The Causes of Malocclusion Jawes C. Anetz, D. D. S* Formerly of Santa Barbara, California When I undertook to write this paper I was moved to do so through a realization of the things which had caused me the greatest trouble in the past. I also noted an apparent lack of appreciation on the part of many other orthodontists, whose patients came under my observation, that causes must be discovered and treated equally as much as the effect of these causes—malocclusion and its attendant evils, I believe that not enough attention has been paid to the subject of causes in the past and consider this to be a matter most worth while. Now the minute I mention the word ‘Causes’, there no doubt comes to the mind of each and every one of you the list of the generally and commonly known ‘Causes of Malocclusion’. From prenatal influences on through disuse—the premature loss or prolonged retention of deciduous teeth—the tardy eruption of permanent teeth—their loss for one reason or another—supernumerary, missing or transposed teeth; nasal obstruction—im- perfect fillings, crowns, etc.; habits, abnormal frenum labium, faulty diet, endoctrine disturbances or other errors of metabolism, and so on. There is probably not one of us here who would overlook nasal obstruction as a cause of malocclusion or prematurely lost or too long retained deciduous teeth, or poor dental work, or nearly any of the other causes mentioned, for that matter, with the possible exception of one—and that one is ‘habits’. Even now we feel within ourselves that we would not be likely to overlook thumb sucking or cheek sucking, (the results of which somewhat resemble those coming from the child’s sleeping with doubled fist under the cheek), or the resting of the tongue between the upper and the lower incisors as a contributing cause of the deformity presented for our attention and correction. Some of these, indeed, have become so commonly known and understood that intelligent mothers are often acquainted with their “Editor's Note: | The tragic death, by earthquake, of Dr. James C. Angle, took from our specialty a young man of highest ideals, brilliant scholastic ability and masterful technical skill. This paper was written by Dr. Angle in the early years of practice and read before the First Annual Meeting of the Edward H. Angle Society of Orthodontia. “It was recently brought to the attention of the Editor, in manuscript form, and is now published for the first time in the belief that it contains much of practical value and is an excellent example of sound and logical reasoning. 36 THE ANGLE ORTHODONTISTdangers and pass the information on to other mothers. Certainly we could not imagine anyone really practicing orthodontia who could not readily discover these causes and work for their removal. But there are habits that each and every one of us have overlooked in the past and which are commonly overlooked today. These habits, which I especially refer to, are habits or tricks of the muscles of the face, ordinarily spoken of as the muscles of facial expression, and habits of the tongue and the muscles associated with the functions of mastication and deglutition. Now certainly these muscles are right before our eyes and scarcely an appointment passes with our patient without a goodly manifestation of the actions of which I speak, if they be present. How is it then, that they so often have been overlooked? I believe you will all agree with me, in going back over your own experiences, as I recall my own, as to the truth of the statement that ‘we have overlooked them,’ Why have we missed on our causes and gone on treating results only to find, in the end, that in spite of our best efforts at treatment and retention, the inevitable appears in so many cases—a recurrence of the trouble? Well, it is usually asserted that we see what we are looking for. If it be wild flowers that we are interested in, every journey afield will bring new delights. We are in a degree familiar with the dainty creatures and as our familiarity develops into deeper knowledge, through observation of and further interests in, we come to see them more readily—they flash upon us—they appear in our consciousness as never before, So is it with the stars above us, with Indian basketry, with old and time worn books and manuscripts, with all that lies within range of human attention. Why, then, has the profession of orthodontia at large apparently lost out so often in detecting these peculiarities of habit—these “mannerisms” of individuals, as they might be called? Tt may be due to the fact that, look about us as we may, we find so few adult individuals who have not peculiar facial manifestations of ex- pression—some habit of bending or screwing the muscles of the face, or some compression or pouting or biting of the lips, and hence we have come to look upon these movements as characteristics of the individual, not un- natural. We have taken it as a matter of course. Indeed many adults who do this very thing in a slight degree, may have beautiful dentures harmoniously arranged. What, then, is the explanation? I have given con- THE ANGLE ORTHODONTIST 37siderable thought to this apparent paradox, and the following is my belief in the matter, gained from the writings of our teacher and others, and from my own experience and reflections. The time was when the life of a child was relatively simple. Being a boy or a gir] meant growing—physically, mentally, and spiritually; develop- ing after the natural enforced methods of childhood; plenty of sleep, as well as work and play; natural curiosity with well meaning parents to answer tie questioning and to guide the child on through the developmental years, toward the time of maturity and the assumption of life’s responsibilities. A happy childhood full of the business of being a real boy or a real girl, but a relatively simple childhood, free from great perplexities. (In this connection, I am reminded of the remarks made by one of our guests a day or two ago of his own happy childhood.) Under such circumstances nature