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Basic Guide to
Orthodontic Dental Nursing
BASIC GUIDE TO
O R T H O D O N T I C D E N TA L
NURSING
Second Edition
Fiona Grist
BA (Hons) OU
This edition first published 2020
© 2020 John Wiley & Sons Ltd
Edition History
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Library of Congress Cataloging‐in‐Publication Data

Names: Grist, Fiona, author.
Title: Basic guide to orthodontic dental nursing / Fiona Grist.
Other titles: Basic guide to dentistry series.
Description: Second edition. | Hoboken, NJ : Wiley-Blackwell, 2020. |
Series: Basic guide to dentistry series | Includes index.
Identifiers: LCCN 2019035284 (print) | LCCN 2019035285 (ebook) |
ISBN 9781119573692 (paperback) | ISBN 9781119573708 (adobe pdf) |
ISBN 9781119573746 (epub)
Subjects: MESH: Orthodontics | Dental Assistants
Classification: LCC RK521 (print) | LCC RK521 (ebook) | NLM WU 400 |
DDC 617.6/43–dc23
LC record available at https://lccn.loc.gov/2019035284
LC ebook record available at https://lccn.loc.gov/2019035285
Cover Design: Wiley

Cover Image: Courtesy of David Morris
Set in 10/12.5pt Sabon by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
Dedication
For Michael,
with love
Contents
Foreword to Second Edition ix

How to use this book xi
Acknowledgements xiii
1 Definition of orthodontics and factors influencing orthodontic treatment 1

2 The first appointment 13
3 Occlusal indices 35
4 Motivation 45
5 Leaflets 53
6 Oral hygiene 59
7 Removable appliances 71
8 Transpalatal arches, lingual arches and quad helix 85
9 Rapid maxillary expansion 93
10 Headgear 101
11 Functional appliances 109
12 Temporary anchorage devices and magnets 119
13 Fixed appliances: what they do and what is used 127
14 Fixed appliances: direct bonding 161
15 Fixed appliances: indirect bonding and lingual orthodontics 177
16 Ectopic canines 187
17 Debonding 197
18 Retention and retainers 203
19 Aligners 215
20 Multi-disciplinary orthodontics 225
21 Adult orthodontics 241
viii Contents
22 Mandibular advancement devices 249

23 Study models and digital storage of records 259
24 Descriptions and photographs of the most commonly used instruments
and auxiliaries267
25 Certificate in Orthodontic Nursing, extended duties and ongoing training 295
26 Orthodontic therapists 305
27 The Orthodontic National Group for Dental Nurses and Therapists 311
Useful contacts315
Glossary 319
Index 327
Foreword to Second Edition
The orthodontic team is in the privileged position of being able to significantly improve
our patients’ lives almost on a daily basis. To do this efficiently and effectively requires not
only an understanding of all the equipment and materials available, but precision team-
work practised day in, day out.
We, as orthodontists, are totally dependent upon our orthodontic assistants to under-
stand exactly what we are doing and to be able to predict what we are going to require
next, to ensure the correct instruments and materials are prepared accordingly. Working
with a well‐prepared and conscientious assistant is a dream, and ensures high‐quality
treatment is delivered to as many patients as effectively as possible.
This second edition of the Basic Guide to Orthodontic Dental Nursing by Fiona Grist
allows the trainee orthodontic nurse to take the first tentative steps on a fascinating and
rewarding lifelong journey. It will also provide extremely useful revision for experienced
orthodontic assistants of many of the orthodontic concepts we are all required to know
intimately.
With its recently updated photographs it now provides an invaluable reference book
for all those wishing to learn and improve their orthodontic knowledge.
Professor P.J. Sandler BDS (Hons), MSc, PhD, FDSRCPS, MOrthRCS

President, British Orthodontic Society
How to use this book
The aim of this book is to give the dental nurse in general practice an introduction to the
world of orthodontics and orthodontic dental nursing. It may also be helpful to trainee
nurses working in an orthodontic environment.
Orthodontics is specialist branch of dentistry and has its own vocabulary. The information
in this book is a basic guide, so it does not set out to:
• examine clinical features (why the problem arose)
• cover treatment planning (what is the best choice of treatment)
• treatment mechanics (how the appliances achieve what they do).
Its objective is to describe what the dental nurse needs to know so they can work effi-
ciently at the chairside when treating an orthodontic patient.
If you feel you want to develop your knowledge further there are several excellent
orthodontic textbooks available. The career pathways for orthodontic dental nurses are
now wide and the possibilities are extensive. Nurses have an important place in the dental
team. This book aims to be a helpful first guide on what is hoped be a long and interesting
journey.
Different procedures for various treatments are outlined in this book. While it is the
nurse’s role to assist the clinician, there are areas that are their sole responsibility; these are
highlighted in the text in italics.
A quick glance into the stock cupboards and cabinets in an orthodontic surgery reveals
quite different contents from that of a general dental surgery. There will be nothing with
which to fill teeth or fissure seal, or root canal trays. Anything that helps to irrigate a peri-
odontal pocket, whiten a tooth, prepare abutments for a bridge or fit veneers will be miss-
ing. Cupboards in orthodontic units and practices may share the basics, such as mirrors,
probes and College tweezers, and use the same alginates and disposable sundries, but
beyond that they have very little in common. However, these cupboards are full and it is
not possible to cover all materials or equipment that is in use, or every method or
procedure.
Just as we had to learn what was needed for restorative, endodontic and prosthetic
procedures, we need to learn what is needed for orthodontic treatment, which instruments
are used for what procedure and why they are used.
Each chapter will cover a topic, with a short background and guide to what you will
need to prepare so that the treatment can be undertaken as efficiently as possible. It is
hoped that the photographic examples are helpful, the aim being to show the instruments
as clearly as possible. The photographs are not all on the same scale.
This book does not go into detail regarding decontamination and sterilisation. The
areas to focus on are those that concern the effect repeated sterilisation has on stiffening
xii How to use this book
box joints on pliers. It can also have a detrimental effect on pliers that have cutting edges.
When sterilising pliers and instruments with beaks, always have the beaks open. The same
procedures and protocols apply in orthodontics as in other specialties. These you already
know. As dental care professionals it is up to the nurse to ensure that they are fully aware
and comply with all the current legislation, standards and codes of practice.
As with every skill, be it orthodontic treatment or baking a cake, everyone will have
their individual method of working and their favourite tools. There is no hard‐and‐fast
rule that says each procedure must be carried out using only certain instruments in the
same way or in an exact order. Every clinician has their preferred methods of working and
each and every nurse organises the layout of their trays as they like them. This is as it
should be – do what works best for you.
There is a saying,
You don’t know what you don’t know
This book contains a lot of information but at the same time there will certainly be omissions.
Every day brings new materials, new techniques and new treatment philosophies. Orthodontics
is inevitably becoming split into specialties within a specialty. The pace of development and
change ensures that what is current today is not so tomorrow.
I hope that this book achieves what it sets out to do, which is to provide enough written
and visual information for a reasonable grounding of basic knowledge. Its aim is to
encourage dental care professionals, especially dental nurses, to understand more about
orthodontic nursing.
As trained or trainee dental nurses there is so much that you are already expert at
doing, so this book will not cover knowledge you already have or skills you already pos-
sess. It does not set out to be comprehensive, but aims to give you a basic insight into the
world of orthodontic nursing – it is merely a guide.
Acknowledgements
This is the second time I have written acknowledgements for this book and there are now
so many more people to thank! So many that is seems like a mini chapter in itself. Firstly,
the tremendous support from my home team: my husband Michael and grand‐daughter
Kate had unlimited patience when computers, cameras and all manner of technology was
out to get me. They just quietly sorted it out. I could not have done it without them.
The format and structure of the original book, which benefited from the expertise and
enthusiasm of Alan Hall, has remained, enlarged and hopefully improved. Jo Clark has
generously taken over the task as my ‘go‐to’ clinical guru. She has been helpful with pro-
viding material for new photographs, advice and encouragement, not least in offering her
proofreading skills. Her expert eye looked over my shoulder to ensure I had not got my
clinical wires crossed. Also thanks to Maureen Dickinson who tried to make sure I did not
leave out major facts whilst busily including the minor ones. They devoted many hours to
this and I am truly grateful. Colin Anderson was my ‘lay’ proofreader, who also spent
hours crossing the t’s and dotting the i’s. My thanks to you all for sharing your expertise
so generously and for giving the book the benefit of your time, knowledge and experience
with such graciousness.
Special thanks must also go to my young photographer, Kate Meheux, whose contribu-
tion to the aesthetic appeal and clarity of this book was huge. She was efficient, knowl-
edgeable and enthusiastic and was a pleasure to work with over the many hours we spent
chasing our vision.
I must thank David Morris who again gave permission for the images on the cover,
Steven Jones who allowed me to re-use his photographs of TADs, Paul Ward who supplied
photographs of fixed lingual appliances, Simon Littlewood who supplied the image of a
Barrer spring retainer and Daljit Gill for his RME and cone beam CT images. Tracey
Buckfield at NEBDN was helpful with permission to reproduce the Certificate in
Orthodontic Nursing Syllabus as was Elena Scherbatykh at the GDC with the Certificate
of Orthodontic Therapists Syllabus. The Occlusal Indices are reproduced by kind permis-
sion of Professor Steve Richmond and Ortho‐Care (UK) Ltd. There were also many images
supplied by Alan Hall, and Jo Clark let me photograph a wide variety of her orthodontic
goodies. I appreciate the kindness of Alison Williams in sharing her knowledge of aligners
with me. My sincere thanks also to Alex Cash, and Wendy Bull in the office, for sending
me full records of four of his cleft patients, Douglas, Emily, Georgia and Harvey. I want to
thank them specially for kindly agreeing to be part of this book. I have tried to give an idea
of their treatment journey and show you how great they look now.
Without a doubt one of the most noticeable aspects of this edition is the updating of
many of the clinical photographs. This has been made possible by a generous offer from
Jonathan Sandler to access his vast database. I am more than grateful for this and his
xiv Acknowledgements
permission to use these photos in the book and the help given by Sue Mallender and Anne
McTighe: merely looking at his seemingly endless files was a masterclass in clinical
photography.
Orthodontics has some of the very best supply companies and I appreciate their encour-
agement and willingness to help. These include Richard Garford, Kelvin Scott and Lisa
Howorth at Ortho‐Care, David Rees and his helpful staff at TOC, Justyn Gumienna at TB
Orthodontics, and Mandy Mills at 3M Unitek. All have been really generous with their
time.
I have had the pleasure of working with the Orthodontic National Group for Nurses
and Therapists from the beginning. Their contribution to the role of dental nurses today
was encouraged by their vision. It would be impossible to include everyone but special
mention must go to Janet Robins, Maureen Dickinson, Alex Moss and Sally Dye.
I am grateful to Anjli Patel, Chair of Publications and Joe Noar, Head of Clinical
Governance at BOS for their help with permission to use PILs and Guidelines. Anshu Sood
and Rod Ferguson kindly allowed me to use the BOS Courses on Impression Taking and
Clinical Photography. Ann Wright used all her co-ordinating skills with this too!
My respect for the British Orthodontic Society is unquantifiable. They have long been
in the forefront of fostering the ‘team’ approach in orthodontics in the UK and have blazed
a trail for other specialties to follow. The Society has always, and continues to be, hugely
supportive of orthodontic nurses and therapists. Thanks to Professor Jonathan Sandler for
generously agreeing to write a foreword for this book. Special thanks to Ann Wright, Ann
Humphrys and Tony Kearney at BOS headquarters in Bridewell Place for their unflagging
good humour and willingness to help and share their expertise. You may not realise it but
your bar is high, you really do set the standard.
Caroline Holland first encouraged me to write an article on orthodontic nursing.
Initially sure I couldn’t, she encouraged me to give it a try, for which I will always be in her
debt, as without her I would never have written a word.
Nearly all the names on this page are members of the orthodontic family; they share a
passion for their work and have themselves made a significant contribution to their spe-
cialty, not to mention their patients, colleagues and the sphere of research. They have been
gracious in sharing their expertise. All omissions and errors are down to me.
Huge thanks to the team at Wiley‐Blackwell, especially Loan Nguyen, Susan Engelken,
Jayadivya Saiprasod, Jolyon Phillips, Baskar Anandraj and Nick Morgan. Knowing you
were there was good, but hearing your voices at the end of the phone was better. Thanks
for all the hand holding.
Last, but by no means least, to you, who have made it to the bottom of the page.
Teachers of English will say this piece is woeful as it repeats the words ‘generous’, ‘thanks’
and ‘appreciate’ too often. They are correct but these words are precisely what this page is
all about. I hope that you feel inspired to keep turning the pages and that you begin, or are
continuing, to enjoy your work in orthodontics, probably the best job in the world!
Chapter 1
Definition of orthodontics and factors
influencing orthodontic treatment
Orthodontics is a specialised branch of dentistry. The name comes from two Greek words:
• orthos, meaning straight or proper
• odons, meaning teeth.
So the meaning is clear – ‘straight teeth’.
Orthodontics is the study of the variations that occur in the development and growth
of the structures of the face, jaws and teeth and of how they affect the occlusion of the
teeth. Ideally there should be the same number of permanent teeth in each arch.
Any deviation from the norm that affects teeth alignment and the bite relationship is
called a malocclusion. Most malocclusions are genetic – they are inherited (e.g. missing
teeth or a protruding mandible). Other malocclusions can be caused by the patient, for
example digit sucking, or by external factors such as trauma.
Orthodontic treatment can correct a malocclusion by restoring the teeth to their nor-
mal position and occlusal relationship (with surgical help if needed) so that:
• the bite is fully functioning and the patient can bite and chew properly
• oral hygiene is made easier, so helping to prevent caries and gingivitis
• the malocclusion does not cause other damage, often to soft tissues
• the patient looks better and has better self‐esteem.
Orthodontic treatment in conjunction with orthognathic (maxillofacial) surgery can cor-
rect an underlying jaw discrepancy or facial asymmetry. Orthodontic planning is done in
conjunction with the surgeons using clinical and radiographic assessment, with a cephalometric
tracing (Figure 1.1) often analysed using a computer software program.
So orthodontists set out to:
• straighten teeth
• improve the bite
• improve the function
• improve oral hygiene (making teeth easier to clean)
• improve self‐esteem of the patient.
Basic Guide to Orthodontic Dental Nursing, Second Edition. Fiona Grist.

© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
2 Basic Guide to Orthodontic Dental Nursing
85
80
DEFINITION OF ORTHODONTICS
28
8
30
37
Figure 1.1 Cephalometric tracing.

Source: Reproduced by kind permission of
Alan Hall.
CLASSIFICATION OF OCCLUSION
When assessing occlusion there are two aspects to classification:

• incisor relationship
• buccal segment occlusion, left and right.
Both are recorded on a patient’s orthodontic assessment form.
I n c iso r cla ssific ation

• classes have Roman numerals, e.g. I, II, III.
• divisions do not, e.g. Class II/1 or Class II/2.
The incisor classification (Figure 1.2):
• relates to the bite of the tip of the lower central incisors onto the back of the upper
central incisors
• it is divided into three horizontal sections and where the lower incisor occludes will
determine the classification.
Class I
• the incisal edge of the lower incisors bite on or below the cingulum plateau of the
upper incisors.
Definition of orthodontics 3
Class I Class II/1 Class II/2 Class III
Figure 1.2 Incisor classification. Source: Reproduced by kind permission of Alan Hall.
Class II/1
• the upper incisors are proclined or upright (Figures 1.3 and 1.4).
• the lower incisors bite behind the cingulum plateau of the upper incisors.
• the position of these front teeth means they can be damaged more easily because of
their vulnerable position.
Class II/2
• the upper incisors are retroclined.
• the lower incisors bite behind the cingulum plateau.
• the position of the teeth can, when closed, lead to trauma to the lower labial gingivae
and the upper palatal gingivae (Figures 1.5–1.7).
Class III
• the bite is edge to edge or reversed.
• the incisal edge of the upper incisors can bite into the back (lingual) surface of the
lower incisor (Figure 1.8).
• a horizontal overlap is called an overjet.
• a vertical overlap is called an overbite.
Bu cca l se gmen t oc c lusion

The buccal segment occlusion:
• was devised by Edward Angle in 1890
• is still widely used today
Figure 1.3 Large overjet. Source: Reproduced by kind

permission of Jonathan Sandler.
Figure 1.4 Side view of severe overjet. Source: Reproduced by kind

permission of Alan Hall.
Figure 1.5 Bite stripping lower gingivae. Source:

Reproduced by kind permission of Jonathan Sandler.
Figure 1.6 Damage to labial gingivae caused by the

bite. Source: Reproduced by kind permission of Jonathan
Sandler.
Figure 1.7 Bite causing trauma to the palate.
Source: Reproduced by kind permission of Alan Hall.
Figure 1.8 Class III. Source: Reproduced by

kind permission of Alan Hall.
Class I ½ unit Class II Class III

Class II
Figure 1.9 Diagram of buccal segment occlusion. Source: Reproduced by kind permission of Alan Hall.
• is based on the occlusion between the first permanent molar teeth, which erupt when
the patient is about 6 years old.
There are three classes:
• class I: this is near to the correct relationship
• class II: this is at least half a cusp width behind the ideal relationship
• class III: this is at least half a cusp width in front of the ideal relationship (Figure 1.9).
THE MIXED DENTITION

Sometimes parents see their child’s perfectly straight deciduous teeth fall out only to be
replaced by a ‘jumble’ of crowded permanent teeth. This often prompts them to want early
treatment because permanent teeth can look huge in little faces.
H y p o d o nt ia
Patients with hypodontia do not have the full complement of teeth. This can occur in the
deciduous and permanent dentition. In some cases, if it is just a single tooth, it is possible
to close the space orthodontically. If there are too many missing this may require a solu-
tion involving replacements such as bridges and implants, with orthodontic treatment
being used to position the teeth in the correct spaces (Figure 1.10).
The average times for permanent tooth eruption are as follows.
• age 6
• 1/1 lower central incisors
• 6/6 lower first molars
• 6/6 upper first molars
• age 7
• 1/1 upper central incisors
• 2/2 lower lateral incisors
• age 8
• 2/2 upper lateral incisors
• age 11
• 3/3 lower canines (cuspids)
• 4/4 lower first premolars (bicuspids)
• 4/4 upper first premolars (bicuspids)
• age 12
• 3/3 upper canines (cuspids)
• 5/5 lower second premolars (bicuspids)
• 5/5 upper second premolars (bicuspids)
• 7/7 upper second molars
• 7/7 lower second molars
Figure 1.10 Hypodontia. Source: Reproduced by kind

• age 18–25
• 8/8 upper third molars (wisdom teeth)
• 8/8 lower third molars (wisdom teeth).
Normally, patients begin orthodontic treatment between the ages of 10 and 13 years old.
At 10–11 years they are still in the mixed dentition, with
• some deciduous teeth
• some permanent teeth
• some teeth yet to erupt.
INDICATIONS FOR TREATMENT
Clinical indications for orthodontic treatment may be because the teeth:

• are overcrowded
• may have erupted out of position
• are protruding (Class II/l)
• exhibit reverse bite
• exhibit self‐damaging bite (Figure 1.11)
• are spaced
• are absent (hypodontia)
• are damaged.
Mild malocclusions, for example:
• with only very small irregularities
• where the tooth position does not compromise oral hygiene
• which do not interfere with function, such as biting off food and eating,
may not be merit orthodontic treatment, as it may not be seen to significantly improve
dental health.
However, some presentations, for example:
• with overcrowded, protruding teeth
• with rotated teeth that make oral hygiene difficult and cause problems with caries
• which visually deviate from average, e.g. a reverse bite
Figure 1.11 Lower incisor trapped outside the bite.

