts in ensuring that every minute detail is taken care of.
I am indebted to my dear parents for all their love and sacrifices that have made me what I am.
I thank my dear sons Yashas and Vrishank for being the constant source of inspiration to set and
reach new goals in life.
Most of all, I thank God for all the kindness and mercy showered upon me.
Contents
1. History of Dentistry 1
Ancient Dentistry 2
Dentistry During the Middle Ages 6
Dentistry in the Sixteenth and Seventeenth Centuries 7
Dentistry in the Eighteenth Century 10
2. Introduction to Orthodontics 14
Definition of Orthodontics 14
What is Malocclusion? 15
Aims of Orthodontic Treatment 15
Branches of Orthodontics 16
Orthodontic Appliances 17
Timing of Orthodontic Intervention 18

Scope of Orthodontics 18
Benefits of Orthodontic Treatment 19
3. History of Orthodontics from Ancient Civilization to Twentieth Century 20
Ancient Civilization 20
Middle Ages through Seventeenth Century 21
Eighteenth Century 22
Nineteenth Century 23
Twentieth Century 24
4. History of Orthodontics in United States of America 28
Norman Williams Kingsley (1829–1913) 31
5. History of Orthodontics in Great Britain 34
The British Society for the Study of Orthodontics 37
6. History of Orthodontics in Greece and Rome 44
Middle Ages (Fifth to Fifteenth Centuries) to the Eighteenth Century 44
European Pioneers of the Early Nineteenth Century 45
7. History of Dental Lasers and their Applications in Orthodontics 47
All Laser Devices 47
Properties of Laser Beam 48
Focused Versus Defocused Beam 48
Types of Laser 49
Lasers and their Dental Applications 50
Current Clinical Use of Dental Lasers 51
Laser Use in Dentistry 51
Laser Classification 52
Applications of Lasers in Orthodontics 53
Laser Safety 58
Precautionary Measures 58
xiv History of Orthodontics
8. Angle’s Contribution to the Faculty of Orthodontics 59

Edward Hartley Angle—Dental Graduation 60
Angle‘s Dental Practice at Towanda 60
Edward Hartley Angle’s Professional Teaching Career 61
Edward Hartley Angle‘s School of Orthodontics 65
Appliance Contribution by Edward H Angle 66
Angle’s Orthodontic Material Invention 69
Case-Angle Controversy 70
Criticisms 71
9. Dr TM Graber’s Contribution to Orthodontics 76
Thomas M Graber (1917–2007) 76
TM Graber’s Contributions 77
Graber’s Other Contributions to Orthodontics 85
10. James McNamara’s Contribution to Orthodontics 88
James McNamara Analysis 88
Relating the Maxilla to the Cranial Base 89
Relating the Mandible to the Maxilla (Midface) 89

Relating the Mandible to the Cranial Base 91

Dentition Analysis 91
Airway Analysis 92
Studies on Functional Appliances 93
Studies on Rapid Maxillary Expansion 95
Studies on TMJ 96
11. Andrews’ Straight Wire Appliance 98
Why “Straight Wire”? 100
Variable Bracket Sitting Procedures: Lawrence F Andrew’s Remedy 102
Straight Wire Appliance Brackets for Different Clinical Situations 102
Straight Wire Appliance (SWA) 103
12. Evolution of Orthodontic Appliances 106
Brackets and Bands 107
Archwires 114
Properties of Archwire 117
Auxiliaries 119
History of Orthodontic Materials 120
13. History of Model Analysis 122
Carey’s Analysis 123
Pont’s Index 123
Linderharth Index 124
Korkhaus’ Analysis 124
Howe’s Analysis—1954 124
Bolton’s Analysis 125
Cast Analysis: Symmetry and Space 126
Alignment (Crowding), Space Analysis 126
Arvey Peck, Sheldon Peck—1972 127
Huckaba’s Analysis 127
Hixon and Old Father Method—1958 128
Contents xv
Marvin M Tanaka, Lystle E Johnston in 1974 128

Nance Analysis 129
Total Space Analysis—1978 130
Wylie 131
Kesling Model Analysis 131
Martinek Analysis 131
Suwannee Luppanapornlarp 131
3D Model Analysis 132
14. History of Cephalometrics 133
History Prior to the Advent of Radiography 134
Cephalometric Radiography 137
Holly B Broadbent’s Contribution 138
Other Important Contributions 139
Cephalometric Analysis 139
Evolution of Cephalometrics 140
Patient Orientation 140
X-ray Source Position 140
Film Position and Enlargement 140

Posteroanterior (Frontal) Cephalometry 141

Steiner’s Analysis: Cecil C Steiner (1896–1989) 143
15. History of Extraction in Orthodontics 145
Arch-Length Analyses 146
Second Premolar Extraction 147
Evolution of the Philosophy of Extraction in Conjunction with Orthodontic Therapy 148
Need for Extraction 150
Choice of Teeth for Extraction 150
Serial Extraction 150
Historical Perspective 151
Tweed’s Method (1966) 152
16. History of Expansion Appliances 154
Wescott’s Expansion Device 154
Angell’s Palatal Expansion Device 154
Fixed Rapid Maxillary Expansion Appliances 156
17. History of Removable Orthodontic Appliances 160
Development of Removable Orthodontic Appliances 161
Components of Removable Orthodontic Appliance 162
18. History of Fixed Orthodontic Appliances 167
E-Arch Appliance 171
Pin and Tube Appliance 171
Ribbon Arch Appliance 172
Edgewise Appliance 172
What was Orthodontics before Angle System? 173
Evolution and Development of the Edgewise Appliance 173
Evolution of Bracket 174
Evolution of Edgewise Buccal Tubes 174
The Concept of the Ideal Arch 175
The Ideal Arch Wire 176
xvi History of Orthodontics
Advantages and Disadvantages of Edgewise Appliance 178

Building Treatment into the Edgewise Appliance 178
Begg Appliance 179
Straight Wire Appliance 180
Andrews Six Keys to Optimal Occlusion 180
Limitations of Straight Wire Appliance (SWA) 182
Lingual Technique 183
19. History of Myofunctional Orthodontic Appliances 186
Activator 187
Frankel Appliance 189
Bionator 189
Class III or Reverse Bionator 190
Oral Screen (Vestibular Screen) 190
Herbst Appliance 190
Twin-Block Appliance 190
The Double Plate 191
The Tooth Positioner 191
20. History of Surgical Orthodontics 193

Pioneers 195
Mandibular Procedures 196
21. History of Cleft Lip and Cleft Palate 197
Demographic Data 199
Embryological Aspects 200
Classification 200
Etiology of Cleft Lip and Palate 201
Clinical Features 202
Cleft Lip and Palate Associated Problems 203
22. History of Malocclusion Indices 205
Index of Orthodontic Treatment Needs (IOTN) 218
Peer Assessment Rating 219
Index of Complexity, Outcome and Need 220
Dental Aesthetic Index 221
23. History of Interproximal Enamel Reduction in Orthodontics 223
History of Interproximal Enamel Reduction 223
Indications 224
Contraindications 225
24. History of Invisalign 226
Historical Perspective of Invisalign 227
What Exactly the Invisalign Means? 228
Developing the Invisalign Brand 228
Philosophy of Invisalign 229
Fabrication of Invisalign 229
Principle of Stereophotolithography 231
Summary of the Invisalign Technique 231
Indications of Invisalign 232
Advantages of Invisalign 232
Contents xvii
Disadvantages of Invisalign 232

Limitations of Invisalign 232
Procedure of Treatment with the Invisalign 232
Benefits of Invisalign 233
Care of Teeth with Invisalign 233
Study 1 233
Outcome Assessment of Invisalign and Traditional Orthodontic Treatment
Compared with the American Board of Orthodontics Objective Grading System 233
Study 2 234
How Well does Invisalign Work? A Prospective Clinical Study Evaluating the Efficacy of
Tooth Movement with Invisalign 234
Study 3 235
Retaining Alignment Changes with Invisalign 235
Study 4 235
Structural Conformation and Leaching from In Vitro Aged and Retrieved Invisalign
Appliances 235
Study 5 235
Cytotoxicity and Estrogenicity of Invisalign Appliances 235
Study 6 236
Color Fading of the Blue Compliance Indicator Encapsulated in Removable Clear

Invisalign Teen Aligners 236
Study 7 236
A Comparison of Treatment Impacts between Invisalign Aligner and Fixed Appliance
Therapy during the First Week of Treatment 236
Other Studies 237
Scientific Studies 237
25. History of Molar Distalization in Orthodontics 238
History of Molar Distalization 238
Indications for Molar Distalization 239
Contraindications of Molar Distalization 239
An Ideal Intraoral Molar Distalization Appliance 240
Mechanism of Action of Distalizing Appliances 240
Pendulum Appliance 240
Pend-X Appliance 241
M-Pendulum Appliance 241
Pendulum F Appliance 243
Jones Jig 243
Intermaxillary Class II Malocclusion Correction Appliances 243
Vertical Holding Appliance 243
Removable Molar Distalization Splint 244
Symmetric Distalization with a TMA Transpalatal Arch 244
Tube Plates for Distalization of Molars 244
Cetlin Appliance 245
Anchorage Need 245
Extraoral Force 245
The Force Applied 245
The Lokar Appliance 245
K-Loop Molar Distalizer 246
The Distal Jet Appliance 246
The Crozat Appliance 247
xviii History of Orthodontics
Molar Distalization by Magnets 247

The Magnets 248
The Klapper Superspring 248
Herbst Appliance 248
The Mandibular Anterior Repositioning Appliance (MARA) 249
Saif Springs 249
The ‘Fastback’ Appliance for Molar Distalization 249
Features of Fast Back Appliance 250
Suggested Reading 251
Index 259
History of Dentistry 1
• Ancient Dentistry • Dentistry during the Middle – Nathaniel Highmore

– I-Em-Hetep Ages – William Cowper
– Saracens – Abulcasis – James Drake

– Prof George Ebers – Garriopontus – Wilhelm Fabry
– Hwang-ti – John Gaddesden – Antoni Van Leeuwenhoek

– Ya-tong – Guy de Chauliac – Matthias Gottfried Purmann
– Aesculapius – Giovanni Plateario • Dentistry in the Eighteenth
– Celius Aurelianus • Dentistry in the Sixteenth and Century
– Hippocrates Seventeenth Centuries – Lorenz Heister
– Galen – Walter Herman Ryff – Johann Adolph Goritz
– The Etruscans – Andreas Vesalius – Pierre Fauchard
– Dr Guerini – Gabrielus Fallopius – Bourdet
– Saint Apollonia – Bartholomeus Eustachius – Thomas Berdmore
– Marshall H Saville – Ambro’ise Pare – John Hunter
– Johann Stephan Strobelberger – Robert Bunon
These seems to be little doubt that dentistry in years ago, show evidence of tooth decay. The
some form has been practiced from the most earliest recorded reference to oral disease is from
ancient times, there seems to be but little doubt, a Sumerian text (circa 5,000 BC) that describes
since considerable fragmentary evidence still “tooth worms” as a cause of dental decay.
exists as to the general methods used by the
ancients. If we stop to enquire who first extracted Dentistry, as a part of the medical art, was first
teeth, made plates or filled carious cavities we practiced by the priests as a sort of religious rite,
shall find that all such information is shrouded but later material remedies were added to aid in
in the mists of antiquity along with the history effecting cures and help to maintain the prestige
of the pyramids and other relics of early of the priesthood. Later the laity became
interested, and surgery, including dentistry, was
civilization.
for a long period practiced by barbers and
Oral disease has been a problem for humans
travelling charlatans, who resorted to music and
since the beginning of time. Skulls of the Cro-
various other forms of entertainment to attract the
Magnon people, who inhabited the earth 25,000
2 History of Orthodontics
people. Finally, a few of the more far-seeing

medical and dental practitioners became
convinced of the necessity for better educated
men to practice this important speciality, and
thus dentistry gradually rose from about the
beginning of the sixteenth century from a
desultory trade or calling to the dignity of a
learned profession.
However, not until the latter half of the
nineteenth century and the first part of the
twentieth century did it really make rapid
progress. It is a notable fact that many worthy
dentists of modern times began their career in the
laboratory or office of older practitioners. Later,
however, they added to this training such
scientific knowledge as was obtainable at the time
and reached an honorable position among
professional men. Not until 1840 was a dental
Fig. 1.1: GV Black

college organized to teach systematically the
theory and practice of dental surgery. This, the

Baltimore College of Dental Surgery, was chartered much that is considered new in medicine, dentistry
February 1, 1840, opened in that year, and is still and surgery was known to Hippocrates, Fauchard,
in existence. Galen and Pare. Sacerdotal Medicine, which was
Perhaps it is within the last thirty-two years practiced in remote times by the priesthood, was
that the greatest progress has been made by this mostly derived from the false notion prevalent
young profession, during which time Dr Black among primitive peoples that the afflicted person
had been stricken by the wrath of some divinity.
(Fig. 1.1) introduced scientific cavity preparation
The priests were always ready to treat such cases,
and a balanced alloy, Drs. Callahan, Rhein, Best
as they were well paid, and if the person recovered,
et al gave us scientific root-canal work, and Dr
their prestige was considerably increased, while if
Taggart perfected and introduced the gold inlay,
the patient did not improve it was because the
while silicate fillings have come to occupy an
supposed offender was not worthy of receiving the
important place in operative work, and the
desired pardon.
Roentgen ray has become an indispensable aid in
The first physician of record was I-Em-Hetep
diagnosing pathological conditions. In 1910 Dr.
(“He who cometh in peace”), who lived in the
William Hunter, of London, contributed his
region of King Tosher of the Third Dynasty of
celebrated paper on the “Relation between Oral
Egypt, about 4000 BC. He was evidently a man of
Infection and Systemic Disease,” and woke the
great prominence, since the Egyptians constructed
dental profession to its responsibilities. Oral
a pyramid at Sakkra in his honor, and as many
prophylaxis has progressed to a point where
statuary likenesses of him have been found, it is
unclean mouths are no longer tolerated, and the
evident that after his death he was worshipped
prosthesis has come to our aid with removable
as the Egyptian God of Medicine. That the early
bridge-work and more scientific methods of
Egyptian surgeons had to use great skill in the
denture-making.
treatment of disease is proven by the oldest book
in existence, called The Instruction of Path- Hetep.
ANCIENT DENTISTRY
Ancient Egypt was the seat of culture and
In the words of a distinguished writer, “To know learning; many students were drawn there from
the history of a profession is to know the profession other lands in search of knowledge, and we are
itself.” It has also been said, “There is nothing new told that during the time of Herod- Otus, about
under the sun;” but be that as it may, it is a fact that 500 BC, dentistry was practiced as a specialty, so
that “Egypt is quite full of doctors: those for the for a tooth” was a part of the law of the land, as,
eyes, those for the head, and some for the teeth, also, “If a man smite out one of his servant’s teeth
others for the belly or for occult maladies.” he shall let him go free.”
The Saracens invaded Egypt in the seventh The Chinese boast a very ancient civilization,
century, and in 642 A.D., shamefully destroyed and it is not unlikely that dentistry in some of its
the great library at Alexandria. It is probable that cruder forms was known to them at a very early
much valuable literature pertaining to early period in the world’s history. The Chinese “Father
medicine and dentistry was thus lost, among of Medicine,” was Hwang-ti, who lived about 2700
others the writings of Herophilus and Erasistratus, BC.
who, about 300 B.C., were pioneers in dissection The celebrated medical works of China refer
not only of cadavers but of living men condemned to toothache, which is called “Ya-tong,” and
to death by the kings of Egypt. describe nine varieties of this malady, and in
Dental art among the ancient Egyptians is addition there to seven distinct diseases of the
described at some length in the papyrus of Ebers a gums. Puncturing the gums as well as distant
name derived from the material on which it is parts of the body for the relief of toothache and
written (papyrus, a form of ancient parchment, or abscesses was practiced, this being, perhaps, one
paper), and the discoverer, Prof George Ebers who of the oldest forms of dental or oral surgery. The
found it at Thebes in 1872. This work, which dates same method of treatment, known as acupuncture,
from 3500 to 1500 BC, gives many remedies for was applied to many other diseases as well and
toothache and the so-called “Benut blisters in the the Chinese doctors chose their points of election
teeth.” These remedies consisted of dough, honey, in a very scientific and learned manner, having
oil, fennel seeds, incense, onions and similar altogether three hundred and eighty-eight sites
ingredients used in various combinations, to be for puncturing, twenty-six of which were for the
made into a plaster and applied to the aching relief of toothache. For this purpose they used gold,
tooth. One prescription consists of the following: silver or steel needles and cauterized the site
It is evident that dentistry in some of its cruder afterward with a cone of moxa, a sort of slow-
forms must have come into being as soon as man burning vegetable wool applied through a hole in
began to experience trouble with his teeth. The a coin. The moxa is compact and burns slowly,
teeth are likewise largely relied upon to furnish drawing up the epidermis into a blister without
diagnostic evidence in determining whether violence or excessive heat.
prehistoric skulls found in excavating are of According to Dabry, the Chinese believed there
human or animal origin. Prehistoric teeth do not, were worms in the teeth, and among the remedies
as a rule, show evidence of caries, and if it be used therefore arsenic is said to have been made
present it is said to be an evidence of considerable into pills, and one placed near the aching tooth or
age, though it is difficult to understand the reason into the ear on the opposite side from the aching
for this assumption, since caries is usually most organ, whereupon the pain would positively
prevalent among children. Signs of abrasion are cease. Another favorite prescription used by the
quite common, owing to the food habits and long Chinese read as follows: “Roast a bit of garlic and
life of the subject. crush it between the teeth; mix with chopped
The oldest written account of a dental horseradish seeds or saltpeter; make into a paste
operation, other than extraction, is found in a with human milk; form pills and introduce one
statement by Archigenes, of Rome, who advocated into the nostril on the opposite side to where the
the repining of a tooth which ached without there pain is felt.”
being evidence of caries, his idea being that the According to the Greeks, Aesculapius, the God
pain was caused by morbid material in the interior of Medicine, is supposed to have been the son of
of the tooth, which by this means could be Apollo. Cicero mentions three deities of this name,
evacuated. the third of which was said to be the son of
Among the ancient Hebrews neither the Bible Arsippus, who was the first to teach tooth-drawing
nor the Talmud makes any mention of dental and blood-letting. The instrument used for tooth-
operations, though the teeth and their beauties drawing is supposed to have been the
are often extolled. “An eye for an eye and a tooth “odontagogon” of lead mentioned by Celius
Aurelianus and exhibited in the temple of Apollo teeth have something to do with the sense of taste.
at Delphi, sculapius, who was worshipped by the In his anatomical researches he recognized seven
Greeks as one of their many Gods, was said to have pairs of cranial nerves and classified the
healed the sick and to have raised the dead as well. trigeminal as the third pair. He was also of the
As time elapsed there were reputed to be not only opinion that the teeth grow and thus repair the
one, or, as related by Cicero, three sculapii, but wear on them, basing his opinion on the fact, no
tradition gave rise to many Gods of this name to doubt, that a tooth having no opponent became
whom numerous temples known as “Asklepeia” longer. In painful Dentition Galen advised
were erected, among which was the famous temple rubbing the gums with the milk of a bitch or the
of Cos, where Hippocrates gained most of his brains of hare.” He was, in his day, one of the
knowledge of medicine. The priests or followers of most famous medical men of Rome and the
Esculapius were known as “Asklepiadi.” author of many works on medicine.
To Hippocrates is accorded the honorable title By this time the doctors’ shops were well
of Father of Medicine, and even in those early days supplied with medicines, bandages and a great
the “oath of Hippocrates” was a solemn variety of instruments, showing that the medical
obligation to be taken by all who undertook the art had made considerable advancement.
study or practice of medicine. Hippocrates was Dentistry had not yet become a separate
born on the island of Cos about 460 BC and first profession, but was practiced by the doctors along
studied medicine under his father, but later with medicine and surgery.
devoted his attention to the medical books in the

temple of Cos. Hippocrates wrote much in regard The Etruscans, or early Italians inhabiting that
to dental maladies and their remedial measures, part of Italy known as Etruria, between the Tiber
among which were considered extraction and and Arno, about 1000 to 200 BC, used bridges
cauterization. He was the inventor of certain crude made of gold rings holding ox teeth, for the
dental forceps and other dental instruments. He purpose of replacing lost dental organs.
practiced the extraction of loose teeth and Just who these Etruscans or Toshi were, from
cauterization of those that ached but were not whence they came or what became of them is not
loose. He also recognized that the first teeth are definitely known, and their language is equally
formed before birth by the nourishment of the fetus extinct, no code having been discovered by which
in the womb. their writings can be deciphered.
The Romans have also left us some specimens
In speaking of fracture of the lower jaw,
of bridge-work and other prosthetic appliances,
Hippocrates recommended binding the teeth next
which for the most part are found in tombs or in
to the lesion together. He distinguished between
the urns containing the ashes of those cremated.
the complete and the incomplete fractures and
It was said to be a custom to remove such pieces
treated separately of fractures of the symphysis. If
from the mouth before cremation and afterward
the teeth were loosened he advised binding
place them in the urn with the ashes. According
several together on either side of the fracture until
to the Law of the Twelve Tables, written in Rome
consolidation of the bone had taken place, using
about 450 BC, it was not unlawful to bury or burn
for this purpose either gold wire or linen thread.
corpses with the gold that was used to bind the
At this time lay medicine had begun to
teeth together.
supplant sacerdotal medicine, and healing by the
At this early period in the world’s history,
priests as a religious rite was slowly giving place
Rome must have had dentists, though she had as
to more scientific and rational methods.
yet no doctors. According to Dr. Guerini and
Galen, who lived about six hundred years after others a gold crown is now in the museum of Pope
Hippocrates, was an able writer and commented Julius, in Rome, which was discovered in
on Hippocrates’s work. Galen was a noted excavating at Satricum, near that city.
anatomist, and although he classified the teeth This would tend to prove that the Etruscans
as bones, he said they were unlike other bones. not only did bridge-work, but were versed in the
He was the first to recognize nerves (pulps) in art of making crowns also. The appliance found
the teeth, and also erroneously believed that the at Satricum was made of two plates of gold
stamped to represent the labial and lingual the cause of pain and decay in the teeth. As we
surfaces of the lower central incisor, and were shall find later this superstition existed
then soldered together to form the crown of the throughout the Middle Ages, and it was not until
tooth. It is soldered to a narrow strip of gold the early part of the eighteenth century that
which is contoured in such manner as to encircle Fauchard first cast doubt on their existence. As a
the neighboring teeth, which act as a support for remedy for these worms, Scribonius Largus
the appliance. suggested that if the seeds of hyoscyamus
(henbane) be burned on charcoal and the fumes
Saint Apollonia in the year 300 AD, was inhaled they would cause the worms to fall from
canonized by the Church of Rome, and since then the teeth. It is a noteworthy fact that the seed buds
has been the patron saint of dentistry. The ninth of henbane, when burned, form an ash that much
day of February has been observed by the Church resembles worms, and as the drug has a narcotic
of Rome in her commemoration. A photograph of effect that probably soothed and relieved the pain,
the painting of this saint was, in 1900, presented it is no wonder that the ignorant populace of that
to the Academy of Stomatology of Philadelphia, time readily gave ear to such seemingly plausible
on behalf of Dr Mary H Stillwell, of Pittsburgh, by humbug.
Dr C N Pierce, together with this historical sketch:
Celius Aurelianus gave an account of the
“Longing to obtain the grace of baptism, she
odontagogon of lead found in the temple of Apollo

made her way to Saint Leonine, a disciple of St.
at Delphi, by which it was assumed that teeth
Anthony of Egypt, and, as he baptized her, he

should not be extracted unless loose enough to be
bade her go to Alexandria and preach the faith.
removed with a leaden instrument, though some
So she went forth, and though she was only a
have contended that this was only a model placed
woman, young and frail, yet so eloquent were her
there, probably by Esculapius, to be reproduced
words, so fervent her zeal, that she made many
with an iron instrument by those wishing to copy
converts. About this time a tumult had been stirred
it, lead being less affected by corrosion, and
up in the city against the Christians and the mass
therefore more lasting. He also wrote on fractures
of the people were enraged at her teaching and
and dislocation of the jaw, and described the
came with bitter complaints to her father, who
methods to be used in their reduction.
gave her up to be judged by the governor.
They brought her before the idol temple and Celsus gave a prescription for producing sleep in
bade her worship the graven image. It is reported persons afflicted with toothache. It contained
that she made a sign of the cross, and there came acorns, castoreum, cinnamon, poppy, mandrake
forth from the statue an evil spirit shrieking, and pepper. When there was a large carious
‘Apollonia has driven me hence!’ This was more hollow in the tooth to be extracted, Celsus
than could be borne; the people thirsted for recommended that it should first be filled either
vengeance, so they tried by torture to overcome with lint or lead, in order to prevent the tooth from
her constancy. She was bound and one by one her breaking under the pressure of the instrument. It
teeth were drawn out, but still she did not flinch is not definitely known that he used fillings as a
or fear, and on her refusal to accede to the demands means of preserving the teeth or relieving
of her persecutors and renounce her faith, she was toothache.
brutally clubbed about the head and face, and
Marshall H Saville, according to an article in the
subsequently suffered death by fire.
Bulletin of the Pan- American Union, reported the
“For a period of nearly fifteen hundred years
finding of teeth inlaid with gold, turquoise, rock
her intercession has been sought for relief from all
crystal, red cement and other foreign substances
pain incident to dental diseases, and her relics
in skulls of the aborigines who lived in various
have been and are regarded as possessing great
parts of North and South America. These teeth
efficacy in the cure of the same.”
had been bored out with some tool and the filling
Scribonius Largus, writing during the first skillfully placed in the cavity.
century of the Christian era, was perhaps the first This custom was quite common in Mexico,
author to give rise to the belief that worms were Central America and the province of Esmeraldas,
Ecuador. In this latter province he also secured In Eastern India some of the people plane their
an upper jaw from one of the natives which teeth down to an even level and dye them red by
contained not only teeth inlaid with gold, but also masticating areca nuts. It is also said to be a
a right lateral incisor which had been custom in New South Wales for a young man to
transplanted to replace a lost central incisor, have his front teeth knocked out with a stone on
showing that dentistry had reached a high stage reaching the age of virility, this being supposed to
of development as a means of ornamentation at enhance his personal appearance. The natives of
least. He also discovered in an excavation at the Hawaiian Islands knock out their front teeth
Copan a lower jaw with a left lateral incisor that as a sacrifice to their god Eatoa.
had been carved from some dark stone and
implanted to take the place of one that had been DENTISTRY DURING THE MIDDLE AGES
lost. In one case several teeth were found bound Abulcasis (1050–1122), an Arabian author, who
together with gold bands. lived at Cordova, was one of the most able writers
There are in the Peabody Museum of Harvard and surgeons of the Middle Ages. He wrote a
University teeth in which had been placed inlays treatise on medicine, entitled De Chirurgia,
of jade, iron pyrites and gold, some of them consisting of three volumes, the first of which was
arranged symmetrically in triangles, also banded devoted entirely to the subject of cauterization, a
inlays, all of which apparently were used for form of treatment much practiced at that time. His
ornamentation (Dental Cosmos, 1916, Iviii, 281). method of performing this operation was to insert
Among Primitive People, even at the present a red-hot cautery through a tube to protect the
time, some very peculiar customs prevail which surrounding parts.
have, no doubt, been a heritage from ancient times. He was especially interested at that early date
Most of these people have beautiful strong teeth in prophylaxis and devoted special attention to
which they ornament and embellish in various the tartar on the teeth, illustrating and describing
ways for cosmetic or religious purposes, much to fourteen forms of scrapers or sealers for its removal.
the detriment of these valuable organs. The He was a very religious and devout man, cautious
substitution of gold teeth for missing ones has in the treatment of his patients and firmly opposed
been practiced in Java from remote times, and to the needless extraction of teeth. When it became
among the natives in many parts of Asia and the necessary to extract, he used one form of forceps
Pacific Islands there is prevalent the custom of to loosen the tooth and another for its removal.
dyeing the teeth black. In Sumatra the women file Elevators were used if the forceps failed or the
their teeth down to the gums or into points, or tooth was broken. According to this author,
partially remove the enamel, so as to be able to replantation was extensively practiced and
apply the dye. artificial substitutes were made of ox bone to replace
In Japan the married women dye their teeth teeth that had been lost. He advocated replanting
black in order to distinguish them from the single teeth that had been removed by mistake or accident,
women, using a dye that is made of urine, iron holding them in place with ligatures of gold or
and a substance called “saki.” It is claimed that silver wire until they had again become firm.
this dye is very durable and does not wear off for Garriopontus, an Arabian writer, in 1045 AD, said:
many years. Dr L Ottofy, in an article on “Dentistry “On the island of Delphi a painful molar tooth,
in Japan,” says, “The practice of blackening teeth, which was extracted by an inexperienced physician,
as a symbol of the marital state, on the part of occasioned the death of a philosopher, for the
women is becoming obsolete, yet a number still marrow of the tooth, which originates from the
continue the practice.” Formerly large quantities brain, ran down into the lungs and killed that
of black artificial porcelain teeth were exported philosopher.” For all we know this is the first record
from America to Japan, where artificial plates for of a death resulting from the extraction of a tooth.
men and single women were made with white
teeth and those for married women with black John Gaddesden (1400–1450), an English doctor
teeth. There are on exhibition in the Army Medical at Oxford, stated that dried cows’ dung or the fat
Museum at Washington, D C, several sets of teeth of a green frog would positively cause teeth to fall
of Japanese origin, carved from wood, that bear out when applied to them, and said, “If an ox,
out the foregoing statement. peradventure, chewed a little frog with the grass,
its teeth would fall out on the spot”. He is also vinegar and applied, or the juice of the rue fennel
authority for the statement that “The brains of a was placed in the patient’s nostrils. This fact is of
hare rubbed on the gums not only facilitate great importance, as it marks the first step in
dentition but will make teeth grow again where general anesthesia and antedates Horace Wells’s
they have been lost”. All of these remedies were discovery by five hundred years, though it is
recommended and employed by many later doubtful if this old method was ever used
writers, who claimed to have performed extensively. This author is the first to cast doubt
marvellous cures by such absurd treatment. on the efficacy of the fat of green frogs for the
Such statements as the foregoing seem purpose of causing the teeth to fall out.
ridiculous to us, as anyone could have easily Superstition being uppermost in the lives of the
satisfied himself of their falsity. The application people in those days, it took considerable courage
of the cautery or arsenical compounds must have to contradict the old authorities on such a well-
met with some success, as the latter is known to established belief.
produce extensive necrosis. In 1308, the barbers and surgeons of London
were incorporated into one guild and the name of
Guy de Chauliac (1300–1368) was the most noted
barber-surgeon was used to denote practitioners
surgeon of the Middle Ages. He and others of that
in all branches of surgery. This arrangement lasted
period wrote extensively of dental ailments and
until 1745 before it was finally dissolved, after
operations for their relief by both physicians and

which the barbers were only allowed to extract
barbers. Guy followed in the foot-steps of the
teeth. This should give one a fair conception of

Arabians, who had made considerable progress
the low repute into which surgery had fallen
before him, and referred explicitly to dentators and
during that period.
their instruments, thus beginning the recognition
The title of Doctor was first bestowed by the
of dentistry as a specialty of medicine. He advised
universities during the twelfth century and was
that dental operations be performed for greater
used to denote a learned man in any profession.
security under the supervision of doctors, but had
The title of Doctor of Medicine was first bestowed
no criticism to make of dentators. This learned
on William Gordenia by the College at Asti, in
doctor used camphor, sulphur, myrrh and
Italy, in 1329. Whether this title was earned or
asafcetida as a filling material for carious cavities,
honorary is not known. The title of Surgeon
and, like his predecessors, lent belief to the
Dentist was first given to Gillies and several other
superstitious idea of worms in the teeth. It is
men in France in 1622, though the title was not
uncertain whether the worms referred to by him
fully established for many years afterward.
were particles of decaying food, nerves, larvae of
insects or the burning henbane seed, as previously Giovanni Plateario (1450–1525), a professor at
referred to, but the accepted belief was that they Pisa, was the first dentist to use the sitting posture
were responsible for the pain in odontalgia. for performing operations on the teeth, others
Fumigations with seeds of leek, onion and before him having used the horizontal position.
henbane mixed with goats’ tallow were resorted The prevailing custom was to let the patient lie
to in order to drive out the worms, after the manner prone on ground and to hold his head between
first described by Scribonius Largus. operator’s knees with a vise-like grip.
Guy de Chauliac also refers to medicines which
DENTISTRY IN THE SIXTEENTH AND
send the patient to sleep, among which are
SEVENTEENTH CENTURIES
decoctions of opium, hyoscyamus and lettuce. A
new sponge was soaked in these medicines and Dentistry, with the other arts and sciences, made
then dried, and when sleep was to be produced it its most notable advancement as a learned
was wet and applied to the patient’s nostrils. This profession during the sixteenth century, for it was
form of anesthesia must have been very effective, about this time that the world as we know it, made
for it is related that it was used for surgical its first rapid strides forward. The invention of
operations, amputations actually being performed the printing press in 1436, the taking of
in this manner. To awaken the patient from this Constantinople by the Turks in 1453 and the
deep slumber, another sponge was wet with discovery of America in 1492 all led to much
migration of peoples and the dissemination of of the development of the teeth and corrected
knowledge, which constituted the beginning of a Vesalius’ error by showing that the permanent
new era in which dentistry had its part. teeth do not grow from the roots of the temporary
In Germany, dentistry had been practiced for teeth, but that they are generated twice over, the
many centuries, as shown by artificial teeth in the first time in the uterus. He gave the first account of
urns of those who had been cremated, and at this the dental follicle, and likened the teeth in their
time the Germans had made considerable formation to the feathers of a bird ( De Dentibus
progress. Here, as elsewhere, medicine was first Libellus, Venice, 1563).
practiced as a religious rite combined with Bartholomeus Eustachius (died in 1574) was
witchcraft and empirical remedies. As early as another great anatomist of the sixteenth century.
1460 Heinrich von Pfolsprundt wrote a book on After long and patient research he brought much
medicine and surgery in which he described light to bear on the macroscopic (gross) anatomy
wounds and fractures and the mode of their of the teeth, the number and variations of the roots,
treatment. Pains of the teeth and gums were the alveoli, etc,. and gave a very clear description
treated by him by the use of beverages, showing of the ligaments of the teeth and the means by
his lack of skill in that direction. which they are held in the alveolus. He also gave
Walter Herman Ryff (died 1570) wrote the first an account of the central cavity of the tooth, and
stated that it contains blood- vessels and nerves,
book which treated of dentistry independently of

medicine in 1548. He is conspicuous for the fact and not marrow, as was claimed by some
that his book was written in German, a living anatomists. He also investigated the embryology
tongue, instead of the customary Latin, so that he of the teeth and confirmed the claim of
may be looked upon as the first who attempted to Hippocrates that the first teeth are formed in the
diffuse useful medical knowledge among the uterus. Eustachius is the first to deny that the teeth
common people. One of the most interesting things grow during a whole lifetime, as was first claimed
about his writings is that he is the first author to by Aristotle. Speaking of dental diseases, this
author remarked that dental surgery was in his
recognize the relation between diseases of the eyes
days a most abject calling, notwithstanding its
and teeth, declaring that because of their intimate
having had as its initiator no less a person than
relation, neither can be healthy without the other
Aesculapius, the God of Medicine.
being so too. While this reasoning is clearly wrong
in the light of our present knowledge, it Ambro’ise Pare, born in France (1517–1592), is
nevertheless marks a step in the right direction. justly entitled to the credit of being known as the
According to Ryff the principal causes of dental “Father of Modern Surgery.” As an anatomist he
diseases are heat, cold, traumatism and the is less accurate than either Vesalius or Eustachius,
gathering of humors, and he says “The most but as a surgeon he gained great renown, having
atrocious pain is when an apostema ripens in the been successively a barber, surgeon- barber, and
root”. finally, in 1562, chief surgeon to the court. In his
works this surgeon treated of dental maladies very
Andreas Vesalius (1514–1564), who at the early
thoroughly, which fact may be attributed to his
age of twenty-five years became famous as an
having first been a barber and consequently a
anatomist, was the first who dared to correct the
tooth-puller. He described fractures of the jaw and
errors in Galen’s work, and gave a much more
the methods of their reduction with considerable
accurate description of the anatomy of the teeth
thoroughness, and related some interesting cases
than that given by Galen. His researches in regard
which he had treated. In one instance a friend of
to the teeth are incomplete, since he states that the
his had his jaw broken and three teeth knocked
permanent teeth grow from the roots of the
out by a blow from a dagger, whereupon Pare so
temporary teeth. This erroneous conclusion was
skillfully treated the injury that all the teeth were
due to the fact, no doubt, that the deciduous teeth
successfully replaced and made of use.
have no roots when shed.
The Golden Tooth, in 1593 much was said in
Gabrielus Fallopius (1523–1562), a pupil of Germany of a Silesian child, aged seven years, in
Vesalius, carried out more fully his investigations whose mouth a golden tooth had erupted. Great
credence was given to this story and the learned time the maxillary sinus named for him is
doctors and philosophers speculated upon the accurately described), though its existence had
phenomenon without the slightest doubt as to its long been known. He pointed out for the first time
genuineness. Many books and papers were the anatomical relation between the teeth and
written to explain the strange occurrence, and one antrum, and related a most amusing incident in
writer, Jacob Horst, claimed that on the date of the connection with perforation of this sinus. A lady,
child’s birth, that is, December 22, 1585, the Sun having much pain in her teeth finally had the
was in conjunction with Saturn in the sign of upper canine tooth extracted, after which there
Aries, and in consequence the nutritive force had was an incessant flow of humors (pus) from the
developed so much that instead of osseous antrum. The patient herself wishing to learn the
substance, golden matter had been secreted. It cause thereof passed a silver probe into the cavity
appears that the golden tooth was nothing more its entire length, which produced the effect of its
than a crown or lamina of gold let down deep into having reached the eye. Much amazed she
the gum, and made by a dentist or jeweler for the stripped a long feather and passed it into it so
purpose of deception, since a fee was charged for great a distance that she concluded that it had
seeing the child. Balthasar Camindus, a doctor of reached her brain, not knowing that the feather
Frankfort, had noted that the boy had not lent simply curled up in the cavity. He was able to
himself to being examined by the learned, who allay her fears by informing her of the cavity in
were likely to expose the fraud, and further relates the bone and the opening produced by the
that a certain nobleman, being denied the privilege extraction of the canine tooth.
of seeing the tooth, struck a dagger into the boy’s
mouth and wounded him so badly that a surgeon William Cowper (1666–1709) was the first to
was called and the fraud exposed. practise opening the antrum by the extraction of
In the early part of the seventeenth century the the first molar. This was toward the end of the
dental art was still in a pitiful state of development, seventeenth century, and he seems to be the first
as shown by the literature on the subject, only to recognize antral diseases. This was something
about twenty publications having appeared in like 50 years after Highmore had described the
Europe during the preceding century. antrum.
Johann Stephan Strobelberger, physician to the James Drake, a contemporary of Cowper,
Imperial Baths at Carlsbad, published a book in operated in the same manner, and it was this
1630 in which he referred to “Gout in the teeth”, author who made known in a book entitled
which included all of the diseased humors of the Anthropologia nova, published in 1707, the
teeth that were supposed to fall by drops into the method of Cowper, for which reason the above-
articular cavities and surrounding parts. In his mentioned proceeding is sometimes called the
writings we find that many crude and worthless “Cowper-Drake operation.”
remedies were still used for toothache, and the
Wilhelm Fabry, better known under the Latin
instruments for extraction consisted for the most
name of Fabricius Hildanus (1560–1634), chief
part of the pelican, named from its likeness to the
doctor to the city of Berne, gave some very
beak of that bird, and also some very rude forceps.
interesting clinical reports on the relation between
He was one of the first to cast doubt on the value
dental affections and tic douloureux, and cited
of fumigations with hyoscyamus seeds to cause
an instance where a lady who had suffered
worms to fall from the teeth, though he did not in
atrociously for four years with pain in the head
the least doubt the existence of the worms
was completely cured by the extraction of four
themselves, suggesting oil of vitriol or a decoction
decayed teeth. He also gave an account of an
made of a frog cooked in vinegar to kill them
interesting case of rhinoplasty performed by Dr J
instead. Among the remedies he suggested for
Griffon, an eminent surgeon of that day, upon a
odontalgia is the American tobacco plant
young girl of Geneva, whose nose had been cut
(Nicotiana tabacum).
off by the Duke of Savoy’s soldiers in a fit of rage.
Nathaniel Highmore (1613–1684) (published a Fabry testifies to the natural appearance of the
treatise on anatomy in 1651, in which for the first nose even for twenty years afterward. He stated
that Gaspare Tagliacozzi, of the University of removing the decayed part of a tooth with a file or
Bologna, was the inventor of this operation. toothpick and filling the cavity with white wax,
mastic or gold or lead-foil. In this work he gave a
Antoni Van Leeuwenhoek (1632–1723), a
very concise description of removable prosthetic
Dutchman, was the first to make high-powered
pieces made of ivory or hippopotamus tusks and
microscopes with which, in 1678, he made
maintained in position simply by their form.
discovery of the tubular structure of dentine, and
Heister also refers to nasal prosthesis, which was
in 1683 he discovered microorganisms in tartar
then carried out by applying noses of wood or
scraped from between the teeth. From a perusal of
silver, properly painted. There was at this time
his writings and drawings it appears that these
much contention among dentists as to the
bodies were bacteria rather than animalcules, as
advisability of removing caries by the use of the
he supposed. Both Carpenter and Beal state that
file, as practised by Heister and others,because of
his work was done with single lenses, as the
the destruction of the enamel of the tooth. We find,
compound microscope did not reach a useful
however, that this was practised for a long period,
stage until about 1820 to 1830. It is astonishing
and was advocated in a modified form by such
how much was accomplished by such primitive
eminent dentists as Drs. Chapin A. Harris and
means. This in all probability represents the first
Robert Arthur more than a century later.
step in bacteriology, which was only made
Upto the eighteenth century the clumsy pelican
possible by the aid of high-powered lenses.

or rude forceps, used to exert lateral force on the
Matthias Gottfried Purmann (1648–1721) has the tooth, was still in general use, but this was
honor of being the first writer to make mention of modified about this time into what was known as
wax models in connection with prosthetic work. the key of Garengeot, named after the man who
Whether these models were made from molds or perfected, though he did not invent, the instrument.
not is a disputed question, but the supposition is According to some writers this instrument had its
that they were carved to the desired shape and origin in Germany, not in England. It was a most
then passed on to a craftsman who reproduced efficient instrument for extracting teeth and was
them in bone or ivory. in general use for more than a century, having
Many other incidents of considerable interest been extensively used in America, and is much
during the seventeenth century have to be omitted used in France and other European countries at
in a history of this character, and consideration the present time.
will now be given to the development of the
eighteenth century. Johann Adolph Goritz, of Regensburg, writing in
1725, opposed too many extractions and also the
DENTISTRY IN THE EIGHTEENTH CENTURY insertion of prosthetic pieces, because they caused
In 1700, France took the lead in the dental art and the loss of the teeth to which they were attached.
had recognized the importance of dentistry by This was due to their being wired to the natural
requiring prospective practitioners to take an teeth, causing great strain on and consequent
examination under the edict of 1699 to show their loosening of the abutments.
qualifications before entering the profession. There Pierre Fauchard (born in Brittany about 1690 and
is abundant evidence that the Germans had also died in Paris in 1761) was the founder of modern
made considerable progress during the two dentistry. He published a work in 1728 entitled
preceding Centuries and they have likewise left Le Chirurgien Dentiste, which marked a new
us considerable literature upon dental surgery. epoch in the history of the dental art. This book
Dentistry had already begun to flourish as a was highly commended by the leading medical
distinct specialty of medicine, but it remained, as authorities of the day. It was translated into
we shall see later, for Pierre Fauchard to effect the German in 1733, and a second revised French
final separation. edition was issued in 1746, and a third in 1786. It
consisted of two volumes in duodecimo, with 40
Lorenz Heister (1683–1758), of Frankfurt-am- full-page plates, 863 pages in all, and treated of
Main, published a treatise on dentistry entitled all branches of dentistry as understood and
De Dentium Dolore in 1711, in which he advised practiced at that time. According to Fauchard
dentistry was then an important calling, as he origin, growth and anatomical parts as, body, root
refers to the examination which prospective and neck. He described accurately the pulp cavity
practitioners were compelled to undergo even as and root canals, and after a most thorough
early as 1700, and advises that a dentist be macroscopic description, goes into the histology
included in the board of examiners. He expressed of the teeth, following the writings of La Hire in
himself in no uncertain terms as to the need of a 1699. Fauchard agrees with the popular idea of
school of surgery in which the theory and practice his day in regard to caries, and states that it may
of dental surgery could be properly taught. have its origin within the tooth as well as without.
Fauchard lamented that so little was written From a passage in the fifth chapter of
by able dentists who had preceded him, because Fauchard’s work one learns that tooth-brushes
these men guarded their knowledge with secrecy were then already in use, but he says that those
lest someone might profit at the author’s expense. made of horsehair are too rough and frequently
It is a mistake to think that he created the art of have a destructive action upon the teeth. He
dentistry, but that he placed it on a higher plane advised using small sponges, with which the teeth
by many valuable inventions and by collecting should be rubbed up and down, inside and
and publishing all of the available knowledge on outside, every morning. Before using the sponges
the subject, there is no doubt. To show how they were to be dipped in tepid water or preferably
concisely he wrote, it may suffice to quote the aqua vitae, “the better to fortify the gums and
following account of work that may be done on render the teeth firm.”
teeth : He was strong in his condemnation of elixirs

“They may be cleaned; they may be straightened; and cures by magical means so much practised in
they may be made shorter; caries may be removed his day, and a reference is made to the large and
from them; they may be cauterized; they may be filled increasing number of Charlatans of the day,
with lead; they may be separated; they may be placed wherein he exclaimed, “There will shortly be more
in proper position; they may be fastened; they may be dentists than persons affected with dental
removed from the jaw; they may be replaced in the diseases.” He laments over the poor quality of
jaw; or they may be taken out to be placed in another work done by them, relating a case where a
person’s mouth; and at last teeth are artificially deciduous tooth was extracted without roots,
constructed, and may be placed instead of those that whereupon the dentist in an effort to extract the
have been lost. All of these operations demand a roots removed the permanent tooth just erupting.
skillful, steady and trained hand and a complete Fauchard advised seating the patient in an
theory.” easy arm-chair for the purpose of performing
In this work he refers to the popular idea of dental operations, and condemned the practice of
worms in the teeth, which idea had existed for seating him on the ground or floor and holding
more than one thousand years. He admits the his head between the operator’s knees, as was
possibility of them, but states that he has never commonly done, as unskillful and unsanitary, and
seen them, and that if they do exist they are not in the case of pregnant women, as capable of doing
the cause of caries, but the eggs of insects may great harm. He practiced opening the tooth for
have entered carious cavities and there hatched relieving abscesses by evacuating the pus. After
and produced worms. three months he stopped these teeth to prevent
Although Andry relates seeing very small their getting worse, but no mention of root-canal
worms with a powerful glass, Fauchard states that work is made, though he placed a little cotton-
he employed the same means but could not see wool in the cavity with oil of cinnamon and
them. Thus he sets forever at rest this foolish allowed it to remain several weeks before filling
superstition in regard to worms in the teeth as a them.
cause of dental ailments so long indulged by the
people of those times. Perhaps it is only as a matter Fauchard practiced orthodontia, and relates a
of courtesy toward the many authors who case in which he used the file and pelican and
preceded him that he admits their presence at all. put a crooked tooth in place, which operation
Fauchard gave a very accurate description of required about ten minutes. The most difficult
the anatomy of the teeth, their structure, position, cases he states required from three to ten days,
and sometimes several months, to complete. He with springs or clasps. He also practiced
used gold and silver plates, which were perforated transplantation of teeth as well as the correction
with holes through which he passed a silk thread of dental irregularities, and gained great renown
for correcting irregularities, and when this was thereby. He used subluxation of the teeth for the
not sufficient he forced them in place with the purpose of severing the dental nerve as a remedy
pelican or forceps. against toothache.
In 1737, Fauchard made a full upper set of Philip Pfaff, dentist to Frederick the Great,
teeth for a lady of high rank, holding the same in deserves passing mention, since he was the first
place with springs, and relates that the lady ate German to write a real treatise on dentistry. He is
with it easily and could not get along without it. the first author who practised capping an exposed
He also relates having made a full upper and lower nerve before placing a filling in the cavity,
set for a gentleman, who had worn them for more Fauchard usually filling the cavity directly over
than twenty-four years. When a full upper set of the exposure. He also described the construction
teeth was made, Fauchard used flat springs to of artificial teeth in which he made use of not only
hold the piece in place, atmospheric suction not ivory, bone and tusks of the hippopotamus and
being recognized and used until the year 1800. the sea cow, but also of silver, mother of pearl and
He states, however, that he has been successful in even enameled copper. His most important
three cases in placing full upper sets without the contribution to science was the invention of the
aid of springs. He also brought palatine prosthesis plaster model, poured in a beeswax impression.
to a high degree of perfection and described five

kinds of obturators, which were, however, Bourdet, dentist to the King of France, wrote a
somewhat-complicated. The materials most in use book on dentistry in 1757, in which the novel idea
in dental prosthesis were human teeth, was advanced of extracting carious teeth, filling
hippopotamus tusks, ivory of the best quality and them with gold or lead and then replanting them.
ox bone. Crowns were placed on natural roots (if If the alveolus was injured he replanted the teeth
healthy) and held in place with screws or bound immediately and performed the operation of filling
to neighboring teeth. afterward. He also used prosthetic pieces made
The second edition of Fauchard’s work, which entirely of gold and covered them with flesh-
appeared in 1746, contains (pp. 275-277) the first colored enamel on the outside, showing that some
account of pyorrhea alveolaris, familiarly called dentists of olden times were even more artistic
“Riggs’s disease,” after the American dentist, Dr than a large proportion of the practitioners of the
John M Riggs, who, in 1876, introduced the present day who make no pretence of hiding their
method of scraping the tartar from the crowns and glaring gold crowns. He also made use of
roots for its cure. prosthetic pieces of hippopotamus tusk, to which
In the first edition of Fauchard’s work (vol. ii, human teeth were fastened with rivets.
p. 30) mention is made of a machine for preparing
and drilling into teeth. This machine is illustrated Thomas Berdmore, who was dentist to George III
in Siemens d’Odontologie (Jourdain, 1756, p. 207). of England and the first dentist to the English
This was no doubt the beginning of the dental Royal Family, is mentioned as having instructed
engine, and antedates the dental engine that the Robert Wooffendale, by many reputed to have
Greenwoods made from an old spinning wheel. been the first dentist in America. Wooffen dale
Summing up his writings, we may say that, emigrated to America in 1766, and though he was
notwithstanding the falsity of some of his ideas, preceded by several men who practised the art, he
he was far in advance of his profession and was was probably far more efficient than any who
truly the founder of modern dentistry, and has preceded him. In 1768 Berdmore published an
given inestimable service to suffering humanity. excellent work on dentistry which went through
During the first part of the nineteenth century, many editions three English, two German and the
almost all plates were fitted for the attachment of last an American edition, appearing in Baltimore,
springs in case they were needed look natural. the cradle of American dentistry, in 1844, 76 years
Mouton also invented a method of applying after the first edition, affording splendid proof of
partial dentures by fixing them to the natural teeth its value.
John Hunter (the celebrated English surgeon Robert Bunon (died 1749), a French dentist born
(born February 13, 1728), studied under his at the beginning of the eighteenth century, was
brother William, who conducted a school of one of the first to deny that the eye tooth has
anatomy in London. In 1771 he published a book anything to do with the organ of sight, showing
entitled Natural History of the Human Teeth, that it is supplied by the infraorbital nerve. He
and in 1776 another work entitled Practical was an ardent champion of conservative dentistry
Treatise on the Diseases of the Teeth. He was a and prophylaxis and succeeded in converting
great lecturer and writer and kept a superb many medical men, surgeons and priests to his
anatomical collection and extensive library. So views. When Fauchard’s book, Le Chirugien
great did his fame become that he was made Dentiste, appeared he was disappointed to find
Surgeon-General to the English Army. Hunter but little therein that interested him, and set about
was a strenuous partisan of replanting and to write a book of his own. Before publishing his
transplanting teeth, and described these work he entered the College of Surgery to undertake
operations much more fully than had been done two years’ practice with a regularly licensed
before. He experimented by transplanting a surgeon, to undergo theoretical and practical
sound tooth drawn from a living person into a examinations and to take oath before the Chief
cock’s comb by making an incision with a lancet. Surgeon of the Realm in accordance with the edict
When, some months later, the cock was killed of May, 1699, in order to obtain the diploma of
the head was injected and examined and the surgeon- dentist. He was highly eulogized by the
tooth was found to be attached and circulation principal journals of the time, and by this means
established as is found in the natural gums. If won much fame and many wealthy clients.
we may judge from early writings, transplanting One of the chief merits of his book is that of
and replanting were far more common at that having ascribed to the deciduous teeth all of the
time than at present, and also profitable, as may importance that they really have. In cases of
be judged by the charges of Paul Eurialius Jullion, stomatitis, Bunon advised the complete removal
whose fee was five pounds five shillings for of tartar before administering other treatment. He
transplanting a live tooth and two pounds two used the same measures against mercurial
shillings for a dead tooth. stomatitis in the specific treatment of syphilis.
Introduction
to Orthodontics
2
• Definition of Orthodontics – Fixed Orthodontic – Correcting Malocclusions of

• What is Malocclusion? Appliances Dental Origin
– Functional Appliances – Correcting Malocclusions of
• Aims of Orthodontic
– Orthopedic Appliances/ Skeletal Origin
Treatment
Extraoral Force Appliances – Adult Orthodontics
– Functional Efficiency
• Timing of Orthodontic – Guards
– Structural Balance
Intervention – Management of Dentofacial
– Esthetic Harmony
– Deciduous Dentition Anomalies
• Branches of Orthodontics
– Early Mixed Dentition • Benefits of Orthodontic
– Preventive Orthodontics
– Late Mixed Dentition/Early Treatment
– Interceptive Orthodontics
Permanent Dentition
– Corrective Orthodontics
• Scope of Orthodontics
• Orthodontic Appliances
– Monitoring and Assessment
– Removable Orthodontic
of Developing Dentition
Appliances
Humans have attempted to straighten teeth for chart 2.1). The term orthodontics was first coined
thousands of years before orthodontics became a by Le Felon in 1839.
dental specialty in the late nineteenth century.
Proper alignment of teeth has long been DEFINITION OF ORTHODONTICS
recognized to be an essential factor for esthetics,
Knowing the definition is often an important
function and overall preservation of dental health.
initial step in understanding any subject. A
Malposed/poorly aligned teeth may predispose
number of definitions have been put forward over
to a number of unfavorable sequelae such as poor
oral hygiene predisposing to periodontal diseases
and dental caries, poor esthetics giving rise to
Box 2.1: Unfavorable sequelae of malocclusion
psychosocial problems, increased risk of trauma,
abnormalities of function and temporo- • Poor facial appearance
mandibular joint (TMJ) problems (Box 2.1). • Poor oral hygiene maintenance
Orthodontics is the branch of dentistry concerned • Risk of dental caries
with the growth of the face, development of • Risk of periodontal diseases
occlusion and the prevention and correction of • Abnormalities of functions
occlusal anomalies/abnormalities. The term • Psychosocial problems
“orthodontics” comes from Greek: “orthos” meaning • Risk of trauma to the teeth
right or correct and “odontos” meaning tooth (Flow • TMJ problems.
Introduction to Orthodontics 15
Flow chart 2.1: Derivation of the term orthodontics and father’s large teeth may have teeth that are
too big for the jaw, causing crowding in the arch.
Abnormal oral habits, such as thumb/digit
sucking, lip biting and mouth breathing may
also cause malocclusion by adversely affecting
the normal occlusal development. Malocclusion
can be presented in a number of ways. Some of
the common characteristics of malocclusion
include:
• Overcrowded teeth
the years to explain what orthodontics is. Some of • Spacing between the teeth
the widely followed definitions are given below: • Improper “bite” between maxillary and
In 1911, Noyes gave the first definition of mandibular teeth
orthodontics as, “The study of the relation of the • Disproportion in the size and the alignment
teeth to the development of the face and the correction between the maxillary and the mandibular
of arrested and perverted development.” jaws.
In 1922, The British Society of Orthodontists It must be appreciated that not all malocc-
proposed that, “Orthodontics includes the study of lusions need treatment. Treatment of malocclus-
growth and development of jaws and face ions that are mildly unesthetic and not detrimental
particularly and the body generally, as to the health of the teeth and their supporting
influencing the position of the teeth; the study of structures may not be needed and is not justified.
action and reaction of internal and external
influences on the development, and the prevention AIMS OF ORTHODONTIC TREATMENT
and correction of arrested and perverted
Although orthodontic treatment improves facial
development.”
appearance and is occasionally performed for
Later, the American Board of Orthodontics
cosmetic reasons, it should be aimed at restoration
(ABO) and the American Association of
of overall dental health.
Orthodontists (AAO) stated that, “Orthodontics is
Jackson has summarized the aims of
that specific area of dental practice that has as its
orthodontic treatment that are popularly known
responsibility, the study and supervision of the
as Jackson’s triad (Fig. 2.1). They are:
growth and development of the dentition and its
i. Functional efficiency
related anatomical structures from birth to dental
ii. Structural balance
maturity, including all preventive and corrective
iii. Esthetic harmony.
procedures of dental irregularities, requiring the
repositioning of teeth by functional or mechanical
Functional Efficiency
means to establish normal occlusion and pleasing
facial contours.” The teeth along with their surrounding structures
are required to perform certain significant
WHAT IS MALOCCLUSION? functions such as mastication and phonation.
Orthodontic treatment should increase the
The term ‘malocclusion’ was first coined by
efficiency of the functions performed.
Guilford and it refers to any irregularities in
occlusion beyond the accepted range of normal.
Structural Balance
Malocclusions are caused by hereditary or
environmental factors or more commonly, by both Orthodontic treatment not only affects teeth but
the factors acting together. One of the most also the soft tissue envelop and the associated
common causes of malocclusion is a skeletal structures. The treatment should maintain
disproportion in size between the jaw and the a balance between these structures and the
teeth or between the maxillary and the mandibular correction of one should not affect the health of
jaws. A child who inherits mother’s small jaw the other.
change the normal course of events. They include

the care of deciduous dentition with restoration
of carious lesions that might change the arch
length, monitoring of eruption and shedding
timetable of teeth, early recognition and
elimination of oral habits that might interfere with
the normal development of the teeth and jaws;
removal of retained deciduous teeth and
supernumeraries which may impede eruption of
permanent teeth and maintenance of space
following premature loss of deciduous teeth to
allow proper eruption of their successors.
Interceptive Orthodontics
Interceptive orthodontics implies that when the
action is taken, an abnormal situation (maloc-
clusion) already exists. Certain interceptive
Fig. 2.1: Aims of orthodontic treatment (Jackson’s triad)

procedures are undertaken during the early
manifestation of malocclusion to lessen the
severity of malocclusion and sometimes to

eliminate the cause.
Esthetic Harmony Interceptive orthodontics is defined by the
American Association of Orthodontists as “That
The orthodontic treatment should enhance the phase of the science and art of orthodontics
overall esthetic appeal of the individual. This
employed to recognize and eliminate potential
might just require the alignment of certain teeth or
irregularities and malpositions in the developing
movement of the complete dental arch, including
dentofacial complex.”
its basal bone. The aim is to get results which go
Interceptive procedures include serial
well with the patient’s personality and make him
extraction, correction of developing anterior
or her look more esthetically appealing.
crossbite, control of abnormal oral habits, removal
of supernumeraries and ankylosed teeth and
BRANCHES OF ORTHODONTICS
elimination of bony or tissue barriers to erupting
The general field of orthodontics can be divided teeth.
into the following three categories based on the Certain procedures undertaken may be
nature and time of intervention: common to both preventive and interceptive
• Preventive orthodontics orthodontics. However, the timing of the services
• Interceptive orthodontics rendered is different. Preventive orthodontic
• Corrective orthodontics. procedures are carried out before the manifestation
of a malocclusion, while the goal of interceptive
Preventive Orthodontics orthodontics is to intercept a malocclusion that
has already been developed or is developing, so
Preventive orthodontics is defined as “Action taken
as to restore a normal occlusion.
to preserve the integrity of what appears to be the
normal occlusion at a specific time.” As the name
Corrective Orthodontics
implies, preventive orthodontics includes actions
undertaken prior to the onset of a malocclusion, Corrective orthodontics, like interceptive
so as to prevent the anticipated development of a orthodontics, is also undertaken after the
malocclusion. manifestation of a malocclusion. It employs
Preventive orthodontics encompasses all those certain technical procedures to reduce or correct
procedures that attempt to ward off untoward the malocclusion and to eliminate the possible
environmental attacks or anything that would sequelae of malocclusion.
Corrective surgical procedures may require therapy, e.g. retainers. Removable orthodontic
removable or fixed mechanotherapy, functional appliances can be used in conjunction with fixed
or orthopedic appliances, or in some cases an mechanotherapy.
orthognathic/surgical approach.
Fixed Orthodontic Appliances
ORTHODONTIC APPLIANCES Fixed orthodontic appliances are so called because
Today orthodontists have a wide array of they are fixed to the teeth and cannot be removed
appliances in their armamentarium to treat by the patient. Fixed orthodontic therapy involves
malocclusions. Success of orthodontic treatment fixation of attachments (brackets) to the teeth and
depends on the appropriate selection of the application of forces by arch wires or auxiliaries
appliances, the timing of the treatment, the type of via these attachments (Fig. 2.3).
tooth movement and/or skeletal changes desired, Fixed appliances are indicated when multiple
age of the patient and other factors. There are tooth movements are required for correction of
basically four types of orthodontic appliances, malocclusion, such as rotations and bodily
which can either be used singly or in combination movement of teeth. Fixed mechanotherapy allows
to treat malocclusions. fine finishing and settling of occlusion. There are
i. Removable orthodontic appliances a number of fixed orthodontic techniques such
ii. Fixed orthodontic appliances as: Begg’s, edgewise, preadjusted edgewise,

straight wire and lingual techniques.
iii. Functional appliances

iv. Orthopedic appliances/Extraoral force
appliances. Functional Appliances
Functional appliances/myofunctional appliances
Removable Orthodontic Appliances are those appliances that utilize the forces of the
Removable orthodontic appliances are so called circumoral musculature for their action to effect
because they can be removed and fitted back into the desired changes (Fig. 2.4). They act principally
the mouth by the patient (Fig. 2.2). by holding the mandible away from the normal
Use of removable appliances requires careful resting position to effect growth modification of
case selection for the success of the treatment. They the mandible.
are ideally used when simple tipping movement
Orthopedic Appliances/Extraoral
of teeth is sufficient to correct a certain type of
Force Appliances
malocclusion. The range of malocclusions that can
be treated with removable appliances alone is Orthopedic appliances use extraoral forces of high
limited. They can also be used as passive magnitude (> 400 gm/side) to bring about skeletal
appliances to maintain the teeth in their corrected changes. Intermittent application of such high
positions after active phase of orthodontic forces in the growth period aids in correction of
Fig. 2.2: Removable orthodontic appliance Fig. 2.3: Fixed orthodontic appliance
Fig. 2.4: Activator, a myofunctional orthodontic appliance
skeletal malocclusions by growth modification.

Orthopedic appliances like functional appliances
require good patient compliance for their success, Fig. 2.5: Orthopedic appliance
e.g. headgears and chin cup (Fig. 2.5).

TIMING OF ORTHODONTIC INTERVENTION • Reduction or elimination of abnormal

swallowing or speech problems
Appropriate timing of orthodontic treatment is
• Growth modification using functional and
essential to accomplish the desired treatment
orthopedic appliances is best done in this
outcome and its long-term stability. Timing of
period where significant growth is taking place
orthodontic intervention is related to the stage of
• Shortening and simplification of later
dentition.
orthodontic treatment
• Prevention of later tooth extractions
Deciduous Dentition
• Improvements in appearance and self-esteem
Orthodontic treatment during this stage mainly • Parental education.
includes the following:
• Parental education Late Mixed Dentition/Early
• Care of deciduous dentition Permanent Dentition
• Space maintenance
Most corrective orthodontic treatments are carried
• Elimination of abnormal oral habits.
out in late mixed dentition or early permanent
dentition stage.
Early Mixed Dentition
Orthodontic treatment during this stage includes Late Treatment
the monitoring of shedding timetable, serial
• Many types of orthodontic treatments are
extraction, space maintenance and control of
feasible after adolescence. However, growth
abnormal oral habit. Although most corrective
modification procedures to correct skeletal
orthodontic procedures are performed in older
malocclusion may not be feasible due to
children and adolescents, it may be advantageous
cessation of growth.
in some cases to begin the treatment early before
• Surgical treatment involving orthognathic
all the permanent teeth have erupted and facial
surgeries are best carried out in late teens/
growth is complete.
early adulthood after the cessation of growth.
Advantages of early orthodontic treatment
include:
SCOPE OF ORTHODONTICS
• Correction of bite problems by guiding jaw
growth and controlling the width of the upper From the era of finger pressure application to
and lower dental arches invisalign treatment, the field of orthodontics has
witnessed profound development in the form of appliance design has made orthodontic treatment
newer appliance designs and techniques, which feasible in adult age as well. Orthodontic treatment
have only increased the scope of orthodontics. in adults may involve the following:
• Adjunctive orthodontic procedures: They refer to
Monitoring and Assessment limited orthodontic treatment carried out to
of Developing Dentition facilitate other dental procedures. Adjunctive
orthodontic procedures include uprighting of
• Shedding and eruption schedule is closely
tilted abutment teeth prior to bridge work,
monitored to ensure the normal course of
space gaining for placement of implants, etc.
events.
• Comprehensive orthodontic treatment: It is
• Space maintainers are given in case of
usually carried out in young adults and
premature loss of primary teeth to facilitate
involves full fledged orthodontic treatment
the eruption of successor teeth.
with or without extraction of teeth.
• Habit breaking appliances are given to
eliminate deleterious oral habits, such as
thumb/digit sucking and lip biting which can Guards
adversely affect the development of dentof- • Mouth guard/Sports guard: Mouth guards are
acial structures. often used during contact sports, such as
• Planned extraction of certain deciduous and/ boxing to prevent trauma to the teeth.
or permanent teeth (serial extraction), done in
• Night guards: Night guards can be given in

selected cases, can prevent future development bruxism to prevent further loss of tooth
of crowding by providing adequate space for structures by attrition.
the remaining teeth to erupt.
Management of Dentofacial Anomalies
Correcting Malocclusions of Dental Origin
Dentofacial anomalies such as cleft lip and palate
Malocclusions of dental origin include
are usually associated with impaired facial
abnormalities of intra-arch alignment and
appearance, speech, hearing, mastication,
interarch relationship of teeth. They can be
deglutition, and dental occlusion. Thus, manag-
managed by removable or fixed orthodontic
ement of such patients often requires a
appliances.
multidisciplinary approach with a long-term
treatment plan and individualized rehabilitation
Correcting Malocclusions of Skeletal Origin
program designed to address the treatment needs.
Skeletal malocclusions include conditions where Malocclusion is usually present and orthodontic
the upper and lower jaws are abnormally related therapy with or without corrective jaw surgery is
to each other. frequently indicated.
• Growth modification: Skeletal malocclusions
can be treated successfully by modifying the BENEFITS OF ORTHODONTIC TREATMENT
growth of jaws during active growth period
using functional or orthopedic appliances. • Improved confidence.
• Surgical correction: Severe skeletal malocclusion • Well aligned teeth that are easier to keep clean
in adults can be corrected by orthognathic/ and healthy.
surgical approach. • Ideally positioned teeth, which lessen the
chance of gingivitis and advanced gum
disease.
Adult Orthodontics
• Closed spaces to avoid the need for a bridge or
Better understanding of bone cell reactions to denture.
orthodontic forces and improvements in • Better chewing and food digestion.
History of
Orthodontics from
Ancient Civilization to 3
Twentie
Twentiethth Century
• Ancient Civilization • Eighteenth Century

• Middle Ages Through • Nineteenth Century
Seventeenth Century • Twentieth Century
Since the beginning of human history, human orthodontists to diagnose and treat patients; and
beings have understood at a very basic level that even though methods for straightening teeth, like
without a proper bite, survival is very difficult. If dental braces, have dramatically changed since
you cannot chew well, you cannot eat well. the early 1900s, Dr Angle’s classifications have
Remains of the ancient Egyptians, Romans and stood the test of time.
the Etruscans show that these societies used The history of orthodontics is interesting and
various kinds of metal and ‘wires’ to straighten at the same time complex. It is the oldest speciality
or adjust the teeth. of dentistry. It would be wise to follow the
Many advances in dentistry and some development of this exciting field of science right
pioneering efforts in teeth straightening began in from the era of ancient civilization to the current
the 18th century, but it was really in the 19th century times. Prior to 1900s, the orthodontics was referred
that orthodontics became a science of its own. as “Regulation of Teeth” and as “Orthodontia”
Many inventors have contributed significantly up to 1930s and “Orthodontics” up to 1970s and
to the fascinating science of orthodontics. The currently it is addressed as “Orthodontics and
person, to whom, given the most credit for Dentofacial orthopedics” (Box 3.1).
pioneering modern orthodontics is Dr Edward
Angle, who is rightly honored as the “Father of ANCIENT CIVILIZATION
Modern Orthodontics”. Angle developed a
method for scientifically classifying, categorizing The history of orthodontics has been intimately
and identifying irregular bites. His classification interwoven with the history of dentistry for more
of malocclusion, also known as the Angle than 2000 years. Dentistry in turn, has its origins
classifications is still being used by dentists and as a part of medicine.
History of Orthodontics from Ancient Civilization to Twentieth Century 21
Box 3.1: Evolution of the term orthodontics until the Renaissance that the infallibility of his
medical expertise was questioned. In his medical
• Orthodontics writings, he described dental anatomy and
– “Regulation“ prior to 1900s
embryology by specifically identifying the origin,
– “Orthodontia” up to 1930s (“ia” referred to a
growth, and development of the teeth and
medial condition)
– “Orthodontics” up to 1970s enumerating the functions of each. He believed
– Currently “Orthodontics and Dentofacial the teeth to be true bones. Because dissection was
orthopedics” performed on animals rather than on human
beings, he erroneously applied some of his
findings to human beings (e.g. the presence of an
The Greek physician, Hippocrates (460–377
intermaxillary bone and the insensibility of teeth).
BC), was the first to separate medicine from fancy
or religion. He established a medical tradition
MIDDLE AGES THROUGH SEVENTEENTH
based on facts and the collected information was
CENTURY
gathered into a text known as the ‘Corpus
Hippocraticum’. This text of the pre-Christian era There is little reference to dentition during this
contains many references to the teeth and to the period. An Arabic physician Paul of Aegina
tissues of the jaws as part of the medical text, which (Paulus Aegineta 625–690) wrote about
includes descriptions of irregularity and crowding irregularities in the dental arches caused by
of teeth. supernumerary teeth. He advised extraction of
such teeth.
Aristotle (384–322 BC), the Greek philosopher was
the first writer who studied the teeth in a broad Ambrose Paré (1517–1590), a French surgeon,
manner. In his work entitled De Partibus paid specific attention to the cleft palate. He was
Animalium (On the Parts of Animals), he the first surgeon to devise an obturator for
compared various dentitions of the known species treatment of cleft palate.
of animals of that time.
Renaissance Period
Aulius Cornelius Celsus (25 BC–50 AD), the
(Fourteenth to Sixteenth Century)
prominent Roman author of the first century,
described finger pressure to move teeth in his work During the Renaissance, one of the greatest
De Re Medicina (on Medicine) (Table 3.1). geniuses of history, Leonardo da Vinci (1452–
When in a child, a permanent tooth appears 1519), is remembered because he painted a smile
before the fall of the milk tooth, it is necessary to on the lips of Mona Lisa. Her smile remains most
dissect the gum all around the latter and extract provocative; yet the brush was only one of the
it. The other tooth must then be pushed with the many tools he mastered. He was the first artist to
finger, day by day, towards the place that was dissect the human body for the acquisition of
occupied by the one extracted; and this is to be anatomic knowledge and the first to draw accurate
continued until it reaches its proper position. pictures of these dissections.
The medical art of the Romans reached its Leonardo was the first to recognize tooth form
zenith under Claudius Galenus, commonly and the first to realize that each tooth was related
known as Galen (AD 130–200). For 15 centuries to another tooth and to the opposing jaw as well,
he dominated medical thought, and it was not thus perceiving the articulation of the teeth. He
Table 3.1: Ancient civilization

Years Authors Contributions to orthodontics
460–377 BC Hippocrates Description of irregularity “Corpus Hippocraticum”.
384–322 BC Aristotle Comparison of various dentitions of different species
of animals in his work “On the Parts of Animals”.
25 BC–50 AD Aulius Cornelius Celsus Described finger pressure to move teeth in his work
‘De Re Medicina (On Medicine)’.
described the maxillary and frontal sinuses and Bartholomaeus Eustachio (1520–1574),
established their relationship to facial height. He commonly known as Eustachius, also an Italian
determined and made drawings of the number of anatomist, described the minute structure of many
teeth and their root formations. He noted that organs, especially the tube that connects the
“those teeth that are the farthest away from the middle ear with the nasopharynx and that bears
line of the temporomandibular articulation are at his name. He wrote Libellus de Dentibus (Book
a mechanical disadvantage as compared with on the Teeth) in 1563, which is the first important
those that are nearer.” specialized monograph on the anatomy of the
Those (teeth) that act most powerfully, the teeth. In this book, he collected the writings of
mascellari (molars) have broad flattened crowns various authors from Hippocrates to Vesalius,
suitable for grinding the food, but not for tearing added the results of his own researches, and gave
or cutting it. Those that act less powerfully, the the first accurate account of the phenomenon of
incisors, are suitable for cutting the food but not the sequential development of the first and second
for grinding it. The maestre (canines) are dentitions. He described the eruption and the
intermediate between these two sets, their function function of the teeth, contending that there was
being presumably that of tearing the food. no analogy between the deciduous and permanent
dentitions. Eustachius devoted more attention to
Andreas Vesalius (1514–1564), a Belgian
the teeth than most anatomists, giving full
physician and anatomist, set a precedent for the

descriptions of the different forms, number and
study of human anatomy when he personally
varieties. He indicated the manner of articulation

performed a dissection. It had been the custom for
of the teeth and gave a somewhat ambiguous
students to do the dissections while the lecturer
explanation of the nature of the attachment of the
described the procedure and specimen. He proved
teeth to the socket and the gingival tissues,
Galen wrong in many areas of anatomic
comparing the latter to the attachment of the nails
knowledge. His classic work, On the Fabric of
to the skin. His explanation of the internal
the Human Body, became the foundation that
structure of the teeth differentiated the two layers
reconstructed our knowledge of human anatomy
and compared the enamel with the bark of trees.
and thereby laid the basis for the practice of
Eustachius described the dental follicle and
medicine and surgery.
its blood supply. He refuted the doctrine that roots
In this book, he described the minute anatomy
of the deciduous dentition served to form the
of the teeth, particularly the dental follicle and
permanent teeth. He maintained that the germs of
subsequent pattern of tooth eruption:
the permanent teeth are too small to be seen in the
Gabriele Fallopio (1523–1562), commonly known fetus. He also mentioned that the teeth are
as Fallopius, an Italian anatomist, wrote in his nourished differently than other bones, as
Observationes Anatomica (Anatomic Observ- witnessed by their inability to repair when
ations) a detailed description of the dental follicle. He fractured.
wrote the terms hard and soft palate. The first book in the German language to have
A membranous follicle is formed inside the reference to the teeth was entitled “Arzei
bone furnished with two apices, one posterior (that Buchlein” (A Book of the Surgical Art) and was
is to say, deeper down, more distant from the published in 1530 (author unknown). It contains
gums), to which is joined a small nerve, a small the following comment. When teeth begin to drop
artery and a small vein; the other anterior (that is, out push the new one every day toward the place
more superficial) which terminates in a filament. where the first one was, until it sits there and fits
Inside the follicle is formed a special white and among the others, for if you neglect to attend to
tenacious substance, and from this the tooth itself, this, the old teeth (deciduous) will remain and the
which at first is osseous only in the part nearest young ones (permanent) will be impeded from
the surface, while the lower part is still soft, that growing straight.
is, formed of the above mentioned substance. Each
EIGHTEENTH CENTURY
tooth comes out traversing and widening a narrow
aperture, bare and hard; and in process of time 18th Century witnessed major events in the
the formation of its deeper part is completed. development of dental science and dentistry
Table 3.2: Eighteenth century

Years Author Contributions to orthodontics
1772–1789 Etienne Bourdet • Extraction of 1st premolars to preserve the symmetry of the
jaws
• Extraction of the mandibular 2nd molars shortly after eruption
in case of child with protruded chin
1723 Pierre Fauchard • Father of modern dentistry
• He published his two-volume book entitled “The surgeon
dentist, a treatise on the teeth”
• Developed first expansion appliance called “Bandlette”
1728–1793 John Hunter • Natural history of teeth
• Growth and development of jaws
• Internal structure of teeth
• Functions of teeth
(Table 3.2) were separated. France was the leader what is probably the first orthodontic appliance.
in dentistry throughout the world in the 18th It was called a Bandelette (Fig. 3.1). It was
century. This was mainly due to one person; Pierre designed to expand the arch, particularly the
Fauchard. No one person exerted a stronger anterior teeth and was the forerunner of the
influence on the development of the profession expansion arch of modern times.
than he did. In fact, he is referred to as the ‘Founder
John Hunter (1728–1793), an English surgeon and
of Modern Dentistry’. He created order out of
a great teacher of anatomy, published his book
chaos, developed a profession out of a craft and
‘The Natural History of the Human Teeth” in
gave to this new branch of medicine a scientific
1771. He demonstrated the growth, development
and sound basis for the future. He published his
and articulation of the maxilla and mandible, and
two-volume book entitled “The Surgeon Dentist,
outlined the internal structure of the teeth and
A Treatise on the Teeth”, which had an entire
bone and their separate functions. He gave the
chapter, on ways to straighten teeth. With reference
basic nomenclature of dentistry incisors,
to orthodontics, as early as 1723, he developed
bicuspids and molars.
The art of modern dentistry based on scientific
foundation was first developed in Europe. It then
came to the United States through the European-
trained Operators for the teeth who came to
America seeking fresh opportunities. Many native
practitioners of America then began to “Regulate”
teeth. Malocclusion was called ‘irregularities’ and
their correction ‘regulation’ during this period.
NINETEENTH CENTURY
Foundations were laid in the 19th century to the
oldest specialty of dentistry – Orthodontics. It was
in the latter part of the 19th (1880s) century that
the speciality began to emerge.
By the mid–19th century, basic concepts of
diagnosis and treatment had begun. It was a time
when each practitioner attempted treatment by
devising their own method based on purely
Fig. 3.1: Bandelette designed by Pierre Fauchard to
expand dental arches mechanical principles. At that time, orthodontics
was part of prosthetic dentistry and the literature he who gave impetus to the scientific
on the subject described orthodontics in the area investigations that permitted the understanding
of partial or total replacement of missing teeth. of the theory and practice of orthodontics. During
As early as in 1841, William Lintott, his studies, he investigated the physiologic and
introduced the use of screws in his work ‘On the pathologic changes occurring in animals as the
teeth’. He described premature loss of deciduous result of orthodontically induced tooth movement.
teeth as a cause of malocclusion, recommended He published two volumes entitled
that treatment be begun at age of 14 or 25 years “Irregularities of the Teeth and Their Correction”
and also described a bite opening appliance. in 1888 and 1889. This textbook was the first great
work devoted exclusively to orthodontics. Farrar
JS Gunnell, in 1840, introduced the chin strap as
was good at designing brace appliances and was
occipital anchorage for the treatment of
the first to suggest the use of mild force at timed
mandibular protrusion, the principle of which is
intervals to move teeth—‘in regulating the teeth,
used even today.
the traction must be intermittent and must not
Emerson C Angel (1823–1903), in 1860 was the exceed certain fixed limits.’
first to advocate the opening of the median suture He also was the first to recommend root or
to provide space in the maxillary arch, since he bodily movement of the teeth.
strongly apposed extraction. This began the use Another man who also deserves much credit
of arch expansion in orthodontics (Fig. 3.2). during this period of time is Norman N Kingsley
(1829–1913), a prominent dentist, artist, sculptor

William and Magill, developed molar bands (Fig.
and orthodontist. He is known for his works on
3.3) on the teeth as early as in 1871.
”Correction of cleft palate”. As early as in 1866,
It was not until the latter part of the 19th
he devised a technique called ‘Jumping the bite’
century, when a few dedicated dentists gave
with the use of a bite plane. He used vulcanite on
special attention and importance to this phase of
conjunction with ligatures, elastic bands made of
dentistry, that orthodontics began to emerge as a
rubber, jackscrews and the chin cap.
speciality science. It was known at that time as
‘Orthodontia’, the suffix ‘ia’ referred to a medical Henry A Baker, is remembered for the
condition. In the last three decades of 19th century, introduction of the so-called Baker anchorage or
some great contributions were made to the the use of the intermaxillary elastics (Fig. 3.4) with
speciality by the following dentists. rubber bands in 1893 (Table 3.3).
John Nutting Farrar (1839 – 1913), is often referred
TWENTIETH CENTURY
as the “Father of American Orthodontics”. It was
The most dominant, dynamic and influential
figure in the specialty of orthodontics was
Fig. 3.2: Expansion appliance developed

by Emerson C Angel Fig. 3.3: Molar band
Table 3.3: Nineteenth century

Year Author Contributions to orthodontics
1841 William Lintott Introduced the use of screws
1840 JS Gunnell Introduced chin strap
1860 Emerson C Angel • First to introduce arch expansion by opening midpalatal
suture
• “Father of expansion appliances”.
1871 William and Magill Developed molar bands
1888 and 1889 John Nutting Farrar • “Father of American orthodontics”
• Wrote “Irregularities of the Teeth and Their Correction”.
This textbook was the first great work devoted exclusively
to orthodontics
• Laid the foundation for “Scientific orthodontics” (intermittent
forces, limits to amount of tooth movements)
1829 to 1913 Norman N Kingsley • “Treatise on Oral Deformities“ worked on correction of cleft
palate
• Extraoral traction
1893 Henry A Baker Baker’s anchorage (Intermaxillary elastics)
Fig. 3.4: Baker’s anchorage (Intermaxillay elastics)
Edward H Angle (1855–1930) (Fig. 3.5). He is

Fig. 3.5: Edward Hartley Angle (1855–1930)
regarded as the “Father of Modern Orthodontics”.
His classification of malocclusion was published
in the Dental Cosmos, in 1899. Angle developed a
book on orthodontics was published, and the last
classification of malocclusion based on this
fully revised seventh edition appeared in 1907.
principle, which is still used today.
He became professor of orthodontics in the year
1892.
Edward Hartley Angle (1855–1930)
Angle started the first school of Orthodontics
Angle was born on June 1, 1855, in Herrick, in St Louis in 1900, independent from any
Pennsylvania. He graduated from Pennsylvania university. From 1900 to 1928 he was the active
College of Dentistry, in 1878. It was then that he head of his school, first in St Louis, later in New
started his first orthodontic case on his preceptor’s London, Connecticut and finally in Pasadena,
son. The problems that arose stimulated him to California. Under Angle’s aegis, the American
devote the rest of his life to orthodontics. School of Orthodontists was founded in 1901.
He presented his first scientific paper in 1887 Angle introduced the most universally used
before the ninth International Medical Congress. classification of malocclusion, and even developed
In the same year, his first paper bound edition a number of appliances such as the E-arch, the
pin and tube appliance, the ribbon arch appliance advocate of the relationship of malocclusion to
and the edgewise appliance. facial improvement. Facial improvement was a
He has been given the most credit for guide to treatment.
pioneering modern orthodontics is Dr Edward
Angle. Dr Angle developed a method for 1847–1923
scientifically classifying, categorizing and
One of the great pioneers in orthodontics, Calvin
identifying irregular bites. His malocclusion
Case, was born in Jackson, Michigan, on April 24,
classifications, also known as the Angle
1847. He graduated dentistry and medicine from
Classifications are still used by dentists and
Ohio Dental College in 1871 and University of
orthodontists today to diagnose and treat patients.
Michigan Medical School in 1884, respectively.
And even though methods for straightening teeth,
He became Professor of Prosthetics and
like dental braces, have dramatically changed
Orthodontics, at Chicago College of Dental
since the early 1900’s, Dr. Angle’s classifications
Surgery. He dropped his professorship of
have stood the test of time.
prosthetics in 1896 and later continued in only
Although Angle died on August 11, 1930, his
orthodontics throughout his life.
influence is still felt very strongly in the orthodontic
As a prolific writer, Case wrote 123 articles in
field. The whole world still uses his classification
dental literature alone on orthodontic diagnosis,
of malocclusion and his excellent descriptions of
orthodontic appliance, problems of tooth

occlusion are hardly less important than his
movement, cleft palate and associated speech
classification of malocclusion. His strong

problems, and prosthetic restorations of normal
opposition against extraction of teeth as a part of
speech and function. He was the second author
orthodontic therapy has served as a balance wheel
next to Angle. His textbook, the Techniques and
against promiscuous tooth removal. His
Principles of Dental Orthopedia, was published
mechanical genius has provided some of the most
in 1908.
efficient appliances in use at present.
Case was also a pioneer in orthodontic
Another distinguished orthodontist was
mechanotherapy. He was the first one to stress the
Calvin S Case [(1847–1923) (Fig. 3.6)]. He
importance of root movement (1892). He was one
developed a classification of malocclusions that
of the first to use rubber elastics in treatment (1892),
included 26 divisions. Case published his major
small gauge, and light resilient wires for tooth
work “A practical treatise on the techniques and
alignment (1917). He pioneered the use of relieves
principle of dental orthopedic and prosthetic
to stabilize orthodontic results. He is regarded as
correction of the cleft palate”. Case was a strong
the outstanding man of his time in the prosthetic
aspect of rehabilitation of cleft palate deformities.
Charles A Hawley (1861–1929), used a celluloid
sheet containing a geometric figure that when
adapted to a model determined the extent of
proposed tooth movement (1905) and introduced
the retainer appliance (Fig. 3.7) that bears his name
(1908) (Table 3.4).
In 1931, B Holly Broadbent published an
article in the first issue of the new Angle
Orthodontist entitled. “A New X-ray Technique
and its Application to Orthodontia”. It was the
introduction to the specialty and to dentistry of
cephalometric roentgenography (Fig. 3.8) and, of
course, cephalometric tracing and evaluation.
Broadbent devised the roentgenographic
cephalometer, which is the instrument that
Fig. 3.6: Calvin S Case (1847–1923) accurately positions the head relative to the film
Table 3.4: Twentieth century

Year Author Contributions to orthodontics
1855 to 1930 Edward H Angle • Father of orthodontics
• Classification of malocclusions
• E-arch appliance
• Pin and tube technique
• Edgewise technique
1847 to 1923 Calvin S Case • Advocated extractions to correct facial deformities
• First to use elastic
• First to use light wires
• Great contribution to prosthetic correction in cleft palate patients
1861 to 1929 Charles A Hawley Hawley retainers
Fig. 3.7: Hawley’s retainer introduced Fig. 3.8: Cephalometric roentgenography (Lateral
by Charles A Hawley cephalogram)
and the X-ray source. His study, supported by the Changes in the area of practice include a
Bolton family, consisted of a longitudinal study resurgence of treatment of the adult patient and
of 3,500 school children from birth to adulthood. its concomitant expertise, as the public becomes
In honor of his sponsor, Broadbent established a aware of personal dental health and esthetics.
new point of reference on the skull, known as the Included also are the invasion of areas that had
Bolton point. not received much attention in the past, namely,
H D Kesling introduced his philosophy of tooth orthognathic surgery and the problems associated
movement by using a rubber tooth positioning with the temporomandibular joint. Orthodontics
device, in which the teeth were moved into a more has achieved the status of a recognized specialty
ideal cuspal relationship after major correction of dentistry because of a long period of
has been accomplished (1945). craftsmanship and professional expertise.
in United States of 4
America
• American Orthodontics (1800– – Thomas W Evans – Alton H Thompson

1840) – Emerson C Angell – Isaac B Davenport
– Benjamin James – O A Marvin – Henry A Baker

– Samuel S Fitch – William E Magill – Eugene S Talbot
– M Bourand • American Orthodontics (1875– – Simeon H Guilford

