American

Journal of Orthodontics
and Oral Surgery
(All rights reserved)

VOL. 31 JUNE, 1945 No. 6

Original Articles

TIIE PHTLOSOPIIY OF THE TOOTH POSITIONING APPLIANCE

H. D. KESIJNG, M.D.S., L:\ PORTE, IKD.

T HIS new appliance grew out of a desire to create some simple appliance
that would influence all of the teeth to flow into their best possible position
with relation to oile another without any interference from bands or wires,
that would be efFective under functional forces, that would produce arch form
in accordance with type, that would further attain the desired harmony be-
tween facial features and tooth arrangement, and that would serve as a re-
tainer to conserve all the advantages gained above. As this appliance was
developed, it was found to be most practical for t,he final artistic positioning
and retention of the teeth after basic treatment had been accomplished.
In the last few years we have heard much about lack of bony base, mesial
drift, bimaxillary protrusion, bimaxillary bony retrusion, and so forth. All
of this has been expressed because of a realization of a lack of harmony and
balance between the teeth, the jaws, and the features of the face. Perhaps
no two operators would agree upon a certain pattern or profile as a typically
beautiful face. It is quite encouraging that those teeth that have sufficient
space in the denture to assume an upright. position over t,heir bony bases pro-
duce a pleasing profile aud dentures of which the teeth are stable under func-
tional forces. Perhaps this will be th’e media by which orthodontists in general
will finally agree to some extent as to what constitutes balance and harmony
of the dentures and facial contour.
Except in the presence of abnormal muscular habits, teeth that are un-
hampered by proximal contacts or inclined plane interference tend to assume
positions which are stable as well as in balance with one another and with the
immediate tissues surrounding them. Therefore, the diagnosis and plan of
treatment of the average orthodontic case is greatly simplified when we accept
our limitations of bone development and leave in each arch only those teeth
Read before the Fall Meeting of the New York Society of Orthodontists, Nov. 14, 1944.
297
29s H. D. KESLING

which will have suficielit space to be positioned npright and properly rotated,
with correct proximal contacting. Theil with the mechanic3 we have at hand,
we call place tllc maxillaq- denture in its p~opr~* rclatioll to t,hr lllantlibular.
With the exception of cases wit11 esa.gg(~i*atetl 1,011~~ tlcforlilitics, orthodontic
cases have a very favorable prognosis rnlle~l treatetl ill this simple and realistic
manner. It wonld be itleal to have a case treatctl from start to finish with
an appliance that did not interfere with the proximal contacting of the teeth
nor increase their mesial-distal dimensions. To date, the profession has not

Fig. I.-Basic treatment. Kiqht. original model. Left. basic treatment model.

Fig. 2.-Basic treatment. Left, original model. Right, basic treatment. Note spaces.

ken favored with au appliance that would adequately control the teeth that
required major movements without banding or capping these teeth. We have
in the “ Tooth Positioning Appliance” an active treating appliance for the
final artistic positioning of the teeth as well as an cflective retaining device.
This appliance allows the teeth to flow iuto their most ideal position without
interference from bands, caps, or wires. Also, this appliance is most effective
under functional forces.
 PHILOSOPHY OF TOOTH POSITIONIL\‘G .WPLIAI\‘CE 299

The proved practicability of the Tooth Positioning Appliance is for ‘the final
artistic positioning and retention of the teeth of cases that have already had
basic treatment completed with a conventional type appliance. Basic treat-
ment need only be carried until each tooth is properly rotated and is approach-
ing its desired position. Arch form need not be ideal, slight spaces may re-
main, overbites may still be exa,,o,o,eruted, and mesial-distal or buccal-lingual
relationships of the maxillary teeth to the mandibular need not be perfect so
long as the cusps are starting into their proper inclined plane relationships.
At t’his point all of the bands and wires are removed and impressions are
taken immediately. From the impressions two sets of models are prepared
from hard plaster. The art portions of these models should be carved and
proportioned like those of any clisplap or study models of orthodontic cases.
One of the models is used to make the setup and the other is used as a control.
The teeth are dissected from the setup model ancl arc rearranged in wax on
these bases to the desired arch form, axial positioning, and occlusion. This
gives the operator a chance to express himself in detail as to the arch form and
tooth positioning he would prefer for each patient. All orthodontic treatment
is tooth positioning, but here is a practical reason for positioning with the
hands plaster teeth which are an exact reproduction of the crowns of the teeth
in the mouth.