Figure 1.12 Scissors bite. Source: Reproduced by kind

• which look unattractive and affect the smile

• which seriously affect function, e.g. make chewing food difficult,
are classed as malocclusions warranting treatment.
S c i sso rs b it e
This is a lingual crossbite, where the buccal cusps of the lower premolars and molars
occlude palatal to their opposing upper tooth (Figure 1.12).
UNDERLYING CAUSES OF MALOCCLUSION OF THE TEETH
There may also be:

• underlying skeletal abnormalities
• facial asymmetries.
These can be:
• hereditary (e.g. tendency to being Class III)
• a result of injury
• a result of illness affecting facial or skeletal growth
• a result of a syndrome or cleft.
These may require orthodontic treatment as part of a multidisciplinary care treatment
pathway.
Mu lt id iscip lin ar y approac h

In cases requiring a multidisciplinary approach, patients receive their orthodontic treat-
ment in co-ordination with other specialties.
These specialties include:
• restorative (e.g. hypodontia patients requiring implants/bridges or microdontia
patients needing veneers or crowns)
• surgical (e.g. patients needing an osteotomy)
• cleft (e.g. patients requiring alveolar bone grafting).
PROBLEMS WHEN THE ARCH IS NOT INTACT
One of the aims of orthodontic treatment is to have each tooth in its correct place within
the dental arch.
If a tooth is malaligned (out of its correct position), it is not necessarily an isolated
problem – it has a ‘domino’ effect. The teeth either side of it may also be out of their cor-
rect position and the opposing tooth does not have the correct occlusion.
If there is no tooth to oppose it, a tooth may supra‐erupt. Contact points are lost, teeth
rotate and, because they are no longer self‐cleansing, food traps are created where fibres
can get lodged or packed. As a consequence of this, plaque is encouraged to accumulate,
which in turn:
• inflames the gingivae
• encourages periodontal pockets.
In the young patient this is not too drastic, as it probably has not yet become a significant
issue.
In adult patients, however, following orthodontic treatment it may be necessary to
restore incisal edges or fill cervical abrasion cavities, which only become apparent when
the teeth have been corrected.
BRUXISM
• young patients, towards the end of the deciduous dentition, can often present with
teeth almost ground down to gingival level. It may continue into the mixed dentition
and is often quite noisy and noticeable when it occurs in sleep.
• for some older patients with severe bruxism, an occlusal guard can be made to be
worn at night during sleep. This attempts to limit the damage that is done to the
incisal and occlusal surfaces of the teeth.
• anxious patients also grind and clench their teeth during the day when under stress.
Patients often also clench their teeth when doing weight training at the gym.
DIGIT SUCKING
Some patients continue to suck their fingers or thumbs well beyond the age when their
deciduous teeth have been replaced by their permanent successors. A prolonged habit is
one which exists until the age of 7 years.
It may adversely affect the bite and position of the anterior teeth and can produce:
• a unilateral buccal crossbite
• an asymmetrical anterior open bite where the finger or thumb enters the mouth (Figure 1.13)
• an increased overjet.
Figure 1.13 Anterior open bite due to digit sucking.

Figure 1.14 Leaflet on digit sucking. Source: Reproduced by kind

permission of British Orthodontic Society.
How much damage is caused depends on how long, and how frequently, the thumb or
finger is sucked and how strong the habit is (i.e. occurs not just when alone going to sleep
but also during the day when tired, bored or stressed).
These patients try really hard to break this habit but sometimes they need a bit of help
(Figure 1.14). It is possible to fit a removable upper anti‐habit appliance, which has prongs
in the centre of the palate that act as a positive deterrent for the thumb or finger. This is
worn full time or only when the individual is asleep.
Once the habit is broken, the problem is often solved. However, some patients
experience strong emotional comfort from digit sucking and this compulsion may
need to be assessed in detail. An image of an anti‐habit device is provided in
Chapter 7.
DENTAL HEALTH
Some problems are caused by:

• diet (too much sugary or acidic food or drink, causing dental caries)
• tooth brushing (the wrong technique, too hard a brush)
• acid reflux (a symptom of bulimia in anorexic patients)
• medication (side effect of some medication inhalers).
Damage to teeth resulting in tooth surface loss comes under the following general
headings:
• attrition: bruxism (patients who grind their teeth, often during sleep)
• abrasion: excessive wear (e.g. overenthusiastic tooth brushing)
• erosion: of the enamel by acid, found in fresh fruit juice, diet drinks and stomach acid
(found in reflux)
• abfraction: a tooth being ‘high on the bite’ and being overloaded.
Charting of teeth is an area you all know well, and follows the standard numbering com-
monly used in the UK.
Permanent dentition (as the clinician looks at the patient)
Upper right upper left

87654321 12345678
Lower right lower left
87654321 12345678
Deciduous dentition (as the clinician looks at the patient)
edcba abcde
edcba abcde
There are other methods of tooth numbering, of which the World Dental Federation (FDI)
and the universal numbering systems, are notable examples. Sometimes you may receive
transfer cases which use an alternative method to the one you are used to, so it is good to
know the alternatives.
The FDI code is one most commonly used and it uses the existing numbers but just adds
an extra number:
• upper right is 1, so upper right canine would be 13
• upper left is 2, so upper left lateral would be 22
• lower left is 3, so lower left wisdom tooth would be 38

• lower right is 4, so lower right first premolar would be 44.
And in the deciduous dentition

• upper right is 5, so upper right lateral is 52
• upper left is 6, so upper left canine is 63
• lower left is 7, so lower left central 71
• lower right is 8, so first lower right molar is 84.
CONDITION OF THE SURROUNDING SOFT TISSUES
L ip s
• competent: when they are at rest and come together easily and form a good oral
seal.
• incompetent: when at rest do not close, or if they are closed, the lips are strained,
often as a result of posturing. This closure is only temporary.
To ngu e
• the tongue works with the lower lip to form a seal when swallowing.
• a tongue which tends to thrust can push forward and ‘splay’ the front teeth out.
The position of the teeth and the form of the dental arches are determined by the balance
of the soft tissues between tongue and lips/cheek. If the tongue’s free movement is restricted,
when the lingual frenum is attached too far forward on the tongue, this interferes with,
and restricts, function and is called a tongue tie. It can also interfere with speech, hence the
expression ‘to be tongue tied’ (Figure 1.15).
Figure 1.15 Tongue tie. Source: Reproduced by kind

Chapter 2
The first appointment
Orthodontic patients are usually referred by their own dentist (their general dental practitioner)
for specialist orthodontic treatment.
These referrals can be sent to:
• an orthodontic specialist practitioner
• a community orthodontist
• a consultant orthodontist
• a GDP with enhanced skills.
Some adult patients may choose to self‐refer.
The referring dentist may wish to send the patient to an orthodontist to:
• see and advise
• if there are teeth that are slow to erupt
• if there are teeth that have submerged
• if there are teeth in a self‐damaging position
• see and monitor
• if the patient is dentally too young for treatment
• if there are already signs of adverse dental development, i.e. growth, facial asymmetry
or crowding
• see and treat
• if the second dentition has developed but is overcrowded
• if there is a complex problem
• if there is a multidisciplinary need.
The referral letter needs to contain as much relevant information for the orthodontic
practitioner as possible.
Apart from basic personal data, such as:
• name
• address
• telephone numbers (land, mobile, work, etc.)
• date of birth
• National Health number (if relevant)
Basic Guide to Orthodontic Dental Nursing, Second Edition. Fiona Grist.

© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
• name of GP (doctor)
• name of GDP (dentist),.
it also needs to give:
• clinical reason for referral (what the dentist feels is the problem)
• medical history (if it is helpful to know in advance, e.g. attention deficit hyperactivity
disorder, autism, deafness, dental phobia)
• dental history (good oral hygiene, high caries level, etc.)
• any previous orthodontic history (e.g. previous assessment or treatment)
• social history (e.g. supportive family, regular check‐ups)
• what concerns the patient/parent (‘fangs’, teasing)
• whether the patient is bothered at all (quite happy to stay as they are)
• likely compliance (supportive family, the patient is keen).
When the referral letter is received, the patient (or their parent or guardian if they are
under age) is sent an appointment.
On the first visit a full orthodontic assessment is carried out (Figures 2.1 and 2.2). This
includes:
• checking the name and age of the patient
• what is of concern to the patient
• full medical history, including whether the patient
• has any known allergies (nickel, latex, etc.)
• is currently under the care of a doctor for any reason
• has had any operations
• is taking medication of any kind
• has asthma; if so, which type of inhalers
• has diabetes
• has or had chest or heart conditions.
Patients and/or parents are also asked to fill in and sign a health questionnaire. This
should be updated and checked regularly.
This also contains details of:
• school or college (day or boarding)
• work
• contact sports
• musical instruments played by mouth
• any digit (thumb or finger) sucking, bruxism (tooth clenching or grinding)
• lip, cheek or tongue jewellery, e.g. studs
• any known allergies, e.g. latex, nickel.
THE CLINICAL ASSESSMENT RECORDS
These begin with extra‐oral features and then move on to intra‐oral ones.
The first appointment 15
/ /
NAME
D of B
REF/GDP
SKEL PATT

FM ANGLE
HABITS/MUSIC/SPORTS
ASYMMETRY
INCS REL CL 1 CL11/1 CL2/2 type CL111
OVERJET normal increased (mm) reduced e/e reversed
OVERBITE norm increased reduced e/e open (mm)

complete complete to palate incomplete traumatic
UPPER INCS average proclined retro sl crowded sl spaced CL L/R

diastema (mm) infra-occl fractures rotations
UPPER CANINES average mesial distal buccal palatal high

unerupted palpable/not palpable
LOWER INCS average proclined retro sl crowded sl spaced

sup erupted infra occl CL L/R
LOWER CANINES average mesial distal lingual erupting unerupted
MOLAR REL right left
CROSS/SCISSOR BITE left / right displacement init contact on
GEN DENTAL CONDITION

CARIES
GINGIVA
OPT supplied by GDP dated

form given to patient for Worthing Hospital films
T
TREATMENT PLAN
Figure 2.1 Sample of assessment form from a specialist orthodontic practice. Source: Reproduced by kind
permission of Alan Hall.
S ke le t a l p a ttern
The maxilla to mandible relationship in the antero‐posterior plane:
• class I
• class II
• class III
• mild
• moderate
• severe.
ORTHODONTIC CONSULTATION -
Patient Details Age: years months Medical History Dental History
Complaint Social Details
Skeletal Pattern
AP 1 2 3 Vertical ↑ ↓ Average Lateral Asymmetry Yes No
Soft Tissue Pattern
Lips Competent Incompetent Lip Line High Low Average Habit Yes No
Teeth Present Missing Teeth
Tooth Quality Oral Hygiene Caries/Decalcification
Good Fair Poor Good Fair Poor

Lower Labial Segment
Mild Mod Severe Mild Mod Severe
Aligned Crowded Spaced Proclined Retroclined Average CL L R Centre

Upper Labial Segment
Mild Mod Severe Mild Mod Severe
Aligned Crowded Spaced Proclined Retroclined Average CL L R Centre

Lower Buccal Segments Aligned Crowded Spaced
Upper Buccal Segments Aligned Crowded Spaced
In Occlusion OJ ↑ ↓ Average mm
OB ↑ ↓ Average Complete Incomplete
I II III 1 1 3 1
Molar Relationship Right
4 2 4
Molar Relationship Left I II III 1 1 3 1
4 2 4
Incisor Relationship I II/i II/ii III
Crossbites Yes No Displacement Yes No
Figure 2.2 Sample of assessment form from a hospital orthodontic department. Source: Reproduced by kind
permission of Jo Clark.
FM (Fra nk for t–m an dibular) ang l e (F i g ur e 2 .3 )

• high
• average
• low.

A symme t r y
• this is usually mandibular.
S oft t issu e s
Lips
• line (if high, is there a ‘gummy’ smile)
• competency (do they close when resting)
• expressive behaviour
• if lower lip is behind upper incisors.
(This is the end of the extra‐oral examination.)
Sella-nasion plane
Frankfort plane
Maxillary plane
Occlusal plane
Aesthetic plane
Mandibular plane
Figure 2.3 Drawing showing relation of FM angle. Source: Reproduced by kind permission of Alan Hall.
Tongue
• size
• position in mouth
• swallowing behaviour
• presence of a tongue tie.
Tonsils
• if there is a history of difficulties in breathing through the nose, snoring or repeated
sore throats.
Frenum
• upper
• lower.
G i ngiv a e a nd oral h y gien e

• health of the gums
• presence of plaque.
C h ar t ing o f th e teeth
• present
• absent (unerupted or extracted)
• presence of caries/restorations/fissure sealant
• erosion
• enamel hypomineralisation
• hypoplasia
• size discrepancy:
• microdont, small tooth (microdontia)
• megadont, large tooth (megadontia)
• supernumeraries, i.e. teeth which are additional to the norm:
• most often found in the anterior maxilla
• can be conical, supplemental or tuberculate.
I n c iso r re la t ion ship ( F igure 2.4 )

• class I
• class II/1
• class II/2
• class III.
O v e rje t
Horizontal measurement between upper and lower incisors:
• normal (3 mm)
• increased (record the measurement in millimetres)
• edge to edge
• reversed.

Class I Class II/1 Class II/2 Class III
Figure 2.4 Diagram of incisor relationship. Source: Reproduced by kind permission of Alan Hall.
O v e rb it e
Upper incisors overlapping lowers in vertical plane:
• normal
• increased
• reduced
• edge to edge
• open (record the measurement in millimetres)
• complete
• complete to palate
• incomplete
• traumatic.
U p p e r a nd l ow er in c isors
• average inclination
• proclined
• retroclined
• crowded
• rotations
• spaced
• diastema (record space in millimetres)
• centreline
• infra‐occluded
• supra‐erupted
• any fractures/restorations
• any abnormal mobility
• mesial or distal
• buccal or palatal.
U p p e r ca nines
• high
• unerupted but palpable
• unerupted but not palpable
• mesial or distal
• buccal or palatal.
L o w e r ca nin es
• mesial
• distal
• buccal
• lingual
• erupting
• unerupted.
Mo la r re la t ionsh ip ( buc c al segm e nt o c c l usi o n)

( F i gu re 2. 5)
• class I
• ½ unit class II
• class II
• class III.
C rossb it e
• localised
• unilateral (arch widths do not match one side)
• bilateral (arch widths do not match both sides).
S c i sso rs b it e
• lingual crossbite of lower teeth.

Class I ½ unit Class II Class III
Class II
Figure 2.5 Diagram of buccal segment occlusion. Source: Reproduced by kind permission of Alan Hall.
O p e n b it e
• anterior
• posterior
• lateral.
D isp la ce me nt of m an dible w h e n c l o si ng
• left
• right
• anterior
• initial contacts.
NB This distinguishes the term from displacement of teeth in the Index of Orthodontic
Treatment Need (IOTN).
Note must also be made of:
• submergence (teeth that have ‘sunk’ down back into the gum)
• impactions
• damaged teeth (e.g. repaired/unrepaired, root filled or ankylosed)
• teeth with a poor‐quality long‐term outlook (e.g. heavily filled or hypoplastic)
• any transpositions (teeth in exchanged positions, e.g. a canine mesial to a lateral)
• any other anomalies.
There is a ‘benchmark’ to achieving the ideal occlusion known as the six Andrews’ keys,
comprising:
• class I molars
• correct incisor inclination
• correct tip
• no spaces
• no rotations
• flat curve of Spee.
It is important at this stage to discuss with the patient exactly what they feel is wrong
and what they are hoping to achieve. Sometimes a patient comes in with a very obvious
orthodontic problem which would seem to members of the clinical team to be their main
concern. However, this may not be the case. Their worry can be a relatively mild problem
but to the patient this may be what they want to have changed.
It may also be that what the patient is asking is just not feasible and if this is the case
the patient must be advised accordingly. In order to give informed Consent the patient
and/or their parent or guardian must fully appreciate the advantages and disadvantages of
treatment, all the options possible, and even that the problem cannot be resolved to the
extent to which they hoped.
RADIOGRAPHS
If the orthodontist wants to further assess the patient, then radiographs are needed. These
are an invaluable diagnostic tool when formulating a treatment plan.
The two formats most routinely used in orthodontic assessment are the orthopantomogram
(OPT) and the lateral cephalometric radiograph.
The orthopantomogram (Figure 2.6)
This is an extra‐oral radiograph that:
• is a panoramic view of both the maxilla and mandible
• shows all the underlying skeletal structures, including:
• temporo‐mandibular joints (TMJs)
• position of the condyles (head of the rami)
• level of alveolar bone (in older patients there can be bone loss)
• sinuses
• position of dental nerve canals (e.g. inferior dental nerve)
• any cysts
• radiolucencies.
• also shows the dental features:
• position of the teeth
• any unerupted or impacted teeth
Figure 2.6 Example of OPT radiograph. Source:

Reproduced by kind permission of Jonathan Sandler.
• any ectopic teeth (teeth that have developed and erupted or not erupted in their
correct position)
• supernumerary teeth
• any anomalies of the teeth (e.g. fusing of roots)
• presence of third molars

• indicate the condition of any teeth that may have cavities or deep restorations
(these may influence any decision on the possible need for extractions).
NB OPTs are not taken to show caries but often do. Bite‐wing radiographs are needed if
there is concern regarding cavities.
The lateral cephalometric radiograph (Figure 2.7) is an extra oral radiograph that:
• shows a true lateral image of the skull and face
• shows angulation of incisor teeth
• is used to monitor skeletal growth, e.g. if the mandible is developing adverse forward
growth (Class III)
• may be used to carry out cephalometric tracings for surgical planning in cases with
severe skeletal disproportion.
Tracings can now be done using computer software rather than being drawn by hand.
Other radiographs used for diagnosis and treatment in orthodontics include:
• upper occlusals (used if the OPT is not clear in the upper incisor region)
• upper lateral occlusals
• peri‐apicals
• postero‐anterior (PA) skull.
Figure 2.7 Example of cephalometric radiograph.