• American Orthodontics (1840– 1900) – WGA Bonwill
1875) – John H Farrar
– Chapin A Harris – Norman W Kingsley
In Colonial America, primitive conditions for first cutting in children” (1804). B Fendall of
dental care existed for almost a century until Baltimore advertised that he “regulates the teeth
European-trained operators for the teeth came of children” (1784).
to this country seeking fresh opportunities. The
art of dentistry in America can be said to have Leonard Koecker (1728–1850), practiced in
had its origin with the importation of these Philadelphia, advertised that he supplies
practitioners to the colonies. ligatures to teeth of an irregular position. He
One of the most important native practi- stated this in his published articles in the medical
tioners was John Greenwood (1760–1819). His press (1826): “Irregularities of the teeth is one of
skills were first learned from his father, who was the chief predisposing causes of disease, and
an instrument maker. He was apprenticed to Dr never fails even in the most healthy conditions
Gamage, who taught him the rudiments of the to destroy, sooner or later, the strongest and best
dental art. Through experience, he became set of teeth unless properly attended to. It is not
proficient in the practice. only a most powerful cause of destruction of the
Other practitioners include Josiah Flagg health and beauty of the teeth but also to the
(1763–1816) of Boston, who advertised that he regularity of the features of the face, always
“regulates teeth from their first teeth, to prevent producing, though slowly, some irregularity, but
pain and fevers in children, assists nature in the frequently the most surprising and disgusting
extension of the jaw, for a beautiful arrangement appearance. It is, however, a great pleasure to
of a second set of teeth.” know that dental surgery is abundantly provided
In 1798 CW Whitlock of Philadelphia stated with a remedy, and in most delicate subjects if
that he supplies the deficiencies of nature files, placed under proper care at an early age, the
regulates, and extracts teeth. John Le Tellier, also greater portion of the teeth of the permanent set
of Philadelphia states, “regulates teeth from their may invariably be preserved to perfect health and
History of Orthodontics in United States of America 29
regularity”. A note about his recomm-endation Other practitioners found various forms of
for extraction is as follows. He advocated the treatment, such as the use of gold or silver plates “to
extraction of first molars “since they are generally exert a gentle but continued pressure.” Shearjashub
predisposed to disease and if these teeth be Spooner (1809–1859) wrote in his Guide to Sound
extracted at any period before the age of twelve Teeth (1838), “we have to consider, first, their general
years, all the anterior teeth will grow more or appearance as to regularity to the central circle; and,
less backwards, and the second and third molars second, the state of preservation of each individual tooth
so move toward the anterior part of the mouth to in cases where there is a predisposition to a projecting
fill up the vacant space”. chin”.
M Bourand from Paris observed that the parents
American Orthodontics (1800–1840)
should be alerted to the shedding of the deciduous teeth
Irregularity of the teeth had been recognized by and any possible deformity. He stated: “Defects,
dental surgeons early in the nineteenth century. sometimes, which are of such magnitude, that I have
Benjamin James (1814) noted that he was “often known, in my long practice in both hemispheres, some
called upon to cure irregularity, than to prevent young ladies of respectable families and of elegant
it.” Levi S Parmly (1819) stated, “where features who could not observe their smiling
irregularities are allowed to proceed and become countenances in a looking glass without blushing at
fixed, it is often a matter of difficulty, and the irregularities of their teeth; when comparing their
sometimes of impossibile to rectify them.”
mouths with some of their young friends toward whom

their parents had bestowed all the necessary care to
Samuel S Fitch, MD, whose book entitled A
System of Dental Surgery, published in 1829, is regulate their growth from childhood”.
considered the first definitive work on dentistry
in this country, devoted a significant amount of American Orthodontics (1840–1875)
information to irregularities of the teeth. He was The correction of irregularities, however, easy in
the first to classify malocclusion, what is as theory, will be found most difficult and delicate
follows: in practice; not only will much skill be found
‘There are four states of this kind of irregularity. requisite, but, in equal degree, patience.
The first when one central incisor is turned in, and the Thus, by the mid-nineteenth century basic
under teeth come before it, whilst the other central concepts of diagnosis and treatment had begun.
incisor keeps its proper place, standing before the under It was a time when each practitioner attempted
teeth. The second is, when both the central incisors are treatment by devising his own method based on
turned in, and go behind the under teeth; but the lateral purely mechanical principles. Orthodontics was
incisors are placed properly and stand out before the part of prosthetic dentistry, and the literature on
under teeth. The third variety is when the central the subject described orthodontics in the area of
incisors are placed properly but the lateral incisors
partial and total replacement.
stand very much in; and when the mouth is shut, the
under teeth project before them and keep them backward. Chapin A Harris (1806–1860), one of the most
The fourth is, when all incisors of the upper are turned influential dental surgeons during this period,
in, and those of the under jaw shut before them’. published the first modern classic book on
His treatment consisted of applying “a force which dentistry, “The Dental Art”, in 1840. In it he gives
shall act constantly upon the irregular teeth and bring much attention to various orthodontic treatment
them forward; the other force to remove that obstruction procedures that were adapted from French and
which the under teeth, by coming before the upper, English practitioners. His personal technique
always occasion.” This is done by “application of an included the use of gold caps on molars to open
instrument adapted to the arch of the mouth, fastening the bite and knobs soldered to a band for tooth
a ligature on the irregular tooth and removing the rotations.
resistance of the under teeth by placing some Materials generally used were cotton or silk
intervening substances between the teeth of the upper ligatures, metallic wedged arches, and wooden
and under jaw, so as to prevent them from completely wedges, but the discovery of vulcanite, a material
closing.” used for artificial dentures, permitted the
construction of bite plates and other forms of report was given by E J Tucker, a respected dental
removable appliances. In addition, springs that surgeon of Boston, in 1853. He condemned the
were to be attached to the metal frames for use practice of early extraction of deciduous teeth and
in individual tooth movement were introduced. advocated the use of rubber bands, or tubes, for
As early as 1841, William Lintott introduced tooth movement. He said, “The exact position of
the use of screws. They were described in the the teeth, the lines of force to be observed, and the
chapter entitled “Irregularities of the Teeth”, as: tenacity of the power exerted, are all
“When any one or more teeth project beyond the considerations requiring study and a careful
right line, and it is desired to move them inwards, judgment.” This same society sponsored the
a small hole must be drilled through the bar, over publication of the first book on orthodontics,
against the most prominent point of each; a Essay on Regulating the Teeth (1841). It was
screw-thread is then to be cut and a short screw written by Solymon Brown (1790–1876) of New
introduced, which working through the bar, will, York, and was intended to inform parents by
by a turn or two, each day, keep up such a stressing the importance of preventing
continued pressure against each tooth as will irregularities.
quickly force it back as desired.
He described the premature loss of deciduous In 1854 Thomas W Evans (1823–1897), an
teeth as a cause of malocclusion, explained that American dentist practicing in Paris, France,
crowding was due to faulty growth and published the requirements for an appliance in
development. He recommended that treatment the Dental Newsletter, which are as follows:
should begin at the age of 14 or 15 years and also First: a firm support which shall not loosen
described a bite-opening appliance, which or in any way injure the teeth to which it is
consisted of a labial arch of a light bar of gold or attached; Second: a steady and sufficient
silver passed around the front surfaces of the pressure; Third: great delicacy of construction
teeth by means of ligatures (known as Indian that the apparatus may be a light as possible;
twist), and the necks of the irregular teeth with Fourth: as a mechanism as simple as the case will
pressure applied for movement. admit.
In this manner, any required movement of In 1860 Emerson C Angell (1823–1903) was
the teeth, inwards or outwards may be affected probably the first person to advocate the opening
with great ease, and in very little time causing of the median suture to provide space in the
no serious annoyance to the patient, the whole maxillary arch, since he took a strong stand
apparatus being removed and cleansed every against extraction. James D White also perfected
two or three days. a removable vulcanite appliance with a hinge in
A modification of the screw, called the crib, a split palate (1860).
was introduced by the Frenchman JMA Strange
in 1841. Strange also introduced the use of the OA Marvin (1828–1907), in 1866, outlined
clamp band. For retention he advised: Of use a the objectives of orthodontic treatment–first:
rubber band attached to some hooks on the the preservation of correct facial expression;
appliance surrounding the molars for retention.” second: the restoration of such expression;
The chin strap as occipital anchorage for the Third: the proper articulation of the teeth for
treatment of mandibular protrusion was better mastication; Fourth: their orderly
introduced by JS Gunnell in 1840, and the arrangement, with a view to preventing
principle of this may be seen today. Occipital decay.
anchorage was obtained by the use of headgear As early as 1871 William E Magill (1825–
devised by F Christopher Kneisel. 1896) had cemented bands on the teeth.
In 1852 the American Society of Dental It may be of interest to know that in 1864
Surgeons, the first National Dental Association, George J Underwood of New York presented his
established in this country (1840), committed to graduation thesis at the Pennsylvania College of
a great interest in this phase of dentistry, formed Dental Surgery (Philadelphia) entitled
a committee on dental irregularities. The first ”Orthodontia”.
American Orthodontics (1875–1900) NORMAN WILLIAMS KINGSLEY (1829–1913)

It was not until the latter part of the nineteenth Norman Williams Kingsley (Fig. 4.1) was born on
century when a few dedicated dentists gave 2nd October 1829. Kingsley was one of the
special attention and importance to this phase founders, who served as the first Dean of the
of dentistry, that our specialty began to emerge. New York University College of Dentistry. He
Known in that time as orthodontia, it required received honorary degree from Baltimore College
special mechanical skills and knowledge in such of Dental Surgery in 1871.
basic sciences as anatomy, physiology, and Kingsley was a prolific writer, with over 100
pathology. articles on cleft palate rehabilitation, the
The period of the last three decades of the inadequacies of cleft palate surgeries, obturators,
nineteenth century is studied in the framework orthodontic diagnosis, and orthodontic
of individual dentists and their contributions. appliances. He was a prominent dentist, artist,
Each practitioner developed his own theory and and orthodontist. As early as 1866, he
practice, some to a greater degree of excellence experimented with appliances for the correction
than others. Those to be discussed briefly include of cleft palate and is associated with a technique
John H Farrar (1839–1913); Norman W Kingsley known as jumping the bite with the use of a bite
(1829–1913); Alton H Thompson (1849–1914); plate. It was the treatment for protrusion of the
Issac B Davenport (1854–1922); Henry A Baker
maxilla, not necessarily with extractions, shaping

(1848–1934); Eugene S Talbot (1847–1925); the dental arches to be in harmony with each
Simeon H Guilford (1841–1919); and WGA other. He used vulcanite in conjunction with
Bonwill (1833–1899). ligatures, elastic bands made of rubber,
John H Farrar could be referred to as the Father jackscrews, and the chincap. In 1880 he published
of American Orthodontics. It was he who gave A Treatise on Oral Deformities, which remained
impetus to the scientific investigations that a textbook for many years. He, too, emphasized
permitted the understanding of the theory and the importance of the relationship between
practice of orthodontics. He began his studies in mechanics and biology as the principle on which
1875, during which time he investigated the orthodontics should be based. His book was the
physiologic and pathologic changes occurring in first to recommend etiology, diagnosis, and
animals as the result of orthodontically induced treatment planning.
tooth movement. As a result of his studies, he
published a series of articles, between 1881 and
1887, in the Dental Cosmos, one of the leading
dental journals, enunciating the principle that “in
regulating teeth, the traction must be intermittent
and must not exceed certain fixed limits.” He also
published “Irregularities of the Teeth and Their
Correction” (Vol. 1 in 1888 and Vol. 2 in 1889), in
which he demonstrated the many uses of the
screw as the motivating attachment and the basis
of what he referred to as a system of orthodontia.
(Copies of these books are in the American
Association of Orthodontists library in St Louis,
Mo). He stressed the “importance of the
observance of the physiologic law which governs
tissues, during movement of the teeth, the subject
being to prevent pain.” Farrar was the originator
of the theory of intermittent force, and the first
person to recommend root or bodily movement
of the teeth.
Fig. 4.1: Norman W Kingsley (1829–1913)
Dr Kingsley died in 1913 in Patterson, New influence on the orthodontists. To provide a

Jersey. Many of his contemporaries felt that the normal occlusion the practice of extraction of
father of modern orthodontics had passed away. teeth was almost abandoned, being replaced by
Calvin S Case wrote: “The longer orthodontics the expansion of the arch and the realignment of
is practiced, the more respect the author has for the teeth.
the general teaching.” Enunciated 40 years ago While admitting the value of extraction as a
and published in his inestimable text, by that means of correction of certain irregularities of the
most ingenious man of his days, Dr Norman teeth, I am forced to believe that far more
Williams Kingsley, were the acceptable bases of irregularities have been caused by extractions
practice, “Much success in treating irregularities than could ever have been corrected by
will depend upon a correct diagnosis and extraction.
prognosis.” Henry A Baker is remembered, because in 1893
Alton H Thompson was one of those forgotten he introduced the so-called Baker anchorage, or
dentists who made a valuable contribution to the the use of intermaxillary elastics (Fig. 4.2) with
specialty. He was recognized as an authority on rubber bands. The introduction of intermaxillary
comparative dental anatomy, which is certainly elastics was interpreted by some practitioners to
a basic consideration for orthodontists (He was mean the elimination of the need for extraction.
Clark Goddard was an early advocate of the
a founder of the American Anthropological

Society). He devoted himself to research into the study and research into comparative odontology,
dynamics of occlusion. This led him to the the study of skulls and teeth. This led to the
following analysis: acceptance of an expansion screw for the forcible
a. The construction of the temporomaxillary separation of the maxilla. He also attempted to
articulation allows for lateral, anteroposterior, classify malocclusion, which included 15
vertical, and oblique movements. separate types of irregularities.
b. The extent of maxillary development is Eugene S Talbot was equally proficient in
reflected for the necessary support of the periodontics and orthodontics. He stressed the
extensive masticating mechanism. study of the causes of malocclusion to be the key
c. There is a suppression of density and to treatment. He stated that, “without the etiology
diameter of the maxillary bones. of irregularities no one can successfully correct
d. There is a predominance of the rotatory over deformities, as is evident in the many failures by
the elevating muscles of mastication; and men who profess to make this a specialty.” He
e. The special construction of the masticatory added, “Eighteen years of experience in the
armature, i.e. the teeth, their vertices, parallel correction of irregularities of the teeth and a
arrangement of the dental tissues, and the practical knowledge of the laws of mechanics
apposition of the crushing teeth.
Isaac B Davenport, as early as 1881, had created
an interest in the study of occlusion. He
developed a theory that the masticatory
apparatus was subjected to the laws of nature,
that imperfect occlusion was deleterious to the
dentition, that extraction of teeth in treatment
could affect the efficiency of the masticatory
apparatus. He lectured before the New York
Academy of Medicine in 1887. His lecture entitled
“The Significance of the Natural form and
Arrangement of the Dental Arches, With a
consideration of the changes which occur as a
result of their artificial derangement by Filing or Fig. 4.2: Baker’s anchorage (Intermaxillary
by the Extraction of Teeth” has a tremendous elastic—class III elastic)
have taught me not to rely on any particular with it greater possibilities for good or evil to the
appliance. Frequently, though a certain patient than that of extraction”.
appliance has worked well in one case it may
WGA Bonwill said, “in vying with nature in
not have been efficient in another case of similar
matching the teeth, there must be more than mere
nature. He advised that close attention to
mechanics, more than being capable of filling a
disproportion in the size of the maxilla and
tooth or treating an abscess–we must be dental
mandible, general contour and profile of the face,
artists.” He developed what is known as the
and the family history including hereditary
Bonwill equilateral triangle. It is based on the
factors important. He was one of the first to
mandibular analysis of a tripod arrangement,
recommend the surgical exposure of impacted
extending from the center of the condyloid process
canines.
to the median line at the point where the
In a paper presented to the Mississippi Valley
mandibular central incisors touch at the cutting
Association of Dental Surgeons in March 1891,
edge. His measurements of more than 2,000 cases
entitled “Scientific Investigation of the Cranium
showed that from the center of one condyloid
and Jaws,” he demonstrated intraoral
process to the center of the other was four inches
measurements on cast with such instruments as
and that from the center to the incisor was also
the registering calipers and the T-square with
four inches. He used this theory in his orthodontic
graduated sliding indicator. This was one of the
treatment. He advocated a specialty of

earliest attempts applying specific analysis of
orthodontics many years before Angle:

casts that reflected measurement of the jaws.
“Really, in every city, someone should make
Simeon H Guilford, dean of the Philadelphia of this a special practice, and the profession
Dental College, was regarded as one of the finest should encourage such by sending cases for
practitioners of that period. At the request of the inspection and consultation. And such a
National Association of Dental Faculties, he specialist should do all he can, in return to teach
wrote the first textbook for students, Orthodontia: by example and demonstrations by clinics, to
Malposition of Human Teeth, Its Prevention and enlighten those who are placed so far from large
Remedy, published in 1889. In this, he attempted cities that they are compelled to take such cases.
to offer a classification of malocclusion. “There When we can have that understanding between
are two divisions—simple irregularities or the us, then we may feel as banded brothers more
malposition of few teeth with no important facial fully equipped for those hitherto difficult and
disharmony, and complex irregularities, that is, thankless operations.”
malposition of many teeth having corresponding The principles of resorption and deposition
facial deformity” (These divisions contain eleven of alveolar bone during tooth movement were
classes of malposition). discussed by LE Custer (Ohio) in March, 1888,
He commented on extraction in treatments: at a meeting of the Mississippi Valley Dental
“Probably no operation in the practice of Association, in a paper entitled “Intermittent
orthodontia is more important, or has associated Pressure: Its Relation to Orthodontia.”
History of
Orthodontics 5
in Great Britain
• Orthodontics in Britain – Sir John Russell Reynolds • The British Society for the
– Bell – Charles Goodyear Study of Orthodontics
– Medical Act of 1858 – 1878 Dentists Act – Badcock

– Tomes – JA Donaldson
Several eighteenth-century British authors, misgivings regarding the quality of much of the
notably John Hunter, discussed the problems treatment on offer to “regulation cases”, as they
associated with irregular dentition. However, the were then termed.
first English textbook to be devoted to the subject There is not a subject connected with that
matter of what would later be termed branch of practice, of which the present work
orthodontics appeared in 1803. Joseph Fox’s professes to treat, which has given rise to such
Natural History of the Human Teeth, subtitled, gross charlatanism, or to so much gratuitous
describing the proper mode of treatment to cruelty, as that which regards the treatment or
prevent irregularities of the teeth, detailed prevention of irregularity in the permanent teeth.
several practical methods for altering the position Concerns of this sort were, however, not
and orientation of teeth in the mouth. In 1829, uncommonly voiced with regard to many aspects
Thomas Bell published The Anatomy, of dentistry at this time. The practice of dentistry
Physiology and Diseases of the teeth, in which was still unregulated; there were no recognized
he also discussed orthodontic problems and training programs or prerequisite educational
techniques. Five years later, William Imrie, in his requirements. The better-qualified practitioners,
interestingly titled Parents’ Dental Guide, such as Bell, MRCS (later FRCS) and FRS, found
attributed irregularity of teeth to “intemperance much to complain about.
of various kinds, combined with artificial modes In Britain, for much of the nineteenth century,
of living”. James Robinson published, The dental work was undertaken by three dissimilar
Surgical, Mechanical, and Medical Treatment of groups of practitioners. The members of the first
teeth in 1846, which contained his ideas on group, small in number but perhaps the most
etiology and treatment. It is clear, from these influential, had recognized medical qualific-
texts, that procedures aimed at straightening the ations, which they had augmented by a short
teeth were already part of the general dental period of training in dentistry. These men were
surgeon’s repertoire by the first half of the based predominantly in London and some of the
nineteenth century. larger provincial cities; most of them, like Bell,
In 1829, Bell, lecturer at Guy’s Hospital on the held hospital or dispensary appointments at
anatomy and diseases of the teeth, expressed some stage in their careers. The authors whose
History of Orthodontics in Great Britain 35
publications have been discussed above are the Royal College of Surgeons of England began
representative of this group. examining for the newly created LDS. The
The second group had acquired their dental Edinburgh Dental Dispensary, run and staffed
skills primarily by way of an apprenticeship, of by surgeons, was founded in 1860. In 1863, the
variable length and effectiveness, to an Odontological Society of Great Britain was
established dental practitioner. The number of formed, from the merger of two older, rival
this category of practitioners grew as the century dental societies, under the leadership of Tomes
progressed. The third group, perhaps the largest, and Samuel Cartwright, the professor of dental
and the most readily available to the general surgery at King’s College Hospital.
population, had little formal training and often A long political campaign achieved success
combined their dental work with some other in 1878, with the passage of the first Dentists Act,
occupation, such as druggist or barber. which extended the remit of the GMC to allow
The forms of treatment offered by the some regulation of dental practice. The Act also
different groups varied. Those who were empowered the surgical colleges of Edinburgh
medically qualified tending towards a surgical and Dublin, and the Faculty of Physicians and
orientation, which encompassed the whole of the Surgeons of Glasgow to offer examinations in
buccal cavity. The second group, those who had dentistry similar to that of the London College.
followed the apprenticeship route, generally While it would be more than a further 40 years
adopted a more mechanical approach, with an before all unregulated practice was finally
emphasis on the filling of teeth and the fitting of controlled, the passing of the 1878 Act was an
prosthesis. They would also perform extractions. indication of the growing professional and social
The activities of this group most closely status of dentistry.
resembled the general dental practitioners of Generalism had been the dominant ideology
today. The services offered by the third group of nineteenth-century British medicine. In 1881,
were more basic, chiefly involving the extraction Sir John Russell Reynolds, later president of the
of painful teeth. Royal College of Physicians and the British
The Medical Act of 1858 regulated the Medical Association, maintained that
practice of medicine, laying down statutory “specialism” denoted “miserable retrogression
educational requirements and establishing a instead of evolution (and) the survival not of the
Medical Register, which was administered by the fittest, but of the charlatan and the quack”. As
General Medical Council (GMC). The Medical we shall see, similar views continued to be
Act also empowered the Royal College of articulated by many, well into the twentieth
Surgeons of England to award, by examination, century. However, as David Innes Williams has
a License in Dental Surgery. The first diet of this pointed out, the formation of the Royal Society
examination took place in 1860. Realizing the of Medicine (RSM) in 1907 signaled a new, more
benefits of the Medical Act, the leading dentists, positive, attitude to specialization within
many of whom were, as noted above, medically medicine itself. The RSM was organized into
qualified, and urged that similar provisions be thirteen sections, rather than the traditional
made for dentistry. Sir John Tomes, MRCS (later tripartite division of physic, surgery and
FRCS) and FRS, was prominent in these obstetrics. The Odontological Society was
campaigns. incorporated into the RSM as one of its original
While Tomes and his peers were constituent sections, which represented an
campaigning for the establishment of a regulated acceptance of the place of dentistry within the
system of dental qualification and registration, medical establishment.
they were also active in expanding dentistry’s By this time, specialization had little impact
institutional base. The Dental Hospital of London within general dentistry. However, many of the
was founded in 1858, and it’s associated London leading dentists, mostly members of the first
School of Dental Surgery (LDS) in the following group described above, regarded dentistry as a
year. The rival Metropolitan School of Dental division within medicine and themselves as
Surgery (which later became the National Dental medical practitioners who had taken a special
Hospital) was also established in 1858, just before interest in dentistry. The meaning of specialism
varied, in other words, according to whether one the production of both dentures and regulation
regarded medicine or dentistry as the parent, plates. In a series of papers published in the
generalist discipline. 1870s, FH Balkwill described a further
Meanwhile, the demand for treatment to refinement in the use of the material, whereby
correct irregularities of the teeth and jaws the vulcanite was applied directly to the working
continued to grow. Earlier in the nineteenth plaster model of the teeth. This avoided the need
century patients undergoing treatment to to construct a model of the appliance in wax. The
straighten their teeth were described as new technique significantly improved accuracy,
“regulation cases”; references to the fact that the and drastically reduced workshop time.
aim of treatment was to correct what were called Balkwill’s papers demonstrate that British
“irregularities of the teeth”. By the middle of dentists were actively involved uninnovation in
the century, however, the term “malocclusion” the field of orthodontics in the second half of the
was coming into common use. This change of nineteenth century. Although his appliances may
vocabulary signaled a shift of emphasis away seem crude by modern-day standards, they
from a narrow focus just on the position of the demonstrated many ingenious features, and
front teeth, towards the consideration of both the appear to have been effective. Many of the
relationship of teeth to each other, and to the nuances of tooth movement were, evidently, well
teeth in the opposing jaw. The clinical practice appreciated at this time. Moreover, the fact that
of correcting malocclusion then became known Balkwill worked in Plymouth indicates that the
as “orthodontia”. Later the term “orthodontics” provision of orthodontic treatment was not
was preferred. limited to the metropolis.
As the nineteenth century proceeded, the Following the 1878 Dentists Act, the newly
materials available to practitioners of created dental schools incorporated some
“orthodontia” were improved and new methods teaching of orthodontics into their curricula. The
were widely adopted. William Imrie, for 1882 “Student Supplement” of the British Journal
example, made significant changes to of Dental Science listed lectures on irregularities
orthodontic technique in the 1830s. He used of teeth as part of the dental surgery also
plaster models of the dentition, made caps for pathology courses were offered at both the
teeth, which were soldered to arches to reinforce National Dental Hospital and the Dental
anchorage, and introduced gold bite plates to be Hospital of London. Orthodontic subject matter
used over the palate. A treatise by Charles Gaine, appeared both in the major general textbooks and
of Bath, published in 1856, is interesting in that in more specific volumes. Of the latter, James
it draws on the record of successfully treated Oakley Coles’ On deformities of the mouth,
cases. Gaine is credited with the introduction, congenital and acquired, and their mechanical
treatment, first published in 1868, and J F
simultaneously with WH Dwinelle in the USA,
Colyer’s Notes on the treatment of irregularities
of the jackscrew into orthodontics, an innovation
in position of the teeth, are notable. Articles on
that was to have a great impact on the ability to
orthodontics began to appear regularly in the
move individual teeth and to expand the distance
dental periodical literature. The first formal
between rows of teeth. Gaine also recognized the
course of lectures on “what was later known as
need to maintain the teeth in their corrected
orthodontics” was delivered by John Henry
positions for a period of time after tooth
Badcock, dental surgeon to Guy’s Hospital,
movement had been completed. Like Bell, he
shortly after his appointment in 1900.
urged that orthodontic treatment be undertaken
only by those competent to do so. The JA Donaldson, in his history of The National
development of a technology specific to the Dental Hospital, accurately describes the
correction of irregular dentition gave its situation existing in most dental schools around
practitioners a stronger claim to a distinctive skill, the turn of the century:
as well as a greater sense of professional identity. There was an increasing interest in
Vulcanite was patented, in 1844, by Charles orthodontics, partly as a result of lectures and
Goodyear and rapidly found application in writings by practitioners who had studied in the
dentistry, providing a distinct improvement in United States of America, and partly because it
was a field soon to be included in the the teaching and the practice of orthodontics in
requirements of examining bodies. By 1902, this North America were more established, better
led to the adoption by the National Dental organized and more sophisticated, or that Angle
Hospital of “rules for regulation cases” and the was a dominant (if controversial) figure in
fitting up of a room on the first floor for their American orthodontics. It is telling, for instance,
treatment, but no teacher was appointed at this that Angle’s pupils from the British Isles, notably
time. The treatment of each case was undertaken Chapman, Friel and Visick, came to occupy
by a student under the supervision of the dental leading positions within British orthodontics.
surgeon of the day. Prolific authors of research papers, all three were
In other words, orthodontic theory and founder members of the BSSO, Chapman and
practice were still being taught as integrated Friel serving as president.
aspects of general dentistry. Angle’s teaching was predicated upon the
Nevertheless, from 1903 onwards, the staff assumption that orthodontics should be a
lists of the Manchester Dental Hospital contained specialty wholly independent of general
the names of a number of orthodontic dentistry. Part of the rationale for a specialist
demonstrators or tutors. In 1909, mention is made service, as he articulated it, was that the aim of
for the first time of the existence of a separate treatment had become more ambitious. Its goal
Orthodontic Department. In the same year, was now the establishment of “normal
George G Campion was appointed as lecturer in occlusion”. The objective was to place all the teeth
orthodontics to the Victoria University, in their correct relation, not only to their
Manchester. By 1905 a “Regulation Room” had immediate neighbors, but also to their
been established in the Royal Dental Hospital, antagonists in the opposite jaw, and in a
staffed by the “Regulation Room House harmonious relation to the whole face. There was
Surgeon”. By the beginning of the next decade, intense debate among orthodontists, in America
a number of other hospitals had followed suit. and elsewhere, as to whether or not this ideal
However, no formal postgraduate courses in could be achieved in all patients and, if so, how.
orthodontics existed and many British dentists But the fact that this debate took place
interested in the subject went to the United States demonstrates the rising technical and aesthetic
for advanced training. For example, in the first aspiration of practitioners of orthodontics.
decade of the twentieth century, Harold Angle’s bold assertion that orthodontics
Chapman, Hubert Visick, AC Lockett, David Fyfe should be divorced from dentistry met with little
and Ernest Sheldon Friel, all attended the school support in Britain. An editorial in the British
run by the pre-eminent American orthodontist, Dental Journal of 1902 stated:
Edward Angle, originally in St Louis. By this “Where the specialization of specialities may
time, there were several full-time orthodontists lead can hardly be foreseen, and we even await
in North America, most notably Angle himself, the prophesed eminent rhinologist devoted to the
who had entered dedicated practice in 1892, but, left nostril. That dental speciality admits of much
as yet, none at all in Britain. A pupil of Angle, division of labor without detriment is
Friel, in Dublin, set up the first such practice in unquestionable, but the swing of the pendulum
the British Isles in 1909. may well be too far. It appears that the
Orthodontics appears to have caught the orthodontist has already arrived in America, and
dental imagination in the early years of the there is a Society.”
twentieth century. It is revealing, for instance, In North America, however, the trend to
that the American, the British, the German, and separate orthodontics from general practice was
the European orthodontic societies were all gathering pace.
founded within ten years of each other. Some
THE BRITISH SOCIETY FOR THE STUDY OF
authorities, notably the leading historian of
ORTHODONTICS
orthodontics BW Weinberger, have attributed
this widespread surge of interest to the impact It was from within this context of growing
of Angle’s writings. There is certainly no doubt professional status and confidence, coupled with
that, when compared to the situation in Britain, considerably improved technical capability, that
the British Society for the Study of Orthodontics similar appointment at the London Hospital
sprung up. Practitioners in Britain were aware Dental School, in the founding of which he had
of the increasing presence of orthodontic been closely involved. Sim Wallace, the author
specialists in North America, but did not seek of the influential text Essay on the irregularities
immediately to emulate them in their advocacy of the teeth (1904), was on the staff of several
of a separate specialty. There was, in any case, London hospitals over the course of his career,
as an editorial in the dental journal Items of while Hopson eventually became head of the
Interest noted, a difference in the interpretation Dental School at Guy’s Hospital.
of the word “specialist”, between England and The social and professional background of the
the USA. In England, a “specialist” was often a early leaders of the BSSO is very revealing as to
general practitioner having an interest and the character of the society and its aims. As Weisz
expertise in a particular aspect of dentistry, has pointed out, in Britain, unlike North America
whereas, in the USA, the term was used to or the rest of Europe, specialist expertise came
designate someone who exclusively practiced in to be identified as the unique possession of senior
that field. The English interpretation of hospital staff. It was to hospital consultants, and
specialization would certainly be formative, as only hospital consultants, that general
we shall see, of the first British specialist society. practitioners referred patients in need of an
The driving force behind the creation of the expert opinion. What was odd and distinctively
BSSO was, without doubt, George Northcroft, British about this arrangement, was that the
who was a successful London dental practitioner. hospital consultants espoused an ideology of
On 15 October 1907, Northcroft wrote to a gentlemanly holism and regarded themselves as
number of his fellow practitioners inviting them medical generalists, albeit often with some
to attend a preliminary meeting to discuss the degree of specific focus in their clinical interests.
foundation of a society, the object of which would Thus, even the major beneficiaries of the process
be the promotion of the study of orthodontia. of specialization within British medicine did not
This meeting was held on 21 October 1907, in present themselves as specialists per se. Such was
his rooms at 115 Harley Street, London. Eleven the authority and prestige of the hospital
practitioners attended, in addition to North croft. consultant, especially those in the London
Nine of those practiced in the West End of teaching hospitals that this model came to be the
London, the other two being based in Wimbledon definitive one for specialization in Britain. As we
and Eastbourne, respectively. At least seven had shall see, this pattern of specialist interest within
hospital appointments. The founders of the BSSO an ostensibly generalist framework can be readily
were evidently drawn from the upper strata, in identified within the agenda of the BSSO.
terms of their institutional, educational and social In his address to the inaugural meeting,
status, of the British dental profession. They were Badcock, as president-elected, pointed out “there
the heirs of the group of practitioners who had was now sufficient demand for a society, “where
campaigned to raise the professional standing of members could consult and advise each other
dentistry in the second half of the nineteenth upon the problems of the already large but
century. It was agreed to proceed with the plan increasingly important branch of dental surgery,
of setting up a society. orthodontia”. He felt, “the proposed name for
An inaugural meeting was held, by general the society should indicate that it was not the
invitation, in the room of the Medical Society of intention to create a group of specialists,
London, on 5 December 1907, which thirty-five practising orthodontia, but to provide an
people attended. Badcock was elected president, opportunity when everybody who was
with Northcroft, James Sim Wallace, and interested in both theory and practice could meet
Montagu Hopson being vice presidents. All four for mutual benefit”.
senior office-bearers held or had recently held, The rules of the new society were closely
posts in one or other of the London hospitals. modeled upon those of the existing Odontol-
As already noted, Badcock had been, until ogical Section of the Royal Society of Medicine,
1905, dental surgeon and lecturer in dental which were intended to ensure that the
surgery at Guy’s Hospital. Northcroft held a organization was non-political and disengaged
from controversy. One feature of the rule book, quotation from Badcock indicates, that the
very revealing of the society’s self-image, was founding figures of the BSSO evidently believed
that members were to be prohibited from holding that development of the scientific and academic
any commercial patents relating to dentistry. content of the subject would assist orthodontics
There was also an injunction against secret in achieving a much more prominent place
remedies, which were regarded as the staple of within dentistry as a whole.
the “quack” specialist. One speaker at the Badcock acknowledged that anxieties had
inaugural meeting thought that the prohibition been expressed that the creation of a new society,
against patents would have an inhibiting effect devoted solely to one particular branch of
upon the future development of dental dentistry, could be divisive within the dental
technology. Nevertheless, the gentlemanly ethos profession. But he regarded this apprehension
of the upper strata of London medicine, with its as being groundless. He was not, however, in
pronounced antipathy to trade, prevailed and the principle against specialization in the North
rule was confirmed. This was again in marked American sense. He foresaw that eventually, at
contrast to American practice, where several least in the larger centers of population, only full-
orthodontists had taken out patents on technical time specialists might provide an orthodontic
innovations. service. In his judgment, this development would
The first full meeting of the BSSO took place be beneficial. Interestingly, Badcock compared
in January 1908. As president, Badcock presented the advantages to be gained from orthodontic
the first official paper. He chose, as his topic, the specialization to those that would accrue from
objectives of the new society and his views are the administration of anesthetics by specialist
very indicative of the state of orthodontics in anesthetists, as against administration by general
Britain at this time. practitioners with an interest in anesthesia,
This is a very broad and inclusive remit for a which, he stated, was the usual practice at the
special interest in dental or medical society, and time. In other words, Badcock was prepared, at
is quite different in character from the nearest least partially, to repudiate the view, widespread
North American equivalent. It is clear that, in still among medical practitioners in Britain, that
offering membership to all with an interest in full-time specialization was necessarily to be
orthodontics, regardless of occupational status, deplored.
the BSSO did not constitute itself, at least As mentioned earlier, in the first decades of
primarily, as an organization to advance the the twentieth century, North American orthod-
professional interests of orthodontists. Rather ontics was riven by acrimonious controversy,
than, the society defined its mission as the more relating to both the cause and the treatment of
disinterested one of encouraging the malocclusion. The society’s founders were very
advancement of knowledge in the field. Again anxious that these divisions should not be
there are resonances here with the constitution replicated within the BSSO. With characteristic
of the RSM. As Innes Williams has recently moderation, Badcock emphasized the Council’s
argued, while the RSM represented the desire to include representatives from all schools
acceptance of a degree of specialization within of thought. Another of the early presidents, Harry
British medicine, in presenting itself as a purely Baldwin, described the society as a “model of
learned society, it effectively recognized seductive humility” and was evidently proud
specialties as categories of knowledge rather than that the society enjoyed a harmonious
divisions of practice. While the BSSO sought to relationship with the generalist British Dental
encourage the improvement of corrective Association.
technique as well as the scientific understanding Some of the controversy which disturbed
of normal and irregular dentition, the similarity North American orthodontics centered on
of its aims with those of the RSM is noteworthy. Angle’s rigid insistence that it was bad practice
To some extent, as Innes Williams notes, this to extract healthy teeth to facilitate tooth
emphasis was chosen to avoid engagement in realignment. This tenet became the governing
issues relating to competition in the medical principle of those full-time American
marketplace. Nevertheless, it is also true, as the orthodontists who practised the Angle method.
Badcock argued, however, that many potential had links with the London teaching hospitals
orthodontic patients could not afford either the and/or with socially exclusive private practice,
money or time for prolonged and sophisticated of the Harley Street variety. While not necessarily
treatment, and for those patients extraction was or wholly antipathetic to specialist practice, most
a necessary part of successful management. This of the leading members identified themselves,
was, effectively, a recognition of the differences as we shall see, as generalists with a special
between the British and American circumstances interest in orthodontics, rather than as specialist
of orthodontic practice. Several of Badcock’s practitioners, per se. The BSSO was, in other
audience would have held appointments in words, a distinctively British specialist body.
voluntary hospitals where they would provide The BSSO met seven or eight times a year.
economical treatment for charitable patients. Each meeting usually consisted of the
Moreover, British orthodontists knew that if they presentation of a long paper and several short
wished to expand the range of patients that they papers or demonstrations. Sometimes, papers
treated, it was necessary to make available a shared a related theme. Approximately twenty
simplified form of treatment. papers or demonstrations were subsequently
On the other hand, Badcock also deplored published in the Society’s annual Transactions.
those orthodontists who viewed treatment Every year its president addressed the Society,
purely in empirical, mechanical terms. In his and these addresses, also published in the
view, the realignment of the teeth could be Transactions, provide a valuable record of the
successful, in the long-term, only if it was based opinions of the leading figures in British
upon sound biological principles. He admitted orthodontics, from 1907 onwards.
that the profession was still woefully ignorant It is evident from the Transactions that not
in the fields of etiology, pathology and all the members of the Society were content with
prophylaxis. Again the stated purpose of the the first president’s relatively relaxed attitude to
Society was to be a disinterested forum, a vehicle the prospect of full-time practice. In 1910, Sim
for the advancement, not merely of technique, Wallace was elected president. His presidential
but of science. address reaffirmed his commitment to
Badcock concluded by outlining the Council’s generalism, in terms with which many of his
plans for furthering the aims of the Society. colleagues in metropolitan medicine and
Future meetings would consist of the reading and dentistry would have been very familiar. The
discussion of papers, casual communications and danger of specialization was, he argued, that it
clinical evenings of a practical nature. A library confined its practitioners to a narrow route,
and museum would be created; investigation distorting the sense of proportion and limiting
committees, comprising small groups of the large and liberal outlook, which should be
members, would be setup to look at selected characteristic of a learned profession. Such
topics. He mentioned normal arch determin- restriction of vision was stigmatized as the curse
ation, classification and orthodontic terminology of specialism. Sim Wallace emphasized that the
as possible topics for the attention of these BSSO had been setup to serve the high ideal of
investigating committees. the study of orthodontics and not merely to
Thus, we can discern, in its first presidential improve its practice or even its teaching. The
address, some of the distinctive characteristics implication was clear; full-time specialization, by
of the British Society for the Study of depriving those interested in orthodontics of a
Orthodontics. Its constitution emulated the broad intellectual outlook, would hinder rather
gentlemanly ethos of London patrician medicine, than advance the development of their subject.
with its disdain for trade and its antipathy But those presidents who concerned
towards factional enthusiasm. It saw the future themselves with the quality of the British
progress of orthodontics as being best achieved teaching of orthodontics frequently tended to a
through the liberal ideals of the advancement of different view. This was particularly true of those
knowledge and the improvement of education, who contrasted the situation in Britain with that
rather than by the pursuit of specialization and in North America, to whose specialist
professional organization. Many of its founders institutions, as we have seen many British
prospective practitioners travelled to receive opportunities for postgraduate training. The

postgraduate training. For instance, in 1915, establishment of a dedicated clinical center in
Frank Bouquet Bull, a leading member of the London would meet both needs. Samuel
Society and a future president, firmly expressed proposed the Forsyth Institute in Boston as a
his low opinion of the quality of the teaching of model for orthodontic education in Britain.
orthodontics in Britain. He attributed this Bull’s and Samuel’s papers were both
deficiency to the fact that both lectures and delivered in the second year of the First World
clinical instruction in orthodontics were War. The war imposed a hiatus on British
combined with dental surgery. With very few dentistry as a whole and upon the activities and
exceptions, the actual teaching was still carried development of the BSSO in particular. Many
out by generalists rather than specialist dentists were heavily involved in the war effort,
orthodontists. Bull pointed out that the dealing with maxillofacial injuries. Orthodontic
prolonged nature of orthodontic treatment made work was substantially curtailed. Even after
it difficult to incorporate within the standard peace returned, orthodontic treatment remained
curricula of general dentistry. Most dental available to only a very small section of the
students undertook just over two years of clinical population. The vast majority of the work was
instruction but this was rarely long enough to still carried out by dentists who also practised
follow a single orthodontic case to conclusion. other branches of dental surgery. Even the
Bull also believed that, until students had gained teachers in the orthodontic departments of the
some basic knowledge of orthodontics, they dental schools were not necessarily orthodontic
could not fully appreciate its value. Thus many specialists in the North American sense, although
would-be practitioners, who might otherwise they would certainly have had considerable
have been attracted to orthodontics, chose to expertise in the subject. However, the British
remain with restorative dentistry. Islands had, as we have already noted, begun to
Bull recommended that orthodontic acquire their first full-time orthodontists. The
instruction should be separated from that of case for and against specialization would
general dental surgery, and that it should be continue to be discussed at the meetings of the
postponed until the second year of clinical Society for many years to come. But when JL
studies. By this stage students would be better Payne gave his presidential address in 1921, he
prepared to benefit from the teaching. In the seems to have considered that the principle of
second year, a period of three months should be specialization had become accepted. S Spokes,
set aside exclusively for orthodontics. Bull president in the following year, judged that the
applauded the fact that the London Dental development of orthodontics as a specialty had
Hospital and the Birmingham Dental School had not been detrimental to the general dental
already implemented such a system. He practitioner but had benefited the profession as
suggested that independent Orthodontic a whole.
Departments be created, each to be under the Throughout the 1920s and 1930s, the technical
direction of someone with a particular interest repertoire of the orthodontist continued to
in orthodontics, preferably assisted by a improve and expand. A notable advance was the
demonstrator and a specialist orthodontic house introduction of stainless steel, which was
surgeon. This, he believed, would enable both employed in the construction of bands, arches
patient management to be more effective, and and springs. Stainless steel was much cheaper
the standard of teaching to be improved. and more clinically effective than the previous
Bull was not the only eminent British metal of choice, gold. However, considerably
orthodontist concerned about these matters. In more skill was required to work the new
1916, Bertram B Samuel gave a short paper material, stainless steel being difficult to weld.
entitled ‘Suggestions for the formation of a Friel was a major pioneer for the introduction of
London orthodontic center’. As he saw it, stainless steel, and several other British
orthodontics in England had two serious orthodontists contributed to the realization of its
deficiencies, the dearth of treatment facilities for clinical potential. A further important innovation
less well-off children and the absence of was the adoption, with modifications, by British
orthodontists of Angle’s pin and tube method of in Britain. The principle of a state-funded health
effecting tooth movement. This new procedure, care system seems to have been enthusiastically
together with other similar techniques, again endorsed by the leadership of the BSSO. In 1942,
enhanced clinical effectiveness, while the Society set up a committee to examine the
demanding great precision in its construction implications of the Beveridge Report for
and manipulation. orthodontics. Faced with the prospect of a need-
In 1921, unregistered dental practice was driven health service, free at the point of delivery
finally made illegal in Britain. There was, and presumably including orthodontics in its
however, a considerable shortage of dentists, and comprehensive provision, the committee
therefore little economic incentive for the considered what sort of orthodontic care could
ordinary dentist to diversify his practice. From be delivered to the general population, and by
the 1920s onwards, for a variety of reasons like whom. In 1945, giving the first presidential
awareness of lack of knowledge and equipment, address for six years, tellingly titled ‘Our
legal considerations, ready availability of other opportunity’, Norman Gray welcomed the
remunerative work, many general practitioners forthcoming peacetime expansion of health care
were unwilling to undertake orthodontic work. as providing the prospect of raising the standards
And those who did perform such work tended of British orthodontics and increasing the
to employ the cheaper and easier techniques. numbers of its practitioners. Noting that his
They were inclined, for instance, to favor predecessors had expressed differing opinions
removable appliances rather than the fixed ones, on the subject, Gray affirmed his belief that the
which were generally more precise and powerful time for specialization had finally arrived. He
but required more skill to fit and took up more envisaged that the demand for orthodontic
chair time. Thus, the gap between the standards treatment would greatly increase once the
of orthodontic work carried out by the general financial obstacles that had excluded poorer
practitioner and that undertaken by the full-time children, were substantially removed. The
specialist, or taught within the orthodontic challenge was to train sufficient numbers of
departments of the dental hospitals, continued specialists to meet the orthodontic needs of the
to widen. British orthodontists, meanwhile, population.
looked across the Atlantic and saw that, if the In the same year, Friel also urged his fellow
standard of the teaching of orthodontics in orthodontists to embrace the ideal of full-time
Britain was to match its American counterpart, specialization as the only way, as he saw it, to
then more specialized facilities and specialist raise British orthodontic standards to the level
teachers were required. Between the wars, calls that had been achieved in the United States. Friel
for the setting up of a dedicated postgraduate deprecated the fact that much treatment in
center for orthodontics in London were regularly Britain was still undertaken by, as he put it,
repeated. It was even suggested that it could be “skilled amateurs”. He argued that attempts to
run under the auspices of the BSSO. expand the provision of treatment without the
Nothing came of these plans. However, in introduction of adequate postgraduate education
1931, the Eastman Dental Clinic opened in would simply prolong this unwelcome
London. This included a separate orthodontic circumstance. His choice of terms is an indication
department, which provided both affordable of how far the discourse surrounding
treatment and postgraduate orthodontic training. specialization in British dentistry had changed.
After the Second World War, the Eastman was Whereas previously the integration of
incorporated into the British Postgraduate orthodontics within the general practice of
Medical Federation. Under the leadership of dentistry had been praised as conducive to a
Clifford Ballard, its orthodontic department “sense of proportion” and a “large and liberal
came to play a very important role in the further outlook”, it was now stigmatized as
development of the subject in Britain. “amateurism”. The “curse of specialism” had
The establishment of the National Health evidently been lifted.
Service in 1948 created the conditions for a great The administrative structure that was chosen
expansion in the provision of orthodontic care for the NHS imposed a rigid division between
hospital doctors and community-based general Society’s constitution was interpreted, by

practitioners, an arrangement which was very successive meetings of its Council, as precluding
conducive to the establishment of specialties. its involvement in any discussion or consultation
Gradually, many more consultants were remotely political, even when orthodontic service
recruited in virtually every branch of medicine provision was involved. In 1919, the Parliam-
and dentistry, including orthodontics. At the same entary Health Committee invited the BSSO to
time, the universities became more involved in send a report on its activities. The Secretary was
orthodontic education. The first reader in instructed to decline, and reply that their
orthodontics, Corisande Smyth, was appointed in activities did not extend to political affairs. When,
1951 at the Royal Dental Hospital School and the in 1920, the Federation of Medical and Allied
first professor, Clifford Ballard, at the Institute of Societies invited the BSSO to affiliate, the
Dental Surgery, University of London, in 1956. Secretary replied that it was not empowered by
Other educational innovations were made. In its bye-laws to join.
1949, the Faculty of Physicians and Surgeons of This fastidiousness also prevented the society
Glasgow awarded their first Diploma of Dental from exercising its full influence during the
Orthopedics. The Royal College of Surgeons of planning and implementation of the NHS. It was
England followed suit in 1954. initially reluctant, for instance, to become
By the mid-1950s, it was apparent, however, involved in the consideration of specialist titles
that the impact of the setting up the NHS on the within the service. The BSSO also declined to give
process of specialization in orthodontics had any advice to the British Dental Association
been, to an extent, paradoxical. Many more regarding charges for orthodontic appliances. In
specialists were being trained but, owing to 1962, the Society was invited to submit evidence
demand for treatment vastly outstripping to the Standing Dental Advisory Committee, on
supply, more orthodontic work was being hospital dental services. It again refused,
undertaken by general practitioners, often using expressing a wish not to become involved in
limited means of treatment and under great time administrative problems. This decision was
pressure. The membership of the BSSO eventually reversed, under pressure from the
continued to include a substantial number of membership of the Society, but the damage had
general practitioners, reflecting the dual avenues been done. Widespread dissatisfaction with the
of service provision. aloofness of the BSSO from matters relating to
The changes that the founding of the NHS professional interest, particularly among
had set in train did not come fully into effect until members carrying out a significant amount of
the 1960s, when substantial number of orthodontic treatment in practice as opposed to
orthodontic specialists were appointed, either as the hospital service, led to the formation of the
consultant in dental hospitals or with regional British Association of Orthodontists in 1965. The
hospital boards. Oddly enough, however, this BSSO lost a number of members to the new body,
expansion of the specialty was to prove fatal for whose membership was restricted to those who
the BSSO. As noted above, its founders had were full-time, or nearly full-time orthodontic
conceived the BSSO rather as a learned society practitioners. The British Association sought
for the advancement of orthodontics than as a actively to articulate its members’ point of view
professional body to speak for orthodontists. This in the political arena. Eventually, in 1994, the
direction was taken partly to avoid the BSSO lost its separate identity, merging with a
factionalism that had marked orthodontic number of other orthodontic groups to form the
societies in North America. However, the British Orthodontic Society.
History of
Orthodontics in 6
Greece and Rome
• Middle Ages (Fifth to Fifteenth – Etienne Bourdet – Joachim Lefoulon

Centuries) to the Eighteenth – John Hunter – Christophe-François Delabarre
Century • European Pioneers of the Early – JM Alexis Schange

– Matthaeus Gottfried – Friedrich Christoph Kneisel
Nineteenth Century
Purmann – Joseph Fox – John Tomes
The earliest description of irregularities of the teeth of practicing dentistry exclusively was made by
was given about 400 BC, by Hippocrates (ca 460– Pierre Dionis (1658–1718). He called dentists
377 BC). The first treatment of an irregular tooth “operators for the teeth” and stated that they could
was recorded by Celsus (25 BC–AD 50), a Roman also open or widen the teeth when they are set too
writer, who said, “If a second tooth should happen close together.
to grow in children before the first has fallen out,
Matthaeus Gottfried Purmann (1692) was the
that which ought to be shed is to be drawn out
first to report taking wax impressions. In 1756,
and the new one daily pushed toward its place by
Phillip Pfaff used plaster of Paris impressions.
means of the finger until it arrives at its just
Malocclusions were called “irregularities” of the
proportion”. That might still be good advice, but
teeth, and their correction was termed
children today do not need ancient history to tell
“regulating”. It remained for the enlightenment
them how to goad a high canine into place.
to reawaken the spirit of scientific thought
Probably the first mechanical treatment was
necessary to advance dentistry and other
advocated by Pliny the Elder (AD 23–79), who
disciplines.
suggested filing elongated teeth to bring them into
Beginning in the 18th century, the leading
proper alignment. This method remained in
country in the field of dentistry was France. This
practice until the 1800s.
was due, in large measure, to the efforts of one
man: Pierre Fauchard (1678–1761 ) has been called
MIDDLE AGES (FIFTH TO FIFTEENTH
the “Father of Orthodontia”. He was the first to
CENTURIES) TO THE EIGHTEENTH
remove dentistry from the bonds of empiricism
CENTURY
and put it on a scientific foundation. In 1728, he
Progress during the Middle Ages was nil. published the first general work on dentistry, a
Dentistry entered a period of marked decline, as two volume opus entitled The Surgeon Dentist: A
did all sciences. After the 16th century, Treatise on the Teeth.
considerable progress was made, although little Fauchard described, but probably was not the
was written of orthodontics during this period. first to use, the bandeau, and an expansion arch
In France, students of dentistry were admitted consisting of a horseshoe-shaped strip of precious
to a University, as early as 1580. The first mention metal to which the teeth were ligated. This became
History of Orthodontics in Greece and Rome 45
anatomy of the teeth and jaws. His text, The

Natural History of the Human Teeth (1771),
presented the first clear statement of orthopedic
principles. He was the first to describe normal
occlusion, to attempt to classify the teeth. He
established the difference between teeth and bone
and gave the teeth names like cuspidati and
bicuspidati. He was the first to describe the growth
of the jaws, not as a hypothesis, but as a sound
scientific investigation. His findings have never
been successfully challenged.
EUROPEAN PIONEERS OF THE EARLY
NINETEENTH CENTURY
Joseph Fox (1776–1816)
Joseph Fox (1776–1816), a student of Hunter, was
another Englishman who made notable
contributions to the budding science of
orthodontics. He devoted four chapters of his

book, the “Natural History and Diseases of the

Human Teeth” (1814), to that topic. The first to
classify malocclusion (1803), he was also one of
Fig. 6.1: John Hunter the first to observe that the mandible grows mainly
by distal extension beyond the molars, with little
or no increase in the anterior region.
the basis for Angle’s E-arch, and even today its According to Weinberger, Fox was the first to
principles are used in unraveling a crowded give explicit directions for correcting the
dentition. He also “repositioned” teeth with a irregularities of teeth. He was particularly
forceps, called “pelican” because of its interested in the judicious removal of deciduous
resemblance to the beak of that bird, and ligated teeth, treatment timing, and the use of bite blocks
the tooth to its neighbors until healing took place. to open the bite. His other appliances included an
At that time, little attention was paid to anything expansion arch and a chin cup (about 1802).
other than the alignment of teeth and then almost
exclusively to the maxilla. Joachim Lefoulon
Etienne Bourdet (1722–1789) Joachim Lefoulon, a Frenchman, is probably best

known for having given the science a name:
Fauchard’s bandeau was refined by Etienne orthodontosie (1841), which roughly translates
Bourdet (1722–1789), dentist to the king of France. into orthodontia. He was also the first to combine
His was the first record of recommending serial a labial arch with a lingual arch. In the area of
extraction (1757) and of extracting premolars to etiology, he arrived at factors of an entirely
relieve crowding. He was also the first to practice different character from those of most authorities.
“lingual orthodontics”, expanding the arch from These were based on biologic phenomena
the lingual. There followed a long line of lingual controlling the growth, form, and dimension of
appliances, including the jackscrew, the organs and tissues.
expansion plate, and, closer to our time, the
lingual arch. Christophe-François Delabarre (1787–1862)
John Hunter (1728–1793) Christophe-Fraçnois Delabarre (1787–1862;
Although he was not a dentist, John Hunter (Fig. French) introduced the crib and the principle of
6.1) (1728–1793) made the greatest advances in the lever and the screw (1815). He separated
dentistry of his time. An English anatomist and crowded teeth by means of swelling threads or
surgeon, Hunter took a particular interest in the wooden wedges placed between them.
JM Alexis Schange Prussia. He was the first to use plaster models to

JM Alexis Schange (1807, French) in 1841 record malocclusion (1836). That same year, when
published the first work confined to orthodontics. he fitted his prognathic patient with a chin strap,
He introduced a modification of the screw, the he became the first to use a removable appliance.
clamp band, and, in 1842, three years after the Kneisel wrote the first French and German treatises
vulcanization process had been developed, devoted exclusively to orthodontics. He and John
rubber bands (actually, sections of rubber Tomes (1812–1895, English) used various
tubing). He also coined the term anchorage. removable appliances to treat regularities of this.
Tomes was also first to demonstrate bone
Friedrich Christoph Kneisel (1797–1847) and
resorption and apposition.
John Tomes (1812–1895)
Friedrich Christoph Kneisel (1797–1847,
German), was the dentist to Prince Charles of
History of Dental Lasers and their Applications in Orthodontics 47
History of Dental Lasers

and their Applications 7
in Orthodontics
• All Laser Devices have • Focused versus Defocused • Laser use in Dentistry
Following Components Beam • Laser Classification
– Laser Medium • Types of Laser • Applications of Lasers in

– Optical Cavity or Laser Tube
• Lasers and Their Dental Orthodontics

– Clinicians can Control
Applications • Laser Safety
Several Variables of Laser
Exposure • Current Clinical use of Dental • Precautionary Measures
Lasers
• Properties of Laser Beam
Light amplification by the stimulated emission of exactly to the absorption energy. This result in two
radiation. In 1956, American Physicist Townes photons of light emitted with the same wavelength,
first amplified microwave frequencies by the with temporal and spatial coordination.
stimulated emission process and Maser Using Einstein theory laser is produced.
(Microwave Amplification by Stimulated Emission
of Radiation) came into the use. In 1959, Schawlow ALL LASER DEVICES HAVE FOLLOWING
and Townes discussed extending the Maser COMPONENTS
principle to the optical portion of the
Laser Medium
electromagnetic field, laser.
In 1960, Theodore Maiman, Scientist with the This can be solid, liquid or gas. This determines
Hughes Aircraft Corporation developed first the wavelength of emitted light from the laser.
working laser device, that emitted a deep red
colored beam from a ruby crystal. In 1964, Patel Optical Cavity or Laser Tube
developed CO2 laser. In 1964, Geusic developed Having two mirrors, one fully reflective and other
Nd: YAG Laser. partially transmissive which are located at either
Einstein, early in the 20th century described end of the optical cavity.
three possible mechanisms involving proton An external mechanical, chemical or optical
radiation. Absorption occurs when an atom in a power source which excites the atoms in the laser
lower energy level is raised to a higher energy medium to higher energy levels. Atoms in excited
level by absorbing a photon of energy. state spontaneously emit photons of light which
Spontaneous emission is the process in which an bounce back and forth between the two mirrors in
atom in a higher level decays to a staler lower the laser tube striking other atoms and causing
energy level, releasing a photon. more stimulated emissions. Photons of energy of
Stimulated emission occurs when an atom the same wavelength and frequency escape
already in the excited state decays to a stale state, through the transmissive mirrors and form a laser
after interaction with a photon corresponding beam.
Clinicians can Control Several Variables of effectively after reflection, there is little danger of
Laser Exposure damage to other parts of the mouth. It limits the
amount of energy that enters the tissues.
Wavelength
• Determines the quality or type of reaction Scattering
between laser and tissue
When beam is scattered within the tissue. When
• It is determined by composition and structure
light energy bounces from molecule to molecule
of active medium
within the tissue. High absorption minimizes
• It in turn, predominantly influences whether
scattering. Scattering distributes the energy over
absorption occurs.
a large volume of tissue, dissipating the thermal
effects.
Power
• Instant measure of energy output. Transmission
• Optical properties of the tissue including its
Light energy can also travel beyond a given tissue
water content.
boundary. This is called transmission.
• Wave from described the manner in which
Transmission irradiates surrounding tissue and
laser power is delivered over time. It can be:
must be quantified.
– Continuous: They deliver the power output

at a constant level over a prolonged period
Absorption
of time, generally any time span exceeding
1 sec, e.g. CO2 laser. Refers to how far beam is absorbed within the
– Chopped/gated beam: It is similar to tissue or whether it is absorbed at all.
continuous one except beam is
alternatively released and interrupted by FOCUSED VERSUS DEFOCUSED BEAM
a shutter mechanism; this chopping can
Laser beam can be focused through a lens to
be either a single chop or series of timed
achieve a converging beam, which increases in
chops.
intensity to form a focal spot, the most intense
• Pulsed lasers: In this, energy is emitted in
part of the beam. This focused beam cuts the tissue.
short bursts according to a set repetitive series
In defocused beam, intensity is less, beam
of pulses. Between the pulses no laser energy
diverges and power decreases. So a larger
is emitted.
circumferential area of the beam hits the tissue
• Because the amount of heat generated during
surface causing ablation of the tissue. The laser
the procedure translates directly into the
tip cuts soft tissue through ‘ablation’ of tissue. This
amount of collateral damage and thus
means that the cellular temperature is raised
postoperative discomfort – it is generally
rapidly through the absorption of laser energy by
recommended that the laser be used at a low
the melanin in the cells and the cells virtually
setting and in pulsed mode for soft tissue
explode. This characteristic is useful in both
procedures.
cutting and contouring gingival tissues.
PROPERTIES OF LASER BEAM The principal effect of laser energy is photo-
thermal: This thermal effect of laser energy on
Coherent: All the photon of light are in spatial tissue depends on degree of temperature rise and
and temporal coherence. corresponding reaction of interstitial and
Mono Chromaticity: Of one particular wavelength. intracellular water as the laser energy is absorbed,
Collimation: No divergence of the beam heating occurs.
Laser beam interaction with tissue: Laser beam Hyperthermia occurs when tissue is
and tissue interact in four ways: elevated above normal temperature but is not
destroyed at temperature of approximately
Reflection
60oC. Proteins begin to denature without any
A reflected light bounces off the tissue surface and vaporization of the underlying tissue.
is directed toward as energy dissipates so Coagulation refers to the irreversible damage
to tissue, congealing liquid into a soft semi 98% of the energy is converted to heat and
solid mass. Soft tissue edges can be ‘welded’ absorbed at the tissue surface with very little
together with a uniform heating to 70–80oC scatter or penetration (0.2 to 0.3 mm).
where there is adherence of the layers because • CO2 lasers reflect off mirrors, allowing access
of stickiness due to collagen molecule. to difficult areas. Unfortunately, they reflect
When the target tissue containing water is off dental instruments making accidental
elevated to temperature of 100oC, vaporization of reflection to non target tissue causing concern.
water occurs, process is called ablation. If the tissue • CO2 laser is absorbed by optical fibers and lack
temperature is raised to about 200 oC, it is of fiber optic delivery system make CO2 laser
dehydrated and then burned in presence of air difficult for allows the beam to be delivered
with carbon as end product. If laser energy through a flexible tube giving access to all areas
continues to be applied, the surface carbonized of oral cavity.
layer absorbs the incident beam, becomes a heat • CO2 laser works in no contact mode with the
sink and preventing normal tissue ablation. The tissue and no tactile feedback occurs.
heat conduction causes a collateral thermal • Depth of laser incision is proportional to the
trauma to a wide area. power and duration of exposure. Laser soft
tissue surgery is performed with power 5–15
TYPES OF LASER watts in either pulsed for continuous mode.
• It is the fastest laser in removing tissue for oral

Soft Lasers
use.
They provide (a thermal) low energy at
wavelengths believed to stimulate circulation and Nd:YAG Laser
cellular activity. Used to promote healing and
reduce inflammation, edema and pain, e.g. diode • Developed by Geusic in 1964. Refers to
laser. neodymium: yttrium-aluminium-garnet, a
crystal of yttrium-aluminum-garnet doped with
Hard Lasers neodymium. Lasers are in infrared range, 1.06
microns wavelength and cannot be seen. These
Have been used for surgical applications, e.g., CO2 lasers use a red helium-neon laser for aiming.
laser.Lasers are named according to the laser • It is not well-absorbed by water but is partially
medium employed: absorbed by hemoglobin and melanin. It has
• Solid state—e.g. ruby laser, neodymium laser an affinity for pigmented tissues.
• Gas state—e.g. argon laser, CO2 laser • ND: YAG laser light transmits through water
• Semiconductor state—e.g. diode laser and penetrates wet tissue more deeply than
CO2 laser. Heat build-up, scatter and depth of
CO2 Laser tissue penetration by the beam remain major
• CO2 laser were first developed by Patel in 1964. considerations.
• Have a wavelength of 10.6 microns. • They can be delivered by fiber optic technology.
• Since the beams of this laser fall into the far Their access into the mouth is unlimited.
infrared range on the spectrum, they are not • Laser work in either contact or noncontact
visible. These lasers often use a quartz-fiber mode when working on tissue contact mode
incorporating a 630 nm (Red) coaxial helium- is recommended by using pulsed rate, a coated
neon laser into the device to act as an aiming sapphire tip or combination of water and air
beam and thus facilitate use. cooling in contact mode, penetration depth can
• It received safety clearance by the U.S. Food be reduced to a point equal to CO2 .
and drug administration for use in soft tissue • Contact tip provide surgeon a tactile feedback.
surgery in 1976. • For dental use, it can deliver power up to three
• CO2 lasers have an affinity for wet tissues watts in either pulsed or nonpulsed mode.
regardless of tissue color. Tissue pigment does
Erbium– YAG Laser
not affect the performance of CO2 laser.
• CO2 laser wavelength is readily absorbed by In 1997, FDA saftey clearance for use on hard
water as soft tissue is 75%–90% water, about tissues such as enamel, cementum and bone.
It consists of two wavelengths: using some combination of aluminum, indium,

• Erbium: yttrium-aluminum-garnet laser at gallium and arsenic.
2940 nm wavelength. • Wavelength 812 nm for active medium-
• Erbium: chromium-yttrium-scandium- aluminum to 980 nm for active medium-indium,
gallium-garnet at 2780 nm wavelength. placing them at the beginning of near infrared
• These lasers are delivered by a special optical portion of invisible nonionizing spectrum.
fiber or hollow wave guide technology; operate • The laser energy is absorbed by pigmentation
in pulsed mode with an accompanying helium in the soft tissues and this makes the diode
neon laser as an aiming beam, since laser an excellent haemostatic agent.
wavelength is invisible. • As it is used in contact mode, it provides tactile
• Wavelength 2940 nm, is ideal for absorption feedback during surgical procedure.
by hydroxyapatite and water making it efficient • It can be delivered through a flexible quartz
in ablating enamel and dentin. fiber optic hand piece in continuous wave and
• It is essential to use a water spray to wet the gated pulses modes and is used in contact with
surface during laser radiation to achieve soft tissues for surgery or out of contact for
maximum efficiency of tissue removal with deeper coagulation.
minimal heat generation. • These lasers are poorly absorbed by tooth
• They have highest absorption in water and structure so that soft tissue surgery can be
have shallow penetration into soft tissue of safely performed in close proximity to enamel,
any wavelength. dentin and cementum.

• They can be used to cut soft tissue precisely • It can often be used without anesthesia to
due to high water content. perform very precise anterior soft tissue
• These lasers are well-absorbed by hard tissues; esthetic surgery or surgery in other areas of
the surgeon must protect adjacent tooth the mouth without bleeding or discomfort.
structures in the operative field. • It is an excellent soft tissue surgical laser.
Argon Lasers LASERS AND THEIR DENTAL APPLICATIONS

• Argon laser light has 2 primary wavelengths, Carbon Dioxide Laser
488 and 514.5 nm. These manifest as blue and Clinical applications removal of soft tissue by
green visible light. ablation. Recommended for gingivectomy,
• Argon is highly absorbed by hemoglobin, frenectomy and excision of soft tissue pathology
strongly absorbed by melanin and poorly (both benign and malignant). Also used for laser
absorbed by water. de-epithelization of flaps during and after surgery.
• It is absorbed well by oral soft tissue and Precautions avoid hard tissue contact by laser
provides excellent hemostasis. emission, especially tooth structure. Use expanded
• May be well suited for selective destruction of margins when performing a laser excisional
blood clots and hemangiomas with minimal biopsy to prevent fulguration of diagnostic areas.
damage to adjacent tissues. Tissue penetration from laser irradiation will be
• It is not absorbed by hard tissue; no particular approximately 0.5 mm deep, depending on power
care is needed to protect teeth during laser density; very little heat damage occurs below
surgery. visual depth of wound.
• Travel fiber optically.
• Either an attenuated argon or helium neon red Neodymium:YAG Laser
beam can serve as an aiming beam. Clinical applications: Removal of soft tissue by
• They have the ability to cure composite ablation. Recommended for gingivectomy,
resins. frenectomy and excision of soft tissue pathology
especially hemorrhage lesions. Also used for laser
Diode Lasers subgingival curettage procedure.
• Diode is a solid active medium laser, Precautions: Avoid hard tissue contact by laser.
manufactured from semiconductor crystals Same precautions as listed for CO2 laser. Tissue
penetration from laser may cause thermal damage CURRENT CLINICAL USE OF DENTAL LASERS
2 to 4 mm below surface wound causing
underlying hard tissue damage. Application CO2 Nd:YAG Ar
Coagulation X X X
Diode Laser Hemostasis X X X
Frenectomy X X X
Clinical applications: Removal of soft tissue by
Gingivectomy X X X
ablation. It is recommended for gingivectomy, Gingivoplasty X X X
frenectomy and excision of soft tissue pathology, Vestibuloplasty X X X
especially hemorrhagic lesions. Similar Incisional/excisional biopsy X X X
applications as Nd:YAG laser. Used for laser- Implant recovery X X X
assisted subgingival curettage and periodontal Removal of fibroma X X X
pocket disinfection. Epulis X X X
Hyperplasia X X X
Precautions: Avoid contact with hard tissues. May
Malignant lesions X X
damage root cementum and bone during
Oral lesion therapy X X X
subgingival curettage. Tissue penetration is less Caries removal X X
than comparable Nd:YAG effects, with potential Primary incisions X X
for heat damage to underlying bone reduced. Gingival retraction X X X
Aphthous ulcer/oral
Erbium:TAG Laser lesion therapy X X X

Root desensitization X X
Clinical applications: Cavity preparation of Curing light-activated resins X
incipient caries. Root preparation similar to acid Interproximal decay detection X
etching following root planning. It has not been
studied extensively for soft tissue applications.
LASER USE IN DENTISTRY
Precautions: Must use adequate water spray when
cutting hard tissues with laser. Minimal heat Periodontics
damage reported when used on dental hard tissue
Initial (nonsurgical) pocket therapy
at appropriate power densities.
Nonosseous Gingival Surgery
Potential Soft and Hard Tissue Applications • Frenectomy
of Laser in Dentistry • Gingivectomy
Soft tissue applications:Incise, excise, remove or • Graft
biopsy tumors and lesions such as fibromas, Periodontal Regeneration Surgery
papillomas and epulides. Vaporize excess tissues,
• De-epithelization
as in gingivoplastry, gingivectomy and maxillary
• Removal of granulomatous tissue
or lingual frenectomy. Remove or reduce
• Osseous recon touring
hyperplastic tissues. Remove and control
hemorrhaging or vascular lesions such as Fixed Prosthetics/Cosmetics
hemangiomas.
• Crown lengthening/soft tissue management
Hard Tissue Applications around abutments
• Osseous crown lengthening
• Vaporize carious lesions. • Troughing
• Desensitize exposed root surfaces. • Formation of ovate pontic sites
• Endodontically: vaporize organic tissue, glaze • Altered passive eruption management
canal wall surfaces and fuse an apical plug • Modification of sift tissue around laminates
with the potential to resist fluid leakage. • Bleaching
• Roughen tooth surfaces, in lieu of acid etching,
in preparation for bonding procedures. Implantology
• Preventively, to treat enamel, arrest
demineralization and promote remineralization. • Second-stage recovery
• Debond ceramic orthodontic brackets. • Peri-implantitis
Removable Prosthetics Laser Safety

• Epulis fissurate 1. Precautions for patients and dental staff
• Denture stomatitis during laser procedures to protect non-target
• Residual ridge modification tissues particularly the eyes from stray beams.
• Tuberosity reduction 2. Reflective surfaces such as instruments, mirror
• Torus reduction and even polished restorations have potential
• Soft tissue modification to redirect laser energy.
3. Matte instruments and protective eye glasses
Pediatrics/Orthodontics for patients and staff
– Green safety glass– Nd: YAG laser
• Exposure of teeth
– Amber colored glasses– Argon laser
• Soft tissue management of orthodontic patients
– Clear glasses– CO2 laser.
4. Patients eyes should be covered with moist 2 x
Oral Surgery/Oral Medicine/Oral Pathology
2 gauze pads.
• Biopsy 5. Non target oral tissues should be shielded with
• Operculectomy wet gauze, packs.
• Apicoectomy 6. Laser plume created when tissue vaporizes
• Oral soft tissue pathologies should be considered infectious. Use of an

appropriate evacuation system to draw off and
Operative Dentistry filter the plume is essential.

7. Extreme caution must be used when operating
• Deciduous teeth
laser in vicinity of explosive gases such as
• Permanent teeth
anesthetics.
8. Staff who will operate a laser or attend laser
Advantages of Lasers in Soft Tissue Surgery
procedures must be thoroughly trained to
1. Laser cut is more precise in tissue removal with respect this powerful tool and follow standard
greater visibility since it seals off blood vessels protocol.
and lymphatic leaving a clear, dry field. 9. At some operating powers of CO2 laser can cause
2. Laser sterilizes as it cuts to reduce the risk of damage to dental hard structures, clinicians
blood borne transmission of disease. have emphasized need for an adequate shield
3. Minimal pain and swelling has been reported such as flat bladed instrument or silver foil
after surgery. between gingival and teeth, so that beam will
4. Less postoperative infection has been reported, strike the instrument rather than the tooth.
since the wound is sealed with a biological
dressing. LASER CLASSIFICATION
5. There is less wound contraction during They are based chiefly on the potential of the
healing and mucosal tissue does not scar. primary laser beam or reflected beam to cause
6. Less damage occurs to adjacent normal tissue. biologic damage to the eyes or skin. Higher the
7. Access is better to parts of oral cavity, classification number, greater the potential hazard.
especially the mandibular, lingual, retromolar
and parapharyngeal areas. Class I
8. Better patient acceptance, less operative time
and fewer postoperative adverse squeal. • Lasers working under normal operating
9. In treatment medically compromised patient conditions do not pose a health hazard.
HIV +ve and mentally retarded patients. • Devices are totally enclosed, beam does not
10. Lasers can be adjusted to cut, vaporize or exit housing, e.g. CD player.
coagulate tissue, they offer greater versatility
than conventional instruments. Class II
11. Pain is reduced to absent 90% of time due to • Lasers emit only visible light with lower power
the sealing of nerve fibers. output and do not normally pose a hazard
because of normal human blinking and Frenectomy by Laser

aversion reactions, e.g. supermarket bar code
As permanent maxillary central incisors erupt in
scanner.
the oral cavity, the labial frenum shifts apically,
in some instances frenum may persist even after
Two Subclasses
complete eruption of permanent maxillary central
• Class II A: Hazardous when directly viewed incisors termed as high labial frenum attachment.
for longer than 1000 sec. Abnormal frenum attachment prevents
• Class II B: Has a dangerous viewing time of approximation of maxillary central incisors
one-fourth of a sec., which is the length of time resulting in midline diastema. Frenectomy by laser
of an ordinary blinking, reflected. (Fig. 7.2A) prevents recurrence and facilitates
diastema closure. Patient acceptance with laser
Class III a: Lasers application is very high even in condition like
tongue tie, as it facilitates healing, reduces the
• Lasers can emit any wavelength and have
discomfort and no sutures are required (Fig. 7.2B).
output power less than 0.5W of visible light. It
does not harm the unprotected eye.
Reduction of Pain in Orthodontic Patient by
• These labels have a caution label on them.
Application of Laser
Class III b Procedures like separators placement and

banding procedures are considered to be painful

• These lasers can produce a hazard to the
in the whole course of orthodontic treatment.
unprotected eye if viewed directly or viewed
from reflective light for any duration.
• These lasers will not cause reflective hazards
when using matted surfaces and do not
normally produce fire hazards.
Class IV
• Hazardous for direct viewing and may
produce hazardous diffuse reflections.
• Power output greater than 0.5W measured in
continuous or pulsed emission.
• May ignite flammable objects and may create
hazardous airborne contaminants. A
• Lasers used in dentistry: Class III b or class
IV.
APPLICATIONS OF LASERS IN
ORTHODONTICS
Lasers have wide range of applications in
dentistry. In this chapter only few important
applications in orthodontics are discussed.
Exposure of Impacted Tooth by Laser

Canine is the most commonly impacted tooth in
the anterior segment of the dental arches due to
arch length—tooth material discrepancy, this may B
delay the progress of orthodontic treatment.
Exposure of impacted tooth by laser facilitates
Figs 7.1A and B: Exposure of impacted tooth by laser
accessibility and decreases the risk of bond failure (A) Exposure of impacted canine with laser; (B) Exposed
(Figs 7.1A and B). canine is bonded and ligated to the arch wire
A(i) A(ii)
B(i) B(ii)
B(iii)
Figs 7.2A and B: (A) Frenectomy by laser (i) Abnormal frenum attachment prevents approximation of maxillary central
incisors resulting in midline diastema. (ii) Frenectomy by laser followed by active fixed mechanotherapy; (B) Tongue tie
excision by laser (i) Tongue tie (ii) Excised tongue tie with laser (iii) Nearly completion of healing
Studies proved that the application of laser in increases the efficiency of bonding especially in
patient with separators reduces the level of pain uncooperative and very apprehensive patients.
threshold.
Laser Ablation of Surface Enamel for
Application of Laser in Bonding Orthodontic Bracket Placement
Orthodontic Bracket
Laser ablation has been proposed as an alternative
Nowadays laser is used in curing of orthodontic method to acid etching. Common problems during
bracket in bonding procedure. Curing of orthodontic treatment after acid etching the enamel
orthodontic bracket by laser takes approximately are demineralization and susceptibility to caries
(3–5) seconds. It reduces the chair time and around brackets. Er:YAG laser ablation might
overcome this drawback while offering other placement. In such cases either we have to wait
benefits like reduction in clinical time, good until tooth erupts completely till the occlusal plane
moisture control during bonding and bond or refer the patient to periodontist for removal of
strength similar to that of acid etching. tissue to gain access for bracket placement. Either
choice could add significant time to the overall
Gaining Access for Bracket Placement on treatment.
Partially Erupted Teeth Exposure of teeth by laser facilitates accessibility
In certain cases, the orthodontic treatment is often and decreases the risk of bond failure. The patient
prolonged due to incomplete or delayed eruption in the Figures 7.3A to F, the progress of orthodontic
of the tooth, because the labial surface is covered treatment was delayed by thick mucosal barrier
by the gingival, which hinders the bracket covering the left permanent central incisor. The
A B
C D
E F
Figs 7.3A to F: Gaining access for bracket placement on partially erupted teeth (A) Mucosal barrier covering the
permanent central incisor and preventing it from erupting. (B) Exposure of permanent central incisor by laser; (C) Begg
bracket bonded on the exposed permanent central incisor and ligated to the arch wire;. (D and E) Nearing the alignment of
permanent central incisor; (F) Almost the permanent central incisor has brought into alignment
tooth is exposed by laser and then bracket is Removal of Operculae on

bonded, thereby bringing it into alignment. Second Molar by Laser
In some cases, second permanent molar is also
Removal of Redundant Gingival Tissue by
bonded to provide additional anchorage and to
Laser during Orthodontic Treatment
avoid excessive repair visits. If second permanent
Poor oral hygiene in orthodontic patient results molar is the last tooth in the arch, it is often
in swollen gingival tissue, which delays the associated with operculum. Presence of
orthodontic treatment. Laser can be used in the operculum hinders the band placement. Removal
removal of redundant tissue, which fastens the of operculum by soft tissue laser facilitates the
progress of orthodontic treatment. exposure of tooth, later providing accessibility for
band placement (Figs 7.5A and B).
Management of Aphthous Ulcer by
Laser during Orthodontic Treatment Use of Laser in Controlling the Growth of
Facial Structure
One of the most uncomfortable experiences for
orthodontic patients is the formation of aphthous Orthodontics is one of the important domains with
ulcer. Application of laser for aphthous ulcer (Figs interests in human growth and development with
7.4A and B) helps in reducing the pain and also the advent of “high energy lasers” (that are not
promotes healing. Healing usually takes place in deleterious), it may prove that research could lead
a day. Laser irradiates the surface nerve ending to the use of lasers in the practice of orthodontics
and eliminates the painful stimuli. “High energy lasers” might be applied to
A A
B B
Figs 7.4A and B: Management of aphthous ulcer by laser Figs 7.5A and B: Removal of operculae on second molar
(A) Aphthous ulcer on the lateral borer of the tongue; by laser (A) Showing operculum in relation to second molar;
(B) Healing of the aphthous ulcer followed by laser therapy (B) Operculum has been removed with the laser
manipulation of human facial growth leading to Depigmentation of Gingiva by Laser

new methods to cope with problems either
Gingival pigmentation gives unesthetic
overgrowth or undergrowth.
appearance, especially during smiling and seen
more commonly in black race groups. Lasers can
Caries Control during Orthodontic
be used to remove gingival pigmentation and
Treatment
helps in restoring the lost esthetics (Figs 7.7A
Development/occurrence of dental caries is not and B).
an uncommon complication in orthodontic patient
especially around brackets and in interproximal Crown Lengthening Procedure by Laser
area after proximal stripping of teeth to gain space. (Figs 7.8A and B)
Studies have demonstrated that Nd:YAG laser
An excellent application of crown lengthening is
irradiation with (APF) fluoride application acts
when a canine is substituted for a congenitally
as an effective method of caries control during
missing lateral incisor. When first premolar is the
orthodontic treatment.
canine position, its crown height looks too short.
Some clinicians recommend intrusion of the
Tooth Whitening by Laser
premolar and placement of a laminate veneer to
Laser can be used for removal of intrinsic stains restore length. Another option, however is to
(Figs 7.6A and B) and or postoperative tooth lengthen the premolar crown by laser gingivectomy.
whitening to brighten the smile.