had at least a chance to develop a normal denture and an integral part of the normal individual, working in her wondrous way toward the fulfillment of her plan as seen in the highest creature on earth, ‘Man’, In due time, a child no longer, the individual entered life's arena, as he does today, to take up the struggle through the years which are his. It is not all easy. Problems confront him. ‘The battle may be strong, dangers beset him, the responsibilities increase, life assumes great com- plexity. He grits his teeth; his lips become tense, We see this every day about us, We have come to accept it as part of being alive, active, doing. But, mind you, this is in the adult. The teeth are erupted; the roots are formed; the bone surrounding them has become more generally hardened; the muscles may have, through years of normal functioning, accustomed themselves to their respective duties. As a result the balance of the ‘Mill’ may or may not be upset by the problems of the mind as expressed in the mind’s mirror, the face. Now compare the child of yesterday, if you will, (or of the present day in places where the simple life may yet be found) with the majority of those children presented to us today for treatment. Consider the handicap of this little class. Precocious children, so often born of mothers who were physically unable to do justice to them before birth or to nurse them properly for the needed length of time, (or I might add who were so busy socially that they would not nurse them) into homes where their companions are often, for a great part of the time, nursemaids who frequently are over indulgent, (and some of the mothers are too, for that matter) fed upon 38 THE ANGLE ORTHODONTISTthe softest and most delicately prepared foods, which not only may be unsuited for their nourishment, but which are usually so soft as to require little effort to chew or swallow; surrounded through the early years, by the hustle and excitement of our strenuous generation; hustled off to school, at an early age; attending dancing classes, dramatics, music lessons, and elocution (I know whereof I speak, for I have had just such patients); given a weekly program that allows so little time for being just a girl or boy; given a life of such perplexity and complexity during these very tender years and long before it is due! What chance has nature to work out her plan in a child brought up under such circumstances during the develop- mental period? Witness the disturbed nervous system—the wrinkled brow— the bitten lip—the tense mouth—the distorted faces and jaws, in these little children. And so, as a result of such precociousness and too early nervous ex- citement, we see the evil effects in the child’s health and note the horrible moulding, in all manner of deformity, of the soft jaws and the developing teeth. It is the effect of this early, unnatural, merciless, abnormal play of the muscles upon them, No orthodontist, by the use of appliances, can ‘ever hope to gain ultimate success unless he recognizes this perverted muscle influence and its power, as a contributing cause to the deformity, and succeeds in removing it, and the causes of it, together with whatever other causes there may be present, To remove the particular cause in question is often a very difficult thing to do, Indeed, it seems sometimes impossible. For to go further back to the causes of the cause, it is sometimes no easy matter to change the habits of a lifetime that even concern the method of living in a home. Neither is it easy to change human nature as it directs that method of living in that particular home. But it is obviously the orthodontist’s duty to, at least, recognize in the beginning the underlying causes of the trouble, and, in as tactful a manner as possible, explain just what can be done and what can not be done unless cooperation is given by the parents and patient. Needless to say this is an extremely delicate matter at times, but be as- sured, it is not half so embarrassing for the orthodontist as it will be, after ong years of earnest effort on his part, to try to explain just why results have not been obtained an anticipated and either to ‘wear his patients out’ or admit failure, after having held out hope for so long. Just what are some of these ‘Habits’. In many cases, the habit consists in biting, sucking, or repeatedly sticking out the tongue to wet THE ANGLE ORTHODONTIST 39the lower lip; or the sucking may be of the cheek or cheeks; or of the front part of the lower lip at the angle of the mouth and anterior to it. ‘Again we see a tenseness, a compression of the lips, which sometimes will drive both the teeth and our appliances backwards. In addition to this, a number of smiling or laughing habits produce serious trouble, such as when we find the lips separated and the whole force of a strong lower lip repeatedly pressing against the teeth of the lower jaw. I:have also seen it at work in the form of a fleeting smile which ended in a whorl of the muscles of one cheek, resembling a morbid dimple, but which was sufficient to undo the work of two specialists, who had previously treated the child, and bring about a relapse to unilateral, distal occlusion. Is this precociousness referred to the sole cause of these many habits, a few of which I have enumerated? By no means, At times they are but temporary matters, such as embarrassment, and may be outgrown as quietly as they were developed. Again, they may result from an extremely dry climate which makes the lips seem to dry out uncomfortably. Or they may be the aftermath of this dry climate or of nasal obstruction and mouth breathing, which, through the open mouth, may have originally started the trouble. Forced nasal breathing in patients suffering from hay fever or catarrah, etc., is also a contributing factor It is not the intention of the present paper to go into the many details of the various causes of some of these most commonly overlooked etiological factors of malocclusion, but it is purposed to show that the operator is remiss if he fails to