Source: Reproduced by kind permission of Jonathan Sandler.
The use of cone beam computed tomography, more routinely called cone beam CT, is
becoming more widespread for orthodontic use (see Chapter 16 for examples). There is
also the opportunity to take three‐dimensional radiographs known as computed axial
tomography scans, which can assist in producing computer‐aided design/computer‐aided
manufacturing (CAD/CAM) models of the skull, maxilla and mandible, and three‐dimen-
sional facial soft tissue scans. These are often taken in conjunction with planning for
orthognathic surgery and records.
Following clinical assessment and using the OPT and lateral skull radiograph, if
required, the orthodontist can then formulate the treatment plan.
It is important to establish why the patient is seeking treatment as this will influence
their keenness and compliance.
• are they themselves motivated (they want it for themselves)?
• are they being told they need it (they are trying to please someone else)?
With the X‐ray films in hand, the orthodontist can then ask the patient and parent if they
have any questions. These may include:
• the aim of orthodontic treatment
• how it is to be achieved
• what the treatment involves
• the best time for treatment to be done
• whether it is better to do the treatment in stages
• duration of treatment once started
• how many weeks between the appointments
• need for extractions as part of the treatment
• which appliance or sequence of appliances will be needed
• whether treatment will be painful or uncomfortable
• what type of retention will be needed and for how long it will need to be worn
• whether it will be possible to play sport (e.g. whether a mouthguard can be worn with
a brace)
• whether it is possible to continue to play musical instruments by mouth (e.g. flute).
PHOTOGRAPHS
Photographs must only be taken with prior written consent from the patient or their par-
ent/guardian. Patients can change their minds and remove consent at any time and they
can also ask for a copy of the photographs taken.
The photographs can be taken in two ways:
• using a clinical camera with ring flash with details recorded in the patient’s records
and a photographic log book
• using a clinical camera with ring flash, with details recorded in the patient’s records
and the images stored and accessed on the computer.
Photographs must never be taken using a mobile phone or similar device.
If photographs are stored as a hard copy, they must be filed in either the patient’s notes
or hanging photo files. Photographs, like radiographs, are part of the patient’s records. In
either hard copy or digital format, these must be of good quality as they form part of the
written clinical record. Clinical governance and good practice require that they must be
stored securely to comply with current legislation concerning data protection. Everyone

must comply with the current legislation concerning data protection regardless of where
you work. Should guidance be needed, practices come under the Information Commissioners
Office while hospital trusts will have their own data protection officers. There are strict
protocols in place for the safe storage of images. A digital image can be enhanced when
displayed on the computer screen but the original image must always be retained. Please
see Chapter 23 for further information on encryption, etc.
The taking of photographs usually follows an established procedure that involves:
• a set position of each view required both intra‐ and extra‐orally
• the number of photographs taken
• the same camera and background
• the same angles.
This ensures standardisation of all images taken.
Photographs should include extra‐oral views, including facial views and profiles, and
intra‐oral views, using lip retractors. If there are any unusual areas of specific interest (e.g.
traumatic bite), these must also be taken using photographic mouth mirrors.
Photographs are subsequently taken at the end of each stage of treatment, for example
after rapid maxillary expansion and functional appliance therapy and then at the end of
treatment. If the patient is undergoing orthognathic surgery, then more photographs are
needed to record clinical changes and progress.
Some clinicians have access to a photographer, some take them themselves but the
majority of orthodontic nurses are excellent photographers.
RISKS OF ORTHODONTIC TREATMENT
When assessing treatment options and the benefits that treatment will bring, the ortho-
dontist will also advise the patient and parent/guardian of any possible risks that might
occur. These risk factors are present in a minority of cases and some can easily be avoided
(Figures 2.8 and 2.9).
D e ca lcifica tion
Patients with poor oral hygiene can develop inflamed and unhealthy gums and may not be
accepted for treatment. Patients who do not comply with oral hygiene instructions may
experience decalcification/caries as a result of poor brushing, eating sweets and drinking
fizzy drinks. The end result may be damaged teeth. In these cases the use of fluoride tooth-
pastes and mouthwashes and mousse must be encouraged.
Failure to comply with oral hygiene may result in the early termination of treatment.
Figure 2.8 Leaflet on risks of orthodontic treatment.

Source: Reproduced by kind permission of British
Orthodontic Society.
Re so rp t io n
Sometimes, end‐of‐treatment radiographs show that there has been slight shortening of
the roots on some teeth. This resorption happens during tooth movement. It is monitored
and is rarely of significance but both patient and dentist need to be aware if it is significant
for future dental reference. Teeth which have been previously damaged and teeth with thin
roots are more prone to severe root resorption (Figure 2.10).
Re la p se
This is the name given to tooth movement after completion of orthodontic treatment.
Relapse can be caused by adverse growth or failure to comply with retainer wear.
P at ie nt d issatisfac tion
The patient feels that the aims and objectives set out during discussion of treatment were,
in their opinion, not met.
(a) (b)

Figure 2.9 Am I sure? Source: Reproduced by kind permission of Ortho‐Care (UK) Ltd.
Figure 2.10 Radiograph showing resorption.

Source: Reproduced by kind permission of
Jonathan Sandler.
DISCUSSION AND CONSENT
Patients often have lots of questions and the orthodontic nurse is frequently the person
they ask. It is at this time that the relationship starts to build between them. The nurse will
get to know the patient over the course of the many visits and various procedures, and a
friendly relaxed relationship will help to encourage their motivation and compliance. It is
important that, as much as possible, the patient enjoys contributing and feeling part of
their orthodontic journey.
It is important to remember that any baseline records taken:
• are legal documents
• help in diagnosis and treatment planning
• are needed for monitoring and scoring occlusal indices
• are needed for case presentations.
At a subsequent appointment the orthodontist, having looked at the models and radio-
graphs, will formulate a treatment plan and then discuss this with the patient and their
parent/or guardian and obtain informed consent.
If the patient is under the legal age of consent, then their parent or guardian usually
gives informed consent. However, if the patient has full understanding of the proposed
procedures, then they can consent themselves even if they are under 16 years of age
(Figures 2.11 and 2.12).
Information leaflets may be given at this stage to be taken home and read.
TAKING BASELINE RECORDS
On the first appointment for treatment, the nurse needs to prepare:

• the patient’s clinical notes
• mouth mirror
• probe
• orthodontic ruler (Figure 2.13)
• hand mirror
• alginate, bowls and a spatula (vinyl polysiloxane can be used, but less likely when
taking study models)
• impression trays
• wax (and bite registration recorder if used)
• wax knife
• method of softening wax (e.g. flame, blowtorch, hot water)
• glass of mouthwash and tissues
• laboratory sheet with instructions for technician
• solution to disinfect impressions
• camera (ring flash and digital)
• lip retractors (Figure 2.14)
• photographic mouth mirrors (Figure 2.15), if to be used
Unit No: ..................................................
NHS No: .................................................
Name: ....................................................

CONSENT FOR AN INDIVIDUAL COURSE OF ORTHODONTIC TREATMENT
Treatment plan:
Benefits of treatment:
Risks of treatment (please see overleaf for more details):
Permanent marks on teeth if not kept clean during treatment
Shortening of the roots of teeth- occasionally this may be severe leading to tooth mobility or loss
Discomfort
Accidental swallowing of parts of brace requiring medical intervention
Damage to nerve supply/ blood supply to individual teeth requiring root canal treatment
Tooth movement after treatment if retainers not wom as advised
Gum recession
Other risks: ....................................................................................................

..........................................................................................................................................................
..........................................................................................................................................................
Patients should continue to see their family dentist for routine dental care during their orthodontic treatment
Information leaflets about orthodontic treatment have been provided as listed overleaf
Patient (or parent/ legal gardian) Clinician
Signed .............................................. Signed ..............................................
Print .................................................. Print ..................................................
Date .................................................. Date ..................................................
Copy given to patient/ parent of legal guardian
Figure 2.11 Consent forms giving consent to orthodontic treatment. Source: Reproduced by kind permission
of Jo Clark.
Information leaflets given:
Keeping teeth and gums healthy (British Orthodontic Society)
Fixed appliances (British Orthodontic Society)
Removable appliances (British Orthodontic Society)

Risks of treatment (British Orthodontic Society)
Retainers (British Orthodontic Society)
Functional appliances (British Orthodontic Society)
Impacted canines (British Orthodontic Society)
Brace - friendly food and drink (British Orthodontic Society)
Interproximal reduction (British Orthodontic Society)
Care of fixed appliances (Tepe)
Other .............................................................................................
Further information
Toothbrushing
It is essential that the teeth are kept clean and that the gums stay healthy during treatment. If toothbrushing
is not kept up to standard during treatment, especially during fixed brace (train track) treatment, teeth can
be permanently damaged leaving white or brown marks and possibly cavities where the brace has been. If
toothbrushing is not kept up to standard during treatment then your orthodontist may advice that the brace
should be removed before the teeth have been completely straightened.
Risks
1. Teeth can be damaged if toothbrushing is not up to standard (as above). A letter will be sent to you
detailing how to keep your teeth and gums healthy after fixed braces are fitted
2. Discomfort: braces can be uncomfortable and your orthodontist will advice you about how to manage this
eg. with painkillers and eating soft foods
3. Shortening of the teeth roots: The roots of the teeth will shorten as they are moved during treatment.
This usually does not give problems but in a small percentage of patients it may be more severe and can
lead to tooth mobility and loss. This cannot always be predicted but some people may be more susceptible
and your orthodontist will discuss this you if they think you may be at increased risk.
4. Relapse: teeth will tend to move after treatment if retainers aren’t worn as advised
Length of treatment
Your orthodontist will advice you about the likely length of treatment. Your treatment time will extend if your
brace is broken frequently or if you miss your booked appoitments
Frequency of appointments
The teeth and braces need to be checked/ adjusted regularly (usually every 4-8 weeks). We cannot always
guarantee appointments after school.
Failed and cancelled appointments