Fig. 3.-Setup and positioner. Left, setup model. Right, Tooth Positioning Appliance.

When completed, this setup model is used as a pattern over which the Tooth
Positioning Appliance is constructed. The setup models are articulated 011
au anatomic articulator and the bite is opened to the physiologic rest position.
The Positioner is a one-piece pliable rubber appliance that is made to completely
fill the freeway space between the upper and lower dentures as well as to cover
the labial, buccal, and lingual surfaces of both the maxillary ancl the mandib-
ular teeth.
If basic treatment has been properly accomplished, each tooth will have
sufficient space in the arch. The material of the Positioner allows it to stretch
over the teeth, and while it is being worn its resiliency influences each tooth
300 H. D. I~ESLING

toward its position in the predetermined pattern, or setup. Experience has

shown that in this way arch forms may be modified, slight rotations may be
accomplished, and axial position influenced.
In the past after orthodontic treatment has been completed, the average
orthodontist has depended upon Nature to settle the teeth into positions of
balance and harmony. Examination of a cross section of orthodontic cases
throughout the country reveals that this procedure has been disappointing,
even where treatment has been carefully executed.
When the Positioner is applied at the end of major tooth movements, it
t.akes advantage of the fact that in this condition the teeth are most susceptible
to its gentle forces. The teeth are unstable from previous manipulation and re-
spond to the influence of the Positioner very readily. Not only does the Posi-
tioner maintain the advantages gained by the conventional treatment, but the
teeth are actually influenced toward more harmonious and stable positions
through its wearing.

Fig. I.-Changing arch form. Left, basic treatment model,. Center, setup model. Right, model
after treatment with Positioner.

Orthodontic service is certainly a personal service, and we can personalize

it even more by developing a distinctive arch form and tooth arrangement ac-
cording to type for each individual under treatment. With the predetermined
pattern it is possible for the operator to shift the teeth within reason into any
desirable position, and, in proportion to his artistic ability, to give each case
a distinctive, artistic touch.
Every orthodontist has hoped to develop for each of his patients an. arch
form according to type. In the main this has failed, because, in a high per-
centage of the cases treated, arch forms have been produced that would allow
the teeth to assume positions which would least resist the desired tooth move-
ments. Thus, arch forms frequently have come to be a result of expediency
rather than a true development according to type. In fairness, we must give
credit to the rare orthodontist who takes the trouble and succeeds in develop-
ing each arch form in accordance with type after major tooth movements have
been achieved.
Not infrequently, teeth of individuals under orthodontic treatment are tipped
into abnormal axial positions. This is especially true in the molar and premolar
areas where the teeth are invariably tipped buccally. With the Tooth Position-
ing Appliance, this condition can be corrected in the setup, and in the mouth
 PHILOSOPHY OF TOOTH POSITIONING APPLIANCE 301

the Positioner will influence the teeth, not only by reducing the arch vvidth,
but also by the functional forces working through the occlusal surfaces of the
teeth, their roots being thrown buccally and their crowns lingually. Teeth so
positioned with the Tooth Positioning Appliance will more nearly approximate
the axial positioning of the same teet,b in llonorthodoatio normals.

Fig. 5.-Mesial-distal correction. I,eft, basic treatment model. Right, model after correction
with Positioner.

Fig. 6.-Buccal-lingual correction. Left, basic treatment model. Right, model after correc-
tion with Positioner. Note space closure.