Debonding of Brackets by Laser
Debonding of brackets is one of the most important
procedures carried out after the active fixed
mechanotherapy. Debonding of ceramic bracket
is difficult and often results in fracture of brackets.
Studies proved that application of lasers in
debonding of brackets not only helps in
B B
Figs 7.6A and B: Tooth whitening by laser Figs 7.7A and B: Depigmentation of gingiva by laser
(A) Before; (B) After (A) Before; (B) After
Fig. 7.9: Always put on the protective eye glasses prior to

the application of lasers. It is recommended to use only
laser specific protective eye glasses
Figs 7.8A and B: Crown lengthening procedure by laser

(A) Before; (B) After
debonding of metal brackets but also makes easy PRECAUTIONARY MEASURES

of ceramic bracket debonding and prevents
Following are the important precautionary
fracture of enamel.
measure prior to the handling and clinical
applications of Lasers;
LASER SAFETY
1. Always put on the protective eye glasses prior
Lasers are excellent tools, but they also bear a very to the application of lasers. It is recommended
high risk for high risk for severe injury and to use only laser specific protective eye glasses
damage. Laser radiation mainly endangers eyes, (Fig. 7.9).
the retina cornea and the lens are concerned. 2. Make sure the door of the operatory room
Damage of the retina usually is permanent. Thus should always be closed.
just a slight carelessness can impair your vision. 3. Use of nonreflective instrument is
The second affected organ is skin although it is recommended to avoid indirect hazard.
much less sensitive than eyes and damages occur 4. Cover the endotracheal tube with wet gauge
only at high energies. Hence, the high risks require piece or use special stainless steel tube to avoid
suitable protective measures; their strict combustion of anesthetic gases by laser beam
observation is the responsibility of the clinician 5. Use of high vacuum suction or smoke
and the management. evacuator for evacuations of toxic gases.
Angle’s Contribution
to the Faculty of 8
Orthodontics
• Edward Hartley Angle –Dental • Edward Hartley Angle‘s School – Edgewise Appliance
Graduation of Orthodontics at Pasadena, • Angle’s Orthodontic Material
• Angle’s Dental Practice at California USA Invention

Towanda • Appliance Contribution by • Case-Angle Controversy

• Edward Hartley Angle’s Edward H Angle
• Criticisms
Professional Teaching Career – E-arch Appliance
– Pin and Tube Appliance • Edward H Angle’s Publications
– Ribbon Arch Appliance and Presentations
Edward H Angle is one of the most dominant, many of his qualities and quirks in adulthood.
dynamic, and influential figures in the specialty From the southern boundary of District no. 1 of
of orthodontics. He separated orthodontics from Herrick Township in Bradford County, you could
the other branches of dentistry. Edward H almost see the deep, winding chasm of the
Angle’s early years reflect elements of a classic Susquehanna River valley. This area was
American success story of his era: a fiercely nicknamed “Ballibay” in the 1820s by the new
determined young man of no remarkable settlers from the town of Ballybay, County
heritage serendipitously finding his Monaghan, Ireland. Edward Hartley Angle was
considerable aptitudes and blazing trails in born here June 1, 1855 in a modest, white wood-
pursuit of his visionary goals. At various times framed house near the crest of a hill on his father’s
in his letters, he expressed his admiration for a 200-acre dairy farm (Fig. 8.1). He is recorded in
pantheon of archetypes with traits akin to his the 1860 Bradford County census book as
own, such as the indomitable messenger in “A “Hartly”, the fifth of six children, and third son,
Message to Garcia”, the popular, inspirational to Philip Casebeer Angle and Isabel Erskine
short story (1899) by Elbert Hubbard, which Angle. His father’s roots were primarily Dutch
became required reading for Angle’s students. and his mother was born in Ireland. From
Samuel L Clemens (Mark Twain), poet- childhood, he was called “Hart” by his family
storyteller James Whitcomb Riley, George and close friends. The Angles had a seventh child,
Catlin, Benjamin Franklin, and Rembrandt van William, a bright lad, who died of illness at age
Rijn were among his favorite heroes. All were 11. Teen-aged Hart was hurt terribly by the loss
creative achievers and resolute individualists of of his younger brother Willie, his favorite sibling.
humble birth and with great connection to Hart showed no enthusiasm in school or on
everyday people. the farm, to the utter dismay of his
Dr Angle never forgot his farm-boy life in unsympathetic father. He was always behind in
northeastern Pennsylvania that helped shape his learning, especially mathematics, and he
understanding mother Isabel. Recognizing his

nascent mechanical skills, she secured a position
for Hart with a dentist in nearby Herrick, as an
office apprentice. He got on well in dentistry—it
appealed instantly to his keen manual and visual
senses, his love of tools and his need for
orderliness. Two years later, he applied to dental
colleges. His scratchy, brief letter of inquiry dated
September 6, 1876, to the Baltimore Dental
College is the earliest document extant from his
hand. In it, he touted his proficiencies in the
Fig. 8.1: Angle’s white wood-framed house where he was indispensable texts of the day: Harris’s The
born
Principles and Practice of Dental Surgery (1863) and
avoided farm work as much as he could. He was Piggot’s Chemistry and Metallurgy, as Applied to
a natural tinkerer, a whittler, a maker of things. the Study and Practice of Dental Surgery (1854).
In reminiscences, his wife Anna told about his Although his English constructions and spelling
heavily scarred knees, lifetime reminders of were rather crude for a schooled 21-year-old,
young Angle exuded the restless confidence that
boyhood knife slips. When his father needed a

more efficient hay rake, 11-year-old Hart would mark his entire adult life and would win
invented one. However, he did not get much him success in many adventures to come. He was
appreciation for the new machine, and soon invited to enroll at Pennsylvania College of
someone else applied for and was awarded the Dental Surgery in Philadelphia for their DDS
patent for Hart’s instinctively clever work. It was program, then arranged in two 6-month terms
an early lesson in life’s unfairness that the spaced over a nominal 2 years and located in a
sensitive boy probably long remembered. building at the northwest corner of Twelfth and
In Angle’s letters, we find a man who Filbert Streets. Angle alluded to his college
cherished his boyhood friendships throughout experiences years later in friendly letters with
life. He never lost contact with some of his classmates EL Townsend and Charles J Tibbets.
Herrick chums, like Cyrus Camp, Guy Fuller, and In 1895, Angle completed his MD degree from
Jerry Sanger. His correspondence with them is Marion Sims College.
often in the playful tones of a kid still horsing
around the farmyard. Angle peppered his letters ANGLE‘S DENTAL PRACTICE AT TOWANDA
to his hometown friends with monikers After dental school graduation in 1878, Edward
concocted from the names of town fathers with Angle went to the Bradford County seat,
whom the boys occasionally skirted trouble. Towanda, and set-up a general practice of
“Cy” Camp was sometimes referred to as “J. mechanical dentistry in the center of town. He
Rufus Avery” or “Gideon Squares” in Hart’s became a boarder in the home of Towanda’s
jocular letters to him. Angle also showed his self- leading physician, Dr David Shepard Pratt, a
deprecating humor to old, dear friends in the good strategic decision for the bright new dentist
variety of comical aliases he used in signing his
in town. Young Dr Angle advertised in local
letters: Alexander J Horatio, Alonzo Revellen, Big
newspapers, such as The Sullivan Review, and
Foot, Colossus Doc the Great, Flat-nosed Hart,
appeared to be rapidly successful. Here in his
Little Harty Angle, Old Man Friar, Uncle Reuben,
leisure as an unmarried young professional,
and sometimes simply the geometric notation“.
Angle developed his first interests in
mechanisms for tooth alignment or “regulation”,
EDWARD HARTLEY ANGLE—DENTAL
considered the main purpose for moving teeth
GRADUATION
at that time.
In 1874, at age 18, Edward Hartley Angle was In Towanda, Angle experienced declining
introduced to dentistry with coaxing from his health that was to plague him on and off for the
Angle’s Contribution to the Faculty of Orthodontics 61
rest of his life. He was diagnosed with pleural

pneumonia. Today, we may understand this
chronic respiratory condition as a consequence
of tuberculosis. One popular treatment of the day
was for the sufferer to move to fresher, cleaner
air—to a pristine resort set up for this purpose
or to the mountains or the desert. Angle formed
special bonds throughout his career with those
who shared the same affliction, former student
Albert “Leaf” Ketcham being the most prominent
among them.
After 3 years of dental practice in Towanda,
in the spring of 1881, 26-year-old Dr Angle
abandoned dentistry and took a train to
Minneapolis, Minnesota, on a physician’s advice,
in search of better health. Within a few months,
his condition improved and, with his recovery,
came renewed confidence and resolves to make
something of himself. For his health’s sake, Angle

was considering permanent retirement from

dentistry in favor of work that was less confining
and more outdoors. In Minneapolis, he heard
that sheep farming in Montana was where the
“big money” could be made. In the fall, he
returned briefly to Pennsylvania to entice some
of his old farm buddies from Herrick to join him
in setting up a lucrative sheep-raising business.
Fig. 8.2: Edward Hartley Angle
They signed on excitedly, and the lot of his
Ballibay cronies—including his older brother
Mahlon and close friend Cy Camp—traveled
Department of the Minnesota Hospital College in
with the freewheeling Hart to the fresh air of the
Minneapolis regarding faculty employment.
Montana wilderness in search of their “pot of
Impressed with what he had to offer, the college
gold” (Fig. 8.2).
administrators tailored a position to suit his skills
Angle invested all his savings into their
and their needs. In 1886, 31-year-old Edward
sheep-farming venture, all to be undone by the
Angle was appointed a professor of histology and
great blizzard of 1882, a record-breaking deep
lecturer on comparative anatomy and
freeze that killed off the entire herd. The empty-
orthodontia. A few years later, after the Hospital
handed boys from Ballibay sullenly returned to
College merged into the University of Minnesota,
Pennsylvania, except for Hart. A defeated Angle,
he was elevated to professor of orthodontia, a
feeling physically better but mentally depleted,
rare position in those days when orthodontia was
hobbled in to Minneapolis by mid-1882 looking
a neglected part of the prosthetics department
for work—again in dentistry.
at dental colleges. At the same time, he quickly
ascended through the ranks to become president
EDWARD HARTLEY ANGLE’S
of the Minneapolis City Dental Society in 1888.
PROFESSIONAL TEACHING CAREER
He also was able to maintain his small private
Edward Hartley Angle got back into general dental office, where he experimented more and
dental practice and soon resumed the creative more with novel approaches in orthodontic
thinking and tinkering with tooth-regulating mechanisms. In sum, through his resilience,
appliances that he began in Towanda. Within a industriousness, and good fortune, Angle
couple of years, Angle inquired at the Dental seemed to have landed on his feet
psychologically and financially from the Montana contemptuous treatment he received at this 1887
get-rich-quick debacle a few years earlier. Congress helped harden him for the professional
His big break came in 1887 when Angle was “fights” he was to invite and encounter
permitted on the speaking program of the Ninth throughout his adventurous career. To those who
International Medical Congress convened in would challenge him, his style often seemed
Washington, DC. On the fourth day of this abrasive, sometimes brutal; to others, those loyal
important Congress, Thursday, September 8, to him and backing his causes, he was as
1887, the section on “Dental and Oral Surgery” charming and gentle as a puppy.
was called to order at 11 AM in the Universalist The year 1892 was a watershed in Angle’s
Church at the corner of 13th and L Streets. Thirty- professional development: he announced that he
two-year-old Dr Angle was the youngest of the would be practicing orthodontia to the exclusion
session’s speakers and was scheduled last on the of all other dental therapies. With this decision,
day’s program. Two prominent authorities on he became the first acknowledged exclusive
orthodontics directly preceded Angle: Clark specialist in orthodontics in the world. Until this
Goddard, professor at University of California, moment, none of the authorities on orthodontics
San Francisco, and Eugene Talbot, textbook worldwide and in history ever mustered the
writer and professor from Chicago. vision and confidence to limit their dental or
A confident Edward Angle presented his talk, medical practice to only this emerging type of
entitled “Notes on Orthodontia with a New treatment. Angle was no longer on the faculty at
System of Regulation and Retention”, using the University of Minnesota. He resigned to

lantern slides—a relatively new visual aid for concentrate his energies on experimentation in
lecturing. He demonstrated his classification of orthodontia and the development of marketable,
tooth movements and his novel orthodontic prefabricated (“ready-made” in his vernacular),
devices, such as piano wire in a soldered “pipe” new treatment appliances. He also needed time
(tube) and the jackscrew and traction screw. The to work on his textbook’s third edition, his first
open discussion that followed was sometimes real book, a 51-page work, 20 pages longer than
acrimonious. Many well-known dentists in the his 1890 edition, which had been published as
audience, including John N Farrar and Victor H an appendix in the second edition of Haskell’s
Jackson, accused Angle of falsely claiming prosthetics laboratory book. He hired Anna
originality. They cited others (including Hopkins, a bright young Minneapolis secretarial
school graduate, to help him with his book and
themselves) who earlier introduced similar
practice. It was the beginning of a life-shaping
appliances. Angle carefully explained how his
relationship for both of them.
devices were different and better, indeed “new”,
but apparently, he did not prevail. The edited
Angle‘S Married Life
paper and subsequent inflammatory discussions
were published in the Transactions of the Ninth In March 1887, Edward Hartley Angle married to
International Medical Congress under an imposed, 22-year-old Florence when he was running 31
truncated, noncontroversial title, “Notes on years old. Less than 9 months later their daughter
Orthodontia”. This 1887 article commonly has Florence Isabel Angle (Fig. 8.3) was born in
been called the “First Edition” of his classic Minneapolis, only 3 months after her father’s
textbook on the treatment of malocclusion. disastrous appearance at the Ninth International
Actually, Angle considered that his first edition Medical Congress in Washington.
was his 14-page chapter appended to Loomis P Angle’s correspondence a dozen years later
Haskell’s new book on dental laboratory described a disintegration of this marriage from
procedures published in 1887; he titled this the start. The couple was grossly mismatched,
version of his Congress paper “Extracts of Notes he the ambitious idea man and she the day-
on Orthodontia, with a New System by dreaming reader of romances. Angle gradually
Regulation and Retention” and it did not contain lost respect for Florence “Senior”, as he referred
the discrediting commentaries. to his wife in some letters, and he became by
Years later, colleagues observed that the default an absentee father to their sickly daughter
bitterness Angle developed from the “Florencie”. By July 1900, his personal confidence
Fig. 8.3: Angle’s daughter—Florence Isabel Angle on the

left
in his new directions was strong enough to prompt

him to move out of their boarding-house
apartment in St Louis. He had his thriving
practice, his income-producing books, patents

and appliances, his growing international fame,
his prospering proprietary school, and perhaps

most significantly, Anna Hopkins, his secretary,
amanuensis, confidante, and sympathetic soul
mate (Fig. 8.4). It took Angle another 9 years to
deliver an acceptable divorce settlement for
Florence senior in May 1908. Angle’s mother had
conversationalist. In addition, he was a talented
died a few months earlier, and the delay and
artist, not only with intricate line drawings and
particular timing of his divorce may well reflect
creations for clinical orthodontics, but also in
the determination of a devoted son to shield his
crafting gold jewelry, such as stickpins set with
devout mother from the shame of his broken
semiprecious stones, which he often gave as gifts
marriage. On June 28, 1908, Hart and Anna were
to friends.
married in St Louis (at ages 53 and 36,
Furthermore, Angle was an avid collector of
respectively) and within 2 months the
things of the world. He gladly received and
newlyweds had moved to New York to begin a
studied valuable arts and crafts from friends and
new chapter in their lives, as retired gentry.
his grateful foreign correspondents in South
Africa, Japan, and elsewhere. Angle asked his
Angle as an Artist
well-known orthodontist-friends and mentors
It should not be forgotten that Edward Hartley for photographs of themselves and other dental
Angle’s personal vision was wide and deep, not celebrities, both earlier and contemporary, to add
simply confined to his profession. He was keen to his lantern slide collection, which he projected
observer of nature in all its forms. The preamble as a historical prelude to his lectures at various
of the citation accompanying the honorary Doctor meetings. He loved American-Indian artifacts,
of Science degree awarded to Dr Angle in 1915 arrowheads and tomahawk heads which he
by the University of Pennsylvania acknowledged challenged his patients and friends to find and
his broad intellectual base: “Lover of art and trade to him. He collected animal and human
nature, intimate friend of trees and flowers, but skulls and osteological materials in plentiful
preeminently founder of the science of supply from archeologists excavating the burial
orthodontia….” Angle exercised his mounds around St Louis. He and Anna
intellectualism with an active sociability. He was nourished for over three decades an extensive
a worldly man who enjoyed people and places; collection of American-Indian weavings,
he was an outgoing celebrant and beadwork, textiles, clothing, and baskets, mostly
Fig. 8.5: Archeological and ethnographic collections of

Angle and his wife Anna Hopkins
from the tribes of the Plains and Great Basin areas

of the United States (Fig. 8.5). Most of their

archeological and ethnographic collections were

donated to institutions and museums in their
lifetimes. Almost 300 valuable objects of
American–Indian ethnography were given by
Anna Hopkins Angle from 1930, the year of
Fig. 8.6: Anna Hopkins
Edward Angle’s death, to 1959, two years after
her death, to the museum of Claremont College,
Dentistry at the University of Iowa from 1900 to
now the Pomona College Museum of Art in Los
1902. Angle’s letters to Anna are just as colorful
Angeles. It represents a living testament to the
and articulate as the rest of his correspondence.
broad tastes and intellectual vigor of the Angles.
However, Anna did provide valuable technical
skills and judgment. She knew how to craft solid,
About Anna Hopkins (Angle’s Second Wife)
well-spelled, grammatically correct text. She
About 1908, Angle married his longtime likely served as a trusted sounding board for her
secretary, Anna Hopkins (1872–1957) (Fig. 8.6), exuberant boss, and she surely must have woven
who had obtained her DDS degree from the some subtle corrections and softened phrases into
University of Iowa and her orthodontic training his sometimes acerbic commentaries. Dr Angle
in his school. “Mother Angle” became secretary often appended his own handwritten
of the American Society of Orthodontists, a corrections, notes, or comments to the final
founding coeditor of the Angle Orthodontist, and typewritten letters. And to almost all addressees,
honorary chair of the Angle Society executive including some close relatives, he hand-signed
committee, but she would be best remembered his letters boldly as “Edward H Angle.” Only
as Angle’s amanuensis, editor, foil, and buffer with old friends would he let go and sign a
for many of his downtrodden students. Some creative or diminutive nickname. At rare times
observers have suggested that Anna deserved during the 1899 to 1910 period, Anna would sign
much of the credit for the high quality of Angle’s his letters in his absence. Her version of his
written record through her significant literary signature is rather authentic looking, but still
input during typing. There is absolutely no recognizably not his own.
evidence to support this assertion, given the For a period in 1901–1902, when Anna
admirable consistency of Angle’s literary output, Hopkins was away at the University of Iowa
handwritten as well as typewritten, even during studying for her dental degree, Angle’s
periods when Anna’s absence was known, such correspondence was managed by his younger
as when she was attending the College of sister, Lillian, an accountant by occupation. The
technical quality of the letters that “Lillie” professional journals in the United States, Europe,
attempted to transcribe during that time was and Australia between 1887 and his death in
noticeably weaker and Angle knew it. He had to 1930. In addition, during his lifetime, close to 100
apologize often to his correspondents for lateness abstracts and commentaries about his work were
and errors, and he resorted to handwritten published. Another 150 articles are recorded in
corrections and appended notes more frequently. the indexed scientific literature about Edward
Angle and his legacy, and this number continues
Angle as a Writer to grow.
In addition to his own writing, Angle’s letters
Angle’s style of writing was largely verbal: his
show that he served enthusiastically as a mentor
letters (and probably his speeches) were dictated
in scientific writing and editing, long before the
to and transcribed by his talented secretary (and
era of peer review. He generously volunteered
later, second wife), Anna Hopkins. He was gifted
ideas and topics for former students and
with the turn of phrase, using colorful language
colleagues, including one of his first four students,
in original ways, and often waxing effusively in
Milton T Watson, longtime friend William J Brady,
a highly readable way.
and brother-in-law/editor Cy Camp, who was
Angle became convinced that anomalies of
essential in the final editing and proofing of the
molar occlusion were prime factors in the origins
sixth edition (1900) of Angle’s textbook. Angle
of most orthodontic problems, including dental

conscripted all of them and three other colleagues
crowding. Thus, he took the bold step of
to write popular articles to increase public

popularizing the word “mal-occlusion” in the
awareness of the young specialty of orthodontia
late 1890s, around the time he was creating his
in the first decade of the 20th century.
landmark work “Classification of Malocclusion”.
Minneapolis merchants Robert Foster and
Published in 1899, that article brought order out
Otto Keidle remained close friends with the
of chaos, simplicity from existing diagnostic
Angles from their formative years there. In the
complexity, transformations that Angle’s creative
Angle letter archive from 1899 to 1910, “Bob and
mind seemed particularly adept at seeing and
Otto” (also called “White Child and Baron”)
doing. Quickly, he changed the title of his
received some of the most entertaining yarns and
textbook from a prosaic “The Angle system of
homespun dialects from Edward Angle at his
regulation and retention of the teeth …” (1890–
charmingly best. Angle, who no longer used his
1899) to the then ground-breaking concept,
childhood name “Hart” with newly acquired
“Treatment of malocclusion of the teeth …”
friends, still often signed off humorously as
(1900, 6th edition).
“Rube” or “Reuben” or the like. In his well-
Angle was a perfectionist whose painstaking
written personal ramblings to friends, Angle’s
exactness in his scientific thinking and writings
broad and deep nonprofessional interests in
became a hallmark of his lifetime of work in
people, poetry, literature, history, and the world
orthodontics. His detailed letters to managers
through clearly.
and book editors of the SS White Dental
Manufacturing Company show him as a
EDWARD HARTLEY ANGLE‘S SCHOOL OF
polymath with a remarkable understanding of
ORTHODONTICS AT PASADENA,
the tasks of typesetter, illustrator, and publisher.
CALIFORNIA, USA
Angle edited his book six times over, modifying
and adding to it every time, as his own expertise Angle’s attempts at teaching undergraduate
developed and progressed, turning what began dental students at 4 schools had been frustrated
as a 20-page article in 1887 into a 628-page text in by his inability to separate orthodontics from the
1907. He always seemed to be at work on an dental curriculum, although he finally
address, an illustrated presentation, or established the first department of orthodontics
publication. He prepared by hand many of his in a university (Marion Sims Dental College,
intricate drawings and by 1900 had a library of Saint Louis, 1897). After the meeting of the
over a thousand glass lantern-slides for projection. National Dental Association in 1899, several
Besides his well-known textbook editions, Angle members persuaded Angle to train them in his
wrote around 80 articles for publication in various office. This was the first postgraduate course in
orthodontics, as well as the first school devoted growth, development, and functioning of the
exclusively to the specialty, and it was 3 weeks denture. He also expected the applicant to be
long. In 1908, he gave up his practice in Saint reasonably familiar with history, general science,
Louis and moved, first to New York, then to New and English literature. Filing, soldering, and wire
London, and finally to Pasadena, Calif (1916). bending had to be mastered before the student
Wherever he went, the Angle School went with was permitted to do any appliance manipulation.
him. His students erected what was to become Only after surviving the rigors of discipline,
the first building exclusively devoted to the theory, technique, and case analysis, the student
teaching of orthodontics (1922). In 1924, the was allowed admission to the clinic.
school was chartered as the Angle College of In June 1922, the members of this school
Orthodontia (Fig. 8.7). founded a formal association: The Edward H
After heading orthodontic departments at Angle Society of Orthodontia (commonly called
several dental schools, Angle decided he could the Angle Society). The meeting of this society
be more effective by teaching small, select groups in New London in 1928 was the last meeting that
in his Saint Louis office. Thus was founded (1900) Angle ever attended.
the first postgraduate school of orthodontics They had no acrylics, no alginates, no light
(Angle School of Orthodontia, Fig. 8.8). He also wires, no model trimmers and no preformed
founded the first orthodontic journal, The bands. Impressions were taken in plaster and,
American Orthodontist, in 1907, but could not because undercuts prevented removing the stony
prolong its publication beyond 1912. mass in one piece, the operator was obliged to
Prior to admission, student was thoroughly score the material and pry it off, piece by piece.
grilled in the basic sciences, either by Dr Angle he poured impression was later trimmed by hand
or one of his staff. The applicant was expected to with a plane, a saw, or a huge file.
know the anatomy, embryology and histology
of the head and neck (exclusive of the brain), the APPLIANCE CONTRIBUTION BY
EDWARD H ANGLE
Edward H Angle’s correspondence and patents
reveal features of the most dynamic side perhaps
of this multidimensional man: the rapt and
consummate inventor, a human wellspring of
new ideas (Fig. 8.9). During his lifetime, Angle
applied for and received 45 patents (his wife
Anna obtained his 46th patent in 1934, four years
after his death). Most were appliances and
instruments related to clinical orthodontics, but
they included laboratory equipment and a novel
Fig. 8.7: Angle school of orthodontia automobile wheel. His contemporary role
models were likely among the new breed of
inventive, risk-taking industrialists, such as
Thomas Edison, George Eastman, and Charles
Kettering. America led the world by the
beginning of the 20th century in technological
innovation and entrepreneurship. In the first
years of the 1900s, American medicine was
ablaze with new light and directions for the
medical and dental community. At Johns
Hopkins University, William Osler initiated
creative reforms in clinical education and single-
handedly systematized the field of internal
Fig. 8.8: Angle School of Orthodontia, first postgraduate medicine. At Northwestern University, Greene
school for orthodontists
Vardiman Black introduced the nomenclature of
to develop orthodontic appliances and

instruments: Jacob Lowe Young, Spencer R
Atkinson and Albert H Ketcham each jointly held
patent rights to one or more inventions with
Angle. Furthermore, trusting the biomechanical
acumen of his former student Milton T Watson,
Angle asked him to try out competitors’
orthodontic appliances and to conduct a
comparative study and report back to Angle with
his conclusions.
Angle, the enterprising innovator, worked
and reworked designs to develop the best
appliances. As President of the E H Angle
Regulating Appliance Company, incorporated in
St Louis in May 1907, he kept track of the work of
other inventors active in the budding field of
orthodontia and maintained a folder with
relevant patents filed by others. Within the 11-
year record of correspondence covered by the

Angle letter archives, he relentlessly hounded

those he perceived as idea stealers, patent
tooth anatomy and the modern principles and infringers, and plagiarists—Clarence D Lukens,
James N MacDowell, and Miland Knapp, and
tools of operative dentistry.
manufacturers Julius Aderer, Claudius Ash, and
Edward Angle’s rationale for patenting his
Blue Island Specialty Company. In anger, he
inventions was to take legal claim of his ideas
slapped some with lawsuits and inflammatory
and to protect his business interests. However,
defamations.
many of Angle’s colleagues criticized him for the
The age-old rule that brilliant inventors make
zeal with which he protected his breakthrough
poor business people did not apply to Edward H
appliances and systems for doing “tooth
Angle. He was in fact the consummate, confident
regulation” and “orthodontia” more easily.
businessman, maximizing income and minimizing
Patent protection certainly makes sense in
today’s high-stakes environment of corporate expenses. Angle was a demanding taskmaster in
espionage and intellectual property rights, but his detailed letters to the machinists to whom he
in Angle’s time, patenting—particularly in outsourced appliance manufacture at various
medicine—was viewed in many circles as selfish times: William Hahn, the Hardinge brothers, and
and mercenary. John E Canning. They were required to fabricate
Angle’s enthusiasm for advancing the his devices with tight tolerances and on tight
materia technica of orthodontics was so strong budgets. He held the SS White Dental
that he freely mentored, encouraged, and Manufacturing Company, which by 1895 became
worked with colleagues in their efforts to develop the exclusive distributor of the Angle System, to
new appliances. This is seen in Angle’s letters to a rigorous Angle-controlled business relationship.
Henry A Baker of Boston in which he praises the His detailed handwritten invoices from the “E H
“Baker method of anchorage” and later seeks to Angle Regulating Appliance Co” show his (and
protect Baker’s professional reputation as the first Anna’s) arithmetic accuracy in billing to the penny,
to use inter-maxillary anchorage against equal making a lie of his schoolboy reputation of being
claims made by Calvin S Case of Chicago. It is weak with numbers.
also apparent in his letters to E L Townsend Angle’s Patented Orthodontic Devices, first
where he encourages Townsend to write and patent in 1889 is push type jackscrew which was
publish articles concerning Townsend’s idea for used to increase the width of the arches there by
a prosthetic bridge appliance. Angle worked treating the malocclusions. In 1851, a lingual arch
cooperatively with several of his former students soldered to bands that are cemented on teeth;
forcing teeth “outward and forward”. Special

pliers pinched the wire increasing its length.
In 1899 Edward H Angle developed the “E”
(expansion) arch appliance where in the arch
wire with threaded ends, extended in the tube
of an anchor molar band. Nut is provided with a
thread less extension that works with a friction
sleeve to hold the adjustment. According to the
nut’s position, the teeth could be moved either A
distally or mesially. The banded teeth were
attached to the arch with the help of a soft wire
that allowed their tipping or aligning.
E-arch Appliance
E-arch appliance was developed by Angle in early
1900. It is also referred to as Edward Angle‘s E-
arch. It was the first Angle’s Orthodontic
appliance developed to treat malocclusions .E-

arch appliance consists of bands which are placed
on molar teeth on either side of the arch of a heavy

labial arch wire extended around the arch. The B
ends of labial extended arch wire threaded to the
buccal aspect of the molar bands allowed the arch
wire to be advanced so that the arch perimeter
increased. Individual teeth were ligated with the
heavy labial extended arch wire with ligature wire
of 0.010" (Figs 8.10A to D).
Pin and Tube Appliance

Pin and tube appliance was also developed by
Edward H Angle. In this pin and tube appliance,
all teeth are banded. Vertical tubes were welded
to the bands on the labial surface in the center of
the crown for all teeth in the arch. Arch wires
were secured with soldered pins that inserted
into the vertical tubes (Figs 8.11A to C).Tooth
movement was achieved by altering the placement
of these pins. Pin and tube appliance is also used C
for treating malocclusions.
Ribbon Arch Appliance

Ribbon arch appliance was also developed by
Edward H Angle and it is the modification of
pin and tube appliance. This appliance was
introduced in 1910. Ribbon arch was the 1st
appliance to use a true bracket .The bracket has
a vertical slot facing occlusally.The brackets were
attached to the bands at the center of labial D
surface of teeth (Figs 8.12A to C). Figs 8.10A to D: E-arch appliances
B
C B
Figs 8.11A to C: Pin and tube appliance
Edgewise Appliance
In order to overcome the deficiencies encountered
with his previous techniques Angle desired a metal
bracket that could give a better control over
individual tooth movement. The edgewise bracket
has a rectangular slot facing labially, rather than
occlusally or gingivally, which receives a
rectangular arch wire. This unique feature of
rectangular arch wire in a rectangular slot enabled
control of tooth movement in all three planes of
space. Furthermore, the bracket has four wings,
two occlusal and two gingival, which increase C
the surface of arch wire with the bracket slot and Figs 8.12A to C: Ribbon arch appliance
thus give accurate control over tooth movement
(Figs 8.13A to C). The term Edgewise refers to the
the biological response to foreign bodies used in
method by which rectangular arch wire is inserted
oral environment. Reflected in many of his patents
into the horizontal slotted bracket. The edgewise
in which he has constantly tried to cover all
appliance was developed and introduced to
possibilities for adverse use or unfavorable
orthodontic by Edward H Angle in the year 1925.
reaction. Angle made an inventory of the
available materials—gold, silver, platinum,
ANGLE’S ORTHODONTIC MATERIAL
platinous silver, iridio-platinum, platinoid,
INVENTION
aluminum, brass, copper, aluminum bronze,
The highly popular Broussard bracket of the 60s steel, iron and vulcanized rubber. He found that
and 70s was based on this patent. Concern about “the material most fitting was nickel silver”, a
A
Fig. 8.14: Calvin Case
arches. In 1887 introduction in orthodontics of

soldering and a “baser” alloy which contained,
60% to 70% copper, 10% to 20% zinc and10% to
15% nickel.
Angle was influenced by Julius Wolff. “Wolff’s
law of bone”—bone trabeculae arranged in
response to stress lines on the bone. Angle had an
uncompromising position against extraction. It
C was his credit that “The best balance, the best
Figs 8.13A to C: Edgewise appliance harmony, the best proportions of the mouth in its
relation to the other features require that there shall
be a full complement of teeth, and that each tooth shall
brass (copper-zinc alloy) that did not have any
be made to occupy its normal position, i.e. normal
silver in it at all!
occlusion.”
He was largely self-taught, and yet he mastered
complex metallurgy. In one of his publications,
CASE-ANGLE CONTROVERSY
he explains that pinching the arch. “Not only
spreads the particles of metal, so as to increase Originally, Calvin Case (Fig. 8.14) was a genuine
the length of the rod, but tempers the part subjected admirer of Angle. He advocated the Angle
to the pinching action, thereby largely system at every turn and hoped to place this
compensating for the reduction in the area of the system before the dental profession. In fact, he
rod section at that point, and consequently gave up the general practice of dentistry because
maintaining the strength and rigidity of the rod of Angle’s influence. The discord started over the
under the longitudinal strain thereon.”His claim that Angle attributed the origin of the use
knowledge of noble metals is witnessed also by of inter-maxillary elastics to Baker, while Case
his use of gold and of platinum-iridium arches in thought that he should have received that credit.
orthodontics. He was the first to use coil springs. In fact, when Angle described this procedure, he
But he connected them only to nobler metal never mentioned Case. This led to charges and
countercharges between them in 1903. Case’s claim in New York City with his death in 1933. His
was that in 1890 he started this procedure and influence was much felt since he was the editor of
reported it at the Chicago Dental Society and also the International Journal of Orthodontia for 17
at the Columbian Dental Congress in 1893. years and also the president of the American
The second point of contention was and is the one Dental Association in 1931.
usually remembered the question of the extraction
of certain teeth as a means of treatment. Angle’s CRITICISMS
thesis was that “there shall be a full complement
of teeth, and that each tooth shall be made to Bernstein
occupy its normal position.” Case defended the Dr Angle did great harm to many persons, and to
discreet use of extraction as a practical procedure, orthodontics, at the same time he was making his
while Angle believed in non-extraction. However, many contributions.
the unexpected result of this controversy was that
it convinced general practitioners that they should Theodore Adler
not attempt orthodontic treatment but should refer
patients to the specialist. By all accounts Angle was a difficult man. He is
The extraction story was continued into 1911 reputed to have harbored much of the bigotry
with Martin Dewey (1881–1933) (Fig. 8.15) an and some of the xenophobia of his time.
ardent champion of non-extraction. Dewey served

as professor of Orthodontics at Kansas City Dental Wuerpel

School, the University of Iowa Dental Department, • “He did not like the Germans. He was
the Chicago Dental College, and the New York broadminded but he had prejudices.”
College of dentistry. He gained a wide reputation • “He lost many friends, or at least he alienated
as an outstanding teacher. He had started his own them”.
graduate school in orthodontics in 1911 as the • “If people had heard the terms he used in
Kansas City School of Orthodontia and continued regard to them he would have had still more
it as he traveled from one city to another, ending enemies”.
Frederick Noyes
• Angle “could never take criticism or
argument”.
• When his ideas were verbally attacked, he
would call his attackers “fools”.
Tom Graber
• Edward.Hartley.Angle. was obviously a
disturbed man, and his image has been built
up, far beyond what he deserved”
• “Approach became a classic example of
cultism and dogma.”
• “Case was more successful as a contemporary
leader than Angle. Case was on the inside
leading while Angle was the maverick. He
resented Calvin Case.”
Lischer
“So I turned to the first special course then being
offered. Unfortunately, being a resident of St.
Louis, where the course was then given, I was
Fig. 8.15: Martin Dewey
asked to sign a contract to locate elsewhere on constructing machinery, inclu-

completion of the instruction. Angle added: ‘You ding a hay rake (at age 11); at-
know, Lischer, I can pick the flowers in my garden tends high school in Canton,
myself.‘ Pennsylvania.
1874–1876 Apprentices with a local dentist
Robert Rubin in Herrick.
Angle possessed many of the personality qualities Fall 1876– Attends the Pennsylvania
seen in geniuses. They can be difficult, demanding, February 1878 College of Dental Surgery in
and unforgiving. They tend to be so devoted to Philadelphia, receiving DDS
their field that they fail to develop other aspects of degree on February 28, 1878;
their lives. Angle seems to fit that category.” beings practicing dentistry in
Towanda, the county seat of
Wuerpel Bradford County, Pennsylva-
nia. Here he develops an inter-
It (orthodontics) was his religion and his god. He
est in orthodontia.
would sacrifice everything for its sake. He could
Spring 1881 Develops a chronic respiratory
only see his life and his work and his devotion in
ailment, called pleural pneu-
terms of orthodontia.”
monia, probably tuberculosis.

Autumn 1881 Moves to Minneapolis, Min-
Edward H Angle’s Publications and

nesota, for health reasons.
Presentations
Within months, his health re-
Though Angle died 1930, his influence is still felt covers and he returns to Penn-
strongly in orthodontics. Even his enemies sylvania briefly to join his older
recognized the many contributions made by brother Mahlon and friends in
Edward Hartley Angle. His pioneer efforts in planning a sheep-raising ven-
orthodontic education, his contribution to ture in Montana.
orthodontic literature, and his developments of Late 1881 Moves to Montana with associ-
innumerable instruments and appliances are not ates to enter the sheep-ranching
the accomplishments for which he will be business.
remembered. Long after these have faded into Early 1882 The severe winter of 1882 kills
history, Angle’s name will be associated with the their sheep flock and dooms the
onward march of biologic science and it will be venture financially.
realized how perceptive was the mind that could 1882–1883 Relocates to Minneapolis and
penetrate the empiricism of his day and proclaim resumes the private practice of
the significance of normal occlusion. This dentistry; continues his interest
established orthodontia as a science and it will in orthodontia.
remain Angle’s greatest monument. Characteristic 1886 Accepts position as professor of
of the man was a remark made shortly before he histology and lecturer on com-
died: “I have finished my work. It is as perfect as I parative anatomy and orth-
can make it.” odontia in the Dental Depart-
ment of the Minnesota Hospital
Date Event
College in Minneapolis. Two
June 1, 1855 Eward Hartley Angle born to year later, it becomes part of the
Philip Casebeer Angle (1820– University of Minnesota, and he
1907) and Isabel Erskine Angle is elevated to professor of orth-
(1824–1908) in district 1 odontia. Maintains his part-time
“Ballibay”, Herrick Township, private practice of dentistry.
Bardford County, Pennsylva- March 1887 Marries florence A Canning of
nia. The fifth of seven children. Minneapolis, sister of his ma-
Demonstrates early talent for chinist Hohn E Canning.
using tools and devising and September 8, Present of his first major address
1887 describing aspects of the Angle 1895 Fourth american edition is pub-
System of Regulating Appli- lished, a 112-page hard-cover
ances before the 9th Interna- book now titled. The Angle Sys-
tional Medical Congress in tem of Regulation and Reten-
Washington, DC. Angle’s origi- tion of the Teeth and Treatment
nality is challenged in the of Fractures of the Maxillae.
heated discussion that ensues. 1895 Relocates to St Louis, Missouri
Angle later considers a 14 page (with his wife Florence, his
extract of this paper, published daughter florence Isabel, and his
without discussion in an 1887 secretary-assistant Anna
textbook by Loomis P Haskell, Hopkins; sets up a private prac-
as the “first edition” of the Seren tice there limited to orthodontia.
American editions of his famous 1896–1899 Professor of orthodontia in the
book. Dental Department of Marion-
December 3, Daughter Florence Isabel Angle Sims College of Medicine, St
1887 is born in Minneapolis. (She Louis.
died in 1970 in Morganton, 1897–1898 Teaches in the Dental Depart-
North Carolina.) ment of Washington University,
1888 Elected president of the Minne- St Louis.

apolis City Dental Society. 1897 Fifth American edition is pub-

March 5, 1889 Patents a jack-screw lished by SS White,
machinism, the first of 46 pat- philadelphia; also a German
ents held by angle. translation of his fourth (1895)
1890 “Second edition” of his book is American edition is published
published, as a 30-page appe- by SS White Co, Berlin.
ndix to the second edition of a 1897 Is awarded MD degree from
dental laboratory handbook by Marion-Sims College of Medi-
Loomis P Haskell. cine.
1892 Resigns from the faculty at the 1899 Dental Cosmos publishes
University of Minnesota; limits Angle’s “Classification of Mal-
his practice exclusively to orth- occlusion”, his most important
odontia, thus becoing ostensibly journal article to date.
the world’s first specialist in 1899 Claudius Ash publishes
orthodontia. Gustave Darin’s French trans-
1892 Hires Anna Hopkins (1872– lation of Angle’s book under the
1957) of Minneapolis as his sec- title Methode du Professeur
retary and office assistant. Angle Pour la Regularisation et
1892 Publishes third edition, a 51- le Traitement des Dents et Pour
page pamphlet entitled, The le Traitement des Fractures des
Angle System of Regulation and Maxillaires.
Retention of the Teeth. June 6, 1899 Patents the E-Arch, his expan-
1892–1898 Professor of orthodontia at the sion archwire mechanism.
American College of Dental Sur- August 1899 Angle’s paper on orthodontia
gery (later merging into North- prepared for presentation at the
western University School of National Dental Association
Dentistry) in Chicago. meeting at Niagara Falls is by-
1894 Appointed surgeon to the Great passed at the last minute by pro-
Northern Railroad for the treat- gram officials. This personal
ment of fractures of the maxil- slight fuels Angle’s desire to
lae. found a postgraduate school of
orthodontia and a professional 1905 Contributes chapter on orth-

society devoted to orthodontia. odontia in Edward C Kirk’s
November 1899Teaches a postgraduate course American Textbook of Oper-
on orthodontia in his office in ative Dentistry (also in 1911
the Olivia Building, St Louis. edition, revised).
Attending are thomas B mercer, Spring 1906 Resigns membership in Ameri-
Henry E Lindas, Herbert A can Society of Orthodontists;
Pullen, and Milton T Watson. encourages establishment of The
December 8, Resigns his appointment of Alumni Society of the Angle
1899 Marion Sims college of medi- School of Orthodontia (Earliest
cine. Forer-unner of the Edward H
1900 Founds the Angle School of Angle Society of orthodontists).
Orthodontia; first 5-week course Winter 1906– Retires from practice of
is held from May 1 through early 1907 orthodontia in St Louis;
june 1900 in the odeon Build- focuses on writing seventh
ing, St Louis. American edition of Treatment
July 1900 Separates from wife Florence of Malocclusion of the Teeth,
Canning Angle.
Angle’s System (628 pages).

October 1900 Publishes sixth edition, a 315- 1907 Father Philips Casesbeer Angle
page work, Treatment of dies, age 87.

Malocclusion of the Teeth and May 1907 Incorporates the EH Angle
Fractures of the Maxillae. Regulating Appliance co in St
Angle’s System. Louis, Missouri.
Early 1901 Founds the Society of Orthod- June 1907 Founds The American Orth-
ontists (antecedent of the Ameri- odontist, the first journal in the
can Association of Ortho-
world devoted exclusively to
dontists) and serves as its first
orthodontics (discontinued in
president.
1912); it is the forerunner of The
Early 1901 Founds the Society of Dental
Angle Orthodontist.
Science of St Louis.
1908 Mother Isable Erskine Angle
July 1901 First meeting of the Society of
dies, age 84.
Orthodontists (renamed in 1902,
May 1908 Divorces Florence Canning
The American Society of Orth-
Angle in Minneapolis, Minne-
odontists) is held in St Louis,
sota.
Missouri.
June 27, 1908 Marries Anna Hopkins in St
1902 With Angle’s encouragement,
Louis, Missouri.
Anna Hopkins graduates from
Summer 1908 Moves from St Louis with wife
the University of lowa with a
Anna H Angle to Larchmont,
DDS degree. New York.
December Offered the editorship of orth September 15– The Angle School of orthodontia
1902 odontia of the international October 31, is in New York City for a 6-week
Dental Journal; Angle declines 1908 course, in an office building at
the offer. rhe corner of West 72nd Street
August 29– Chairman of Section VI and Broadway.
September 3, (Orthodontia) of the fourth Fall 1908 Hemann Muesser publishes
1904 International Dental Congress, Josef Grunberg’s German trans-
St Louis. lation of Angle’s sixth (1900)
1904 German translation of his fifth American edition under the title
(1895) American edition is pub- Behandlung der Okklusions-
lished by SS white Co Berlin. anomalien der Zahne.
April 1909 Purchases home at 58 Bellevue nia by graduates of the Angle

Place, New London, Connecti- School of Orthodontia.
cut. 1922–1923 Grateful students fund con-
July 1909 Wins patent infringement suit struction of a building in Pasa-
against appliance manufacturer dena for the Angle School of
Julius Aderer. Orthodontia at 550 Jackson
October – The Angle School of Orthodontia Street, next to Angle’s home; it
December 1909 moves to New London, conn- is dedicated on January 8, 1923.
ecticut; course session length- 1924 The Angle College of Orthodon-
ened to 9 weeks, given in the tia and Infirmary is chartered by
Munsey Building.
California. No tuition is charged
July– Second (final) course session in
for the college’s 12-month pro-
September New London at the Harbor
gram (which is followed with
1911 School, after which Angle closes
periodic faculty supervision
Angle School of Orthodontia
due to his declining health. during the first year of private
1913 Revised and expanded German practice). All patients were
edition of Angle’s book (1907 treated free of charge.
American edition) is published September 15, Patents the edgewise arch

with new chapters by Josef 1925 mechanism.

Grunberg and Albin Late 1927 The Angle College of Orthodon-
Oppenheim (778 pages). tia closes unofficially due to
February 22, Awarded Honorary ScD degree Angle’s deteriorating health.
1915 by the University of Penns- August 11, Edward H Angle dies in Santa
ylvania. 1930 Monica, California, at age 75
Late 1916 Angle moves to southern from heart failure; burial at
Califomia for health reason; Mountain View Cemetery,
purchases home at 1025 North Altadena, California.
Madison Avenue, Pasadena. November 17, The Angle Orthodontist, a
1917 At request of Hames C Angle (no 1930 scientific journal devoted exclu-
relation), he reopens the Angle sively to orthodontics, is
School of Orthodontia at his founded in chicago in Dr
home in Pasadena. Angle’s memory by the newly
1922 Edward H Angle Society of orth- reorganized Edward H Angle
odontists is started in Califor- Society of Orthodontia.
Dr TM Graber’s
Contribution to 9
Orthodontics
• Thomas M Graber (1917–2007) • Graber’s Other Contributions

• TM Graber’s Contributions to Orthodontics
THOMAS M GRABER (1917–2007) 1969–1982, where he was the head of the Section
of Orthodontics; and at the University of Illinois
Dr TM Graber as an Orthodontist,
at Chicago College of Dentistry from 1994 until
Researcher, and Dental Educator
his death. He also served as a visiting professor
Dr Thomas M. “Tom” Graber, known inter- on the faculties of the University of Michigan. The
nationally as an orthodontist, researcher, and University of Freiburg, Germany, and the
dental educator, born in St Louis on May 27, 1917 University of Gothenburg, Sweden. A natural
and died on June 26 at age 90, in Evanston, Illinois. teacher, he was “one of those people who could
Dr Thomas M Graber was certainly a pioneer take complex subjects and explain them clearly to
amongst men. His complete devotion and love for students,” said his wife, Doris, a professor of
the specialty of orthodontics is reflected in his political science at the University of Illinois at
extensive works on a myriad of topics, spanning Chicago.
over a period of nearly six decades. As Dr Graber’s A pioneer in orthodontics and craniofacial
family friend and colleague Dr Jim McNamara biology, Dr Graber did research on craniofacial
noted, “Tom’s energy and enthusiasm for our anomalies, cleft palate, cleft lip, temporomandi-
profession make him a wonderful role model for bular joint anatomy and disturbances, orthopedic
future generations of orthodontists.” The passing growth guidance of the dentofacial complex, and
of Dr Thomas M Graber marks the end of an era in the use of magnetic forces in orthodontics and
orthodontics. dentofacial orthopedics. His 60 years of research
have added to our knowledge in these fields and
Dr TM Graber’s Dental Graduation changed the way they are taught around the
world.
Dr Graber earned a DMD degree in dentistry
He gave more than 475 continuing education
(Washington University, 1940), an MSD in
courses around the world and was on the
orthodontics (Northwestern University, 1946),
American Association of Orthodontists Annual
and a PhD in anatomy (Northwestern University,
Session program more than any other person in
1950).
AAO history. Beginning in 1951, he made annual
lecture tours to university departments and
Dr TM Graber’s Working Experience
medical and dental societies around the world.
Dr TM Graber served as a captain in the United He wrote 28 books on orthodontics and dental
States Army Dental Corps from 1941–1945. He anatomy and contributed chapters to 20 other
was on the faculty of Northwestern University books. He wrote more than 175 scientific articles
from 1946–1958 at the University of Chicago from in refereed dental and medical journals, not to
Dr TM Graber’s Contribution to Orthodontics 77
mention hundreds of book and journal article Michigan and contributed to the University of
reviews and abstracts. Illinois at Chicago College of Dentistry as well.
From 1985 to 2000, he served as editor-in-chief Dr Graber enjoyed travel, visiting countries
of the American Journal of Orthodontics and around the world and even the North Pole and
Dentofacial Orthopedics. He went on to found the Antarctica. He enjoyed photography; he skied,
World Journal of Orthodontics, and he continued played tennis, bicycled, swam, went scuba diving,
as editor-in-chief of that publication until his death. and sailed—pursuing many of these activities well
Dr Graber’s contributions to organized into his 80s.
orthodontics and orthodontic education were He is survived by his wife of 66 years, Dr Doris
unsurpassed. He served on the AAO Council on Graber; sons Dr Lee W Graber, Dr Thomas W
Orthodontic Education from 1962 to 1973; Graber, Jack D Graber, and Dr Jim M Graber;
founded the Audiovisual Council of the AAO in daughter Dr Susan Graber; and 14 grandchildren.
1962; was general chairman of the AAO Annual
Session twice; founded the Kenilworth Dental TM GRABER’S CONTRIBUTIONS
Research Foundation; was director of Continuing
TM Graber’s contribution are listed and explained
Education for the G. V. Black Institute since 1967;
below;
was director of Dental Continuing Education for
the University of Chicago Center for Continuing
Physiology of Occlusion
Education from 1971 to 1981; founded the
Northwestern University Cleft Lip and Palate Normal Occlusion

Institute and the Orthodontic Section at the — TM Graber (DCNA, 1968)
University of Chicago Medical School; was a
In this paper, Dr Graber states that any definition
founding member of the Illinois Society of
of normal occlusion cannot be static and merely
Orthodontists; and was a former president of the
descriptive of tooth relationships. Normal
Chicago Society of Orthodontists, the Midwest
occlusion involves not only the teeth, but also the
Component of the Edward H. Angle Society, and
investing tissues, the contiguous and motivating
the Illinois Society of Orthodontists.
musculature, curve of Spee, inter-occlusal
Dr Graber held appointments at Children’s
clearance, and the TMJ morphology and function.
Memorial Hospital and Wyler Children’s Hospital
He has organized the historical progress in the
in Chicago. He received honorary doctoral degrees
development of current concepts of occlusion into
from the University of Gothenburg, Sweden, 1989;
three periods:
Washington University, St Louis, 1991; the
• Fictional period (before 1900)
University of Michigan, 1994; Kunming Medical
• Hypothetical period (1900–1930)
University, China, 1996; and Aristotle University
• Factual period (1930 – present).
of Thessaloniki, Greece, 2005. His honorary-
degrees from Washington University and the Fictional Period
University of Michigan were the first and only
ones ever given to a dentist. • Concepts were developed from inductive
Dr Graber received awards too numerous to analysis.
list. He was quite proud to be the first non-Japanese • Terminology was loose and reflected the
person to be inducted as a member of the Japan personal preferences of the authors.
Orthodontic Society in 1997, and he received the • Authors talked about dental antagonisms,
Emperor of Japan’s Order of the Sacred Treasure, “meeting” or “gliding” of teeth.
the highest Japanese award ever bestowed upon • Good descriptions of the morphologic nature
a noncitizen of Japan, in 2003. of individual teeth existed, but an appreciation
Active in his community, Dr Graber was a of the functioning dentition as a whole was
member of the Sons of the American Revolution, lacking.
Fort Dearborn Chapter; and had been a leader in
Hypothetical Period
the Boy Scouts of America where all four sons
became Eagle Scouts. It was EH Angle who organized the existing
He was a generous philanthropist, having concepts of occlusion at the time and formulated
endowed a professorship at the University of definite principles of diagnosis in treatment.
• He gave the ‘key of occlusion’ based on the configuration in Class I, Class II, and Class III
position of the upper first molar. malocclusions.
• Angle described normal occlusion using a • “Whenever there is a struggle between muscle
skull that he called ‘Old Glory’. and bone, bone yields.” Muscle function can
• Calvin Case developed the concept of “apical be adaptive to morphogenetic pattern.
base”. He also called attention to the effect of • A change in muscle function can initiate
the nose and chin button on the profile. morphologic variation in the normal
• In 1908, Bennett suggested the functional configuration of the teeth and supporting bone,
analysis or the dynamic approach to occlusion or it can enhance an already existing
for the first time. He noted that the mandible malocclusion.
had a resting position (depended on • In the latter instance, the inherent structural
musculature) and a functional position mal-relationship calls for compensatory or
(depended on the teeth in maximum contact). adaptive muscle activity to perform the daily
functions.
Factual Period • The structural abnormality is increased by
compensatory muscle activity to the extent that
• With the introduction of biometric procedures
a balance is reached between pattern,
and scientific methodology, this period saw a
environment, and physiology.
trend toward the dynamic and a de-emphasis

• It is imperative that the orthodontist appraise
on the static.
muscle activity and that he conduct his

• In 1931, B. Holly Broadbent introduced
orthodontic therapy in such a manner that the
radiographic cephalometry.
finished result reflects a balance between the
• Occlusion now meant inter-digitation of teeth
structural changes obtained and the functional
plus the influence of the musculature as well
forces acting on the teeth and investing tissues
as that of the temperomandibular joint.
at that time.
The Developing Occlusion—Orthodontic The Role of Upper Second Molar Extraction
Considerations for the Handicapped in Orthodontic Treatment
— Owen, Graber (DCNA, 1974). — TM Graber (AJO, 1955)
• The authors state that the nature and severity • In Class II treatment, the greatest change
of the handicap in a child may totally dominate produced by the orthodontic appliances is in
the dental diagnostic and treatment the maxilla. Distal adjustment of tooth position
considerations. in the maxilla alone, or in conjunction with
• They have described the type of care to be mandibular growth, is the basis for correction.
rendered according to the severity of the • If space required for the tooth adjustment is
handicap – mild, moderate, severe. gained in the second molar area, only as much
• Timing, case selection and management are space as required need be used, with the
the main factors in treating or not treating the subsequent mesio-vertical eruption of the
handicapped patient. maxillary third molars filling the gap.
• It is important to weigh the possible benefits • Maxillary 2nd molar removal expedites
to the child with the individual’s physical and correction of Class II division 1 malocclusion,
dental status as affected by his ability to provided that:
comprehend and cope with orthodontic • There is excessive labial inclination of the
procedures. maxillary incisors, with no spacing.
• Overbite is minimal.
The “Three M’s”: Muscles, Malformation • 3rd molars are present in the maxilla, in good
and Malocclusion position and of proper shape.
— TM Graber (AJO, 1963) • The cases offering the poorest prognosis for
• In this classic article, Dr Graber has analyzed maxillary 2nd molar extraction are severe
muscles and their relationship to structural basal dysplasias with vertically inclined
maxillary incisors, no spacing, and severe • Possible unilateral response in correction of

overbite. class II relationship, and
• Difficulty in the control of excessive overbite.
Maxillary Second Molar Extraction in Class II
Malocclusion Dentofacial Orthopedics versus Orthodontics
— TM Graber (AJO, 1969) — Graber, Chung, Aoba (JADA, 1967)
• In this paper, Dr Graber has again dwelled • In this paper, the authors have reported that
upon the removal of upper 2nd molars as a orthopedic therapeutic measures with heavy
therapeutic means for correction of Class II and interrupted force against the bone may be
malocclusion. used successfully in orthodontics.
• He recommends the extraction of maxillary • Greater use of this type of extraoral force is
2nd molars in those instances in which there recommended because of its superior ability
are good maxillary 3rd molars and where there to correct basal jaw anteroposterior mal-
is a significant Class II/1 malocclusion and relationships.
involvement of all 4 tissue systems – teeth, bone, • In addition, there is greater stability, a lower
muscle and nerve. percentage of tooth extractions, minimal use
• A fixed lingual arch is used to prevent the of intra-oral appliances, less attendant
mandibular 2nd molars from over-erupting. orthogenic damage (decalcification, root
• The results appear to be stable over a long resorption), minimal chair time, and longer
period of time. intervals between appointments.

• The iatrogenic reaction is minimal or non- • An occipital base of anchorage is more
existent. satisfactory for correction of Class III
mandibular prognathism.
Extraoral Force—Facts and Fallacies • In cases of open bite, the direction of restrictive
— TM Graber (AJO, 1955) force must be as vertical as the design of the
• Dr Graber studied 150 cases of Class II/1 cranial cap will permit.
malocclusion treated with extra-oral force • In Class II/1 malocclusion, a cervical source
using the same type of appliance. of anchorage is satisfactory.
• The appliance consisted of molar bands, a .045
Heavy Intermittent Cervical Traction in
inch stainless steel labial arch wire with
Class II Treatment: A Longitudinal
vertical spring loops at the lateral-canine
Cephalometric Assessment
embrasure to receive the cervical gear. This was
— Mills, Holman, Graber (AJO, 1978)
a metal tube with a continuous spring inside
to provide distal motivating force. Investigated the changes brought about in the
He concluded that: dentofacial complex as a result of the use of
• Class II/1 malocclusions are amenable to heavy cervical traction forces applied
correction by the use of extraoral force. Marked intermittently in the maxilla in growing Class II
improvement in the basal relations can be division 1 patients, and compared with
obtained; overbite and overjet problems can untreated controls.
be helped greatly. Their findings showed that there was:
• Coordination of treatment with the pubertal • A stable reduction in the ANB angle is seen.
growth spurt ensures a greater likelihood of • SNA did not move downward during
success [10–12 years in girls; 12–17 years in boys]. treatment; no significant tipping of PP
• Certain untoward sequale may be seen in the occurred.
use of extraoral force. These include: • Less forward progress of point B and Pog
• Incomplete correction of tooth malrelationship, occurred in treated group. Thus, SNB was
• Excessive distal tipping of maxillary 1st molars, constant.
• Possible impaction of maxillary 2nd or 3rd • Mandible was rotated downward and
molars, backward—slight increase in SN-MP angle.
• Possible excessive lingual tipping of maxillary • Significant decrease in overbite occurred
incisors, during treatment.
• U1-SN decreased during treatment, but are older than 10 years of age, and that
increased during follow-up. protraction in combination with an initial
• Treatment had marked withholding effect on period of expansion may provide more
normal downward and forward eruption of significant skeletal effects.
maxillary 1st molars. However, in post-
treatment period, these teeth erupted more than Craniofacial Features of Patients with
in controls, losing some of the treatment effect. Class III Abnormalities: Growth-related
• Distal tipping of upper molars occurred during Changes and Effects of Short-term and
treatment, but relapsed after appliance Long-term Chin-cup Therapy
removal. — Deguchi, Kuroda, Minoshima and Graber
• Distal uprighting of lower molars and incisors (AJODO, 2002)
occurred during treatment. Molar position was • The craniofacial features of patients with
stable, but incisors relapsed following Class III abnormalities, including growth-
treatment. related changes and effects of short-term and
• Sagittal arch length decreased significantly long-term chin-cup therapy, were studied.
during treatment. This effect was stable. • Twenty female subjects were treated with chin-
• Both the downs OP and functional OP tipped cups and an orthopedic force of 500 g for 31
downward anteriorly as a result of treatment, months (short-term treatment group). Another
and relapsed insignificantly following 36 female patients were treated with chin-cups
treatment. and a force of 250 to 300 g for 86 months (long-

• Anterior facial height increased more than term treatment group).
normally as a result of treatment. Most of this • Cross-sectional lateral films of 562 skeletal
change took place in the lower facial height. Class III girls served as controls.
Their results showed that:
The Effectiveness of Protraction Face Mask
• Short-term treatment resulted in a slight
Therapy: A Meta-analysis
improvement in ANB angle and Wits
— Kim, Viana, Graber, Omerza and BeGole
appraisal, while long-term treatment resulted
(AJODO, 1999)
in a significant improvement in ANB angle
This study examined the effectiveness of maxillary and Wits appraisal.
protraction with orthopedic appliances in • Such treatment also resulted in a significant
Class III patients. A meta-analysis of relevant inhibition of the growth of the ramus (2.2 mm)
literature was performed to determine whether a and body length (3.6 mm) of the mandible, a
consensus exists regarding controversial issues backward rotation of the mandible, and a
such as the timing of treatment and the use of reduction (8.2°) of the gonial angle.
adjunctive intra-oral appliances. • However, there was no alteration of any
The results showed that there was: parameter of the maxilla and the cranial base,
• No distinct difference between the palatal except the length of S-N and N-S-Ar in the long-
expansion group and non-expansion group term treatment group.
except for 1 variable, upper incisor
angulations, which increased to a greater Long-term Application of Chin-cup Force
degree in the non-expansion group. This Alters the Morphology of the Dolichofacial
finding implies that more skeletal effect and Class III Mandible
less dental change are produced in the — Deguchi, Kuroda, Hunt and Graber (AJODO, 1999)
expansion appliance group. • Investigated the immediate and long-term
• Examination of the effects of age revealed effects of prolonged use (mean, 7 years 2
greater treatment changes in the younger months) of chin-cup appliances in subjects
group. with dolichofacial Class III mandibles.
• Results indicate that protraction face mask • Thirty six female subjects with severe skeletal
therapy is effective in patients who are Class III malocclusions, associated with large
growing, but to a lesser degree in patients who gonial angles, were studied.
• At post-treatment (T1, 65 months duration) and Magnetic versus Mechanical Expansion with
post-retention (T2, 56 months after T1), Ar-Me Different Force Thresholds and Points of
and Wits appraisal cephalometric parameters Force Application
were significantly different between patients —Vardimon, Graber, Voss and Verrusio (AJODO, 1987)
and control subjects (n = 230). Studied the effects of force magnitude (high vs
• The Go-Me parameter in treated subjects was low) and point of force application (tooth vs direct
longer than that of the controls at T0 but palatal endosseous pins) on palatal expansion
became significantly shorter at T2. treatment in 4 Macaca fascicularis monkeys.
• Ar-Go parameter increased less than the
controls at T2. Animal 1 (IS)
• Results indicate that long-term use of the
chin-cup appliance (>5 years) is effective in • Received an upper acrylic appliance with an
subjects with severe skeletal Class III expansion screw.
abnormality. • The appliance was bonded bilaterally from
canine to 1st molar.
Rare Earth Magnets and Impaction • Thus, high forces (2033 g) were transmitted
— Vardimon, Graber, Drescher and Bourauel (AJO, 1991) indirectly to the mid-palatal suture via the
abutment teeth.
Introduced a new, magnetic attraction system,
with a magnetic bracket bonded to an impacted

Animal 2 (IM)
tooth and an intra-oral magnet linked to a
Hawley-type retainer for stimulating the natural • Received two permanent SmCo5 magnets in
eruption of an impacted tooth into the oral repelling configuration.
cavity. • The appliance was bonded to the abutment
• The magnetic system consisted of a magnetic teeth (canine and 1st molar).
bracket and an intra-oral magnet. • It transmitted low forces (258 g) indirectly to
• A miniaturized prism-shaped Nd2Fe14B the mid-palatal suture.
magnetic alloy in an un-magnetized form was Sliding (A) and stationary (B) acrylic housings
ground down (width = 2.20 mm × height = to receive the magnets. (C) Acrylic occlusal
2.59 mm × depth = 2.02 mm) to fit into an extensions to be bonded to dental arch. (D)
enlarged intra-bracket space, i.e. into the space Horizontal tubes to receive the U-shaped bar (E)
created between two machined down-tie Vertical holes (F) to retain the reactivation holders
wings of a twin bracket. (G) Teflon rings (H) to serve as barriers in the
• Vertical and horizontal magnetic brackets reactivation process.
were designed, with the magnetic axis
magnetized parallel and perpendicular to the Animal 3 (DM)
base of the bracket, respectively.
• Received a magnetic unit linked to a plate
• The vertical type is used for impacted incisors
attached to the palate via 4 endosseous pins.
and canines.
• It transmitted low forces (258 g) directly to the
• Horizontal magnetic bracket is applied for
palatal shelves.
impacted premolars and molars.
Animal 4 (control): received a passive sham
Rare Earth Magnets appliance bonded to abutment teeth.
Graber described the potential for the clinical Their results showed that:
utilization of rare earth magnets for the following • Treatment time was longer in the low force,
purposes: magnetically-induced appliances groups – 33
• Space control (space closure/opening) days in IS, 135 days in IM and 95 days in DM
• Open bite therapy (intrusion of posterior teeth) groups.
• Palatal expansion • In animal IS, a diastema developed between
• Growth guidance (functional appliances) the incisors and the force was directed supero-
• De-impaction of canines and molars. laterally and then transmedially, thus causing
fractures in the nasal complex and other Magnetic Strength and Corrosion of
iatrogenic sequelae. Rare Earth Magnets
• In the magnetically-induced appliances, the — Ahmad, Drummond, Graber, BeGole (AJODO, 2006)
force radiated supero-laterally, dissipating in • Evaluated several magnet coatings and their
the zygomatico-frontal suture, and the overjet effects on magnetic flux density.
significantly increased due to marked • Sixty neodymium-iron-boron magnets were
widening of incisive and transverse sutures. divided into 6 equal groups—polytetra-
• The palatally pinned magnetic appliance fluoroethylene-coated (PTFE), parylene-
produced bodily tooth movement, the greatest coated, and noncoated.
increase in inter-molar distance, and a • They were subjected to 4 weeks of aging in
superior positioning of the maxillo-palatine saline solution, ball milling, and corrosion
region. testing.
• Their results suggested reduction of • Their results showed a significant decrease in
conventional forces for palatal expansion by magnet flux density after applying a protective
up to eight-fold, through the use of rare earth layer of parylene, whereas a slight decrease
magnets. was found after applying a protective layer of
PTFE.
Stability of Magnetic versus Mechanical • After 4 weeks of aging, the coated magnets
Palatal Expansion were superior to the non-coated magnets in

— Vardimon, Graber and Voss (EJO, 1989) retaining magnetism.

Spatial stability following palatal expansion (PE) • The corrosion-behavior test showed no
treatment was studied longitudinally on 8 significant difference between the 2 types of
Macaca fascicular is monkeys. coated magnets, and considerable amounts of
• The sample was divided into short-term and iron-leached ions were seen in all groups.
long-term groups. • The authors concluded that throughout the
• The 4 animals in each group received: processes of coating, soaking, ball milling, and
• An indirect screw (IS) PE appliance (F = 2035 g). corrosion testing, PTFE was a better coating
• An indirect magnetic (IM) PE appliance (F = material than parylene for preserving magnet
258 g and 360 g). flux density. However, corrosion testing
• A direct magnetic (DM) PE appliance (F = 258 g showed significant metal leaching in all
and 360 g). groups.
• A sham appliance.
• Direct force transmission was via pinning to Functional Orthopedic Magnetic Appliance
the palatal shelves, indirect transmission was (FOMA) II—Modus Operandi
via abutment teeth. — Vardimon, Stutzmann, Graber, Voss, Petrovic
This study indicated that: (AJODO, 1989)
• Transverse stability was greatest in the • Introduced a new functional appliance (FA)
skeletally borne appliance. to correct Class II dentoskeletal malocclusions.
• Inter-canine distance relapse was 53% for IS • The FOMA II uses upper and lower attracting
and 23% for DM groups. magnets (Nd2Fe14B) to constrain the lower jaw
• Inter-molar expansion was more stable than in an advanced sagittal posture.
inter-canine expansion due to selective activity • In vitro, a special gauge transducer measured
of circummaxillary sutures and root the magnetic attractive path and forces.
configuration. • In vivo, 13 prepubertal female Macaca
• Sagittal advancement and vertical superior fascicularis monkeys received facial implants
translation were greater in the magnetic and were treated for 4 months with the
appliances with low force PE regimen. following appliances:
• Clinical implication – low force PE regimen – Conventional FA (4 subjects)
can be of substantial benefit in young skeletal – FOMA II (5 subjects)
Class III patients with transverse maxillary – Combined FOMA II + FA (2 subjects)
deficiency. – Sham (control) appliance (2 subjects).
1. The FOMA II consisted of upper and lower malocclusions that exhibit midface sagittal
magnetic plates. deficiency with or without mandibular excess.
• Buccal (solid line) and lingual (dashed • The FOMA III consists of upper and lower
line) 0.035-inch stainless steel arch wires acrylic plates with a permanent magnet
formed the metal substructure. incorporated into each plate.
• The two arch wires were linked together • The upper magnet is linked to a retraction
by acrylic overlaying the incisor and molar screw and is retracted periodically (e.g.
crowns. monthly) to stimulate maxillary advancement
• The FOMA II was designed with a and mandibular retardation.
magnetic inclined plane (25°). • The upper plate of a FOMA III consists of a
2. The conventional FA (feedback plates) guided 0.031-inch stainless steel arch wire forming
the mandible to a forward position by using a the metal substructure. The arch wire bypasses
slanted guide bar attached to the upper plate the premolar-canine segment to permit
and a lower oblique plane of the lower plate. eruption and crosses the occlusal plane at the
3. The combined FOMA II + FA appliance M1-M2 embrasure (a).
consisted of a labial magnetic unit and a • The upper magnetic housing (b) is linked to a
lingual prong system. retraction screw (c).
4. The sham appliance with its passive upper • The magnetic unit (b + c) is positioned along
and lower plates. the midpalatal line.

• The screw housing is linked to the plate at the

The in vitro results showed the following:
M1-M2 level (d).
• Vertico-sagittally displaced upper and lower
• Two guiding bars (e), attached to the plate
magnets attracted ultimately along an oblique
(lingually to the central incisors and laterally
line with a terminal horizonal slide to become
to the screw housing), and restrains the
fully superimposed.
magnetic unit from vertical deflection via
• The functional performance improved when
guiding tubes (f).
the magnetic interface acted as a magnetic
inclined plane.
Upper Plate of a FOMA III in
• The magnetic force was able to guide and
an Experimental Animal
constrain the mandible toward the constructive
protrusive closure position. • The attractive mode neodymium magnets used
The in vivo results demonstrated the following: in their study produced a horizontal force of
• Functional performance increased in FOMA 98 g and a vertical force of 371 g.
II (22%) and in the combined FOMA II + FA • The ratio of horizontal to vertical force vectors
(28%) over the conventional FA. is dictated by inclination of magnetic interface
• Mandibular length increased significantly in in the sagittal plane.
the treated animals over the control animals. • The more perpendicular the magnetic interface
• Incisor proclination was lower in magnetic is to the occlusal plane (sin 90° = 1), the greater
appliances than in the conventional FA. is the horizontal force vector.
• Mandibular elongation and condylar posterior The interaction between sutural and condylar
inclination resulted from posterosuperior growth sites appeared biphasic, characterized by
endochondral growth and by bony an immediate and rapid excitation of the
remodeling of the condylar neck. circummaxillary sutures followed by a delayed
• No anterior displacement of the post-glenoid and slow suppression of the condylar cartilage.
spine nor the articular eminence was found.
Maxilla
The Functional Orthopedic Magnetic 1. The target area of the protractive force was
Appliance (FOMA) III found to be localized in the pterygomaxillary
— Vardimon AD, Graber TM, Voss LR, Muller fissure.
(AJODO, 1990) 2. Three-dimensionally, the separation of the
• Developed an intraoral inter-maxillary sutures at the PMF was found to diminish in
appliance for the treatment of Class III inferosuperior and lateromedial directions.
Mandible • The impairment/repair dynamics were found

to be dominated by 3 principles: ERR level of
The fact that no pathologic change was found in
irreversibility, delayed resorption response
the condylar cartilage encourages a long-term use
and jiggling.
of the FOMA III appliance, initiating treatment at
an early skeletal age.
Repair of Orthodontically Induced Root
• A later radiographic and histologic study by
Resorption by Ultrasound in Humans
Vardimon, Graber et al (AJODO, 1994), again
— El-Baily, El-Shamy and Graber (AJODO, 2004)
on nine Macaca fascicularis monkeys who were
treated for 4 months with FOMA III revealed • This study evaluated the effect of low-intensity
the following data: pulsed ultrasound (LIPUS) on the healing
1. The growth pattern of the cranial base process of orthodontically induced tooth-root
(saddle angle) was not altered. resorption in humans.
2. Midfacial protraction occured along a • Twelve orthodontic patients who were seeking
recumbent hyperbolic curve with a orthodontic treatment that necessitated
horizontal maxillary displacement and an extracting the first premolars before
anterosuperior premaxillary rotation. mechanotherapy participated in this study.
3. Cumulative protraction of the maxillary • For each patient, buccally activated springs
were used to tip the maxillary first premolars
complex was initiated at the pterygom-

axillary fissure with an additional buccally, with an initial force level of 50 g.
contribution provided by other • A short period of LIPUS was applied to 1 side

circummaxillary sutures (zygomaticom- of each patient’s mouth, with the other side
axillary s., transverse s., premaxillary s.). used as a control.
4. Inhibition of mandibular length was • After 4 weeks, the experimental premolars of
minimal, but a tendency toward a vertical all patients were extracted, and the premolars
condylar growth pattern was observed. of 6 patients were studied by scanning electron
microscopy (SEM); the premolars of the other
Determinants Controlling Iatrogenic 6 patients were studied histologically.
External Root Resorption and Repair • The SEM study showed a statistically
During and After Palatal Expansion significant decrease in the areas of resorption
—Vardimon, Graber, Voss, Lenke (AO, 1991) and the number of resorption lacunae in the
• In this study, the mechanisms controlling LIPUS-exposed premolars.
external root resorption (ERR) and repair were • Histologic examination showed healing of the
studied on 8 Macaca fascicularis monkeys. resorbed root surface by hypercementosis.
• The animals were treated with jackscrew, • The results of this study provide a non-
magnetic and sham palatal expansion screws. invasive method for reducing root resorption
They were divided into short- and long-term in humans.
groups.
• SEM morphometric analysis found major Repair Process of External Root Resorption
evidence of ERR in the tooth-borne jackscrew Subsequent to Palatal Expansion Treatment
appliance, in the long-term group, in the —Vardimon, Graber and Pitaru (AJODO, 1993)
maxillary premolars, on the buccal and • The repair process of external root resorption
furcation root surfaces, on the mesio-buccal (ERR) and the role of retention mechanics in
root and in the apical zone. enhancing ERR repair were studied on eight
• Correspondingly, the ERR mechanism is Macaca fascicularis monkeys that were divided
controlled by impulse (F. Δt) and the critical equally into short- and long-term groups. Six
barrier of the PDL as primary determinants monkeys received palatal expansion
and by the environment density as the appliances, and 2 received sham appliances.
secondary determinant. • The short-term group received active
• ERR is initially regulated by the force treatment.
component of the impulse and, with increased • The long-term group received additional
duration, by the time component. retention (4 months) and relapse (2 months)
treatment periods with biweekly injections of • There is an abnormally large contribution of

individual vital dye per phase, i.e. procion red upper face height to total face height when the
H-8B and violet H-3R (80 mg/kg B.W.), teeth are in occlusion, due to vertical maxillary
respectively. deficiency.
Their results showed that: • There is markedly larger inter-maxillary
• The short-term group demonstrated penetrated clearance or freeway space in CP individuals
resorption with pulp exposure at sites with when compared to normal. This suggests that
initial deficiency of the protecting odontoblastic while there is a bony insufficiency, the general
layer (apical zone, nutrition canal). musculature attempts to maintain a normal
• The long-term group showed two forms of ERR developmental pattern and relation of parts.
repair: • Mandibular growth on the whole appears
1. Non-functional retarded repair cementum, normal. Values taken with the teeth in
comprised of overlapped incremental lines occlusion indicate over closure.
and deprived of extrinsic fibers, was • There is excessive lingual axial inclination of
delineated in severe pulp exposure. the lower incisors to the mandibular plane.
The pulp/dentin complex showed intense • The maxillary 1st molar tends towards a distal
incorporation of procion dye in the position with reference to craniometric
dentinal tubuli, conceivably related to a measurements outside the maxilla.
defense response in the form of sclerotic • Surgical correction can limit the growth
dentin. potential of the maxillary denture.

2. Functional rapid repair cementum, • The clinical results of orthodontic treatment,
comprised of discriminated incremental while improving the tooth-to-tooth
lines mainly of mixed cellular cementum, relationship in some cases, does not
with a consistent pattern of five sequential necessarily stimulate basal bone development.
phases: the lag phase (14–28 days), the Therapeutic results are often unstable and
incipient phase (14 days), the peak phase have to be maintained indefinitely.
(14–28 days), the steady phase (42–56 days)
and the retreating phase (70 days). A Functional Study of the Palatal and
Sharpey’s fibers at functional ERR sites Pharyngeal Structures
were scarce, never emerging from the — Graber, Bzoch, Aoba (AO, 1959)
dentinocemental junction, and not • Using high speed roentgenographic
developing into principal fibers. The pulp/ equipment, the soft tissue morphology of
dentin complex showed an increase in normal subjects was studied during the instant
pulp stones but no formation of tertiary of production of various consonant sounds
dentin. The apical area responded by (p, b, f, w, m).
hypercementosis in the form of apical • Biometric analysis was made.
occlusion and a displaced pulp canal. Following conclusions were drawn:
• Soft palate increases significantly in length
GRABER’S OTHER CONTRIBUTIONS TO from the rest to functional position.
ORTHODONTICS • The greatest extent of the upward and
A Cephalometric Analysis of the backward movement of the palate takes place
Developmental Pattern and Facial at the midpoint of the posterior superior
Morphology in Cleft Palate surface of the palate (mean = 16 mm).
— TM Graber (AO, 1949) • The velopharyngeal valve is consistently
closed for all the consonant sounds during
• Thirty three cleft palate patients (22 males, 11
normal speech production.
females) were studied cephalometrically.
• Slight anterior movement of the posterior
It was found that: pharyngeal wall is seen in 50% of normal
• The maxilla in Cleft palate patient’s cases is cases.
deficient in antero-posterior, lateral, as well The authors concluded that the orthodontist,
as vertical growth. as well as the prosthodontist and speech
therapist, should profit from a better correct a variety of developmental jaw

appreciation of normal speech physiology. deformities, whether they are hereditary or
traumatic in origin.
Postmortems in Post-treatment Adjustment • The patient is best served by this teamwork,
— TM Graber (AJO, 1966) not only during the actual mechanical and
• In this classic article, Dr Graber stresses the operative phases, but also during the initial
need for a longer period of orthodontic diagnostic and treatment planning phases,
management in many cases. that are every bit as important.
• He says that, with the orthodontists’ • Proper diagnosis requires a thorough
dependence on pattern and growth and knowledge of growth and development, of
development, it is essential to keep patients cephalometric analysis, of occlusion and
under observation longer and observe the proper jaw relationships, and of surgical and
status of the stomatognathic system in its orthodontic techniques to correct these
biologic continuum. deformities.
• The concept of treating the malocclusion once • Here, the orthodontist, because of his training
and then considering it finished is un- and experience in these aspects, can be
physiologic. Thus, the philosophy of a longer invaluable to the surgeon.
orthodontic management and responsibility,
with two or three shorter periods of orthodontic Post-pharyngeal Lymphoid Tissue in Angle
mechanotherapy, is more appropriate. Class I and Class II Malocclusions

— Sosa, Graber and Muller (AJO, 1982)
Serial Extraction: A Continuous Diagnostic • Studied the relationship between the adenoid
and Decisional Process tissue and type of malocclusion.
— TM Graber (AJO, 1971) • Xeroradiographic lateral cephalograms were
• Serial extraction is a guided, progressive made of 80 Class I and 64 Class II/I
removal of deciduous teeth ahead of the time malocclusions.
they would normally be shed, to enlist the • The epipharyngeal lymphoid tissue,
fundamental phenomena of adaptability and nasopharyngeal airway, nasopharynx and
adjustment. certain cephalometric landmarks were
• Dr Graber states that the technique is measured.
biologically sound, proven, and should not be Their results showed that:
considered a compromise. • There is no clear-cut relationship between
• In almost all instances of serial extractions, either Class I or Class II/I malocclusions and
conventional orthodontic therapy is required the total nasopharyngeal area.
to complete the alignment of teeth, to parallel • Sexual dimorphism was seen:
the roots, to eliminate overbite and to effect – Class I males: widening of antero-posterior
residual space closure. However, the duration dimension of nasopharynx is associated
of such mechanotherapy is significantly with anterior rotation of the mandible,
shorter, is likely to produce less damage, and longer maxillas, larger SNB angles,
the results are more stable. opening of cranial base angle, and
increased distance from sella to PNS. Thus,
Orthosurgical Teamwork these patients have more anteriorly
— Olson, Mincey and Graber (JADA, 1975) positioned maxilla and mandible.
• Using the examples of 6 patients with different – No association was present at all for Class
malocclusions, the authors have reported on II/I males.
the combined orthodontic-surgical approach – Class II/I females: larger nasopharyngeal
towards treatment. area is associated with longer maxillae and
• They state that surgery and orthodontics can smaller palatal plane angles, and anterior
separately, but surely better in combination, rotation of mandible.
Orthodontics and Temporomandibular • They received therapeutic US on one side of

Disorder: A Meta-analysis the mandible for 20 minutes/day for four
— Kim, Graber and Viana (AJODO, 2002) weeks.
• In this meta-analysis, the relationship between • Anthropometrical and histological evaluations
traditional orthodontic treatment, including revealed that US enhances mandibular growth
the specific type of appliance used and by condylar endochondreal bone growth and
whether extractions were performed, and the consequently mandibular ramus growth.
prevalence of temporomandibular disorders • It thus increases the mandibular condylar,
(TMD) were investigated. ramal, and total mandibular heights in
• Their data indicated that traditional growing rabbits.
orthodontic treatment did not increase the Dr Thomas M Graber was certainly a
prevalence of TMD. pioneer amongst men. His complete devotion
and love for the specialty of orthodontics is
Growth Modification of the Rabbit reflected in his extensive works on a myriad of
Mandible Using Therapeutic Ultrasound: topics, spanning over a period of nearly six
Is it Possible to Enhance Functional decades.
Appliance Results? As Dr Graber’s family friend and
— El-Bialy, El-Shamy, Graber (AO, 2003) colleague, Dr Jim McNamara noted, “Tom’s
• The objective of this study was to evaluate the energy and enthusiasm for our profession
effect of therapeutic US on condylar and make him a wonderful role model for future
mandibular growth in the rabbit model. generations of orthodontists.” The passing of
• Eight growing New Zealand male rabbits were Dr Thomas M Graber marks the end of an era
chosen for this study. in orthodontics.
James McNamara’s
Contribution to 10
Orthodontics
• James McNamara Analysis • Relating Mandible to Cranial • Studies on Functional

• Relating the Maxilla to the Base Appliances
Cranial Base • Dentition Analysis • Studies on Rapid Maxillary

• Relating the Mandible to the • Airway Analysis Expansion

Maxilla (Midface) • Studies on TMJ
Dr McNamara received his dental and of Michigan Elementary and Secondary School
orthodontic education at the University of Growth Study, one of the largest longitudinal
California, San Francisco, and a Doctorate in studies of untreated individuals in the world.
Anatomy from the University of Michigan. He This unique collection allows the study of facial
serves as the Thomas M and Doris Graber development from the early juvenile period to
endowed Professor of Dentistry in the middle age in the same group of untreated
Department of Orthodontics and Pediatric subjects, providing a basis of comparison for
Dentistry, Professor of Cell and Developmental ongoing clinical investigations.
Biology in the University of Michigan Medical
School and Scientist at the Center for Human JAMES McNAMARA ANALYSIS
Growth and Development. He is the author Presented by Dr James A McNamara as an
(with artist William L Brudon) of the new text, original article in the December 1984 issue of the
Orthodontics and Dentofacial Orthopedics. He American Journal of orthodontics.
has maintained a private practice in Ann Arbor • He asserts that his analysis method is
since 1971. He is a Diplomate of the American presented as a language, which can be used
Board of Orthodontics and a Fellow of the by the clinician to better identify and describe
American College of Dentists. In addition, Dr the structural relationships of the jaws, as well
McNamara is editor-in-chief of the 40 volume as to communicate easily with other clinicians
Craniofacial Growth Monograph Series as well as lay persons.
published through the University of Michigan. • This method of analysis is derived in part from
He has published over 180 scientific articles in the principles of the Ricketts’ and Harvold
refereed journals, has written, edited or analyses.
contributed to 53 books, and has presented • The James McNamara analysis is useful in
courses and lectures in 30 countries. More diagnosis and treatment planning of the
recently, McNamara has focused on clinical individual patient when values derived from
studies of the effects of orthodontic, orthopedic the tracing of the patients’ head film are
and surgical interventions on the growth of the compared to established norms; the norms
face. He serves as the curator of The University from three groups have been derived:
James McNamara's Contribution to Orthodontics 89
– The Bolton study Normative Standards in McNamara Analysis are

– The Ann Arbor sample (200 adults) listed below (Table 10.1).
– The Burlington sample. Table 10.1: Normative Standards in McNamara
• This analysis consists of five major sections: Analysis
– Relating maxilla to cranial base
Midfacial Mandibular Lower anterior
– Relating maxilla to mandible
length (mm) length (mm) facial height (mm)
– Relating mandible to cranial base (Co-point A) (Co-Gn) (ANS-Me)
– The dentition
– Airway analysis. 80 97–100 57–58
81 99–102 57–58
82 101–104 58–59
I. RELATING THE MAXILLA TO THE
CRANIAL BASE (FIG. 10.1) 83 103–106 58–59
84 104–107 59–60
Soft Tissue Evaluation 85 105–108 60–62
The nasolabial angle and cant of upper lip should 86 107–110 60–62
be examined both clinically and cephalometrically. 87 109–112 61–63
The nasolabial angle is formed by the intersection of 88 111–114 61–63
a line tangent to the base of the nose with a line 89 112–115 62–64
tangent to the upper lip. Norms for nasolabial angle 90 113–116 63–64
91 115–118 63–64
according to: Ann Arbor adult sample = 102 ± 8°.