recognize them and to point them out to the parent. It may be added that in some cases they can be removed while in others they apparently cannot. In the latter instance it is obviously the part of wisdom to call the cases incurable from our standpoint and the sooner we recognize this and cut loose, after reasonable trial, the better for all parties concerned. It is the wise man who can, in justice, discern the cases to decline, As to the more intricate psychological causes, they have been or will be taken up in other papers at this meeting. It will be interesting to refresh our memory by reading some of Doctor Angle's (he refers to Edward H, Angle) own remarks upon this very subject—written many years ago, but overlooked by too many of us in our practice. “In cases of malocclusion strikingly characteristic abnormaliti 40 THE ANGLE ORTHODONTISTlip function are often noticeable, leading to the suspicion that more often than is recognized the peculiarities of lip function may have been the cause of forcing the teeth into the malposition they occupy.” “In these cases (Division 1, Class II) over activity of the lower lip assists in augmenting the protrusion (of upper teeth), for in closing the lips, the inner edge of the lower is forced against the lingual surfaces of the upper incisors instead of their labial surfaces.” “The abnormally frequent contraction of the upper lip, manifest in the case of patients suffering from snuffles, forces the upper incisors more or less inwardly, producing an end to end bite and an abnormal wearing of the cutting edges of the upper incisors.” “Doubtless, also, peculiarities of disposition and their manijestations in the movements of the lips, in many instances so modijy the force exerted upon the teeth as to influence the form of the dental crches.” “The pernicious habit of biting the lower lip, or pressing the occlusal edges of the upper incisors against its outer surface will always, however slightly persisted in, move the upper central incisors forward, thus lessening their natural resistance to the narrowing of the lateral halves of the arch. This habit is more common than seems to be generally supposed, is often extremely difficult to overcome, and probably accounts jor many ultimate Jailures in orthodontic treatment, We know of nothing in orthodontia that causes more annoyance and discouragement to the practioner. Ojten after long retention, when he believes his work satisfactorily completed, he finds the habit has never been broken and that a few weeks have been sufficient to reestablish the old conditions, or conditions even worse.” “The habit is almost invariably a marked accompaniment of cases be- longing to Division T, Class II and is a subdivision, and unless it is overcome and the normal function of the lips regained, the incisors can never be kept in their normal. positions.” “The habit of sucking the lower lip, though quite rare, (Doctor Angle now says it is very common) must, if persisted in, produce marked mal- occlusion, The most repulsive deformity due to malocclusion that the author (E. H. A.) has yet seen, was caused by this habit. The nose was amply developed with no indication of nasal obstruction.” Speaking of tongue habits, the writer, (E. H. A.) states that “There are as many variations in the habit as there are cases met with, with resulting NGLE ORTHODONTIST ALcorresponding variations in the malocclusion. The difficulty of breaking the habit is even greater than that of overcoming the pernicious lip habits, resting, as it does, almost wholly with the patient and very few having sufficient character and persistence to overcome it.” “With our present knowledge of orthodontia these cases are the most difficult to treat successfully. The orthodontist should be thoroughly con- versant with their peculiarities, and with the obstacles to be overcome in their treatment, before beginning which he should have a complete understanding with the patient and his parents as to the responsibility of both.” (The above quotations are all from Doctor Edward H. Angle’s Mal- occlusion of the Teeth, Seventh Edition, published in 1907.) Here we see some of the “Bugbears” of orthodontic practice today, which are altogether too commonly overlooked. Improper surgical removal of the tonsils, with damage to the adjacent tissues, causing abnormal swallowing and thus acting as a cause of mal- occlusion, is being investigated at the present time, particularly by Atkinson, of Atlanta, and gives evidence of being a contributing factor in many cases. So the speaker would urge a more careful scrutiny, upon the part of all orthodontists, into the causes, or combination of causes, of the various conditions presented for treatment, and particularly into the subject of habits, which he believes are etiological factors in over ninety per cent of our patients today. He would again emphasize the fact that unless the causes are discovered and made known in such cases where cooperation is needed, not only will failure be the outcome but blame can justly fall upon the operator for he has been negligent and remiss in his duty. No matter how skilled a technician he may be from the beginning of treatment to the end, if he cannot see the causes of the trouble he is treating, and the causes behind the causes, and if he does not work toward removing them at the same time he is correcting the effect, he is a blunderer, doomed to failure,— and not a truly scientific man, There has been, and is today, in some quarters, too much blind attempt to treat effects, overlooking causes. The speaker is greatly indebted to Dr. Edward H. Angle, for much that is contained in this paper, and also for the following quotation, with which he feels in keen accord: “In conclusion the author would not be understood as implying that he believes he has exhausted the subject. On the contrary, he feels, as all students of the subject must feel, that there is much concerning the etiology of malocclusion that is as yet unknown.” (Angle, Malocclusion oj the Teeth.) 42 THE ANGLE ORTHODONTIST