Poor or irregular attendance may lengthen the treatment and lead to a poorer result. If you need to change
or cancel an appointment, please telephone xxxxxxxx
Stability of the treatment result

Most patients will be required to wear removable retainers part-time on a lifelong basis. Without retainers,
teeth will tend to move. We will monitor your retainers for the first year after braces are removed. After this,
we will write to your dentist to ask them to monitor your retainers. Your dentist will charge for new retainers
when your retainers need replacement.
Figure 2.11 (Continued )

Unit No: ........................................................
NHS No: ........................................................ Orthodontic Department

Clinical
Surname: ........................................................
Photography/dental models

Forenames: ........................................................ Consent Form
This form is to be used to gain consent for taking pictures or making models of your teeth to
enable clinical staff to assess your teeth and bite, monitor treatment progression and assess
the outcome of your orthodontic treatment. These images/ dental models may be used for
teaching purposes with your consent.
PATIENT SECTION
To comply with the Data Protection Act 2018, we need your permission before we take any
photographs of you. Your health professional will have explained why they need to do this to
best meet your health needs. If you have any further questions, please ask your health
professional.
You have the right to change your mind at any time, including after you have signed this
form.
PATIENT AGREEMENT
I understand the benefits and risks as described to me by my health professional.
I understand the recorded information will be used to support my (my child’s)’ treatment and
I consent to the images/recordings being taken and stored safety with (my child’s) health
records.
I do/do not* give consent for these images (photos)/ dental models to be used for teaching
purposes.
* delete as relevant
Name ...................................................................................................
Signature ...................................................................................................
Date ...................................................................................................
Full name of legal guardian if a child ...................................................................................................
Version 15.9.2018
Figure 2.12 Consent form giving consent to having dental photography. Source: Reproduced by kind
permission of Jo Clark.
Figure 2.13 Orthodontic ruler. Source:

Reproduced by kind permission of
Ortho‐Care (UK) Ltd.
Figure 2.14 Lip retractors. Source: Reproduced by kind

permission of TOC.
Figure 2.15 Photographic mouth mirrors. Source:

Reproduced by kind permission of Ortho‐Care (UK) Ltd.
• information leaflets for the patient

• oral hygiene instruction leaflet for the patient.
For the chairside procedure, the nurse ensures that:
• the patient and staff wear personal protection
• the patient is seated comfortably
• a wax squash bite is taken to record the occlusion
• upper and lower alginate impressions are taken
• after disinfection, both impressions and bite are taken to the technician with
instructions
• patient photographs are taken using lip and cheek retractors and photographic mirrors
where appropriate.
These photographic views should include:

• intra‐oral:
• left lateral
• centric

• right lateral
• profile or lateral incisor view
• extra‐oral:
• full face (smiling)
• full face (not smiling)
• three‐quarter view
• profile (not smiling).
The nurse then:
• gives the patient a leaflet on proposed treatment
• answers any further questions
• ensures that the patient has the correct series of appointments booked.
Patients benefit from being given leaflets on their proposed treatment and on oral hygiene
at this appointment because it gives them an opportunity to spend some time reading them
before their next ‘fitting’ appointment. They can then get an idea of what will be happening
when they come to start treatment.
ORTHODONTIC MODELS
Orthodontic study models can be obtained by taking either:

• alginate impressions, or
• a digital recording.
If the former, the study models must be boxed and a record made of the identification
number and the patient’s name. If the latter, then the scan must be securely stored on a
computer system (Chapter 23 covers the storage of records in detail).
NB Orthodontic study models are reproductions of the dental arches and how they
occlude together as they were on the day they were taken, and must always be marked
with the patient’s name and date when taken.
They are trimmed in a specific way, known as Angle’s trimming. The upper model base
does not have a rounded front, but is ‘pointed’ and angled. The lower model does have a
rounded front (Figure 2.16).
Also, when the upper and lower models are trimmed together with the wax bite between
them, it should be possible to:
• lay them on their backs or ‘heels’ (i.e. with the front teeth facing you) on a flat surface
• pick them up in the same position that you put them down
• make them stand without rocking and the teeth should stay together in the correct
occlusion.
Figure 2.16 Example of trimmed orthodontic models.

Where records are taken digitally, please refer to Chapter 23.

Depending on the treatment plan, the patient is now ready:
• for the active treatment to begin and for an appliance to be fitted, or
• to undergo a period of watchful waiting, usually when there is a need to monitor
adverse growth.
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probable that the system was perfected, perhaps several centuries
earlier, by a wealthier and more important people, one more in
contact with foreign nations, such as the Phœnicians, and that from
them it spread to their neighbors, the Hebrews, Moabites, and
Aramæans of Syria. This spread must have been facilitated by the
close kinship of the speech of these nations, enabling any of them to
adopt the alphabet of another without material modification.
The Phœnicians founded Carthage, and consequently the
Carthaginian or Punic writing until after the extinction of the great
trading city was also Phœnician.
135. The Greek Alphabet: Invention of the

Vowels
More important was the spread of the Phœnician letters to an
entirely foreign people, the Greeks, whose language was largely
composed of different sounds and possessed a genius distinct from
that of the Semitic tongues. The Greeks’ own traditions attest that
they took over their alphabet from the Phœnicians. The fact of the
transmission is corroborated by the form of the letters and by their
order in the alphabet. It is also proved very prettily by the names of
the letters. As we speak of the ABC, the Greeks spoke of the Alpha
Beta—whence our word “alphabet.” Now “alpha” and “beta” mean
nothing in Greek. They are obviously foreign names. In the Semitic
languages, however, similar names, Aleph and Beth, were used for
the same letters A and B, and meant respectively “ox” and “house.”
Evidently these names were applied by the Semites because they
employed the picture of an ox head to represent the first sound in the
word Aleph, and the representation of a house to represent the
sound of B in Beth. Or possibly the letters originated in some other
way, and then, names for them being felt to be desirable, and the
shape of the first rudely suggesting the outline of an ox’s head and
the second a house, these names were applied to the characters
already in use.
The third letter of the alphabet, corresponding in place to our C
and in sound to our G, the Greeks called Gamma, which is as
meaningless as their Alpha and Beta. It is their corruption of Semitic
Gimel, which means “camel” and may bear this name because of its
resemblance to the head and neck of a camel. The same sort of
correspondence can be traced through most of the remaining letters.
From these names alone, then, even if nothing else were known
about the early alphabets, it would be possible to prove the
correctness of the Greek legend that they derived their letters from
the Phœnicians. A people who themselves invented an alphabet
would obviously name the letters with words in their own language,
and not with meaningless syllables taken from a foreign speech.
The Greeks however did more than take over the alphabet from
the Phœnicians. They improved it. An outstanding peculiarity of
Semitic writing was that it dispensed with vowels. It represented the
consonants fully and accurately, in fact had carefully devised letters
for a number of breath and guttural sounds which European
languages either do not contain or generally neglect to recognize.
But, as if to compensate, the Semitic languages possess the
distinctive trait of a great variability of vowels. When a verb is
conjugated, when it is converted into a noun, and in other
circumstances, the vowels change, only the consonants remaining
the same, much as in English “sing” becomes “sang” in the past and
“goose” changes to “geese” in the plural. Only, in English such
changes are comparatively few, whereas in Semitic they are the
overwhelming rule and quite intricate. The result of this fluidity of the
vowels was that when the Semites invented their letters they
renounced the attempt to write the vowels. Apparently they felt the
consonants, the only permanent portions of their words, as a sort of
skeleton, sufficient for an unmistakable outline. So, with their
ordinary consonants, plus letters for J and V which at need could be
made to stand for I and U, and the consistent employment of breaths
and stops to indicate the presence or absence of vowels at the
beginning and end of words, they managed to make their writing
readily legible. It was as if we should write: ’n Gd w’ trst or Ths wy ’t.
Even to-day the Bible is written and read in the Jewish synagogue by
this vowelless system of three thousand years ago.
In the Greek language more confusion would have been caused
by this system. Moreover, the alphabet came to the Greeks as
something extraneous, so that they were not under the same
temptation as the Phœnicians to follow wholly in the footsteps of the
first generation of inventors. As a result, the Greeks took the novel
step of adding vowel letters.
It is significant that what the Greeks did was not to make the new
vowel signs out of whole cloth, as it were, out of nothing, but that
they followed the method which is characteristic of invention in
general. They took over the existing system, twisted and stretched it
as far as they could, and created outright only when they were
forced to. While the Phœnician alphabet lacked vowel signs, the
Greeks felt that it had a superfluity of signs for breaths and stops. So
they transformed the Semitic breaths and stops into vowels. Thus
they satisfied the needs of their language; and incidentally added the
capstone to the alphabet. It was the first time that a system of writing
had been brought on the complete basis of a letter for every sound.
All subsequent European alphabets are merely modifications of the
Greek one.
The first of the Semitic letters, the Aleph, stood for the glottal stop,
a check or closure of the glottis in which the vocal cords are situated;
a sound that occurs, although feebly, between the two o’s in
“coördinate” when one articulates distinctly. In the Semitic languages
this glottal stop is frequent, vigorous, and etymologically important,
wherefore the Semites treated it like any other consonant. The
Greeks gave it a new value, that of the vowel A. Similarly they
transformed the value of the symbols for two breath sounds, a mild
and a harsh H, into short and long E, which they called Epsilon and
Eta. Their O is made over from a Semitic guttural letter, while for I
the Semitic ambiguous J-I was ready to hand. U, written Y by the
Greeks, is a dissimilated variant of F, both being derived from
Semitic Vau or the sixth letter with the value of V or U. The vocalic
form was now put at the end of the alphabet, which previously had
ended with T. Its consonantal double, F, later went out of use in
Greek speech and was dropped from the alphabet.
136. Slowness of the Invention