An acute nasolabial angle can be a reflection of 92 117–120 64–65
dentoalveolar protrusion, but it can also occur 93 119–122 65–66
because of the orientation of the base of the nose. 94 121–124 66–67
The cant of the upper lip should be evaluated relative 95 122–124 66–67
96 124–127 67–69
to the vertical orientation of the face. The upper lip to
97 126–129 68–70
nasion perpendicular angle should be:
98 128–131 68–70
14° ± 8.2° in females 99 129–132 69–71
8.4° ± 7.8° in males. 100 130–133 70–74
101 132–135 71–75
Hard Tissue Evaluation 102 134–137 72–76
103 136–139 73–77
In an evaluation of the position of the maxilla
104 137–140 74–78
relative to the cranial base, two factors are
105 138–141 75–79
considered:
• The skeletal relationship of point A to the
nasion perpendicular. Nasion Perpendicular to Point A
• The first measurement to be made is the linear
distance from point A to the nasion
perpendicular.
• In the composite norms for adults of both sexes
in this analysis, point A is 1 mm ahead of the
nasion perpendicular line.
II. RELATING THE MANDIBLE TO THE

MAXILLA (MIDFACE)
• The lengths of the mandible and the maxilla
(midfacial region) are related.
• The effective maxillary length—line from
condylion to point A.
• The effective mandibular length—line from
Fig. 10.1: Relating the Maxilla to the cranial base condylion to anatomic gnathion.
• A geometric relationship exists between the mandibular length and are not directly related
effective length of the midface and that of the to the age or sex of the individual subject.
mandible. Any given effective midfacial length • Once the effective length of the midface is
corresponds to a given effective mandibular known, the effective mandibular length can
length. be estimated.
• If the effective midfacial length is subtracted
from the mandibular length, the maxillo- Vertical Relationship (Fig. 10.2)
mandibular differential can be determined.
• Lower anterior facial height. It is measured
• Ideally this differential is 20 mm for small-
from ANS to Me.
sized persons, 25–27 mm for medium-sized
• In well-balanced faces the vertical dimension
persons and 30–33 mm for large-sized persons.
correlates with the effective length of the
• Composite norms have been extrapolated from
midface.
the values derived from the Bolton and
• Mandibular plane angle(Fig. 10.3): Angle
Burlington samples, as well as from the Ann
between F-H plane and Go-Me.
Arbor sample.
– Normal Value: 22°+/–4°
• These norms represent a geometric relationship
– Higher Value: Excessive lower facial
between effective midfacial length and effective
height
A B
Figs 10.2A and B: (A) Vertical maxillary excess results in downward and backward positioning of the mandible creating
excessive anterior facial height (ANS-M); (B) Vertical maxillary dentoalveolar deficiency causing an upward and forward
positioning of the mandible and deficient lower anterior facial height (ANS-M)
A B
Figs 10.3A and B: (A) Mandibular plane angle of 22 degrees to Frankfort horizontal in average normal individual; (B) High
mandibular plane angle suggestive of excessive lower facial height
–Lower Value: Deficiency in lower facial Relating the Lower Incisor to the Mandible
height
Anteroposterior position of Lower Incisor: Determined
• Facial axis angle: Angle between Postero-
by using a traditional version of the Ricketts
superior aspect of pterygomaxillary fissure to
measurement of the facial surface of the lower
gnathion and Line joining Basion to Nasion.
incisor to the A-Pog line.
– Balanced Face = 90°
Bolton study Norms:
– Excessive vertical development, less than
1.5 mm anterior to the A-Pog Line.
90°(negative value)
Ann Arbor Norms:
– Deficient vertical development, higher
2.3–2.7 mm anterior to the A-Pog Line.
than 90°(positive value).
III. RELATING MANDIBLE TO CRANIAL BASE

(FIG. 10.4)
• The relationship of the mandible to the cranial
base is determined by measuring the distance
of the pogonion to the Nasion perpendicular.
• According to the composite norms:
– In a mixed dentition (balanced face) pog

lies 8 mm to 6 mm (posterior) with respect
to Nasion perpendicular and moves

forward with growth.
– In adult male the chin position is usually –2
mm to +2, relative to Nasion perpendicular.
IV. DENTITION ANALYSIS

Relating Upper Incisor to Maxilla (Fig. 10.5
and 10.6)
A vertcal line is drawn through point A parallel to Fig. 10.5: Method of determining position of upper incisor
relative to point A. NP = nasion perpendicular; PNP = point A
nasion. The distance from point A to the facial vertical constructed parallel to nasion perpendicular through
surface of Upper incisor is measured → A-P position point A; D anteroposterior distance from upper incisor to
of Upper incisor Norms = 4–6 mm (Adults). point A (should be 4–6 mm)
A B
Figs 10.4A and B: Mandible to cranial base measured from pogonion to nasion perpendicular. Tracing (A) shows normal
mandible to cranial base relationship in an adult woman. Tracing (B) shows serverly retrusive mandible (–31 mm) and mildly
retrusive maxilla (–3 mm)
Upper Pharynx
• The upper pharyngeal width is measured
from a point on the posterior outline of the soft
palate to the closest point on the posterior
pharyngeal wall (Fig. 10.7A and B).
• This measurement is taken on the anterior half
of the soft palate outline because the area
immediately adjacent to the posterior opening
of the nose is critical in determining upper
respiratory patency.
• Apparent airway obstruction, as indicated by
an opening of 5 mm or less in the upper
pharyngeal measurement, is used only as an
indicator of possible airway impairment.
• A more accurate diagnosis can be made only
Fig. 10.6: Severely protrusive upper incisors (11 mm) in a by an ENT specialist.
protrusive maxilla
Lower Pharynx
Vertical Position of Lower Incisors

• Lower pharyngeal width is measured from the
Evaluated on basis of existing lower anterior facial intersection of the posterior border of the
height. First, the lower incisor tip is related to the tongue and the inferior border of the mandible
functional occlusal plane. to the closest point on the posterior pharyngeal
If curve of Spee is excessive: lower incisor is to be wall (Fig. 10.7A).
intruded (if LAFH is normal/excess) OR lower • Average measurement is 11–14 mm
molar is allowed to erupt and lower incisor independent of the age.
extruded (when LAFH is inadequate). • According to the measures derived from the
Ann Arbor sample, the average value for this
V. AIRWAY ANALYSIS measurement is 10–12 mm and does not
change appreciably with age (Fig. 10.8).
Two measurements are used to examine the
possibility of airway impairment.
A B
Figs 10.7A and B: (A) Average normal upper pharyngeal airway space A, in this instance 15 mm. Lower pharyngeal
airway space B measurement is 11 mm; (B) Possible upper airway obstruction; measurement A is approximately 2 mm
functional appliance than in those wearing

the tissue-borne appliance.
Treatment and Post-treatment Effects of

Acrylic Splint Herbst Appliance Therapy
—Franchi L, Baccetti T, McNamara JA Jr. AJO 1999
• This study evaluated the skeletal and
dentoalveolar changes induced by acrylic
splint Herbst therapy of Class II malocclusion.
• The study showed that two-thirds of the
achieved occlusal correction was due to
skeletal effects and only one-third to
dentoalveolar adaptations.
• Both skeletal and dentoalveolar effects were
mainly due to changes in mandibular
structures. A significant amount of relapse in
Fig. 10.8: A patient with a normal lower pharyngeal
measurement molar relationship occurred during the post-
treatment period, and this change could be
ascribed to the mesial movement of the upper

molars.
• Obstruction of the lower pharyngeal area
because of a posterior positioning of the tongue Linda Ratner Toth, James A McNamara Jr.
against the pharyngeal wall is rare. AJO 1999
• A greater than average pharyngeal width on
the other hand suggests a possible anterior • Twin-block and FR II compared with untreated
positioning of the tongue either due to habitual class II.
posture or due to tonsillar enlargement. • Mandibular length increase in Twin-block-
• Clinical conditions that can be associated with 3 mm
a forward tongue position and/or enlarged • Mandibular length increase in FR II- 1.9 mm.
tonsils: • The present study suggests, that Class II
– Mandibular prognathism correction with the Twin-block appliance is
– Dentoalveolar anterior crossbite achieved through normal growth in addition
– Bialveolar protrusion of the teeth. to mandibular skeletal and dentoalveolar
changes.
STUDIES ON FUNCTIONAL APPLIANCES • Class II correction with the FR-2 is more
—James A McNamara Jr, Raymond P Howe, skeletal in nature, with less dentoalveolar
Terry G Dischinger. AJO 1990 changes noted.
• The present study suggests, therefore, that
• This study investigated the treatment effects
Class II correction can be achieved with either
produced by the tooth-borne (Herbst
appliance system evaluated here. The FR-2
appliance) and one primarily tissue-borne
appliance appears to have primarily a skeletal
(FR-2).
effect, whereas, the Twin-block appliance
• The results of this study indicated that both
produces both skeletal and dentoalveolar
appliances had influenced the growth of the
adaptations.
craniofacial complex in treated persons.
Significant skeletal changes were noted in both
Tiziano Baccetti, Lorenzo Franchi, Linda
treatment groups, with both groups showing
Ratner Toth, James A McNamara Jr. AJO 2000
an increase in mandibular length and in lower
facial height, as compared with controls. • The findings of this short-term cephalometric
• Greater dentoalveolar treatment effects were study indicate that optimal timing for the
noted in the group wearing the tooth-borne orthodontics treatment.
Cephalometric parameter used in McNamara analysis are summarized in this below table along with
their respective normative value (Table 10.2).
Table 10.2: McNamara Analysis

Name of Patient _______________________________________________ Age _______ Sex ______
Normal Patient Comment

1. Maxilla to Cranial Base
Nasolobial angle 14• (±8•) __________
8• (±8•) __________
No. Perp. to point A 0–1 mm __________
2. Maxilla to Mandible*
Anteroposterior
Mand. length (Co-Gn) __________ __________
Max. length (Co-Point A) __________ __________
Max./mand. differential Small 20–23 mm __________
Med. 27–30 mm __________
Large 30–33 mm __________
Vertical
L. ant. fac. ht. (ANS-Menton) Small 60–62 mm __________

Med. 65–67 mm __________
Large 70–73 mm __________
Mand. PL (FH-Go-Menton) 22• (±4•) __________
Facial axis (Ba-N) = (PTM-Gn) 0• (±3.5•) __________
3. Mand. to Cranial Base

(Pog-Na Perp.) Small –8 to –6 mm __________
Med. –4 to 0 mm __________
Large –2 to +2 mm __________
4. Dentition
1 to Point A 4–6 mm __________
1 to A-Po 1–3 mm __________
5. Airway
Upper pharynx 15–20 mm __________
Lower pharynx 11–14 mm __________
Summary Conclusion
• Twin-block therapy of Class II disharmony is The Importance of the Assessment of

during or slightly after the onset of the pubertal Skeletal Maturity and the Onset of the
peak in growth velocity. Pubertal Growth Spurt in Individual Patients
• When compared with treatment performed has to be Emphasized as a Fundamental
before the peak, late Twin-block treatment Diagnostic and Decision-making Tool in
produces more favorable effects that include Treatment Planning for Class II Malocclusion
– Greater skeletal contribution to molar — Faltin KJ, Faltin RM, Baccetti T, Franchi L,
correction Ghiozzi B, McNamara JA Jr. AO 2003
– Larger increments in total mandibular • The findings of the present study on Bionator
length and in ramus height therapy followed by fixed appliances indicate
– More posterior direction of condylar that this treatment protocol is more effective
growth, leading to enhanced mandibular and stable when it is performed during the
lengthening. pubertal growth spurt.
• Optimal timing to start treatment with the STUDIES ON RAPID MAXILLARY EXPANSION
Bionator is when a concavity appears at the
Joyce Y Chang, James A McNamara
lower borders of the second and the third
Jr,Thomas A Herberger. AJO 1997
cervical vertebrae (CVMS II). In the long-term,
the amount of significant supplementary • The purpose of this investigation was to
elongation of the mandible in subjects treated examine the long-term effect of the Haas-type
during the pubertal peak is 5.1 mm more than in RME on bite opening and on the antero-
the controls, and it is associated with a posterior position of the maxilla.
backward direction of condylar growth. • There was no significant difference among
• Significant increments in mandibular ramus groups receiving rapid maxillary expansion,
height also were recorded. followed by edgewise treatment (RME),
standard edgewise therapy alone (SET), or no
de Almeida MR, Henriques JF, de Almeida treatment (CTRL).
RR, Weber U, McNamara JA Jr Angle. • The current investigation of long-term
Orthod 2005 treatment effects concludes therefore that RME
therapy used in the treatment of patients with
• The results indicated that the treatment effects
Class I and Class II malocclusions does not
of Herbst produced in the mixed dentition
have a significant long-term effect on either
patients were primarily dentoalveolar in

the vertical or the anteroposterior dimensions
nature.
of the face.
• The mandibular incisors were tipped labially,
and the maxillary incisors were retruded; a
McNamara JA Jr, Baccetti T, Franchi L,
significant increase in mandibular posterior
Herberger TA. AO 2003 RME Followed by
dentoalveolar height occurred, and there was
Fixed Appliances
a restriction in the vertical development of the
maxillary molars. • In comparison with controls, a net gain of 6 mm
• There was no difference in the forward growth was achieved in the maxillary arch perimeter,
of the maxilla between the two groups. whereas a net gain of 4.5 mm was found for the
• In comparison with the controls, however, the mandibular arch perimeter.
Herbst treatment produced a modest but • The amount of correction in both maxillary
statistically significant increase in total and mandibular intermolar widths equaled
mandibular length. two-thirds of the initial discrepancy, whereas
treatment eliminated the initial deficiency in
Paola Cozza, Tiziano Baccetti, Lorenzo maxillary and mandibular intercanine widths.
Franchi, Laura De Toffol, and James A • The amount of correction for the deficiency in
McNamara, Jr. AJO 2006 maxillary arch perimeter was about 80%,
whereas in the mandible a full correction was
Two-thirds of the samples in the 22 studies
achieved.
reported a clinically significant supplementary
elongation in total mandibular length (a change
Geran RG, McNamara JA Jr, Baccetti T,
greater than 2.0 mm ) as a result of overall active
Franchi L, Shapiro LM. AJO 2006
treatment with functional appliances. The amount
of supplementary mandibular growth appears to • Treatment with an acrylic splint RME followed
be significantly larger if the functional treatment by fixed appliances produced significantly
is performed at the pubertal peak in skeletal favorable short-term and long-term changes
maturation. The Herbst appliance showed the highest in almost all maxillary and mandibular arch
coefficient of efficiency (0.28 mm per month) followed measurements.
by the Twin-block (0.23 mm per month). The • The amount of change in both maxillary and
coefficient for the bionator 0.17 m per month). For mandibular intermolar and intercanine widths
the activator, it was slightly lower (0.12 mm per fully corrected the initial discrepancies.
month). The coefficient of efficiency for the Fränkel • Approximately 4 mm of long-term relative increase
appliance, was the lowest (0.09 mm per month). in maxillary arch perimeter, and 2.5 mm additional
maintenance of mandibular arch perimeter were • Pre-chondroblastic – chondroblastic layer

observed in the TG compared with the CG. showed responses.
• These results suggest that this protocol is • Initial adaptations along the posterior border
effective and stable for the treatment of of the condyle followed by changes in the
constricted maxillary arches, and can relieve posterosuperior region.
modest deficiencies in arch perimeter. • This study demonstrated that significant
adaptive responses can occur in the
Cozza P, Baccetti T, Franchi L, McNamara mandibular condyle of the juvenile rhesus
JA Jr. Am J Orthod Dentofacial Orthop. 2006 monkey following alteration in the functional
position of the mandible.
• The aim of this study was to investigate the
• And that the condyle is highly responsive to
effectiveness of a quad-helix/crib (Q-H/C)
changes in the biomechanical and biophysical
appliance in a group of growing subjects with
environment of the TMJ region during growth.
thumb-sucking habits and both dental and
skeletal open bites.
Kristine S West and James A McNamara, Jr.
• The Q-H/C appliance was effective in
AJO 1999
correcting the dental open bite in 90% of
growing subjects with thumb-sucking habits • The purpose of the present study was to evaluate
and dentoskeletal open bites. cephalometrically the craniofacial growth

• The average increase in overbite during Q-H/ changes and adjustments that occur from late
C therapy (3.6 mm more), the maxillary and adolescence to mid adulthood in persons who
mandibular incisors had significantly greater had no previous history of orthodontic
lingual inclinations (about 4.0 degrees) treatment. Mandibular and midfacial lengths as
associated with greater extrusion (1.4 and 1.0 well as posterior and lower anterior facial heights
mm, respectively) in the Q-H/C group. had increased significantly for males and
• The Q-H/C protocol produced a clinically females over both time intervals.
significant improvement in the vertical skeletal • The pattern of expression of these changes was
relationships because of downward rotation different in the two genders: males showed an
of the palatal plane. Neuromuscular and anterior rotation of the mandible, whereas
skeletal adaptations to altered function in the females demonstrated a posterior rotation of
orofacial region. the mandible.
• Soft tissue changes also were somewhat
James A McNamara, Jr. AJO 1973 different between genders. In males, the nose
and chin grew downward and forward, with
• The nature of intrinsic musculoskeletal
the lips generally moving straight
adaptations resulting from experimental
downward.
alterations of the orofacial environment.
• In contrast, females had nasal growth that
• Neuromuscular adaptations.
progressed downward and forward, and there
• Mandibular adaptations – changes in the
was a slight retrusion of the lips over time.
growth pattern of the condylar head and
• Continued tooth eruption was noted in both
compensatory migration of the dentition.
genders as well.
(depending on the maturational level).
• Maxillary adaptations – changes in the extent
STUDIES ON TMJ
and vector of growth of the skeletal components.
McNamara, Jr. OOO 1997
James A McNamara, Jr and Carlson DS.
• The relationship between orthodontic
AJO 1979
treatment and TMDs has long been of interest
• TMJ adaptations to protrusive function. to the practicing orthodontist.
• Significant adaptive responses can occur in • The interest in orthodontics and TMD in part
the mandibular condyle of the juvenile rhesus was prompted in the late 1980‘s after litigation
monkey following alteration in the functional that alleged that orthodontic treatment was the
position of the mandible. proximal cause of TMD in orthodontic patients.
• This resulted in an increased understanding specific gnathologic ideal occlusion does not
of the need for risk management as well as for result in signs and symptoms of TMD.
methodologically sound clinical studies. • Thus far there is little evidence that
The findings of current research investigating orthodontic treatment prevents TMD,
the relation of orthodontic treatment and TMD although the role of posterior unilateral
are as follows: crossbite correction in children may warrant
further investigation.
Signs and Symptoms of TMD May Occur in
Healthy Persons Conclusion
• Signs and symptoms of TMD increase with • The overall goal of McNamara’s research
age, particularly during adolescence, until is to provide a sound biological basis for
menopause and so TMD s that originate understanding how the face normally
during treatment may not be related to the grows and how facial growth can be altered
treatment. by experimental and therapeutic interven-
• Treatment performed during adolescence does tion.
not increase or decrease the chances of TMD • His past research involved studies of both
later in life. normal and experimental alterations in the
• Extraction of teeth as a part of treatment plan growth of the facial region in a non-human
does not increase the risk of TMD. primate, using the rhesus monkey as a model
• There is no increased risk of TMD associated of human craniofacial development.

with any particular type of orthodontic • More recently, McNamara has focused on
mechanics. clinical studies of the effects of orthodontic,
• Although a stable occlusion is a reasonable orthopedic and surgical interventions on the
orthodontic treatment goal, not achieving a growth of the face.
Andrews’ Straight
Wire Appliance
11
• Why “Straight Wire”? Overcome in the ‘Straight • Straight Wire Appliance

• Deficiencies in the Wire Brackets’ Brackets for Different Clinical
Situations
Conventional Edgewise Bracket • Variable Bracket Sitting

Design, and How they are Procedures: Lawrence F • Straight Wire Appliance (SWA)
Andrew’s Remedy
The ‘straight wire’ appliance is an example of examiners appointed at these prestigious

what a motivated person could achieve with societies, and yet they differed considerably.
determination and perseverance. It is a Therefore, Lawrence F Andrews concluded that
fascinating story of a man fully engaged in the then existing criteria for measuring the
practice that carried out outstanding research
extending into numerous projects and
culminated in the development of an appliance
that has profoundly affected the practice of
orthodontics.
After his graduation in 1959, Laurence F
Andrews (Fig. 11.1) was looking for a topic to write
a thesis that was required for certification by the
American Board of Orthodontics. The theme that
he chosed was the prevalent quality of American
orthodontic practice with respect to static
occlusion. He started an assessment of post-
treatment orthodontic study models exhibited at
the meetings of American Board of Orthodontics,
Angle Society and Tweed Foundation. Although
the records indicated that the patients’ occlusion
had shown remarkable improvement over the
original condition, and there were few common
findings (such as class I molar occlusion, normal
overjet, absence of cross bites and incisor
rotations), many other features like angulations
and inclinations of various teeth and curve of
Spee were quite disparate. These cases had been
judged as the outcome of excellent treatment by Fig. 11.1: Lawrence F Andrew
Andrews’ Straight Wire Appliance 99
quality of finishing were ill defined and needed Andrews later stated in his interview that he
to be revised. considered finding the facial axis of clinical
He rightly decided that the answer to his crown as his most significant contribution to
question rested in the nature’s ideal cases. Thus orthodontics, because it can be used for both
started his tryst with the normal, which he latter angulations and inclination. Also it has a reliable
on called optimal occlusion. He collected correlation with planes of crown at all times and
orthodontic study models of 120 non-treated with the mid-transverse planes of all the crowns
individuals whose occlusion was considered to in an arch when the teeth are correctly
be ideal by him and his peers. With a keen eye positioned. “Without it there would have been
and logical mind, he picked out the six consistent no six keys and no straight wire appliance.”
features related to the clinical crowns, which Andrews reexamined the treated cases
were common to all the study models. He named applying the criteria of the six keys. This study
these as the six keys to normal occlusion. They revealed that most of them failed to attain many,
describe the characteristics of best static natural if not all, keys. The failures were, in a descending
occlusion as related to molar relation, angulations order of occurrence, errant angulations of the
and inclinations of the teeth and stipulate that teeth; interarch relations, inclinations of the teeth,
there should be no rotations and spaces, and the rotations of remaining teeth, excess curve of Spee
curve of Spee should be flat. He published his and persistent spaces.
results in the American Journal of Orthodontics Lawrence F Andrew started analyzing the
in the year 1972. The article since has attained causes for the above short comings and came to
the status of mandatory reading for anyone the conclusion that the standard edgewise
aspiring to become an orthodontist. appliance had too many deficiencies to obtain
The uniqueness of Andrews’ study was that consistent results. These were in the following
the tooth positions were referenced from form:
clinically visible teeth crowns (or, more 1. Variability in wire bending from operator to
specifically, the labial and buccal surfaces of operator and even with the same operator.
clinical crowns) and not from the long axis of 2. Deficiencies in the standard edgewise bracket
the teeth, which can be judged only from the design.
radiographs. Further, the referents selected were 3. Variations in the bracket sitting procedures.
such that optimal occlusion based on them Lawrence F Andrew’s next study was aimed
obviated the need to use articulating paper to at exploring the conceptual feasibility of
check the interfacing of occlusal surfaces or view developing an appliance, which would facilitate
the occlusion from the lingual side. The most obtaining the six keys consistently in treated
important of the referents was the facial axis of cases. It consisted of numerous measurements
clinical crown, formerly termed long axis of the on the plaster casts of non-orthodontic normal
clinical crown. For all the teeth other than the occlusion. These ascertained the natural
molars, it is the most prominent ridge on the anatomic similarities (earlier named ‘tendencies’
crown’s face; while for the molars it is the by Wheeler) in human dentitions. Specifically,
dominant groove on the crown’s face. From the they were related to constancy of position and
facial perspective it appears as a straight line. shape within each tooth type, and consistency
From the mesial or distal perspective it is of relative size of crowns within an arch. The
perceived as a straight line tangent to the conclusions from this study were:
midpoint of the crown’s face. The midpoint of 1. Most individuals have normal teeth
facial axis of clinical crown is named as the facial regardless of whether they have normal
axis point (FA point), which is formerly termed occlusion or malocclusion. Abnormally
long axis point. It is used for assessing the shaped crowns in the rest of the persons are
positions of the teeth as also for placing the generally amenable to restorative procedures
brackets accurately on the teeth. When all the to normalize them before orthodontic
teeth are correctly positioned, the plane joining treatment is started.
the FA points of all the teeth is named as 2. Each normal tooth type (such as the central
Andrews’ plane. incisors, lateral incisors, cuspids, etc.) is
similar in shape from one individual to is built in the brackets instead of depending
another. on the wire bends, more consistent results
3. All the teeth in any individual’s mouth are could be obtained.
generally proportionate though they may 2. Other wire bends (secondary bends) are
vary in size from person to person, i.e. all the required for compensating for faulty
teeth tend to be large, medium or small. placement of the brackets or the deficiencies
4. The size of normal crowns within a dentition in the bracket design. One example is the
has no effect on the relative prominence of buccal root torque in the posterior region of
their facial surfaces, or the curvatures both the archwire that is needed in the
vertical and horizontal of the labiabuccal conventional edgewise treatment, which is
surfaces on which the brackets will be placed, given not to effect any torquing movement
or on the location of contacts between two but to avoid unintentional torque. Standard
teeth types. Also, optimal crown angulation edgewise brackets placed on the curved
or inclination as well as interarch relation are buccal surfaces of the posterior teeth, on
not related to the size of the crowns and hence receiving a flat (untorqued) archwire, would
are attainable, whatever may be the size of create an unintended torque on the teeth in a
the crowns. crown buccalroot lingual fashion that is
5. When the upper and lower jaws are generally undesirable. Buccal root torque in
proportionate and properly related, it is the archwire prevents this from happening.
always possible for the teeth to be brought in These wire bends are needed in all the
optimal occlusion. successive archwires and in almost all the
The study thus paved the way for creating a patients. This repetitive wire bending could
new appliance by taking advantage of the be eliminated if the bracket design
anatomic similarities in the human dentition, and shortcomings are corrected by suitable
by recognizing the fact that similarities exist in modifications (for example, by having built-
the positions of the normal teeth when they are in torque in the brackets itself to remedy the
optimally occluded. Andrews developed his above mentioned situation).
appliance to address all the above mentioned 3. Even for the same operator, the bends placed
problems with respect to variability in wire in the successive archwires are likely to vary.
bending, deficiency in bracket design and They will certainly be different for different
variable bracket sitting procedures. operators. Since every bend in the archwire
not only causes some action but also has a
WHY “STRAIGHT WIRE”?
reaction, the results from such differing bends
The term straight wire in the present context are unpredictable and often lead to undesired
refers to an archwire that is given the arch form tooth movements. Additional secondary wire
and often the curvature to open the bite, but bends will be required for overcoming them.
which is free from the first, second or third order 4. Some of the bends influence the actions of
bends. It is a ‘formed’ but ‘unbent’ archwire. other bends, e.g. torque in the anterior section
Lawrence F Andrew’s endeavor to develop an of the archwire negates the tip by a ratio of
appliance that would permit the use of such an 1:4 (wagon-wheel effect). Accurate wire
archwire by transferring most of the tooth bending to negate such ill effects is extremely
guidance functions from the archwires to the difficult but provision could be made in the
brackets (by modifying the bracket design), was bracket design to overcome them to a large
based on the following reasoning: extent.
1. Some of the bends in an archwire are needed However, it should be noted that in only few
for effecting first, second and third order cases, the entire treatment could be completed
tooth movements (Lawrence F Andrews using ‘straight’ archwires. Andrews stated that
termed these as the primary bends). It is straight wires in progressively larger dimensions
difficult to make these bends precisely for take the treatment close to the treatment
affecting the exact amount of tooth objectives, but in many cases would require some
movement. Hence, if precise tooth guidance wire bending in the final archwires to fine tune
the results. The analogy he gave was of reaching (which he described as fully programmed
some destination far away. You need not walk brackets) had the following features:
all the distance. The straight wire appliance is 1. Every tooth type had a specifically designed
like an airplane that takes you to the nearest bracket, which had precisely builtin
airport quickly and effortlessly. Final wire angulations and inclinations to eliminate the
bending is like walking the last few kilometers. second and third order bends. The magnitude
Deficiencies in the conventional edgewise of angulations and inclinations for different
bracket design, and how they are overcome in teeth (‘prescription’ values in degrees) were
the ‘straight wire brackets’ derived from his study of normal occlusion.
The conventional edgewise brackets are 2. Unlike in the conventional edgewise brackets,
identical for all the teeth except some mesiodistal in which the slots are perpendicular to the
width differences. However, different teeth have vertical edges of the bracket, the slots were
different relative prominences, angulations and cut at an angle to the vertical edges for
inclinations. This necessitates giving first, second attaining the built-in angulation in the
and third order bends in the archwire. bracket. This obviated the need to rotate the
1. Bracket base is perpendicular to the brackets for angulating them.
faciolingual axis, and the slot is cut parallel 3. The bases of the brackets were inclined (the
to the facio-lingual axis. This leads to angle of inclination precisely matching the
targeting the bracket slots to different inclination of the facial plane of the respective
inclinations and occlusogingival levels. When crown at the FA point) in order to effect the
placed on different teeth with varying torque needed for the particular tooth type;
curvatures, the latter may result in functional the bracket slots were not torqued within the
interferences. bracket body. In other words, the torque was
2. Because the bracket bases are not contoured built in the bracket bases and not in the face
occlusiogingivally, they can rock on the of the bracket. This made it possible to make
curved crown facial surfaces, which further the mid-transverse planes of each crown and
affect the slot inclination and occlusogingival bracket stem and slot, coincide, and also to
positions. Similarly, lack of mesiodistal base align the mid-transverse planes of all the
contour could lead to rocking of the brackets, crowns and bracket slots so that they
which will affect the rotational control. coincided with Andrews’ plane when the
3. Because the brackets are not angulated, teeth were correctly positioned.
second order bends in the archwire become 4. The thickness of the brackets stem was varied
necessary. Angulating the brackets according to the facial prominence of each
themselves does not solve the problem tooth, thus eliminating the need for the first
because of rocking potential of the bracket order bends. The bracket bases were made
base. such that the slot in every bracket was
4. Stems of equal prominence necessitate the perpendicular to the mid-sagittal plane of the
first order bends such as the bends required crown. This necessitated a built-in offset in
between the upper central and lateral incisors. the maxillary molar tubes or brackets.
Similarly, because the molar tubes or brackets 5. The bracket bases were contoured both
have no offset built-in, first order bends occlusogingivally and mesiodistally,
become necessary mesial to the molars. (compound contouring) according to the
Andrews rightly observed that what stands facial surface anatomy of each tooth type to
between the orthodontist and the teeth are the eliminate rocking of the brackets on the teeth;
brackets, and therefore the brackets should be since bracket rocking in the occlusogingival
designed and affixed on the teeth such that their direction would affect the built-in torque, and
planes should reflect the planes of the teeth bracket rocking in the mesiodistal direction
crowns. Hence he set about designing a new would affect the rotational control.
system of edgewise brackets (and a more precise Thus it became possible to use flat unbent
way of attaching them on the teeth. His brackets archwires in the appliance through most part of
the treatment. The treatment could be started with distance from the incisal edge or the cusp tip would
small diameter wires, which would flex in the cause variation of slot inclination depending on
brackets on malpositioned teeth. The resilient the crown heights of the same type but different
wires, while regaining their original shape and size teeth.
form, would correct the malpositions to some Lawrence F Andrews emphasized that the
extent. As one gradually moves to bigger accurate placement of the brackets was an
diameter archwires, they would progressively integral part of the straight wire appliance. He
align the teeth till a full size ‘straight’ archwire, suggested a bracket sitting procedure, which was
could passively fit in all the brackets. aimed at targeting the slot within two degrees
Two types of bracket configuration were and 0.5 mm of the precise placement over the
originally made available. The vertical edges slot site (This is the area on a tooth that would
were always parallel to the facial axis of clinical accept the bracket such that the bracket slot
crown, while the horizontal edges were would receive a ‘straight’ archwire passively
perpendicular to the vertical edges in the square when the tooth gets optimally positioned). He
type brackets and at a different angle in the demonstrated that most of the people are able to
rhomboid shaped or so-called ‘diamond’ - mark the midpoint of a line about 10 mm in
brackets. The latter type bracket became more length (a figure close to the length of facial axis
popular since the horizontal edges could be well of clinical crown of a maxillary central incisor)
aligned with the incisal edges. to the accuracy of within 0.5 mm. Further, they
Some other features called the convenience can also judge the parallelism of two or more
features meant for increasing the ease of the lines within the accuracy of two degrees. Hence
operator such as marking on the brackets to he reasoned that it should be possible for anyone
identify them, and gingival tie wings on the with average skill to draw with a pencil the facial
posterior teeth extended laterally for ease of axis of clinical crown of all the teeth, mark their
ligation were added to the brackets. Similarly, midpoints and align the midpoint of the base of
for comfort of the patients some features were each bracket with the facial axis point in such a
incorporated, as for example, the facial aspects way that the sides of the brackets are parallel with
of the incisor and canine brackets being curved the facial axis of clinical crown. This is done by
and parallel to the crown’s facial surface so as to placing the brackets on the crowns straddling the
reduce irritation to the lips. Some more features facial axis of clinical crown with the vertical
named auxiliary features such as power arms, components of the brackets (viz. the vertical
hooks, face-bow tubes, tubes for utility arches edges of brackets and the tie wings) parallel to
and rotation arms were also added. the facial axis of clinical crown and the horizontal
midpoint of the brackets equidistant from the end
VARIABLE BRACKET SITTING points of the facial axis of clinical crown. This
PROCEDURES: LAWRENCE F ANDREW’S would provide the accuracy needed in using the
REMEDY full potential of the fully programmed brackets.
Many authors earlier had suggested different
STRAIGHT WIRE APPLIANCE BRACKETS
landmarks for bracket locations on the teeth.
FOR DIFFERENT CLINICAL SITUATIONS
Lawrence F Andrews felt that the traditional
referents for angulation (long axis of the crown Andrews initially introduced brackets for the
or the tooth, incisal edges for incisors and cusp treatment of non-extraction cases, with an ANB
tips for other teeth, marginal ridges, contact differential of less than five degrees, which he
points, etc.) were neither reliable nor practical. referred to as the standard brackets.
Similarly, inclination referents viz. long axis of Subsequently he developed brackets for
crowns or teeth were unsatisfactory. extraction cases.
Additionally, the inclination of the bracket slots There was one standard (non-extraction)
at varying heights on these axis would vary bracket for every tooth except for the incisors,
because of the curvature of the facial surface. that had three, and the maxillary molars, that had
Thus, a location of the landmark at a specified two. The differing features were built-in
inclination for the incisor brackets and counter rotation and counter mesiodistal tip) to
angulations, and offset angles for the molars. All neutralize the buccal crown-tipping tendency.
other features remained the same. The upper and The additional (negative) inclination was four,
lower incisor inclinations were different for five and six degrees for minimum, moderate and
different skeletal types. For skeletal class I, class maximum translation. For mandibular molars,
II and class III, the upper central incisor only counter rotation and counter-mesio-distal
inclinations were 7, 2, and 12 degrees, the upper tip were added.
lateral incisor inclinations were 3, -2 and 8 The canine, premolar and molar brackets
degrees, and for all mandibular incisors the tubes acquired attached ‘power arms’ to move
inclinations were –1, 4 and –6 degrees, them in a bodily manner instead of permitting
respectively. For maxillary first molars, the any tipping (The usage of these was originally
angulation and offset were 5 and 10 degrees, for envisaged and the term originally coined by
class I molar finish occlusion, while these were 0 Calvin Case. Andrews retained the name in his
and 0 degree for class II molar finish occlusion. honor). The length of power arm was adjusted
The brackets for extraction cases were such that the amount of moment generated from
developed in a more elaborate fashion. Series of it, when added to the moment created by the
brackets were developed for different built-in angulation for counter tip, would equal
combinations of extractions, ANB differentials, the moment arising from application of the
and anchorage requirements. As the teeth are mesially or distally directed force on the tooth,
translated, they tend to tip mesiodistally and thus nullifying the latter.
rotate into the extraction sites since the force acts All these modifications were bound to create
at the brackets away from the center of resistance, an impression of the necessity of keeping a very
both in the lateral as well as occlusal perspectives. large inventory of brackets. However, Andrews
In addition to these tendencies, the maxillary argued that there are only 12 treatment plan
molars during translation also tend to tip during possibilities for each arch, which are met by a
translation on account of the drag created by the mixture of some standard and some translation
prominent lingual root. Hence the relevant brackets. Hence depending on one’s practice
existing features of the brackets were altered or requirements, one could keep the standard and
new features were added to counter these effects commonly required translation brackets in stock
to an extent that would overcorrect them. and order for the remaining as and when
Depending on the amount of translation required.
required, the built-in angulation for the canines
and premolars was varied. For teeth undergoing STRAIGHT WIRE APPLIANCE (SWA)
distal or mesial translation, 2, 3 and 4 degrees
Lawrence F Andrews made some interesting
were added to or subtracted from the
remarks when he introduced the straight wire
corresponding angulations of the standard
appliance to the profession. He was candid to
brackets for minimum (up to 2 mm), moderate
(2 to 4 mm) and maximum (4 to 6 mm) retraction admit that he did not consider the appliance as
respectively. This was meant for giving the the ultimate one (“Will there ever be one?”). He
counter mesiodistal tip. further emphasized that although he had his own
Anti rotation adjustments were built in the treatment philosophy and mechanics, his
extraction series to prevent the teeth from appliance was not meant to serve only his way
rotating into the extraction site. This was in the of treatment, but was for universal use to suit
form of deviation of the mesiodistal axis of the any philosophy and mechanics employing
slot from its normal (perpendicular to the edgewise brackets. He felt that his appliance
midsagittal plane) position by 2, 4 and 6 degrees could successfully treat about 90 percent of cases
respectively for minimum (less than 2 mm), leaving out the 10 percent of extreme cases
moderate (2 to 4 mm) and maximum (4 to 6 mm) (which would need surgical orthodontics).
retraction. As was mentioned earlier, the SWA did not
For maxillary molars needing translation, the gain universal acceptance instantly. Although
inclination values were altered (in addition to majority of the edgewise practitioners changed
over to some form of pre-adjusted edgewise as facial axis point). This is also not accepted by
appliance by eighties, there were some who these authors. Dellinger found it erratic and
voiced serious misgivings. Further, many inconsistent. Germane et al also questioned
researchers critically examined the concept of the Andrews’ contention that the facial surface
SWA, and found several flaws in the concept contour is more consistent when long axis. point
itself. The comments/observations of some of the is used to locate the brackets and that the
prominent critics is summarized below. clinicians can place the brackets within an error
The main drawback of the SWA is that it of ± 2 degrees torque.
overlooks biological variation in the anatomy of The colum angle, i.e. the angle between the
teeth of different individuals (this criticism long axis of crown and the long axis of root differs
would hold true for other versions of pre- from tooth to tooth and also for the same tooth
adjusted edgewise appliances also). Dellinger, in different persons. In class II division 2 cases
Vardiman, Lamberts, Germane and other have the central incisors have a more acute collum
discussed this aspect. They used more angle than that seen in class II division 1 cases.
sophisticated gadgets to study the crown surface Hence, even when crowns are correctly
curvatures (‘profile’) of different teeth. Dellinger positioned (which is difficult on account of earlier
used an optical comparator. Germane et al used mentioned reason) root placement will vary.
magnified projections of the X-ray pictures of Teeth with more acute collum angle will be
extracted teeth for making the measurements. placed closer to the palatal cortical plate in some
Dellinger argued that the basic data should have cases even pressing against it. What effect the
been collected from individuals having variation in root placement will have on the
malocclusion and not from ideal occlusion casts health of the teeth or stability of the results is not
as was done by Andrews. known yet.
One of the important features of SWA (and Different vertical growth patterns have
other pre-adjusted edgewise appliance) is the different inclines of occlusal plane with respect
torque built in the brackets, which ideally should to the cranium. The inclination value of the
eliminate third order bends in the archwire. A maxillary incisors are preadjusted with respect
uniform torque value in the bracket slots for any to the occlusal plane. While the angle of U1 to
given tooth of all the patients is based on the SN remains almost same in all groups, that
premise that individual teeth of any given type between U1 to OP varies in high, average or low
(e.g. right upper central incisors or left mandibular plane angle cases. Hence, a uniform
mandibular second premolars, etc.) in all the built-in torque value for all the patients would
patients would exhibit identical curvatures of place the upper incisors in positions other that
facial surfaces. Only then, at a particular height optimum in high or low angle case. The upper
on any type of tooth (e.g. at the facial axis point) incisors would be placed more upright or more
brackets with properly contoured bases would proclined respectively in these cases. Such cases
fit in identical manner. The above mentioned would require different torque values for correct
authors have challenged this axiom. According placement of these teeth.
to them this curvature could vary by as much as Dellinger made a scathing attack on SWA. He
5.2 0 to 10.40 for teeth with low variation and stated, “Clinicians are being saved not by what
12.80 to 25.60 for teeth with high variations. Such the SWA does but by what it does not do” (since
variations are bound to affect the torque values less than full size wires are used). And further
in most of the individuals. Therefore, use of “If full sized unbent archwires are placed in the
prescribed bracket torque value may improve mouth and are allowed to totally work out, the
care in some patients but not the others. results would be erratic, inconsistent and
Treatment must be tailored to the biologic clinically unacceptable”.
variation presented by each patient. This implies There is at least some truth in this comment
that the third order bends will be often required because Andrews stated, in his interview
in most of the patients. published few years later after the above criticism
Andrews had laid great stress on the appeared, that his preference is for 0.022 brackets
consistency of the long axis point (later renamed and that the largest wire he uses in these brackets
is 0.018" X 0.025" (He does not use full size wires, article of Ross et al that summed up neatly the
not even the NiTi wires). place of SWA in modern orthodontics. “The
Schudy also made comments similar to straight wire appliance should not be
Dillinger- “Placing a lot of torque in the upper considered an inappropriate tool. It is an
incisor brackets and then never using it by not important step forward in orthodontic
filling the brackets is an admission that it is not mechanotherapy that has maximum
right for some of the patients”. He also pointed effectiveness on average or good skeletal
out the possibility of abuse of the appliance by patterns. It is clear that the concept of ‘one
the general dentists. “It (the SWA) does not place appliance fits all’ defies normal biologic
the teeth in their proper position automatically variation among orthodontic patients. Hence,
as it allegedly is supposed to do. It provides an skilled orthodontic care is still needed in spite
easy way for the general dentist to try to do of technologic advances”.
orthodontics, believing that it automatically Whatever inventions have occurred from his
produces good results” (JCO Aug 92). time to till date in orthodontics is purely on the
Perhaps a balanced view of the basis of Andrews Angle’s keys to normal
contradictory opinions can be found in the occlusion.
Evolution of
• Brackets – Lewis Bracket • Manufacturing of Archwire

– Metal Brackets – Steiner Bracket • Methods of Straightening of
– Plastic Brackets – Broussard Bracket Orthodontic Wires

– Ceramic Brackets – Lang Brackets
• Properties of Archwire
– Weldable Brackets – Jaraback – 1963
– Pseudoelastic Effect
– Bondable Brackets – Roth – 1976
– Thermoelastic Effect
– Ribbon Arch Brackets • Bands – Strength of the Wire
– Modified Ribbon Arch/
• History of Archwires – Formability
Brackets in Begg Technique
– Gold – Solubility And Weldability
– Tip Edge Brackets
– Stainless Steel – Friction
– Edgewise Brackets
– Nickel–Titanium Alloys – Environmental Stability
– Preadjusted Edgewise
– Beta–Titanium or TMA or Can – Shape Memory Effect
Brackets
Wire • Auxiliaries
– Lingual Brackets
– Cobalt-Chrome-Nickel Alloy
– Self-ligating Brackets • History of Orthodontic Materials
– Optiflex Archwire
– Single Width Bracket – Use in Dentistry
– Multistrand Archwires
– Twin Brackets – Uses in Orthodontics
Man has long enhanced his appearance. Evidence Despite all this evidence and experimentation,
dates back some 3000 years. Archaeologists have until the 1700s the most aesthetic though not
discovered mummified remains with crude metal effective appliance remained the finger. The
bands wrapped around individual teeth with French surgeon, Pierre Fauchard the “Founder of
catgut thought to have been used to apply forces. Modern Dentistry” described procedures for
Later in 400-500 BC, Hippocrates and Aristotle aligning the teeth, including: filing them,
both considered ways to straighten teeth. The manipulating them with forceps, and then tying
Etruscans were using appliances to maintain them with thread to a silver or gold “bandeau”.
space and prevent collapse of the dentition; while A contemporary of Fauchard, Etienne Bourdet,
in a Roman tomb in Egypt, a researcher found a dentist to the King of France, went a step further
number of teeth bound with a gold wire, the and recommended the extraction of first premolars
original ligature wire. At the time of Christ, to maintain symmetry of the jaws. He also used
Aurelius Cornelius Celsus first recorded the the first and more aesthetic lingual appliances.
treatment of malaligned teeth using finger The discovery of vulcanite, when combined
pressure. with gold wire springs and screws, allowed the
Evolution of Orthodontic Appliances 107
use of removable appliances to induce individual 1. Weldable brackets

tooth movement. By 1937, the discovery of acrylic 2. Bondable brackets
had allowed translucent acrylic plates to replace III. Depending on technique for which they are
black vulcanite. used
1. Ribbon arch brackets
Edward H Angle (1855–1930), the “Father of
2. Begg modified ribbon arch brackets
Modern Orthodontics” developed the first
3. Tip-edge bracket
widely adopted system for correcting
4. Edgewise brackets
malocclusions using brackets soldered to the
5. Pre-adjusted edgewise brackets
labial of metal bands. Thus the Edgewise system
6. Lingual brackets
was born.
BRACKETS AND BANDS Metal Brackets
Until the early 20th century, 14 to 18 carat gold • Metal brackets (Fig. 12.1) are routinely used in
was the principle metal used for constructing orthodontic practice of which steel brackets
orthodontic brackets and bands. However, with are the most frequently used.
the metallurgical developments of World Wars I • Titanium brackets are recently introduced
and II appropriate forms of stainless steel became and have high biocompatibility and low
available. The introduction of stainless steel
friction.
allowed the development of progressively
smaller appliances. The road to smaller Advantages of Metal Brackets

appliances had begun and it was significantly
accelerated with Buonocore’s direct bonding of a. They can be sterilised.
resin to enamel and Newman’s use of epoxy resin b. They can be recycled.
in 1965 to directly bond brackets to the labial c. They resist deformation and fracture.
surface of teeth. d. Exhibit less friction with the arch wire.
e. They are comparatively less expensive.
BRACKETS
• Brackets are passive components which Disadvantages
provide a means of transferring tooth-moving
a. Easily noticeable, metallic brackets are
forces from archwires, elastics and other
aesthetically not pleasant.
active components of fixed orthodontic
b. They may corrode and cause staining of the
appliance.
teeth.
• They can be welded to the bands which are
then cemented onto the teeth (weldable
Plastic Brackets
brackets). Bondable brackets being
increasingly used in recent years, although Plastic brackets (Fig. 12.2) initially made from
weldable ones have to be opted in some cases. acrylic and later from injection moulded poly-
• Brackets manufactured from a variety of carbonate, were introduced in the 1970s. They
materials are available and they can be of promised significantly enhanced aesthetics;
various designs suitable for different
orthodontic techniques.
Brackets can be classified in a number of ways
as listed below:
I. Depending on material used for manufacture
1. Metal brackets
a. Gold
b. Stainless steel
c. Titanium
2. Plastic brackets
3. Ceramic brackets
II. Depending on mode of attachment Fig. 12.1: Metal brackets
Fig. 12.2: Plastic brackets A
unfortunately, problems of staining, odour, time-

dependent creep, and breakage soon became
apparent. Permanent deformation, or creep,
occurs when a material is subjected to a constant

load over an extended period. It is particularly

important for thermoplastic materials such as
polycarbonate and polyurethane resins.
Compensation for the lack of strength and
rigidity is reinforcement with ceramic or
fiberglass fillers and/or metal. This has
improved their popularity. B
Plastic brackets made of polycarbonate and
Figs 12.3A and B: Ceramic brackets
other related materials were introduced to
improve aesthetics. However, they are not
preferred as they have a number of difficulty in debonding the brackets. These
disadvantages such as: problems are being overcome and the brackets
1. They tend to get discolored easily especially now offer quite an aesthetic alternative to
in patients who smoke or drink coffee, tea, stainless steel. Transparent and opaque tooth
etc. colored ceramic brackets are available and are
2. They have poor dimensional stability generally made of alumina or zirconium based
3. Their slots tend to distort products.
4. There is a high amount of friction between
plastic bracket and metal archwire. Advantages
1. They are highly a esthetic not easily
Ceramic Brackets noticeable.
Ceramic brackets (Figs 12.3A and B) were first 2. Resist discoloration unlike plastic brackets
introduced in the 1980s. There are two basic forms; 3. Dimensionally stable, do not distort in oral
monocrystalline, which is almost transparent; cavity
and polycrystalline which is tooth colored.
Disadvantages
Offering better aesthetics than either stainless
steel or polycarbonate; they also exhibit good 1. They are very brittle and thus tend to fracture
resistance to wear and deformation, as well as easily during active treatment and also while
color stability. However, they have problems debonding.
when compared to stainless steel brackets 2. Exhibit greater friction at wire/bracket
including greater frictional resistance, bracket interface than metallic brackets
breakage, iatrogenic enamel damage, and 3. High cost of material.
Fig. 12.5: Bondable brackets

Figs 12.4A and B: Weldable bracket
Weldable Brackets (Figs 12.4A and B)

• They are either welded or soldered to the band
which is then cemented over. The weldable
brackets have metal flanges on the base to
facilitate welding.
Bondable Brackets (Fig. 12.5)
• They are directly bonded onto the teeth using Fig. 12.6: Ribbon arch brackets
bonding adhesives
• Base of these brackets generally exhibit
meshwork or indentations to facilitate
bonding with the adhesive material.
Ribbon Arch Brackets (Fig. 12.6)
• Ribbon arch brackets had a simple design with
occlusally facing vertical slot in it
• They were used in ribbon arch technique.
Modified Ribbon Arch/Brackets in Begg

Technique (Fig. 12.7)
• Begg technique uses modified ribbon arch
brackets in which the vertical is facing
gingivally rather than occlusally
• This modification allowed easy tipping of the Fig. 12.7: Modified ribbon arch/brackets in Begg
teeth. technique
Fig. 12.10: Preadjusted edgewise brackets
Fig. 12.8: Tip edge bracket

Fig. 12.11: Lingual brackets
Fig. 12.9: Edgewise brackets
Tip Edge Brackets (Fig. 12.8) Preadjusted Edgewise Brackets (Fig. 12.10)
They are used in tip-edge technique. The bracket They are modified edgewise brackets with in-built
design is a modification of the conventional tip, torque angulations incorporated in their
Edgewise bracket where two diagonally opposite design.
corners of the conventional edgewise bracket slot
are removed and a vertical rectangular slot is also Lingual Brackets (Fig. 12.11)
added.
Lingual brackets are arguably the most
aesthetic, appliance of all as they are placed on
Edgewise Brackets (Fig. 12.9)
the lingual aspect of the teeth. Despite being
Edgewise brackets and their modifications becomes made of stainless steel they are virtually
the mainstay in orthodontic practice today. They invisible to the casual observer. Unfortunately
are employed in edgewise technique. Most these appliances are generally considered to be
Edgewise brackets have rectangular horizontal slot more time consuming to both place and adjust,
with four wings, two gingival and two occlusal. and therefore attract a significant premium in
The rings help securing archwire in the slot and cost over conventional labial brackets and are
brackets may also have hooks for attaching initially more uncomfortable than labial
auxiliaries such as elastics. They are available as a brackets. Consequently fewer patients are
set of different brackets for different teeth. attracted to them.
Fig. 12.13: Vertical Slot Lewis bracket

Fig. 12.12: Self-ligating brackets
Self-ligating Brackets (Fig. 12.12)

Self-ligating brackets were first popularized in the

1980s, one of the earliest being the speed system.
They are more aesthetic as they have a much

smaller labial “footprint” than other stainless steel
brackets of the day and no longer require the use
of either steel or elastomeric ligature ties.
Stainless steel self-ligating brackets have been Fig. 12.14: Tooth that is badly rotated, the wing in the direction
of the rotation can be removed. The bracket can then be
shown, in-vitro, to have the lowest static and positioned properly, with the remaining wing serving to rotate
kinetic frictional forces. Polycarbonate self- the tooth into proper position
ligating brackets generate significantly greater
static and kinetic frictional forces than stainless
steel self-ligating brackets but are comparable to
conventional stainless steel brackets. • Decreased amount of archwire, Interbracket
span and resiliency
Single Width Bracket • Closing loop archwires
• Narrow width - ineffective tooth rotation. • Second order bends
• Angle - gold eyelets - on the orthodontic
bands. Lewis Bracket
• Two brackets - single tooth. Lewis bracket is wedge shaped bracket, which
Twin Brackets places the tie wing close to the tooth occlusally
and further away gingivally.
• Two edgewise brackets on a common base.
• ‘Siamese twin bracket’ by Swain Vertical Slot Lewis Bracket (Fig. 12.13)
• Space between two brackets is 0.050 inch, • A vertical slot 0.020 × 0.020 inch.
which 0 equal to the width of one bracket. • Uprighting springs - correct axial inclinations
Advantages
Additional Benefit
• Rotational control : mainly by deflection of arch
wire For tooth that is badly rotated, the wing in the
• Positive control direction of the rotation can be removed (Fig.
12.14). The bracket can then be positioned
Disadvantages
properly, with the remaining wing serving to
• 10 percent play of archwire rotate the tooth into proper position
Fig. 12.17: Joseph Johnson introduced twin arch

appliance
Fig. 12.15: When a Lewis or Steiner bracket is completely

tied into a cuspid, there is a tendency to flatten the curvature

of the archwire
Fig. 12.18: Oren A Oliver introduced labiolingual appliance
Lang Brackets (Fig. 12.16)

• By Dr Howard Lang
• Placed in large, round surfaced teeth-
Fig. 12.16: A Lang bracket avoids this effect, while
maxillary and mandibular cuspids.
retaining the rotation wing capability
• Contoured so that bracket fits beautifully on
most cuspids.
• When a Lewis or Steiner bracket is completely
Steiner Bracket (Fig. 12.15)
tied into a cuspid, there is a tendency to flatten
• Flexible rotation arm. the curvature of the archwire.
• The flexibility arms gives a rotational effect . A Lang bracket avoids this effect, while
retaining the rotation wing capability.
Broussard Bracket
Later Modifications
• Graffard Broussard modified edgewise bracket
• 0.0185 × 0.046 inch vertical slot • Burstone modified canine bracket - a vertical
• II accept a doubled 0.018 inch auxiliary wire tube - retraction assemblies.
• Edgelock bracket and Hanson speed

appliance bracket:
• These brackets eliminate the need for ligature
ties as they possess self-ligating mechanism.
In 1938 Joseph Johnson introduced twin arch
appliance (Fig. 12.17)
In 1940 Oren A Oliver introduced labio-
lingual appliance (Fig. 12.18)
Holdaway – 1952 Fig. 12.19: Self-ligating bracket
Angulated brackets on the teeth adjacent to

extraction spaces aid in:
• paralleling the roots .
• setting up posterior anchorage.
• obtaining correct axial inclinations or ‘artistic
positioning’ of the teeth.
John J Stifter – 1958

• U S patent - designing an edgewise bracket

comprising a male and female component
Ivan Lee – 1960
Torqued slots - regional and basic edgewise
bracket. To eliminate - adding torque - anterior
portion of the upper archwire. Manufacturers –
1960: raised the base of lateral incisor. Raised
Fig. 12.20: Peter C Kesling
bases eliminated the need for lateral offset bends.
Jaraback – 1963
• Appliance in position. It is impossible to
Described the use of torqued brackets position the teeth precisely into occlusion.
• Andrews Straight Wire Appliance - 1970 • After appliance removal, the teeth will shift
• Two varieties. slightly.
• The standard prescription for non extraction
cases and ‘Translation series’ for extraction Self-ligating Brackets
cases .
• Self-ligating brackets (Fig. 12.19) don’t need
• Limitations of conventional Straight Wire
tie wires or elastic ligatures to hold the
bracket
archwire onto the bracket. They are held on
• Moving teeth apex first generates maximum
by a “trap door” built into each bracket.
anchorage resistance
• As early as 1935, the idea of a self-ligating
• Torque control - unwanted reciprocal torque
brackets began to take shape.
reaction in adjacent teeth
• Over the years many designs were patented,
• Full expression of torque not achieved-
but few were commercially available until
“Torque slop” due to play between bracket
Ormco created the edgelock system in 1972.
and arch wire
• Nowadays, we have a number of self-ligating
Roth – 1976 choices, such as Orec’s speed braces, Ormco’s
Damon system, GAC’s In-Ovation, and
• Bracket set up containing modifications of tip,
Adenta’s Evolution.
torque and rotations.
• Purpose of Roth - over corrected tooth Peter C Kesling (Fig. 12.20) decided to combine
positioning. both the techniques. He modified a straight wire
bracket, to create tip edge bracket and differential Table 12.1: The stainless steel strips are available in
force technique. In this technique initial crown different widths and thickness to suit different teeth
tipping was done followed by controlled root Teeth Band Thickness Band Width Figure
uprighting with straight arch wires (differential (Inches)
tooth movement with straight arch wires).
Therefore it is known as the “differential straight Incisor 0.003 0.125
Canine 0.003 0.150
arch technique”. Archwire slot permits initial
Premolar 0.003 0.150
crown tipping mesially or distally and faces
Molar 0.0050.006 0.0180.018
horizontally, the slot and bracket are termed
Kesling determined that: • It orients the archwire slot to relative to the
• It is necessary for each tooth to tip either facial surface of each tooth on the model.
mesially or distally but not in both directions
• All teeth tip distally except those distal to the BANDS
extraction sites, which tip mesially
• Anchor molars should remain upright Bands (Fig. 12.21) are passive components that
throughout Rx. provide space for fixing various attachments onto
• Diagonally opposite corner were removed the teeth. They are generally made of soft stainless
steel. The stainless steel strips are available in
• Permits desired distal crown tipping

• Preadjusted in three dimensions- different widths and thickness to suit different
• tip, torque, in and out built in teeth (table 12.1). Weldable brackets, buccal tubes
• Slot size - 0.022" × 0.028 and other auxiliary attachments are soldered or
welded over the bands, which are then cemented
Alexander – 1983 around the intended teeth.
Vari–simplex discipline: Availability
• Vary - variety of bracket types used;
• Simplex - KISS principle (Keep it Simple Sir) 1. Custom-made bands are fabricated using band
Discipline was chosen rather than the materials which are available in the form of
appliance. spools.
• Based on edgewise philosophy 2. Preformed seamless bands are available in
different sizes which can be directly cemented
Creekmore – 1993 around the tooth. Preformed bands are
increasingly being used in recent years.
Slot machine onies solution to the
• Inaccuracies of bracket placement, ARCHWIRES
• Anatomic and biologic variations, over
correction for tissue rebound and relapse and History of Archwires
• Mechanical differences of preadjusted By the 1960s, gold as an archwire had largely been
edgewise orthodontic appliance replaced. It gave way to thinner, more resilient
stainless steel wires such as Wilcox’s Australian
wire. However, in 1974, Unitek patented its nitinol
(Nickel Titanium Naval Ordnance Laboratory)
wire having the lowest modulus of elasticity and
most extensive deactivation range of any
equivalent cross sectional wire of the time. This
allowed the application of light forces over a
protracted range. By 1986, “superelastic” alloy
wires that undergo stress induced change in their
crystal form had been developed. These offered
significant advantages over nitinol. The range of
Fig. 12.21: Bands wires available to orthodontist has been futher
extended by the addition of various other elements temperature. At the annealing temperature,
(Table 12.2) including cobalt-chromimum. Beta- atoms become mobile enough to move about
titanium and, in 1994 copper. Copper NiTi and thereby get relieved of some of the internal
changes its crystal form at a specific temperature. stresses, which had been introduced during
Most recently, a nickel free wire, titanium-niobium rolling. When the metal cools down, the grain
has been introduced. With these new wires, structure is seen to be uniform.
especially the super elastic wires, it is no longer 3. Drawing: This is the final step, wherein this
necessary to incorporate multiple loops, small cross section wire is further drawn into
significantly enhancing aesthetics as well as its final size. This is a more precise step in
comfort. which the wire is pulled through a small hole
A number of manufacturers now offer NiTi in a die. The hole is slightly smaller than the
and stainless steel archwires coated with tooth starting diameter of the wire; so that the wall
colored material to enhance their aesthetics, is squeezed uniformly from all sides as it
especially when combined with ceramic brackets. passes through. The cross section of the wires
Unfortunately, these coatings tend to wear away are the same as the die.
with time; however, further research should see
this resolved. Methods of Straightening of Orthodontic Wires
The search for improved aesthetics is leading Following are the two methods of straightening
us down the road of fiber reinforced composites. of wires;

These materials are not yet clinically useful as 1. Spinner straightening.

archwires; however, they have been incorporated 2. Pulse straightening.
into bis-GMA ribbons and bonded, as strips, to 1. Spinner straightening: In this type of
multiple teeth, to provide retention and also straightening, the wire is pulled through a
anchorage, reducing the number of conventional bronze roller, which torsionally twist the
brackets required. wires. However, this mode does not produce
wires as mechanically efficient as the the ones
Manufacturing produced by ‘pulse straightening’.
Disadvantages: Disadvantages of spinner
The manufacture of metal alloy wires involves straightening are as listed below
making an ingot followed by rolling and drawing: • Deformation
1. Making the Ingot: This involves pouring of • Decreased yield stress value.
molten metal into a mold. The result obtained 2. Pulse straightening: This is a recent and more
is the cast wire to produce an ingot. A accepted method of straightening of wires,
magnified view of this ingot shows crystals or which employs special machines to straighten
grains; it is mainly this grain structure, which wires which lead to:
ultimately controls the significant mechanical • Maintenance of the yield strength
properties of the final wire. Grain formation • Smooth finish, which would be also,
depends on the rate of cooling and the size of beneficial as it produces less friction.
the ingot. Pulse straightened wires have superior
2. Rolling: The formed ingot is rolled into a long qualities in comparison to spinner straightened
bar. This is done with the help of a device wires as shall be discussed in the following section
termed as the roller. During rolling, the on stainless steel.
individual grains retain their identity
throughout this process. Each grain gets Basic metallurgy: At this juncture, it is mandatory
elongated proportional to the ingot. The to understand briefly the metallurgical properties.
squeezing and massaging actions of roller 1. Metal: According to the Metals Handbook
increases the strength by causing the grains to (1992); a metal is defined as ‘an opaque
mesh and interlock. The rolling procedure is lustrous chemical substance that is a good
continued till the crystals are so locked that conductor of heat and electricity and, when
they can no longer adjust. At this point, the polished is a good reflector of light’.
rolling is interrupted and the metal structure 2. Alloy: An alloy is defined as ‘a metal containing
is annealed by heating it to a suitable two or more elements, at least one of which is
a metal, and all of which are mutually soluble • Because of this, the strength values could be
in the molten state’. altered by the phenomenon of either work
3. Alloy system: ‘An alloy system is an aggregate hardening or heat treatment. This could be either
of two or more metals in all possible beneficial (for example: the formation of ‘dead’
combinations’. ligature wires) or could be deleterious (properties
of a wire may be lost during soldering
Metallic Bonds and Crystalline Structure procedures) and should be kept in mind.
Metallic bonds imply the primary ionic interaction, Solidification of Metals
which holds the metal structure. Atoms with free Liquid state: The liquid or ‘molten state’ represents
valence electrons as the metal atoms are able to a multitude of random atoms or molecules
lose their outer shell (valence) electrons and form surrounding numerous unstable atomic
a positive ion. The free electrons are able to move aggregates. This can be seen in the solidification
about in the metal space lattice and they are termed curve as shown in the:
as an ‘electron cloud’. The electrostatic attraction If a metal is allowed to cool, it first cools down
between the positive ions and the electron cloud uniformly (as shown by the portion A-B). After this
forms the ‘metallic bond’. there is a gradual increase in temperature (till B),
It is this metallic bond that is responsible for also known as the latent heat of solidification. The
luster, conductivity properties and ability of the portion below the fusion temperature (B-B’) is
metal to deform plastically.
termed as super cooling. It is during this period

A regular crystalline configuration is typical that the crystallization of the metal begins. This
for metals. This is referred to as ‘space lattice’ or takes place around ‘nuclei’; also termed as embryos.
‘crystal’ (grain). B-B1 → Super cooling
The common lattice configurations are: Tf → Fusion temperature
1. Simple cubic.
2. Body-centered cubic or ‘BCC’, e.g. austenite This nucleus formation can either be homog-
NiTi. enous or heterogeneous. This eventually leads to
3. Face-centered cubic or ‘FCC’, e.g. austenite ‘grain’ or crystal formation. It is at the Grain bound-
SS. ary that the areas of lattice imperfections can exist.
4. Body-centered Tetragonal ‘BCT’, e.g. Lattice Imperfections and Dislocations
martenisitc SS.
As would have been seen in the solidification of
5. Close packed Hexagonal, e.g. martensitic
metals:
NiTi.
• Crystallization does not occur in a uniform
It can be inferred from the above examples that
manner and some lattice positions may be
the lattice configurations (in turn, the grain
‘vacant’ or ‘overcrowded’. These are termed
structure and their orientation) play a significant
as “lattice imperfections”. Dislocations are
role in determining the ultimate mechanical
defects along a particular path in a
properties.
polycrystalline structure. e.g. edge dislocation.
Cast versus Wrought Metals • Dislocations tend to build up at grain
• Generally, all metals and their alloys originate boundaries, greater stress is required to
from castings. A cast metal which is produce greater slip. Thus, the material
plastically deformed, either by machining or becomes stronger, harder and less ductile. This
working, is termed as a wrought metal. is termed as the phenomenon of ‘strain
• Cast structures are close to equilibrium hardening’ or ‘work hardening’.
conditions and are incorporated in some • The ultimate result of strain hardening is
dental applications. However, the orthodontic fracture.
wires are in the wrought form. Wrought metals Heat Treatment
have a fibrous structure with extremely
elongated crystals. Also this structure exhibits Heat treatment is the thermal processing of an
enhanced mechanical properties like increased alloy for a length of time above room temperature
tensile strength and hardness. but below its solidus temperature.
Quenching: A process wherein the metal is cooled through the medium of brackets and welded
rapidly from an elevated temperature. buccal tube on the palatal aspect of the molar
The Heat treatment procedures are carried out bands.
for the following reasons:
Gold
a. Preservation of a phase at room temperature,
which is stable usually at higher Before 1950’s, gold and other precious alloy
temperatures. combinations like platinum and palladium with
b. Rapidly terminate a process that only occurs gold and copper were routinely used for
at elevated temperature. orthodontic purposes. Gold and gold alloy
archwire exhibit excellent formability,
Types of Heat Treatment
environmental stability and biocompatibility.
1. Stress relief: This refers to a ‘low’ temperature Angle’s Ribbon arch appliance utilized a gold
heat treatment to relieve the stresses due to platinum alloy combination as the ‘archwire’.
strain hardening. Cobalt-chromium alloy is However, their popularity lost ground due to two
very responsive to stress relief. It also, improves main reasons:
ductility. a. The marginal properties and cost factor
2. Annealing heat treatment: This employs a involved.
heat treatment at a substantially higher b. Advent of stainless steel or the ‘rust free’ alloys.
temperature as compared to the stress relief.

Consists of three phases: Stainless Steel

i. Recovery. Stainless steel (Fig. 12.22) was introduced by
ii. Recrystallization. Wilkinson in 1929. Stainless steel archwire (Table
iii. Grain growth. 12.2) exhibit adequate strength, high resilience,
3. Age hardening heat treatment: It is a long term formability, high stiffness, biocompatibility and
process in which the temperature is slightly economic feasibility.
lesser than the anneal temperature. The metal The drawback of these archwires includes
is then cooled rapidly by quenching. high modulus of elasticity; more frequent
PROPERTIES OF ARCHWIRE activations are required to maintain the same force
level.
Different types of archwire, right from gold to till
date invention in archwire, are explained below Nickel-titanium Alloys (Fig. 12.23)
with their properties.
Archwires are one of the active components of Nickel titanium alloyl also known as nitinol,
fixed orthodontic appliances, which when used (Nickel titanium Naval Ordnance Laboratory)
bring about various tooth movements (tipping, was invented by William R Buchler at Naval
bodily, torque, rotational and vertical movements) Ordnance Laboratory. The main advantage of this
Table 12.2: Classification of archwires

I. Based on material used
1. Gold and gold alloys
2. Stainless steel
3. Nickel-titanium alloys
4. Beta-titanium
5. Cobalt–chromium- nickel alloys
6. Optiflex archwires
II. Based on cross-section
1. Round
2. Square
3. Rectangular
4. Multistranded Fig. 12.22: Stainless steel
braided or twisted and may have three strands or

six strands. The main advantage of these arch
wires is that they exhibit increased flexibility.
Physical Properties of Wire

The first group of properties is concerned with
the elastic behavior which represents the internal
stress/strain in the wire. This is produced by an
external force deflecting the wire, the stress being
the internal load and the strain the internal
distortion.
1. Stiffness/Springiness
Fig. 12.23: Nickel-titanium alloy
i. Pseudoelastic effect: When an austenitic wire
is placed in the mouth and deformed by
alloy over others is the high elasticity and shape forcing it into the misaligned brackets, the
back memory. The drawback of these archwires is pseudoelastic effect is induced. This
that they cannot be neither welded nor soldered, transforms the austenitic alloy into a
and cannot receive bends or loops or helices. martenstic state which, as the teeth align,
Various phases of NiTi, like the austenitic-active, gradually reverses to the austenitic state.
with pseudoelasticity and the latest being ii. Thermoelastic effect: Martensitic-active alloys
superelastic Cu-NieTi were brought out. Other are stable at room temperature, but when
varieties like martensitic active alloy or raised to mouth temperature, the material
thermoelastic NiTi alloy also evolved. The credit changes into an austenitic state which exhibits
for introducing the superelastic NiTi goes to Fujio shape memory.
Miura and to Dr Rohit Sachdeva for introducing iii. Martensitic stabilized alloy (e.g Unitek’s original
Cu-NieTi. nitinol): The alloy, introduced in 1970 by
Beta-titanium or TMA or Can Wire Andreasen.
It is stabilized by introducing a certain amount
Goldberg and CJ Burrstone invented beta-titanium
of work hardening during processing and does
and it is also known by TMA or CAN wire. The
not show true memory shape properties.
main advantage of these arch wires include high
Austenitic-active Alloy: “Active “ means that it
range of action, high spring back, receive bends,
exhibits the shape memory, in this case of the
loops and helices, and they can be welded or
soldered. pseudoelastic type, the shape memory effect
being induced by stress distorting the arch
Cobalt-chrome-nickel Alloy wire in malaligned teeth. Examples of
Cobalt- chrome-nickel alloy is also known as superelastic Niti are Titanol from Forestadent
elgiloy. These wires exhibit excellent formability, and Nitinol SE from Unitek.
joinability, spring back and biocompatibility. Martensitic-active Alloy: Again this exhibits
shape memory, but of the thermally activated
Optiflex Archwire variety. This alloy is stable at low temperatures
Optiflex archwire was invented by MF Talass in but when is placed in the mouth, and the
1992. Optiflex archwires are composed of clear temperature increased to mouth temperature,
optical fibers and are therefore highly aesthetic. it exhibits the shape memory effect. Examples
The drawback of these archwire is that they cannot of thermally activated Niti are Neo Sentalloy
receive sharp bends. from GAC and Nitinol XL from Unitek.
Multistrand Archwires 2. Range of Deflection – Spring Back
Multistranded archwires are made up of number The range of wire is the distance it will bend
of thinner wires. They can be round or rectangular, elastically before permanent deformation occurs.
If the wire is deflected beyond its yield point, it b. Heat, as in the thermoelastic effect in the
will not return to its original shape. Martensitic-active alloy where the transition
temperature is between room and mouth
3. Strength of the Wire
temperatures.
The strength of a wire is important because it
determines the maximum force it can deliver. AUXILIARIES
The above three properties are related by the
formula: strength = stiffness X range. Brass wire was initially used to ligate the arch
wire to the band/bracket combination. However,
4. Formability by the 1960s, the thinner and more aesthetic
This is the amount of permanent deformation a stainless steel had replaced it as the ligature tie of
wire can withstand before it breaks. choice. The advent of polyurethane materials has
seen the introduction of aesthetic colored
5. Solubility and Weldability
elastomeric modules to ligate the arch wire to the
Stainless steel can be soldered and welded, but bracket. While offering good aesthetics when
NiTi cannot. Miura recently reported a method initially placed these modules are prone to
of soldering nickel-titanium wires. TMA is discoloration and breakdown over time and so
weldable as described by Burrstone. must be regularly replaced. They also tend to
6. Friction increase the friction between the bracket and the

archwire. Nevertheless, their ease of placement

The laboratory understanding of friction is not
relevant to the clinical situation. Because every and appeal to younger patients has ensured their
time the patient bites together, the tooth is liable general use.
to move a small distance in all three planes of The latest innovation to the orthodontist’s
space. More important is the concept that the two aesthetic armamentarium is the sequential clear
components, bracket and wire, may damage each plastic aligner. The principles of this process were
other as they moved across their surfaces. This is actually developed by kesling in 1945. However,it
borne out by the fact that it is difficult to slide did not achieve more widespread use until
teeth with ceramic brackets along a wire, as the invisalign combined the technique with 3D
abrasiveness of the ceramic notches the surface computer graphic and CAD/CAM technology to
of the metal. allow phased movement of multiple teeth to correct
7. Environmental Stability mid to moderate malocclusions. Since invisalign
appeared a number of other companies have
Any material used for the construction of wire released similar products, including an
must be stable in the oral environment. This has Australian company, Clear Smile. Unfortunately,
been one of the limitation aesthetic. these appliances are not suitable for treating all
8. Shape Memory Effect malocclusions. Those with significant crowding
or spacing, and/or interarch discrepancies (such
The shape memory effect exhibited by the more
as Class II and III relationships) often cannot be
recent nickel-titanium wires has revolutionized
the selection of wires for appropriate tooth treated properly with these systems alone.
movement. The wires manufactured for Similarly, individuals with very short crowns and
orthodontic purposes are composed of an alloy younger adolescents where teeth are not fully
of nearly equal parts of nickel and titanium. The erupted are generally not suitable. Although some
shape memory effect is brought about by a change extraction treatments are being carried out they are
in the internal crystal formation from the not normally as suitable as non-extraction cases.
martensitic phase with a hexagonal crystal Precise alignment and finishing with these systems
structure to or from the austenitic phase with a can be more difficult compared to traditional fixed
cuboids crystal structure (Kusy, AJO Sep 1991). appliances so that a compromise result may need
The shape in crystalline structure can be to be accepted. Further, they are still somewhat
brought about by either: visible on the labial surface and over the incisal
a. Stress, as in the pseudoelastic effect in the edges. However, clear aligners are considerably
Austenitic Active Alloy. more aesthetic than traditional braces.
HISTORY OF ORTHODONTIC MATERIALS chemists worldwide try to find a substitute for

this natural polymer of isoprene (C5H8)n. Success
Baptized with a name resulting from the
occurred in 1910 when Karl Dietrich Harries, in
contraction of the words “elastic” and
Germany, polymerized with the help of sodium
“polymer”, elastomer is an umbrella term which
(Na), 2,3 dimethyl Butadiene. This rubber
encompasses materials which resist distortion
substitute, which received the name Buna, was
and resume their original shape or volume.
followed by the invention of Buna-S (S standing
Classified according to their chemical structure,
for styrene) by K Ziegler in 1927. In the U S, a
however, materials which are not necessarily
sulfur-substituted elastomer was invented by J C
flexible are still called elastomers.
Patrick in 1930, and produced under the name
Their resilience has been exploited since anti-
Thiokol. The next year, a chlorine-substituted one,
quity. A century and a half after Fauchard’s use
invented by F J A Nieuwland and W H Carothers,
of silk, the first elastomer, rubber, allowed the
was launched by Dupont Company under the
upgrade of simple ties to gradual movements.
name Duprene (name changed today to
This started for rubber a career which was not
Chloroprene or Neoprene).
challenged for another century.
Otto Bayer invented polyurethanes, in
Returning from Columbus’ second voyage,
Germany, in 1937. While the latter may not
Michele de Cuneo reported in 1495 the strange
represent a major category of elastomers for the
custom “Indians” have to milk trees (latex means

general use, these most interesting for
milk in Latin). In 1521, Hernando Cortes reported
orthodontics. In the recent years, polyurethanes

that Aztecs use this coagulated and dried milk
have become increasingly important due to
to make balls for game and to waterproof textiles.
advances in telechelic polymers (from tele,
In 1750, Francois Fresneau was the first to describe
distance, and chele, claw, in Greek). These
the tree which is now known as Hevea brasiliensis.
polymers (especially polyols) contain reactive
The tree was called by the indigenes caa (tears)
end groups which can be used to further increase
ochu (wood), i.e. the tree which sheds tears. This
their molecular weight (mw), or to generate other
gave in French its current name, “caoutchouc”.
copolymers with a wide range of properties.
Its name in English came from the famous scientist
Usually, as the molecular weight). Increases, the
Joseph Priestley who described the material in
more valuable are the polymers.
1770 as “excellently adapted for wiping from
The above series of discoveries has led to a
paper the marks of a black lead pencil”, in other
diminished share of consumption for natural
words, a good ”rubber”. A similar product is gutta
rubber (only 35% among all elastomers). Not only
percha, extracted from another tree, Pallaquium
that the plantations in Southeast Asia are both
gutta, which grows in Southeast Asia.
expensive to maintain and subject to weather
The first attempt to commercialize the new
conditions, but the substitutes prove to be better
material were deterred because it softened when
and by far more versatile.
heated and was partially soluble in water. It was
not until 1839 when Charles Goodyear
Use in Dentistry
accidentally discovered “sulfur cross-linking”
that rubber became a substitute for the omnipresent While maxillofacial prostheses were described by
plastics. Ambroise Pare’ (1517-1590), their massive use
Soon, rubber became precious, and Brazil was was determined by the two world wars. While the
fast to monopolize it. Henry Wickham elastomers used years ago were mainly vinyl
succeeded, however, in smuggling the nuts of the plastisols (plasticized polyvinyl chloride), today
tree to England. Starting 1976, England developed polyurethanes, as such or modified with acrylics,
large rubber plantations in Ceylon (Sri Lanka) and and silicone rubbers (HTV, high temperature
Malaya (Malaysia, Indonesia). An invention with vulcanized) are preferred.
important consequences was that of J Dunlop After minor uses of elastomer, in the making
who, in 1888, invented the pneumatic tires for of dams, cups, points, special filling materials
bicycles. The extension of this idea by the (gutta percha), a major impact was prompted by
burgeoning industry of automobiles made the spread of AIDS. This has led to a new
assessment of the cross-infection procedures, in impressions have a limited life, even if kept in
which gloves were essential. Their routine wearing “humidors”.
during treatment became mandatory in the U S Elastics, elastomeric auxiliaries recalled by the
following OSHA’s regulations and FDA’s alert of famous Case-Angle controversy (Angle attributed
March 1991. their first use to Baker, instead of Case), the first
Among the elastomeric impression materials use of intermaxillary elastics has been
used in large amount are the polysulfides, the documented to date as early as 1880. Initially used
“addition” and “condensation” polysiloxanes, to exert interarch forces, today elastics are used to
and the polyethers. All of these are identified by close spaces within the arches, hold archwires in
the American Dental Association (Specification brackets and act as force-delivery systems for
19) as “non-aqueous elastomeric dental retraction, protraction, tipping, intrusion,
impression materials”. extrusion and rotation.
The advantage of these elastomers is related Natural rubber, the first elastomer used for
to their hydrophobicity, which renders them both
such purposes, has lost considerable ground in
accurace and physically and chemically stable.
the last years. Due to proprietary “secrets”, it is
Polyethers are less water repellent and therefore
difficult to make a correct estimate. The chemical
less dimensionally stable in the presence of
nature of the elastomers used is often withheld,
humidity. This reflects also on their
as are some characteristics like the thermal
biocompatibility, since these are not inert and can

behavior (thermoset vs thermoplastic). At the
lead to tissue irritations whenever the material is

left in the sulcus. Likewise, “condensation” recent A A O Annual convention in Denver, none
polysiloxanes are less accurate due to reasons of the exhibitors selling gloves knew the material
which we will examine later. these were made of (the alternative was “latex” or
“non-latex”).
Uses in Orthodontics Polyurethanes are now preferred due to their
superior properties such as biocompatibility, better
In addition to the elastomers generally used in
dentistry, some particular uses and tensile and tear strength, and higher elasticity
developments are specific to orthodontics. Thus, modulus and abra-sion resistance than the best
while water-based alginates are used in dentistry natural rubber. A review of their properties has
for study and record models, in orthodontics these been recently published. Unfortunately, all
are the preferred impression materials. A similar elastomers lose 50 to 70 percent of their initial
case is that of composites, which are used in force during their first day of application, and after
dentistry as restoratives, filling materials, onlays three weeks, only 30 to 40 percent of it is left6. To
and inlays, while in orthodontics, as adhesives. compensate for this diminished force, stronger
Alginates the insoluble salts rather than elastics have to be used. To prevent possible
polymers, alginates are of low cost, convenient damage, these are prestressed in advance to 50 to
and enough accurate for most orthodontic 100 percent of their length. Unfortunately, this
operations. Their advantage resides in a gel leads to a lack of certitude when it comes to know
structure which can resume its shape when the the force applied.
impression is made over undercuts. Succeeding Functional appliances used as early as 1902
the agar-agar impression materials (colloidal for Robins’ monobloc, Vulcanized rubber was for
suspensions in water which can be reused), long time the only material available for functional
alginates is commonly classified as “irreversible appliances. Tooth positioners, bite planes, chin
hydrocolloids”. Both before and after gelation, cups, oral screens, wedges, cushions and elastic
alginates are altered by heat and water: in water straps can all be made of elastomers. As it will be
presence, these materials expand: in its absence, shown, that some feels soft or hard is just a matter
they contract (syneresis). As a result, alginate of cross-linking which is adjustable as needed.
History of
Model Analysis
13
• Carey’s Analysis • Alignment (Crowding), Space – Long Method

– Procedure Analysis – Problems
– Inference – Principles of Space Analysis • Total Space Analysis—1978

• Pont’s Index • Arvey Peck, Sheldon Peck— – Anterior Area
– Drawback of Pont’s Analysis 1972 – Middle Area

• Linderharth Index • Huckaba’s Analysis – Posterior Area
• Korkhaus’ Analysis • Hixon and Old Father • Wylie
• Howe’s Analysis—1954 Method—1958 – Commenting on Model
– The Procedure • Marvin M Tanaka, Lystle E Analysis
• Bolton’s Analysis Johnston in 1974 • Kesling Model Analysis
– Procedure – Short Method—Tanaka- • Martinek Analysis
– Determination of Overall Johnson – Comparative Analysis of
Ratio – Procedure in the Maxillary Arch Howes, Rees, Kesling and
– Determination of Anterior – Modifications Strayer
Ratio • Nance Analysis • Suwannee Luppanapornlarp
• Cast Analysis: Symmetry and – Procedure for Mandibular • 3d Model Analysis
Space Arch—1976
Orthodontic diagnosis and treatment planning is diagnostic aids such as cephalogram and OPG
done by taking into consideration the tooth and hence diagnostic value of such independent
material, skeletal and muscle balance and growth model analysis is questionable.
potential. Among the various decisions taken, an Model analysis provides us with valuable
important decision is the one taken for or against information and when it is correlated with other
extraction of certain teeth to achieve the desired diagnostic aids will help us in diagnosing and
results. Model analysis is one of the essential planning treatment for a case. Among other
diagnostic aids. Study models help us to benefits, model analysis provides a means of
visualize the patient’s occlusion from all aspects evaluating the amount of space required for
and also help us in making the necessary proper alignment of teeth; by allowing accurate
measurements of the teeth and the dental arches assessment of Arch length—Tooth material
and basal bone. Most of the model analysis discrepancy. Various methods of model analysis
suggested by various authors does not correlate have been described and appropriate analysis
the findings of model analysis with their must be selected for a given case.
History of Model Analysis 123
CAREY’S ANALYSIS material excess, which can be managed by

proximal stripping.
Arch length—Tooth material discrepancy is one
2. Extraction of second premolar: If the discrepancy
of the important causative factors of
is 2.5–5 mm. second premolar may need be
malocclusion. Carey’s analysis is aimed at extracted.
determining the extent of the discrepancy. 3. Extraction first Premolar: If the discrepancy is
Carey’s analysis is performed on the mandibular more than 5 mm, then extraction of first
cast. If the same analysis carried out on the premolar is advised.
maxillary arch, then it is called as Arch Perimeter
Analysis. PONT’S INDEX
Procedure Pont in 1909, proposed a method of

predetermining the ideal arch width which has
1. Determination of arch length: The arch length become to be known as Pont’s index. However,
anterior to the mandibular first molars is he felt that the method of measuring teeth to
measured using a 0.012 inch soft round brass determine arch width was not the only factor to
wire which adapted to the model of the consider in orthodontic treatment planning. He
mandibular arch so that one end engaged first also stressed the assessment of facial profile,
permanent lower near the marginal ridge. determination of Angle classification,
The wire is next passed over the buccal cusps relationship of upper and lower jaws to one
of the premolars, then over the normal cuspal another and the midline as important essentials
position of the cuspid, then over the anterior to be considered.
teeth at ridge center and finally around the Pont devised a method of predetermining an
same course on the opposite side, ending in “ideal” arch width based on the mesiodistal
the mesiobuccal line angle of the lower first width of the crowns of the maxillary incisors.
permanent molar of the other side. The wire Pont suggested that the ratio of combined
is cut at this point and straightened, and the incisor to transverse arch width (as measured
length is recorded. from the center of the occlusal surface of the
• In case of proclined anteriors, the soft teeth) was ideally 0.8 in the bicuspid area and
round brass wire is passed along the 0.64 in the first molar area. He also suggested
cingulum of anterior teeth. that the maxillary arch can be expanded 1 to 2
• In case of retroclined anteriors the soft mm more during treatment than the ideal to
round brass wire is passed labial to the allow for relapse. In recent years there has been
anterior teeth. an unfortunate revival of the use of the Pont’s
• In case of well aligned anterior teeth, the index in a most sloppy manner. Its only occlusal
guide Researchers at the University of
wire passes over the incisal edges of the
Washington applied the pont’s index to patients
anterior teeth.
who had undergone complete orthodontic
2. Determination of arch width/tooth material:
treatment and were out of retention for at least
Tooth material is determined by measuring
10 years. No permanent teeth had been
the mesiodistal width of the teeth anterior to
extracted in any of the patients. They found very
the first permanent molars (incisors, canines
poor correlations between the combined
and premolars) at the maximum contour
maxillary incisor width and the ultimate arch
using bow divider.
width in the bicuspid and molar areas, and
3. Determination of the discrepancy: The
concluded that measuring the mesiodistal width
discrepancy refers to the difference between
of incisors to predetermine maxillary bi-molar
the arch length and tooth material.
and inter bicuspid width is of no value.
Mandibular arch form and mandibular inter-
Inference
canine diameter have been repeatedly found to
1. Non-extraction case: If the discrepancy is 2.5 be more reasonable treatment guides for both
mm or less, it indicates minimal tooth mandibular and maxillary ultimate arch width
than the Pont’s index. It’s of little use in rational shaped dental arches. He concluded that due
treatment planning. consideration must be given to the shape of the
In an interesting prelude to the index itself, Pont skull in assessment of arch form and width.
noted that the mesiodistal width of the maxillary
central and lateral incisors could be used to predict LINDERHARTH INDEX
the mesiodistal width of the maxillary canines in
Linder Harth G in 1961, on a study on Rhineland
normal dental arches. He sugested that half the
population proposed index values of 85 and 64
mesiodistal diameter of central plus the mesiodistal
rather than Pont’s values of 80 and 64.
diameter of lateral would generally, equal the
mesiodistal width of the canine. Pont did not
KORKHAUS’ ANALYSIS
indicate the size of the sample used to determine
the proposed index, but did state that they were of Korkhaus used Linder Hart’s measurements and
French nationality only. introduced a third measurement from the
For each normal dental arch, he suggested midpoint of the inter premolar line of upper arch
that a constant relationship existed between the to a point incision between the incisal edges of
width of four upper anterior teeth and the width upper central incisors. For a particular width of
of the dental arch in premolar and molar area. incisors there is a specific value of the distance
All his measurements and predictions were from the incision to the interpremolar line
related to the maxillary arch and did not include according to Korkhaus.
an assessment of the mandibular arch. If the perpendicular distance from

Pont determined a constant ratio between interpremolar line is more than ideal, then the
1. The width of the four maxillary incisors anterior teeth are proclined, if it lesser than the
2. The width of the maxillary arch as measured ideal then the teeth are retroclined.
from the center of the occlusal surface of the
first premolars and first molars. In the ideal HOWE’S ANALYSIS—1954
dental arch he concluded that the ratio of
Howe devised a formula for determining whether
combined incisors width to transverse arch
the apical bases could accommodate the patient’s
width was 0.8 in the premolar area and 0.64
teeth.
in the molar area.
In orthodontic procedure Pont suggested that
The Procedure
the maxillary dental arch should be expanded
one or two millimeters more than that found in Tooth material (TM) equals the sum of the
normal occlusion to allow for relapse. mesiodistal width of the teeth from the first
permanent molar forward. Premolar diameter
Drawback of Pont’s Analysis (PMD) is the arch width measured at the top of
the buccal cusps of the first premolars. Premolar
JA Stifter in 1958, tested Pont’s analysis in ideal
diameter to tooth material ratio (PMD:TM) is
and normal class I dentitions. Cases with
slightly slipped contacts, minor rotations and obtained by dividing the premolar diameter by
insignificant deviations from perfect occlusion the sum of the width of the 12 teeth.
were used, but were considered in a group Premolar basal arch width (PMBAW) is
separately from ideal sample, a significant obtained by measuring, with the bowed end of
correlation existed between the combined the boley Gauge, the diameter of the apical base
maxillary incisors widths and the inter molar on the casts at the apical of the first premolars.
and inter premolar width. No corresponding The ratio of the premolar basal arch width to
correlation was found for normal group. The tooth material (PMBAW:TM) is obtained by
sample consisted of French nationalities. Hence dividing the premolar basal arch width by the
Pont’s index universal validity is questionable sum of the width of the 12 teeth.
and analysis does not taken into consideration Basal arch length (BAL) is measured at the
and the alignment of teeth. midline from the estimated anterior limits of the
Hotz in 1961, suggested that deviations from apical base to a perpendicular that is tangent to
Pont’s index may be related to long and narrowly the distal surface of 2nd molar. The ratio of BAL
to tooth material (BAL:TM) is obtained by dividing second permanent molars are measured and
the arch length by the sum of the width of the 12 summed up.
teeth. 2. Sum of maxillary 12 teeth: The mesiodistal
Howe’s believed that the premolar, basal arch width of all the teeth mesial to the maxillary
width (he called it the canine fossa diameter) second permanent molars are measured and
should equal approximately 44% of the summed up.
mesiodistal width of the 12 teeth in the maxilla 3. Sum of mandibular 6 teeth (anteriors): The
if it is to be sufficiently large to accommodate all mesiodistal width of all the teeth mesial to
the teeth. When the ratio between basal arch the mandibular first permanent premolars
width and tooth material is less than 37%. are measured and summed up.
Howe’s considered that to be a basal arch 4. Sum of maxillary 6 teeth (anterior): The
deficiency necessitating extraction of premolars. mesiodistal width of all the teeth mesial to
If the premolar basal width is greater than the the maxillary first permanent premolars that
premolar coronal arch width, expansion of the is maxillary anteriors are measured and
premolars may be undertaken safely. summed up.
Since this method was introduced, rapid
palatal expansion has came into more common Determination of Overall Ratio
use and clinicians have more opportunity to alter
According to Bolton’s study, the sum of

the apical base itself.
mesiodistal width of the mandibular teeth

Howe’s analysis is useful in planning
anterior to second permanent molars is 91.3% of
treatment of problems with suspected apical base
the mesiodistal width of maxillary teeth anterior
deficiencies and dividing whether to 1) extract
to the second permanent molar.
teeth 2) Widen the dental arch or 3) expand
rapidly the palate. Sum of mandibular 12 100
Overall Ratio =
Mandibular apical base distance is more Sum of maxillary 12
critical than that of maxillary. In the authors
opinion Howe’s analysis is more logical and
Inferences
superior to the pont’s Index because the Howe’s
analysis is applicable to each arch and has been If the ratio is less than 91.3%, then it indicates
represented as an aid to thoughtful diagnosis and maxillary tooth material excess.
planning while the Pont’s index is often used as Amount of maxillary excess is determined by the
a rigid rule and an illogical excuse for not formula,
extracting. Sum of mandibular 12 × by 100
Sum of maxillary 12 =
91.3
BOLTON’S ANALYSIS
If the ratio is more than 91.3%, then it indicates
Bolton’s analysis gives significance to tooth size. mandibular tooth material excess.
According to Bolton, there exists a ratio between Amount of mandibular excess is determined by
the mesiodistal widths of maxillary and the formula,
mandibular teeth. Malocclusion occurs when
Sum of mandibular 12 × 91.3
there is disparity between the mesiodistal Sum of mandibular 12 =
dimensions of maxillary and mandibular teeth. 100
Bolton’s analysis helps in determining
disproportion in size between maxillary and Determination of Anterior Ratio
mandibular teeth.
According to Bolton’s study, the sum of mesio-
distal widths of mandibular anteriors should be
Procedure
77.2% of the mesiodistal width of maxillary
1. Sum of mandibular 12 teeth: The mesiodistal anteriors. The anterior ratio is obtained by the
width of all the teeth mesial to the mandibular formula,
Sum of mandibular 6 × 100

analysis using the dental casts is required for this
Anterior Ratio = purpose.
Sum of maxillary 6
Principles of Space Analysis

Inferences
Since malaligned and crowded teeth usually result
If the ratio is less than 77.2%, then it indicates from lack of space, thus analysis is primarily of
maxillary tooth material excess. space within the arches. Space analysis requires
Amount of maxillary excess is determined by the a comparison between the amounts of space
formula, required to align them properly.
Sum of mandibular 6 × 100 • Analysis can be done either directly on the
Sum of maxillary 6 = dental casts or by computer after appropriate
77.2
digitization of the arch and tooth dimensions.
If the ratio is more than 77.2%, then it indicates
• Dental cast analysis is two dimensional.
mandibular tooth material excess.
• If a computer method is preferred, it is easier
Amount of mandibular excess is determined by
and more practical to use an office copying
the formula,
machine to obtain a 2-D usage of the occlusal
Sum of mandibular 6 × 77.2 view of the dental casts, then digitize from that.
Sum of maxillary 6 =
100 • A readable and surprisingly accurate image

can be obtained by simply placing the casts
CAST ANALYSIS: SYMMETRY AND SPACE on the center of the copying machine,
avoiding the edges of its image area, where
An asymmetric position of an entire arch should distortions often appear.
have been detected already in the facial/esthetic • Whether done manually or computerized, the
examination. An asymmetry of arch form also first step in space analysis is calculation of
may be present even if the face looks asymmetric. space available. This is accomplished by
A transparent ruled grid placed over the measuring arch perimeter from the 1st molar
upper dental arch and oriented to the palatal to the other over the contact points of
raphe can make it easier to see a distortion of posterior teeth and incisal edge of anteriors.
arch form. Asymmetry within dental arch, but There are two ways to accomplish this.
with symmetric arch form, also can occur. It 1. By dividing the dental arch into segments that
usually results either from lateral drift of incisor
can be measured as straight line approxim-
or from drift of posterior teeth unilaterally. The
ations of the arch.
ruled grid also helps in seeing where drift of teeth
2. Or by contouring a piece of wire (or a curved
has occurred. Lateral drift of incisors occurs
line on computerize screen) to the line of
frequently in patients with severe crowding,
occlusion and then straightening it out for
particularly if a primary canine was lost
measurement. The 1st method is preferred for
prematurely on one side. This often results in
manual calculation because of its greater
the permanent canine being locked out of the
reliability.
arch while the other canine is nearly in its normal
Second step is to calculate the amount of
position with all the incisors shifted laterally.
space required for alignment of teeth. This is
Drift of posterior teeth is usually caused by early
done by measuring the mesiodistal width of each
loss of a primary molar, but sometimes develops
tooth from contact point to contact point and then
even when primary teeth were exfoliated on a
summing the width of the individual teeth. If
normal schedule.
the sum of the widths of the permanent teeth is
greater than the amount of space available, there
ALIGNMENT (CROWDING), SPACE ANALYSIS
is an arch perimeter space deficiency and
It’s important to quantify the amount of crowding would occur. If available space is larger
crowding the arches, because treatment varies than the space required (excess space), gaps
depending in the severity of crowding. Space between some teeth would be expected.
Space analysis carried out in way is based on The primary sources of facio lingual tooth size
two important assumptions data for the incisors have been skeletal material
1. Anteroposterior of the incisors is correct. (i.e. and extracted teeth and not plaster casts.
incisors are neither excessively protrusive nor The index proposed for clinical orthodontics
retrusive. utilizes an MD/FL ratio. It’s constructed in the
2. The space available will not change because following manner.
of growth; neither assumption can be taken
MD crown diameter in mm
for granted. Index = × 100
It must be remembered that incisor protrusion is FL crown diameter in mm
relatively common and that retrusion though Mandibular incisors of two groups of young
uncommon, does occur. There is an interaction female Caucasian adults from North eastern
between crowding of tooth and protrusion of region, i.e. Boston were studied.
retrusion. • One group was designated as group with
• If the incisors are positioned lingually, this perfect mandibular incisors alignment, while
accentuates crowding but if the incisors the other was designated as the “Control
protrude, the potential crowding will be at population group”. The members of both
least partially alleviated. sample were all within same age range
• If there is not enough room to properly align (17-27 years).
the teeth, the result can be crowding, • For each subject in both groups, the
protrusion or some contribution of the two. maximum mesiodistal (MD) crown diameter
For this reason, information about how much and the maximum FL crown diameter were
the incisors protrude must be available from measured directly in the mouth. The
clinical examination to evaluate the results of mandibular central incisors of the group with
space analysis.
perfect alignment has a mean MD/FL index
The second assumption, that space available will
of 88.4 with a SD of 4.3
not change during growth is valid for adults but
• The mandibular lateral incisors of the groups
may not be for children. In a child with a well
with perfect alignment had a mean MD/FL
proportioned face, there is little or no tendency
for the dentition to the displaced relative to the index of 90.4 with a standard deviation of 4.8.
jaw during growth, but the teeth often shift • Take the lower incisor measurements in a
anteriorly or posteriorly in a child with a jaw sequence beginning with the four MD
discrepancy. For this reason, space analysis is less measurements, right lateral incisor to left lateral
accurate and less useful for children with skeletal incisor followed by four FL measurements,
problems (Class II, Class III, long and short face) left lateral incisor to left lateral incisor.
than in those with good facial proportions. • Male-female differences in MD/FL indices
Even in children with well proportioned for the mandibular incisors appear to the
faces, the position of the permanent molars below clinical significance.
changes when primarly molars are replaced by
premolars. If space analysis is done in the mixed HUCKABA’S ANALYSIS
dentition it is necessary to adjust the space
• It uses both study casts and radiographs for
available measurement to reflect the shift in
determining the width of unerupted tooth.
molar position that can be anticipated.
• It is necessary to compensate for enlargement
ARVEY PECK, SHELDON PECK—1972 of radiographic image. This can be done by
measuring an object than can be seen both in
It has been shown that naturally well aligned radiograph and on the cast. A simple propor-
mandibular incisors possess distinctive dimensional tional relationship can then be established as
characteristics; these teeth are significantly smaller
follows;
mesiodistally and significantly larger facial-
lingually when compared with average population Actual width of primary molar (X1)
=
tooth dimensions. y molars (X2)
Apparent width of primary
combined width of the maxillary cuspid and

Actual width of unerupted premolar (Y1)
bicuspids.
nerupted premolar (Y2)
Apparent width of un c. Compute the amount of spee to left in the arch
for molar adjustment by subtracting the
X1 × Y1
OR Y 1 = estimated cuspid and bicuspid size from the
X2 measured space available in the arch after
This can be used for both arch groups. alignment of the incisors. Record these values
for each side. From all the values now
HIXON AND OLD FATHER METHOD—1958
recorded, a complete assessment of the space
They examined the dental casts and periapical situation in the mandible is possible.
radiographs of 41 children in the mixed dentition
and the casts of the same children taken Procedure in the Maxillary Arch
following the eruption of canines and premolars.
Utilizing a 16 inch target film distance they found The procedure is similar to that for the lower
a weak correlation between the mesiodistal arch, with two exceptions: 1) A different
widths of the primary and permanent teeth. The probability chart is used for predicting the upper
correlation coefficient between the sum of the cuspid and bicuspid sum. 2) Allowance must be
widths of mandibular permanent incisors and made for overjet correction when measuring the
that of mandibular permanent canines and space to be occupied by the aligned incisors.
Remember width of the lower incisors is used to
premolars measured on the casts, was similar to

reported by other authors. The strongest predict upper cuspid and bicuspid widths.
correlation was between, on the one hand, the It is good practice to study the radiographs
sum of the width of the central and lateral when mixed dentition analysis is done in order
incisors in one quadrants, measured on the casts to note absence of permanent teeth, unusual
added to the sum of the width of the two malpositions of development, or abnormalities
premolars in the same quadrant, measured on of crown form. For example, mandibular 2nd
radiographs and on the other, the sum of the premolars sometimes have two lingual cusps,
width of the canines and premolars after their when they are so formed, the crown is larger than
eruption. From these results the authors devised might be expected from the probability chart;
a table for prediction of mesiodistal width of therefore a higher predicator value is used.
unerupted canines and premolars.
Modifications
MARVIN M TANAKA, LYSTLE E JOHNSTON
IN 1974 A technique for mixed dental analysis that
compensates nicely for radiographic
Dental casts of 506 orthodontic patients in enlargement of tooth images in periapical films
Cleveland area were obtained from the is available. Its based on the assumption that
Orthodontic Department of Case Western the degree of magnification for a primary tooth
Reserve University School of Dentistry. To be will be the same as that for its underlying
included in the study, patients had to be of permanent successor on the same film.
probable European ancestry and less than 20 1. Measure the width of the primary tooth on
years old.
the X-ray film (Y1) and the width of its
underlying permanent successors (X1) on the
Short Method—Tanaka-Johnson
X-ray film.
A shorter but less precise method has been 2. Measure the primary tooth (Y) directly in the
developed which is of merit, but does not allow mouth or on the dental cast. The width of
for sexual dimorphism with equal accuracy. the unerupted permanent totoh (X) can then
a. Add the width of the mandibular incisors and be calculated by simple mathematical
divide by two. proportion
b. To the value obtained add 10.5 mm to predict X : X1 = Y : Y1 or X = X1Y / Y1
the combined widths of mandibular cuspid X/X1 = Y/Y1
and bicuspids and 11.0 mm to predict the X = X1Y/ Y1
Inaccuracy in radiographic tooth size 3. Many have presumed than to have an

measurements is not dentist fault. It occurs accuracy that is not present in any of the
because the developing tooth are not always methods yet developed.
placed exactly at right angles to the central ray, None of Mixed Dentition Analysis are as precise
therefore, the radiographic image of the tooth, as one might like, and all must be used with
when slightly rotated or tipped, is significantly judgment and knowledge of development.
larger than the actual size of the tooth. Mandibular incisors have been chosen for
Ballard and Wylie 1947, conducted an measuring since they are erupted into the mouth
investigation to evaluate the assumption that early in the mixed dentition, easily measured
there is harmony in tooth size in any one accurately and are directly in the midst of most
individual that is, if the incisors are larger than space management problems.
average, the canines and premolars and molars Maxillary incisors are not used in any of the
are also correspondingly larger than average.
predictive procedures, since they show too much
They examined the casts of 441 individuals
variability in size and their correlations with
who had permanent incisors, canines, premolars
other groups of teeth are of lower predictive
and 1st molars fully erupted.
value. Therefore, the lower incisors are measured
They developed a predictive formula.
to predict the size of upper as well as lower
X = 9.41 + 0.527Y and
posterior teeth.
Which X = sum of mesiodistal width of

canines and premolars and Y = Sum of

mesiodistal width of mandibular incisors. Procedure for Mandibular Arch—1976
1. Measure with tooth measuring gauge, the
NANCE ANALYSIS greatest mesiodistal width of each of the four
Determined the space available in the arch mandibular incisors and record the values in
for unerrupted canines and premolars by mixed dentition analysis form.
measuring the mesiodistal width of primary 2. Determine the amount of space needed for
molars and canine as dental casts, and determined alignment of the incisors. Set the Boley gauge
the space required by measuring the mesiodistal to a value equal to the sum of the width of
width of the unerupted teeth on radiographs. the left central incisors and left lateral incisors.
He claimed that this assessment was accurate in Place the point of the gauge at the midline of
most cases. He also measured total arch length the alveolar crest between the central incisors
from mesial surface of one permanent first molar and set the other point along the line of the
to the other and showed that, in transition from dental arch on the left side. Mark on the tooth
mixed to permanent dentition, molar move or the cast the precise point where the distal
mesially on average 1.7 m in lower arch and 0.9 surface of the lateral incisors will be when
m in upper arch. aligned. Repeat this on the right side of the
Clinical judgment: arch. If the cephalometric evaluations show
• It’s not time consuming the mandibular incisors to be too far labially,
• It requires no special equipment or the Boley guage tip is placed at the midline
radiographic projections but moved lingually a significant amount to
• Although best done an dental casts, it can be simulate the expected uprighting of the
done with reasonable accuracy in the mouth. incisors as dictated by the cephalometric
• It may be used for both dental arches. evaluation.
Mixed Dentition Analysis have been misused in 3. Compute the amount of space available after
several ways: incisor alignment. To do this, measure the
1. They have been applied mechanically distance from the point marked in the line of
without proper regard for biologic dynamics the arch. To the mesial surface of the first
of a critical stage is dentitional development. permanent molar. This distance is the space
2. Naive assumptions have been made (e.g. A available for the cuspid and 2 bicuspids and
universal 1.7 mm late mesial shaft). for any necessary molar adjustment after the
incisors have been aligned. Record data for the arch perimeter need to be prevented for
both sides. molar adjustment and all the space can be
4. Predict the size of the combined widths of the made available for incisors, cuspids and
mandibular cuspid and bicuspids. bicuspids.
Perhaps the most severe termination of mixed
Long Method dentition analyzes is their inability to reflect the
position of the incisors with respect to the skeletal
Experienced clinicians may choose to use the 50%
profile. There are a number of crude rules of
prediction since it is a more precise estimate.
thumb for determining how much arch
Those who are inexperienced or without the use
perimeter deduction occurs for each degree or
of cephalometrics and a precision appliance
millimeter the incisor edge is changed in the
method would do well to proceed more
conservatively (i.e. use 75% level of prediction). cephalometric visualization of treatment. For
Prediction of the combined width of cuspid, example, one degree of tipping or 1 mm of lingual
first bicuspid and second bicuspid is done by use displacement of the mandibular incisal edge is
of probability charts. said to be equal to 1 mm of arch shortening on
The tables used herein are based on size each side.
variations and relationships in teeth. North
American whites and may or may not be valid TOTAL SPACE ANALYSIS—1978
for other ethnic groups. This analysis is developed by Levern Merrifield.