As basic treatment is completed in severe Class 11, Division 1 cases, the

maxillary anteriors often assume a lingual axial inclination. This position is in-
evitable because of the distance the incisal edges of these teeth must travel
lingually in order to reach Class I relationship to those of the mandibular in-
cisors. When using the Tooth Positioning Appliance it is quite convenient
to exaggerate the labial axial inclination of these teeth on the setup, and
302 H. D. lIESLING

through the appliance influence them into their normal positions. This same
condition will often prevail in cases where it is necessary to eliminate some
of the dental units in order to complete basic treatment properly.
When using the Tooth Positioning Appliance for the final positioning of
the teeth, it is not necessary that all of the teeth completely interlock in inclined
plane relationship before basic treatment is discontinued. If the maxillary
buccal teeth are approaching their normal relationship both buccolingually and
mesiodistally to their antagonists in the mandibular arch, the teeth can be
forced into the Positioner, and it will influence all the teeth toward their com-
plete interdigitation. If it is necessary to shift the mandible laterally or mesi-
ally in order to engage the Positioner, the proper force for positioning these
teeth will be brought into play when the patient, after seating his teeth into
the Positioner, carries the mandible back into its normal position. The func-
tional forces will add greatly to reduce this type of discrepancy, if the patient
is not lazy and works against any shift of the mandible created by the Posi-
tioner.
There are some types of major tooth movements that the conventional type
of appliance has utterly failed to produce. Deep overbites are corrected not
by the depression of t,he anterior teeth but by the elevation of the other teeth
to their line of occlusion. There surely are cases of closed-bite malocclusion
in which the most favorable treatment would be the depression of the anterior
teeth rather than the elevation of the posterior teeth. Since the pressure re-
quired to elevate teeth is very light compared with that necessary to depress
teeth generally speaking, all conventional types of appliances elevate the pos-
terior teeth in these closed-bite cases rath,er than depress the anterior teeth.
When dealing with such cases the intelligent arrangment of the teeth on the
setup would be an alrnost end-to-end relation of the anterior teeth. A Positioner
processed from such an arrangement and worn by the patient would not only
throw all the occlusal forces onto the anterior teeth, but also through the elas-
ticity of-the appliance would give additional “kick” to this depressing action.
No other appliance previously available to t,he profession has such possibilities.
Only as ‘the anterior teeth are depressed would the Positioner influence the
posterior teeth to any great extent. Certainly the most active force would
he toward the depression of the anterior teeth.
Open-bite malocclusions have been difficult to handle with the conventional
type appliance, and although in cases carefully treated the anterior teeth have
been brought into the line of occlusion, this is usually entirely accomplished by
the elongation of the anterior teeth. Invariably the faces of individuals with
open-bite malocclusion are Ion,08 and the mandible has the appearance of being
depressed even though a few of the posterior teeth are in occlusion. The ideal
treatment of such cases would be t,he depression of these posterior teeth and
not, the elongation of the anteriors. To date, there is not sufficient practical
evidence that this can be accomplished, but certainly the Positioner offers the
best possibilities of such a correction. It would be expecting too much to
think that the Positioner, even under functional forces, would accomplish this
result. The most favorable results so far have been accomplished with the
 l’HII~OSOPHY OF TOOTH POSITIONIN(; AI’I’IJ.~NCE ml

Positioner in place, and with a headgear bein,w worn to which powerful elastic
forces were connected with a chin cup. As in the closed-bite cases, the pressure
of the occlusal forces as well as that of the elastic force from the headgear and
chin cup were at first entirely directed against the teeth that should be de-
pressed. The elasticit,y of the Positioner between the maxillary and manciibular
posterior teeth oRered an ideal additional force for the depression of these teeth.
The Tooth Positioning Appliance has tremendous possibilities as a splint
for the reduction of fractures of the maxilla or mandible. This field is almost
entirely unexplored. In one case, however, where there were multiple fractures
of both the maxilla anti mandible. t,he Tooth Positioning Appliance has been
used successfully for their reduction. III this case the Positioner n-as worn in
conjunction with a rigid headgear connected by elastic force to a chin cup.
The Posit,ioner has many uses other than final positioning and retention.
Major toot,h movements cotild be accomplished with a series of Positioners by
changing the teeth on the setup slightly as treatment progresses. At present
this type of treatment does not seem to be practical. It still remains a pos-
sibility, however, and the technique for its practical application might be cle-
veloped in the future.