The Greeks did not make these alterations of value all at once.
The value of several of the letters fluctuated in the different parts of
Greece for two or three centuries. In one city a certain value or form
of a letter would come into usage; in another, the same letter would
be shaped differently, or stand for a consonant instead of a vowel.
Thus the character H was long read by some of the Greeks as H, by
others as long E. This fact illustrates the principle that the Greek
alphabet was not an invention which leaped, complete and perfect,
out of the brain of an individual genius, as inventions do in film plays
and romantic novels, and as the popular mind, with its instinct for the
dramatic, likes to believe. One might imagine that with the basic plan
of the alphabet, and the majority of its symbols, provided ready-
made by the Phœnicians, it would have been a simple matter for a
single Greek to add the finishing touches and so shape his national
system of writing as it has come down to us. In fact, however, these
little finishing touches were several centuries in the making; the final
result was a compromise between all sorts of experiments and
beginnings. One can picture an entire nationality literally groping for
generation after generation, and only slowly settling on the ultimate
system. There must have been dozens of innovators who tried their
hand at a modification of the value or form of a letter.
Nor can it be denied that what was new in the Greek alphabet was
a true invention. The step of introducing full vowel characters was as
definitely original and almost as important as any new progress in
the history of civilization. Yet it is not even known who the first
individual was that tried to apply this idea. Tradition is silent on the
point. It is quite conceivable that the first writing of vowels may have
been independently attempted by a number of individuals in different
parts of Greece.
137. The Roman Alphabet

The Roman alphabet was derived from the Greek. But it is clear
that it was not taken from the Greek alphabet after this had reached
its final or classic form. If such had been the case, the Roman
letters, such as we still use them, would undoubtedly be more similar
to the Greek ones than they are, and certain discrepancies in the
values of the letters, as well as in their order, would not have
occurred. In the old days of writing, when a number of competing
forms of the alphabet still flourished in the several Greek cities, one
of these forms, developed at Chalcis on Eubœa and allied on the
whole to those of the Western Hellenic world, was carried to Italy.
There, after a further course of local diversification, one of its
subvarieties became fixed in the usage of the inhabitants of the city
of Rome. Now the Romans at this period still pronounced the sound
H, which later became feeble in the Latin tongue and finally died out.
On the other hand the distinction between short and long (or close
and open) E, which the Greeks after many experiments came to
recognize as important in their speech, was of no great moment in
Latin. The result was that whereas classic Greek turned both the
Semitic H’s into E’s, Latin accepted only the first of these
modifications, that one affecting the fifth letter of the alphabet,
whereas the other H, occupying the eighth place in the alphabetic
series, continued to be used by the Romans with approximately its
original Semitic value. This retention, however, was possible
because Greek writing was still in a transitional, vacillating stage
when it reached the Romans. The Western Greek form of the
alphabet that was carried to Italy was still using the eighth letter as
an H; so that the Romans were merely following their teachers. Had
they based their letters on the “classic” Greek alphabet which was
standardized a few hundred years later, the eighth as well as the fifth
letter would have come to them with its vowel value crystallized. In
that case the Romans would either have dispensed altogether with
writing H, or would have invented a totally new sign for it and
probably tacked it on to the end of the alphabet, as both they and the
Greeks did in the case of several other letters.
The net result is the curious one that whereas the Roman alphabet
is derived from the Greek, and therefore subsequent, it remains, in
this particular matter of the eighth letter, nearer to the original
Semitic alphabet.
There are other letters in the Roman alphabet which corroborate
the fact of its being modeled on a system of the period when Greek
writing still remained under the direct influence of Phœnician. The
Semitic languages possessed two K sounds, usually called Kaph
and Koph, or K and Q, of which the former was pronounced much
like our K and the latter farther back toward the throat. The Greeks
not having both these sounds kept the letter Kaph, which they called
Kappa, and gradually discarded Koph or Koppa. Yet before its
meaning had become entirely lost, they had carried it to Italy. There
the Romans seized upon it to designate a variety of K which the
Greek dialects did not possess, namely KW; which is of course the
phonetic value which the symbol Q still has in English. The Romans
were reasonable in this procedure, for in early Latin the Q was
produced with the extreme rear of the tongue, much like the original
Koph.
138. Letters as Numeral Signs

In later Greek, Koph remained only as a curious survival. Although
not used as a letter, it was a number symbol. None of the ancients
possessed pure numeral symbols of the type of our “Arabic” ones.
The Semites and the Greeks employed the letters of the alphabet for
this purpose, each letter having a numeral value dependent on its
place in the alphabet. Thus A stood for 1, B for 2, C or Gamma for 3,
F for 6, I for 10, K for 20 and so on. As this series became
established, Q as a numeral denoted 90; the Greeks, long after they
had ceased writing Q as a letter, used it with this arithmetical value.
Once it had acquired a place in the series, it would have been far too
confusing to drop. With Q omitted, R would have had to be shifted in
its value from 100 to 90. One man would have continued to use R
with its old value, while his more new-fashioned neighbor or son
would have written it to denote ten less. Arithmetic would have been
as thoroughly wrecked as if we should decide to drop out the figure 5
and write 6 whenever we meant 5, 7 to express 6, and so on. Habit
in such cases is insuperable. No matter how awkward an established
system becomes, it normally remains more practical to retain with its
deficiencies than to replace by a better scheme. The wrench and
cost of reformation are greater, or are felt to be greater by each
generation, than the advantages to be gained.
139. Reform in Institutions

This is one reason why radical changes are so difficult to bring
about in institutions. These are social and therefore in a sense
arbitrary. In mechanical or “practical” matters people adjust
themselves to the pressure of new conditions more quickly. If a
nation has been in the habit of wearing clothing of wool, and this
material becomes scarce and expensive, some attempt will indeed
be made to increase the supply of wool, but if production fails to
keep pace with the deficiency, cotton is substituted with little
reluctance. If, on the other hand, a calendar becomes antiquated,
which could be changed by a simple act of will, by the mere exercise
of community reason, a tremendous resistance is encountered. Time
and again nations have gone on with an antiquated or cumbersome
calendar long after any mediocre mathematician or astronomer could
have devised a better one. It is usually reserved for an autocratic
potentate of undisputed authority, a Cæsar or a Pope, or for a
cataclysm like the French and Russian revolutions, to institute the
needed reform. As long as men are concerned with their bodily
wants, those which they share with the lower animals, they appear
sensible and adaptable. In proportion however as the alleged
products of their intellects are involved, when one might most expect
foresight and reason and cool calculation to be influential, societies
seem swayed by a conservatism and stubbornness the strength of
which looms greater as we examine history more deeply.
Of course, each nation and generation regards itself as the one
exception. But irrationality is as easy to discern in modern institutions
as in ancient alphabets, if one has a mind to see it. Daylight saving is
an example very near home. For centuries the peoples of western
civilization have gradually got out of bed, breakfasted, worked,
dined, and gone to sleep later and later, until the middle of their
waking day came at about two or three o’clock instead of noon. The
beginning of the natural day was being spent in sleep, most
relaxation taken at night. This was not from deliberate preference,
but from a species of procrastination of which the majority were
unintentionally guilty. Finally the wastefulness of the condition
became evident. Every one was actually paying money for
illumination which enabled him to sit in a room while he might have
been amusing himself gratis outdoors. Really rational beings would
have changed their habits—blown the factory whistle at seven
instead of eight, opened the office at eight instead of nine, gone to
the theater at seven and to bed at ten. But the herd impulse was too
strong. The individual that departed from the custom of the mass
would have been made to suffer. The first theater opening at seven
would have played to empty chairs. The office closing at four would
have lost the business of the last hour of the day without
compensation from the empty hour prefixed at the beginning. The
only way out was for every one to agree to a self-imposed fiction. So
the nations that prided themselves most on their intelligence
solemnly enacted that all clocks be set ahead. Next morning, every
one had cheated himself into an hour of additional daylight, and the
illuminating plant out of an hour of revenue, without any one having
had to depart from established custom; which last was evidently the
course actually to be avoided at all hazards.
Of course, most individual men and women are neither idiotic nor
insane. The only conclusion is that as soon and as long as people
live in relations and act in groups, something wholly irrational is
imposed on them, something that is inherent in the very nature of
society and civilization. There appears to be little or nothing that the
individual can do in regard to this force except to refrain from adding
to its irrationality the delusion that it is rational.
140. The Sixth and Seventh Letters