This method has divided the lower dental arch

Problems into 3 areas. Anterior middle and posterior to
A problem arises when considering the space left analyze the space requirement in the lower arch.
for molar adjustment. If this value in the chart is Measurement from study casts and cephalograms
negative, that is, the predicted sizes of 3, 4, and 5 are used in this analysis
are greater than the space left after the alignment
Anterior Area
of the incisors, then crowding will occur in the
arch even without any forward molar adjustment Space Required
when the first permanent molars are in an end
to end relationship (i.e. a flush terminal plane of • Measure width of mandibular incisors on the
the second primary molars, approximately 3.5 models and width of canine from radiographs.
mm of space (one half a cusp width) is required • Cephalometric correction for incisor position
to convert to a class I molars relationship. This is calculated according to Tweeds method.
needed 3.5 mm might be acquired, without FMIA is taken into consideration. The incisors
orthodontic intervention, in any of three ways are then repositioned and the difference is the
1. 3.5 mm more late mesial shift of the actual and proposed FMIA is determined.
mandibular first permanent molar than the The difference in angulations is multiplied by
maxillary. 0.8 mm to get difference in multi meters.
2. At least 3.5 mm more forward growth of the • Soft tissue modification: Upper lip is measured
mandible than the maxilla. from vermilion border of upper lip to greatest
3. Some combination of dental adjustment and curvature of labial surface of central incisor.
differential skeletal growth. Since we cannot The total chin thickness is measured from soft
yet predict accurately the amongst of tissue chin point to NB Line.
differential skeletal growth that will occur, • If lip thickness is greater than chin thickness
treatment planning must be based on dental the difference is determined and multiplied
adjustment factors. If differential skeletal by 2 and added to the space required. If less
growth occurs during this period, in the no modification is necessary.
molar relationship will result and the mixed • Measure Z angle of Merrifield and add the
dentition analysis prediction must be altered cephalometric correction to it. If corrected
accordingly. When there is class I molar angle is greater than 80°, the mandibular
relationships in mixed dentition, no part of incisor angulations is modified is necessary.
If the correlate angle is less than 75° additional b. Estimated increase: The increase is 3 mm per
uprighting of mandibular incisor is necessary. year, i.e. 1.5 on either side until 14 years of
age in girls and 16 years in boys.
Space Available Total space deficit: This is arrived by comparing
the space required and space available in
Measure space availability by using brass wire
anterior, middle and posterior. Thus we can
from mesiobuccal line angle of first primary
know where the discrepancy is present.
molar of one side to another.
WYLIE
Middle Area
Commenting on Model Analysis
Space Required
In the year 1959, Commenting on model analysis
• Measure mesiodistal width of first premolar methods point out “first of all, it is next to
as the cast and measure width of the impossible to measure bone dimension from
unerupted premolar from the radiographs. even the best plaster cast.”Teeth, yes with great
• Curve of occlusion: A flat object is placed on accuracy. But no one can arrive a reliable ratio
the occlusal surface of mandibular teeth without measuring the both components
containing the incisors and first molar. The accurately. As a matter of fact, only the procedure
deepest position between the flat surface is
of Howe’s Pretends to measure anything but

measured and occlusal surface of primary tooth-size and between teeth. Second, one over
molars was measured on both side. simplifies the problem when he Presumes that
Depth on right side + depth of left side + 0.5 mm crowding can be analyzed completely. When he
2 mm knows the size of teeth basal bone. But admits
that we cannot ignore the abundant Empirical
Space Available evidence that such procedures work, because
through trial and error, we have discovered the
Using brass wire measure from mesiobuccal line dimensions which we should accept as timing
angle of first primary molar to the distal buccal factor.
line angle of first permanent molar on either side.
KESLING MODEL ANALYSIS
Posterior Area
In the year 1945, he reported his analysis. Kesling
Space Required gave a method of analysis, which was so-called
a. Mesiodistal width of II and III molars is “diagnostic setup”. Aim of this analysis is to
obtained from radiographs as they might be determine the needs of reducing tooth material.
unerupted. If not visible Wheelers method is
MARTINEK ANALYSIS
used for calculation
X = Y-X1/Y1 Comparative Analysis of Howes, Rees,
Kesling and Strayer
X = Estimated width of 3rd molar
Y = Actual size if premolar 1 mandibular molar Martinek, in the year 1957, presented an
X’ = Wheelers value for 3 molars. interesting paper on comparing the analysis of
Y’ = Wheelers value for 1 molars. Howes, Rees, Kesling, Strayer on five treated
cases.
Space Available
SUWANNEE LUPPANAPORNLARP
Amount of space available consists of space
presently available on casts and estimated In the year 1993, Suwannee luppanapornlarp,
increase. studied the long-term comparative effects of
a. Space presently available; obtained by premolar extraction in clear-cut extraction and
measuring the distance on occlusal plane to non extraction class-2 patients. He concluded that
distal surface of I molar to anterior border of premolar extraction produced a significantly
ramus on lateral cephalogram greater reduction in hard and soft tissue protrusion
both treatments produced the mandibular mesial breakthroughs for tried and true practices. The
displacement—extraction significantly more than first time 3D modeling technologies were applied
non-extraction. However, at recall the two groups to the dental industry was in 1987 by Dr Mormann.
did not differ with respect to signs and symptoms The 3D modeling technology, at this point and
of dysfunction. time, allowed Dr Mormann to revolutionize the
reconstructive dental industry. Over the years,
3D MODEL ANALYSIS as 3D modeling technologies improved, the
In the current age, where today’s technological application became ever more revolutionary. Here
barrier is tomorrow’s technological breakthrough, is a partial list of currently available treatments
we are continuously reinventing industries, designed with the aid of 3D modeling software:
manufacturing and design practices and finding Bending ART system Invisalign® treatment,
innovative applications of new technological Suresmile process Orthocad, E-models, etc.
History of Cephalometrics 133
History of
Cephalometrics 14
• History Prior to the Advent of - Broca • Other Important Contributions

Radiography - Paul Topinard – Allan G Brodie
– Classifying Physiques - Ihering – Thompson and Brodie

– Measurements and – Margolis
• Cephalometric Radiography
Proportions – Wilhelm Conrad Roentgen – Wylie
– Renaissance to the – Wilhem Koening and Dr Otto • Cephalometric Analysis
Twentieth Century Walkhoff • Evolution of Cephalometrics
- Leonardo da Vinci – Van Loon • Patient Orientation
- Albrecht Durer – AJPacini and Carrera • X-ray Source Position
- Spigel – Atkinson • Film Position and Enlargement
- Pieter Camper – Simpson • Posteroanterior (Frontal)
- Deschamps – Dewey and Riesner Cephalometry
- Johann Friedrich
• Holly B Broadbent’s – Down’s Analysis
Blumenbach
Contribution – Steiner Analysis
- Anders Retzius
– Paul Simon – Tweed’s Triangle
- Thomas Huxley
– Charles Bingham Bolton – Wit’s Appraisal
Ever since God created man in his image, man Cephalometry had its beginning in
has been trying to change man into his image. craniometry. Craniometry is defined in the
Attempts to change facial appearance are Edinburgh encyclopedia of 1813 as “the art of
recounted throughout recorded history. The measuring skulls of animals so as to discover their
question of what is a normal face, as that of what specific differences”. For many years, anatomists
constitutes beauty, will probably never be and anthropologists were confined to measuring
answered in a free society. craniofacial dimensions using the skull of dead
Orthodontists, in their attempts to change individuals. Although precise measurements
facio-orodental deviations from accepted norms, were possible, craniometry has the disadvantage
have adopted cephalometric measurement, a for growth studies.
method long employed in physical anthropology. Cephalometry is concerned with measuring
With the introduction of roentgenography, it was the head inclusive of soft tissues, be it living or
inevitable that this procedure should be employed dead. However, this procedure had its limitations
as a medium for the purpose of roentgenographic owing to the inaccuracies that resulted from
cephalometrics. Cephalometric radiography was having to measure the skulls through varying
introduced into orthodontics during the 1930s. thickness of soft tissues.
With the discovery of X-rays by Roentgen in Sheldon’s temperamental components,

1895, radiographic cephalometry came into viscerotonia, somatotonia, and cerebrotonia,
being. It was defined as the measurement of head convey behavioral traits commonly associated
from bony and soft tissue landmarks on the with physique. With a seven-point scale for each
radiographic image (Krogman and Sassouni 1957). somatotype component, there is a wide
This approach combines the advantages of distribution in the dense midrange around the
craniometry and anthropometry. The disadv- 4-4-4 type; a close relation between somatotype
antage is that it produces two-dimensional image and temperament becomes tenuous.
of a three-dimensional structure. Nonetheless, common knowledge suffices to
recognize dominant behavioral trait in many
HISTORY PRIOR TO THE ADVENT OF
instances, and that information can be revealing
RADIOGRAPHY
about the people in general. It may also give some
Classifying Physiques clues relating to the orthodontic treatment by
providing an insight to the character of the
History prior to the advent of radiography
patients—their expectations concerning the
should begin with the mention of attempt of the
treatment’s contribution to their well being, even
scientists to classify the human physiques. In 500
their understanding and willingness to accept the
BC, the Greek physician and Father of medicine,
discipline of cooperation needed for successful
Hippocrates, designated two physical types —

conclusion of therapy.
habitus phithicus with a long thin body subject to
tuberculosis, and habitus applecticus— a short Measurements and Proportions

thick individual susceptible to vascular diseases
Early History—the Canons
and apoplexy. The search was continued by
Aristotle, Galen (200 AD) and Rostan (1828). Portrayal of human form demands not only
Rostan was the first to include muscle mass as a artistic talent and technical ability but also
component of physique. Viola’s (1909) disciplined and consistent style. To ensure these
morphological index recognizes three stipulations when images of royalty and deity
morphological types. Kretschmer (1921) adhered were commissioned and executed, the ancient
to the three Greek terms: the pyknic (compact), Egyptians developed an intricate quantitative
aesthetic (without strength), and athletic. system that defined the proportions of the human
Kretshmer also included dysplastic physique body. It became known as the Canon. The theory
which was taken up by Sheldon again in 1940. of proportions according to Panofsky is a system
The long historic thread extended into the of establishing the mathematical relations
twentieth century when Sheldon introduced his between the various members of the living
method of somatotyping, based on three creature, in particular of the human being. The
components of physiques, each rated on a seven mathematical relation can be expressed by the
point scale and expressed as a three digit number division of a whole as well as by the
called somatotype. It also included a rating of multiplication of the unit; the effort to determine
dysplasia in the five regions of the body. them could be guided by the desire for beauty as
“Dysplasia is literally bad shape or form. In well as interest in the norms, or finally by the
somatotyping, it refers to disharmony or uneven need for establishing a convention.
distribution of a component or components in Initially the canons were enclosed in a grid
different parts of the body,” according to Carter system of equalized squares with 18 horizontal
and Heath. lines, line 18 drawn through hairline. Later it was
Moreover their definition of a somatotype included in a grid system of 22 horizontal lines,
quantifies relative fatness or endomorphy, relative line 21 drawn through the upper eyelid.
musculoskeletal robustness or mesomorphy and After the outline of the human figure, was
relative linearity or ectomorphy. The somatotype drafted on papyrus leaves the iconographic
then stands as a “measuring of overall appraisal norms or canon, served to insert the figure into a
of body shape and composition, an anthropological network of equal squares. The image could be
identification tag and a useful description of transferred to any required size by first drawing
human physique.” a coordinate system to proper size; into this
system the image can then be drawn readily and Using strictly geometrical methods, he
accurately for displaying in a tomb or on a wall. provided a proportionate analysis of the
This procedure is still universally used to enlarge leptoprosopic (long) face and euryprosopic
or reduce any kind of illustration. (broad) face in coordinate system, where the
Indian econometric studied extensively by horizontal and the vertical lines were drawn
Ruelius, was transmitted through sanskrit through the same landmarks or facial features.
literature and extensively reviewed in Indian His drawings attest continuous efforts to define
texts of architecture. The proportional canons of variations in the facial morphology. One of this
that system were already detailed in older is significant as the key to cephalometric analysis.
sources and did not materially change with time. In the difference between the retroclined and the
Face height was used as the module of both the proclined, facial profile is shown by a change of
Sariputra and Alekhyalakshana proportional angle between the vertical and the horizontal
system, which closely reflected the natural axes of a rectangular coordinate system to
relation of the parts of the body with each other. characterize the facial configuration of each
The Sariputra system, dated 1200 AD are known subject.
for the sculptures honoring the God Buddha. Sixteenth century saw the first truly scientific
attempt in cranial measurement and the
Renaissance to the Twentieth Century introduction by Spigel (1578–1625 AD) of the
“lineae cephalometricae”. Spigel’s linear

Fifteenth century saw the advent of specific
cephalometricae consisted of four lines: the facial,

measurements being made to compare the occipital, frontal and sincipital lines. He
features of different skulls and heads. Leonardo described these lines as follows:
da vinci (1452–1519 AD) was probably one of • Facial: from the most inferior point of the chin
the earliest people of note to apply the theory of to the most superior point on the forehead.
head measurement to good effect in practice. • Occipital: from the crown of the head to the
He used a variety of lines related to specific atlas.
structures in the head to assist in his study of the • Frontal: from one temple to the other.
human form. His drawings included a study of • Sincipital: from the lowest part of the ear, in
facial proportions in natural head position. the region of the mastoid process, to the
According to the notes, the profile was divided highest part of the sinciput, sinciput being the
into seven parts by eight horizontal lines. anterior part of the head or skull from
Subdivision is made with vertical lines. In his forehead to the crown.
study of horse and horse men, he used a scheme According to him, in a well proportioned
of facial measurement within a grid system with skull, these lines should all be equal.
five horizontal and six vertical lines and the The Dutchman Pieter Camper (1722–1789
subject in natural head position. The joining of AD) was credited with the introduction of facial
the lower lip and the chin and the tip of the jaw angle and for famous publication “Dissertation
and the upper tip of the ear with the temple forms sur les varietes naturelles de la physionomie”
a perfect square; and each face is half a head. which appeared posthumously in 1791. The key
Albrecht Durer (1471–1528 AC) was a to his methodology was to orient crania in space,
brilliant, unusually productive and an exuberant horizontal from the middle of the porus
artist of great virtuosity. He published a treatise acusticus to a point below the nose. Camper’s
in 1528 on cranial measurements which horizontal became the reference line for the
comprised “Vier Bucher von menschlicher angular measurements used to characterize
Proportion” dealing with the proper proportion evolutionary trends in studies of facial
of human form in the first two books, the morphology and aging.
proportions according to mathematical rules in The facial angle as he described, was formed
third book, the human figure in motion in the by the intersection of a facial line and a horizontal
fourth book. Durer’s four books mark a climax, plane. The facial line was a line tangential to the
which the theory of proportions had never most prominent part of the frontal bone and to
reached before or was to reach ever after. the slight convexity anterior to the upper teeth.
The horizontal plane passes through the lower distance. The second line passes from the posterior
part of the nasal aperture, backwards along the margin of the foramen magnum to the tip of the
line of the zygomatic arch and through the center nasal spine. Broca’s occipital angle was formed
of the external auditory meatus. by two different lines giving alternative angles,
Camper’s facial angle was readily accepted originating from the posterior and anterior
as standard measurement in craniology. The margins of the foramen magnum and passing
terms prognathic and orthognathic introduced anteriorly through the junction of frontal and nasal
by Retzius are tied to Camper’s illustrations of bones. The magnitude of occipital angle decreases
facial form in man and primates. As a result, the as the habitual posture of the animal tend more
angle between a horizontal line and the line from towards upright.
nasion to prosthion became the time-honored An antagonist of Camper, Johann Friedrich
anthropological method to determine the facial Blumenbach (1752–1840 AD) rejected the
type. The term prognathism refers to the method of lines and angles as a test of national
prominence of the face or jaws, relative to the characteristics and proposed a minute survey of
forehead, and a straight facial profile became the skull particularly the frontal and maxillary
labeled as orthognathous. bones. In 1795, he described a method of
The drawbacks of Camper’s facial angle were: positioning the cranium which has to be
• It ignores the contribution made by the lower measured in a standard reproducible manner.
jaw to facial forms. His method was simple, consisting of resting the
• He did not adhere strictly to his location of skull on its base and looking down vertically
posterior reference point for the horizontal upon its vault. The points to be noted were, the
plane. projection of the maxilla anterior to the frontal
• The direct comparison of skull of different arch, the direction, of the jaws and cheek bones
ages was not possible because the locating (outward, forward, etc.) and the proportional
point might alter in position relevant to other breadth or narrowness of the head.
bony structures with advancing age. Anders Retzius (1796–1860 AD) correlated
Shortly after this, Deschamps (1740–1824 the two schemes, i.e. of Camper and Blumenbach,
AD) introduced the cephalic triangle made up thereby providing a basis for the methods of
of facial, occipital, and coronal angles. The facial craniology used today. He is also credited with
angle was the lesser angle formed by the the introduction of cephalic index, the ratio of
intersection of a horizontal line that passes from breadth to length of the skull expressed as a
the external auditory meatus to the base of the percentage.
nose, which crossed a profile line. This is similar Nineteenth century produced three great
to Camper’s facial angle. Fortunately, the use of men in the history of craniology: Huxley, Broca
external auditory meatus as a reference point and Topinard.
enabled a rough comparison to be made between Thomas Huxley (1825–1895 AD) wrote in
different skulls. 1876, “the so-called facial angle, in the fact, does
In the same period as Camper, there was a not simply express the development of jaws in
French man, Daubenton who was very relation to face, but is the product of two factors,
concerned with the relative position of the facial and cranial, which vary independently. The
foramen magnum in man and lower animals. He face remaining the same, prognathism may be
made use of new angles, including the occipital indefinitely increased or diminished, by rotation
angle to make measurements. Although his of the frontal region of the skull, backward or
measurements were not very reliable, a similar forward, upon the anterior end of the basicranial
angle was later used by another craniologist, axes”. He also introduced two new angles, the
Pierre Broca. sphenomaxillary and sphenoethmoidal angles.
Daubenton’s occipital angle is formed by two He preferred the sphenomaxillary angle to
lines, the first line passes along the level of Camper’s angle when comparing the degree of
opening of the foramen magnum, from the initial prognathism in different skulls. This angle is
edge of the foramen along the surface of the formed by the two lines drawn from basion and
occipital condyles and anteriorly for short prosthion to prosphenion. The other angle,
sphenoethmoidal tends to be less than 180° in center of each auditory meatus to the lower point
man. on the inferior margin of each orbit by Von
Broca (1824–1880 AD) who is the founder of Ihering (1850–1930). The Frankfurt agreement
the Paris society of anthropology believed that modified Von Ihering’s definition such that the
the great variability of the cranial form plane passes through the upper border of the
constituted a principal difficulty for the bony meatus vertically above their centers.
craniologist. He was the first craniologist to However, the reproducibility of this plane on an
institute a precise and accurate technique which intact skull is less than Broca’s condyloalveolar
could be used to compare crania so that it was plane. Subsequent to the agreement, the
made possible to discriminate between the definition of the horizontal plane has been
variation in racial types among human skulls. altered so that it is now taken as passing through
He introduced a base line “plan alveolo- the right and left porion and left orbitale.
condylien” which passes through the alveolar Thereby, reducing the problems incurred by
point and tangential to the inferior surfaces of asymmetrical skulls.
the two occipital condyles. He also developed a
craniostat, mainly constructed of wood for CEPHALOMETRIC RADIOGRAPHY
positioning the skull. In 1895, Professor Wilhelm Conrad Roentgen
It was generally accepted at this time that the made a remarkable contribution in the field of
angles were best determined on projected science with the discovery of x-rays. On December
drawings of the skull. Broca devised a simple 28, 1895, he submitted a paper “On a new kind
method to trace the outline of the skull on to a of rays, A Preliminary Communication” to the
piece of paper by fixing the skull in the craniostat Wurzburg Physical Medical Society for publication
and positioning a drawing board with paper in its journal.
attached to it parallel to the midsagittal plane and Professor Wilhem Koening and Dr Otto
a pencil held in a frame perpendicular to the Walkhoff simultaneously made the first dental
paper. The resultant tracing was equivalent to a radiograph in 1896. It was clear that the use of
tracing of the peripheral, as depicted on a lateral X-rays provided the means of obtaining a
skull radiograph. different perspective on the arrangement and
Paul Topinard (1830–1912 AD) used a similar relation of bones, thus expanding the horizons
craniostat with some additional modifications. of craniometry and cephalometry.
Topinard wrote in 1890 “the craniometer The evolution of cephalometry in the
substitutes the mathematical data for the twentieth century is universally linked to
uncertain data founded on judgment and Edward Hartlay Angle’s publication of his
opinion. Moreover it studies the skeleton of the classification of malocclusion. But the dogmatic
ensemble, the cranium and the face separately inferences of the new school were criticized for
and each of the plates as well”. failing to include differential diagnosis of facial
During nineteenth century, the need for profile in patients with class III and class II
standardization of methods used in craniometry malocclusion.
became an important issue and since then, many Van Loon was probably the first to introduce
bodies have met to better define those points and cephalometry to orthodontics, when he applied
planes in use. The most important meeting as far anthropometric procedures in analyzing facial
as the dental profession is concerned was held growth by making plaster casts of face into which
in Frankfurt-am-Main in August 1882. This was he inserted oriented casts of the dentition.
the 13th General congress of the german Hellman used cephalometric techniques and
anthropological society and it is to this congress described their value beginning with 1920s.
that the Frankfurt horizontal plane owes its The first X-ray picture of skull in the standard
name. lateral view was taken by AJ Pacini and Carrera
Earlier in 1859, a horizontal plane following in 1922. Pacini received a research award from
the zygomatic arches was suggested by a Russian the American Roentgen Ray Society for a thesis
craniologist, Von Baer. Later, the plane was entitled “Roentgen ray anthropometry of the
defined more precisely as line drawn from the skull”. Pacini introduced a teleroentgenographic
technique for standardized lateral head This development enabled orthodontists to

radiography and thereby opened a way, which capture the field of cephalometry from the
proved to become a tremendous advance in anatomists and anthropologists who had
cephalometry, as well as in measuring the monopolized craniometric studies, particularly
growth and development of face. His method, in nineteenth century.
which was rather primitive, involved a large
fixed distance from the X-ray source to the HOLLY B BROADBENT’S CONTRIBUTION
cassette. The head of the subject, placed adjacent
to a standard holding the cassette, was Broadbent’s interest in craniofacial growth began
immobilized with a gauze bandage wrapped with his orthodontic education under E H Angle
around both the face and the cassette after the in 1920. He continued to pursue that interest
patient’s midsagittal plane was carefully oriented along with his orthodontic practice, working
parallel to the cassette. with a leading anatomist J Wingate Todd.
He identified the following anthropometric The idea of diagnosing dental deformities by
landmarks on the roentgenogram: gonion, means of planes and angles was first proposed
pogonion, nasion, and anterior nasal spine. He in 1922 by Paul Simon of Germany in his book,
also located the center of the sella turcica and “Fundamental principles of a systematic
the external auditory meatus. He measured the diagnosis of dental anomalies”. Although his
gonion angle and the degree of maxillary “Law of the canines” was later disproved by
protrusion. Broadbent, his theories stimulated the latter to

Atkinson in 1922 advocated the use of apply the principles of craniometry to living
roentgenograms in locating the ‘key ridge’ and the subjects.
soft tissue relations to the face and jaws. In 1923 The uncertainty of locating landmarks in the
McCowen reported on profile roentgenograms that skull of the living child by approaching through
he used for orthodontic purposes to visualize the skin and soft tissues led him to search for a means
relationship between the hard and soft tissues and of recording craniometric landmarks on the
to note the changes in profile which occur during living child accurately as done with a craniostat
treatment. in measuring the dead skull.
Simpson presented a method for obtaining During 1920’s, Broadbent refined the
profile roentgenograms in 1923 before American craniostat into craniometer by the addition of
Society of Orthodontists. In 1927, Ralph Waldron metric scales. This proved to be the first step in
of Newark, NJ made mention of measuring the
the evolution of craniostat into a radiographic
gonion angle from a roentgenogram taken at 90o
cephalostat. It did not take him much longer to
to the facial profile. Waldron was the first to
convert the direct measuring instrument into a
construct a cephalometer, which differed little
radiographic craniometer.
from those used today.
Meanwhile, the course of Broadbent’s
In 1928, Dewey and Riesner published an
orthodontic practice corrected the malocclusion
article, “A Radiographic study of facial
deformity”. Dewey and Riesner immobilized the of Charles Bingham Bolton, son of Chester and
patients head in a head clamp and placed the Francis P Bolton. His discussions of facial growth
cassette against the patient’s face. They took with Congress woman, Bolton led to the addition
profile roentgenograms by aligning the eye to ear of Bolton study of facial growth to the long list
plane by a right angle leveling technique. They of Bolton philanthropies. As Charles grew to
used a target distance of three feet. adulthood, this study became a major personal
In 1931, the methodology of cephalometric as well as financial commitment.
radiography came into full function when B Cephalometrics was neither developed as a
Holly Broadbent in USA and H Hofrath in technique looking for an application nor was it
Germany simultaneously published methods to developed as a diagnostic tool. Broadbent’s single
obtain standardized head radiographs in the goal was the study of craniofacial growth. The
angle orthodontist (A new X-ray technique and Broadbent’s technique for cephalometric
its application to orthodontia) and in radiography was one of the tools which he
Fortschritte der Orthodontie, respectively. developed for the implementation of that study.
The technique and apparatus perfected for the and the pattern once attained at an early age,
Bolton fund study of the normal developmental did not change.
growth of the face, eliminated practically all of • Thompson and Brodie (1942) in a report on
the technical difficulties encountered in previous the rest position of the mandible, concluded
methods of recording dentofacial changes, and that:
proved to be a convenient as well as scientific 1. Morphogenetic pattern of the head was
method of measuring orthodontic procedures. established ata early age and did not
According to Broadbent, the patient’s head change,
was centered in the cephalostat with the superior 2. Presence or absence of teeth has little bearing
borders of the external auditory meatus resting on the rest position of the mandible and
on the upper parts the two ear rods. The lowest 3. Vertical facial proportions are constant
point on the inferior bony border of the left orbit, throughout life.
indicated by the orbital marker, was at the level Margolis (1943) wrote on the relationship
of the upper parts of the ear rods. The nose clamp between the inclination of the lower incisor and
was fixed at the root of the nose to support the the incisor-mandibular plane angle and was the
upper part of the face. The focus film distance first to corroborate Tweed’s clinical observation
was set at five feet (152.4 cm) and the subject film that, in normal occlusions, the lower incisors are
distance could be measured to calculate image 90° to the mandibular basal bone.
magnification. With the two X-ray tubes at right In 1947, Wylie produced a method of
angles to each other in the same horizontal plane, assessing anteroposterior dysplasias and that
two images (lateral and posteroanterior) could same year, Margolis contributed his maxillo-
be simultaneously produced. facial triangle.
Germany’s Hofrath’s technique differed from
CEPHALOMETRIC ANALYSIS
Broadbent’s technique in this way of the central
ray was not fixed in relation to the head and no The major use of radiographic cephalometry is in
plan was suggested for super-positioning characterizing the patient’s dental and skeletal
subsequent X-rays. relationships. This led to the development of a
number of cephalometric analyzes to compare a
OTHER IMPORTANT CONTRIBUTIONS
patient to his or her peers, using population
In 1937, using serial records of twins; Broadbent standards. William B Downs (Fig. 14.1 ) in 1948
showed how growth or its lack was the greatest
limiting factor in clinical success. In 1943, he
stipulated that, eruption of the third molars had
no ill effect on the denture, particularly the lower
incisors.
• In 1938, Allan G Brodie at the University of
Illinois presented a cephalometric appraisal
of orthodontic results:
1. The use of elastic causes a disturbance in
the Bolton plane-occlusal plane angle;
2. Axial inclinations of orthodontically-
moved teeth tend to return to their
original inclinations.
3. Bone changes during treatment are
restricted to the alveolar process.
• Brodie, in a landmark study (1941) used for
his PhD in anatomy, corroborated
Broadbent’s contention that the growth
pattern of the normal child’s face develops
in an orderly fashion downward and forward Fig. 14.1: William B Downs (1899–1996)
2. The landmarks to locate the FH plane, orbitale

and porion, especially the latter, are difficult
to identify on a cephalogram.
An alternative to overcome this problem was
to use a functionally derived NHP. According to
Morrees and Kean, it was obtained by asking
the subject to look at the image of their eyes in
the mirror located at eye level. A frame of
reference was originally intended as a reliable
procedure for orienting facial profiles so that,
same orientation could be established on
different occasion by different investigators.
Although the functionally derived NHP was
Fig. 14.2: Herbert I Margolis (1900–1984) more accurate, its reproducibility was less than
FHP (anatomic approximation of NHP). Lateral
and posteroanterior views perpendicular to each
developed the first cephalometric analysis. Its
other in the horizontal plane were specified for
significance was that, it presented an objective
three-dimensional analyses.
method of portraying many factors underlying

Bjork’s studies of facial prognathism
malocclusion and there could be a variety of
illustrated the unreliability of intracranial

causes of malocclusion exclusive to teeth. This
reference lines in cephalograms.
was followed by another analyzes by Cecil C
Kroagman and Sassouni (1957) conducted an
Steiner (1953), CH Tweed (1953) , RM Ricketts
exhaustive survey of roentgenographic
(1958), V Sassouni (1969), HD Enlow (1969), JR
cephalometry in which the FHP (Frankfort
Jaraback (1970), Alex Jacobson (1975), etc.
horizontal plane) coincided with the physiologic
or true horizontal.
EVOLUTION OF CEPHALOMETRICS
Sassouni made an attempt to standardize the
The thoroughness of Broadbent’s approach to the orientation of cephalograms by means of an
design of the cephalometric method is evident optical plane advocated in 1862 by Broca, who
from the fact that the basic technique has stated that “when a man is standing and when
survived almost unchanged for over seventy his visual axis is horizontal, his head is in natural
years. position”.
In about two decades time, the instrumen-
tation had evolved to a form more suitable for X-RAY SOURCE POSITION
the individual practitioner through the
pioneering efforts of Margolis (Fig. 14.2), Higley The X-ray source is positioned five feet (152.4 cm)
and others. from the subject’s midsagittal plane. A change
to 150 cm has been adopted by some as a
PATIENT ORIENTATION conveniently round metric number, but the
difference is negligible. A major improvement
The ears were established as the basis for in lateral cephalostats is, the capability of taking
orientation and fixation in the beam axis. lateral and posteroanterior views with a single
Frankfurt plane was adopted for horizontal X-ray source instead of two.
orientation with nasion for stabilization. The
Frankfort horizontal plane (FHP) was chosen
FILM POSITION AND ENLARGEMENT
because this was approximate the natural head
position (NHP). But the FHP also had its The other significant change from the original
drawbacks and those were: technique is adjustability of film position. The
1. Some individuals show a variation of their original cephalostat was based on the design of
FHP to the true horizontal to an extent of ± the anthropometric craniometer and cassettes were
10°. attached to these mechanisms. The disadvantage
of this very efficient mechanical design is that it since it requires rather large equipment with two
makes cassette position and resultant enlargement X-ray sources.
depended on head size. Evaluation of serial Modern equipment uses one X-ray source.
changes by direct superimposition is made Therefore, following lateral cephalometric
unreliable by this variable enlargement. registration, the patient must be repositioned if
The relative immunity of angular a posteroanterior cephalogram has to be
measurements to enlargement distortions led produced. A head holder or cephalostat that can
many researchers to opt for angular over linear be rotated 90° is used, so that the central X-ray
values whenever possible. Also newer instruments beam penetrates the skull of the patient in a
have been developed that can over come this posteroanterior direction and bisects the
drawback of variable enlargement by providing transmeatal axis perpendicularly. Maintaining
independent adjustments for head holding the identical horizontal orientation from lateral
mechanisms and cassette. to the posteroanterior projection is critical when
comparative measurements are made on each
POSTEROANTERIOR (FRONTAL) other (Moyers et al, 1988).
CEPHALOMETRY In using natural head position for postero-
anterior cephalometric registrations, some
Since the introduction of a standardized method practical problems are encountered. The patient’s
for obtaining skull radiographs, cephalometrics head is facing the cassette; which makes it
has become one of the major diagnostic tools in
difficult for the patient to look into a mirror to

orthodontics. The posteroanterior cephalogram register natural head position (Solow and
contains diagnostic information not readily Tallgren, 1977). Furthermore, space problems
available from other sources. This information make it impossible to place a nose piece in front
allows the practitioner to evaluate the width and of nasion to establish support in a vertical plane.
angulation of the dental arches in relation to their For better evaluation of patients with
osseous bases in the transverse plane; evaluate craniofacial anomalies that require special
the width and transverse positions of the maxilla attention to the upper face, the patient head
and mandible, evaluate the relative vertical should be positioned with the tip of the nose and
dimensions of bilateral osseous and dental forehead lightly touching the cassette holder.
structures; assess nasal cavity width, and analyze (Chierci, 1981)
vertical and/or transverse facial asymmetries. In cases of suspected significant mandibular
Malocclusions and dentofacial deformities displacement, the posteroanterior cephalogram
constitute three-dimensional conditions or should be taken with the mouth of the patient
pathologies. Although all orthodontic patients slightly open in order to differentiate between
deserve an equally comprehensive three functional mandibular displacements and
dimensional diagnostic examinations, dentoskeletal facial asymmetry (Faber, 1985). As
assessment of posteroanterior cephalometric far as exposure conditions and considerations are
views are of particular importance in cases of: considered, more exposure is needed for postero-
1. Dentoalveolar and facial asymmetries anterior cephalograms than lateral views (Enlow,
2. Dental and skeletal cross bites 1982).
3. Functional mandibular displacements. Cephalometric radiography, which came into
The same equipment that is used for the widespread use after the Second World War,
lateral cephalometric projections is utilized. The enabled orthodontist to measure the changes in
initial unit described by Broadbent consisted of tooth and jaw positions produced by growth and
a set up in which two X-ray sources with two treatment. Among other findings, these radiog-
cassettes were simultaneously used, so that raphs revealed that many class II and Class III
lateral and frontal cephalograms were taken at malocclusions resulted from faulty jaw relation-
the same time. Although precise-three- ships, not just malposed teeth. By the use of cephal-
dimensional evaluations are possible using this ometrics, it was also possible to see that jaw growth
technique, it has now been almost abandoned could be altered by orthodontic treatment.
According to Salzmann, cephalometric skeletal ossification, have proven to be more

radiograph can show following features; accurate.
1. Show dimensional relationship of the The standard method to evaluate skeletal
craniofacial components. maturity has been the use of hand-wrist
2. Reveal manifestations of growth and radiographs, matching the overall pattern of the
developmental abnormalities. subject’s maturation to a set of reference patterns,
3. Helps in treatment planning. available in an atlas. Skeletal maturation is
4. Helps in diagnosing the patient, especially of generally determined by evaluating either the
skeletal origin. stage of ossification of bones of the hand and
5. Helps in evaluating the dentofacial growth wrist, due to the large number of different types
changes during and after the orthodontic of bones available in these areas, or the
treatment. ossification onset of the ulnar sesamoid.
The goal of cephalometric analysis is to However, to avoid taking additional radiographs,
estimate the relationship, in all three planes that the cervical vertebrae, as seen on routine lateral
is in anteroposterior, vertical and transverse cephalograms, have been used to determine the
relationship of the jaws to the cranial base and skeletal maturity.
to other, the relationship of the teeth to their It is well known that the lateral view of
supporting bone, and the effect of the teeth on cervical vertebral bodies change with growth. In
the profile. 1972, Lamparski stated that the cervical

In the 16th century, artists Durer and Da Vinci vertebrae were as statistically and clinically
sketched a series of human faces with straight reliable in assessing skeletal age as the hand-wrist
lines joining homologous anatomic structures. technique. In recent years, evaluation of cervical
Variations in these lines highlighted the structural vertebrae has been increasingly used to
difference among the faces. These facial determine skeletal maturation. Several authors
proportions were basically an artist’s attempt, have reported a high correlation between cervical
with beauty and harmony as the guiding vertebrae maturation and skeletal maturation of
principles, to quantify the basic structures of the the hand-wrist. It has been found that cervical
human face. vertebrae could offer an alternative method for
Much later, the anthropologists invented an assessing maturity without the need of hand-
instrument—the craniostat, which helped in wrist radiographs. However, cervical vertebrae
orienting dry skulls and facilitating standardized were used to evaluate growth in a subjective
measurement. This improved the art of manner because the method consisted of a
comparisons as the instrument improved qualitative comparison between the patient
reproducibility but this also did not allow the radiographs and the images contained in the
study of skulls of living humans. The discovery atlas.
of the X-rays in 1895 by Sir William Conrad Mito et al (2002) established a new method
Roentgen, proved to be a boon in this direction. for objectively evaluating skeletal maturation on
Orthodontic diagnosis and treatment cephalometric radiographs. A regression formula
planning for growth children must involve was determined to obtain cervical vertebral bone
growth prediction. The pubertal growth spurt is age based on ratios of measurements of the third
considered to be an advantageous period for and fourth cervical vertebral bodies. However,
certain types of orthodontic treatment and the population used to derive the formula
should be taken into account together with consisted of Japanese girls only.
orthodontic treatment planning. The study of facial form as revealed in the
Because of the wide individual variation in analysis of lateral skull radiographs. In addition
the timing of the pubertal growth spurt, to clinical examination, analysis of a lateral
chronological age is an unreliable guide for cephalogram permits a more detailed evaluation
assessment of children development status. of facial and dentoskeletal structures to aid
Other parameters such as, growth velocity, diagnosis and treatment planning, especially in
secondary sex changes, dental development and cases with a skeletal discrepancy. Also provides
baseline measurements to monitor the effects of

growth and development.
Lucien De Coster: Lucien De Coster of Belgium
in the year 1939, was the first to publish an
analysis based on proportional relationships in
the face conforming to the principles used in
antiquity.
Wits analysis: The Wits analysis (1967) gets its
name from the University of Witwatersrand in
South Africa; it was brought stateside by
Alexander Jackobson of the University of
Alabama. Rejecting dependence on the ANB
angle, Jacobson relates A and B linearly by
Fig. 14.3: Tweed’s triangle
verticals from the occlusal plane.
Like the Harvold analysis, the Wits analysis
concentrates on the skeletal discrepancy between
the jaws. It determines the magnitude of the jaw
discrepancy by relying on the linear difference

between points A, B and the occlusal plane. The

wits take into account, the horizontal and vertical
relationship of the jaws, but its weakness is that
it is influenced by the dentition and therefore
skews the analysis from indicating the true
skeletal discrepancies between the jaws.
Tweed’s Triangle
Tweed in the year 1954 based on the hypothesis
that, in the normal occlusion, the mandibular
incisors are upright over the basal bone,
constructed a triangle formed by the lower
central incisor, mandibular plane, and Frankfort Fig. 14.4: Richard A Riedel (1922–1994)
horizontal plane. The Tweed’s triangle (Fig. 14.3)
makes use of three planes that form a diagnostic studies at the University of Washington of long-
triangle called Tweed’s triangle. Following are range treatment stability have left us an
the planes of Tweed’s triangle: unsurpassed legacy.
1. Frankfort mandibular plane angle (FMPA) The ANB angle is defined as the mutual
2. Incisor mandibular plane angle (IMPA) relationship, in sagittal plane, of the maxillary
3. Frankfort-mandibular incisor plane angle and mandibular bases.
(FMIA)
STEINER’S ANALYSIS: CECIL C STEINER
ANB Angle (1896–1989)
Richard A Riedel (1922–1994) (Fig. 14.4), Cecil C Steiner was Angle’s second student at
introduced ANB angle before completing his the Pasadena school. He was initially rebuffed
Master’s degree at Northwestern University in because he did not know who Charles Darwin
United States of America. Nowadays this is most was. Later with mother Angle’s encouragement,
widely used diagnostic cephalometric angle. The he not only got the admission but also carved
ANB angle represents the anteroposterior his name in the orthodontics. The Steiner
relationship of the maxilla with the mandible. In analysis, published in 1953, offered specific
addition to his cephalometric research Riedel’s guides for the use of cephalometric measurements
in treatment planning, based on what to determine, for example, if extractions were

compromised incisor positions would be necessary. Through this step-by step approach,
necessary to achieve normal occlusion when the the Steiner analysis has been instrumental in
ANB angle was not ideal. It I also incorporated “popularizing“ cephalometrics. At one time,
arch length and other considerations, such as the southern California was known cephalomtrically
profile, enabling even the neophyte orthodontist as Steiner Territory”.
History of Extraction in Orthodontics 145
History of Extraction in
Orthodontics
15
• Arch-Length Analyses – Case or Angle Controversy • Historieal Perspective

• Second Premolar Extraction • Need for Extraction – Dewel’s Method 1978
– Tweed’s Method (1966)

• Evolution of the Philosophy of • Choice of Teeth for Extraction
– Nance Method
Extraction in Conjunction with • Serial Extraction – Grewe’s Method

Orthodontic Therapy
Extraction of one or more teeth is sometimes described euphemistically as “reduction in the

necessary to establish normal functional total number of dental units”. According to
occlusion, especially when jaws are not large Lischer, “The extraction of one or more
enough to accommodate all the teeth. Tooth permanent teeth to facilitate an orthodontic
extraction may also be needed to correct the treatment dates back at least to Fauchard (1728),
anteroposterior dental arch relationships. The and has been resorted to ever since. . . . The
space gained by extraction is utilized to relieve narrow, orthodox view that extraction of a tooth
crowding or to retract the proclined anteriors. is never justified is being discarded. . . . The profile
The decision of extraction should always be of a growing child must never be regarded as a
based on sound judgment, taking patient’s age, fixed line, but one in which further changes will
development and amount of space needed for continue to take place.” As early as 1920, George
tooth alignment into consideration. The decision W Grieve (1870–1950, Angle School, 1907; Fig.
to opt for extraction should be made only after 15.1), considered the dean of Canadian
careful clinical evaluation, cephalometric and orthodontists, recommended the removal of
model analysis to assess the need and outcome of permanent teeth. However, the increase in
such extraction. First premolars are most extractions that took place in the mid-1940s was
frequently extracted as a part of orthodontic due, in large part, to the influence of Charles
treatment followed by the second premolars. Tweed, whose teachings had become widely
Injudicious extractions may lead to undesirable accepted. He advocated positioning the
consequences such as arch collapse, deep overbite, mandibular incisors upright over basal bone
spacing and tissue damage. (approximately 90° to the mandibular plane
By the 1930s, the relatively common extraction angle) and argued that expansion of dental units
practices of the late 19th century, dictated largely off this bone led to instability. Extractions in the
by technique limitations, had given way to permanent dentition rapidly became the most
Angle’s non-extraction dogma. Although a more common treatment strategy for the correction of
tempered position continued to be held by Case Class I and II malocclusions, and, as Allan Brodie
and others, the word “extraction” had become ruefully remarked, “soon the air was filled with
all but unmentionable. Thus, when it was bicuspids”. The prevalence of extractions soared
mentioned in the literature, it was frequently from a modest 30% in 1953 to 76% in 1968.
prominent lips. Abraham Goldstein studied

patients 21 years after retention and found that
non-extraction patients looked better.
• Lack of incisor prominence.
• Narrowed maxillary arch.
• Desire to avoid extended treatment.
• The increased fear of malpractice
litigation. In the 1980s, claims were made
that temporomandibular disorder
problems could be attributed to the
removal of maxillary premolars. But there
were also some positive factors.
• Increased use of extraoral traction and
functional appliances to take advantage
of growth.
• More arch length gained by the use of
bonded brackets.
• Better understanding of retention.
• Reproximation (e.g. air-rotor stripping,

“slenderizing”).
• Increased use of removable appliances
(which rely mainly on a full complement
Fig. 15.1: George W Grieve
of teeth).
• Revival of “arch development”14 (lateral
Tweed did not extract indiscriminately, but, in expansion, rotation or distalization of
too many patients, practitioners looked on the molars, and controlled proclination of
removal of 4 premolars as the easy way out of an mandibular incisors). By 1993, the
arch-length problem. Conservative leaders, prevalence of extraction had returned to
although acknowledging that extraction had its 1950s levels (28%). Proffit and Fields
place, were reluctant to endorse it publicly, out believe that nonextraction is once again
of fear that it would lead to abuses. Brodie, who being carried to an extreme.
became Angle’s torchbearer, said, “If I say it’s
OK to extract, the first thing you know, ARCH-LENGTH ANALYSES
everybody’s going to be extracting instead of
making a proper diagnosis. Doctor Angle told In the 1950s, to a considerable extent a result of
me that and it’s true”. Silas J Kloehn’s (1902–85, Fig. 15.2) revival of
By the 1980s, the pendulum had swung back cervical traction and Nance’s arch-length analysis,
toward non-extraction as orthodontists began there was increased interest in mixed-dentition
using new appliances and technologies to treatment and serial extraction. Perceiving a need
increase arch length and width, making it easier for improvement in mixed-dentition tooth-size
to treat crowded dentitions without extractions. measurement, Hixon and Oldfather in 1958
Several other factors were responsible for this developed an analysis based on the widths of the
shift, including some negative ones. mandibular permanent incisors and the X-ray
• Relapses (including the return of rotations measurements of the unerupted canines and
and overbite) and the reopening of extraction premolars, using a 16-in cone. This contribution
spaces. proved to be the most popular of its kind to date;
• Gingival depressions at extraction sites. however, it was later revised because it was learned
• The finding that extraction is no guarantee that this analysis often under predicted the widths
of stability. of unerupted teeth. Moyers’ analysis (1973), based
• Flattened lips—”aged” look. The general on linear regression equations and the widths of
public often prefers fuller and more the mandibular incisors, achieved widespread
extreme cases, a mandibular incisor might require

extraction.
SECOND PREMOLAR EXTRACTION

A borderline patient presents the dilemma of
extracting first premolars when the amount of
crowding does not warrant the 14 or 15 mm per
arch thus gained, or the alternative of non-
extraction, which might be equally undesirable
for reasons of esthetics or stability. The idea of
extracting teeth other than the first premolars
must have occurred to early clinicians, and some
might very well have done so. Surely, many had
to deal with congenitally missing second
premolars. But it was well into the 20th century
before it is mentioned the literature. One of the
first authors to spell it out was Clarence W (Clu)
Carey (1904–2003, Fig. 15.3). Carey was an

innovator whose many contributions to
orthodontics include laminated arches, the Bi-Po

toothbrush, and the tooth-size dental calculator.
He was nevertheless more cautious when he
advocated (1947) extracting 4 second premolars
if the discrepancy is more than 2.5 mm and if the
Fig. 15.2: Silas J Kloehn operator is willing to accept a compromised
result. In 1949, Nance spoke of removing the
second rather than the first premolars to keep
clinical acceptance because of its simplicity and the incisors over basal bone. Perhaps the most
ease of application. Offering insight into why some definitive description of second-premolar
occlusions did not “fit”, Wayne Bolton devised extraction procedures during those years was
an analysis based on average measurements to written by B F (Tod) Dewel (1902–99, Fig. 15.4 ),
determine tooth-size discrepancies between the who emphasized that closure of extraction spaces
maxillary and mandibular arches. This analysis requires “a delicate balance . . . between anterior
made it possible to determine whether the anchorage and posterior resistance”. He
maxillary or the mandibular teeth (commonly, reminded us that “extraction of second premolars
the 6 anterior teeth) have deficient or excessive decreases by 2 teeth the resistance the buccal
mesiodistal diameters. His analysis immediately segments present when the spaces are being
became a standard part of the complete diagnostic closed”. In 1964, Ricketts (1920–2003) advocated
analysis of malocclusion, although, in 2000, Smith placing the mandibular incisors within 1
et al, examining the validity of Bolton’s ratios for standard deviation of the Point A-pogonion
various ethnic groups, concluded that the ratios plane. That same year, Schoppe suggested that a
apply only to white women and should not be discrepancy of 7.5 mm or less should be the
used arbitrarily for white men, Hispanics, or blacks. criterion for considering second premolar
Peck and Peck, believing that tooth shape (rather removal, if there is no need for incisor retraction.
than tooth width) might be a factor in determining He offered these advantages for the option:
whether crowding of the mandibular incisors • Permits more rapid mesial movement of
would occur, devised an index based on the ratio molars.
between the mesiodistal and faciolingual widths. • Permits less lingual movement of incisors.
With this and Bolton’s ratios, it became possible • Is probably the best means of gaining space
to determine the need for re-proximation. In when a minimum of space is necessary.
• Tends to alter the profile less.

• Tends to hasten closure of the extraction
space.
Reminiscent of Tweed’s “100 cases”, Logan
showed 100 case records of patients treated with
second premolar extractions at the 1970 annual
Pacific Coast Society of Orthodontists’ meeting.
In a 1973 article, he listed these advantages of
second-premolar extraction, over and above
those proffered by Schoppe.
• Eliminates problems of rotated, tipped, or
late-erupting second premolars.
• Facilitates closure of anterior open bite by
reducing posterior vertical dimension.
• Eliminates need to bond mandibular second
premolars, which are less-than-ideal
candidates for bonding.
• Gains additional space for second and third
molars.
• Makes it easier to control rotations, axial

inclinations, and anterior torque.
• Requires less Class II elastic force and
headgear.
Fig. 15.3: Clarence W (Clu) Carey
• Produces fewer end-to-end bites because of
the comparative widths of maxillary and
mandibular premolars.
• Maintains the maxillary first premolar, which
is usually stronger than the second premolar.
EVOLUTION OF THE PHILOSOPHY OF

EXTRACTION IN CONJUNCTION WITH
ORTHODONTIC THERAPY
The role of extractions in orthodontic treatment
has been a matter of controversy for years.
Although John Hunter recognized the role of
extraction as early as 1771 in his book Natural
history of the teeth, it was not until mid 20th century
that extraction of teeth in conjunction with
orthodontic therapy became more acceptable.
Case-Angle Controversy
Originally, Calvin Case (Fig. 15.5) was a genuine
admirer of Angle. He advocated the Angle
system at every turn and hoped to place this
system before the dental profession. In fact, he
gave up the general practice of dentistry because
of Angle’s influence. The discord started over the
claim that Angle attributed the origin of the use
Fig. 15.4: BF Dewel of inter-maxillary elastics to Baker, while Case
Fig. 15.5: Calvin Case Fig. 15.6: Martin Dewey
thought that he should have received that credit. Department, the Chicago Dental College, and the
In fact, when Angle described this procedure, he New York College of dentistry. He gained a wide
never mentioned Case. This led to charges and reputation as an outstanding teacher. He had
counter charges between them in 1903. Case’s started his own graduate school in orthodontics
claim was that in 1890 he started this procedure in 1911 as the Kansas City School of Orthodontia
and reported it at the Chicago Dental Society and and continued it as he traveled from one city to
also at the Columbian Dental Congress in 1893. another, ending in New York City with his death
The second point of contention was—and is in 1933. His influence was much felt since he was
the one usually remembered—the question of the the editor of the International Journal of
extraction of certain teeth as a means of Orthodontia for 17 years and also the president
treatment. Angle’s thesis was that “there shall of the American Dental Association in 1931.
be a full complement of teeth, and that each tooth The climax of this conflict was a debate in
shall be made to occupy its normal position”. 1911 at the annual meeting of the National Dental
Case defended the discreet use of extraction as a Association (former name of the ADA). Bitterness
practical procedure, while Angle believed in non- and animosity were rampant. It took many years
extraction. However, the unexpected result of after this episode for the problem to become a
this controversy was that it convinced general matter of calm and objective evaluation and
practitioners that they should not attempt respectful appreciation of various points of view,
orthodontic treatment but should refer patients each of which has made its contribution to
to the specialist. orthodontics.
The extraction story was continued into 1911 The first decade of the twentieth century was
with Martin Dewey (1881–1933) (Fig. 15.6) an an era of the manufacture of standardized
ardent champion of non-extraction. Dewey appliances. These appliances were made as sets
served as professor of Orthodontics at Kansas of various kinds mounted on cards and sold by
City Dental School, the University of Iowa Dental dental supply companies. By the use of a few
simple soldering techniques, the dentist could the diagnosis of “mouth breathing”, which took
make a required “fitting”, as it was called. on special meaning (1907).
William J Brady (Iowa City) advertised as a In 1907 Benno Lischer (1876–1959)(Figure
consulting specialist in orthodontia: 14.7), dean and professor of dental orthopedics at
Advice by mail upon regulating cases of all Washington University Dental School in St. Louis,
kinds. Appliances fitted to models with full founded the International School of Orthodontia,
instructions for handling from beginning to end. and in 1912, he published Principles and Methods
Instructions: send good models of both upper of Orthodontia. He was an advocate of early
and lower, with thin wax bite. Give age and sex. treatment. Lischer wrote: “It is my firm belief that
Pack carefully. After examination, an estimate irreparable damage is done by oft repeated advice to
of the cost of instructions of appliance will be wait until the permanent teeth are all erupted before
submitted free of charge. If satisfactory, remit the beginning operations for correction of malocclusion.”
amount by bank draft or money order. Other publications included the first separate
George C Ainsworth patented a regulating journal entitled American Orthodontist, which
appliance that used vertical tubes and the started in 1907 and ceased publication in 1912. In
principle of the loop wire in 1904.Varney Barnes 1909 CN Johnson (Chicago) edited a work entitled
patented the so-called Barnes posterior tube A Textbook of Operative dentistry, which
consisting of a soldered band that held several contained a chapter, “Orthodontia”, written by
teeth together, with vertical tubing applying root Herbert A Pullen covering over 275 pages of text.
pressure to individual teeth. It contained not only etiology, diagnosis, and

Many innovative ideas and procedures were treatment modalities but also instruction in
introduced. Victor H Jackson (1850–1929) was laboratory procedures.
experienced in mechanics and devised a specially
designed appliance known as the Jackson crib, NEED FOR EXTRACTION
which incorporated the use of an auxiliary spring Extraction of teeth in orthodontic treatment is
(finger) as an aid in tooth movement. His appliance necessary in two main circumstances:
was one of the first “systems” of treatment to 1. For the relief of crowding caused by arch
influence the development of modern lengthtooth material discrepancy
orthodontics. Jackson published Orthodontia and 2. For the correction of anteroposterior dental
Orthopaedia of the Face in 1904. In it, he claimed arch relationship.
that with his method a large number of patients
could be cared for as contrasted to the highly CHOICE OF TEETH FOR EXTRACTION
sophisticated techniques in vogue at the time that
The choice of teeth for extraction should be
limited the number of patients.
carefully made with consideration to the
Another contribution was reintroduction of
following factors:
the maxillary suture opening by Herbert A
• The amount of tooth material excess in
Pullen (1874–1938) in 1902. Charles A Hawley
relation to arch length, degree and site of
(1861–1929) used a celluloid sheet containing a
crowding.
geometric figure that, when adapted to a model
• The anteroposterior inter-arch relationship.
determined the extent of proposed tooth
• Profile of the patient.
movement (1905) and introduced the retainer
• Age of the patient and his/her dental
appliance that bears his name (1908).
developmental status.
Scientific studies included research in dental
• The direction of jaw growth.
histology, particularly by Frederick B Noyes
• Carious status of the teeth.
(1904); the influence of heredity and environment
• General health status of the dentition.
on dental structures (1905); emphasis on
rhinology, which brought the medical fraternity
SERIAL EXTRACTION
into cooperation (1907); the study of the
deciduous dentition vis-a-vis nasodental growth, Serial extraction is an interceptive orthodontic
especially by Edward A. Bogue (1838–1921); and procedure undertaken in the (early) mixed
dentition period that involves planned removal Although popular, the term “serial extraction”
of certain primary and permanent teeth in a does not stress the importance of thorough
programmed sequence, so as to relieve crowding knowledge of growth and development, compre-
in the arches and to guide the remaining erupting hensive analysis based on investigative records
permanent teeth into a more favorable position. required to execute the procedure properly and
A thorough understanding of the dynamics of thus may be misleading.
orofacial growth and development and that of the Hotz (1970) recommended the term “guidance
stomatognatic system is essential for the success of eruption”. It is also sometimes referred to as
of serial extraction procedures. When executed “guided extraction”, while other authors prefer
properly in carefully selected patients with the to call the procedure “Guidance of Occlusion”.
proper assessment, skilled timing and careful
monitoring, programmed serial extraction Dewel’s Method 1978
procedures can produce best possible and most Dewel’s has proposed a three step serial extraction
stable results with minimal or in some cases no procedure in 1978 (Table 15.2).
further need of corrective mechanotherapy at a Step 1: In this step the deciduous canines are
later stage when all permanent teeth erupt. extracted to create space for the alignment of the
Although occasionally used to intercept Class incisors (Fig. 15.7A). The main objective of
II and Class III malocclusions, serial extraction extracting primary canines is to establish the
procedure is mainly used to intercept and/or integrity of upper and lower incisors. This
treat Class I malocclusions with crowding prevents development of lingual cross bite of
resulting from severe tooth size arch length maxillary laterals and resultant mesial migration
discrepancy. of maxillary canines.
Step 2: In this step deciduous first molars are
Definition extracted at 8-9 years of age. The objective of
• Tweed: Serial extraction as ‘the planned and Table 15.1: Authors and their inventions
sequential removal of the primary and
permanent teeth to intercept and reduce Authors Diseases of teeth
dental crowding problems.’ Robert Bunon (1743) First reference to extraction
• Iondon: The correctly timed, planned of primary teeth to facilitate
removal of certain deciduous and permanent alignment of permanent
teeth in mixed dentition cases with teeth
Kjellgren (1929) First coined the term Serial
dentoalveolar disproportion.
Extraction
Nance (1940s) Popularized the procedure
HISTORICAL PERSPECTIVE considered father of serial
Robert Bunon in the early 1743 advised extraction extraction technique
of primary teeth to achieve a better alignment of Hotz (1970) Argued against the term
serial extraction to call it
permanent teeth in his diseases of teeth (Table
guidance of eruption
15.1).
Later several authors like Bourdet (1757), Table 15.2: Dewel’s method
Hunter (1771), Robinson (1846) and Harris
(1855) advocated removal of primary canines and Steps Tooth extracted Purpose
the premolars when permanent incisors Step 1 Extraction of Alignment of
crowded. deciduous canines incisors
The term “serial extraction” was first coined Step 2 Extraction of To facilitate the eruption
by Kjellgren in 1929. However it was Nance who deciduous first of first premolars ahead
molars of permanent canines
popularized the procedure in 1940’s in England
Step 3 Extraction of first To facilitate eruption
and is considered as the Father of Serial
premolars of permanent canines
Extraction technique practiced today.
A B C
D E
Figs 15.7A to E: Dewel’s method of serial extraction: (A) Deciduous canines are extracted to create space for the
alignment of the incisors; (B) Deciduous first molars are extracted to facilitate eruption of first premolars; (C) First
premolars are extracted to facilitate the eruption of permanent canines; (D) Favorable eruptin of canines after removal of
first premolars; (E) Proper occlusion after minimal period of fixed orthodontic mechanotherapy
deciduous first molar extraction is to accelerate of proper intercuspation usually requires

eruption of first premolars. This ensures that the orthodontic mechanotherapy of minimal duration
first premolars emerge into oral cavity ahead of (Fig. 15.7E), although it may not be necessary in
the permanent canines (Fig. 15.7B). rare cases.
Step 3: In this step first premolars are extracted to
facilitate the eruption of permanent canines
TWEED’S METHOD (1966)
(Fig. 15.7C).
After serial extraction procedure, the teeth are This method involves the extraction of the
fairly aligned (Fig. 15.7D). However, establishment deciduous first molars at 8 years of age. This is
followed by the extraction of the first premolars molar is delayed. The first premolars should
and the deciduous canines simultaneously. be extracted as they emerge.
2. Class 1 malocclusion with severe mandibular
Nance Method anterior crowding.
Deciduous Canines are extracted when there
Nance method of serial extraction is a
is arch length deficiency and more than 5 mm
modification of Tweed’s method which involves
per quadrant. The deciduous first molars are
the extraction of the deciduous first molars
extracted next on completion of at least half of
followed by the extraction of the first premolars
first premolar root formation and the extraction
and the deciduous canines.
of first premolars follow as the erupt into the
oral cavity.
Grewe’s Method
3. Class 1 malocclusion where minimal
Grewe’s method of serial extraction is based on mandibular anterior crowding is 6–10 mm
the planning of extraction sequence for different arch deficiency.
clinical conditions. In such conditions the first premolars are
1. Class 1 malocclusion with premature loss of extracted. The deciduous first molars are
a mandibular deciduous canine. extracted when the roots of the premolars are
Class 1 malocclusion with premature loss of a more than half formed, as this would in turn
mandibular deciduous canine will result in result in premature loss or eruption of the first
midline shift, when the arch length premolar as soon as the first premolars erupt
discrepancy is 5–10 mm/arch, then the into the oral cavity; these are extracted followed
remaining deciduous canines should be by deciduous canines. If this is bound to be
extracted the deciduous first molars are eruption of permanent canines before that of
extracted next, if the first premolar have their first premolar, then the deciduous canine is
roots more than half formed. If the roots of the extracted first followed by the extraction of the
first premolars are not developed more than deciduous first molar and encleation of the
half then extractions of the deciduous first first premolar.
History of Expansion
Appliances 16
• Wescott’s Expansion Device – Kingsley’s Incline Plane

• Angell’s Palatal Expansion Device – Herbst’s Retention-Joint Appliance
– Goddard Expansion Device – Coffin Appliance

– Kingsley’s Extraoral Traction • Fixed Rapid Maxillary Expansion

Appliance Appliances
WESCOTT’S EXPANSION DEVICE ANGELL’S PALATAL EXPANSION DEVICE

Wescott first reported the placement of mechanical A year later, Angell’s performed a similar
forces on the bones of the maxilla, in 1859. He procedure with a differentially threaded
used two double-clasps separated by a telescopic jackscrew connected across the palate to both
bar to correct a cross bite in a 15-year-old girl. One bicuspids on one side and the second bicuspid
double clasp was soldered to the tube and the on the other (Fig. 16.2). The patient was given a
other was soldered to a screw that fit into the tube, key to turn the screw and instructed to keep it
thereby allowing lengthening of the screw to uniformly firm. Upon her return, 2 weeks later
widen the palate. Adjustable spurs were also she had developed a space between her central
attached perpendicular to the telescopic bar to incisors, which Angell claimed “showed
allow forward repositioning of the incisors (Fig. conclusively that the maxillary bones had
16.1). separated”.
Goddard, in 1893, further standardized the
palatal expansion protocol. He activated the device
twice a day for 3 weeks, followed by a
consolidation period to allow the deposition of
“osseous material” in the created gap. The
description of his appliance is similar to Hyrax
appliance, being attached to the first bicuspids
and second molars bilaterally.
In addition to palatal expansion, two other
orthodontic techniques utilized traction for the
correction of craniofacial skeletal deformities. In
1866, Kingsley first applied extraoral traction to
correct the protrusion of the maxilla. His appliance
consisted of a gold frame that covered the incisors
and a head cap, which was connected to the frame
Fig. 16.1: Wescott’s expansion device
by elastic ligatures (Figs 16.3A and B).
History of Expansion Appliances 155
Nine years later, Potpeschnigg described a

“Tooth Regulating Machine” that consisted of a
head cap connected to a steel rod, that was secured
to the tooth by means of an elastic ring. Traction
was applied to the tooth by tightening the elastic
band between the head cap and metal rod (Fig.
16.4).
In 1892, Kingsley successfully used principles
of traction to treat mandibular retrognathia, with
a functional appliance. He developed an inclined
plane attached to the upper arch to force the entire
mandible forward as the patient closed his mouth.
Thirteen years later, Herbst demonstrated his
“retention-joint appliance” which consisted of
two telescoping rods attached to the teeth (Fig.
Fig. 16.2: Angell’s palatal expansion device 16.5). As the patient closed his mouth, the
placed on the maxillary teeth mandible was forced forward into a normal
position.
A B
Figs 16.3A and B: Kingsley’s extraoral traction appliance
(A) and Potpeschnigg’s “tooth regulating machine” (B)
Fig. 16.4: Kingsley’s incline plane
Fig. 16.5: Herbst’s “retention-joint appliance”

Arch expansion is one of the methods of orthodontic community at that time. Later in 1956,
gaining space in orthodontics. The concept of arch this expansion device was reintroduced to
expansion was explained for the first time by orthodontics by Andrew Hass, in the United States
Emerson C Angel. Hence, he is considered as of America.
father of expansion appliances. Arch expansion Removable expansion appliance may be a
can be slow or rapid, removable or fixed. Slow simple expansion appliance with incorporated
arch expansion brings about mainly dentoalveolar jackscrew or Coffin appliance. Fixed arch
expansion whereas rapid maxillary expansion expansion appliances are toothborne expansion
brings about both skeletal as well as dentoalveolar appliance (Hyrax, Isacson) or tooth and tissue
expansion. borne expansion appliance (Derichsweiler Haas
Rapid maxillary expansion appliances are the expansion appliance). How much to expand and
best appliances of the orthopedic expansion. In when to expand are evaluated by model analysis.
this, changes are produced mainly in the
underlying skeletal structures rather than by the FIXED RAPID MAXILLARY EXPANSION
movement of teeth through the alveolar bone. APPLIANCES
Rapid maxillary expansion not only separates the
Fixed rapid maxillary expansion appliances are
midpalatal suture but also affects the circum-
fixed expanders and cannot be removed by the
zygomatic and circummaxillary sutural systems.
patient. These fixed expanders can be classified

Rapid maxillary expansion is also called
into tooth and tooth tissue-borne appliances.
palatal expansion or split palate. Rapid maxillary

Tooth and tissue borne appliances are:
expansion is a skeletal type of expansion, which
• Derichsweiler type
produces skeletal changes by separation of mid
• Haas type.
palatal suture.
Most commonly used fixed expander of tooth
Rapid maxillary expansion device was first
borne appliances are:
used by Emerson C Angel in the year 1860. He
• Hyrax type
used a jackscrew type of rapid maxillary
• Isaacson type.
expansion device between two premolars in
maxillary arch on palatal side in a 14-year-old Derichsweiler-type expander: Derichsweiler
girl and achieved arch expansion by ¼ inch in 14 expansion appliance consists of molar bands on
days. For this significant valuable contribution to right and left permanent first molars and first
the expansion in orthodontics, he is considered premolars with wire tags soldered into the palatal
as the Father of rapid maxillary expansion. surface of all molar and premolar bands. The outer
Walter Coffin in 1877, developed a spring for free ends of wire tags are inserted into split palatal
the purpose of arch expansion which has come to acrylic incorporating a jack expansion screw in
be known as Coffin spring. This spring also its center (Fig. 16.6).
produces arch expansion by separation of mid
Haas-type expander: Haas expander was
palatal suture, when used in young patients. This
designed and popularized by Andrew Hass in
expansion device was of gained popularity by
the year 1961. This appliance consist of molar
bands on right and left permanent molars and
premolars. A jackscrew is incorporated in the
midline into the two acrylic pads that closely
contact the palatal mucosa. Support wires also
extend anteriorly from the molars along the buccal
and lingual surface of the posterior teeth, to add
rigidity to the appliance (Fig. 16.7).
Haas states that, more bodily movement and
less dental tipping is produced when acrylic
palatal coverage is added to support the appliance
thus permitting the forces to be generalized not
only against the teeth but also against the
Fig. 16.6: Derichsweiler type expander underlying soft and hard palatal tissues
Fig. 16.8: Hyrax expander

Fig. 16.7: Hass expander
Hyrax–type expander: The more commonly used

type of banded RME appliance is the Hyrax–type

expander. This type of expander is made entirely

from stainless steel. Bands are placed on the
maxillary first molars and first premolars. The
expansion screw is localized in the palate in close
proximity to the palatal contour. Buccal and
lingual wires may be added for rigidity (Fig. 16.8).
Isaacson expansion appliance: It is a fixed tooth
borne appliance without acrylic covering. This
appliance consists of molar bands on first right
and left, permanent molars and premolar bands
on right and left permanent premolars. Metal Fig. 16.9: Isaacson expansion appliances
flanges are soldered into the molar and premolar
bands (14, 16, 24, and 26) on buccal and palatal
sides (Fig. 16.9). A spring loaded expansion screw
(Minne) expander having a nut which can
compress the spring and is made to extend
between palatal metal flanges. Activation: It is
activated by closing the nut, so that the spring
gets compressed.
Bonded rapid maxillary expansion: These
appliances consist of an acrylic splint covering
variable number of teeth on either side in the
maxillary arch, to which a jack screw is attached.
Splint can be either cast cap made of silver copper
alloy or acrylic splint made of polymethyl
methacrylate (Fig. 16.10). A wire framework may
be adapted around the teeth to reinforce the
Fig. 16.10: Bonded rapid maxillary expansion appliances
acrylic.
Expansion Screw
A typical expansion screw (Figs 16.11A to D) halves. Each half has a threaded inner side that
consists of an oblong body, divided into two receives one end of a double ended screw. The
A B
C D
Figs 16.11A to D: Different types of expansion serews
A B
Figs 16.12A and B: (A) Expansion screw key; (B) Showing activation of expansion screw by placing the key in the hole
screw has central bossing with four holes. These Various types of expansion screws are
holes receive a key called expansion screw key available to carry out different types of expansion
(Figs 16.12A and B) which is used to turn the screw. as enumerated in Table 16.1.
Table 16.1: Different types of expansion screws Table 16.2: Timm’s schedule of activation of
expansion screw
Expansion screw type Use
Age of the patient Degree of Number of
Symmetrical bilateral Bilateral expansion
activation activation in a day
expansion screw
Traction screw Closing spaces Up to 15 years 90o 2 times in a day
o
Expansion screw with Separate expansion of More than 45 4 times in a day
split activator maxilla or mandible 15 years
Three-dimensional Anterior and bilateral
screw expansion
Table 16.3: Expansion orthodontic appliances
Expansion Screw Activation Schedule
Author Contributions to
orthodontics
Schedule by Timms
S.No. Type of expansion appliance Developed by
See Table 16.2.
1 Derichweiler expansion Derichweiler
appliance
Expansion Orthodontic Appliances 2 Isaacson’s expansion Isaacson
Expansion orthodontic appliances (Table 16.3) appliances

3 Haas expansion appliance Haas

are used to relieve crowding in cases of arch
4 Coffin spring Walter coffin
length—tooth material discrepancy. Following are
5 Jack expansion screw Jack
the researchers involved in the development of
various type of expansion appliances.
History of Removable
• Development of Removable – Contraindications

Orthodontic Appliances – Advantages
– Victor Hugo Jackson – Disadvantages

– George Crozat
• Components of Removable
– Robin Orthodontic Appliances
– Andersen – Retentive Components
– Adam – Active Components
– Martin Schwartz – Base Plate
– Indications
Removable orthodontic appliances are so-called type of malocclusion. The range of malocclusions
because they are designed to be fitted and that can be treated with removable appliance
removed by the patient. Removable orthodontic alone is limited. They can also be used as passive
appliances are limited to tipping and simple appliances to maintain teeth in their corrected
rotatory movements of teeth, which are sufficient positions after active phases of orthodontic
for many orthodontic treatments. They depend therapy, e.g. retainers. Removable orthodontic
on cooperation and a certain degree of skill on appliance is often used in conjunction with fixed
the part of patient. Removable orthodontic mechanotherapy.
appliances may be active or passive. The most familiar removable device is the
The use of removable orthodontic appliances retainer, specifically the Hawley or Begg device.
was always more popular in Europe than the Its function, however, is retention—keeping teeth
United States, but even there, the use of fixed in their place after the desired tooth-movement
appliances [using (generally metal) bands and has been achieved.
brackets] has largely become the primary method The main drawback of removable orthodontic
of treatment. Nevertheless, as the authors of appliances is that they can only apply a tipping
Removable Orthodontic Appliances point out, force (whereas fixed appliances can also apply a
removable appliances are often an effective rotating force), this means they are not suitable
means of addressing many patients’ needs and for the complete treatment of some cases
in some cases have considerable advantages over (specifically, serious class II and III cases). Among
fixed appliances. the big advantages of removable orthodontic
Use of removable appliances also requires appliances are in the area of anchorage (since the
careful case selection for, success of the treatment. palatal area is also used for this), significant since
They are ideally used when simple tipping fixed appliances must generally rely on adjacent
movement of teeth is sufficient to correct a certain teeth (As the authors note, the use of removable
History of Removable Orthodontic Appliances 161
appliances generally involves the upper arch; that is still used occasionally. Crozat appliance
lower arch treatment with them is limited by consists of:
difficulties with retention and bulk, as well as – Modified Jackson’s clasp.
the limited space available for active components – Heavy gold wire framework.
on the appliances themselves). – Lighter gold finger springs to produce
desired tooth movement.
DEVELOPMENT OF REMOVABLE
ORTHODONTIC APPLIANCES Robin
Removable orthodontic appliances begin with a
In the year 1900, forerunner of all functional
brief general introduction, and then discusses the
appliances, the monobloc was developed by
‘Biomechanics of tooth movement’, various
Robin.
active components that can be utilized, and how
they function and are integrated into devices,
Andersen
including a variety of springs, bows, and screws.
The next survey ‘Appliance retention’, ‘The In the 1920s, andersen developed activator in
baseplate’, and ‘Anchorage’, discussing the Norway. He was the first person to develop
factors that should be taken into consideration functional appliance.
which designing the device, both generally
(going so far as to note: “Removable appliances Adam

should ideally be fitted within two weeks of the In the 1921s, Adam developed a clasp called
impression being taken”) and also in tailoring it Adam’s clasp.
to the individual case. Anchorage issues, in
particular, must be closely monitored from visit Martin Schwartz
to visit, and as the authors point out: “if space is
critical, it may be wise to plan for extraoral anchorage • He developed split plate appliance.
from the start”. Clearly, the use of extraoral
anchorage headgear, which in the case of Indications of Removable Orthodontic
removable appliances cannot be cervical (since Appliances
the pull must be upwards so as not to displace Use of removable orthodontic appliances
the appliance) allows for much greater flexibility requires careful selection. They should not be
in treatment, as headgear can be used as the sole used in circumstances where fixed orthodontic
source of anchorage or to reinforce intraoral appliance therapy would be more appropriate.
anchorage, as well as extraoral traction be an May be used as an adjunct to fixed orthodontic
active component for tooth movement. appliance treatment.
Victor Hugo Jackson Contraindications of Removable

Victor Hugo Jackson is from United States of Orthodontic Appliances
America. He was the chief proponent of Removable orthodontic appliances are
removable appliances. contraindicated in case, where bodily movement
• At that time, neither the modern plastics for is required.
base plate material nor stainless steel wire-
clasp, springs were available. Advantages of Removable Appliances
• Appliances are fabricated with bases and
Advantages of removable orthodontic appliances
precious metal or nickel silver wires.
are listed below:
• In early 20th centuries.
1. Removable appliances permit easy cleaning.
2. They need less chair side time.
George Crozat
3. They are good for overbite reduction.
In early 1900s, Crozat developed a removable 4. They can tip the teeth efficiently.
appliance fabricated entirely of precious metal 5. They eliminate occlusal interferences.
Disadvantages of Removable Retentive Components

Orthodontic Appliances Evolution of Clasp Design
Disadvantages of removable orthodontic • Jackson describes the construction of a crib
appliances are listed below: clasp which has a square form and is designed
1. Removable orthodontic appliances can bring not only to grasp the tooth buccally but, by
about only a limited type of tooth movement. running forward and backward and turning
2. Anchorage of tooth movement is sometimes sharply at a right angle, to grasp the tooth
difficult, since anchor teeth cannot be anteroposteriorly. The next real advance in
prevented from tilting. clasp design was the introduction of the
3. Retention with removable orthodontic arrowhead type of clasp, usually attributed
appliance is more difficult than with fixed to Schwarz and introduced in England by
appliances. Tischler.
4. A high degree of cooperation and a certain • The arrowheads depend on the use of the
amount of skill is required from the patient, spaces below the point of contact between
who has to remove, clean and replace the two teeth. Several arrowheads are usually
appliance at frequent interval. embodied in a clasp.
5. Limited scope on lower arch. • The modified arrowhead clasp, introduced by
6. They affect speech. Adam in 1949 and today widely referred to

as the Adam clasp, makes use of the mesial
Advantages of Removable Appliances and distal undercuts of a single tooth only

a. They are removable and therefore easier to and can in practice be applied to any tooth,
clean. deciduous or permanent.
The success of a removable orthodontic
b. They can provide increased vertical and
appliance mainly depends upon good retention
horizontal anchorage due to palatal coverage.
of the appliance. Adequate retention of a
c. They can produce efficient over-bite
removable orthodontic appliance is achieved by
reduction in a growing child.
incorporating certain wire components, got
d. They can transmit forces to blocks of teeth.
engaged the undercuts on the teeth. These wire
components that help in retention of a removable
Disadvantages of Removable Appliances
appliance are called clasps. Following are the
a. The appliances can be left out. different type of clasps which aids in retention
b. Only tilting movements are possible. to the appliance:
c. They affect speech. i. ‘C’clasp or Circumferential clasp
d. A technician’s input is required to make the ii. Jackson’s clasp or Full clasp
appliances. iii. Adam’s clasp
e. Intermaxillary traction is more difficult. iv. Schwartz clasp
f. They are inefficient for multiple tooth v. Crozat clasp
movements. vi. Triangular clasp
g. Lower removable appliances are more vii. Ball end clasp
difficult to tolerate. viii. Resta clasp
ix. Eyelet clasp
COMPONENTS OF REMOVABLE x. Southend clasp.
ORTHODONTIC APPLIANCE
Modifications of Adam’s Clasp and its Use
Removable orthodontic appliance consists of
following three components: Adam’s clasp offers a unique feature that, its
1. Retentive components design can be modified in a number of ways suit
2. Active components varies clinical requirements. The following are
3. Base plate. some of the modifications of Adam’s clasp.
1. Adam’s clasp with incorporated helix They can also be used for space closure in the
Use: For the attachment of elastics. anterior segment as well as space distal to
2. Adam’s clasp with soldered hook canines. The following are some of the routinely
Use: For attachment of elastics. used design of labial bows (Table 17.1):
3. Adam’s clasp with traction hook 1. Short labial bow
Use: For attachment of elastics. 2. Long labial bow
4. Adam’s clasp with additional arrowhead 3. Split labial bow
Use: For additional retention. 4. Modified split labial bow
5. Adam’s clasp with single arrowhead 5. Reverse labial bow
Use: For partially erupted teeth. 6. Robert’s retractor
6. Adam’s clasp with soldered buccal tube 7. Mill’s retractor
Use: For attachment of face bow. 8. High labial bow
7. Double Adam’s clasp on maxillary central 9. Fitted labial bow.
incisor
Use: For additional retention. Springs
8. Adam’s clasp with distal extension
Use: For attachment of elastic and additional Springs are active components of removable
retention. orthodontic appliances which are used to bring
about tooth movement. There are different types

Active Components of springs (Table 17.2) which can be used

according to the need. The basic principle behind
Bows using springs is that, when a wire is deflected, it
Bows are one of the active components of tries to regain its prefabricated original shape and
removable orthodontic appliance. They are while trying to do so, the springs move the teeth
usually used for overjet retraction of anteriors. along their path.
Table 17.1: Different types of labial bows