Fig. 7.-Reduction of closed-bite. Right, basic treatment model. Left, setup model. Center,
model after treatment with Positioner. Note reduction of closed-bite.

In selected cases it has been practical to LM one or more Positioners to tli-

rect the eruption of the permanent teeth as well as to make slight corrections of
teeth already erupted without the use of any conventional appliance. There
have been several closed-bite cases that have been carried to a successful con-
clusion without the use of any appliance other than the Tooth Positioning Al)-
pliance.
The Positioner is an ideal retaining appliance, because it not only retailis
the arch form and tooth positioning within the arch, but also retains the correct
relationship between the maxillary and mandibular arches. Tt will go into
place and function even though there has been a slight relapse of .the case.
When in place it has the proper stimulus to iron out the relapse and again
position the teeth as they were arranged in the predetermined pattern. As the
conventional types of retainers are rigid, they do not allow for slight changes
which are inevitable in any denture. The Positioner is flexible ancl accommo-
dates itself to these changes that accompany the settling of the teeth.
304 WALTER J. SLY

The Tooth Positioning Appliance has been used, and has possibilities for
extensive use in the future, as an appliance to stabilize teeth of individuals who
have had orthodontic treatment. It can be of equal benefit for cases that have
not had treatment but which are prone to drift into traumatic malocclusion
perhaps through lack of function. By using this new technique of final posi-
tioning of the teeth, it is possible to remove the conventional type of appliance
from four to six months earlier than is practical under the usual form of treat-
ment. Besides reducing the operator’s chair time, the patients appreciate the
shortening of treatment. When the Positioner is properly worn, each tooth is
being forced toward its best possible position, not only in relation t”o the teeth
of its own arch, but also in relation to the teeth of the opposite arch. Slight
spaces are closed, moderate rotations are adjusted, maxillary and mandibular
discrepancies are corrected, and proper iuterdigitation of the maxillary and
mandibular teeth is achieved. Axial positioning is changed, not only by the
pressures exerted on the buccal, lingual, and labial surfaces of the teeth, but
also by the functional forces exerting pressure on the occlusal surfaces of the
teeth. This is especially true of the posterior teeth.
The day of prolonged wearing of orthodontic appliances is past. The major
tooth movements necessary, to properly accomplish the basic treatment of most
orthodontic cases can be completed in about twelve months, if the active treat-
ment is undertaken at the most opportune time. Many cases can have the bands
on and off in from six to eight months, providing that the final positioning is
to be accomplished, not by bands and wires, but with the Tooth Positioning
Appliance.
910 INDIANA AVENUE.

RESTOR’ATION OF FUNCTION THROUGH EARLY CORRECTION OF

MALOCCLUSION

WALTER J. SLY, D.M.D., BOSTON, MASS.

URING any meeting such as the present one (devoted to the discussion of
D orthodontics), frequent reference is made to growth and development.
Growth is generally taken to mean an nmrease in bulk b’y proliferation. De-
velopment, as defined by Conklin, is the progressive and coordinated differ-
entiation of the organism under the influence of heredity and environment, and
interplay of these factors is responsible for changes in relative proportion.
The important thing to remember in the interpretation of the following
material is the division of both growth and development into prefunctional and
functional stages, During prenatal life heredity is the controlling factor in
Read before the New York Society of Orthodontists, Nov. 13. 1944, New York, N. Y,