Type of labial bow Wire used for Description of Activation Flexibility Indications
fabrication the bow
Short labial bow 23 gauge hard It extends from Reduction of Less flexible Minor overjet
round stainless permanent lingual palatal than any other reduction
steel or 0.7 mm canine to canine acrylic of type of labial (upto 3.5 mm)
anteriors bows Mild space closure
Compression in the anterior
of both U loops segment
Long labial bow 23 gauge hard It extends from Reduction of More flexible Minor overjet
round stainless first permanent lingual palatal than short reduction
steel or 0.7 mm premolar to acrylic of labial bow Minor anterior
premolar anteriors space closure
Compression Closure of space
of both U loops distal to canine
Split labial bow 23 gauge hard The bow is split Reduction of More flexible Anterior retraction
round stainless in midline lingual palatal than short
steel or 0.7 mm acrylic of labial bow
anteriors
Compression of
both U loops
Contd...
Contd...
Type of labial bow Wire used for Description of Activation Flexibility Indications
fabrication the bow
Modified split 23 gauge hard The bow is Reduction of More flexible Mainly used for
labial bow round stainless modified to lingual palatal than short, closure of midline
steel or 0.7 mm engage the acrylic of long and diastema
opposite central anteriors split labial
incisors Compression bow
For example, of both
right bowwill U loops
engage left central
incisor below the
contact point and
vice versa
Reverse labial 23 gauge hard It extends from Reduction of More flexible Overjet reduction
bow round stainless permanent lingual palatal than short, (5 to 7 mm)
steel or 0.7 mm canine to canine acrylic of long, split,
or permanent anteriors modified split
premolar to Opening the labial bow

premolar loop resulting in

The bow is lowering the
reversed bow incisally and
compensatory
bend is given to
maintain proper
level of bow
Robert’s 23 gauge hard It extends from Reduction of More than Increased overjet
retractor round stainless permanent lingual palatal short, long, (7 to 9 mm)
steel or 0.5 mm canine to canine acrylic of split, modified
It incorporates anteriors split and
an helix on Closing both reverse labial
either side the helices bow
The diameter
of both helix
should be 3 mm
Mill’s retractor 23 gauge hard Bow having Reduction of More than Large overjet
round stainless extensive lingual palatal short, long, split, (more than 9 mm)
steel or 0.7 mm looping acrylic of modified split,
anteriors reverse labial
Compression bow and Robert’s
of looping retractor
High labial 21 gauge hard Extends in Activated only Apron spring is Proclined incisors
bow with round stainless buccal by apron spring highly flexible
apron spring steel or 0.9 mm vestibule Apron sping is because it is
Apron spring Apron springs activated by fabricated with
fabricated with are made to bending it thinner gauge wire
0.4 mm rest on incisors toward the teeth
Fitted labial 23 gauge hard It is made to be It is not Least as Mainly used for
bow round stainless fitted in the activated compared to retention after
steel or 0.7 mm contour of all all other types completion of
or 21 gauge anteriors of bows fixed orthodontic
hard round therapy
stainless steel
or 0.9 mm
Table 17.2: Different types of springs and their activation and indications
Type of spring Wire used for Description of Activation Indication
fabrication the spring
Finger spring 0.5 mm or 0.6 mm Consist of active Closing the helix Closure of midline
stainless steel wire arm, helix and and moving active diastema
retentive arm arm towards the Closure of minor
Helix is of 3 mm tooth to be moved anterior space
in diameter and
should rest on the
long axis of root
of the tooth to
be moved
Retentive arm is
of 4-5 mm in length
and is made to get
embedded in
acrylic base
Z spring 0.5 mm or 0.6 mm Consists of two Activation depends Correction of
stainless steel or helixes arranged on its indication minor rotation

in pattern of Z For correction of Labial movement

that’s why also minor rotation then of incisors
known as double only one upper helix Labial movement
cantilever spring is activated by of tooth in case of
opening the helix single or segmental
For labial move- cross bite
ment of incisors the
spring is activated
by opening both
the helixes
T spring 0.5 mm or 0.6 It consists of Pulling the free end Buccal movement
mm stainless T shaped arm of T towards the of premolars
steel wire intended direction
of tooth movement
Mattress spring 0.6 mm round It is shaped like a —— Labial movement of
stainless steel wire mattress with ‘U’ upper teeth in cross bite
loops extending
up to the retentive
Helical coil 0.6 mm round Free-ended spring —— Regain the lost space
spring stainless steel wire with two helixes
formed on
different arms
Canine Retractors removable orthodontic appliance with canine

retractor can be efficiently used only when the
Canine retractors are springs that are used to move canine is mesially angulated. When used on
canines in a distal direction. upright or canines, the removable canine
They can be classified in a number of ways retractors can worsen the situation. Thus fixed
(Table 17.3). orthodontic appliances with greater control over
Usefulness of canine retractors depends on tooth movement are preferred over removable
the angulations of the canine to be retracted. The canine retractors.
Table 17.3: Classification of canine retractors Base Plate

According to their location, canine retractors can be Base plate has a greater percentage of bulk in
classified as: removable orthodontic appliance than other
Buccal placed buccally components. The design of base plate varies with
Palatal placed palatally
the type of removable orthodontic appliance. Self
According to presence of helix or loop: cure or auto polymerizing acrylic resins are used
a. Helical canine retractor for the fabrication of base plate. It joins all other
b. Looped canine retractor
(active and retentive) components of removable
According to their mode of action: orthodontic appliance together into a single
a. Push type functional unit.
b. Pull type
The following are some of the commonly used canine
retractors (Table 17.4)
1. ‘U’ loop canine retractor
2. Helical canine retractor
3. Palatal canine retractor
4. Buccal self-supported retractor
Table 17.4: Different types of canine retractors and their activation and indications
Type of canine Wire used for Description of Activation Indication
retractor fabrication canine retractor
(in mm)
U loop canine 0.6 or 0.7 It consists of U Closing the loops For canine retraction
retractor loop, active arm 1 to 2 mm or
and retentive arm cutting the free
which is distal ends of active arm
by 2 mm and
readapting it
Helical canine 0.6 or 0.7 It consists of a coil Opening the helix For shallow sulcus
retractor of 3 mm diameter by 1 mm or by in mandibular arch
and active arm cutting 1 mm of
(towards the tissue) free ends and
and retentive arm readapting it
Palatal canine 0.6 or 0.7 It consists of a coil Opening the helix For retraction of
retractor of 3 mm diameter, 2 mm at a time palatally placed
active arm and canine
guide arm
Buccal canine 0.6 or 0.7 It consists of a coil Opening the helix For retraction of
retractor of 3 mm diameter, or closing the helix buccally placed
active arm (away 2 mm at a time canine
from the tissue)
and retentive arm
Buccal self- 0.6 or 0.7 It consists of a coil Activation by For retraction of
supported canine of 3 mm diameter, closing helix buccally placed
retractor active arm (away 1 mm at a time canine
from tissue) and
retentive arm
History of Fixed
• E-arch Appliance • The Concept of the Ideal Arch • Building Treatment into the
• Pin and Tube Appliance – Comparison of Architectural Edgewise Appliance
• Ribbon Arch Appliance and Dental Arches • History of Begg Appliance

– Cause for Collapse of Arches
• Edgewise Appliance • Straight Wire Appliance

• What was Orthodontics before – Ideal Arch Form • Andrews’s Six Keys to Optimal
Angle System? • The Ideal Arch Wire Occlusion
• Evolution and Development of – Characteristics of an Ideal • Limitations of Straight Wire
the Edgewise Appliance Arch Wire Appliance
– Arch Wire Bends • History of Lingual Technique
• Evolution of Bracket
• Advantages and Disadvantages
• Evolution of Edgewise Buccal
of Edge- wise Appliance
Tubes
For the first third of this past century, orthodontics

found itself dominated by one man, Edward H
Angle (Fig. 18.1), with the resultant intellectual
stagnation that arises from such monomaniacal
control. This recognition in no way detracts from
Angle’s contributions—notably his clear and
simple classification system along with the
edgewise bracket. Both of these inventions have
endured for a century, and that is no mean
achievement in any scientific discipline.
Nevertheless, orthodontists’ unquestioning
acceptance of his limited diagnostic and treatment
planning regimens hindered the advancement of
this discipline more than it helped, and the last
half of this past century was spent trying to
overcome the stupor of the first half.
Angle’s influence continued until an apostate
student of his, Charles H Tweed, had enough
courage and objectivity to challenge Angle’s non-
extraction scheme. It was not a tremendous leap
of intellectual power. Tweed simply and honestly Fig. 18.1: Edward H Angle
recognized that when 100 percent of your patients that bore his name was too immense to permit
relapsed, there might be something wrong with such hubris from a young upstart. But as
the diagnosis and/or treatment planning. Samuelson, the MIT economist, once noted:
Dr Tweed (Fig. 18.2) acted appropriately in “Science progresses slowly—funeral by
the face of this challenge—quite unlike the ancient funeral.” And so it was and is in orthodontics.
dentist who chided a young colleague who was
describing his meticulous technique of Non-extraction Philosophy
endodontic filling to the monthly assembly of
Aside from the edgewise bracket and the
dentists. The old man explained his own
classification system, Angle’s most enduring
technique that used a simple matchstick
legacy has been his belief in non-extraction
sharpened with a pocketknife and then jammed
therapy. Angle had unsuccessfully experimented
into the canal. When the young dentist asked if
with premolar extractions while using his ribbon
a lot of these root canal fillings did not
arch appliance, but he never solved the problem
subsequently fail, the older man replied, “Every
of paralleling the roots to prevent the extraction
damn time!”
spaces from opening. If he could not do it, then,
Tweed tired of those orthodontic abscesses
ergo, no one else could, and this resulted in a
and, unlike his peers, sought to correct the
virulent opposition to any extractions and an
deficiencies he saw in Angle’s philosophy. Some
insistence upon enlarging the arches to

would say that he overcorrected, but that said,
accommodate all of the teeth.
we must pay homage to anyone who has the skill

This dogma stayed dominant for several
and temerity to successfully challenge a mentor
decades until Tweed advocated the extraction of
and his minions. Tweed’s success brings to mind
premolars based on his diagnostic triangle, which
the remark of C S Lewis, who said, “No genius is
was the first systematic treatment planning
so fortunate as he who has the skill and ability to
stratagem orthodontists had. Tweed received
do well that which others have been doing
corroboration simultaneously from another
poorly”.
former Angle protégé in Australia, Raymond
Nevertheless, I do not think that Tweed would
Begg, who had studied aborigines and concluded
have ever been able to deliver his paper
that nature intended for enamel to wear. He
describing his extraction technique if Angle had
decided that orthodontists could mimic nature
still been alive. Angle’s influence over the society
by extracting teeth prior to orthodontic therapy.
The Tweed and Begg extraction philosophies
eventually prevailed and remained uncontested
for some time.
Several years passed before Holdaway ,
published his articles that suggested the soft
tissue as the determining feature of diagnosis.
This disputed Tweed’s narrow diagnostic
regimen that focused on the mandibular incisor
and totally neglected the soft tissue. Tweed’s
triangle set in motion a trend that emphasized
more prudence in the extraction of teeth. Soon
others added their discoveries regarding soft tissue
and the maxillary incisors as main determinants
of diagnosis and treatment planning.
From the inception of this specialty, with Angle,
diagnosis never had too much importance because
everyone received the same non-extraction
treatment with the same expansive appliance. The
marvel of it is all that the collection of orthodontic
Fig. 18.2: Dr Tweed records never became important. A few months
History of Fixed Orthodontic Appliances 169
ago an orthodontist boasted that since invoking a introduced the E arch, i.e. expansion arch that
different treatment regimen, he was treating 98 used a labial wire supported by clamp bands on
percent of his patient non-extraction using the molar teeth which ligated to the other teeth.
treatment. One was tempted to ask if he still took Metallurgical developments by the early 20th
records because with diagnostic certainty such century allowed clinicians to encase all of the
as that, records are clearly redundant. teeth with bands and solder attachments that
Orthodontists should not waste patients’ time could control the horizontal rotations. Angle
and money taking impressions, cephalometric developed a popular attachment known as the
X-rays or doing treatment simulations, if all pin and tube attachment in 1911, and it satisfied
treatment plans are essentially the same. One does many of the requirements of clinicians; but this
not need orthodontic records to come to such a demanded unusual dexterity, patience and skill,
preconceived conclusion. so dental clinicians evolved to a ribbon-arch
Obviously, this one-size-fits-all treatment bracket, which Angle introduced in 1918. It
planning did not benefit patients a hundred years provided good control in two-dimensions and
ago, and it does not in our own age, but such became popular quickly. The ribbon arch
simplicity continues to hold enormous appeal for attachment also marked the first time orthodontic
attachments gained the name bracket.
many orthodontists. Orthodontists pride
When Angle launched the ribbon-arch bracket,
themselves in being scientists, and without doubt

he had already started work on the edgewise
they receive good training in the scientific method;
bracket primarily as a supplement to his ribbon-

but it takes very little anecdotal information to
arch appliance. Nevertheless, the edgewise
eclipse the scientific judgment of many in the
bracket did not suddenly spring full-grown from
profession. Albert Szent-Györgyi was probably
Angle’s fertile mind, but slowly evolved with
more right than he knew when he said, “The brain several iterations. When Angle realized that this
is not an organ of thinking but an organ of survival bracket could deliver three-dimensional control
like a claw and fang. It is made in such a way so of the teeth with horizontal, one directional
as to make us accept as truth that which is only placement and simultaneous engagement of all
advantage.” the teeth, he changed the bracket several times
No matter how spectacularly orthodontic until he achieved it in 1928. It received early and
therapy changes, it will benefit our patients enthusiastic endorsement from dental clinicians
minimally if we do not have a concomitant throughout the United States and eventually
improvement in our diagnostic and prognostic eclipsed other useful orthodontic appliances such
knowledge. This remains the number one as the McCoy open tube appliance, the Atkinson
imperative for those who practice orthodontics. universal appliance and the Johnson twin wire
Orthodontists should view any new therapy attachment.
unaccompanied by equally sophisticated The universal application and durability of
diagnostic knowledge suspiciously. Patients have the edgewise bracket confirmed Angle’s immodest
already received far too much orthodontic claim that it offered the “latest and best in
treatment but diagnosis. orthodontic mechanisms”. Innovators have added
minor but practical trimmings such as rotating
Instrumentation wings, twin brackets, different dimensions,
The first attempts to correct malocclusions used preadjusted appliances, lingual applications, etc.,
simple large arch wires ligated to the malposed but the essence has remained edgewise. For any
teeth. Pierre Fauchard of France developed the instrument, particularly in the health sciences, to
precursor of the modern appliance — expansion remain virtually unchanged (and almost as useful
arch. for close to a century) approaches unbelievability.
This arrangement gave only tipping control, In the automobile industry, this would be equivalent
in one dimension, and soon proved inadequate to the Model T Ford remaining as the epitome of
for controlling rotations. In 1887 Edward H Angle motoring sophistication.
Other than adding wings and doubling the Self-ligating brackets that essentially form a
bracket to make the popular twin edgewise bracket, tube, developed several decades ago with the
Angle’s invention has remained basically Ormco Edgelok 26 being the first, closely followed
unchanged. Holdaway suggested angulations for by the speed bracket. Both of these early self-
brackets to help set anchorage, parallel roots and ligating systems suffered from the fact that the
artistically position teeth, while Lee had built some straight-wire appliance phenomenon debuted at
anterior brackets with the ability to torque incisors. approximately at the same time, plus a lack of
But it was Andrews who was to develop an appreciation for what the newer titanium wires
appliance that would apply first, second and third could achieve.
order movements to the teeth without making Damon has persisted since 1995 with his
changes in the wire—hence the Straight Wire version of a self-ligating bracket and has
Appliance. Preadjusted orthodontic appliances fundamentally changed the types of arch wires
have dominated the profession for the past 30 years, and the sequence in which clinicians use them.
and the belief in them shows little sign of abating, His experience has shown that with many
even though many have questioned the one-size- patients he can often eliminate distalization of
fits-all idea. molars, extractions (excluding those needed to
reduce bimaxillary protrusions) and rapid palatal
And back again... expansion. He offers compelling clinical evidence
The publication of Frankel’s work with functional of doing this with consistency.
appliances illustrated significant enlargement of The Damon bracket is essentially a tube

dental arches and reawakened an interest in non- designed with the right dimensions to foster
extraction therapy. Nevertheless, Frankel sliding mechanics where needed and enough
mechanics required the use of removable play in the system for torque and rotational
appliances, and that did not resonate well with control using the larger cross section wires.
many orthodontists or their patients. After a brief Damon starts cases with a large lumen arch wire
flurry of interest in the United States, few clinicians slot and 0.014 or smaller diameter hi-technology
continued to use the Frankel appliance on a arch wires. Starting cases with a large dimension
regular basis. passive arch wire slot and small diameter wires
Nevertheless, the successful use of orthopedic diminishes the divergence of the angles of the
appliances alerted orthodontists to the possibility slots. This lowers the applied force and binding
of increasing arch widths and arch perimeters friction.
with minimum forces. Although mandibular The most logical questions readers could
canines offer significant resistance to expansion, propose would be why has Damon shown
mandibular premolars and first molars often successful expansion whereas Angle did not?
demonstrate substantial and stable expansion. The quantity of expansion probably differs little,
Brader hinted at this with his work on the tri- but the quality of expansion offers a quantum
focal ellipse arch form, but he did not follow change. Mollenhauer has suggested as much
through about how this might give wider and with his appeal for light forces. Even though
more accommodating arch forms. Angle used a ribbon arch, (which suggests a thin,
Low-force titanium coil expanders have delicate wire) the actual size of the wire had the
shown their ability to develop arches laterally, dimension of 0.036 × 0.022 inches. Ligating to this
and recently Damon has suggested that low arch wire would overwhelm the periodontium and
wire forces, coupled with a passive tube and a prevent the development of a supporting
small wire-to-lumen ratio, enable teeth and their dentoalveolus. Rather than forming new bone, the
accompanying dentoalveoli to expand in all supporting dentoalveolus would simply bend and
planes of space. Damon feels that using small, upon completion of treatment quickly return.
low-force wires such as those of Copper Ni-Ti™ Astute clinicians often see this with molar
(Ormco Corporation, Orange, CA) achieves the distalization from headgear use and over treat
ideal biological forces proposed long ago by such movement in order to compensate for this
several investigators. regressive bone bending.
Schwartz stated that it takes 20 to 26 g/cm² of

force to collapse the capillaries in the Periodontal
ligament. With RPEs and headgears, this force
sometimes exceeds 10 pounds! Proffit states that
optimal force levels for orthodontic tooth
movement should be just high enough to stimulate
cellular activity without completely occluding
blood vessels in the periodontal ligament.
True biomechanics is staying in the optimal
force zone, i.e. keeping forces below capillary blood
pressure. Conventional ties (o-rings and stainless
steel ligatures and spring clips) make staying in
the optimal force zone nearly impossible due to the
increased binding and friction.
The most important caveat Damon offers
clinicians is not to use their ordinary mechanics
with his system, and I could not agree more. When
I first began to use the Damon system, I continued
to use the regular sequence of arch wires and saw

little advantage to these new, more expensive

brackets. Nevertheless, as I began to use the
brackets according to Dr Damon’s advice, I started
seeing phenomenonal changes. The following
patient illustrates typical responses to the
biomechanics offered by the Damon system.
E-ARCH APPLIANCE
E-arch appliance was developed by Angle in early
1900. It is also referred to as Edward Angle‘s E-
arch. It was the first Angle’s orthodontic appliance
developed to treat malocclusions. E-arch
appliance consists of bands which are placed on
molar teeth on either side of the arch of a heavy
labial arch wire extended around the arch. The
ends of labial extended arch wire threaded to the
buccal aspect of the molar bands allowed the arch
wire to be advanced so that the arch perimeter
increased. Individual teeth were ligated with the
heavy labial extended arch wire with ligature wire
of 0.010" (Fig. 18.3).
PIN AND TUBE APPLIANCE

Pin and tube appliance was also developed by
Edward H Angle. In this pin and tube appliance,
all teeth are banded. Vertical tubes were welded
to the bands on the labial surface in the center of
the crown for all teeth in the arch. Arch wires
were secured with soldered pins that inserted into
the vertical tubes (Fig. 18.4). Tooth movement was
Fig. 18.3: E-arch appliances
Fig. 18.4: Pin and tube appliance
achieved by altering the placement of these pins.

Pin and tube appliance is also used for treating
malocclusions
RIBBON ARCH APPLIANCE
Ribbon arch appliance was also developed by
Edward H Angle and it is the modification of pin
and tube appliance. This appliance was
introduced in 1910. Ribbon arch was the first
appliance to use a true bracket. The bracket has a
vertical slot facing occlusally. The brackets were
attached to the bands at the center of labial surface Fig. 18.5: Ribbon arch appliance
of teeth (Fig. 18.5).
EDGEWISE APPLIANCE surface of arch wire with the bracket slot and thus
In order to overcome the deficiencies encountered give accurate control over tooth movement (Fig.
with his previous techniques, Angle desired a 18.6). The term Edgewise refers to the method by
metal bracket that could give a better control over which rectangular arch wire is inserted into the
individual tooth movement. The edgewise bracket horizontal slotted bracket. The edgewise appliance
has a rectangular slot facing labially, rather than was developed and introduced to orthodontics by
occlusally or gingivally, which receives a Edward H Angle in the year 1925.
rectangular arch wire. This unique feature of Every generation of men admires his own
rectangular arch wire in a rectangular slot enabled wisdom, skill, science, art and progress. In light
control of tooth movement in all three planes of of today’s progress, it is interesting to know that
space. Furthermore, the bracket has four wings, two today orthodontists believe he is doing something
occlusal and two gingival, which increase the heretofore never practiced. Although the practical
suitably placed. The flat strip of metal was

made in the form of an arch of various crooked
teeth were secured to it by threads passing
around them and through the holes. The
threads were tied for force application. Thus
the first Expansion arch was introduced.
ii. Dwinelle’s jackscrew (1849): In 1849, Dwinelle
invented the regulating Jackscrew. It delivered
a pushing force on the teeth. Angle improved
the jackscrew by making it more delicate and
by increasing the force.
He developed later a regulating retracting
screw which delivered pulling force on the
teeth soldering was introduced at this time
to provide for the attachment of the Jackscrew
and the retracting screw to bands.
iii. Kingsley’s headgear: In 1861, Kingsley
introduced the headgear to apply extra-oral
force and provide acceptable anchorage.

Angle respected Kingsley so much that he

incorporated this headgear into his system.
iv. Magill’s band: The practice of orthodontics
has changed forever in 1870 with an invention
that most orthodontist have not seriously
associated with treatment. It was the
invention of dental cements by Magill which
later lead to the development of band which
could be attached to tooth.
v. Coffin flexible piano wire: In 1861, Coffin
introduced flexible piano wire and after 26
Fig. 18.6: Edgewise appliance years, Angle (1887) developed the prototype
of the first bracket attachment a delicate metal
growth of orthodontist has occurred during the tube soldered to the band. These two
last hundred years, hardly we find any material inventions which took 26 year apart enabled
progress in this science until within the last half the orthodontist to apply the rotation force on
century. Out of the great achievement by mankind teeth.
in orthodontics the edgewise mechanics was one vi. Bakers (case) rubber elastic: In an article “the
of the last and greatest contribution of Edward H use of Indian Rubber in Regulating teeth”
Angle after a lifetime devoted to the development (1896) according to him, very light forces
of the orthodontic appliance. The edgewise generated by the Indian rubber is sufficient for
appliance reflexes the philosophy of Edward H regulating the tooth movement .
Angle. This was designed to allow orthodontists He used it to provide intermaxillary force of
to place the teeth into Angle concept of “Lines of anchorage.
Occlusion”.
EVOLUTION AND DEVELOPMENT OF THE
WHAT WAS ORTHODONTICS BEFORE EDGEWISE APPLIANCE
ANGLE SYSTEM?
To start with, simple basic E-arch which is the
i. Funchard’s bow (1728): The first scientist first appliance described by Angle in early 1900,
attempt at tooth movement occurred in 1728 is capable of tipping tooth crowns into proper
by a French Physician, Pierre Fauchard, made alignment. This is the first appliance to employ
use of a flat strip of metal, pierced with holes stationary anchorage or bodily control of the
anchor molar teeth. But Dr Angle realized the short orthodontists who have conscientiously studied
comings in this approach and thereafter developed the possibilities and potentials of this appliance.
the pin and tube appliance in 1910, by which the It is interesting to note, that in 1943 Dr Robert
tooth roots could be brought into proper axial Strang made the statement that he was certain
relationships. But the difficulties encountered that undiscovered possibilities are still to be
with this mechanism involved the high degree of brought forth, from this device to aid the specialist
skill necessary to obtain proper parallelism in difficult corrective procedures. However, it is
between the tubes and the arch wire and also the necessary to constantly bearing mind the basic
necessity to unsolder the pins every time. It was philosophy and concepts of the edgewise
designed to move teeth in different locations on appliance as originally presented by Dr Angle.
the arch wire and also correction of rotations. The basic concepts are still the key success with
The next step in the evolutionary process was its use.
the development of the ribbon arch appliance in
1915. The ribbon arch bracket was actually the EVOLUTION OF BRACKET
first bracket as such, to be used in an appliance. It
The evolution of edgewise bracket is the study
is obvious, therefore this was a great step forward
that has to be heard and read and never to be
in the development of orthodontic appliances. The
forgotten. This story started in 1916 in the form of
chief advantage of the ribbon arch appliance was
ribbon-arch bracket as devised by Dr E H Angle.

the fact that rotations were easily accomplished.
Although it became very popular at that time the
It is also offered buccolingual and incisogingival

bracket could not mask its deficiencies. Some of
movements. Gingivo-incisal and gingivo by
the highlighting faults of these brackets were:
occlusal movements are also possible.
a. It could not control tooth movement in all three
The main disadvantage was that mesiodistal
planes.
axial movement was difficult to obtain, second
b. Root control was not upto expectations.
disadvantage is the difficulty in obtaining distal Hence, Angle decided to modify this bracket
tipping movements of the buccal segments, third and the year 1925 the “edgewise bracket” was born
the size of ribbon arch itself did not offer the to overcome the deficiencies of the ribbon arch.
stability thought necessary for stabilization or Angle reoriented the soft from vertical to horizontal
anchorage of the posterior teeth. and inserted to rectangular wire rotated 90 degrees
Dr Angle’s final achievement was presented to the orientation. It had with the ribbon arch, thus
shortly before his death. The edgewise appliance the name “edgewise”. The bracket was referred to
was introduced to the dental profession in 1925. initially as “open face” or “tie bracket”.
The edgewise arch mechanism was designed to The edgewise bracket by Angle was made
allow the orthodontist to place the teeth into with soft gold with a 0.022 × 0.028" slot that was
Angle’s concept of “Line of occlusion”. The readily deformed by the forces of occlusion and
original bracket was designed with slot 0.022 by by tying ligature wires to the bracket. The original
0.028 inch. Over the years, many changes and edgewise bracket was redesigned into the cross
modifications have been made in the basic section that is used today. The original design
appliance itself. has been modified to provide a slightly larger
Gold alloy arch wires were used exclusively bracket and one with greatly increased tying area
in the formative years of the appliance. Although under the wings; this increased area makes the
Dr Angle intended the edgewise appliance to be placement and tying of ligature wires much easy.
used only for treatment without the removal of The brackets are modified in so many ways.
teeth, to fit into is concept of the line of occlusion, For examples, single width bracket, twin bracket,
the mechanical principles of this original thinking curved base twin bracket, twin bracket tooth
were so sound that the basic philosophy is still in rotation, etc.
use today. It will probably have considerable value
EVOLUTION OF EDGEWISE BUCCAL TUBES
in orthodontics for many years to come.
Over the years, new principles of force The last tooth in the arch that is banded, which is
application and control have been evolved by usually a molar, has been commonly referred to
as the anchor tooth. A section of tubing instead of The architect must determine geometrically, the
some type of edgewise bracket is placed on the curvature of the arch and the weight is to be
buccal surface of the anchor molar and as is called maintained, because each unit of an arch is an
the buccal tube. In edgewise appliance, the active, working component tending to maintain
original buccal tube was a piece of 0.22 × 0.028" its own position and to give support to its
gold or nickel silver tubing soldered to the molar adjacent component. There is a central distribution
band. The buccal tube is for insertion and of force between the various blocks that maintain
stabilization of the arch wire, which is inserted this structure in equilibrium.
into the tube horizontally and is therefore The same principle applies in a dental arch;
completely encased in the sheath like structure. consider each of the teeth as supporting
structures, each maintaining itself against the
THE CONCEPT OF THE IDEAL ARCH pressures transmitted from the adjacent teeth. The
line of force resistances which maintains the teeth
At an early stage in his development, man
are properly positioned anatomically or
recognized in the arch, a strong, stable frame work
mechanically to produce a balanced arrangement.
upon which to build structures. The igloos of the
Therefore, it is imperative that each unit in a dental
Arctic and the mud huts of the plains are examples
arch be in a precise anatomical relationship to its
of structures employing the keystone and
neighbors and that each contact relationship be

balancing effect of arches and domes.
such that forces are distributed through the center
An excellent comparison of the orthodontic

of mass of the crown in the horizontal plane.
arch with other natural arch formations was made
some time ago by Dr Mathew Lasher. He noted There is arch integrity along a smooth curve,
that the shell of an egg has extreme strength in through the center of mass in the mesiodistal plane
spot of its delicate structure and that the curved in the anterior teeth. These may be termed the
walls and ceilings of caves maintain their integrity “haunches” of the arch. The basis of this smooth
for millions of years. Dr Lasher went to compare curve is the cuspids, which may be called the
the architectural arch with the dental arch, a “Springers”. The bicuspids and molars are
comparison, with slight modification, that is supports and may be termed the “pillars”. This
worth reviewing. structure is buttressed or reinforced laterally by
the cheek on the outside and the tongue on the
Comparison of Architectural inside. Theoretically the dental arch will maintain
and Dental Arches itself if the bicuspids and molars are not disturbed
by lateral force. If such forces are present, then the
To appreciate the concept of the ideal dental arch, entire arch may lose its continuity and its integrity
it is necessary to describe the basic principles
will be destroyed.
which lead stability to the architectural formation
known as the voussoir arch. A series of wedge— Cause for Collapse of Arches
shaped units usually made from blocks of stone Four basic reasons for failure of arches:
are arranged to form a structure with a curved 1. Slipping of the voussoirs: The curvature of
outer surface and a curved inner surface. This arch the arch is either too flat or too pointed and
will be self supporting even without and joining the haunches or side blocks are more in or
material and it is possible to determine the out because they cannot take the strain, e.g.
distribution of forces which tend to maintain and Irregular arrangement of teeth.
support it. 2. Rotation of voussoirs: The line of action or
The top block [A] is known as the keystone. Block resistance passes to the outer or inner third
B, resting on the ground itself or the structure upon of the blocks, rather than through the middle,
which the arch rests is called the abutment. Blocks C creating a tendency in part of the blocks to
known as haunches. The curved inner surface is rotate in the arch and to cause failure.
called the intrados and the curved outer surface is 3. Crushing: The weight imposed on the arch is
called the extrados. The height of the arch is called greater than the strength of the material to
the rise, and the width is called the span. resist.
4. Failure of the buttresses: If lateral stresses the curvature of the lingual surfaces of the
exceed the limits of the additional support, maxillary anterior teeth should conform to a
the buttress will fail, and the entire structure continuous smooth arch. This being the case, the
will collapse. labial outline of the maxillary anterior teeth at the
The similarity of problems of the anatomical brackets will vary according to the differences in
arrangement of teeth to those of the architectural thickness of the teeth themselves. The general
arch has been noted for many years. In dental position of all the maxillary anterior teeth must
arches, only slipping and rotations will cause the relate to the labial contour of the mandibular
collapse of arches. Slipping is mainly because anterior arch.
which irregular arrangement of the teeth and In the mandibular arch, arch wire
rotations of the teeth occurs when the line of force configuration again is governed by tooth shape
does not pass through the center of mass of the and size. The variation of the labial outline will
tooth. Crushing of the voussoir arch, does not be governed by the dimensions of the individual
occur in the dental arch. teeth at bracket level. Consequently, there is a
difference between the labial outlines of the
Failure of buttresses: The buttressing effect of the maxillary incisal teeth and of the mandibular
cheeks and tongue against bicuspids and molars incisal teeth which relate to the labial contour of
is demonstrated clearly by the integrity and the mandibular incisal teeth. In the mandibular
stability of this area when arch widths are not arch, the labiolingual dimensions of the four
changed during treatment.
anterior teeth are the same, so that a continous arc

is contoured. The smaller labiolingual dimensions
Ideal Arch Form
of the mandibular canine reduce the effect in this
A consideration of the causes of failure of the area.
dental arch automatically gives an insight into In its normal position, the mesiobuccal cusp
the primary objectives of orthodontic treatment in the maxillary and mandibular molar is much
for maximum stability, it is essential that arch more prominent than rest of the tooth. Therefore,
integrity be established of ideal arrangement of an offset, or a step out, as it is sometimes called is
the teeth. The teeth should be positioned as necessary to make the wire conform to the buccal
indicated by Edward H Angle to conform to the surface of maxillary and mandibular molars.
“line of occlusion”. The general form assumed by the arch wire in
Accepting this it is also necessary to accept each arch, therefore, must be a curve in the anterior
the concept of the ideal arch as essential to a well section and a general tapering distally,
balanced tooth arrangement, that is progressively increasing in arch width.
fundamentally stable and will more likely THE IDEAL ARCH WIRE
maintain its integrity, with this objective all arch
wires made, and towards it all planned tooth The purpose of an ideal arch wire is: to transmit
movements are predicted. to the brackets through the contour of the wire,
The variation in dimension and shape of the the ideal arch form of the teeth, for particular
different teeth in each arch makes their patient.
relationship which each of them unique and Forming the arch wire: There are different
precise, if arranged in an ideal arch form. Since methods of forming an arch wire as well as
there is a variation in anatomical dimension in a different techniques for different wires, i. e. gold
labiolingual direction of various teeth at the alloys and stainless steel. Arches are made in one
bracket level, it is necessary to consider several of the three ways.
anatomical demands that determine the 1. By indirect measurement
arrangement of teeth in an ideal arch form, the a. The Angle methods—using graph
maxillary arch, the central incisor is a thicker b. The Bonwill-Hawley method
tooth than the lateral incisor, and so as the cuspid. 2. By direct measurement—patient mouth (Chair
Since the maxillary anterior teeth contact the side)
mandibular anterior teeth, it is safe to assume that 3. By adaptation: on a plaster, model
The ideal arch wire can be made by any one of 2. Secondary or second order bends : Are also
those three methods, depending upon the known as tip back bends are bends placed in
understanding and skill of the operator. The the arch wire in the vertical plane. They are
“Angle” and “Bonwill-Hawley” methods provide utilized to tip the teeth in the buccal segments
a means of obtaining perfect arch symmetry by of both dental arches either mesially or distally.
intermittent checking during the formation of the In edgewise appliance, three types of second
arch wire. order bends are there;
Characteristics of the Ideal Arch Wire i. Tip back bends
ii. V bends
An ideal arch wire has certain identifying iii. Artistic positioning bends
characteristics. It is flat and without bends in its i. Tip back bends: Tip back bends for
vertical plane other than the curve of speed. It is preparing anchorage in edgewise
bilaterally symmetrical and has the following appliance. It is an upward and downward
bends in the horizontal plane. bend. These bends are placed between II
The anterior bend: This is the arch that extends bicuspid, first molar, and in between I
around the labial of the teeth from cuspid to cuspid. molar and II molar. The degree of tip back
The lateral set-back bends: Because of the in the terminal molar is such that, when
labiolingual thickness of central and cuspids as the arch wire is placed in the buccal tubes,
compared to the lateral incisors known as the it will cross the cuspid teeth at the dento-
lateral set-back bends. enamel junction.

The mesial cuspid bends: The demarcation The arch wire when raised and ligated to
between the cuspid eminence bends and the lateral the two brackets on the first molars are
set-backs is made at the mesial of the cuspid and depressed. At this point, the arch wire will
is known as the mesial cuspid bend. lie gingival to the brackets of the second
premolar teeth.
The buccal sweep: The part of the arch wire that
ii. V bend: These V bends are placed between
extends distally from the cuspid eminence is not
the lateral and cuspid teeth. The apex of
a straight line, but instead it has a slight or gentle
the V is pointed gingival.
curve running from the cuspid to the end of the
Significance: It separates anterior segment
arch wire. This gentle curve forms an arch that is
and posterior segment. It differentiates
at least equal to the thickness of the archwire.
torque in anterior and posterior segment.
The molar bayonet bends: The first and second iii. Artistic positioning bends: Are important
molars usually extend buccally out from the line for the finishing phase of treatment. These
of the cuspid and bicuspid surfaces due to the bends are necessary because the long axis
buccolingual thickness of those teeth. To of each tooth is inclined relative to the plane
compensate, the arch wire is bent abruptly of a continuous arch wire. Without
outward by a double bend called the bayonet bend. adequate artistic positioning bends, the
incisor teeth are positioned straight up and
Arch Wire Bends down with the roots too close together
producing an effect sometimes
All bends placed in arch wires during treatment disparagingly called “orthodontic look”.
of the various types of malocclusions with the 3. Tertiary or third order bends: Better known
Edgewise arch mechanism may by classified into as torque are placed in the arch wire to effect
three general types. buccolingual or labiolingual root and crown
1. Primary or first order bends: Are those bends movements in single teeth or groups of teeth.
placed in the arch wire that do not alter the Torque is a twist in the wire in the horizontal
horizontal plane of the wire. plane. In upper anterior teeth the torque value
Examples: The various bends used to form the in positive means palatal root torque or labial
ideal arch wire when properly placed, permit crown torque and in upper/lower in posterior
the arch wire to lie tangent to a glass slab in its teeth torque given in negative is buccal root
entirety. torque.
ADVANTAGES AND DISADVANTAGES OF 5. Tipping of tooth crown is impossible with

EDGEWISE APPLIANCE rectangular wires. It is most important in
certain stage of the treatment of almost every
The edgewise appliance was invented by Angle
patient, to produce no tooth movement other
and introduced to the dental profession in 1925.
than tipping of tooth crowns. For example,
It was then far the advance of any other appliance
in the control that it give the orthodontist over bidentoalveolar potrusion.
the movement of the teeth, and it has never lost 6. Patient cooperation: Heavy forces cause pain,
that position. as well as for anchorage using headgears.
From mechanical viewpoint, the best appliance 7. Anterior movement of dental arches: It has
would be one that offers the most complete control been found that, soon after edgewise arch
of the teeth in all three planes of space with the wires are fully engaged in tie brackets on all or
least amount of material. Edgewise is an exacting most of the teeth their is in most patients, some
appliance, requiring thorough understanding anterior movements of the dental arches as a
and skill in its manipulation. It is a labial arch whole. The explanation for this anterior
technique offering excellent control in the movement is that the sum of the forces exerted
labiolingual, mesiodistal and vertical directions. by the arch wires and transmitted through the
It is possible with one rectangular arch wore to tie brackets to the roots of teeth is to produce
an anterior thrust on the dental arches. It is
move teeth in three planes of space. Other

appliances may be able to achieve a comparable because tie brackets have a significant
degree of control, but not without auxillary mesiodistal dimension arch wires exert force
attachments to the main arch wire. mesially or distally on tooth roots when
1. The ability to obtain tooth movements in all engaged in the brackets.
three planes of space with a single arch wire. BUILDING TREATMENT INTO THE EDGEWISE
This is true for all the teeth in both arches. APPLIANCE
2. The philosophy of treating to an ideal arch
or the Angle’s concept of the line of occlusion. There are several basic principles of appliance
3. The use of rectangular or square edgewise construction that have been referred to as
arches which, if properly used; control arch building treatment into the appliance in this
widths, arch form, buccolingual crown instances is defined as the basic components that
inclinations, axial root inclinations and incisor are cemented to the teeth—the bends with their
crown and torque. respective attachments. The shape and
manipulation of arch wire and auxiliaries are
Disadvantages directly related to the basic appliance that is fixed
1. Operator skill is required. Bends incorporated upon the teeth. Many of the adjustments and
in the arch wire should be accurate to get tooth movements that require highly
proper finishing of the case. complicated arch wire bends can be produced
2. Heavy forces generated: Causes pain without these time consuming adjustments, if
discomfort to the patients, damage to tooth some of the treatment is built into the appliance,
roots. by placing the brackets and tubes in such a
3. Anchorage control or extraoral anchorage: position that they become unnecessary. The
Edgewise mechanism was designed to achieve following principles will result in more consistent
universal tooth movements. But the forces results with far less effort. The time spent in
delivered by it are much too high. These incorporation of these details into the basic
excessive forces limit its tooth moving appliance construction will pay large dividends.
efficiency because, high forces prevent tooth Bracket angulations: Angle described how
movements from being kept under control. edgewise brackets were soldered to band stripes,
When force is applied with the edgewise with the bracket slot parallel to the band strip, at
mechanism, there is movement of the anchor the same time, he suggested angulated posterior
teeth as well as of the teeth which are to be brackets to produce desired tooth movements. The
moved. general rule in the earlier days of the edgewise
4. More chair side time. appliance was to place the band strip on the teeth
with the brackets parallel to the long axis of the think of solution and he came up with the light
teeth. In 1941, Tweed pointed out the short wire differential force technique, now popular by
comings of this approach. He advocated arch wire the name Begg technique. He modified the ribbon
bends to obtain correct axial inclinations and arch bracket with a vertical slot facing gingivally.
called them “artistic positioning” bends. Although biocompatible, the gold arch wire
In 1952, a classic article by Holdaway was expensive and forces were insufficient. In
described three uses for bracket angulation. search of an alternative, Begg approached his
1. As an aid in paralleling roots adjacent to
friend AJ Willcock, who was a metallurgist.
extraction spaces.
Willcock developed Australian austenitic arch
2. As a method of sitting up posterior anchorage
wires, which were biocompatible, flexible,
units into tipped back or anchorage prepared
positions. formeable, malleable, resilient and also
3. As a means of obtaining correct axial inexpensive. Begg technique advocates the use of
inclinations or artistic positioning. differential force and tipping of teeth crowns rather
than bodily movement. Roots are torqued at the
Torqued Bracket Slot end of the treatment.
In the original and basic edgewise bracket, the Although a number of other advanced fixed
slot is cut at a right angle to the base. The techniques have been developed lately, Begg
rectangular arch wire must be twisted or torqued technique is still used in many parts of the world.
to obtain correct crown root inclinations. Begg appliance/technique uses stainless steel
At the suggestion of “Ivan Lee”, manufacturers
began to offer brackets with torqued slots. These
brackets introduced in the later 1950s or early
1960s, were designed to eliminate the need for
adding torque to the anterior portion of the upper
archwire.
Jarabak described the use of torque brackets in
1960s that had a raised base of approximately
0.016". This projected the bottom of his bracket
slot further from the labial surface and eliminated
the need for lateral offset bends.
Angulated buccal tubes and brackets in the 1960
have to build the correct rotation into the appliance.
In addition, during this period at least one of the Fig. 18.7: Begg appliance
manufacturers introduced a biangulated tube that
incorporated 10 degree of torque as well as rotational
control for the upper molars.
BEGG APPLIANCE
The Begg appliance (Fig. 18.7) was introduced by
Dr PR Begg (Fig. 18.8) in the year 1930.Begg
studied in Angle‘s school of orthodontics and later
began practicing in Australia. After a couple of
years of practice neither his patients nor himself
were satisfied with the treatment using appliances
available then, namely ribbon arch and pin and
tube appliance. The treatment period was too long,
oral hygiene was a prime issue and soft tissue
irritation and oral ulcers due to extensive metallic
design were common. These problems led him to Fig. 18.8: Dr.P R Beg
arch wires along with a number of auxiliaries and The Straight Wire Appliance
springs to achieve the desired tooth movement. Origins: Since its introduction in 1971, the straight
wire appliance has become widely appreciated
STRAIGHT WIRE APPLIANCE by orthodontists. It was designed by “Lawrence
Straight wire appliance/technique (Fig. 18.9) is a Andrews”, an orthodontist practicing in San
modification of edgewise appliance and it was Diego, California. To assist in establishing a
developed by Lawrence F Andrew in the year definition of ideal occlusion, a study of excellent
1970, based on his six keys to normal occlusion. untreated occlusions was undertaken and a
Brackets used in this technique are having pre- remarkable collection of more than 120 sets of
built tip, angulations and torque. study models amassed. From examination of the
records of these “non-orthodontic normals”
Introduction (Straight Wire Appliance) Andrews arrived at his six keys of normal
occlusion and, with this clear goal in mind, set
Prior to 1970, the Begg’s and Edgewise appliance about designing an appliance to facilitate
were the most commonly used appliances in
attainment of his treatment objectives.
orthodontics. These appliances served the
profession well for many years and quality ANDREWS SIX KEYS TO OPTIMAL
results were achieved by those, who devoted the OCCLUSION
time and effort to learn, their proper use. In the

The following terms are necessary for discussing
1950s, both Begg’s and edgewise practitioners,

the six keys.
began to seriously consider ways to achieve, the
1. Andrews plane: The surface or plane on
same or even higher quality results with less wire
which the mid-transverse plane of every
bending time and more simplified mechanics.
crown in an arch will fall when the teeth are
The results of this effort was the development of
optimally positioned.
the concept of ideal gnathologic or pre-angulated
2. Clinical crown: Normally, the amount of
orthodontic appliance. Such an appliance was
crown that can be seen intraoral, Orban has
envisioned as follows. If an ideal gnathologic set
defined the clinical crown as the anatomical
up was completed on study models of a given
crown height minus 1.8 mm.
patient, the pre-adjusted appliance would;
3. Facial axis of the clinical crown (FACC): For
1. Have bracket bases that accurately fit each
all teeth except molars, the most prominent
tooth at a predetermined point
portion of the central lobe on each crown’s
2. Have bracket slots that are passively a
facial surfaces. For molars, the buccal groove
“straight wire” coordinated to the patient’s
that separates the two large facial cusps.
arch form.
4. Facial axis point (FA point): The point on the
facial axis that separates the gingival half of
the clinical crown from the occlusal half.
Tooth type: A subordinate category within a
class of teeth. I molar, II molar.
5. Crown angulations: The angle formed by the
facial axis of the clinical crown {FACC} and a
line perpendicular to the occlusal plane.
Crown angulation is considered positive when
the occlusal portion of the crown, tangent line,
or FACC is facial to its gingival portion,
negative when distal.
6. Crown inclination: The angle between a line
perpendicular to the occlusal plane and a line
that is parallel and tangential to the FACC at
its midpoint (the FA point). Crown inclination
is determined from the mesial or distal
perspective. Crown inclination is considered
Fig. 18.9: Straight wire appliance positive if the occlusal portion of the crown,
tangent line, or FACC is facial to its gingival Key VIII: Anterior guidance: In mandibular
portion, negative to lingual. protrusion, opening should be guided by the
incisors. There should be disocclusion of all other
Key I : Interarch Relationships: Key I patients to
teeth.
the occlusion and the interarch relationships of
the teeth. This key consists of seven parts: Key IX: Canine guidance: Lateral movements of
• The mesiobuccal cusp of the permanent the mandible should guided by the working side
maxillary first molar occludes in the groove canines. There should be disocclusion of all other
between the mesial and middle buccal cusps teeth on both working and non-working sides.
of the permanent mandibular first molar.
Key X: Cusp embrasure contact: The intercuspal
• The distal marginal ridge of the maxillary first
position should be even throughout both buccal
molar occludes with the mesial marginal ridge
segments.
of the mandibular second molar.
• The buccal cusps of the maxillary first molar Historical Background
occlude in the central fossa of the mandibular
Until the mid 1970s, most fixed appliance therapy
second molar.
was carried out using the standard edgewise
• The buccal cusps of the maxillary premolars
bracket, either in single or twin form, having a 90o
have a cusp embrasure relationship with the
bracket base and bracket slot angulations. Arch
wire bending by the orthodontist was required in
• The lingual cusps of the maxillary premolars
order to achieve adequate results.

have a cusp fossa relationship with the
Two major disadvantages resulted from this
treatment method:
• The maxillary canine has a cusp-embrasure
Arch wire bends were time consuming and
relationship with the mandibular canine and tedious. Even in the hands of experienced operator,
first premolar. The tip of its cusp is slightly adjustments were imprecise and hard work
mesial to the embrasure. requiring hours of additional chairside attention.
• The maxillary incisor overlaps the mandibular The short comings of the bracket system and
incisors and the midlines of the arches match. the extreme skill required of the orthodontist,
Key II: Crown angulations: Essentially all crowns resulted in many undertreated cases which led to
in the sample have a positive angulation. the second disadvantage. Molars were not in a
true class I relationship, lacked torque. In effect
Key III: Crown inclination: the resulting occlusion, had the appearance of a
• Most maxillary incisors have a positive “nice orthodontic result” rather than a pleasing
inclination, mandibular incisors have natural dentition. Equally important, the long-term
negative inclination. stability of tooth alignment was compromised by
• Canines and premolars are negative failing to establish ideal tooth relationships.
inclination. I and II molars have more
negative inclination. The Straight Wire Appliance
Key IV: Rotations: The fourth key to optimal Prior to the 1970s, there were minor appliance
occlusion is an absence of tooth rotations. adjustments made in the direction of preadjusted
Key V: Tight contacts: Contact points should appliances (i.e. tipping of the brackets to minimize
about unless a discrepancy exits in mesiodistal the need for II order bends), but it was not until
crown diameter. Lawerence F Andrews evaluation and
measurement of the non-orthodontic normal study
Key VI: Curve of spee: The depth of the curve of models, followed by his development of the
spee ranges from a flat plane to a slightly concave Andrews’ straight wire appliance that the
surface. preadjusted appliance became a sophisticated
three-dimensional system commercially available
Additional Keys
to the orthodontist.
Key VII: Intercuspal position: Intercuspal It was hailed by clinicians as a radical step
position and retruded jaw relation should be forward offering the dual advantage of less wire
coincident. bending, coupled with an improved quality of
finished cases. For the first time, a system second 7. Self limitations of movement. Hence, even if
to offer an escape from the drudgery of wire the patient misses one or two appointments
bending. If the finished stage of treatment was nothing untoward can happen.
less taxing on the patient and orthodontist then 8. Finishing is excellent, not only is the esthetics
perhaps, the quality of the completed case would enhanced but it is possible to produce
be greatly enhanced. mutually protected occlusion. The stability of
The old mechanics and heavy force levels were result is thereby guaranteed.
developed for standard edgewise brackets. Simply
did not transfer to the new sophisticated bracket LIMITATIONS OF STRAIGHT
system. Operators found that many unwanted WIRE APPLIANCE (SWA)
changes occurred early in treatment in response
It is wrong to assume that no wire bending at all is
to the heavy forces in particular. A “Roller
necessary with Single wire appliance (SWA).
coaster” effect was frequently observed, with
While no bending is necessary in the initial stages
rapid, undesirable deepening of the bite.
of treatment, finishing required some wire bending
Another frequent observation was in the area
in almost every case. First, because the appliance
of the premolars and canines which tended to tip
prescriptions are based on averages, they cannot
and rotate into the extraction sites. Such
possibly account for all the variations of tooth size
unwanted tooth movement retarded treatment to
and shape. This means that detailing bends would

such a great extent, that the theoretical advantage
be needed in finishing wires of some patients.
offered by the new system was dramatically

Second, bracket placement is such an exacting
compromised.
requirement of preadjusted appliance that when
brackets are not properly positioned, they must
The Late 1970s
be repositioned or compensatory bends must be
There was two possible ways to proceed. The route made. Wire bending may be necessary for over
taken by Andrews (and later by Roth) was to correction.
maintain the same force levels and treatment Other criticism that have been leveled against
mechanics, but introduce features into the the SWA include:
bracket system to prevent undesirable changes. 1. The higher forces that may be needed
Hence extra torque was introduced into incisor 2. Torque values
brackets and anti-tip and anti-rotation features 3. Attempt to confirm each patient arch to the
were added to canine, premolar and molar same basic arch form.
brackets. There was the extraction of translation Not withstanding these limitations, the SWA
series of brackets, some of which were alter is a significant step forward in rendering
grouped together to produce the definitive Roth “Quality orthodontic treatment and has come to
appliance. stay at the end of the treatment, a stage of
Today the straight wire concept has been finishing and detailing is required. Rectangular
modified by Roth, Ricketts and Alexander. The finishing arch wires must incorporate a complex
advantages of straight wire appliance include: series of adjustments to compensate for labio-
1. Precise control of premolar and molar torque. lingual crown position (first order bends)
2. Bilateral symmetry of buccolingual mesiodistal root position or tip (second-order
inclination. bends) and labiolingual root position or torque
3. Bilateral symmetry of arch form. (third order bends)”.
4. Use of straight arch wires with few or no Straight wire attachments incorporate
bends. This reduces chairside time. In individual adjustments for each tooth, the
addition, the results are not compromised due thickness of the base of each bracket and tube
to clinicians wire bending limitations. varies so that ideal alignment can be obtained from
5. Precise control of finishing in both areas in all a simplified arch form, omitting the inset and offset
three planes of space. bends required with traditional edgewise
6. Elastic use is very minimal and confined to appliance. The angle at which the arch wire
last stage of treatment. intersects the long axis of the labial faces of the
teeth is also predetermined in such a way so as to associated with potential back pain and related
build in the optimum tip for each tooth. Finally discomfort may have discouraged many
the angle at which the slot is set into the operators— although these difficulties were
attachment is adjusted to provide the ideal torque. overcome with practice and enhanced efficiency
of clinical technique — resulting in the
LINGUAL TECHNIQUE abandonment of many early lingual orthodontic
Since the earliest fixed lingual orthodontic treatments, which were completed with labial
appliances appeared in the mid to late 1970s, they appliances. An early generation of frustrated
have been subject to significant vicissitudes. clinicians came to believe that accurate, efficient
Beginning in 1979, an initial wave of popularity lingual orthodontic treatment was an inherent
occurred when the first mass-manufactured paradox — much like earlier views that, achieving
lingual brackets were released in the United States. manned flight was impossible. Many negative
At that time, the media and public had been made perspectives continue to be propagated,
aware, rather suddenly, of a new technique that particularly in North America. Thus, much of the
would allow straightening of teeth, without the long-term development of lingual orthodontic
requirement for traditional labial “outside therapy has occurred in other parts of the world,
braces”. No matter how vigorously esthetic labial including Japan, Italy, France, Korea, Germany,
brackets (e.g. plastic, polycarbonate, vinyl and Singapore and Australia, Turkey, Israel and South
ceramic brackets) or other moderately effective Africa, although there are a few dedicated
alternatives (e.g. Invisalign [Align Technology practitioners in the United States.

Inc., Santa Clara Calif.]) have been promoted over The lingual technique (Fig. 18.10) was
the years, many adults do not seek orthodontic introduced by Craven kurz in 1976. Dr Craven kurz,
treatment because of the perceived embarrassment
of wearing braces.
The earliest consistently documented work on
lingual appliances began around 1975, when 2
orthodontists working independently in Japan
and the United States started developing their
own systems to place braces on the inside surfaces
of the teeth. The early prototypes were based on
modified, traditional “outside” braces. Much
credit has been given to late Dr Craven Kurz of
California, who with co-workers developed the
early Kurz/Ormco lingual bracket system.
However, over the same period, significant
development was made by Professor Kinya Fujita,
of Kanagawa Dental University in Japan, who
continues to make great advances in this clinical
discipline.
Why Lingual Orthodontics Developed

Slowly in North America
Clinical protocols had not been fully elucidated
in those early days, resulting in many clinicians
feeling impelled to begin lingual orthodontic cases
without being fully prepared. Orthodontists
found that the new lingual technique required
much more rigorous attention in detail, as well as
a fundamentally different approach to treatment
planning and biomechanics. Postural challenges Fig. 18.10: Lingual technique
an assistant professor at UCLA school of dentistry, aspects of life than unattractive people.
realized that many of his patients were adults. Improvement in one’s physical appearance, as is
This led to the development of the concept of common with orthodontic treatment, can
the lingually bonded appliance, consisting of positively affect social and professional
plastic Lee Fisher brackets bonded to the lingual interactions. The use of unattractive labial
aspect of the anterior dentition and metal brackets orthodontic practice can negatively affect one’s
bonded to the lingual aspect of the posterior self-esteem. Many patients, if given the choice,
dentition. The plastic brackets were used for the would opt for an appliance that was not visible,
inherent ease of recontouring and reshaping them provided the course and treatment and quality
to avoid direct contact with the opposing teeth. of results were the same as with a conventional
Dr Fujita of Japan published cases treated with treatment. Thus was born the methodology of
his modification of the Begg light wire appliance. lingual orthodontics.
He had bonded the Begg brackets lingually or Even before the development of true lingual
palatally and used the same AJ Willcock appliance, the orthodontic company Ormco in
Australian austenitic arch wires contoured to the conjunction with Dr Wildman, had attempted to
lingual aspect of the teeth. He explained the arch develop a system to align the dentition using the
form which resembled a mushroom (when viewed lingual approach. This system consisted of a
occlusally) and advocated the same basic steps pedicle positioner, rather than a multibracketed
as in the conventional Begg technique to be used system. Although innovative, the inherent
with the Begg brackets with a modified base. limitations of this system prevented it from gaining
The 1970s was an exciting decade for widespread popularity in orthodontic community.
orthodontics. The straight wire appliance was It was only in early 1970s that Dr Craven Kurz,
developed, treatment demands had increased, and an assistant professor at UCLA school of dentistry,
adults were seeking treatment in greater numbers. realized that a major portion of his private
This increasing demand for adult treatment orthodontic practice was dominated by adult
brought unique concerns to the profession. patients. Dr Kurz developed the first true lingual
Esthetics was then and continues to be a primary appliance, consisting of plastic Lee Fisher brackets
concern of patients. Adult patients present with bonded to lingual aspect of the anterior dentition
unique challenge, of wanting to look good even and metal brackets bonded to lingual aspect of
during orthodontic treatment. They have posterior dentition. The plastic brackets were used
demands of their work and broader social needs for the inherent case of recontouring and
to consider. They think that braces are normally reshaping them to avoid direct contact with
meant for kids. In an effort to provide solution to opposing teeth. Around the same time Dr K Fujita
these esthetic problems, tooth colored brackets and of Japan published cases treated with his
wires were also introduced. But these brackets modification of the Begg light wire appliance. He
were invisible only from a distance and staining had bonded the Begg bracket lingually and used
of the bracket and the tooth presented a significant the same Australian A J Wilcock wire contoured
problem. The search for improved esthetic to lingual aspect of teeth. He explained the arch
alternatives to metal or clear brackets continued. form which resembled a mushroom and advocated
Some orthodontists thought of placing braces on the same basic steps as in conventional Begg
the lingual side, leaving the labial surface technique to be used with Begg bracket with
retouched. modified base. Further, research was carried out
During the evolution of lingual appliance by individuals and group of individuals
therapy, the technique has moved in and out of associated together, with financial finding from
public and professional favor. Over the years, the orthodontic manufacturing companies. The
appliances and techniques have improved lingual task force was setup by Ormco to develop
dramatically and as a result, a reliable system has a commercially viable lingual appliance.
emerged. The lingual task force pioneers Dr Kurz,
Research has shown that physically attractive Gorman and Smith were the first to conduct
people achieve higher levels of success in many courses on the edgewise lingual appliance, Dr
Vince Kelly of Oklahoma and Dr Steve Paige of increased width of PM bracket

Florida were the first to start giving courses using allows better angulation and
Begg appliance lingually. rotation control.
Dr Dilier Fillon of France is the only 9. Ligation.
orthodontist to have restricted his practice to 10. Attachment.
lingual orthodontics exclusively. Modifications were done from time to time
to correct these drawbacks :
Some of the drawbacks encountered during
the development of lingual orthodontics were :
Drawbacks of Lingual
1. Tissue irritation and speech difficulty
2. Gingival improvement 1. Discomfort to the tongue.
3. Occlusal interference 2. Difficulty in speech, which usually improves
4. Appliance control after two to three weeks of appliance
5. Base pad adaptation placement.
6. Appliance placement and bonding 3. Extended chairside time needed for appliance
7. Appliance prescription placement and adjustments.
8. Wire placement. 4. Expensive.
Generation 1 1976 Flat maxillary occlusal bite Advantages
plane from C-C the lower
incisor and PM bracket were • The labial enamel surface of anterior teeth
low profile and half round. plays an important esthetic role.

No hooks. • In labially placed brackets, the susceptibility
Generation 2 1980 Hooks were added to canine of enamel surface to chemical results and
brackets. plaque accumulation with poor oral hygiene
Generation 3 1981 Hooks added to all anterior is increased.
and PM brackets the first • Permanent and unsightly decalcification
molar had a bracket with marks can result in labial.
internal hook. • Easy access for routine oral hygiene
Generation 4 1982–84 Addition of low profile procedures on the labial surfaces.
anterior inclined plane, hooks • Clinical judgment of treatment progress can
optional. be enhanced.
Generation 5 1985–86 Anterior inclined plane
• Evaluation of individual tooth position can be
because pronounced,
easily accomplished by having labial surface
increase in labial torque in
maxillary anterior region
free of distracting metal or plastic brackets.
TPA attachment. • Soft tissue responses of the lips and cheeks to
Generation 6 1987–90 Inclined plane because more treatment can be judged accurately because
square in shape. Hooks on there is no distortion of shape or irritation
anteriors and premolars caused by labial appliance.
were elongated. Hooks on all Four distinct situations exist where lingual
brackets. appliances may be more effective than labial
Generation 7 1990– Maxillary anterior inclined appliances because of their unique mechanical
Present plane is now heart-shaped with characteristics.
short hooks. The lower ante- • Intrusion of anterior teeth
rior brackets have larger incli- • Maxillary arch expansion
ned plane with short hooks.
• Combining mandibular repositioning
The premolars brackets were
therapy with orthodontic movements
widened mesiodistally and
hooks were shortened, the • Distalization of maxillary molars.
History of
Myofunctional 19
Orthodontic Appliances
• History of Activator • History of Herbst Appliances

• History of Frankel Appliance • History of Twin-Block Appliance
• History of Bionator • History of Double Plate

• History of Oral Screen • History of Tooth Positioner
The term “Functional appliance” means that to orthopedic devices. The animal studies of the
when the appliance is fully seated in the mouth, 1960s and 1970s created enormous enthusiasm
the mandible is forced into an eccentric/Non- in the professional community and played an
ecentric relation position. Any such mandibular important role in the rapid acceptance and use of
posture causes the musculature to try to move the functional appliances in the United States that
mandible toward a centric position. This results has been largely ignored up till that time.
in force systems being exerted whenever the There were two important considerations that
appliance is mounted on the teeth or soft tissues were left unanswered. First, would the increase
of the mouth. in overall mandibular length achieved with
Although functional appliances have been used orthopedic devices placed in growing rats and
throughout the century in Europe and in the last monkeys also occur in growing children? Second,
40 years in the United States, it was not until the was the quantitative increase in condylar growth
late 1960s that scientific data were available to demonstrated at a cellular level enough of an
evaluate the empiric rationalization for their clinical increase to make a relevant clinical difference in
effectiveness. This early data consisted of animal humans? In response to these issues, various
experiments demonstrating histologic and investigators in the 1970s and 1980s conducted
radiographic evidence of increased growth of the retrospective clinical studies. This was occurring
condylar cartilage when the mandible was held at the same time that many clinicians were
in a forward position. Breitner’s early monkey embracing functional appliances as the answer
studies and Alexander Petrovic and coworker’s of mandibular deficient patient. A number of these
initial findings and usually rats as models were retrospective studies demonstrated some average
complemented by later primates and rat studies modest increases in mandibular growth (2–4 mm
conducted by number of independent investigators. per year) during treatment with functional
Petrovic suggested that the unique characteristic appliances. Other investigators did not consider
of the condylar cartilage, including cell division the effect of functional appliance on quantities
of the prechondroblast (as opposed to the lengthening of the mandible to be clinically
chondroblast in epiphyseal cartilage of his long significant. In addition, it became clear that there
bones or cartilage in the synchondroses of the was much greater variability in the mandibular
cranial base) make this cartilage more responsive growth response of humans to functional
History of Myofunctional Orthodontic Appliances 187
appliance that in the animal models. Also the

variability of growth potential in response to
orthopedic treatment was much greater for the
mandible than for the maxilla.
The enthusiasm for functional appliance in
the United States during the 1980s considerably
moderated in the 1990s in the light of the less
impressive results of the retrospective clinical
studies complemented by clinical experiences.
Although a modest mean increase in mandibular
growth may occur for a group of patients being
treated with functional appliances, the increase
is not predictable because of the great variability
in patient’s response. In addition, there still is
uncertainty whether discernible mandibular
growth acceleration is nearly temporal and does
not result in an absolute final gain in mandibular
length. In other words, it is possible that the
ultimate length of the mandible may not be altered

appreciably in spite of accelerated growth during

treatment. There still has been no clear
demonstration that the observed treatment effects
represent true growth stimulation beyond the limit
of human growth variation. In spite of the
continued controversy around the reliability of
gains in mandibular length from functional Fig. 19.1: Viggo Andersen
appliance treatment, there are the effects that
sagittal corrections that he could not produce with
contribute to the correction of Class II
conventional fixed appliances. The original
malocclusion.
Andresen activator was a tooth-borne, loosely
fitting passive appliance consisting of a block of
ACTIVATOR
plastic covering the palate and the teeth of both
Viggo Andresen(1870–1950) (Fig. 19.1) in 1908 arches, designed to advance the mandible several
in Denmark designed a loose filling appliance millimeters for Class II correction and open the
which he first used on his daughter. He made a bite 3 to 4 mm. The original design had facets
modified Hawley type of retainer on the maxillary incorporated into the body of the appliance to
arch to which he added a lower lingual horse- direct erupting posterior teeth mesially or distally,
shoe shaped flange which helped in positioning so, despite the simple design, dental relationships
the mandible forward. Viggo Andersen removed in all 3 planes of space could be changed. In
his daughter’s fixed appliances before she left for designing an inert appliance that fitted loosely in
her summer vacation, as was customary at the the mouth and, because of its mobility, transferred
time, and placed a Hawley-type maxillary muscular stimuli to the teeth, jaws, and
retainer. On the mandibular teeth, he placed a supporting structures, Andresen had taken a
lingual horseshoe flange that guided the mandible decisive step in orthodontic treatment. Although
forward about 3 to 4 mm in occlusion. Andresen, he had effectively redesigned Robin’s monobloc
a Danish dentist, did not start specializing in to correct Class II Division 1 malocclusions, he
orthodontics until 1919. On his daughter’s return, declared that he had no knowledge of Robin’s
he was surprised to see that nighttime wearing of work at the time. Andresen’s novel device was
the appliances had eliminated her Class II not initially well received. First, removable
malocclusion, and it was stable. Applying this appliances were not much accepted at that time.
technique to other patients resulted in significant Second, the profession was under the influence of
Martin Schwarz, whose active plate was then a there was no mention of “growth stimulation”.
common form of removable not functional Activator use became so widespread among
appliance. Finally, Andresen advocated European practitioners that there was concern that
extractions, although not necessarily in proper diagnosis was being neglected.
connection with activator treatment. And, in Unfortunately, reminiscent of Angle’s following,
contrast to Angle’s concept of ideal occlusion that “functional jaw orthopedics became a profession
was then prevalent, Andresen advocated a more of faith, a religion, beside which no other opinion
realistic “individual and functional gnathological was tolerated”. Furthermore, Reitan, in his 1952
optimum”. Thus he was subjected to the same type doctoral thesis, questioned Roux’s hypothesis
of ridicule that Tweed endured years later. In 1925, and demonstrated that no special histologic
Andresen, then director of the orthodontic picture emerged from the use of functional
department at the University of Oslo, began appliances. His findings were supported by later
developing for the government a simple method researchers. Andresen and Häupl later
of treating Norwegian children. He modified his collaborated on a textbook (Funktions-
retainer into an orthodontic appliance, using a kieferorthopädie) about their system in 1936. The
wax bite to register the mandible in an advanced sixth edition included Leopold Petrik as coauthor.
position. At the university, Karl Häupl (1893–1960) Although Häupl’s complete rejection of fixed
(Fig. 19.2), an Austrian pathologist and appliances led the profession astray for a time,
periodontist, saw the possibilities of the appliance had it not been for his promotional efforts, the
and became an enthusiastic advocate of what he activator might have languished in obscurity. The
and Andresen called the “Norwegian system”. advantages of the activator include:
Häupl’s theories were inadvertently strengthened 1. Treatment in the deciduous and early or late
by the findings of Oppenheim, who showed the mixed dentition is possible and successful,
potential tissue damage caused by the heavy 2. Appointments can be spread out to 2 months
orthodontic forces of fixed appliances. At that time, or more
3. Tissues are not easily injured
4. The appliance is worn at night only and is
acceptable from an esthetic and hygienic
standpoint
5. It helps eliminate pressure habits, mouth
breathing, and tongue thrusting.
Its disadvantages include:
1. Success depends on patient compliance
2. Activators are of little value in marked
crowding, so that patients must be selected
3. The appliance does not obtain a good
response in older patients
4. Forces on individual teeth cannot be
controlled with the same degree of exactness
as in fixed appliances.
During the time of Viggo Andresen and Häupl
the appliances were made of vulcanized rubber,
but this gave way to acrylic in the 1950s. Over the
year, various modifications have been made to
the original design of Andresen’s appliance such
as:
1. The bow activator of AM Schwartz
2. Wunderer’s modification
3. The propulsor
Fig. 19.2: Karl Häupl 4. Cutout or palate free activator
5. The reduced activator or cybernator of Types of Frankel Appliance

Schmuth
There are five types of Frankel’s Appliances a are
6. Kawetzky modification
as follows:
7. Herren’s modification of the activator.
1. FR-I is further divided into 3 types:
Most of the modifications of Andresen
FR-I a
appliance were based on Andresen’s concepts.
FR-I b
There can be advantages to using a simple design
FR-Ic
in terms of patient cooperation, case of adjustment
2. FR-II
and freedom from breakages.
3. FR-III
4. FR-IV
Graber Observed That
5. FR-V
“Numerous modifications have been made to the
Andresen—Häupl monobloc and have been Indications of Various Types of Frankel
described in texts and periodical contributions by Appliance
Petrik, Eschler, Hoffer, Grossman and others. These FR-I a appliance of Frankel: Treating Angle’s
are surprisingly effective at times but generally a class I malocclusion with deep bite.
simpler design of appliance is performed.” FR-I b appliance of Frankel: Indicated for treating
cases of Angle’s class II division 1 malocclusion

FRANKEL APPLIANCE where the overjet does not exceed 5 mm.

A more recent innovation in functional appliance FR-I c appliance of Frankel: Indicated for treating
design, the functional corrector or functional cases of the Angle’s class II division I maloccl-
regulator or Frankel Appliance was designed by usion where the overjet is more than 7 mm.
Rolf Frankel (Fig. 19.3) in Germany and was FR-II appliance of Frankel: Indicated for treating
introduced to orthodontics in 1966. This appliance cases of Angle’s class II division 1 malocclusion
was unique in that, it was principally tissue-borne, and class II malocclusion.
FR-III appliance of Frankel: Indicated for Angle’s
mostly supported in the vestibule rather than
class III malocclusion
supported by teeth. There are five types of Frankel
FR-IV appliance of Frankel: Indicated for treating
appliances and are used for management of
bimaxillary protrusion and open bite.
Angle’s class I, Class II and class III malocclusions
FR-V appliance of Frankel: It is used with head-
and even it is used in bimaxillary protrusion
gear.
.Types and their indication in specific
malocclusion is explained below. BIONATOR
The Bionator was developed in Germany by
Wilhelm Balter in the early 1950s to increase
patient’s comfort and facilitate daytime wear to
increase the functional use of the appliance. Balter
accomplished this by drastically reducing acrylic
bulk of the appliance. There are three types of
Bionators ,
1. Standard bionator
2. Class III or Reverse bionator and
3. Open bite bionator.
Standard Bionator
Standard bionator is used for the treatment of class
II division 1 malocclusion and Angle’s class I malo-
Fig. 19.3: Rolf Frankel cclusion having constricted (narrow) dental arch.
Class III or Reverse Bionator

Class III bionator is also known as reverse
bionator and is used for the treatment of Angle’s
Class III malocclusion caused due to mandibular
prognathism.
Open Bite Appliance

This type of bionator is used in open bite cases.
Uses of Bionatar
1. Class II malocclusion.
2. Class III malocclusion.
3. Deep bite cases. Fig. 19.4: Pancherz
4. Open bite cases.
ORAL SCREEN (VESTIBULAR SCREEN) determining the amount of anterior mandibular

development. The tube is attached to a maxillary
Newell in 1912 introduced oral screen. It is posterior root, whereas the plunger is fixed
composed of acrylic base material which fits in anteriorly to the mandibular dentition and slides
the buccal/labial vestibule of the mouth. through the tube during opening and closing
movements.
Indications
Indications for oral screen includes TWIN-BLOCK APPLIANCE
1. Oral habits such as Twin-block appliance is a functional jaw
a. Thumb sucking or Mouth breathing orthopedic appliance developed by Scottish
b. Tongue thrusting orthodontist William Clark in the year 1977.
c. Lip biting. The Twin-block appliance is composed of
2. In cases of mild proclination of maxillary maxillary and mandibular retainers that fit tightly
anterior teeth. against the teeth, alveolus, and adjacent
supporting structures. Delta clasps are used
HERBST APPLIANCE bilaterally to anchor the maxillary appliance to
The Herbst bite jumping mechanism was the first permanent molars and 0.030 inch ball
developed by Emil Herbst in the early 1900s.The clasps are placed in the interproximal areas
original banded design of this appliance was anteriorly. The precise clasp configuration
introduced at the International Dental Congress depends on the type of deciduous or permanent
in Berlin (Germany) by Herbst in 1905.It was teeth and number of teeth present at the time of
introduced by Pancherz. Pancherz (Fig. 19.4) used appliance construction.
a banded Herbst design that involved the Various designs are available for the lower
• Placement of bands on molar part of the twin block appliance. The original
and premolar design advocated by Clark and it consists of a
• Bands are connected by copper Maxilla horse shoe of acrylic that extends anteriorly from
lingual wire the mesial of the first permanent molars.
• Bands on lower right first premolar The acrylic covers the lingual aspect of the
and lower right first premolar premolar/deciduous molars and the canines and
• Bands are connected by a Mandible incisors. In this design, delta clasps are used to
lower lingual arch wire anchor the appliance to the first premolar/first
The Herbst appliance is a fixed functional deciduous molar and ball clasp are present between
orthopedic appliance having passive tube and the canines and lateral incisors, additional ball
plunger system with the exact length of the tube clasps can be placed between the incisors if
appliance retention is thought to be a problem. which the patient could insert the remainder of
There should not be any acrylic material touching his mandible. In so doing, however, the pull of
the lower molars, this allows the lower molar to scar tissue led to a slight widening of the maxillary
erupt vertically if the acrylic on the maxillary block arch. Bimler reasoned that it might be possible to
is trimmed to increase the vertical dimension. expand the arch by means of crosswise
The Twin-block appliance has been shown to mandibular movements, and the Bimler appliance
produce increase in mandibular length, incisor was born. Bimler also developed, about 1938, the
proclination and variations in lower anterior “roentgenphotogramm,” by superimposing a
facial height. photograph on a head plate, to show the
The posterior bite blocks of the twin-block relationship between the skull, the teeth, and the
appliance can be trimmed to facilitate the eruption soft tissues something done today by computer.
of the lower posterior teeth in patient with a deep World War II brought European orthodontic
bite and an accentuated curve of spee. The blocks progress almost to a standstill. Nevertheless,
also can be left untouched to prevent the eruption functional appliances got a boost because precious
of the posterior teeth in patients with a tendency metals were no longer available for fixed
toward an anterior open bite. appliances. In Germany, dentists were ordered to
specialize in functional jaw orthopedics. Still, the
Indications war brought its own brand of progress. After
several modifications, the Bimler appliance

Twin-block appliance most commonly used in the
achieved its final form in 1949. Compared with

treatment of class II malocclusions.
previous functional appliances, its reduced size
made it possible to wear all day, its elasticity
Duration of Treatment
allowed muscular movements to translate more
Full time wearing of twin block appliance effectively to the dentition, and, because the upper
including during eating and the duration of and lower parts were connected by a wire, gradual
treatment usually is about (9–12) months. forward positioning of the mandible became
Just as Andresen’s discovery of the activator possible. Also like Andresen, Bimler was attacked
was an accidental outgrowth of his retainer, so by the functional establishment, in particular
was Hans Peter Bimler’s (1916–2003) (Fig. 19.5) Häupl, for his new ideas, but every functional
Elastischer Gebissformer (elastic bite former) a appliance subsequently developed has
fortuitous development. As a surgeon treating jaw incorporated at least one of his innovations.
injuries during World War II, Bimler had devised
a maxillary splint for a patient who had lost his THE DOUBLE PLATE
left gonial angle. The splint provided a guide into
A Martin Schwarz (1887–1963) (Fig. 19.6) began
his career as an ear, nose, and throat physician
but was diverted into dentistry by famed
histologist Bernhard Gottlieb. He became director
of Kieferorthopaedia, Vienna Polyclinic, and the
jaw orthopedics division of the Viennese
government in 1939, where he expanded
orthodontic service from 100 to more than 3000
patients. In 1956, Schwarz attempted to combine
the advantages of the activator and the active plate
by constructing separate mandibular and
maxillary acrylic.
THE TOOTH POSITIONER

In 1944, Harold D Kesling (1901–79) (Fig. 19.7)
developed the tooth positioner. The technique
Fig. 19.5: Hans Peter Bimler involved taking impressions of a patient nearing
Fig. 19.7: Harold D Kesling

Fig. 19.6: A Martin Schwarz
completion, denuding the plaster of appliances, be used as a retainer or a recovery appliance. Later
and resetting the teeth into ideal positions (the versions were made of other materials, including
“diagnostic setup”). From the new models, a clear plastic. Out of these innovations developed
rubber positioner was made that, if worn enough T(ooth) P(ositioner) Orthodontics (LaPorte, Ind),
hours, acted as a finishing appliance. It could also which now markets them as Pre-Finishers.
History of Surgical
Orthodontics
20
• Hullihen • Eiselberg and Pehr Gadd • Mowlem Appliance

• Blair • Rosenthal • Pionears
• Brown • Kazanjian • Mandibular Procedures

• Bruhn and Linderman
Oral and maxillofacial surgical procedures are Children with congenital malformations such
sometimes necessary to optimize the results of as cleft lip and palate often require surgical
orthodontic treatment. Surgical orthodontics procedures along with orthodontic treatment for
encompasses all those surgical procedures that their rehabilitation.
are carried out as an adjunct to, or in conjunction In recent times, new approaches have been
with orthodontic treatment. These procedures adapted in orthodontic treatment such as
may range from minor surgeries such as tooth implant placement to gain anchorage and
extraction to major procedures such as distraction osteogenesis for advancement of
orthognathic surgeries of maxilla and/or maxilla or mandible.
mandible. Although orthodontic treatment provides a
In cases of crowding due to arch length -tooth means of correcting maxilla-mandibular skeletal
material discrepancy, it may be necessary to discrepancies, it is limited to actively growing
extract some teeth to obtain proper alignment of children. In non-growing individuals, surgical
teeth. Unerupted teeth may require surgical intervention has been implemented to
exposure to facilitate bracket placement and their circumvent this limitation.
subsequent alignment. The first surgical procedure for the correction
Adult patients with narrow maxilla may need of a craniofacial deformity was reported in 1848,
surgically assisted rapid maxilla expansion to at which time Hullihen successfully performed
correct malocclusion in transverse plane. a partial osteoplastic resection of a prognathic
Cases with significant skeletal discrepancies mandible. The subapical osteotomy of the
and dentofacial deformities cannot be treated anterior mandible was followed by the removal
satisfactorily by orthodontic management alone. of a wedge-shaped section of bone from each side
In such cases, surgical correction by means of of the mandibular body. The anterior segment
orthognathic surgeries of maxilla and mandible was then setback into the new position.
may be indicated to obtain optimal occlusal and Surgical treatment of mandibular
esthetics results. Adult patients with significant retrognathia, however, was not reported until the
skeletal malocclusion may also benefit from 1st decade of the 20th century, when Blair
orthognathic surgery in whom, growth demonstrated the use of a bilateral horizontal
modification procedures cannot be carried out. ramus osteotomy to advance the mandible.
Two years later, Babcock suggested a similar technique did not gain immediate acceptance. This
osteotomy for mandibular prognathism . was primarily due to the lack of control over bone
Osteotomy of the mandibular corpus has also segment manipulation, inadequacy of distraction
been advocated for advancement of the appliances, and the instability of osseous fixation.
retrognathic mandible. According to Limberg, Instead, corrective osteotomies remained a
Brown in 1918 and Bruhn and Linderman in 1921 principal treatment modality for the management
performed a vertical osteotomy of the mandibular of mandibular deformities, especially after the
body followed by acute advancement of the introduction of the sagittal split osteotomy by
anterior segment. The ensuing defect usually Trauner and Obwegeser.
healed by new bone in growth. However, the Although acute bone segment movements
amount of advancement with these osteotomies remained the treatment of choice, the adaptation
was limited and often associated with instability of orthopedic external skeletal fixation to the
of bone segment fixation. mandible rekindled interest in osteodistraction.
In an attempt to increase the contact surface The application of external skeletal fixation for
area between divided bone segments and craniofacial fractures was first reported by
provide greater stability of bone fixation, Haynes, in 1939. Using a number of pins
different modifications of mandibular connected to a rigid bar, he applied this technique
osteotomies were developed. For example, in to a comminuted, compound fracture of the
order to obtain broader contact surfaces, Cryer mandible.

and Limberg performed C-shaped arcing and Based on external skeletal fixators for the
L-shaped oblique osteotomies, respectively, lower extremities, two other external mandibular
concentric with the desired movement of the fixation devices were developed in 1941. The
mandible. Likewise, Eiselberg and Pehr Gadd Mowlem appliance and the Converse and
developed step-like sliding osteotomies for Waknitz appliance were similarly designed and
lengthening or widening the mandible. consisted of three main parts: two pairs of
According to Wassmund, in 1927 Rosenthal fixation pins with locking plates located on either
performed the first mandibular osteodistraction side of the fracture, and an intervening
procedure by using an intraoral tooth-borne telescoping fixation bar.
appliance that was gradually activated over a Stader, in 1942, further modified the
period of one month. mandibular external fixator by adding double-
In 1937, Kazanjian also performed plane-joint elements and a threaded rod to connect
mandibular osteodistraction by using gradual both pin fixation clamps (Shaar and Kreuz, 1942).
incremental traction instead of acute Stader’s fixation appliance was the first
advancement. After performing modified mandibular device that allowed angular
L-shaped osteotomies in the corpus, he attached adjustments in two planes as well as
a wire hook to the symphysis, thereby providing anteroposterior incremental compression or
direct skeletal fixation to the bone segment to be distraction.
distracted. Three days postoperatively, an “over The early 1950s began a period of rapid
the face” appliance was placed and activated development in orthognathic surgery. In 1954,
with an elastic band, thereby exerting traction Caldwell and Letterman developed a vertical
on the chin and gradually pulling the mandibular ramus osteotomy technique, which had the
anterior segment forward. Seventeen days later, advantage of minimizing trauma to the inferior
the elastic force was removed. Occlusal splints, alveolar neurovascular bundle. This method could
connected by rigid bars, remained in place for be used instead of a body ostectomy to correct
11 weeks at which time complete consolidation mandibular excess. Europe then became the center
of the jaw had taken place. of progress. Pupils of the Vienna School of
Kazanjian’s “over the face” appliance for maxillofacial surgery, Richard Trauner and Hugo
gradual advancement of the mandible. Even Obwegeser (1957), introduced the intraoral
though the first distraction osteogenesis bilateral sagittal split ramus osteotomy, allowing
procedures applied gradual traction to the bone corrections in all three planes of space without a
segments and surrounding soft tissues, this need for bone grafting. Even so, it was not until
History of Surgical Orthodontics 195
the early to middle 1960s that mandibular surgeries this possible, even after the introduction of bonding.
became popular in the United States. Marsh At the same time, training of oral surgeons started
Robinson and SM Moos developed a reliable to include orthognathic procedures. Until about
extraoral procedure for prognathism: the vertical 1975, the prevailing concept of facial deformities
subsigmoid or vertical ramus osetotomy with a was that they existed only the sagittal plane, but,
bone cut posterior to the inferior dental nerve. as diagnosis became more thorough, surgeons
Spectacular changes in the midface resulted from acquired a measure of control over the vertical
the treatment of craniofacial deformities and the and transverse dimensions. Plating techniques
orbital areas by Paul Tessier in France during the (1983) and screws for the fixation of jaw fragments
1960s and 1970s. Derek Henderson also developed reduced the risk of relapse and allowed
appropriate planning techniques using a intermaxillary fixation to be dispensed within many
combination of photocephalometry and accurate patients. By the 1990s, the use of rigid fixation
model surgery. He emphasized anticipating soft- had become routine, increasing precision and
tissue changes. Alveolar surgeries were the next patient comfort (eliminating 6 to 8 weeks of wired
procedures to gain popularity in the United States jaws, liquid diets, inability to brush lingually, and
after being pioneered in Europe. In 1959, Heinz “claustrophobia”). More recently, the use of
Köle, a student of Obwegeser, introduced resorbable bone plates in Helsinki and Groningen
subapical dentoalveolar osteotomies in the anterior reduced the risk of leaving plates permanently
mandible. In 1960, Obwegeser began performing in situ or the necessity of a second operation. Other
maxillary surgery and, by 1969, had described technological improvements have included freeze-
many LeFort I osteotomies, marking the beginning dried bone, bovine bone, and autogenous bone;
of a new era in the correction of dentofacial biodegradable osteosynthesis material;
deformities: before the mid-1960s, maxillary hypotensive general anesthesia (to reduce blood
deficiency was typically treated by mandibular loss); smaller instruments with better intraoral
surgery. Obwegeser also performed the first total designs; computer-aided treatment planning; and
2-jaw surgery (1970), facilitating the correction computerized axial tomography scans
of extensive aberrations in a single operation. (3-dimensional reconstruction).
Advances in mandibular surgery included
intraoral vertical oblique osteotomy (for PIONEERS
advancement or setback), total mandibular
subapical osteotomy, and refinement of lower Wescott first reported placing mechanical forces
border osteotomy. Again, Europeans led the way. on the bones of the maxilla in 1859. He used 2
In 1972, Paul Tessier came to New York to double clasps separated by a telescopic bar to
demonstrate the surgeries he had perfected in correct a crossbite in a 15-year-old girl. However,
the 1960s, and it was not until then that American the entire expansion procedure was slow and
surgeons, concerned as they were about blood tedious, lasting several months. A year later,
supply and total or partial loss of the osteotomized Angell performed a similar procedure with a
fragment, could be convinced of the possibilities differentially threaded jackscrew connected to
of moving the midface skeleton. In 1974, the the premolars. Palatal expansion was achieved
European literature featured 104 LeFort I rapidly in 2 weeks by the separation of the
osteotomies that demonstrated remarkable maxillary bones at the midpalatal suture.
stability and predictability. In the mid-1970s, Bell Goddard, in 1893, further standardized the
and Epker started to popularize the procedure, palatal expansion protocol. He activated the
now commonplace in the surgeon’s repertoire. device twice a day for 3 weeks followed by a
About that time, orthodontists and oral surgeons stabilization period to allow the deposition of
began to realize that, contrary to current practice, “osseous material” in the created gap. Codivilla,
orthodontists, having aligned the separate arches, who lengthened a femur to correct limb length
could better detail the occlusion if the appliances deficiencies, first reported bone lengthening by
were left inplace during surgery. Improvements DO in 1905. Abbot then reported lengthening the
in the stiffness of orthodontic wire helped make tibia and the fibula in 1927. These early efforts
were complicated by edema, skin necrosis, advancement with these osteotomies was limited
infection, and delayed ossification of the and often associated with instability of bone
expanded bone. segment fixation. In 1927, Rosenthal performed
the first mandibular osteodistraction procedure
MANDIBULAR PROCEDURES by using an intraoral tooth-borne appliance that
Osteotomy of the mandibular corpus was also was gradually activated over a month. In 1937,
advocated for advancement of the retrognathic Kazanjian also performed mandibular
mandible. According to Limberg, Brown in 1918 osteodistraction using gradual incremental
and Bruhn- Linderman in 1921, each performed traction instead of acute advancement. After
a vertical osteotomy of the mandibular body performing modified L-shaped osteotomies in the
followed by acute advancement of the anterior corpus, he attached a wire hook to the symphysis,
segment. The ensuing defect usually healed by thereby providing direct skeletal fixation to the
new bone ingrowth. However, the amount of bone segment to be distracted.
History of Cleft Lip
and Cleft Palate
21
• Demographic Data • Etiology of Cleft Lip and Palate • Lip and Palate
• Embryological Aspects • Clinical Features of Cleft Lip and Associated Problems
• Classification of Cleft Lip and Palate Palate

The history of surgery of cleft lip and palates rabbit’s mouth. It was once believed that children
reaches as far backwards as the pre-christian era with cleft lips were born to women who, when
to 390 BC when for the first time a cleft lip was pregnant, were frightened by the devil, who had
closed successfully in China. Although Egyptian assumed the shape of a hare. The incidence of
and Greek medicines developed to a remarkable cleft lip and palate—the single most common
degree, no descriptions of cleft operations have defect affecting orofacial structures is
survived. In the middle ages operations on cleft approximately 1 in 1000 births; for cleft palate
lip have been several times described. A successful only, 1 in 200; isolated cleft lips occur in 20% of
operation on a cleft palate did however not occur all clefts. Cosmetic surgery began in the ancient
until 1816. This can be explained by the fact that world. The Romans performed simple techniques
cleft palates were thought to be secondary to such as repairing damaged ears. Physicians in
syphilis, but also because without anesthetic this ancient India used skin grafts for reconstructive
operation was extremely painful and difficult. work as early as 800 BC. However, the early history
Graefe in 1816 and Roux in 1819 published the of cleft lip and palate surgery describes only
first satisfactory results. After the introduction of unilateral procedures.
chloroform cleft surgery made remarkable The first report of surgical cleft lip repair
progress. The development of cleft surgery has appears in Chin Annals, involving repair of an
been chronologically described and finally the apparently congenital cleft in 390 BC. The
present state of affairs is discussed. treatment consisted of cutting and stitching the
Long before dentists held the notion that they edges of the cleft together, followed by 100 days of
could give patients pretty smiles, innovative complete bed rest, when the patient could eat only
surgeons were coping with a challenge far more thin gruel and was not allowed to smile or talk.
fundamental: how to give certain unfortunate Hippocrates (400 BC) and Galen (150 AD)
infants new faces. Many children born with cleft mentioned cleft lips, but not cleft palates, in their
palates, unable to nurse, failed to survive because writings. The first exact description in the western
of malnutrition. Others were left to die either world of cleft lip surgery was given by Johan
because of superstition or because the anomaly Yperman, who practiced in the 14th century. He
was too hideous to contemplate. The term performed a 2-layer operation with waxed,
“harelip”, now considered demeaning, is believed twisted thread. In 1552, Houlier proposed suturing
to have come from the cleft lip’s resemblance to a palatal clefts; 12 years later, Ambroise Paré
illustrated obturators for palatal perforations. For operation in 1827 with instruments that he designed
centuries, perforations of the palate were himself. In 1828, Johann F Dieffenbach enhanced
considered to be secondary to syphilis, and cleft cleft palate surgery by elevating the hard palatal
palate was not recognized as a congenital disorder mucosa to allow closure of the hard palate cleft.
until 1556, when Pierre Franco, along with Paré, He also performed the first closure of both hard
described in detail the principles and techniques and soft palates in 1834. The introduction of general
of cleft palate surgery. anesthesia in the late 1840s led to great advances
Franco has been called the “father of cleft palate in cleft palate surgery. In the 1840s, Simon P
surgery”. Hendrik van Roonhuyze of the Hullihen (1810–1857) advocated surgical repair
Netherlands (1625–1672) advised that a cleft lip in infancy before eruption of the dentition and
should be repaired when the baby was between 3 used an adhesive strap from cheek to the other
and 4 months of age, because if done earlier, the before surgery. In 1861, von Langenbeck was the
results would be unfavorable. James Cook of first to use a mucoperiosteal flap, which was
Warwick (1614–1688) was the first to warn against separated from the hard palate. This method is
removal of the pre-maxilla because of the danger still used in many centers. Norman W Kingsley’s
of interfering with subsequent growth. Pierre Treatise on Oral Deformities as a Branch of Mechanical
Fauchard, in his book Le Chirurgien Dentiste, Surgery in 1880 was the first recognized work on
described several different obturators to close the orthodontic and prosthetic treatment of cleft palates.
cleft palate defect. The first successful closure of a In the field of cleft lip surgery, Hagedorn was a
soft palate defect was reported in 1764 by Le leading pioneer (1884). He used a quadrangular
Monnier, a French dentist, using sutures along flap to increase the thickness of the medial part of
with cautery of the edges (the first palatorrhaphy). the lip. The first attempts at bone grafting in patients
In the United States, Matthew Wilson, practicing with clefts were performed by von Eiselberg in
in the 18th century, was the first to publish an 1901 and Lexer in 1908. Drachter in 1914 reported
account of a cleft lip surgery. Because of the dangers closure of a cleft with tibial bone and periosteum.
associated with surgery in any form, especially The 1930s were an important decade for
that involving the head or face, it was not until developments in both cleft palate and cleft lip.
the 19th and 20th centuries that such surgeries Blair and Brown (1930) attempted to correct the
became commonplace. A successful operation on anterior nares by shifting the tissues toward the
a cleft palate finally occurred in 1816 when C von midline. Also that year, V Veau, a leading figure
Graefe published the first satisfactory results in cleft surgery, advised that bilateral cleft lips
(Philbert J Roux, called by many the founder of could be closed in 2 to 3 stages, depending on the
modern cleft lip and palate surgery, did so in 1819). width of the gap. His name was perpetuated when
Von Graefe cauterized the margins before suturing he devised a 4-part classification of clefts. Later in
them together. When the wound failed to heal, he the decade, Kilner and Wardill independently
freshened the wound margins and fastened them developed the “pushback” procedure (in which
to the cheeks, so that they could not rip out. Roux’s tissue from the palate is moved back to lengthen
operation is well known because the first patient it). The first cleft palate clinic in the United States
to undergo this procedure, medical student John was established in 1939 when Herbert Cooper
Stephenson, wrote a thesis about it to complete opened the Lancaster (Pa) Cleft Palate Clinic.
his degree in medicine. After the introduction of Cooper’s recognition of the need for
chloroform, cleft surgery made remarkable multidisciplinary involvement resulted in the
progress. In 1820, Jonathan C Warren was probably formation of a clinic that had all the necessary
the first American surgeon to perform reconstructive dental and surgical specialists in one location.
rhinoplasty and close a palate successfully. In 1828, He was also among the first to use cineradiography
he performed a successful closure of a soft palate, to evaluate velopharyngeal function. In a patient
noting that, after closure, the width of the hard with a bilateral cleft palate, the surgical closure of
palate cleft also diminished. Thus, Warren became the lip is different from that of a unilateral condition
an early pioneer in preoperative orthopedic because of the position of the pre-maxilla, the short
repositioning of the pre-maxilla. The first plastic columella, and the absence of the muscles in the
surgeon in the United States was John Peter prolabium. Surgeons who excised the pre-maxilla
Mettauer. He performed the first cleft palate to suture the gap in the lip did not realize the
History of Cleft Lip and Cleft Palate 199
damage being done to maxillary growth with this The term harelip often used to denote cleft lip
operation. Elastic traction to reposition the pre- should be discouraged. Cleft lip and cleft palate
maxilla in bilateral cleft lip and palate patients is exhibit wide range of presentation with varying
still being practiced. In 1950, C Kerr McNeil, often degrees of severity; from a small notch in the lip
called the founder of modern-day, pre-maxillary vermillion to a complete bilateral cleft of lip and
orthopedic treatment, described the use of acrylic cleft palate. Cleft may occur in isolation or as part
appliances to reposition bony cleft segments, in of a syndrome.
addition to traction. Also in 1950, TM Graber, in Management of these patients is quite
his PhD dissertation, was the first to document a challenging since clefts of lip and palate are usually
disturbance in facial growth as a result of palatal associated with impaired facial appearance,
surgery. His work led to the alteration and staging speech, hearing, mastication, deglutition, dental
of surgical procedures. About that time, surgeons occlusion and treatment should address these
in Europe were inserting bone grafts as a primary problems. Thus, management of cleft lip and palate
procedure. In the 1960s, Sheldon W Rosenstein, requires a multidisciplinary approach with a long
working with surgeons, introduced the technique term treatment plan and individualized
of placing a plate in the maxilla of a newborn rehabilitation program designed to address the
before surgical lip closure to guide the maxillary treatment needs have given patient. Malocclusion
segments into proper alignment. After lip closure, is usually present and orthodontic therapy with
the aligned segments helped guide the teeth into or without corrective jaw surgery is frequently
better positions and reduced the incidence and indicated.

severity of cross-bite and segment malalignment. The defects generally have profound
The late 1960s and early 1970s was a period when psychosocial implications on the afflicted children
primary bone grafting and maxillary orthopedics and their patents. It is reassuring that, with a team
were in vogue, but by the 1970s many who had approach, the defects are fairly correctable and
previously advocated the bone-graft procedure had need not adversely affect the child’s future.
abandoned it because their results had negative
effects on the growth of the maxilla and the DEMOGRAPHIC DATA
midface. Others, including Hugo Obwegeser, Race
recommended the LeFort I osteotomy with
The reported incidence of clefts of the lip and
secondary bone grafting after development of the
palate varies from 1 in 500 to 1 in 2500 live births
adult dentition, especially as an aid to orthodontic
depending on geographic origin, racial and ethnic
and prosthetic reconstruction. Additionally, much
backgrounds. The incidence of cleft lip and palate
discussion has occurred over the role and the timing
is reported to be highest in Asians (Mongoloids -
of pre-surgical appliances. Both the hard palate
1 in 500), intermediate in Caucasians and least in
and the alveolus can be molded with passive molds
Negroid populations (1 in 2000 to 2500).
and active devices, with the shared ultimate goals
• Jones C (2000) estimated the occurrence of oral
of facilitating surgical repair and providing an
clefts in UK to be 1 in 700 births.
improved long-term outcome in both facial form
• Fough-Anderson (1956) cited 1 in 665 as
and palatal function.
incidence of cleft lip and palate in Denmark.
The word ‘cleft’ literally means a crack, split
• Overall incidence of cleft lip and palate in
or a gap. Orofacial clefts are congenital deformities,
human appears to be 1:700 live births.
which manifest at birth. Cleft lip and cleft palate
are the most common congenital malformations
Sex
of the head and neck region. The term cleft lip and
cleft palate is commonly used to represent two Males are more commonly affected by orofacial
types of malformation which are embryologically clefts, than females by a ratio of 3:2.
distinct that, is, Cleft lip with or without cleft palate is more
1. Cleft lip with or without associated cleft palate common in males than in females (2:1),whereas
(CL ± CP). isolated cleft palate is observed to be more common
2. Isolated cleft palate (CP). in female.
Type and Side ♦ Two palatine shelves, which extend from

left and right maxillary process towards
• Cleft lip with or without cleft palate is more
the midline.
common than isolated cleft palate.
♦ Nasal septum which grows downwards
• Unilateral clefts are more common as
from the frontonasal process along the
compared to that of bilateral clefts (pre-
midline.
alveolar clefts) .
After the descent of the tongue, the elongated
• Unilateral clefts account for 75% of all cleft
palatine shelves become horizontally oriented
seen, while bilateral clefts account for the
and are in close proximity to each other by 8th
remaining 25%.
week. They fuse with each other in the midline
• In cases of unilateral clefts, left side is more
and is represented by the median palatine raphe.
commonly affected than the right side. The
The palatine shelves also fuse with primary palate
reason why left side is more frequently
and the nasal septum.
involved is unknown.
Incisive foramen is present at the junction of
primary and secondary palates. Fusion between
Syndromic and Nonsyndromic
palatine shelves and nasal septum proceeds from
As stated earlier orofacial clefts can occur alone incisive foramen in a posterior direction ending
(nonsyndromic) or as part of syndrome with at uvula; whereas, fusion between the primary
congenital deformities of other parts of the body palate and anterior borders of the palatine shelves
(syndromic). Over 300 syndromes are known to progresses in an anterior direction towards the
be associated with orofacial clefts. However, lip.
clefting syndromes are rare and make up only 5 %
of all clefts. Cleft Lip and Palate Formation
Cleft lip and palate occur when mesenchymal
EMBRYOLOGICAL ASPECTS
connective tissues from various embryological
An understanding of the embryological structures fail to merge with each other.
development of these structures is essential so as • Cleft lip— Arises from failure of fusion between
to appreciate the etiology of these clefts. medial nasal processes and the maxillary
The embryonic development of palate takes process. It can be unilateral or bilateral; and
place between 6th and 9th weeks of intrauterine can be extended into the alveolar process
life. The entire palate develops from two (CL + CP).
structures: • Cleft palate— Arises from failure of palatine
• Primary palate (premaxilla) and shelves to fuse with each other, or with the
• Secondary palate. nasal septum or with the primary palate.
Primary Palate CLASSIFICATION

• The primary palate is the triangular shaped There are many classifications of clefts. Few
part of the palate anterior to the incisive commonly used ones are given below.
foramen. It is developed from frontonasal
process by fusion of two medial nasal I. Embryologic Classification
processes; primary palate forms the premaxilla
Patients with cleft lip and palate can be divided
which carries the incisor teeth.
into two groups which are embryologically distinct.
1. Cleft lip with or without cleft palate (CL ± CP)
Secondary Palate
Include:
• The secondary palate gives rise to the hard ♦ Patients with cleft lip and cleft palate (CL
and soft palate posterior to the incisive + CP)
foramen. It develops from the fusion of three ♦ Patients with cleft lip without cleft palate
parts as follows: (CL)
2. Isolated cleft palate (CP) include: Patient with IV. Kernahan’s Stripped ‘Y’ Classification
cleft palate alone
Kernahan proposed a symbolic classification of
II. Classification by the International cleft lip and palate deformity using a stripped ‘Y’
Confederation for Plastic and having numbered blocks. The incisive foramen is
Reconstructive Surgery (1968) represented symbolically by a small circle with
the dividing pointing between the primary and
This classification has three main groups.
secondary palates.
Group 1—Cleft of Anterior Primary Palate Each right and left limb is divided into three
portions representing respectively the lip, alveolus
a. Lip: and area between alveolus and incisive foramen.
♦ Right side The stem of the Y is similarly divided into three
♦ Left side
portions representing hard palate and soft palate.
♦ Both
Each block represents a specific area of the oral
b. Alveolus: cavity:
♦ Right side
Block 1 and 4 — lip
♦ Left side
Block 2 and 5 — alveolus
♦ Both.
Block 3 and 6 — hard palate anterior to the
Group 2—Clefts of Anterior and Posterior Palate incisive foramen

Block 7 and 8 — hard palate posterior to the

a. Lip: incisive foramen
♦ Right side
Block 9 — soft palate
♦ Left side
Each individual can be diagrammatically
♦ Both
represented by stippling appropriate areas of
b. Alveolus: clefting. In submucous cleft of palate the
♦ Right side
appropriate section is cross hatched.
♦ Left side
♦ Both
ETIOLOGY OF CLEFT LIP AND PALATE
c. Hard palate:
♦ Right side Despite numerous clinical and experimental
♦ Left side investigations, the etiology of cleft lip and palates
♦ Both. in humans is still largely unknown palate. In most
cleft cases, no single factor can be identified as the
Group 3—Clefts of Posterior Secondary Palate cause. Heredity with superimposed
a. Hard palate: environmental factors is considered to be the most
♦ Right side probable cause of cleft formation.
♦ Left side It is important here to distinguish between two
b. Soft palate : Median. forms of clefts; Non-syndromic clefts with no other
related health problem and syndromic clefts
III. Veau’s Classification associated with other birth disorders or
syndromes.
This classification is morphological and described
as four types of clefts: Syndromic Cleft Cases
Group I Clefts of the soft palate only.
Group II Clefts of the hard and soft palate In syndromic cases, cleft occurs by monogenic
extending up to the incisive foramen. mode of transmission, i.e. by a single mutant gene
Group III Complete unilateral clefts involving producing a large effect. Over 300 syndromes have
the soft palate, hard palate, alveolar been reported in the literatures which have
ridge and the lip on one side. associated clefts along with other defects. Most of
Group IV Complete bilateral clefts of the soft these syndromes are rare. Some of the relatively
and hard palate, alveolar ridge and common syndromes associated with cleft lip and
the lip. palate are listed in Box 21.1.
Velocardiofaial syndrome (velum=palate, cardia palate is genetic in origin; less than 20% of isolated
= heart, facies = face) is the most common cleft palates (CP) are genetically determined.
syndrome to exhibit clefts. The features include
the following— Environmental Factors
• Cleft palate Earlier, heredity was thought be single most
• Cardiac defects important causative factor. However, recent
• Characteristic facial appearance studies have shown that, environmental factors
• Learning problems and speech play a significant contributory role at the critical
• Feeding problems. time of embryogenic development when lip and
palate shelves are fusing.
Box 21.1: Common syndromes associated with cleft A number of environmental factors have been
lip and palate suggested as causative factors including:
• Craniofacial Syndromes 1. A defective vascular supply to the area
• Velocardiofacial syndrome involved during critical time of embryonic
• Apert’s syndrome development.
• Crouzon’s syndrome 2. A mechanical disturbance in which, size of
• Carpenters syndrome the tongue may prevent union of parts.
• Down syndrome
3. Excessive concentration of circulating
• Encephalocele
substances such as alcohol, certain drugs
• Goldenhar syndrome
• Hypertelorism
(antibiotics, steroids, insulin) and toxins.
• Pfeiffer syndrome 4. Viral infections.
• Pierre robin syndrome 5. Exposure to radiation.
• Saethre-Chotzen syndrome 6. Hypoxia.
• Treacher Collins syndrome 7. Vitamin deficiencies and excesses.
• Van der Woude’s syndrome 8. Stress.
Nonsyndromic Clefts Risk of Producing a Child with Cleft Deformity

Recent investigations show that both heredity and 1. Every parent has approximately a 1 in 700 risk
environmental factors act together in causation of of having a child with a cleft.
non-syndromic clefts. Such a mode of transmi- 2. Parents having a child with a cleft have
ssion of a defect/trait caused by interaction of increased risk of having the 2nd child affected-
multiple genes and multiple environmental 2% to 5%.
factors is known as multifactorial inheritance. 3. If more than one person in immediate family
has a cleft→ risk rises to 10% to 12%.
Heredity (Genetic Predisposition) 4. A parent having a cleft→ has 2% to 5% chance
of producing a child with a cleft.
In contrast to syndromic clefts caused by single
5. If a syndrome is involved, the risk for
mutant gene, clefts in non-syndromic patients are
recurrence within a family can be as high as
caused by multiple genes (polygenic), each
50%
producing small effects which together create this
6. Maternal age→ increased risk of clefting is
condition.
observed when age of conceiving is late.
Every individual carries some genetic liability
for clefting, but there is no cleft formation until the
CLINICAL FEATURES
threshold level for expression is reached. When
the total genetic liability of an individual reaches Oral clefts commonly affect the upper lip, alveolar
a certain level, the threshold for expression is ridge and hard and soft palates.
reached and cleft occurs. • The clefting anterior to the incisive foramen is
Genetic basis of cleft lip and palate is defined as the cleft of primary palate.
significant but not predictable. Studies reveal that, • The clefting posterior to the incisive foramen
less than 40% of cleft lip with or without cleft is defined as a cleft of secondary palate.
• A patient may have clefting of primary palate, • Periodontal complications

secondary palate or both. • Crowding may be seen
• The clefts can be complete, i.e. extending the • Spacing may be present.
entire distance from the lip to the soft palate or
incomplete. Occlusal Problems
• CL ± CP can e unilateral or bilateral; isolated
• Clefts involving alveolus and palate
cleft palate occurs in midline.
invariably show malocclusion. Patients with
• Severity of CL ± CP may range from a small
clefts especially of the palate, show
notch on the edge of the vermilion border to a
discrepancies in size, shape and position of
wide cleft extending into the nasal cavity.
their jaws.
• Isolated cleft palate may also present with
• Most patients exhibit class III malocclusion
varying degrees of severity. Mildest form is the
with hypoplastic maxilla and relative
bifid uvula. A more severe form is a cleft of the
prognathism of the mandible.
soft palate. A complete cleft palate constitutes
• Along with missing teeth or supernumerary
a cleft of the hard palate, soft palate and cleft
teeth, retardation of maxillary growth
uvula.
significantly contributes to the development
of malocclusion. Scar contracture following
CLEFT LIP AND PALATE ASSOCIATED
early closure of cleft palate significantly

PROBLEMS
retards the growth and development of maxilla
Most patients with cleft lip with cleft palate (CL + in all three planes of space. Narrow high arch
CP) and isolated cleft palate (CP) present with a palate with constricted and retruded maxilla
myriad associated problems. is a common finding.
1. Dental problems
2. Occlusal problems (malocclusion and Feeding Problems
impaired facial aesthetics)
Structural defects of cleft lip and palate prevent
3. Feeding problems
negative oral pressure required for effective
4. Nasal deformity
sucking. Feeding is a major problem in these
5. Ear problems
patients as food and liquids regurgitate through
6. Speech difficulties
the nose. Thus, breast or bottle feeding by sucking
7. Psychological problems.
is difficult. However, babies can swallow
normally, if they are fed directly toward the hypo-
Dental Problems
pharynx. The problem can be overcome through
Cleft involving alveolus often affects the the use of specially designed nipples that are
development of primary and permanent teeth and elongated and have bigger opening which extend
the jaw. The cleft usually extends between the directly into the hypopharynx. Child may swallow
lateral incisor and canine area. Teeth may be lot of air during swallowing and need frequent
congenitally absent in the area of cleft or even burping.
supernumerary teeth may also be present. Teeth
present near the region of cleft may be Nasal Deformity
morphologically deformed or hypomineralized.
Patients with cleft lips often exhibit deformities of
Crowding or severe displacement of the teeth near
nasal architecture, especially when the cleft
the region is a common finding. The patient with
extends into the floor of the nose. Plastic surgery
cleft lip and palate shows the following features .
of nose is usually done at later stage and treatment
• Lateral incisor on the cleft side may be absent.
after correction of all clefts and associated
• Presence of supernumerary teeth
problems.
• Fusion of teeth
• Enamel hypoplasia
Ear Problems
• Multiple missing teeth
• Ectopically erupting teeth Clefts involving soft palate predispose to middle
• Anterior and/or posterior cross bite ear infections. This is because the levator and
tensor veli palatine, the muscles of soft palate are nasopharynx. This is called valopharyngeal
left unattached in case of soft palate clefts. These mechanism. (Valo = softpalate).
muscles have their origins near the auditory tube During speech and deglutition, soft palate is
and under normal circumstances allow opening elevated towards the posterior pharyngeal wall
of the auditory tube into the nasopharynx by contraction of its muscles. Valopharyngeal
facilitating equilibrium and the pressure. mechanism cannot function when a soft palate is
In palatine clefts this function is disrupted, involved by the cleft. The soft palate cannot elevate
the middle ear becomes a closed space without a to make contact with the pharyngeal wall and
drainage mechanism. When tube opening this result in escape of air into the nasal cavity
mechanism is impaired, there is greater producing hyper nasal speech.
susceptibility of middle ear infections. Hearing impairment may further aggravate the
Accumulation of serious fluids and then bacteria speech problem. Retardation of consonant sounds
can lead to serous otitis media. Chronic otitis (i.e. p, b, t, d, k, g) is the most common problem.
media causes hearing impairment, that is common Speech problem should be addressed at the
in patients with cleft palate. earliest, and several years of speech therapy may
be needed to achieve intelligible speech.
Speech Difficulties
Psychosocial Problems
During normal speech, the tongue, lips, lower jaw

and soft palate work together in a highly Impaired facial aesthetics, hearing and speech
coordinated fashion to produce the sounds. The problems often produce psychosocial problems
soft palate is raised during the speech, preventing in these patients. Support of the family,
air from escaping from the nose. The soft palate professional help and social worker are all
functions as a valve to control the distribution of necessary to the normal well being of these
escaping air between oropharynx and patients.
History of Malocclusion
Indices
22
• Index of Orthodontic Treatment Needs • Index of Complexity, Outcome and Need

• Peer Assessment Rating • Dental Aesthetic Index
Traditional orthodontic thinking has emphasized record treatment need in a sample of 256 patients
the major benefits of orthodontic treatment on: in the Scottish Dental Service, most of the
the ‘improvement of physical functions, the treatment being undertaken with removable
prevention of tissue destruction and the appliances. Some reduction was seen in 88 per
correction of aesthetic impairment’. (Standard cent of cases. However, 30 percent of cases were
Dental Advisory Committee, 1973). In times of minimally improved or made worse, and in those
limited resources, it is important that patients cases which started with a marked malocclusion
who need treatment should be treated and that, only about one-third showed a sizeable
when treatment is undertaken, the malocclusion improvement. Sixty-five percent of cases falling
should be corrected to an appreciable extent. in the ‘No treatment need’ category at the start
Many studies in the UK and Scandinavia have of treatment showed a sizeable improvement.
assessed the success of treatment by recording Thirty-five percent of cases falling in the ‘no
the various occlusal traits before treatment, and treatment need’ category at the start of treatment
after treatment. showed no improvement and, in fact, 15 percent
were made worse.
British Studies In a further survey of 51 cases with a class II
Over recent years, the standard of orthodontic division 1 malocclusion treated with removable
treatment undertaken within the general dental appliances (Elderton and Clark 1984), 41 percent
services has given cause for concern. Several of cases finished in the two best categories and
reports have suggested that British orthodontic substantial improvement was found for one
results are not as good as Northern European quarter of the whole sample. However, 20 percent
countries (Cousins, 1973; Shaw, 1983; Haynes, of the cases showed no improvement at all.
1979; British Orthodontic Standards Working In a study undertaken by the Dental
Party, 1986). Reference Service in 1984 (DHSS 1986), for 59
A report on child dental health in England percent of the estimate references (852), the
and Wales (Todd and Dodd, 1985) found that 30 dental officer disaggreed substantially or
percent of 15-year-olds who had previously fundamentally with the proposed treatment. In
received orthodontic treatment were in need of 49 percent of the completed treatments, the
further treatment. The occlusal index (Summers, dental officer considered the treatment unsatis-
1971) was used by Elderton and Clark, (1983) to factory to a major or fundamental extent.
During the year 1986—87, 35,800 orthodontic treatment. Mohlin suggested that the need was
cases treated within the General Dental services still high as much of the orthodontic treatment
were reported as discontinued (14 percent of all was provided 20-30 years ago, probably as a
non-prior approval cases and 26 percent of prior- compromise owing to limited orthodontic
approval cases). resources, removable appliances having been
used in two-thirds of the treatments. The
Scandinavian Studies treatments had probably reduced the severity of
malocclusions, but had not eliminated them.
Myrberg and Thilander, (1973) assessed
However, Myrberg and Thilander (1973), have
treatment results in 1486 cases. In 60 percent,
reported mild to severe relapse in 24 percent of
removable appliances were used, whilst the
orthodontically treated children, 1–5 years after
remainders were treated with fixed appliances.
treatment.
In 54 percent of the cases the result was good
The long-term stability of orthodontic
and in 1 percent treatment had no effect.
treatment has been reported for a group of 96
However, the criteria for assessing the success
patients treated 12–35 years previously
of treatment were not stated.
(Sadowsky and Sakols, 1982), the majority of
Berg, (1979) analyzed 246 consecutively
cases having been treated with both upper and
treated cases, the majority having undergone
lower Edgewise appliances. The authors
fixed appliance treatment. The author looked at

revealed that 72 percent of cases still had
both dental cast and radiographic records. He
deviations outside the ‘ideal’ range. There was

found that the objectives were only achieved in
a tendency for overjet and overbite to increase,
43 percent of all cases. Root resorption was
as well for the development of lower anterior
present in 14 percent of all cases and overjet was
crowding.
not eliminated in 13 percent of Class II cases. the
Other studies have shown that even when
objectives were not achieved in a substantial
optimal treatment results had been achieved,
percentage of class I, class II, and class III
imperfection in alignment and occlusion often
malocclusions. Although all the objectives had
developed in the long-term (Water, 1953; Simons
not been attained, substantial improvement had
and Joondeph, 1973; Little et al 1981, 1988; Udhe
been achieved and the author coined the phrase
et al 1983; Shields et al 1985). The constraints
‘partial success’.
imposed by underlying skeletal discrepancies
In a further study, Berg and Fredlund, (1981)
which could not be changed by orthodontic
used the Treatment Priority Index, TPI (Grainger,
treatment alone were highlighted in a review of
1967) on 60 cases randomly selected from 329
50 consecutively treated patients with an original
consecutively treated patients in two private
overjet of 10–15 mm. As few as 6 percent
practices. At the end of treatment, 36 cases (60
displayed an overjet within the normal range
percent) achieved normal or near normal
(less than 4 mm) on follow-up (Nashed and
occlusion. They found the greater reduction in
Reynolds, 1989). However, 60 percent of all the
the TPI score resulted from an improvement in
patients had their overjets reduced to less than 5
overjet. It was suggested that the degree of
mm as a result of treatment.
improvement was more important than the
Some studies have attempted to determine
‘success’ of treatment.
the effectiveness of the orthodontic treatment
provision by the hospital orthodontic service,
Post-retention Survey
using recently developed occlusal indices as
There have been several investigations involving measures of outcome and assessed the influence
the prevalence of malocclusions over 20 years of of operator, treatment methods, and individual
age (Ingervall et al 1978 ; Mohlin, 1982 ; Bernhold departments upon treatment outcome in terms
and Lindquist, 1981). These studies indicate that of dento-occlusal change. Pickering and Vig,
the prevalence of malocclusion in men and (1974) in the first application of an index to assess
women is similar to that found in children, the effectiveness of orthodontic treatment used
although 10 percent of men and 25 percent of Summer’s Occlusal Index (Summers, 1971) as an
women had previously received orthodontic outcome measure to evaluate the effectiveness
History of Malocclusion Indices 207
of treatment provided for 351 patients treated in Petterson and Andren (1978) found that the
one London hospital. This study revealed that a majority of orthodontic patients were satisfied
proportion of patients did not benefit from with their treatment results. Although most of
treatment and that fixed appliances were the the patients had found treatment to be
most effective treatment method. Berg, (1979) ‘troublesome’ 76 percent would have been willing
used a criterion based approach to assess a to go through the same procedure again. About
sample of consecutive cases treated in his 94 percent would have had their children treated
practice. He found that optimal treatment results if they had developed a similar malocclusion.
were achieved in only 43 percent of cases. In a Fredlund in 1977 (unpublished material)
similar evaluation, Berg and Fredlund, (1981) examined the treatment results in all of the 209
concluded that 60 percent of a sample of cases cases he had started in 1973. Berg (1979) examined
collected form two private practices had normal
the treatment results in 264 consecutively treated
occlusions following treatment. While both
cases. Both Fredlund and Berg found the
investigations produced favorable results, an
reproducibility of criteria such as ‘good’,
analysis of 256 completed cases at the Scottish
‘acceptable‘, etc. to be questionable and they
Dental Estimates Board using Summer’s Occlusal
therefore based their observations on whether or
Index (Summers, 1971) revealed that treatment
not so-called ‘text-book’ normal occlusion had
change was inadequate and the standard of
been achieved. The results of the two independent

treatment required improvement (Elderton and
studies were similar : text-book normal occlusion
Clark, 1984). More recently, Jones (1988), carried

out an extensive study using a three- dimensional was achieved in less than 50 percent of the cases.
assessment of occlusal change of 109 patients. He While many practitioners are convinced that
concluded that the overall success of treatment orthodontic treatment influences the soft tissue
was high. This was influenced by the method of profile, controversy remains concerning the
treatment; two arch fixed appliances being more precise soft tissue response to changes in tooth
effective than removable appliances. position. A positive correlation between incisor
The only large scale study has been carried out movement and soft tissue changes has been
by Richmond (1991). He assessed 1210 patients’ reported (Roos, 1977). On the other hand, the
records obtained from the Dental Practice Board studies of Angelle (1973) and Hershey (1972)
of England and Wales for orthodontic treatment showed that changes in tooth position are not
need and treatment standards with the Index of systematically followed by proportional soft
Orthodontic Treatment Need (Brooke and Shaw, tissue profile changes. Variables such as lip
1989) and the Peer Assessment Rating (Richmond morphology, type of treatment (extraction versus
et al 1992) respectively. He concluded that the non extraction therapy, choice of extraction),
standard of treatment was poor and many patients patient gender, and age have been held
did not receive an improvement in occlusion responsible for individual differences in soft
following a course of orthodontic treatment. tissue response (Wisth, 1972, 1974).
Again, two arch fixed appliance therapy was the Extraction decisions have to be made not only
most effective treatment method. by considering the among of crowding but also
There are very few recorded studies dealing the eventual influence of orthodontic tooth
with the evaluation of treatment results in large displacement on the soft tissue surface of the face.
samples or in randomly selected cases. In many No information concerning the correlation
published studies, only successful cases are between the initial among of crowding and the
analyzed and the frequency with which the changes in profile during orthodontic treatment
demonstrated results could be achieved is often was found in the literature. In nonextraction
not considered. However, Myrberg and therapy without extraoral traction, one can
Thilander (1973) examined 1486 treated cases assume that tooth alignment protrudes the
and graded the treatment results. In their clinical anterior teeth and the facial profile. In extraction
judgment, good results were obtained in 54% of therapy, tooth alignment partly consumes the
the cases. extraction spaces. Closing the remaining spaces
could retrocline the anterior teeth and retracts the indicated that a high self- esteem could be related
facial profile. to orthodontic concern (Birkeland et al 1996).
Williams and Hosila (1976) found that Whilst many indices exist to record
orthodontic treatment with extraction of malocclusion, it is important to distinguish those
premolars was accompanied by changes of the that classify malocclusions into types (Angle,
soft tissue profile. In some cases these changes 1899) and those that record prevalence in
improved the facial aesthetics; in others an epidemiological studies (Bjork et al 1964), from
undesired profile outcome could be seen. For those indices that attempt to record treatment
this reason, a carefully studied extraction policy, need for priority. Furthermore, indices used to
accounting for all possible changes, would be record treatment success and treatment difficulty
very valuable. The same study indicated that will have differing requirements.
orthodontic treatment with extraction of four first Many indices have been developed with the
molars results in less incisor retraction than cases intention of categorizing malocclusions into
treated with extraction of four-first premolars various groups, according to the urgency and
or maxillary first premolars and mandibular need for treatment (Summers, 1971; Salzmann,
second premolars. Clinical observation points 1968; Linder-Aroson, 1974; Lundstrom, 1977;
in the same direction: therapy with more Grainger, 1967; Draker, 1960). Individuals with
posteriorly situated extraction seems to result in greatest treatment need can then be assigned
less incisor retroclination. De Castro (1974) priority when orthodontic resources are limited
recommended extraction of second premolars in and when the availability of treatment is

cases where retraction of anterior teeth has to be unevenly spread. Similarly, individuals with
avoided. By this choice, the closing of extraction little need for treatment can be safeguarded from
spaces after alignment would be mainly realized the potential risks of treatment (Shaw, 1988).
by mesial movement of posterior teeth instead The early efforts to design indexes were the
of distal movement of anterior teeth. product of workers in the public health field, trying
An important motivation factor for to establish data about pathologic or handicapping
orthodontic treatment is improved dentofacial dental conditions. Thus, Klein et al developed
appearance (Gosney, 1986 ; Birkeland et al 1999). the DMF (decayed, missing, filled) scale that was
The relationship between physical appearance and is the ultimate in simplicity is measuring dental
and perception of an aesthetic deviation, and the conditions for large numbers of people. Early
impact of such a deviation on self-esteem and efforts to quantify the extent of malocclusion were
body image are important issues in determining based on the assumptions about ideal occlusion
the benefits from orthodontic treatment. previously outlined. As a result, researchers like
Attention should be given to the specific occlusal Graineger produced data on that basis. From this
and aesthetic deviations that cause concern to the data, he developed the Orthodontic Treatment
patients, and assumptions based purely on the Priority Index. Salzmann published the
general occlusal condition should be avoided Handicapping malocclusion Assessment (the
(Gosney, 1986). A variety of social, cultural, and Salzmann index) that also measures variations
psychological factors, and personal norms from this arbitrary standard. Others working on
influence perception of physical attractiveness this vein of thought include Massler and Frankel,
(Jenny, 1975; Baldwin, 1980). Studies in social VanKirk and Pennell, Bjork et al, Summers, Freer
psychology indicate that physical attractiveness and Adkin, Ingervall and Ronnerman, and Helm.
plays a major role in social interaction and Experience made it apparent to some
influence the impression of an individual’s social observers that variation from a very narrow ideal
skill (Baldwin, 1980; Shaw, 1981). often failed to equitably identify the truly
As orthodontic treatment improves facial handicapping malocclusions. Because of the
appearance, it is assumed to increase self-worth. CHAMPUS program, the Armed forces of the
However, this hypothesis has been difficult to United States in 1976 contracted with the
verify. One study on self-concept changes during National Research Council to organize a work
orthodontic treatment showed no long-lasting force to define “Seriously handicapping
effect on self-esteem (Korabit, 1994). Another orthodontic conditions”. An excellent committee
of highly qualified workers in the field labored for epidemiological importance in establishing
some time but was unable to produce such a prevalence rates for physically handicapping
definition. orthodontic defects, and degree of the physical
HL Draker Suggested a different approach handicap. These deviations are measurable in
in which selected deviations from ideal were definite units.
scored and weighted. He called it the Fastlicht J in 1970 did a study to compare the
Handicapping Labiolingual Deviation index or degree of crowding of the anterior teeth in cases
HLD Index. Careful reading of the original article which were treated orthodontically years before
makes it clear that he made some of them with those which were not treated, in order to
wanting. Then he suggested some changes but determine whether treatment had an influence
never reported any more test results in his article. through time on the crowding of the incisors. He
A number of indices have been introduced, concluded that the crowding of the incisors was
however, based on his suggestions and have been an anatomic-physiologic phenomenon of
called an HLD Index. adaptation observed in orthodontically treated
Cons et al approached the index problem cases, as well as in untreated cases, which
from purely the appearance standpoint and resulted from the combination of several factors,
developed the Dental Aesthetic Index. They such as sex, anatomic predisposition of
generally used the opinions of the lay public as dolichocephalic or long-faced persons, tooth-size
to what constituted unacceptable dental discrepancies, exaggerated overbite, extrusion of

arrangements from the aesthetic standpoint. The the canines, reduction of the intercanine width,
Dental Index has been accepted by the World age, muscle function, and, in some cases,
Health Organization as a screening tool. imperfect mechanotherapy. There was less
Meanwhile in Europe, probably because of crowding of the incisors in the treated group.
government pressure, much effort was spent on Thus, it was assumed that treatment had a
defining which patients qualified as needing favorable influence over the stability of the dental
orthodontic treatment to be paid for by the arches.
government. It would be helpful to remember Summers CJ in 1971 developed the Occlusal
the extent to which dentistry is socialized in Index (OI) Nine characteristics were scored in
many of those countries. Brook and Shaw in 1989 the occlusal index: dental age, molar relation,
developed the Index of Treatment Need used in overbite, overjet, posterior cross-bite, posterior
the United Kingdom. Richmond et al also open-bite, tooth displacement (actual and
developed the PAR (Peer Assessment Rating) potential), midline relations and missing
Index (1990, 1992) as a tool to measure the results permanent teeth. The purpose of describing these
of orthodontic treatment and not the need. scoring procedures in detail are as follows : to
Espeland et al produced a new approach in standardize scoring procedures, to indicate how
Norway for their mixture of public and private each scoring procedure is mutually exclusive and
funding of treatment. enable investigators to apply subjective
Draker HL, Albany NY in 1960 proposed the classification to the objective measurements. The
Handicapping Labiolingual Deviation (HLD) OI was tested for validity, validity during time,
index which was an attempt to obtain a method and intraexaminer reliability. The OI appears to
which would complement and perhaps substitute correlate highly (rs = 0.920) with the clinical
for clinical judgment which, although useful to a standard indicating high validity; the OI also
degree, is vulnerable because it is entirely appears to be valid during time, since the average
subjective. The three planes commonly used for group scores did not decrease during time. Intra-
orthodontic orientation, i.e. the sagittal plane; examiner reliability was very high (rs = 0.963).
frankfurt plane and orbital plane are the basis Little RM in 1975 proposed the Irregularity
for HLD measurements. The intention was to index, a scoring method which involved
measure the presence or absence, and the degree, measuring the linear displacement of the
of the handicap caused by the components of the anatomic contact points (as distinguished from
index, and not to diagnose “malocclusion”. He the clinical contact points) of each mandibular
found that labiolingual deviations from a fictitious incisor from the adjacent tooth anatomic point,
norm rather than the state of occlusion are of the sum of these five displacements representing
the relative degree of anterior irregularity. Perfect treatment be undertaken or at least supervised by
alignment from the mesial aspect of the left canine specialists, (b) improvement in the ratio of
to the mesial aspect of the right canine would specialists to susceptible age groups by
theoretically have a score of 0, with increased maximizing training capacity, (c) extension of the
crowding represented by greater displacement role of dental surgery assistants, (d) guidelines
and, therefore, a higher index score. Rather than to eliminate unnecessary treatment of acceptable
measuring from contact point to ideal arch form malocclusions.
or to another subjective point, the actual linear Brook PH, Shaw WC in 1989 conducted a
distance between adjacent contact points is study to formulate a valid and reproducible
determined. Such a measure represents the index of orthodontic treatment priority using 222
distance that anatomic contact points must be patients referred to a regional orthodontic center
moved to gain anterior alignment. for advice or treatment. To simulate the use of
Eismann in 1980 carried out an investigation the indices in a screening program, 333, 11–12
on pre-treatment, post-retention and follow-up year old school children were also examined. The
casts of 200 patients treated with removable functional and dental health component of the
orthodontic appliances to assess changes index was based on the index of treatment
resulting from orthodontic treatment. He found priority used by Swedish Dental Board with five
that the extent of abnormal criteria between the grading, grade 1 representing little or no need
initial casts and the post-treatment casts was for treatment and grade 5 representing great
reduced on average to about one-fifth and this need of treatment. The second part of the overall
improvement generally remained constant over assessment of treatment priority, the aesthetic
the follow-up period, apart from slight further component was based on the SCAN index
improvements resulting from reduction of (Standardized Continuum of Aesthetic Need).
extraction spaces. The dental photographs of the patients were
Berg R, Fredlund A in 1981 tried to evaluate evaluated on a 10-point scale in the aesthetic
the degree of morphological improvement component. Satisfactory levels of intra- and inter-
achieved during treatment. 30 cases were examiner agreement was obtained and it was
selected; the recordings were made on pre- and proposed that the main benefit by use of this
post-treatment plaster models. The degree of index to the patient of orthodontic treatment
improvement, or change during treatment, was would be in improved aesthetics and social-
assessed by means of a treatment priority index psychological well-being and additionally the
worked out by a study-group of Norwegian effect this may have on attitudes to dental health.
orthodontists. The findings indicated that Richmond S, Shaw WC, O’Brien KD,
evaluation of treatment results by an index score Buchanan IB, Jones R, Stephens CD, et al in
system may be a contribution to the quantification 1992 developed the PAR (Peer Assessment
of the changes achieved; may relate the degree Rating) index to assign a score to various occlusal
of change to the condition before treatment and traits which make up a malocclusion. The
perhaps to the need for treatment; and may also individual scores were summed to obtain an
permit comparison of the effects of different overall total, representing the degree a case
treatment methods. deviates from normal alignment and occlusion.
Shaw WC in 1983 compared the orthodontic The score of zero indicated good alignment and
manpower, finance and training in England and higher scores (rarely beyond 50) indicated
Wales, the Netherlands, Norway, Sweden and increased levels of irregularity. The overall score
Denmark to find out the criteria for general was recorded on the pre- and post-treatment
acceptance of an adequate orthodontic service. dental casts. The difference between these scores
The following criteria were concluded: (a) represented the degree of improvement as a
treatment should be available to all those in need, result of orthodontic intervention and active
(b) the cost should be reasonable, (c) treatment treatment. After all 272 cases were evaluated by
should be of a satisfactory standard. The 74 examiners and they concluded that the PAR
principles emerging from the comparison that index provided a single summary score for all
seemed to be relevant to these criteria were—(a) the occlusal anomalies and may be used for all
acceptance of the principle that the majority of types of malocclusions, treatment modalities and
extraction/non-extraction cases. The score models. They found that the occlusal index was
provided an estimate of how far a case deviates fairly complicated in use and incorporated
from normal and the difference in scores for pre- several weighting mechanisms appropriate to
and post-treated cases reflected the perceived each developmental stage. The PAR index was
degree of improvement and therefore the success a simple, easy to grasp method of assessing
of treatment. treatment standards as opposed to the more
Richmond S, Shaw WC, Roberts CT, complicated approach of Summer. On the basis
Andrews M in 1992 developed a method for of this study it was found that the PAR index is
relating numerical change in the weighted PAR as reliable and as valid a method of assessing
scores to consensus professional judgments in orthodontic treatment outcome as is the occlusal
order to express the degree of improvement index.
resulting from treatment. A panel of 74 O’Brien KD, Shaw WC, Roberts CT in 1993
examiners was asked to examine 128 pairs of studied the effectiveness of orthodontic
dental casts. Using this index, it was revealed that treatment provided by a sample of 17 hospital
at least 30 percent reduction was needed for a based orthodontic departments. They used index
case to be judged ‘improved’ and a change in of orthodontic treatment need and the PAR index
score usually of 22 to bring about a change judged as a measure of orthodontic treatment need and
to be ‘greatly improved’. It was concluded that standard of treatment respectively, in 120
for a practitioner to demonstrate high standards, consecutively started patients from each
the proportion of an individual’s case load lying department. The influence of operator, treatment
in the ‘worse or no different’ category should be methods and individual departments upon
negligible and the mean percentage reduction treatment outcome in terms of dento-occlusal
should be as high as possible (greater than 70 change was also assessed. They found that the
percent). The greater the mean percentage hospital orthodontic service provided treatment
reduction in weighted PAR scores the higher the of a high standard. It was also seen that the
standard of orthodontics achieved. If the mean greatest influence upon the standard of treatment
percentage reduction is high and the proportion was the choice of treatment methods and
of cases that have been ‘greatly improved’ is also operator experience. Two arch fixed appliances
high, this indicates that the practitioner is treating were found to be more effective than single
a great proportion of cases with a clear need for arched fixed appliances and removable
treatment, to a high standard. appliances. Single arch fixed appliances were
Richmond S, Andrews M in 1993 assessed more effective than removable appliances. There
the outcome of treatment provided by a sample was also an additional effect arising from the
of Norwegian orthodontists using objective aspirations of the consultant and supporting
measures of assessment. A sample of 220 cases staff.
was collected from Norwegian specialist Kerr WJS, Buchanan IB in 1993 used Peer
orthodontists who had agreed to participate in Assessment Rating Index to assess the
this study. The index of orthodontic treatment improvement produced is a series of 150 cases
need and the PAR index were applied to the pre- treated with removable appliances and to
and post-treatment cases. They concluded that ascertain in which circumstances they performed
the indices could be used to identify differences most successfully. The pre- and post-treatment
not only between individual practitioners, but study models were used to assess the
also health care systems in different countries. It effectiveness of the appliance. As measured by
was confirmed that the Norwegian orthodontists the PAR index 89.3 percent of a group of patients
were producing a high standard of orthodontic selected as suitable for treatment with removable
treatment. appliances were either ‘improved’ or ‘greatly
Buchanan IB, Shaw WC, Richmond S, improved’. Of 10.7 percent cases which were
O’Brien KD, Andrews M in 1993 compared the classified as being ‘worse, no different’, six were
relative merits of the PAR index and Summer’s mixed dentition cases where the treatment
Occlusal Index in terms of validity and reliability. objectives were limited to the alignment of one
A panel of 74 examiners rated 256 sets of study incisor tooth and only seven were judged as
being unsuitable for removable appliances on the difficulty, according to the perceptions of a panel
ground of their malocclusion. of orthodontists. As a result, the PAR index may
Richmond S, Roberts CT, Andrews M in be considered to represent a good approximation
1994 assessed the need for orthodontic treatment of malocclusion severity and treatment difficulty,
before and after treatment, on a systematic and may be used as an outcome measure for the
sample of 1225 cases, using the Index of assessment of dento-occlusal change.
Orthodontic Treatment Need (IOTN). The Jenny J, Cons NC in 1996 modified the Dental
results showed that the number of patients Aesthetic Index (DAI), an orthodontic index that
needing orthodontic treatment on aesthetic provides a single score linking the public’s
grounds after appliance treatment fell by 27 perceptions for dental aesthetics with objective
percent for non-prior approval cases and 45 measurements associated with malocclusion. It
percent for prior approval cases. The number of now had decision-points along the DAI scale
patients needing orthodontic treatment on dental defining specified case severity levels. DAI scores
health grounds fell by 36 percent for non-prior of 25 and below represent normal or minor
approval cases and 45 percent for prior approval malocclusion with no treatment needed or slight
cases. They also found that upper and lower fixed treatment need. DAI scores of 26 to 30 represent
appliances had the greatest influence or outcome definite malocclusion with treatment elective.
of treatment in terms of aesthetics and dental DAI scores of 31 to 35 represent severe
health. malocclusion with treatment highly desirable.

Shaw WC, Richmond S, O’Brien KD in 1995 DAI scores of 36 and higher represent very severe
published an article describing the development or handicapping malocclusion with treatment
and validation of two indices, IOTN (an index considered mandatory.
of treatment need) and PAR (an index of Turbill EA, Richmond S, Wright JL in 1996
treatment outcome). To assess the extent to conducted a study in which subjective grading
which the indices reflect current orthodontic of cases at the Dental Practice Board of England
opinion, a validation exercise was carried out. and Wales was compared to the Peer Assessment
A panel of 74 dentists was enlisted. Each member Rating Index (PAR) and Index of Orthodontic
of the panel recorded a personal opinion on the Treatment Need (IOTN) in assessing 1505 cases
need for orthodontic treatment and the change sampled at the Board between late 1990 and mid-
due to treatment of 234 starts and finish study 1991. They concluded that some cases rated as
casts, with standardized rating scales. The ‘greatly improved’ or ‘improved’ by PAR still
models were independently scored with the had substantial residual malocclusion (weighted
IOTN and the Index of Treatment Outcome (PAR PAR at finish) and/or residual need for treatment
index) by the investigating team. Experience and that the dental advisers disliked PAR’s low
with their use in Europe suggested they have a weighting of buccal occlusion and residual buccal
useful role in resource allocation and planning, spaces.
monitoring and promoting standards, better Turbill EA, Richmond S, Wright JL in 1996
uniformity in patient identification and referral, used the Index of Treatment Need and Peer
and informed consent. Assessment Rating index to assess targeting, use
DeGuzman L, Vig PS, O’Brien K in 1995 of appliances, and standards of outcome for
conducted a study to evaluate the relationship General Dental Service orthodontic cases collected
between the subjective estimates of severity of between 1990 and 1991 and compared them with
malocclusion and treatment difficulty by using a sample of cases from an earlier study, collected
a panel of American Orthodontists and to between 1987 and 1988. The samples of cases
evaluate the relationship between severity and used in this study were sub-samples from two
difficulty, and the PAR index. A group of 11 parent samples, each of around 1500 cases. They
orthodontists examined the 200 study casts. The concluded that since the 1988 study, there had
results of this study made it possible to derive a been a trend to acceptance of more cases with
set of weightings for the PAR index and to lower need for treatment, but no increase in
calculate scores that would represent groupings treatments previously defined as ‘unnecessary’.
of malocclusion’s severity and treatment The standard of completed cases had improved
slightly in terms of both residual need for treatment extraction groups but then proclined in the non-
and residual malocclusion (IOTN and weighted extraction group. The upper incisors were
PAR scores at finish). These limited improvements retroclined approximately 2 mm in the extraction
were apparently associated with increased use groups. A change in lip protrusion was found in
of fixed appliances. the non-extraction group, where tooth alignment
Buchanan IB, Russell JI, Clark JD in 1996 was accompanied by proclination. It was concluded
did a study to investigate the usefulness of the that within the appropriate indications, extraction
PAR index as a means of differentiating between of first or second premolars, or non-extraction
results achieved by two different fixed appliance therapy with light-wire appliances and no extra-
techniques: the preadjusted Edgewise and the oral anchorage, leads to good occlusal results
Begg appliance. A group of 41 cases treated using without unfavorable changes in the facial profile.
the Begg appliance and 41 cases treated using Parker WS in 1998 discussed the
the preadjusted Edgewise appliance were Handicapping Labiolingual Deviation Index
gathered. Comparison of results using the (CalMod), a lawsuit-driven modification of some
monogram and percentage reduction on the two 1960 suggestions by Dr Harry L Draker, which
appliance system groups indicated that the cases proposed to identify the worst looking
treated by the preadjusted Edgewise appliance malocclusions as handicapping and offered a cut-
had a better outcome. This comparison showed off point to identify them. The HLD (CalMod)
that there was a significant difference between index went into official use late in 1991, and as
the two appliance types in terms of treatment of January 1 1998, 135,655 patients had been
success when the monogram, percentage examined orally by qualified orthodontists and
reduction and comparison of the actual PAR screened using this index. Of this number, 49,537
scores were considered. Preadjusted Edgewise were found to have a score of 26 or greater, and
cases being more successful than the Begg. This study models of these patients were produced
difference was much more marked in the cases and screened by board-qualified orthodontists
with low start PAR score than it was in the high for the fiscal intermediary. The HLD (CalMod)
start group, where the appliance type seemed to index proved to be a successful tool to identify a
be of less relevance. large number of very disfiguring malocclusions
Birkeland K, Furevik J, Boe OE and Wisth and two known destructive forms of mal-
PJ in 1997 used the Peer Assessment Rating index occlusion (deep destructive impinging bites and
to assess the treatment results in a postgraduate destructive individual anterior cross bites). These
clinic and to assess the occlusion at a 5 year were all then certified as medically necessary
follow-up control, in relation to the original handicapping malocclusions.
malocclusions, and the changes occurring in the Firestone AR, Hasler RU, Ingervall B in 1999
follow-up period. 224 cases were selected and did a study to investigate the objective need for
the treatment result was a 76.9 percent PAR score treatment and the treatment results for two
reduction. The treatment success was greatest for groups of patients who were treated in a dental
Angle Class II division 2 with 80.8 percent PAR school orthodontic clinic approximately 10 years
score reduction, closely followed by Angle Class apart and to investigate factors predictive of
II division 1 (78.4 percent). Extractions did not change in PAR score and the length of treatment.
significantly influence treatment success and They concluded that changes in treatment
neither did the sex difference. techniques and the introduction of new materials
Saelens NA, deSmit AA in 1998 did a study to have had a significant positive effect on
investigate (in extraction and non-extraction treatment outcome in a postgraduate dental
therapy), the initial amount of crowding, the school orthodontic clinic and improvement in
changes in the position of the incisors and molars, occlusion and alignment was primarily the result
the changes in the soft tissue profile, and the clinical of a reduction in overjet, an increase in the
outcome. Three groups of 30 patients were alignment of the maxillary anterior teeth, and a
investigated. In all cases, the orthodontic treatment reduction in overbite.
moved the molars mesially. The lower incisors Hamdan AM, Rock WP in 1999 did a study
remained in about the same position in the to re-test the validity of the PAR index against
assessments by West Midland Consultant post-treatment mean PAR scores of 5.8 in this
Orthodontists, to compare the validity of three study with 6.0 in the former showed a high
new weighting systems and to apply the best new standard of treatment results.
weighting system to unweighted PAR scores and Cooper S, Mandall NA, Dibiase D, Shaw
examine the effect for each malocclusion class. WC in 2000 did a study to establish whether
Eighty sets of pre- and post-treatment dental IOTN was reliable over time, between the age of
casts, representing equal numbers of Class I, 11 and 19 years old, for subjects who had not
Class II division 1, Class II division 2, and Class received orthodontic treatment and to investigate
III cases were randomly selected. The results the changes over time in the occlusal traits that
supported the hypothesis that it is inappropriate comprise the dental health component of IOTN.
to group all orthodontic cases together to derive Study casts of a longitudinal sample of 11 year
a generic weighting formula and that weightings old (n = 314), 15 year old (n = 314) and 19 year
should be derived separately for each old (n = 142) subjects were examined. They found
malocclusion class. The most valid PAR index that the dental health component of IOTN is
weightings were derived by multiple regressions, reliable between 11 and 19 years despite
modified by the addition to base weights for temporal changes in the separate occlusal traits
buccal occlusion and lower anterior displa- that comprise the index and IOTN DHC grading
cements. Assessments of treatment outcome at the age of 11 years is likely to be similar when
using point and percentage reductions were the patient reaches 19 years. They also found that
more valid than using the original PAR most of the occlusal traits contributing to IOTN
monogram. DHC improved over time except posterior cross
Arnett GW, Jelic JS, Kim J, Cummings DR, bite and displacement of contact points that
Beress A, Worley M et al in 1999 presented a worsened between 11 and 19 years.
technique for soft tissue cephalometric analysis. Fastlicht J in 2000 developed a visual
Forty-six adult white models comprised the cephalometric analysis based on two geometric
cephalometric database for this analysis. They constructs the “Tetragon”, a polygon that
concluded that, (a) natural head position must represents the maxillo-dento-mandibular
be adjusted for some patients using clinical complex, made up of reliable and familiar
judgment,(b) the Soft Tissue Cephalometric cephalometric landmarks—the palatal plane, the
Analysis (STCA) is a facial diagnostic tool, (c) mandibular plane, and the axes of the maxillary
STCA diagnosis is used for cephalometric and mandibular central incisors, the “Trigon”, a
treatment planning(CTP), (d) clinical facial complementary triangle situated above the
analysis is used to augment cephalometric Tetragon and formed by one plane that is
information, (e) absolute projection values for intrinsic to the Tetragon—the palatal plane
important soft tissue structures are measured to (PNS-ANS)—and two that are extrinsic – the
the true vertical reference line, (f) the true vertical pterygo-palatal plane (Pt-PNS). He concluded
reference line is placed through subnasal and (g) that the Tetragon and the Trigon provide a clear
the true vertical reference line is moved forward picture of the position of the maxillo-dento-
from subnasale when maxillary retrusion is mandibular structures within the craniofacial
indicated by clinical and cephalometric findings. complexes and that this visual cephalometric
Birkeland K, Boe OE, Wisth PJ in 2000 did a analysis could be a useful diagnostic tool for
study to measure aesthetic and occlusal changes treatment planning, surgical preparation, and
from 11 to 15 years of age using the Index of evaluation of growth, treatment progress, and
Orthodontic Treatment Need (IOTN) and Peer post-treatment results.
Assessment Rating (PAR) Index, to compare Pinto N, Woods M, Crawford E in 2000
treated and untreated groups using the same conducted a study, designed to determine the
indices. Out of a sample of 359 children simple influence of the pretreatment vertical facial
treatment with removable appliances was used pattern on post-treatment occlusal change (as
in 23.8 percent. They found that children were assessed with the PAR index) occuring after
less critical in their aesthetic evaluation fixed-appliance orthodontic treatment of patients
compared with that noted by the examiners. The managed by one orthodontist with consistent
aims and methods. Pretreatment, post-treatment proportion of cases the overjet reduction was
and follow-up casts of 60 patients were assessed achieved by lower incisor proclination, which is
by the PAR index. The pretreatment vertical considered by some authorities to be unstable.
facial pattern for each subject was established Daniels C, Richmond S in 2000 formulated
using the Jarabak Facial Height Quotient. The a study to propose orthodontic indices to assess
results of this study suggested that the treatment need, complexity, treatment
pretreatment vertical facial pattern, at least on improvement, and outcome based on
its own, is not likely to be predictive of the international professional opinion, intended for
amount of post-treatment occlusal change. use in the context of specialist practice, and to
Beatrice M, Woods M in 2000 conducted a compare treatment thresholds in different
study designed to assess whether or not countries and serve as a basis for quality
rotational changes occurring during or after assurance standards in orthodontics. An
treatment, in one accepted indicator of vertical international panel of 97 orthodontists from nine
facial dimension, the Facial Axis, are in any way countries was asked to judge 240 dental casts for
related to post-treatment occlusal changes. The assessment of treatment need and 98 paired
pretreatment, post-treatment and follow-up pretreatment and post-treatment cases for
cephalograms of 55 cases were assigned numbers assessment of treatment outcome. The outcome
and arranged in random order by an was a new index, Index of Complexity, Outcome
independent observer before being traced and and Need (ICON) which was based on the
digitized by one examiner. The pretreatment average opinion of a large panel of international
vertical facial pattern for each subject was orthodontic opinions. For the first time the
established using the Jaraback Facial Height design of the index had been specifically
Quotient. Occlusal assessment using the developed to enable assessments of treatment
pretreatment (T1) post-treatment (T2) and need and outcome using one set of occlusal traits.
follow-up (T3) models was undertaken using the The accuracy of the index to reflect professional
opinion for a diverse sample of cases was
PAR index. They concluded that the facial axis
estimated at 84 percent for decisions of treatment
tends to change in the long-term following
need and 68 percent for treatment outcomes. The
routine, comprehensive orthodontic treatment.
method was heavily weighted by aesthetics.
A change in the Facial Axis does not seem to be
Kim JC, Mascarenhas AK, Joo BH, Vig KWL,
directly related to the underlying vertical facial
Beck FM, Vig PS in 2000 conducted a study to
type. Long-term post-treatment Facial Axis
assess the value of cephalometric variables in
changes and long-term changes occurring in the
predicting orthodontic outcomes for patients with
occlusion are not directly related.
Class II malocculusions and variables that are most
Wijayaratne D, Harkness M, Herbison P in useful as predictors of pre-PAR, post-PAR, percent
2000 conducted study to determine in children PAR reduction, and treatment duration. This study
with Class II, division 1 malocclusions treated evaluated selected cephalometric variables with
with functional appliances, first, if lower incisor the intention of identifying predictors of the
proclination affects the assessment of treatment occlusal outcome of orthodontic treatment in 223
outcome using the PAR index and, second to patients with Class II malocclusions. The results
evaluate the effectiveness of functional showed that Cephalometric variables explained
appliances after adjusting the PAR score for any 39.2 percent of the variation in the pre-PAR scores;
lower incisor proclination. The subjects in this they suggested that cephalometrics may be more
study were 43 consecutively treated children valuable as a diagnostic tool than a prognostic
who were assigned to either an untreated group, tool. The selected cephalometric variables
a group treated with Frankel function regulators, explained only 18 percent of the variance of the
or a group treated with Harvold activators. The post-treatment occlusal result (post-PAR). Sixteen
PAR index showed that improvements were percent of the variance in improvement of the
made during treatment with functional malocclusion (percent PAR reduction) could be
appliances in 50 percent of the cases in this study; explained by cephalometric variables.
however, cephalometric analysis, which is not Mascarenhas AK, Vig K in 2002 did a study
part of the PAR assessment, showed that in a to compare the quality of orthodontic treatment
provided by orthodontists in private practice severity (e.g. the PAR index) or an index of
(experts) with that of graduate orthodontic orthodontic treatment need (e.g., the IOTN)
residents (novice). The sample consisted of 143 could be used to differentiate between easy and
cases treated by private practice orthodontists difficult cases. A further aim was to investigate
and 165 cases treated at the graduate orthodontic whether factors related to the treatment or the
clinic. The results of study showed that although patients were associated with orthodontists’
there was no difference in the final occlusal evaluations of cases as easy or difficult after
outcome there was a difference in the treatment treating the patients. Ten orthodontists practicing
duration between the graduate educational in Ohio were selected by telephone solicitation,
setting and private practice, favoring the GOC. and each orthodontist was asked to identify the
These results indicated that the clinical complete records of 10 treated cases he or she
proficiency of graduate orthodontic program was judged as having been easy to treat and 10 cases
comparable to that of highly experienced private as having been difficult to treat. The cases
practice orthodontists. selected were to be chosen from the last 100
Yang-Powers LC, Sadowsky C, Rosenstein patients the orthodontist had treated. This study
S, BeGole EA in 2002 conducted a study to showed that complexity, or difficulty in
determine whether dental relationships at the achieving an ideal occlusion, increases as the
end of orthodontic treatment in a university severity of the initial malocclusion increases.
postgraduate clinic are within the ABO’s limit Complex cases are associated with patients who
for passing the phase III examination, to assess are seen more often and receive repeated
the contribution of each of the 8 components of warnings about compliance problems. Easy
the OGS to the total OGS score, to determine cases have less severe malocclusions initially, are
whether treatment outcome is different for the associated with compliant patients, and are more
various malocclusion categories, and to likely to have 2-phase treatment.
investigate treatment outcome in a sample of Weerakone S, Dhopatkar A in 2003
cases that passed ABO certification compared conducted a study to demonstrate the potential
with cases treated in a university clinic. The of a new software package, clinical outcomes
sample used in this retrospective study consisted monitoring program (COMP), for use in clinical
of records of 96 patients treated in the graduate research by carrying out a limited audit for
orthodontic clinic at the University of Illinois at illustration. The program can collect data from
Chicago. They concluded that there was a PAR, IOTN, and ICON indexes with built-in
statistically significant difference (P < 0.05) in “Wizards” capable of calculating all 3 scores
overall treatment outcome (OGS score) between automatically. The COMP database contained
the university group (average total score 45.54) information on 205 consecutively finished cases
and the ABO group (total score 33.88). Significant over a period of approximately 1 year after the
differences in treatment outcome (using OGS introduction of the COMP. This study
scores) were found between the university and demonstrated that this approach is useful in
the ABO groups for the components of root comparing outcomes from various providers and
paralleling (panorex), occlusal contact, and monitoring the general quality of treatment in a
overjet. Occlusal contact and overjet were practice with many orthodontists.
significantly higher (worse) in the university Lieber WS, Carlson SK, Baumrind S,
sample. Panorex was significantly higher Poulton DR in 2003 tested the reliability and
(worse) for the ABO group. The ABO group subtraction frequency of the study model—
exhibited better finishing details in the anterior scoring system of the American Board of
segment and in the second molar region than did Orthodontists (ABO). Thirty-six post-treatment
the university group. study models were selected from six different
Cassinelli AG, Firestone AR, Beck MF, Vig orthodontic offices. They found that the greatest
KWL in 2003 did a study to test whether objective limitation of the ABO index, its dependence on
criteria can be used to identify difficult and landmark identification. Most of the scoring
complex cases before treatment, and to determine involved measuring “landmark-to-landmark”
whether objective measures of malocclusion linear distances using the ABO scoring tool.
Reliability was lower than expected, suggesting to examine the outcomes for growing patients with
that the ABO index may still be overly subjective. a range of skeletal anteroposterior and vertical
Subtraction frequency revealed a significant dysplasias, who were treated with orthodontics
emphasis on second molars. and growth modification techniques.
Cangialosi TJ, Riolo ML, EdOwens S, Pretreatment and post-treatment cephalograms of
Dykhouse VJ, Moffitt AH, Grubb JE et al in 100 growing Class II division 1 patients with
2004 have discussed criteria for determining the mandibular skeletal retrusion were divided into
acceptability of a case presented for the American 5 groups depending on initial vertical and
Board of Orthodontics (ABO) Phase III clinical anteroposterior measurements. Post-treatment
examination which is case difficulty. Case soft and hard tissue measurements were assessed
difficulty can often be subjective; however, it is and compared between the groups. They
related to case complexity, which can be concluded that conventional orthodontic therapy
quantifiable. Over the past 5 years, the ABO has successfully correct and Class II division 1
developed and field-tested a discrepancy index, malocculusions in growing patients through a
made up of various clinical entities that are combination of skeletal and dentoalveolar
measurable and have generally accepted norms. changes, with the greatest changes occurring in
These entities summarize the clinical features of patients who initially had the most severe skeletal
a patient’s condition with a quantifiable, dysplasias.
objective list of target disorders that represent Janson G, de Souza JEP, Henriques JFC,
the common elements of an orthodontic Cavalcani CT in 2004 did a study to compare

diagnosis: overjet, overbite, anterior open bite, the occlusal changes of the FRI and the eruption
lateral open bite, crowding, occlusion, lingual guidance appliance, using the Peer Assessment
posterior crossbite, buccal posterior crossbite, Rating (PAR) index. From the treated-patients
ANB angle, IMPA, and SN-Go-Gn angle. The records of the Orthodontic Department, Bauru
greater the number of these conditions in a Dental School, and two samples of Class II
patient, the greater the complexity and the patients were retrospectively drawn. Group 1
greater the challenge to the orthodontist. consisted of 25 patients treated with the FRI.
Read MJF, Deacon S, O’Brien K in 2004 Group 2 included 30 patients treated with the G
conducted a prospective cohort study. Thirty-two series of the eruption guidance appliance known
children were included in the study over a 2-year as Occlus-o-Guide. The results of this research
period. Study casts were analyzed with the Peer showed that there was a similar effectiveness in
Assessment Rating (PAR index), weighted with producing occlusal changes in the two
the UK weights. Cephalometric radiographs investigated appliances, regardless of treatment
were analyzed with the Pancherz analysis. This time. The main shortcoming of the Frankel
prospective cohort study showed that the appliance was its large size and the initial
modification of the Twin-block appliance was an discomfort and the eruption guidance appliance
effective method of treating Class II malocclusion presented advantages because it was smaller but
in terms of the morphological effects on the presented a slightly greater mean treatment time.
dental and skeletal tissues; and the main Abei Y, Nelson S, Amberman BD, Hans MG
theoretical advantages of this appliances over the in 2004 conducted a study to compare
removable twin-block were that patient orthodontic treatment outcome in a sample of
cooperation is enhanced and the appliance is patients divided on the basis of orthodontic
active for 24 hours a day, there is no transition provider education by using 2 outcome
phase between the functional and fixed measures. The first measure was the patient’s
appliances phases, and it is less bulky. perception of the improvement in his or her
Fogle LL, Southard KA, Southard TE, Casko smile. A visual analog scale (VAS) was used to
JS in 2004 conducted a retrospective study to estimate this variable. Second, we used the ABOI
provide soft and hard tissue cephalometric to compare the alignment of the teeth. The goal
analysis of treatment effects after correcting Class was to obtain evidence to support the commonly
II malocclusions in growing patients with held belief that orthodontic specialists provide
moderate to severe mandibular retrognathia and better orthodontic care than do general dentists.
Survey data were obtained from 280 students. In health and perceived aesthetic impairment. It intends
this sample, significantly lower ABOI scores were to identify those individuals who would most likely
found per patients treated by orthodontic benefit from orthodontic treatment. The index has
specialists compared with patients treated by two components, the aesthetic and dental health
general dentists. components, which rank malocclusion in increasing
Malocclusion is a common oral disorder priority according to aesthetic considerations and
which manifests itself during childhood and the dental health implication.
correction of malocclusion (orthodontic
treatment) is frequently carried out during Aesthetic Component
childhood. With the growing demand for
Aesthetic component (AC) consists of a scale of
orthodontic treatment a variety of clinician-based
ten color photographs showing different levels
indices have been developed to classify various
of dental attractiveness. The dental attractiveness
types of malocclusion and determine their
of prospective patients can be rated with
orthodontic treatment need. These indices can
reference to this scale. Grade 1 represents the
be used in estimating orthodontic treatment
most and grade 10 the least attractive
need, prioritizing of treatment need in patients
arrangement of teeth. The score reflects the
referred for orthodontics particularly where
aesthetic impairment. Aesthetic Component
there are limited resources for orthodontics
value indicates patient’s esthetic concern and

among public health care services, and
reflects sociopsychological needs.
safeguarding for the patients.

The most commonly employed malocclusion Grade 1, 2, 3 and 4 — no or slight need for
indices are the Dental Aesthetic Index (DAI), treatment,
Index of Orthodontic Treatment Need (IOTN), Grade 5, 6 and 7 — moderate or borderline
Peer Assessment Rating and Index of need for treatment,
Grade 8, 9 and 10 — need for orthodontic
Complexity, Outcome and Need (ICON).
treatment.
Generally, among the commonly used indices,
IOTN (AC, DHC), DAI and ICON are used to
Dental Health Component
assess the orthodontic treatment needs while
ICON and PAR are used to assess the treatment Dental health component (DHC) involves features
outcome. In some ways, the indices of IOTN, DAI that might impair the health and function of the
and ICON are similar. All include two dentition. DHC records the various occlusal traits
components-morphological and esthetic. The of a malocclusion that would increase the
difference is that for the IOTN, the esthetic morbidity of the dentition and surrounding
component is separated from the dental health structures. The traits of malocclusion are: overjet,
component. All the three indices measure similar reverse overjet, overbite, open bite, crossbite,
traits such as overjet, reverse overjet, open bite, displacement of teeth, impeded eruption of teeth,
overbite, anteroposterior molar relationship, and buccal occlusion, hypodontia and defects of cleft
displacement. However, the weights of these lip and palate. Functional disturbances are also
traits are rated differently by each index. The four recorded which included lip competency,
indices are described below. mandibular displacement, traumatic occlusion and
masticatory or speech difficulties. Only the worst
INDEX OF ORTHODONTIC TREATMENT occlusal feature is recorded. The components of
NEEDS (IOTN) DHC are shown in Table22.1. There are five grades.
Brook and Shaw in 1989, developed a valid and Grade 1 and 2 – no need or slight need for
reproducible index (Index of orthodontic treatment,
treatment need—IOTN) to determine orthodontic Grade 3 – moderate or borderline
treatment need. This index attempts to rank need for treatment,
malocclusion in terms of the significance of Grade 4 and 5 – need for orthodontic
various occlusal traits for an individual’s dental treatment.
Table 22.1: The dental health component is usually 3.e Lateral or anterior open bite greater than 2
recorded at the chair side by direct examination of mm but less than or equal to 4 mm.
the subject but can also be recorded from dental 3.f Deep overbite complete on gingival or palatal
casts need (IOTN) (Shaw et al, 1989) tissues but no trauma.
Grade 2 (Little need)
Grade 5 (Need treatment)
2.a Increased overjet greater than 3.5 mm but less
5.a Impeded eruption of teeth (except for third
than or equal to 6 mm with incompetent lips
molars) due to crowding, displacement,
2.b Reverse overjet greater than 0 mm but less than
presence of supernumerary teeth, retained
or equal to 1 mm
deciduous teeth and any pathological cause
2.c Anterior or posterior crossbites with less than
5.b Extensive hypodontia with restorative
or equal to 1 mm discrepancy between
implications (more than 1 tooth missing in any
quadrant) requiring pre-restorative orthodo- retruded contact position and intercuspal
ntics position
5.c Increased overjet greater than 9 mm 2.d Contact point displacements greater than 1
5.d Reverse overjet greater than 3.5 mm with mm but less than or equal to 2 mm
reported masticatory or speech difficulties 2.e Anterior or posterior open bite greater than 1
5.e Defects of cleft lip and palate and other mm but less than or equal to 2 mm
craniofacial anomalies 2.f Increased overbite greater than or equal to 3.5
5.f submerged deciduous teeth mm without gingival contact
Grade 4 (Need treatment) 2.g Pre-normal or post-normal occlusions with no

4.a Less extensive hypodontia requiring pre- other anomalies (includes up to half a unit
restorative orthodontic or orthodontic space discrepancy)

closure to obviate the need for prosthesis Grade 1 (None)
4.b Increased overjet greater than 6 mm but less 1. Extremely minor malocclusions including contact
than or equal to 9 mm points displacements less than 1 mm
4.c Reverse overjet greater than 3.5 mm with no
mastieatory or speech difficulties
4.d Reverse overjet greater than 1mm but less than
Limitations
3.5 mm with reported masticatory or speech Aesthetic component cannot be used accurately
difficulties in mixed dentition. There is a shortage of
4.e Anterior or posterior crossbites with greater
scientific information regarding the long-term
than 2 mm discrepancy between retruded
contact position and intercuspal position
effects of malocclusion. Nonetheless the DHC of
4.f Posterior lingual crossbite with no functional IOTN provides a structured method for
occlusal contact in one or both buccal segments assessment of malocclusion.
4.g Severe contact point displacements greater
than 4 mm PEER ASSESSMENT RATING
4.h Extreme lateral or anterior open bite greater
than 4 mm. The Peer assessment rating (PAR) index,
4.i Increased and completed overbite with previously refered to as the index of treatment
gingival or palatal trauma standards, was described by S Richmond, W C
4.j Partially erupted teeth, tipped and impacted Shaw, K D O’Briene, I B Buchaman, R Joes, C D
against adjacent teeth Stephens and M Andrew in 1992.The PAR index
4.k Presence of supernumerary teeth. is a quantitative occlusal index measuring how
Grade 3 (Borderline need) much a patient deviates from normal alignment
3.a Increased overjet greater than 3.5 mm but less
and occlusion. This index is designed to measure
than or equal to 6 mm with incompetent lips
3.b Reverse overjet greater than 1mm but less than
the efficacy or the outcome of orthodontic
or equal to 3.5 mm. treatment by comparing the severity of occlusion
3.c Anterior or posterior crossbites with greater on pretreatment and post-treatment casts. The
than 1 mm but less than or equal to 2mm PAR index has five components.
discrepancy between retruded contact position 1. Upper and lower anterior segments: Scores are
and intercuspal position recorded for both upper and lower anterior
3.d Contact points displacements greater than 2 segment alignment. The features recorded are
mm but less than or equal to 4 mm crowding, spacing and impacted teeth.
2. Buccal occlusion: The buccal occlusion is INDEX OF COMPLEXITY, OUTCOME AND

recorded for both left and right sides. The NEED
recording zone is from the canine to the last
The Index of Complexity, Outcome and Need
molar. All discrepancies are recorded when
(ICON) has been developed recently and claims
teeth are in occlusion.
among other things, to evaluate orthodontic
3. Overjet: Positive overjet as well as teeth in
treatment complexity. ICON is based on the
crossbite is recorded. The most prominent
subjective judgments of 97 orthodontists from
aspect of any one incisor is recorded. If the
nine countries. It is a single assessment method
two lateral incisors are in crossbite while the
to quantify orthodontic treatment complexity,
centred incisors are with increased overjet of
outcome and need. The ICON consists of
4 mm, the score will be 3 for crossbite and 1
following five weighted components, Table 22.2:
for the positive overjet, 4 in total.
1. The Aesthetic Component (AC): The dental
4. Overbite: The vertical overlap or open bite of
aesthetic component of the IOTN is used.
the anterior teeth is recorded.
Once this score is obtained it is multiplied by
5. Centerline assessment: The centerline
the weighting of 7.
discrepancy between the upper and lower
2. Crossbite: Crossbite is deemed to be present if
dental midline is recorded in relation to lower
a transverse reaction of cusp to cusp or worse
central incisors.
exists in the buccal segment. This includes

The PAR index is applied to an individual’s pre-
buccal and lingual crossbites consisting of one
and post-treatment study casts. Scores are

or more teeth with or without mandibular
assigned to each component. The individual
displacement.
scores are calculated in each component and
3. Anterior vertical relationship: This trait includes
multiplied by a weight of each component. Scores
both open bite (excluding development
are summed to obtain a total score that represents
conditions) and deep bite. If both traits are
the degree a case deviates from normal alignment
present only the highest scoring raw score is
and occlusion. The degree of improvement as a
counted. Scoring protocol is given in Table
result of orthodontic intervention is obtained by
22.2.
calculating the difference between the pre- and
4. Upper arch crowding/spacing: The sum of the
post-treatment PAR scores. The degree of
mesiodistal crown diameters is compared to
improvement can be assessed using two different
the available arch circumference, mesial to the
methods:
last standing tooth on either side.
1. Nomogram: The degree of change is
Buccal segment anteroposterior relationship: The
separated into 3 sections:
anteroposterior cuspal relationship is scored
a. Worse or no difference,
according to the protocol given in Table 22.2 for
b. Improved and
each side in turn. The raw scores for both sides
c. Greatly improved
are added together.
2. Percentage improvement: This method gives
a more sensitive assessment than the
Calculation of the Final Scores
nomogram which only provides three broad
bands of treatment change. A change of score Once all of the raw scores have been obtained
from 40 to 10 would represent an 80% and multiplied by their respective weights, they
improvement as would a change from 15 to are added together to yield a weighted summary
3. However, the actual reduction in PAR score for a particular cast. The summed score is
scores is also relevant as in the first case where interpreted as following: pre-treatment scores
there has been a much greater change with a give the treatment needs and complexity grades;
30 point reduction as opposed to the second end of treatment scores gives the acceptability;
case in which the degree of change is less with while (pre-treatment scores)—(4 × post-treatment
only a 12 point reduction. scores) gives the degree of improvement.
Table: 22.2: Protocol for occlusal trait scoring (Daniel and Richmond, 2000)
Score 0 1 2 3 4 5
Aesthetic 1–10 as judged

using IOTN
AC
Upper arch Score only the Less than 2.1–5.0 mm 5.1–9.0 mm 9.1–13.0 mm 13.1–17.0 mm >17.0 mm
crowding highest trait 2.0 mm or
either spacing impacted
or crowding teeth
Upper Transverse Up to 2.0 mm 2.1–5.0 mm 5.1–9.0 mm >9.0 mm
spacing
Cross bite Relationship No cross bite Cross bite
of cusp to present
cusp or worse
Incisor Score only the Complete bite Less than 1.1–2.0 mm 2.1–4.0 mm >4 mm
open bite highest trait 1 mm
either open
bite or over
bite
Incisor Lower incisor Up to 1/3 1/3–2/3 1/3 upto Fully covered
over bite coverage tooth coverage full

covered
Buccal Left and right Cusp to Any cusp Cusp to
segment added together embrasure relation up cusp
anteropo- relationship to but not relationship
sterior only, class I, including
II or III cusp to cusp
Limitations weighted on the basis of their relative importance

according to a panel of lay judges. The codes and
The PAR is based solely on study models and
does not account for changes in facial profile, criteria are as follows:
iatrogenic damage, tooth inclination, arch width 1. Missing incisor, canine and premolar teeth: The
or posterior spacing, and is not appropriate for number of missing permanent incisor, canine
assessment of mixed dentition treatment. and premolar teeth in the upper and lower
arches should be counted and recorded.
DENTAL AESTHETIC INDEX 2. Crowding in the incisal segments: Both the
upper and lower incisal segments should be
The Dental Aesthetic Index (DAI) was examined for crowding. Crowding in the
developed by NC Cons, J Jenny, F J Kohaut in
incisal segments is recorded as following: 0—
1986 to assess orthodontic treatment need. It is
no crowding; 1—one segment crowded; 2—
an orthodontic index based on socially defined
two segments crowded.
esthetic norms.
3. Spacing in the incisal segments: Both the upper
The Dental Aesthetic Index (DAI) has been
adopted by the World Health Organization as a and lower incisal segments should be
cross-cultural index. It identifies deviant occlusal examined for spacing. Spacing in the incisal
traits and mathematically derives a single score. segments is recorded as following: 0—no
Its structure consists of 10 occlusal features of spacing, 1—one segment spaced, 2—two
malocclusion; overjet, underjet, missing teeth, segments spaced.
diastema, anterior openbite, anterior crowding, 4. Diastema: A midline diastema is defined as
anterior spacing, largest anterior irregularity the space, in millimetres between the two
(mandible and maxilla), and anteroposterior permanent maxillary incisors at the normal
molar relationship. The ten occlusal features are position of the contact points.
5. Largest anterior maxillary irregularity: and only the largest deviation from the normal
Irregularities may be either rotation out of, molar relation is recorded.
or displacements from, normal alignment. The following codes are used: 0—normal, 1—half
The four incisors in the maxillary arch should cusp, 2—full cusp.
be examined to locate the greatest
irregularity. Calculation of DAI Scores
6. Largest anterior mandibular irregularity: The
measurement is the same as on the upper arch The regression equation used for calculating
except that it is made on the mandibular arch. standard DAI scores is as follows: (missing
7. Anterior maxillary overjet: The largest visible teeth × 6) + (crowding) + (spacing) +
maxillary overjet is recorded to the nearest (diastema × 3) + (largest anterior maxillary
whole millimeter. irregularity) + (largest anterior mandibular
8. Anterior mandibular overjet: Mandibular irregularity) + (anteriormaxillary overjet × 2) +
overjet is recorded when any lower incisor is (anterior mandibular overjet x 4) + (vertical
in crossbite. anterior openbite × 4) + (antero-posterior molar
9. Vertical anterior openbite. relation × 3) + 13. The severity of malocclusion
10. Anteroposterior molar relation: The right and left is classified on the basis of the DAI scores as
sides are assessed with the teeth in occlusion shown in the Table 22.3.
Table: 22.3: Severity of malocclusion and decision of treatment need

Severity of malocclusion Treatment indication DAI Scores
No abnormality or minor malocclusion No or slight need < 25

Definite malocclusion Elective 26–30
Severe malocclusion Highly desirable 31–35
Very severe or handicapping malocclusion Mandatory > 36
History of Interproximal
Enamel Reduction in 23
Orthodontics
• History of Interproximal – Paskow • Indications of Interproximal

Enamel Reduction – Shillingbourg and Grace Enamel Reduction
– Ballard – Tuverson • Contraindications of

– Hudson – Doris, Bernard and Kuftinec
Interproximal Enamel
– Bolton – Sheridan Reduction
– Kelsten – Zachrisson
Interproximal enamel reduction (IER) is Stone age man’s dentition, where he referred to
understood to be the clinical act of removing part the shortening of the dental arch over time, which
of the dental enamel from the interproximal occurred through abrasion. Although the degree
contact area. The aim of this reduction is to create of shortening of the dental arch found by Begg
space for orthodontic treatment and to give teeth was contested, the existence of this natural
a suitable shape whenever problems of shape or reduction led to the publication and
size requires attention. In the literature, this clinical development of the technique for interproximal
act is normally referred to as “stripping”, although enamel reduction.
other names can be found, such as “slendering”, In 1956, Hudson stated that mesiodistal
“slicing”, “Hollywood trim”, “selective grinding”, reduction of the mandibular incisors is only
“mesiodistal reduction”, “reapproximation”, occasionally referred to in the literature, and
“interproximal wear”, and “coronoplastia”. IER listed just three previous articles with direct
is a critical procedure. Therefore, planning and reference to the mesiodistal reduction of
execution need to be carefully assessed. This mandibular incisors. In his study, Hudson stated
treatment should be considered as an exact that stripping should be carried out with medium
reduction of interproximal enamel and not just as and fine metallic strips, followed by final
a simple method to solve problems. polishing and topical application of fluoride. He
stated that it was possible to gain 3 mm of space
HISTORY OF INTERPROXIMAL between mandibular canines, and presented an
ENAMEL REDUCTION enamel thickness table for incisor and
Interproximal dental stripping has been used by mandibular canine contact points.
orthodontists for many years. It was initially used In 1958, Bolton published his seminal study
to gain space when correcting mandibular incisor titled “Disharmony in tooth size and its relation
crowding or to prevent such crowding. to the analysis and treatment of malocclusion”.
In 1944, Ballard recommended a careful This study, together with Ballard’s study,
stripping of the interproximal surfaces, mainly supported the need in dental dimension
from the anterior segment, when a lack of balance discrepancy problems, to use interproximal
is present. In 1954, Begg published his study of stripping to correct problems of dental balance.
In 1969, Kelsten recommended the use of update”. These articles totally revolutionized the
mechanical means to carry out stripping and technique and aims of interproximal enamel
recommended prior alignment of teeth. He reduction. He recommended:
posited that, only after alignment stripping could 1. Use of a turbine with carbide drill, instead of
be simply and accurately achieved. That same diamond disks and strips.
year, Rogers and Wagner described an in vitro 2. Stripping on buccal sectors; in other words,
study that used teeth extracted for orthodontic distally on canines or mesially on the second
reasons. These extracted teeth were subjected to molars on both arches. This achieves greater
stripping and polishing. It was found that if the space and allows the preservation of incisors.
extracted teeth were treated with fluoride after 3. Use of stripping procedures to achieve space
stripping, they offered greater resistance to acid (up to 8 mm per arch) for the correction of
attacks, mainly in the 48 to 96 hours after the moderate dentomaxillary disharmony,
procedure. This scientifically justified the without recourse to extraction or excessive
importance, already highlighted by Hudson, of expansion.
topical fluoride application after stripping and In 1986, Zachrisson proposed a new direction
polishing. for stripping: improvement of the shape of the
In 1971, Paskow published an article that teeth, mainly for incisors and reduction of the
recommended the use of mechanical methods of black triangular space above the papilla.
IER (interproximal enamel reduction).

In 1973, Shillingbourg and Grace wrote an INDICATIONS

article entitled “Thickness of enamel and dentin”,
which was an important study on enamel and The IER (Interproximal enamel reduction)
dentin thickness. The results of this study later technique has evolved over the years; it was first
served as the scientific basis for work on stripping used only for stripping mandibular incisors, with
and allowed the amount of enamel that could be the aim of preventing and correcting crowding.
safely removed from each dental face to be Areas of application have continued to grow:
accurately determined. Also in the 70s, Peck and 1. Tooth size discrepancy: In 1944, Ballard
Peck published articles, on crowding of the recommended careful stripping of the
mandibular incisors and presented the Peck proximal surfaces of the anterior teeth when
index. They advised stripping whenever the there was imbalance.
mesiodistal dimension of the mandibular incisors 2. Crowding of mandibular incisors: Stripping was
did not fall within acceptable figures calculable first used to obtain space for the correction
from their index. They claimed that anything in and prevention of crowding.
excess would constitute predisposition toward 3. Tooth shape and dental esthetics: Stripping can
crowding. and should be used for the reshaping of
In 1980, Tuverson published “Anterior
enamel on some teeth, thus contributing to
interocclusal relations: Part 1”, which presented
an improved finishing of orthodontic
a highly, detailed description of the stripping
treatment and dental esthetics.
technique using a back angle and abrasive disks.
4. Normalization of gingival contour and
In 1981, Doris, Bernard, and Kuftinec
concluded that one of the strongest determining elimination of triangular spaces above the
factors for dental crowding is the dimension of papilla, thus greatly improving esthetics and
teeth in the arch. In 1981, Betteridge presented smile.
the results of stripping on the anterior and 5. Moderate dentomaxillary disharmony: This is a
inferior segment after 1 year without retention. primary area of application for interproximal
She observed some relapse, but concluded that enamel reduction in the technique developed
esthetics were clearly acceptable after by Sheridan in 1985 and 1987, which allowed
observation by a panel of three dentists, three space to be obtained for the correction of
orthodontists, and three non-dentists. moderate dental crowding; up to 8 mm per
In 1985, Sheridan published his article “Air- arch could be achieved without the need for
rotor stripping” and, in 1987, “Air-rotor stripping extraction or excessive expansion.
History of Interproximal Enamel Reduction in Orthodontics 225
6. Reduced expansion and premolar extraction. there is active periodontal disease or lack of
7. Camouflage of class II and III malocclusions: The dental stability. Although little scientific
use of mandibular stripping can be beneficial evidence exists linking IER and increased
in camouflaging slight to moderate class III dental mobility, it is prudent to avoid this
conditions and overjet. In orthodontic treatment technique in these situations. In addition, IER
to camouflage class II with the extraction of should not be used when there is poor oral
two maxillary premolars, correcting the hygiene, the orthodontist could be held
crowding and inclination of the mandibular responsible for all subsequent iatrogenic
incisors with stripping is an ideal solution. activity. Vanarsdall has called attention to the
8. Correction of the curve of spee: For the correction potential deleterious consequences.
of an exaggerated curve of spee, it is necessary 3. Small teeth and hypersensitivity to cold:
to create a few millimeters of space in the Stripping should not be used in these
arch. This can be achieved through moderate situations, as the risk of the appearance of or
stripping. an increase in dental sensitivity is great.
4. Susceptibility to decay or multiple restorations:
CONTRAINDICATIONS There is a risk of causing imbalance in
There are several contraindications for the unstable oral situations, although the
stripping of restorations, instead of enamel
approximation technique:
1. Severe crowding (more than 8 mm per arch): With surfaces, is an option to consider.
application of IER, it would be hazardous to 5. Shape of teeth: Stripping should not be carried
carry out orthodontic correction. There would out on “square” teeth—teeth with straight
be risk of excessive loss of enamel and all of proximal surfaces and wide bases—as these
the ensuing consequences. shapes produce broad contact surfaces, and
2. Poor oral hygiene and/or poor periodontal could potentially cause food impaction and
environment: IER should not be used when reduce interseptal bone.
History of Invisalign 24
• Historical Perspective of • Summary of the Invisalign • Care of Teeth with Invisalign

Invisalign Technique • Study 1
• What Exactly the Invisalign • Indications of Invisalign • Study 2

Means? • Advantages of Invisalign • Study 3
• Developing the Invisalign Brand • Disadvantages of Invisalign • Study 4

• Philosophy of Invisalign • Limitations of Invisalign • Study 5
• Fabrication of Invisalign • Procedure of Treatment with • Study 6
• Principle of the Invisalign • Study 7
Stereophotolithography • Benefits of Invisalign • Other Studies
As far back as 1945, orthodontists realized that a Chishti nor Wirth had any professional dental
sequence of removable plastic appliances could training. Invisalign braces were first made
move teeth toward a predetermined result. Some available to the public in May, 2000 and proved
orthodontists even made simple plastic “aligner extremely popular with patients. Soon similar
trays” in their offices for minor adjustments. But products began appearing on the market, made
it took an adult who’d just had braces to take the by GAC, 3-M Unitek, Ormco, OrthoClear, and
concept a step further. others.
Invisalign was the brainchild of Zia Chishti Manufactured by American dental product
and Kelsey Wirth, graduate students in Stanford manufacturer Align Technology, Inc., these
University’s MBA program. Wirth had aligners are based on the suggestions of dentist
traditional braces in high school (she reportedly Dr H.D. Kessling, who first proposed the removable
hated them). Chishti had finished adult treatment tray alternative to braces in 1945. Of great
with traditional braces and now wore a clear importance was Dr Kessling’s idea that the
plastic retainer. He noticed that if he didn’t wear removable tray be part of a series of trays, with
his retainer for a few days, his teeth shifted each tray forcing teeth to maneuver one step further
slightly — but the plastic retainer soon moved into line. In 1998, Align Technology received full
his teeth back the desired position. In 1997, he FDA approval for Invisalign as a Class II medical
and Wirth applied 3D computer imaging device. Align Technology continues to get FDA
graphics to the field of orthodontics and created testing and approval for modifications made in
Align Technologies and the Invisalign method. the years since. Nearly one million patients have
With a boost from ample Silicon Valley venture used Invisalign under the guidance of their
funding, Align soon took the orthodontic dentists, orthodontists and cosmetic surgeons.
industry by storm. Dentists and other dental When used properly, these aligners get the same
companies were skeptical at first, because neither or similar results as traditional braces.
HISTORICAL PERSPECTIVE OF INVISALIGN Boyd and Vlaskalic(2001), Womack (2002),

Norris(2002), Miller(2002), Christianson (2002),
The movement of teeth through sequential stages,
Joffe (2003), Faltin (2003) have documented
individually planned by a set up in casts, and the
successful treatment outcomes and deliberated on
use of elastomeric appliances was initially
the finer nuances of Invisalign therapy.
suggested by:
Lagravere (2005) conducted a systematic
Remensyner (1926) when he introduced the
review on the system. The authors could make no
FLEX-O-LITE gum massaging appliance, through
conclusion from the same about the indications
which reported minor tooth movements and
for, limitations of and outcomes of use of the
Kesling (1945) by introducing a vulcanite
Invisalign system because the author found no
appliance called the Tooth Positioner.
study that quantified treatment effects or
Though thermoplastic sheets were
accomplishment of treatment goals using it.
manufactured as far back as 1896, thermoforming
Djeu et al (2005) assessed the treatment
as a process was not known until a little before
outcome of Invisalign and traditional orthodontic
1950.
treatment compared with the American Board of
The Dental Contour Appliance was
Orthodontics objective grading system and found
manufactured using an industrial grade vacuum
treatment effects with Invisalign deficient in
former and reported by Nahoum (1964).
certain respects. Tuncay (2006) edited a
Modlin (1974) reported realignment of teeth

publication on the Invisalign concept and its
using vacuum formed appliances.
clinical management.
Ponitz (1971), McNamara et al (1985)
BOYD (2006, 2008) demonstrated use of
described the use and efficacy of invisible
Invisalign in a surgical case, and reviewed
retainers.
previous Invisalign studies showing significant
The Essix System was described by
limitations for complex tooth movement with
SHERIDAN et al. for fabricating retainers in 1993.
current case reports showing successful treatment
Rinchuse and Rinchuse described active
of moderate to severe malocclusions, attributing
tooth movement with the same in 1997.
it to technological advancements in the system
Lindor and Schoff (1998), Hilliard (2000),
during a decade of its existence.
Armbruster (2003), Giancotti (2004) and others
The Clear Aligner concept and branding of
have contributed to the treatment possibilities
an alternative low-cost orthodontic appliance
with the Essix System. The limitations of all Essix
system to both orthodontists and general dentists
appliances were the small magnitude of changes
was introduced by TAE WEON KIM (2004).The
achieved, associated with the technical
system uses digital aid combined with manual
difficulties, to manually subdivide, in stages, a
manipulation to fabricate aligners.
movement, desired in several small progressive
Kim (2007) authored the Clear Aligner
movements.
Manual.
The Invisalign System was developed in 1998
The Orthoclear system introduced itself as an
by Align Technology. This was the first technique
alternative to Invisalign.CHISTI, WEN &
to be based on 3D Digital Technology. A series of
Riepenhausen (2005) were the founders of the
algorithm stages were produced to move teeth into
same.
0.015–0.025 mm, successive precise movements
Miller, Crawford and Nanda (2006) described
using computer programmes that manipulate the
case reports with the Orthoclear system.
virtual images of the individual malocclusion.
Orthoclear was involved in a legal battle over
Chisti and Wirth, 2 MBA Students from
patents with Invisalign and a settlement was
Stanford University were credited with the
reached in 2006 wherein Orthoclear decided to
formation of Align Technology.
stop operations in the US.
Boyd et al (2000) published the first clinical
3D Ortholine was established as a system
study carried out in the Pacific university,
offering aligner therapy by Abouhassan (2006)
California reporting successful treatment
and inculcated an advanced system of virtual set
outcomes in cases with mild crowding and
ups and appliance design where special emphasis
spacing between 3–6 mm.
was placed on the sequential division of tooth
movement to enhance patient comfort and towards their optimum positions. But whereas
increase the scope of tooth movements with aligner conventional braces are built from stainless steel
therapy. and metal wire, Invisalign products are clear
Vaid and Abouhassan (2008) reported clinical plastic aligners that are less than one millimeter
reports and technological parameters of the thick. They are also removable, which makes
system, designed to provide efficacy. Long-term everyday tasks such as eating much easier—as
results were still awaited. you can probably imagine.
Profit (2007) described a role for Aligner One of the reasons why Invisalign has grown
Therapy in treating complex malocclusions with in recent years is because orthodontic work for
limitations in specific scenarios and predicted a adults is becoming much more popular. In the
future for this method of treatment. past, most people believed that braces could only
Namiranian (2008) studied the effect of aligner really make a difference to your teeth as a teenager,
thickness on stress production and concluded that when your teeth were still growing. But that is a
thick and medium aligners were more likely to myth. Braces can still move your teeth as an adult
produce effective tooth movement compared to and you can still achieve the smile you want later
medium aligners.Different Systems of Plastic in life. As more adult orthodontic treatments are
aligners differ in the clinical and laboratory steps becoming available, more people are keen to learn
and the modifications possible, that they offer the about the options available to them.
operator. A lot of the published data is “system The growth in adult orthodontic treatment has
based “rather than “therapy based” and has led to greater consumer demand for more flexible
commercial or system specific allegiance to it. The products that can be adapted to suit a customer’s
literature on the therapy is definitely encouraging, lifestyle. For example, conventional braces may
but is mostly anecdotal including case reports or get just the same results as Invisalign aligners.
clinician’s innovations. But if you’ve got a big presentation with your boss
Randomized clinical trials that follow the next week, what would you rather be wearing: an
CONSORT statement are needed to evaluate the old-fashioned metal and wire bracket or a
treatment effects of Aligners. Technological virtually invisible aligner that you can even
analysis of the biomechanical properties of the remove if you need to? In a nutshell, that’s why
materials used and the permutation of tooth most adults choose Invisalign.
movements effectively possible, with an Over the years, Invisalign has developed into
organized classification of stages involved will a successful brand with a number of products in
and should be the trend of future research. its portfolio. There is the original, definitive
Invisalign program, which this site covers in detail
WHAT EXACTLY THE INVISALIGN MEANS? from treatment through to costs. Recently,
however, Invisalign has also released modified
Invisalign refers to a series of clear, removable
versions of the original system to exploit new
heavy-duty plastic aligners that gradually correct
opportunities within the dental market.
minor crookedness and gaps, overcrowded teeth,
Invisalign Express is a new version of the
overbites and/or minor underbites. When
Invisalign system which is designed to correct
considering your options, there are a number of
minor orthodontic issues in short timescales.
reasons to select this procedure over other choices
Invisalign Teen is the program that Invisalign
such as metal braces, crowns, veneers and
has designed specifically for teenagers. It includes
implants.
a number of modifications that make it easier for
teenagers and parents to manage the treatment
DEVELOPING THE INVISALIGN BRAND
and therefore achieve the desired results.
So where does Invisalign fit into this picture? The For a long time now Orthodontists and patients
Invisalign brand was first launched in America have wanted to correct teeth inconspicuously and
in 1999. Invisalign products work in much the without the use of fixed dental brackets. New
same way as conventional brackets in that technology has turned this dream into reality; the
appliances are fitted to your teeth, and those new type of treatment is called Invisalign (Fig.
appliances then move the teeth slowly and gently 24.1) (Invisible/Align) Technique.
the PVS impressions and to record treatment

changesor modifications immediately in a digital
format. Adding the other 3D compartments
(skeletal, facial, jaw movements and animation to
the current surface map of the teeth) will greatly
enhance the diagnostic and treatment capabilities
of this appliance. Thus the clinician must have
indepth understanding of the biomechanics,
biology, periodontal concerns and optimal
therapeutic occlusion achieved during
orthodontic treatment to successfully plan and
use this appliance.
FABRICATION OF INVISALIGN
The orthodontist submits the following to align
technology:
Fig. 24.1: Invisalign appliance • A set of a polyvinyl siloxane impressions
• A centric occlusion bite registration

Align Technologies introduced Invisalign • A panaromic radiograph
(invisible/align) in 1999. Invisalign incorporates • A lateral cephalometric radiograph

a series of invisible (clear) plastic aligners that fit • Photographs.
comfortably over teeth and are designed to move The impressions are poured up in dental
teeth gradually into the desired position. plaster and then placed in a tray and encased with
Invisalign aligners are manufactured at the align epoxy and urethane. The impressions are
technologies dental laboratory using computer- inspected by the laboratory to ensure that the
aided design/computer-aided manufacturing patients dentition has been fully captured. The tray
(CAD/CAM) processes. is placed into a destructive scanner (Figs 24.2A
and B) using computed tomography. The scanners
PHILOSOPHY OF INVISALIGN rotating blades makes numerous passes over the
Invisalign takes the principles of Kesling, epoxy encased models removing a thin layer with
Nahoum, and Raintree Essix even further, each pass. A computer linked with a scanner then
using cter-aided-design-computer-aided- assembles the scanned information to create a
manufacture (CAD-CAM) technology combined three-dimensional rendering of the models.
with laboratory techniques to fabricate a series of After the bite has been established, based on
custom appliances that are esthetic and the clinician’s treatment plan technicians generate
removeable, and that can move teeth from a virtual correction of malocclusion that is then
beginning to end. reviewed by the clinician this process is called
The Invisalign system has been tested in the Clin-Check. The software cuts the virtual
university clinical trials and is available to public. models and separates the teeth allowing them to
There are currently certain limitations to this be move individually (Fig. 24.3). A virtual gingival
appliance in terms of cost, case selection, is placed along the gingival line of the clinical
experienced required for computer treatment crown to serve as the margin for the manufacturing
planning, difficulty obtaining certain tooth of the aligners (Fig. 24.4).
movements and lack of potential in cases involving After final approval the treatment sequence is
mixed dentition or impacted teeth. However as the divided into a series of algorithmic stages. Each
number of clinicians using this appliance increases stage has maximum tooth movement potential of
more information will be available to evaluate the 0.25 mm/appliance. Models of each stage of
risks and benefits of this system. treatment are made by having the computer direct
A great help in the future will be to use one of their fabrication in a process called
the emerging intraoral scanning devices to replace Stereolithography (Figs 24.5A to C).
These models are then used to fabricate the reason the aligners appear not to be achieving the
aligners on a Biostar pressure molding machine treatment goals (compliance, difficult movements
(Fig. 24.6). The aligners are trimmed and laser etc) a midcourse correction protocol can be
etched with the patients (Fig. 24.7). initiated. Mid course correction involves new
• Patients initial impressions and a new clean check which is send
• Case number to the clinician within 2 weeks. A new series of
• Aligner number aligners are constructed and send to the clinician.
• And arch upper/lower. At the end of the treatment, the clinician may also
They are then disinfected, packaged, and be able to initiate a case refinement for detailing
shipped to the doctor’s office. If for whatever and final corrections if needed.
A Fig. 24.3: Cutters separate teeth
B
Figs 24.2A and B: (A) Destructive scanner; (B) 3D
Generated computer model Fig. 24.4: Placement of virtual gingiva
A B C
Figs 24.5A to C: (A) Stereolithography machines; (B) Stereolithography models; (C) Aligners
Fig. 24.6: Biostar machine

Fig. 24.8: The principle of stereophotolithography applied to
the rapid prototyping of 3D objects
Fig. 24.7: Stereolithographic models
PRINCIPLE OF STEREOPHOTOLITHOGRAPHY
Principle
A system able to create 3D objects of any
complexity by successive layers (slices). Each slice Fig. 24.9: Diagram of a typical stereophotolithograhy system,
according to Kristi S Anseth, Dept Chem. Eng. Univ. of
is produced by action of a laser light on a liquid Colorado at Boulder
material. This 2D shape of the solid slice is
obtained by the movements of the laser, • The impression is inspected by the laboratory
commanded by a computer. The precision is to ensure that patient’s dentition has been fully
defined by the thickness of each slice (Fig. 24.8). captured. Then the impression is scanned
The process called stereophotolithography (SPL) using computer tomography to create a highly
has been developed in the 90’s by Laser 3D accurate and detailed three-dimensional study
(Nancy, France), based on the French Patent No. 84 model.
11 241 (CNRS- July 84 (Fig. 24.9)). • Based on the clinician’s treatment plan
technicians generate a virtual correction of the
SUMMARY OF THE INVISALIGN TECHNIQUE malocclusion that is than reviewed by the
The technique for using the invisalign system is clinicians. This process is called clin-check.
as follows: • The clinician reviews the planned corrections
• The clinician sends a rubber base impression and if necessary, sends any revisions to align
of maxillary and mandibular arches to align technology. The final step of clin-check must
technologies laboratories along with patient be approved by the treating clinician.
facial photograph, radiographs and a detailed • After final approval, the treatment sequence is
treatment plan. divided into a series of algorithmic stages. Each
stage has a maximum tooth movement 2. The treatment procedures do not allow for
potential of 0.25 mm per appliances. continued eruption of teeth, or significant
• Models of each stage of treatment are made by dental arch changes during growth that may
process called stereolithography Individual occur during the mixed dentition phase.
appliances (aligners) are made from the 3. There is currently no capability to incorporate
computer-generated models of each stage. basal orthopedic change with this appliance
• A typical invisalign treatment requires 20 to system, thus restricting it to malocclusions
30 aligners for the maxillary and mandibular requiring pure dental movements.
arches. 4. Unlike fixed or removable appliances, the
• In most of the cases, treatment with invisalign treatment plan cannot be changed once the
is done in less than a year; however, treatment appliance series has begun. If change in
time depends on the specific alignment treatment is desired the current series may be
problem. completed and a new plan and appliances are
made or the current series may be stopped.
INDICATIONS OF INVISALIGN 5. The inability to integrate hard and soft tissues
of the head into the computer treatment thus
According to researchers and align technologies,
there is no direct indication of where teeth are
invisalign can be used to correct the following
in relation to basal bone or in relation to the
types of mild malocclusions:

lips or other soft tissues of head.
1. Malocclusion with mild crowding cases.
6. Invisalign is generally not recommended in

2. Malocclusion with mild spacing case.
treating more complicated malocclusions such
3. In cases mild relapse – after traditional braces
as severe deep bite, anterior-posterior
have been removed, when some relapsing
corrections greater than 2mm, uprighting
tooth movement has occurred.
severely tipped teeth and closure of premolar
extraction spaces.
ADVANTAGES OF INVISALIGN
1. Improved esthetics compared to fixed PROCEDURE OF TREATMENT WITH THE
orthodontic appliance and ability to remove INVISALIGN
the appliance. First Evaluation
2. Invisalign patients showed no measurable root
resorption. • Orthodontist evaluates and creates a program
3. It gives the patient an esthetic choice in their of treatment.
orthodontic treatment. • Records and impressions of arches are taken.
Invisalign Aligners Made and Delivered

DISADVANTAGES OF INVISALIGN
• A CT-scan (Computed Tomography or CAT-
1. Fabrication of the aligners is a very time
scan), is made from your dental impressions
consuming and tedious process that probably
that produces an extremely accurate, 3D
would not be practical day to day orthodontic
digital model of your teeth.
practice.
• CAD (Computer-aided design) software is
2. Severe derotations, complex extrusions and
then used to simulate the movement of your
large translations are less predictable with
teeth during treatment.
invisalign and may require auxiliary
• The treatment plan are reviewed, modified,
treatment.
and approved before the aligners are created.
• Invisalign then uses advanced stereo-
LIMITATIONS OF INVISALIGN
lithography (SLA) technology to build precise
1. All permanent teeth should be fully erupted moulds of teeth at each stage of treatment.
for treatment using invisalign as it is difficult • Individualized, custom-created clear aligners
to achieve retention of the appliance on short are made from these models and sent to
clinical crowns. orthodontist.
Wearing of Invisalign (Fig. 24.10) the teeth. The principal difference is that
Invisalign not only controls forces, but also
• Visits are made to orthodontist for adjustments
controls the timing of the force application. At
and to check progress on a monthly basis.
each stage, only certain teeth are allowed to
• At regular intervals, a new set of custom-
move, and these movements are determined by
molded clear aligners are received to continue
the orthodontic treatment plan for that
the straightening process.
particular stage. This results in an efficient
The total number of clear aligners is specific to
force delivery system.
you, determined by orthodontist for the course of
treatment.
STUDY 1
BENEFITS OF INVISALIGN
OUTCOME ASSESSMENT OF INVISALIGN AND
1. Invisible thus no unwarranted attention to TRADITIONAL ORTHODONTIC TREATMENT
your mouth. COMPARED WITH THE AMERICAN BOARD OF
2. Removable thus easy to eat, brush and floss. ORTHODONTICS OBJECTIVE GRADING
3. No brackets to catch food or plaque. SYSTEM
4. Healthier gums from properly aligned teeth
that help gums to “fit” tighter around each Garret Djeu,a Clarence Shelton,b and Anthony
tooth. Maganzinic
New York, NY
5. Easier cleanings in maintaining a good oral

hygiene program that reduce chances of
plaque build-up, tooth decay and periodontal Introduction
disease. This treatment-outcome assessment objectively
compares Invisalign (Align Technology, Santa
CARE OF TEETH WITH INVISALIGN Clara, Calif) treatment with braces.
1. Teeth and the aligners would need to be kept
cleaned every day if the teeth and gums are to Methods
be healthy during and after orthodontic This study, a retrospective cohort analysis, was
treatment. conducted in New York, NY, in 2004. Records from
2. Follow orthodontist directions on how often 2 groups of 48 patients (Invisalign and braces
to brush, how often to floss and use of other groups) were evaluated by using methods from the
cleaning aids to help maintain good dental American Board of Orthodontics Phase III
health. examination. The discrepancy index was used to
Like brackets and arch wires are to braces, analyze pretreatment records to control for initial
Invisalign aligners move teeth through the severity of malocclusion. The objective grading
appropriate placement of controlled force on system (OGS) was used to systematically grade
posttreatment records. Statistical analyses evaluated
treatment outcome, duration, and strengths and
weaknesses of Invisalign compared with braces.
Results
The Invisalign group lost 13 OGS points more than
the braces group on average, and the OGS passing
rate for Invisalign was 27% lower than that for
braces. Invisalign scores were consistently lower
than braces scores for buccolingual inclination,
occlusal contacts, occlusal relationships, and
overjet. Invisalign’s OGS scores were negatively
correlated to initial overjet, occlusion, and buccal
Fig. 24.10: Wearing invisalign appliance posterior crossibite. Invisalign patients finished
4 months sooner than those with fixed appliances Results

on average. P _ .05 was used to determine
The mean accuracy of tooth movement with
statistically significant differences.
Invisalign was 41%. The most accurate movement
Conclusion was lingual constriction (47.1%), and the least
accurate movement was extrusion (29.6%)—
According to the OGS, Invisalign did not treat specifically, extrusion of the maxillary (18.3%) and
malocclusions as well as braces in this sample. mandibular (24.5%) central incisors, followed by
Invisalign was especially deficient in its ability to mesiodistal tipping of the mandibular canines
correct large anteroposterior discrepancies and (26.9%). The accuracy of canine rotation was
occlusal contacts. The strengths of Invisalign were significantly lower than that of all other teeth, with
its ability to close spaces and correct anterior the exception of the maxillary lateral incisors. At
rotations and marginal ridge heights. This study rotational movements greater than 15°, the
might help clinicians to determine which patients accuracy of rotation for the maxillary canines fell
are best suited for Invisalign treatment (Am J significantly. Lingual crown tip was significantly
Orthod Dentofacial Orthop 2005;128. more accurate than labial crown tip, particularly
for the maxillary incisors. There was no statistical
STUDY 2 difference in accuracy between maxillary and
mandibular teeth of the same tooth type for any

HOW WELL DOES INVISALIGN WORK? A movements studied.
PROSPECTIVE CLINICAL STUDY EVALUATING

THE EFFICACY OF TOOTH MOVEMENT WITH Conclusion
INVISALIGN
In this prospective clinical study evaluating the
Neal D. Kravitz,a Budi Kusnoto,b Ellen BeGole,c efficacy of tooth movement with Invisalign, the
Ales Obrez,d and Brent Agrane following conclusions were made:
South Riding, Va, White Plains, Md, and 1. The mean accuracy of tooth movement with
Chicago, Ill Invisalign was 41%. The most accurate tooth
movement was lingual constriction (47.1%).
Introduction The least accurate tooth movement was
The purpose of this prospective clinical study was extrusion (29.6%). The mandibular canine was
to evaluate the efficacy of tooth movement with the most difficult tooth to control.
removable polyurethane aligners (Invisalign, 2. Maxillary and mandibular canines achieved
Align Technology, Santa Clara, Calif). approximately one-third of the predicted
rotation. The accuracy of canine rotation was
Methods significantly lower than the rotation of all other
teeth, with the exception of the maxillary lateral
The study sample included 37 patients treated incisors. At rotational movements greater than
with Anterior Invisalign. Four hundred one 15°, the accuracy for the maxillary canines was
anterior teeth (198 maxillary and 203 mandibular) significantly reduced.
were measured on the virtual treat models. The 3. With the exception of canine rotation, no tooth
virtual model of the predicted tooth position was was significantly less accurate in movement.
superimposed over the virtual model of the 4. Lingual crown tip was significantly more
achieved tooth position, created from the accurate than labial crown tip, particularly for
posttreatment impression, and the 2 models were the maxillary incisors.
superimposed over their stationary posterior teeth 5. The severity of pretreatment overjet might
by using Tooth Measure, Invisalign’s proprietary influence the accuracy of anterior tooth
superimposition software. The amount of tooth movement with Invisalign.
movement predicted was compared with the 6. There was no statistical difference in accuracy
amount achieved after treatment. The types of between maxillary and mandibular teeth of
movements studied were expansion, constriction, the same type for any tooth movement studied.
intrusion, extrusion, mesiodistal tip, labiolingual These results indicate that we still have much
tip, and rotation. to learn regarding the biomechanics and
efficacy of the Invisalign system. Clinicians microscopy and energy dispersive X-ray
who prescribe Invisalign treatment should microanalysis to identify the elemental composition
fully recognize its limitations and commit of integuments formed on the surface, and (4) Vickers
themselves to providing the gold standard of hardness (HV200) testing. Another set of reference
care for their patients. Providing quality care, and retrieved appliances was subjected to artificial
regardless of the treatment modality, is only aging for 2 weeks, and the extracts were subjected to
way to truly be a premiere provider. gas chromatography-mass spectroscopy. The
retrieved appliances demonstrated substantial
STUDY 3 morphological variation relative to the as-received
specimens involving abrasion at the cusp tips,
RETAINING ALIGNMENT CHANGES WITH adsorption of integuments, and localized
INVISALIGN calcification of the precipitated biofilm at stagnation
sites. Buccal segments of retrieved appliances
Kuncio D, Maganzini A, Shelton C, et al: Invisalign showed an increase in hardness, which might be
and traditional orthodontic treatment attributed to mastication-induced cold work;
postretention outcomes compared using the however, the clinical implication of this effect on
American Board of Orthodontics objective grading mechanotherapy is unknown. In vitro aged and
system. Angle Orthod 77:864-869, 2007. retrieved appliances were found to leach no
Relapse of orthodontic cases, while extensively traceable amount of substances in an ethanol aging
studied, remains poorly understood. In this study,
solution. (Am J Orthod Dentofacial Orthop

while both techniques produced acceptable initial 2004;126:725-8).
results, cases treated with conventional braces
were more stable over time. Retention times were Conclusion
comparable but changes in resultant treatment
forces were more frequent with Invisalign than Retrieved Invisalign appliances demonstrate
with fixed appliances. substantial morphological variation in relation
to new specimens, involving abrasion at the cusp
STUDY 4 tips, adsorption of integuments at stagnation sites,
and localized calcification of the biofilm
STRUCTURAL CONFORMATION AND developed during intraoral service. An increase
LEACHING FROM IN VITRO AGED AND in hardness of the buccal segments of the retrieved
RETRIEVED INVISALIGN APPLIANCES appliances was found; this could mainly be
attributed to cold work during mastication. The
Susan Schuster, DDS,a George Eliades, DDS, clinical implication of this effect in the force
DrDent,b Spiros Zinelis, PhD,c Theodore Eliades, delivery of the appliance requires further study.
DDS, MS, DrMed, PhD,d and T. Gerard Bradley, In vitro aged appliances were found not to release
BDS, MSe traceable monomers or byproducts after
Milwaukee, Wis, and Athens, Greece immersion in an ethanol-water solvent. The aging
The objectives of this study were to investigate the pattern of these appliances intraorally involves
structure of Invisalign appliances (Align abrasive wear arising from mastication, and, thus,
Technology, Santa Clara, Calif) after intraoral no definitive consensus on their reactivity and
exposure, and to qualitatively and quantitatively biological properties can yet be established.
characterize the substances leached from the aligners
after accelerated in vitro aging. Samples of Invisalign STUDY 5
appliances were randomly selected from 10 patients
before intraoral placement and after retrieval, and CYTOTOXICITY AND ESTROGENICITY OF
the prepared specimens were subjected to (1) bright- INVISALIGN APPLIANCES
field optical reflection microscopy to study the
surface morphology; (2) Fourier transform infrared Theodore Eliades,a Harris Pratsinis,b Athanasios
microspectroscopy to characterize the in vivo E. Athanasiou,c George Eliades,d and Dimitris
changes in molecular composition induced on Kletsase
appliance surfaces, (3) scanning electron Thessaloniki and Athens, Greece
Introduction Materials and Methods

Our purpose was to study the in-vitro cytotoxic The compliance indicators in the Invisalign Teen
and estrogenic properties of Invisalign appliances aligners were tested for color resistance in various
(Align Technology, Santa Clara, Calif). Methods: aqueous models with no saliva involved.
Three sets, each consisting of a maxillary and a
mandibular appliance, of as-received aligners Results
were immersed in normal saline solution for 2
Color fading was observed as a function of time,
months. Samples of eluents were diluted to 3
pH, and temperature while compliance
concentrations (5%, 10%, and 20% vol/vol) and
indicators were stored in drinking water or sour
tested for cytotoxicity on human gingival
soft drinks and in conjunction with the use of
fibroblasts and estrogenicity by measuring their
cleaning tablets and a dishwasher. The findings
effect on the proliferation of the estrogen-
of color fading were consistent with the color
responsive MCF-7 breast cancer cells. All assays
changes observed when the aligners were being
were repeated 4 times for each maxillary and
worn by patients. Color fading, notably as
mandibular set, and the results were analyzed
observed in connection with acidic soft drinks
with 2-way analysis of variance (ANOVA) with
and cleaning techniques, introduces uncertainty
appliance and concentration serving as predictors
into the assessment of actual patient compliance,
at the .05 level of significance; differences among

as reflected by the fading colors of compliance
groups were investigated with the Tukey test.
indicators.
Results
Conclusion
There was no evidence of cytotoxicity on human
Compliance indicators are not immune to simple
gingival fibroblasts and no stimulation of
intentional or unintentional manipulations.
proliferation of the MCF-7 cell line at any
Therefore, they can best show an estimate of wear
concentration, indicating no estrogenicity of aligner
time but cannot be recommended as objective
eluents. Conclusions: The use of Invisalign
wear-time indicators. (Angle Orthod.
appliances did not seem to induce estrogenic effects
2011;81:185–191).
under the conditions of this experiment. (Am J
Orthod Dentofacial Orthop 2009;136:100-3).
STUDY 7
Conclusion
A COMPARISON OF TREATMENT IMPACTS
No cytotoxic or estrogenic activity of Invisalign BETWEEN INVISALIGN ALIGNER AND FIXED
appliances was documented in this in-vitro assay, APPLIANCE THERAPY DURING THE FIRST
which used a standard model for the assessment WEEK OF TREATMENT
of estrogenicity of materials.
Kevin B. Miller,a Susan P. McGorray,b Randy
Womack,c Juan Carlos Quintero,d Mark
STUDY 6
Perelmuter,e Jerome Gibson,f Teresa A. Dolan,g
and Timothy T. Wheelerh
COLOR FADING OF THE BLUE COMPLIANCE
Rock Hill, SC, Gainesville and Miami, Fla,
INDICATOR ENCAPSULATED IN REMOVABLE
Glendale, Ariz, Louisville, Ky, and
CLEAR INVISALIGN TEEN ALIGNERS
San Antonio, Tex
Timm Cornelius Schotta; Gernot Go¨ zb
Introduction
Objective
The aim of this study was to evaluate the
To evaluate the color fading in aqueous solutions differences in quality of life impacts between
of the blue dot wear-compliance indicators of the subjects treated with Invisalign aligners (Align
Invisalign TeenH System outside the oral cavity. Technology, Santa Clara, Calif) and those with
fixed appliances during the first week of the effectiveness of the Invisalign system. They
orthodontic treatment. Methods: A prospective, pointed to the need for randomized clinical trials.
longitudinal cohort study involving 60 adult Since this paper, more studies about the clinical
orthodontic patients (33 with Invisalign aligners, effectiveness have been published; for example in
27 with fixed appliances) was completed by using the UK, Dr Paul Humber has analyzed 100 back-
a daily diary to measure treatment impacts to-back Invisalign cases. Assessing the patients
including functional, psychosocial, and pain- after two sets of aligners, he found that 94% of the
related outcomes. A baseline survey was dentitions had achieved the objectives set. In the
completed before the start of treatment; diary USA, Akhlaghi and colleagues compared
entries were made for 7 consecutive days to treatment with the invisalign system with
measure various impacts of the subjects’ treatment with conventional braces and
orthodontic treatment over time. The data were concluded that “conventional fixed appliances
then analyzed for differences between treatment achieved better results in the treatment of Class I
modalities in terms of the subjects’ reported mild crowding malocclusions” In a comparison
impacts from their orthodontic treatment. of outcomes between the two approaches, Kuncio
et al reported that the Invisalign group displayed
Results greater relapse saying “the mean alignment of the
The baseline mean values did not differ between Invisalign group was superior to the Braces group
groups for pain reports (P _ .22) or overall quality before and after the retention phase, but these
of life impact (P _ .51). During the first week of differences were not statistically significant.
treatment, the subjects in the Invisalign group Therefore, even though the Invisalign cases
reported fewer negative impacts on overall quality relapsed more, they appear to have the same, if
of life (P _.0001). The Invisalign group also not better, overall alignment scores.” In a larger
recorded less impact in each quality of life study Djeu and colleagues had similar findings
subscale evaluated (functional, psychosocial, and to Akhlaghi above and concluded that “Invisalign
pain-related, all P _.003). The visual analog scale was especially deficient in its ability to correct
pain reports showed that subjects in the Invisalign large anteroposterior discrepancies and occlusal
group experienced less pain during the first week contacts”. They felt that “The strengths of
of treatment (P _.0001). The subjects in the fixed Invisalign were its ability to close spaces and
appliance group took more pain medications than correct anterior rotations and marginal ridge
those in the Invisalign group at days 2 and 3 (both heights.” They added “Invisalign patients
P _.007). finished 4 months sooner than those with fixed
appliances on average.” Furthermore, work at
Conclusion NYU/Buffalo University by Dr Omar Fetouh was
published in 2009 where 67 patients were studied,
Adults treated with Invisalign aligners
half of whom were treated with Invisalign and
experienced less pain and fewer negative impacts
half with fixed appliances. He concluded that
on their lives during the first week of orthodontic
‘There was no statistical significant difference
treatment.
between the scores of the Invisalign group and
Braces group for Alignment, Occlusal
OTHER STUDIES Relationship and Interproximal Contacts. The
Invisalign group had higher scores in Marginal
SCIENTIFIC STUDIES ridges, Bucco-lingual inclination, Occlusal
In a systematic review of the literature, published Contacts, and Overjet than the Braces group.’ His
in the Journal of the American Dental Association in conclusion was that Invisalign can treat mild
2005.Drs. Manual Lagravere and Carlos Flores- malocclusions ‘as efficiently, if not better, as
Mir were unable to draw strong conclusions about braces.’
History of Molar
Distalization in 25
Orthodontics
• History of Molar Distalization • Intermaxillary Class II • K-loop Molar Distalizer

• Indications for Molar Malocclusion Correction • The Distal Jet Appliance
Distalization Appliances • The Crozat Appliance

• Contraindications of Molar • Vertical Holding Appliance • Molar Distalization by Magnets
Distalization • Removable Molar Distalization • The Magnets

• An Ideal Intraoral Molar Splint • The Klapper Superspring
Distalization Appliance should • Symmetric Distalization with a • Herbst Appliance
meet the following Criteria TMA Transpalatal Arch • The Mandibular Anterior
• Mechanism of Action of • Tube Plates for Distalization of Repositioning Appliance
Distalizing Appliances Molars (MARA)
• Pendulum Appliance • Cetlin Appliance • Saif Springs
• Pend-X Appliance • Anchorage Need • The ‘Fastback’ Appliance for
• M-pendulum Appliance • Extraoral Force Molar Distalization
• Pendulum F Appliance • The Force Applied • Features of Fast Back Appliance
• Jones Jig • The Lokar Appliance
Whenever there is space deficiency, the methods HISTORY OF MOLAR DISTALIZATION

of gaining space that strikes to our mind first are,
extraction, expansion and stripping. Angle, The concept of ‘distal driving’ of the maxillary
proposed expansion of dental arches for nearly posterior teeth has a long orthodontic history in
every patient and extraction for orthodontic 1920s. Class II elastic treatment was thought to be
purpose was not necessary for stability of results an easy and effective tool but early cephalometric
or for aesthetics. He believed that when teeth could studies in 1940s showed little or no distal
be saved by dental treatment, extraction of teeth movement of upper molars. Thus headgears were
for orthodontic purpose seemed particularly reintroduced as means of moving upper molars
inappropriate unacceptable. back. These extra oral appliances were heavily
In 1930’s, Charles Tweed observed relapse after dependent on patient cooperation, forces
non-extraction expansion treatment and decided generated were high and intermittent causing
to retreat with extraction. In recent years, the severe patient discomfort and prolonged
percentage of patients having extraction as a part treatment time.
of orthodontic treatment has decreased To overcome these difficulties, more recently
considerably as experiments has shown that several intra oral appliances employing palatal
premolar extraction does not necessarily anchorage have been used to produce distal
guarantee stability of teeth alignment. Proximal movement of upper molars. Distalization
stripping also has its own limitation. mechanics has found many supporters in its
History of Molar Distalization in Orthodontics 239
quarters since it provides the arch with increase control of the clinician. Relying on the patient’s
length which may correct arch relationship as well willingness to wear an appliance consistently
as do away with extraction and loss of tooth. In may result in increased treatment time, a change
some cases the operator gets bonus of achieving of treatment plan or both.
expansion or molar derotation also. In recent years, appliances largely
• Molar distalization, in recent years is evolved independent of patient compliance increasingly
as an alternative method of gaining space to have been used for maxillary molar distalization.
conventional methods where ever is indicated.
• Kingsley was the first person to try to move the INDICATIONS FOR MOLAR DISTALIZATION
maxillary teeth backwards in 1892 by means
In a Growing Child
of headgear.
• Oppenheim advocated that position of • To relieve mild crowding
mandibular teeth as being the most correct for • Causes permanent increase in arch-length of
individual and use of occipital anchorage for about 2 mm on each side.
moving maxillary teeth distally into correct
relationship without disturbing mandibular Late Mixed Dentition
teeth. In 1944, he treated a case with extra-oral
• When lower E space – utilized for relief of
anchorage for distalizing maxillary molar.
anterior crowding
• Renfroe (1956) reported that lip bumper
• Upper molars distalized to get a class I relation
primarily devised to hold hypertonic lower lip

• Class I malocclusion—with highly/labially
caused a distal movement of lower molars
placed canine/impacted canine
sufficient to change class I to Class II.
• Lack of space for eruption of premolars due to
• Gould (1957) was first person to discuss about
mesial migration of permanent first molars
unilateral distalization of molars with extra-
• Good soft tissue profile
oral force.
• Borderline cases
• Kloehn (1951) described the effects of cervical
• Mild-to-moderate space discrepancy with
pull headgear.
missing 3rd molars/2nd molars not yet erupted
• Graber T-M. (1969) extracted the maxillary II
• Axial inclination : Mesially angulated upper
molar and distalized the first molar to correct
molars
class II div.1.
• Normal or hypodivergant growth pattern
Non-extraction treatment plans for angle class
• Late mixed dentition with mild crowding of
II malocclusions often require the distal movement
anteriors.
of maxillary molars in the initial stage of treatment
to convert the class II molar relationship to a class
CONTRAINDICATIONS OF MOLAR
I molar relationship.
DISTALIZATION
Most traditional approaches to molar
distalization including extra-oral traction • Profile:
through use of a headgear, Wilson distalizing – Retrognathic profile.
arches, spring appliances and inter-maxilalry • Functional:
elastics with sliding jigs, require considerable – Numerous signs and symptoms of
patient compliance to be successful. temperomandibular joint
With heightened awareness of balance and – Posteriorly and superiorly displaced
harmony of the facial profile combined with a need condyles.
to treat patients with marginal space • Skeletal:
discrepancies, a variety of methods have been – Class II skeletal
proposed to move molars distally with reduced – Skeletal open
dependence on patient co-operation. More – Excess lower face height
recently, the subjectivity and problems of – Constricted maxillary arch
predicting patient behavior have led many – Dolicocephalic growth pattern.
clinicians to devise appliances that minimized • Dental:
reliance on the patient and that are under the Class I or III molar relation.
• Dental open bite • Crozat appliance

Maxillary first molar distally inclined. • Crickett appliance
• CETLIN appliance
AN IDEAL INTRAORAL MOLAR • Removable molar distalization splint
DISTALIZATION APPLIANCE SHOULD • Modified Nance Lingual appliance
MEET THE FOLLOWING CRITERIA • Non-extraction treatment (lip bumper)
• Molar distalization with magnets
1. Minimal need for patient compliance.
• Transpalatal arch
2. Acceptable esthetics and comfort.
• Use of Super elastic NiTi
3. Minimal loss of anterior anchorage (as
• Double loop niti
evidenced by axial proclination of the incisors.
• The Pendulum appliance
4. Bodily movement of molars to avoid
• Jones Jig
undesirable side-effects, lengthening of
• C-space regainer
treatment and unstable results.
• Lokar appliance
5. Minimal chair time for placement and
• Intra oral bodily molar distalizer (IBMD)
reactivations.
• Maillary distalizing system (MDS)
• Fixed piston appliance
Advantage
• The K-loop appliance
No patient cooperation was necessary to obtain • The distal jet

molar movement. • Using Implants

• Fixed functional appliances.
MECHANISM OF ACTION OF DISTALIZING
APPLIANCES PENDULUM APPLIANCE
• Passive 0.016 × 0.22 inch wire with stops that This appliance first described by Hilgers in 1992
abut the distal wings of premolar brackets is uses a large Nance button in the palate for
inserted, and the coils are placed on the wire anchorage and 0.032-inch TMA springs (Ormco
between first premolars and molars. The coils Corporation) that delivers a distalizing force to
are activated 8 to 10 mm by compressing and the upper molars. The springs insert into lingual
maintaining them against the molars by sheaths on the palatal surface of the band. The
crimpable hooks. anterior portion of the appliance is retained with
• Since the reaction force of the coil moves the premolar bands, which are joined to the appliance
wire anterior, the function of the stop against using a retaining wire. Occlusally-bonded rests
premolar bracket is to ensure that the wire on the primary molars or second premolars add
cannot move past first premolars, thus placing to the retention. If expansion of the upper arch is
reaction force on Nance appliance. To enhance indicated, then a midline screw can be added to
anchorage, 0.018 inch uprighting spring is the appliance. This version of the appliance is
placed in the vertical slot of the premolar known as the Pend-X appliance.
brackets directing the crowns distally. Byloff and Darendeliler (1997) showed that
• When class II elastics are attached, rectangular the appliance moved molars distally without
wire with 10 degree of incisor lingual root torque creating bite opening, but the molars did tend to
is inserted in the mandibular arch to maintain tip. At the incisal edge was the anchorage loss
lower incisor position. Molar position is was measured at 0.92 mm (SD ±0.67). Second
maintained by inserted of 0.016 x 0.022 inch premolar anchorage loss was measured at a
wire with stops that about the molar tubes. mean of 1.63 mm (SD ±1.23), but distal movement
Various types of molar distalization of the molar represented 71 per cent of the space
appliances in orthodontics are listed below and opened. If molar uprighting bends were
few of them are described in this chapter: incorporated into the appliance it reduced the
• Headgears tipping, but increased the anchorage loss at the
• Wilson Bimetric arch design premolars by 0.61 mm and the incisal edge by
• ACCO 0.62 mm (Byloff et al., 1997).
Ghosh and Nanda (1996) also found that the anchorage along with 0.032" TMA springs that
pendulum appliance is a reliable method for deliver light, continuous force to the upper first
distalizing maxillary molars at the expense of molars without affecting the palatal button. Thus,
moderate anchorage loss. The advantages of the the appliance produces a broad swinging or
appliance lies in its minimal dependence on pendulum of force from the midline of the palate
patient’s compliance, ease of fabrication, one to the upper molars.
time activation, adjustment of the springs, if
necessary to correct minor transverse and vertical PEND-X APPLIANCE
molar positions, and patient’s acceptance. The
• In cases with severe narrowing of maxillary
mean maxillary molar movement was 3.4 mm
posterior segments, if expansion of upper arch
with a distal tipping of 8.4 degrees. There was,
is needed, a mid palatal jack screw can be
however, 2.5 mm mesial movement of the first
incorporated into the center of the Nance
premolar, which represents some anchorage loss.
button.
Thus, for every millimeter of distal molar
• The screw is activated one-quarter turn every
movement, the premolar moved mesially
three days, after a week or so for patient
0.75 mm.
adjustment, to produce a slow, stable
Hilgers (1992) reports that when the
expansion.
appliance is placed before the eruption of the
• The resulting activation is usually sufficient

second molars, two-thirds of the tooth movement
not only to correct any transverse
is molar distalization, one-third is experienced

discrepancies, but also to control molar
as forward shift of the anchor bicuspids. If placed
rotation during distalization.
after eruption of the second molars, the
experience tends to be reversed, one-third distal M-PENDULUM APPLIANCE
movement of the first molar, and two-thirds
anchorage slip. Giuseppe Scuzzo in 1999 introduced M-
pendulum:
Advantages • In this horizontal pendulum loops are
inverted, it will allow bodily movement of
• Minimal dependence on patient compliance both the roots and crowns of the maxillary
• Ease of fabrication molars. Once the distal molar movement has
• One time activation occurred, the loop can be activated simply by
• Adjustment of the springs if necessary to opening it.
correct minor transverse and vertical molar • The activation produces buccal/distal up
positions. righting of the molar roots and thus a true
• Patient’s acceptance. bodily movement rather than a simple tipping
• Unilateral class II corrections. or rotation.
• Used to regain space lost through mesial • Pendulum springs are activated to 40–45o,
drifting of the upper first molars because of resulting in about 125 g of force on each side.
either early loss of second deciduous molars This activation is repeated until the desired
or impaction of first molars under distal crown distalization of the molars is obtained.
contour of the deciduous molars. Rapid
distalization of upper first molars and Advantages
stabilization with an insta Nance provide
• True bodily molar movement
space for the erupting second bicuspids.
• Minimal dependence on patient compliance
• Ease of fabrication
Disadvantages
• Little need for reactivation
James J Hilgers in 1992 introduced an appliance • Patient’s acceptance.
for class II correction in non-compliant patients. An intra-maxillary anchorage unit is needed
The “pendulum appliance” is a hybrid that uses to counteract the reactive forces and moments in
large Nance acrylic button in the palate for molar distalization.
Anchorage Design of the M-pendulum Nance button and permit uniform periodontal
Appliance pressure distribution.
• The anchorage block consists of a Nance Anchorage Quality of Deciduous Molars and
palatal button and anchoring teeth in the same Premolar Root Topography
dental arch. The acrylic button fits tightly
against the palatal mucosa in the region of the • The desmodontal anchorage quality of the
palatal rugae and is linked to the teeth with anchoring teeth depends largely on their root
occlusally bonded onlays. After placement of surfaces and root topography.
the pre-activated pendulum springs, the • Even if root surface of deciduous molars and
anchorage unit is designed to counteract the premolars are identical, anchorage quality of
reactive forces and moments. deciduous molars undergoes a constant
• The anchorage effect of the anterior palatal decrease during physiologic resorption
plate to the resilient palatal mucosa might be resulting in imbalance in the favor of the
due to hydrodynamic interactions. Additional premolars.
vertical stabilization might result from tongue • The results of this study show that extent and
pressure while swallowing. Anchorage value quality of molar distalization are better and
of the soft tissue supported Nance holding side-effects are less pronounced in the
anchorage and the incisor region if premolars
arch should not be overestimated.

• The anchorage mainly depends on the dental alone are used for anchorage.
anchorage quality of the teeth. The resistance • It is advisable to perform an initial test for
potential of these anchorage teeth is increased tooth mobility when using dec.
determined by the size of the anchorage molars for anchorage, to avoid having to
relevant surfaces and thus by the number of remove the appliance prematurely when the
teeth involved, by root topography and the anchorage quality is overestimated.
attachment level and by the bone structure and • A panoramic radiograph provides
the desmodontal reactive state. information on the extent of root resorption of
• The bone structure and attachment level is dec. molars and indirectly quality of such teeth
constant among children and adolescents for anchorage purposes during pendulum
treated with pendulum appliance but appliance therapy.
differences might occur with respect to the
Desmodontal Reactive State, Potential
number of teeth, root topography and
Causes of Reduced Anchorage
desmodontal reactive state.
• The primarily unmoved tooth in a desmodontal
Number of Anchorage Teeth resting state offers the best tissue resistance.
• Initial leveling increases the proliferation rate
• Hilgers used only anterior part of the
of cells relevant to the remodeling process in
appliance, using bands on maxillary first
the anchorage unit and increases readiness
premolars or deciduous molars and a holding
for reactive movement. Therefore initial
arch to the Nance button. He observed that
leveling should not be performed in the region
after placing the springs, Nance buttons
of the anchorage unit when placing pendulum
tended to lift. So the recommended that
appliance.
supporting elements should be bonded
• Omission of Nance anterior palatal plate also
occlusally to the maxillary second premolars
leads to increased loss of anchorage.
or second deciduous molars for additional
stability. Additional bonding of occlusal on
Potential Measures for Increased
lays to the canines to obtain additional
Anchorage
anchorage support is also recommended.
• The reactive segment should consist of as When an end osseous implant is used in the region
many anchorage teeth as possible, which are of the hard palate or miniscrews, stationary intra-
combined to form a multi-rooted anterior oral anchorage can be achieved without teeth being
anchorage unit with occlusal onlays and the incorporated. The fixing of pendulum appliance
to an Osseo integrated palatal implant of the ortho INTERMAXILLARY CLASS II MALOCCLUSION

system not only represents a significant CORRECTION APPLIANCES
improvement in anchorage quality during molar
Several intermaxillary fixed non-complaint
distalization but also permits stationary anchorage
appliances have been proposed and used over
with a transpalatal arch during the subsequent
the past two decades.
distal guidance of premolars and canines. They
are used in exceptional cases such as adults with
Advantages
problematic periodontal anchorage or in mixed
dentitions with early loss of the decidduous molars. • Forward displacement of the mandible.
• Backward displacement of the maxilla
PENDULUM F APPLIANCE • Anterior force on the mandibular dentition.
All above three actions and movements will
Favero modified pendulum appliance for lingual
bring about the correction of class II
technique. Acrylic portion of the Nance button
malocclusion.
has a larger dimension than in other pendulum
appliances and can accommodate in the anterior
Disadvantages
region a segmented wire, which is inserted in the
lingual brackets of the incisors. The common disadvantage of intermaxillary
An increase in biological anchorage quality is appliances is undesirable steepening of the

possible. Occlusal forces can be used occlusal plane with concomitant flaring of the
therapeutically for increased anchorage if the lower incisors and distal tipping along with
composite on lays to which the wires are attached extrusion of the maxillary incisors.
were formed with an occlusal relief.
This method can be applied only if VERTICAL HOLDING APPLIANCE
mandibular arch has sufficient teeth which are
Vertical Holding Appliance is a fixed functional
in stable position (i.e. no orthodontic treatment
intra-oral distalizing appliance, as it is activated
is performed simultaneously in the mandible).
from the functional activity of the tongue.
Drawbacks Wire used for the fabrication of this
appliance: 0.040 inch wire is used for the
1. Lingual tipping of molars. fabrication of this appliance.
2. Difficult to fabricate.
Helices of Vertical Holding Appliance
JONES JIG
• Vertical holding appliance consist of four
The Jones Jig was first introduced by Richard D. helices in its design
Jones and J. Michael White. Jones Jig is one of the • The two helices are placed just distal to each
appliances which accomplish tooth movement maxillary first molar
without the need for patient compliance. The • Other two helices are placed at the center of
appliance uses an open coil Nickel titanium the appliance.
spring to deliver 70–75 g. Over a compressive
range 1–5 mm to the molars. V-Bend
Advantages • V-bend is fabricated using 0.040 inch wire
• V-bend separates the helices of VHA which
The advantages of the Jones Jig appliance are that,
are placed at the center of the appliance
it can achieve class I relationship even when:
• V-bend portion of the wire is embedded in the
• 2nd motors erupted or unerupted
acrylic button.
• In mixed and permanent dentition
• Unilateral as well as bilateral distalization
Acrylic Button
• Growing and non-growing patients.
The appliance is also said to be a predictable, • Acrylic button is composed of self –cure acrylic
painless sand rapid method of correcting class II material
relationship with minimum patient co-operation. • Size of the acrylic button—size of a dime
• Thickness of the button—the acrylic button Advantages

should be 2–5 mm away from the palate
This method has several advantages:
• Acrylic button contributes greater proportion
1. ‘TMA’ has better shape memory and resilience
as compared to the any other portion of the
than stainless steel.
appliance.
2. The arch is simple to construct.
Action 3. The system is hygienic and economic.
4. This is no anterior anchorage loss; the
Vertical holding appliance results in intrusion premolars and canines spontaneously follow
and distally directed force. the molar distally.
REMOVABLE MOLAR DISTALIZATION SPLINT Drawbacks

The removable molar distalization appliance was 1. Because the ‘TMA’ is more fragile than
put forward by Dr A. Korrodi Ritto, to overcome stainless steel, the arch must be bent carefully,
the drawbacks of patient co-operation, needed and fractures in the mouth are more common.
with other removable appliances like the 2. Since the ‘TMA’ arch rotates the anchor molar
removable plates and headgears. more mesiobuccally than a conventional arch
does. It should be combined with a fixed
Advantages
orthodontic appliance using a rectangular
1. It is smaller than conventional removable plates. arch-wire or a passive stainless steel wire
2. It is comfortable. segment between the second molar and canine
3. Esthetics. on the anchor side.
4. Better patient co-operation. 3. The system can only distalize one molar at a
time, and therefore is recommended for use
Disadvantage with unilateral or slight bilateral class II molar
relationships.
There is more amount of molar tipping seen rather
4. An extra-oral appliance should be worn at
than bodily, molar distalization. Therefore the best
night to reinforce anchorage.
cases for treatment with this appliance are those
where the molars are already messily tipped.
TUBE PLATES FOR DISTALIZATION OF
MOLARS
SYMMETRIC DISTALIZATION WITH A TMA
TRANSPALATAL ARCH Lain Benauwt explained the use of a removable
appliance for distalizing the molars. These
The intra-oral distalization methods can all
appliances were introduced as the appliances
produce bodily distal movement of the maxillary
with wires sliding in tubes.
molars, but can also cause a mesial movement of
the maxillary premolars and canines, or a
Advantages
proclination of the mandibular incisors when class
II elastics are used. In addition, the loss of anterior 1. Retention of the appliance is very good, as the
anchorage often leads to relapse of the maxillary movable parts contribute to the retention (due
molars during the correction of canine to incorporation of Adam’s clasp).
relationship, overbite and over jet. 2. It is very helpful in mixed dentition, when
According to Cetlin’s method, maxillary deciduous molars are not too retentive or are
molars can be distalized unilaterally by using a broken down or missing.
Goshgarian transpalatal arch in conjunction with 3. Unwanted displacement of teeth is minimized
extra-oral traction. A toe-in-bend in the due to the Adam’s Clasp who holds the molar
transpalatal arch applies a mesiobuccal rotation and avoids rotation.
to the molar on the side of the bend and a distally 4. An extra-oral appliance can be used along
directed force against the molar on the opposite with this appliance to support and reinforce
side. This procedure does not cause a loss of the stationary part or indirectly the
anterior anchorage. anchorage.
5. Expansion is also possible all the same time supplies only 30 g of force on the molars. The
as the distalization of the molar, and is springs are placed as far gingivally as possible
achieved by changing the angulations of the to minimize crown tipping and to cause molar
tubes in relation to the sagittal plane. movement without Irritation.
6. Repair is easy. • The removable appliance exerts a force, which
moves the molar crowns distally, with relative
Disadvantage ease.
• The extra oral headgear on the other hand
It is a delicate appliance. The two wires must hold
exerts a force of 150 g per tooth and is used to
the movable part without binding.
control root position. The headgear is advised
to be worn for 12–14 hours/day.
CETLIN APPLIANCE
• When using a cervical headgear, it is generally
The appliance involves a combination of an necessary to elevate the outer bow to produce
extra-oral force in the form of headgear and an an appropriate “force couple” that will move
infra oral force in the form of a removable the roots distally, by directing the line of force
appliance. In molar distalization, bodily distal above the outer of mass of the molar.
movement rather than distal tipping of the
maxillary molars is essential. When there is only THE LOKAR APPLIANCE
a distal tipping, the molars relapse messily,

The Lokar appliance was developed by Dr Loter
uprighting under their apices to comeback to its

In 1894.
original position.
To overcome these drawbacks, the Cetlin
Components of Lokar Appliance
appliance utilizes a removable appliance intra
orally to tip the crowns distally and then an The appliance consists of two basic components,
extra oral force to upright the roots. So the intra- and they are:
oral removable appliance can be called the • A mesial sliding component
crown mover while the extra-oral force, is the • A component which inserts Into arch wire tube
root mover. of the molar.
ANCHORAGE NEED Design of the Lokar Appliance

The anchorage for the removable appliance is by • The distalizer is inserted into arch wire tube
proper adaptation to the palate, an acrylic shield of the first molar and the application is
around the four maxillary incisors and a modified adapted such that it is parallel to the plane of
Adam’s Clasp on the first premolars. occlusion and as close to the teeth as possible
tor patient comfort.
EXTRAORAL FORCE • A 0012" S.S. ligature wire hand twisted around
the premolar bracket before the Lokar is fixed
• The extraoral appliance is a headgear, which
to the molar tube. This ligature wire is engaged
is inserted into the molar tube. The headgear
around the mesial sliding component of the
used in generally a cervical or a high pull type,
distalizer and tightened to activate the
depending on the usual consideration of
appliance.
skeletal pattern.
• The removable appliance is worn 24 hours a
Force Applied and Activation of the
day. The appliance also contains a bite plane
Appliance
to disengage the molars (to aid in rapid molar
movements). The force is delivered by NiTi Coil spring, which
gets compressed during activation.
THE FORCE APPLIED
Anchorage
• In the removable appliance, the spring is
activated only 1 to 1.5 mm, measured along The anchorage is by a Nance appliance, soldered
the occlusal surface of the molar and It to the premolars.
Activation important to center the K-loop between the

first molar and the pre molar.
A 0.012" S.S. ligature wire is hand twisted twice
– For additional molar movement, the
around the premolar bracket, such that the free
appliance is reactivated 2 mm after 6-S
ends of the ligature face distally. One of the free
weeks. The loop is easy to remove from the
ends is then passed over the mesial sliding
molar tube, since the distal end of the wire
component of the mainframe and tightened to
is not bent. In most cases, one reactivation,
activate the appliance. The force is delivered by
producing a total of as much as 4 m of distal
the NiTi Coil spring, which gets compressed
molar movement is sufficient.
during activation. The best activation is achieved
– The palatal Nance button, held in place by
by compressing the spring by 2–3 mm.
wires extending from bands on the first
premolars or first deciduous molars, is
Re-activation of the Appliance
primarily responsible for preventing anterior
Re-activation is done at 5–6 weeks interval. movement of the first premolars. The button
should be large enough to, provide adequate
K-LOOP MOLAR DISTALIZER anchorage and prevent tissue impingement,
but should be kept away from the teeth. The
The K-loop molar distalizer was developed by
acrylic should not be built up so that the
Vamn Kalra. The K-loop molar distalizer consists

button acts as a bite plane.
of:
– The premolars moved forward by about ‘1

• A K-loop—to provide the forces and moments
mm’ during ‘4 mm’ of molar distalization.
• A Nance button—to resist anchorage.
If necessary, the anchorage can be
– The K-loop is made of 0.017- x 0.025" TMA
reinforced by attaching a straight pull or
wire. Which can be activated twice as much
high-pull headgear with a force of 150 g to
as stainless steel before it undergoes
the premolars.
permanent deformation. A loop made of
‘TMA’ also produces less than half the force
Advantages
of one made with stainless steel.
– Each loop of the ‘K’ should be 8 mm long The K-loop molar distalizing appliance has the
and 1.5 mm wide. The legs of the ‘K’ are following advantages:
bent down 20° and inserted into the molar • Simple yet efficient
tube and the premolar bracket. The wire is • Controls the moment-to-force ratio to produce
marked at the mesial of the molar tube and bodily movement, controlled tipping or
the mesial of the premolar bracket. Stops uncontrolled tipping as desired
are bent into the wire ‘1 mm’ distal to the • Easy to fabricate and place
distal mark and ‘1 mm’ mesial to the mesial • Hygienic and comfortable for the patient
mark. Each stop should be well-defined • Requires minimal patient co-operation low-
and about 1.5 mm long. These bends help cost.
keep the appliance away from the
mucobuccal fold, allowing a 2 mm THE DISTAL JET APPLIANCE
activation of the K-loop.
The distal jet was designed by Akto Carano and
– The 120° bends in the appliance legs
Miiuro Testa in 1996.
produce moments that counteract the
tipping moments created by the force of the
Appliance Design
appliance, and these moments are
reinforced by the moment of activation as • The appliance consists of bilateral tubes of
the loop is squeezed into place. Thus, the 0.036" internal diameter which are attached
molar undergoes a translatory movement to an acrylic name button. NiTi Coil spring
instead of tipping. Root movement and screw clamps are slide over each tube.
continues even after the force has • The wire extending from the acrylic, through
dissipated. If an extrusive or intrusive force each tube ends in a bayonet bend that is
against the molar is not desired, it is inserted into the lingual sheath of the first
molar band. An anchor wire from the Nance 1. Conversion to Nance holding arch.
button is soldered to the bands on the 2nd 2. Double set screw distal Jet appliance.
premolars. 3. Incorporation of helical loops into bayonet
wire far molar rotation and up-fighting.
Components 4. Incorporation of Jack screws for maxillary
expansion.
1. The transpalatal connectors—rigidly
immobilize the premolars and provide a
THE CROZAT APPLIANCE
support to the Nance button.
2. The Bayonet director unit: Lumen of the tube The crozat appliance is similar to the crickett
portion supports the molar bayonet, while its appliance but has palatal and lingual bars instead
outside diameter supports the spring and the of stainless steel wire components.
activation lock. Dr Crozat viewed the appliance as acting in a
3. The molar bayonet: It is drawn out of the truncated cone or funnel. As the molars are being
bayonet director unit during distalization and translated distally in a divergent direction,
inserted into the lingual sheath. The distal step expansion must be placed in the appliance to avoid
prevents the spring from riding on the vertical the more roots striking the lingual cortical plate,
arm of the molar bayonet while activating the blocking movement. Over-expansion can also
appliance. impede distal movement by emerging the roots

4. NiTi springs: NiTi coil springs of 150 gm are against the buccal plate.
used for children and 250 gm used for adults. Treatment of a bilateral class II malocclusion
5. Stainless steel springs: The appliance can also with a good lower arch is begun with rotation
be fabricated with stainless steel springs. adjustments of the upper molars. First the
6. Activation locks—to compress and activate the measurement is made between the lingual arms;
springs. and each crib clasp complex is rotated to increase
7. Lock wrench: To engage and tighten (the screw this measurement ½ mm per side. Once the
of the activation lock). rotation adjustment is begun every third rotation
adjustment, the molars are expanded to keep the
Activation teeth tracking back into a more divergent portion
• The distal jet is activated by sliding the damp of the arch. Once the molars are derotatad, class II
closer to the first molar once a month. elastics are added to continue distal movement.
• Once the distalization is complete, the Similar unilateral class II can also treated, with
appliance can be converted to a Nance retainer crozat appliance.
simply by replacing the clamp-spring Dr Crozat introduced this appliance in 1919.
assemblies with light-cured or cold cure acrylic Dr Crozat’s goal was to solve crowding by the
and cutting off the arms or the promoters. distal movement of molars. As he moved molars
distally, expansion of the appliance was
Advantages necessary because the bony dental arch itself is
wider in the posterior regions.
The advantages of the distal-jet appliance are
listed below:
MOLAR DISTALIZATION BY MAGNETS
• Minimal patent discomfort
• Minimal or no molar tipping • Magnets have been used intra-orally for a
• Ease of fabrication variety of reasons. More often for retention of
• Ease of insertion prosthesis. In contemporary orthodontics,
• Esthetically acceptable light continuous force (75 to 100 g) are
• Well-tolerated by patients commonly used to correct malocclusion with
• Ease of conversion to a Nance holding arch to typical tooth movement of 0.5 mm/week.
maintain the distalized molar position • Miniature Samarium-cobalt (Sm-Co) magnets
• It can be used with a full-fixed appliance are used and they have been proved to be
There are several modifications to the distal- effective and efficient force delivery systems.
jet appliance, for different purposes. They are: Ferrite, Ainico or platinum cobalt have been
tried but left out due to their very low magnetic facilitates buccolingual adjustment of the springs
strength and hence larger size. in the vestibule and aids patient comfort. The
• The magnets can either be used in the attractive springs can be readily removed for adjustment or
or the repelling state. The repelling state is activation. There have been no studies to date
preferred. It was found that the Sm-Co magnet; documenting results achieved with this appliance.
when used, exert very high forces of more than
200 omi at small separations, while optimum Availability of the Appliance
orthodontic forces were generated (75 to The appliance comes in two sizes:
180 g), when separation was 0.5 to 1.00 mm. • 27 mm primarily designed for extraction cases
• Magnetic Force = (Separation)n = (d)n and
• The force exerted by the magnets decrease from • 40 mm for non-extraction cases.
200 gms at contact to about 409 gms at 2mm, • The springs are paired for left and right sides.
with a rapid decrease of force at greater
separations. Indications
• The magnets used showed good
biocompatibility when they were coated. 1. Dental Class II malocclusion.
• The stainless steel coated samarium-cobalt 2. Deep bite with retroclined mandibular incisors.
magnets can be recycled and showed good
Contraindications
biocompatibility.
1. Cases predisposed to root resorption.

THE MAGNETS 2. Dental and skeletal open bites.
3. Vertical growth with high mandibular plane
• The magnets are four in number and they are
angle and excess lower facial height.
encased in a steel sleeve with a finely machined
hole in the center and coated with a
HERBST APPLIANCE
biocompatible polymer to avoid leaching out
of products. The Herbst bite jumping mechanism was
• Two of the magnets are pre-set in regulation developed by Emil Herbst in the early 1900’s.The
(on each wire) for easy insertion bilaterally. original banded design of this appliance was
Both repelling magnets on each wire are introduced at the international dental congress
clamped together to avoid possible loss of in Berlin (Germany) by Herbst in 1905. It was
magnet. introduced by Pancherz. Pancherz used a banded
Herbst design that involved the:
THE KLAPPER SUPERSPRING • Placement of bands on molar
This appliance is an auxiliary which is fitted to and premolar
• Bands are connected by copper Maxilla
fully banded upper and lower fixed appliances
(ORTHO design, 744 Falls Circle, Lake Forest, lingual wire
Illinois 60045, USA). • Bands on lower right first premolar
and lower right first premolar
• Bands are connected by a Mandible
Design of the Appliance
lower lingual arch wire
The appliance consists bilaterally of a length
multi-flex nickel-titanium which is bent back on it Herbst Appliance
attaching to the upper first molar tube and
The Herbst appliance is a fixed functional
attaching to the lower arch wire by means of a
orthopedic appliance having passive tube and
helical loop. The springs lie in the buccal vestibule.
plunger system with the exact length of the tube
The effect of the spring is to place a distalizing
determining the amount of anterior mandibular
and intrusive force to the upper first molar.
development. The tube is attached to a maxillary
posterior root, whereas the plunger is fixed
Latest Design of Klapper Super Spring
anteriorly to the mandibular dentition and slides
The latest design of the spring requires a special through the tube during opening and closing
oval tube to be fitted to the upper first molars. This movements.
THE MANDIBULAR ANTERIOR • 7 and

REPOSITIONING APPLIANCE (MARA) • 10 mm.
The Mandibular Anterior Repositioning
Pre-requisites of the Spring
Appliance (MARA, Allesee Orthodontics
Appliances, PO Box 725, Sturtevant, WI 53177, No longitudinal research studies on this auxiliary
USA) MARA consists of cams made from 0.060 are available in the literature to date. Starnes
square wire attached to tubes (0.062 square) on (1998) recommends that for successful treatment
upper first molar bands or stainless steel crowns. to be carried out the prerequisites are as follows:
A lower first molar crown has a 0.059 arm • Prior correction of deep bites;
projecting perpendicular to its buccal surface, • Stabilization of each arch with a large
which engages the cam of the upper molar. The rectangular arch wire;
appliance is adjusted so that when the patient • Direction of force as horizontal as possible;
closes, the cam on the upper first molars guides • Sufficient resistant torque (lower incisor
the lower first molars and repositions the lingual crown torque);
mandible forwards into a Class I relationship. • Perfect fit of bands;
There have been no studies to date documenting • Proper placement of hooks for spring
results achieved with this appliance. The attachments.
developers of the appliance recommend a 12-

month treatment time to achieve a bite jumping or
THE ‘FASTBACK’ APPLIANCE FOR MOLAR

orthopaedic effect. Stabilization of the lower DISTALIZATION
molars is assisted by the fitting of a lingual arch
Modern Orthodontic Science is constantly
and on the upper arch a transpalatal bar to
exploring new non-extraction therapies through
stabilize the upper molars is placed. This
research carried out employing appliances that
appliance does not require the placement of
will allow the Orthodontist to gain space both
attachments on teeth other than the first molars.
transversally and distally. Consequentially, in
recent times we have observed an increase in the
Indication
number of appliances for the distalization of the
Skeletal Class II with mandibular deficiency. upper molars. Italians have been particularly
prolific in this area, probably on account of many
Contraindications of our young patients being reluctant to follow
the therapeutic indications that come with extra-
1. Dolichofacial growth pattern.
oral tractions. The common goal for all those
2. Cases predisposed to root resorption.
involved in developing new distalizing
3. Dental and skeletal open bites.
appliances appears to be the ability to provide a
4. Vertical growth with high mandibular plane
dental movement that is bio-mechanically
angle and excess lower facial height.
controlled and generated by adequate forces, while
keeping undesired contramovements to a
SAIF SPRINGS
minimum., the ideal Distalizer should occupy the
Design of the Appliance smallest possible space, interfere as little as
possible with function and provide bodily distal
These are long nickel-titanium closed coil springs
movement of the dental elements involved with
that are used to apply Class II inter-maxillary traction
minimal (or absence of) patient compliance. Distal
when fully banded fixed appliances are in place
movement should occur in the patient with
(Saif Springs, Pacific Coast Manufacturing Inc, 18506
minimal damage to the surrounding tissues and
142nd Ave, NE Woodinville, WA 98072, USA). The
function, generating minimal (or absence of)
springs are tied in place with steel ligatures and are
contra-movements. The appliance used should be
worn in place of inter-maxillary elastics.
engineered in such a way that would make
therapy management easy and safe.
Availability of the Saif Spring
The ‘Fastback’ Molar Distalizer is now fully
The springs are available in two lengths: established as a ‘reference’ appliance in the
Orthodontic field. A growing number of • Reduced or minimal loss of anchorage

Professionals, having had the opportunity to fully • Reduced or minimal contra-movements
evaluate and appreciate the ease and safety of use • Bodily Distalization occurs, no risk of
as well as the bio-mechanical development undesired movements
provided by this device, are now prescribing it • Easy, non-frequent Activation
regularly whenever they need to gain space in the • Checks every 4/6 weeks, cost-effective patient
posterior region. At the time of writing, 6 years • management
have passed since the initial prototypes of • Spherical or long ends ensure the appliance
‘Fastback’ devices were introduced. stops
• when not activated, should the patient skip
FEATURES OF FAST BACK APPLIANCE one or more appointments
Fast back features are as follows: • The ‘Fastback’ can be used in conjunction with
• Easy to plan and assemble fixed
• Reduced bulk • Buccal appliances (brackets).
• Minimal patient discomfort There are three versions of the ‘Fastback’
• Good aesthetics appliance:
• Continuous, constant forces are at work at all • FB1 (Monolateral FB with ‘Tripod’ Anchorage
times unit) with or without ‘Nance’ button

• Intensity and direction of the forces applied • FB2 (Bilateral FB ) with ‘Nance’ button
can be • FB3 (Bilateral FB ) with ‘Nance’ button and

• Accurately controlled Extensions, or Rests, to the Canines.
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Index
Page numbers followed by f refer to figure and t refer to table

A Arch Camper’s angle 136

length analyses 146 Canine
Adam’s clasp 162

wire 114 guidance 181
with incorporated helix 163
bends 177 retractors 165
with soldered hook 163 Carbon dioxide laser 50
Argon lasers 50
with traction hook 163 Care of deciduous dentition 18
Artistic positioning bends 177
Adult orthodontics 19 Carey’s analysis 123
Advantages of B Caries
lasers in soft tissue surgery 52 control during orthodontic
metal brackets 107 Baker’s anchorage 25f, 33f
treatment 57
removable appliances 161, Ball end clasp 162
removal 51
162 Base plate 162, 166
Carpenters syndrome 203
Aesthetic component 218 Begg appliance 179f
Case-angle controversy 70, 148
Aims of orthodontic treatment Benefits of orthodontic treatment
Cast versus wrought metals 116
15, 16f 19
Cephalometric
Alignment of incisors 152f Bleaching 51
analysis 139
Altered passive eruption Bolton’s
of developmental pattern
management 51 analysis 125
and facial morphology
American study 125
in cleft palate 85
Board of Orthodontics 15 Bondable brackets 109, 109f
radiography 137
Orthodontics 29, 30 Bonded rapid maxillary
roentgenography 27f
Anchorage design of expansion appliances 157,
Ceramic brackets 108, 108f
M-pendulum appliance 242 157f
Cetlin appliance 245
Andrews’ straight wire appliance Branches of orthodontics 16 Characteristic
98 British Society facial appearance 202
Angell’s palatal expansion device for Study of Orthodontics 37t of ideal arch wire 177
placed on maxillary teeth of Orthodontists 15 Choice of teeth for extraction 150
155f Broca’s occipital angle 136 Circumferential clasp 162
Anterior movement of dental Broussard bracket 112 Classification of
Buccal archwires 117t
arche 178
self-supported retractor 166 canine retractors 166t
Apert’s syndrome 203
sweep 177 malocclusions 27
Aphthous ulcer 51, 56f
Apicoectomy 52 Cleft
C lip and palate formation 200
Application of laser in
bonding orthodontic bracket Calculation of of anterior
54 DAI scores 222 and posterior palate 201
orthodontics 53 final scores 220 primary palate 201
of posterior secondary palate Dentistry in Enamel

201 eighteenth century 10 hypoplasia 203
palate 202 sixteenth and seventeenth reduction in orthodontics 223
Cobalt-chrome-nickel alloy 118 centuries 7 Encephalocele 203
Common syndromes associated Dentoalveolar and facial Erbium-YAG laser 49
with cleft lip and palate asymmetries 141 Esthetic harmony 15, 16
203 Dentofacial orthopedics versus Etiology of cleft lip and palate 201
Components of removable orthodontics 79 Evolution of
orthodontic appliance 162 Denture stomatitis 52 bracket 174
Comprehensive orthodontic
Depigmentation of gingiva 57, cephalometrics 140
treatment 19
57f clasp design 162
Contraindications of
Design of edgewise buccal tubes 174
molar distalization 239
removable orthodontic appliance 248, 249 orthodontic appliances 106
appliances 161 Lokar appliance 245 Expansion
Correcting malocclusions of Destructive scanner 231f orthodontic appliances 159,
dental origin 19 Determination of 159t
skeletal origin 19 anterior ratio 125 screw 157, 159
Correction of arch Exposure of
cleft palate 24, 25 length 123 impacted tooth 53
curve of Spee 225 width 123 teeth 52

Corrective orthodontics 16 discrepancy 123 Extensive hypodontia 219
Craniofacial overall ratio 125 External skeletal fixation 194

anomalies 219 Development of removable Extraction of second premolar
syndromes 203 orthodontic appliances 161 123
Craniometry 133 Dewel’s method 151, 151t Extraoral
Crouzon’s syndrome 203 of serial extraction 152f force 79, 245
Crowding of mandibular incisors Different types of appliances 17
224 canine retractors 166t traction 25
Crown expansion screws 158f, 159t Eyelet clasp 162
angulations 180, 181 labial bows 163t
inclination 180, 181
Diode laser 50, 51 F
lengthening procedure 57, 58f
Disadvantages of removable Fabric of human body 22
Crozat
appliances 162 Facial
appliance 247t
clasp 162 orthodontic appliances 162 angle 135
Curing light-activated resins 51 Distal jet appliance 246t axis
Current clinical use of dental Down syndrome 203 angle 91
lasers 51 Drawback of of clinical crown 180
Curve of Spee 181 lingual 185 point 180
Cusp embrasure contact 181 Pont’s analysis 124 deformities 27
Factual period 77, 78
D E Failure of buttresses 176
Debonding of brackets by laser E-arch appliance 27, 68, 68f, 171, Fastback appliance for molar
57 171f distalization 249
Deciduous Early Father of
dentition 18 mixed dentition 18 American Orthodontics 24,
teeth 52 permanent dentition 18 25, 31
Deficient lower anterior facial Ectopically erupting teeth 203 expansion appliances 25
height 90f Edgewise modern
Definition of orthodontics 14 appliance 69, 70f, 172, 173f dentistry 23
Dental brackets 110, 110f orthodontics 20
aesthetic index 221 technique 27 orthodontics 27
and skeletal cross bites 141 Edward Hartley angle 67f Features of fast back appliance
contour appliance 227 Elimination of abnormal oral 250
health component 218 habits 18 Fictional period 77
Index 261
Film position and enlargement retention-joint appliance 155 J

140 High labial bow 163
Jack expansion screw 159
Fixed History of
Jackson’s
orthodontic appliance 17, 17f arch wires 114
clasp or full clasp 162
prosthetics/cosmetics 51 cephalometrics 133
triad 16
rapid maxillary expansion cleft lip and cleft palate 197
James McNamara analysis 88
appliances 156 dental lasers 47
Jumping bite 24
Focused versus defocused beam dentistry 1
48 expansion appliances 154
K
Force applied and activation of extraction in orthodontics 145
appliance 245 fixed orthodontic appliances Kernahan’s stripped ‘Y’
Founder of modern dentistry 23 167 classification 201
Frankel appliance 189 interproximal enamel Kesling model analysis 131
Frankfort mandibular reduction 223 Kingsley’s
incisor plane angle 143 malocclusion indices 205 extraoral traction appliance
plane angle 143 model analysis 122 155f
Frenectomy 51 molar distalization in incline plane 155f
Functional orthodontics 238 Korkhaus’ analysis 124
mandibular displacements orthodontic materials 120
141 orthodontics in L
orthopedic magnetic Greece and Rome 44 Labiolingual appliance 112f

appliance 82, 83 united states of america 28 Lack of incisor prominence 146

study of palatal and removable orthodontic Lang brackets 112
pharyngeal structures 85 appliances 160 Laser
Functions of teeth 23 surgical orthodontics 193 ablation of surface enamel for
Fusion of teeth 203 Hixon and old father method orthodontic bracket
128 placement 54
G Howe’s analysis—1954 124 beam interaction with tissue
Gaining access for bracket Huckaba’s analysis 127 48
placement on partially Hyperplasia 51 classification 52
erupted teeth 55 Hypothetical period 77 medium 47
Gingival safety 52, 58
contact 219f I use in dentistry 51
retraction 51 Late mixed dentition 18, 239
Impeded eruption of teeth 219 Lateral
Gingivectomy 51 Incisor mandibular plane angle
Gingivoplasty 51 borer of tongue 56f
143 set-back bends 177
Goldenhar syndrome 203 Index of Latest design of Klapper super
Grewe’s method 153 complexity 220 spring 248
Growth and development of orthodontic treatment needs Lattice imperfections and
jaws 23 218 dislocations 116
Indications of Law of canines 138
H removable orthodontic Limitations of straight wire
Haas expansion appliance 159 appliances 161 appliance 182
Hard various types of Frankel Linder Hart’s measurements 124
lasers 49 appliance 189 Linderharth index 124
tissue Interceptive orthodontics 16 Lineae cephalometricae 135
applications 51 Intercuspal position 181 Lingual
evaluation 89 Intermaxillary elastics 25, 25f brackets 110f
Healing of aphthous ulcer 56 Internal structure of teeth 23 technique 183, 183f
Heavy gold wire framework 161 Interproximal Lokar appliance 245
Helical canine retractor 166 decay detection 51 Long
Helices of vertical holding enamel reduction 223 axis of root 165
appliance 243 Irregularities of teeth 30, 36 labial bow 163
Herbst’s Isaacson expansion appliances Looped canine retractor 166
appliance 190, 248 157f Lower pharynx 92
M Non-aqueous elastomeric dental Poor

impression material 121 facial appearance 15
Magnetic strength and corrosion
Non-extraction philosophy 168 oral hygiene 225
of rare earth magnets 82
Nonosseous gingival surgery 51 maintenance 15
Management of
Nonsyndromic clefts 202 Posteroanterior cephalometry
aphthous ulcer 56, 56f
Normal lower pharyngeal 141
dentofacial anomalies 19
measurement 93f Post-retention survey 206
Mandibular
Normalization of gingival Potential soft and hard tissue
plane angle 90
contour 224 applications of laser in
procedures 196
Normative standards in dentistry 51
Martensitic
McNamara analysis 89t Preadjusted edgewise brackets
active alloy 118
Number of anchorage teeth 242 110, 110f
stabilized alloy 118
Premolar
Maxilla 83
O basal arch width 124
McNamara analysis 94t
diameter 124
Mechanism of action of Occlusal interference 185 Primary
distalizing appliances 240 Open bite appliance 190 incisions 51
Mesial cuspid bends 177 Opening midpalatal suture 25 palate 200
Metal brackets 107, 107f Optiflex archwire 117, 118 Principles of
Metallic bonds and crystalline Oral space analysis 126
structure 116 lesion therapy 51 steriophotolithography 231

Method of
screen 190 Properties of

determining position of upper soft tissue pathologies 52 archwire 117
incisor 90f Orthodontia and orthopaedia of laser beam 48
straightening of orthodontic face 150 Protrusive upper incisors 92f
wires 115 Orthodontic Pulse straightening 115
Mill’s retractor 163, 164 and dentofacial orthopedics Pulsed lasers 48
Modification of Adam’s clasp 162 20 Pyorrhea alveolaris 12
Modified and temporomandibular
Jackson’s clasp 161 disorder 87 R
ribbon arch 109f appliances 17, 186
split labial bow 163 Radiographic
Orthopedic appliance 17, 18f
Molar cephalometry 134
Orthosurgical teamwork 86
band 24f study of facial deformity 138
Osseous recon touring 51
bayonet bends 177 Range of Deflection 118
Overcrowded teeth 15
distalization 239 Re-activation of appliance 246
Mouth guard 19 Reflection 48
P
M-pendulum appliance 241 Removable
Multiple missing teeth 203 Palatal canine retractor 166 molar distalization splint 244
Multistrand archwires 118 Pallaquium gutta 120 orthodontic appliance 17, 17f
Myofunctional orthodontic Paris Society of Anthropology prosthetics 52
appliance 18f 137 Removal of
Pend-X appliance 241 fibroma 51
N Periodontal regeneration granulomatous tissue 51
surgery 51 redundant gingival tissue 56
Nance
analysis 129 Periodontics 51 Residual ridge modification 52
method 153 Permanent teeth 52 Retentive components 162
Narrowed maxillary arch 146 Pfeiffer syndrome 203 Reverse labial bow 163
Nasal Pierre Robin syndrome 203 Ribbon arch
deformity 203 Pieter camper 135 appliance 68, 69f, 172, 172f
septum 200 Pin and tube brackets 109, 109f
Natural history of human teeth appliance 68, 69f, 171, 173f Risk of
23, 34, 45 technique 27 dental caries 15
Nd:YAG laser 49, 50 Placement of virtual gingiva 231f periodontal diseases 15
Nickel-titanium alloy 117, 118f Plastic brackets 107, 108f Roentgen ray anthropometry of
Night guards 19 Pont’s index 123 skull 137
Index 263
Role of upper second molar Strength of wire 119 Two palatine shelves 200
extraction in orthodontic Structural balance 15 Types of
treatment 78 Studies on Frankel appliance 189
Root desensitization 51 functional appliances 93 heat treatment 117
rapid maxillary expansion 95 laser 49
S TMJ 96
Saethre-Chotzen syndrome 203 Submerged deciduous teeth 219 U
Scandinavian studies 206 Supernumerary teeth 219 Unfavorable sequelae of
Schwartz clasp 162 System of dental surgery 29 malocclusion 15
Scope of orthodontics 18 Upper pharynx 92
Second premolar extraction 147
T Uses
Secondary palate 200 Temporomandibular joint 14 in orthodontics 121
Self-ligating bracket 111, 111f, Thickness of button 244 of bionatar 190
113, 113f Timing of orthodontic
Severe crowding 225 intervention 18 V
Shape of teeth 225 Timm’s schedule of activation of Van der Woude’s syndrome
Short labial bow 163 expansion screw 159t 203
Single width bracket 111 Tooth Variable bracket sitting
Size of acrylic button 243 shape and dental esthetics 224 procedures 102
Soft size discrepancy 224 Veau’s classification 201

lasers 49 whitening 56f, 57
Velocardiofacial syndrome 203

tissue Total space analysis 130 Vertical
evaluation 89 Treacher-Collins syndrome 203 holding appliance 243
modification 52 Triangular clasp 162 position of lower incisors 92
Solidification of metals 116 Tube plates for distalization of Vestibular screen 190
Southend clasp 162 molars 244 Vestibuloplasty 51
Spheno-ethmoidal angles 136 Tuberosity reduction 52
Split labial bow 163 Tweed’s W
Sports guard 19 method 152
Steiner bracket 112, 112f triangle 143, 143f Wearing invisalign appliance
Stereolithographic models 230f, Twin 233f
231f arch appliance 112f Weldable brackets 109
Straight wire 180 block appliance 190 Wescott’s expansion device 154,
appliance 103, 180, 181, 181f brackets 111 154f

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First Edition: 2013

Sangamesh BE (USA), Jagadish BE (USA) and Manjunath BE (USA)

Dr Basavaraj Subhashchandra Phulari has made sincere efforts to go into

the depth of each topic providing an exhaustive insight. I am convinced that it

Basavaraj Subhashchandra Phulari

Timing of Orthodontic Intervention 18

8. Angle’s Contribution to the Faculty of Orthodontics 59

Relating the Mandible to the Maxilla (Midface) 89

Relating the Mandible to the Cranial Base 91

Marvin M Tanaka, Lystle E Johnston in 1974 128

Film Position and Enlargement 140

Posteroanterior (Frontal) Cephalometry 141

Advantages and Disadvantages of Edgewise Appliance 178

20. History of Surgical Orthodontics 193

Disadvantages of Invisalign 232

Color Fading of the Blue Compliance Indicator Encapsulated in Removable Clear

Molar Distalization by Magnets 247

• Ancient Dentistry • Dentistry during the Middle – Nathaniel Highmore

– Saracens – Abulcasis – James Drake

– Hwang-ti – John Gaddesden – Antoni Van Leeuwenhoek

people. Finally, a few of the more far-seeing

Fig. 1.1: GV Black

theory and practice of dental surgery. This, the

devoted his attention to the medical books in the

odontagogon of lead found in the temple of Apollo

Anthony of Egypt, and, as he baptized her, he

operations for their relief by both physicians and

teeth. This should give one a fair conception of

book which treated of dentistry independently of

possible by the aid of high-powered lenses.

teeth : He was strong in his condemnation of elixirs

to a high degree of perfection and described five

• Definition of Orthodontics – Fixed Orthodontic – Correcting Malocclusions of

change the normal course of events. They include

Fig. 2.1: Aims of orthodontic treatment (Jackson’s triad)

severity of malocclusion and sometimes to

ii. Fixed orthodontic appliances as: Begg’s, edgewise, preadjusted edgewise,

iii. Functional appliances

Fig. 2.4: Activator, a myofunctional orthodontic appliance

skeletal malocclusions by growth modification.

e.g. headgears and chin cup (Fig. 2.5).

TIMING OF ORTHODONTIC INTERVENTION • Reduction or elimination of abnormal

• Night guards: Night guards can be given in

• Ancient Civilization • Eighteenth Century

Table 3.1: Ancient civilization

physician and anatomist, set a precedent for the

varieties. He indicated the manner of articulation

Table 3.2: Eighteenth century

(1829–1913), a prominent dentist, artist, sculptor

Fig. 3.2: Expansion appliance developed

Table 3.3: Nineteenth century

Fig. 3.4: Baker’s anchorage (Intermaxillay elastics)

Edward H Angle (1855–1930) (Fig. 3.5). He is