The letters, such as Q, in which the Roman alphabet is in
agreement with the original Semitic one and differs from classic
Greek writing, might lead, if taken by themselves, to the conjecture
that the ancient Italians had perhaps not derived their alphabet via
the Greeks at all, but directly from the Phœnicians. But this
conclusion is untenable: first, because the forms of the earliest Latin
and Greek letters are on the whole more similar to each other than to
the contemporaneous Semitic forms; and second because of the
deviations from the Semitic prototype which the Latin and Greek
systems share with each other, as in the vowels.
The sixth letter of the Roman alphabet, F, the Semitic Waw or Vau,
is wanting in classic Greek, although retained in certain early and
provincial dialects. One of the brilliant discoveries of classical
philology was that the speech in which the Homeric poems were
originally composed still possessed this sound, numerous
irregularities of scansion being explainable only on the basis of its
original presence. The letter for it looked like two Greek G’s, one set
on top of the other. Hence, later when it had long gone out of use
except as a numeral, it was called Di-gamma or “double-G.”
The seventh Semitic letter, which in Greek finally became the sixth
on account of the loss of the Vau or Digamma, was Zayin, Greek
Zeta, our Z. This, in turn, the Romans omitted, because their
language lacked the sound. They filled its place with G, which in
Phœnician and Greek came in third position. The shift came about
thus. The earliest Italic writing followed the Semitic and Greek
original and had C, pronounced G, as its third letter. But in Etruscan
the sounds K and G were hardly distinguished. K therefore went out
of use; and the early Romans followed the precedent of their
cultured and influential Etruscan neighbors. For a time, therefore, the
single character C was employed for both G and K in Latin. Finally,
about the third century before Christ, a differentiation being found
desirable, the C was written as C when it stood for the “hard” or
voiceless sound K, but with a small stroke, as G, when it represented
the soft or voiced sound; and, the seventh place in the alphabet, that
of Z, being vacant, this modified character was inserted. Thus
original C, pronounced G, was split by the Latins into two similar
letters, one retaining the shape and place in the alphabet of Gimel-
Gamma, the other retaining the sound of Gamma but displacing
Zeta.
But the letter Z did not remain permanently eliminated from
western writing. As long as the Romans continued rude and self-
sufficient, they had no need of a character for a sound which they did
not speak. When they became powerful, expanded, touched Greek
civilization, and borrowed from this its literature, philosophy, and arts,
they took over also many Greek names and words. As Z occurred in
these, they adopted the character. Yet to have put it in its original
seventh place which was now occupied by G, would have disturbed
the position of the following letters. It was obviously more convenient
to hang this once rejected and now reinstated character on at the
end of the alphabet; and there it is now.
141. The Tail of the Alphabet

In fact, the last six letters of our alphabet are additions of this sort.
The original Semitic alphabet ended with T. U was differentiated by
the Greeks from F to provide for one of their vowel sounds. This
addition was made at an early enough period to be communicated to
the Romans. This nation wrote U both for the vowel U and the
consonantal or semi-vowel sound of our W. To be exact, they did not
write U at all, but what we should call V, pronouncing it sometimes U
and sometimes W. They spelled cvm, not cum.
Later, they added X. An old Semitic S-sound, in fifteenth place in
the alphabet and distinct from the S in twenty-first position which is
the original of our S, was used for both SS and KS. In classic Greek,
one form, with KS value, maintained itself in its original place. In
other early Græco-Italic alphabets, the second form, with SS value,
kept fifteenth place and the X or KS variant was put at the end, after
U. The SS letter later dropped out because it was not distinguished
in pronunciation from S.
The Y that follows X is intrinsically nothing but the U which the
Romans already had—a sort of double of it. The Greek U however
was pronounced differently from the Latin one—like French U or
German ü. The literary Roman felt that he could not adequately
represent it in Greek words by his own U. He therefore took over the
U as the Greeks wrote it—that is, a reduced V on top of a vertical
stroke. This character naturally came to be known as Greek U; and
in modern French Y is not simply called “Y,” as in English, but “Y-
grec,” that is, “Greek Y.”
With Z added to U (V), X, and Y, the ancient Roman alphabet was
completed.
Our modern Roman alphabet is however still fuller. The two values
which V had in Latin, that of the vowel U and the semi-vowel W, are
so similar that no particular hardship was caused through their
representation by the one character. But in the development of Latin
from the classic period to mediæval times, the semi-vowel sound W
came to be pronounced as the consonant V as we speak it in
English. This change occurred both in Latin in its survival as a
religious and literary tongue, and in the popularly spoken Romance
languages, like French and Italian, that sprang out of Latin. Finally it
was felt that the full vowel U and the pure consonant V were so
different that separate letters for them would be convenient. The two
forms with rounded and pointed bottom were already actually in use
as mere calligraphic variants, although not distinguished in sound, V
being usually written at the beginning of words, U in the middle. Not
until after the tenth century did the custom slowly and undesignedly
take root of using the pointed letter exclusively for the consonant,
which happened to come most frequently at the head of words, and
the rounded letter for the vowel which was commoner medially.
In the same way I and J were originally one letter. In the original
Semitic this stood for the semi-vowel J (or “Y” as in yet); in Greek for
the vowel I; in Latin indifferently for vowel or semi-vowel, as in
Ianuarius. Later, however, in English, French, and Spanish speech,
the semi-vowel became a consonant just as V had become. When
differentiation between I as vowel and as consonant seemed
necessary, it was effected by seizing upon a distinction in form which
had originated merely as a calligraphic flourish. About the fifteenth
century, I was given a round turn to the left, when at the beginning of
words, as an ornamental initial. The distinction in sound value came
still later. The forms I and J were kept together in the alphabet, as U
and V had been, the juxtaposition serving as a memento of their
recency of distinction—like the useless dot over small j. Had the
people of the Middle Ages still been using the letters of the alphabet
for numerical figures as did the Greeks, they would undoubtedly
have found it more convenient to keep the order of the old letters
intact. J and U would in that case almost certainly have been put at
the end of the alphabet instead of adjacent to I and V.
J presents a survival—a significant anachronism. Although now
recognized in the alphabet, the letter is not always accorded its full
place in the series; now and then it is treated like an adopted child
whose position in the family is somewhat subsidiary. When a
continental European uses letters to designate rows of chairs in a
theater, paragraph headings in a book, a series of shipping marks, or
any other listing, he often omits J, passing directly from I to K as a
Roman of two thousand years ago would have done. Americans
occasionally do the same: in Washington, K street follows directly on
I street. If asked the reason, we perhaps rationalize the omission on
the ground that I and J look so much alike that they run risk of being
confused. Yet it scarcely occurs to us that I and L, or I and T, can
also be easily confused. The true cause of the habit seems to be the
unconscious one that our ancestors, in using the letters seriatim,
followed I by K because they had no J.
The origin of W is accounted for by its name, “Double-U,” and by
its form, which is that of two V’s. The old Latin pronunciation of V
gradually changed from W to V, and many of the later European
languages either contained no W-sound or indicated it by the device
of writing U or some combination into which U entered. Thus the
French write OU and the Spanish HU for the sound of W. In English,
however, and in a few other European languages, the semi-vowel
sound was important enough to make a less circumstantial
representation advisable. Since the sound of the semi-vowel was felt
to be fuller than that of the consonant, a new letter was coined for
the former by coupling together two of the latter. This innovation did
not begin to creep into English until the eleventh century. Being an
outgrowth of U and V, W was inserted after them as J was after I. It
is a slight but interesting instance of convergence that its name is
exactly parallel to the name “Double Gamma” which the Greek
grammarians coined for F long before.
142. Capitals and Minuscules

The distinction between capitals and “small” letters is one which
we learn so early in life that we are wont to take it as something self-
evident and natural. Yet it is a late addition in the history of the
alphabet. Greeks and Romans knew nothing of it. They wrote wholly
in what we should call capital letters. If they wanted a title or heading
to stand out, they made the letters larger, but not different in form.
The same is done to-day in Hebrew and Arabic, and in fact in all
alphabets except those of Europe.
Our own two kinds or fonts of letters, the capital and “lower case”
or “minuscule,” are more different than we ordinarily realize. We
have seen them both so often in the same words that we are likely to
forget that the “A” differs even more in form than in size from “a,” and
that “b” has wholly lost the upper of the two loops which mark “B.” In
late Imperial Roman times the original “capital” forms of the letters
were retained for inscriptional purposes, but in ordinary writing
changes began to creep in. These modifications increased in the
Middle Ages, giving rise first to the “Uncial” and then to the
“Minuscule” forms of the letters. Both represent a cursive rather than
a formal script. The minuscules are essentially the modern “small”
letters. But when they first developed, people wrote wholly in them,
reserving the older formal capitals for chapter initials. Later, the
capitals crept out of their temporary rarity and came to head
paragraphs, sentences, proper names, and in fact all words that
seemed important. Even as late as a few centuries ago, every
English noun was written and printed with a capital letter, as it still is
in German. Of course little or nothing was gained by this procedure.
In many sentences the significant word must be a verb or adjective;
and yet, according to the arbitrary old rule, it was the noun that was
made to stand out.
To-day we still feel it necessary in English to retain capitals for
proper names. It is certain that a suggestion to commence these
also with small letters would be met with the objection that a loss of
clearness would be entailed. As a matter of fact, the cases in which
ambiguity between a common and proper noun might ensue would
be exceedingly few; the occasional inconvenience so caused would
be more than compensated for by increased simplicity of writing and
printing. Every child would learn its letters in little more than half the
time that it requires now. The printer would be able to operate with
half as many characters, and typewriting machines could dispense
with a shift key. French and Spanish designate proper adjectives
without capitals and encounter no misunderstanding, and all English
telegrams are sent in a code that makes no distinction. When we
read the newspaper in the morning and think that the mixture of
capital and small letters is necessary for our easy comprehension of
the page, we forget that this same news came over the wire without
capitals.
143. Conservatism and Rationalization

The fact is that we have become so habituated to the existing
method that a departure from it might temporarily be a bit
disconcerting. Consequently we rationalize our cumbersome habit,
taking for granted or explaining that this custom is intrinsically and
logically best; although a moments objective reflection suffices to
show that the system we are so addicted to costs each of us, and
will cost the next generation, time, energy, and money without
bringing substantial compensation.
It is true that this waste is distributed through our lives in small
driblets, and therefore is something that can be borne without
seeming inconvenience. Civilization undoubtedly can continue to
thrive even while it adheres to the antiquated and jumbling method of
mixing two kinds of letters where one is sufficient. Yet the practice
illustrates the principle that the most civilized as the most savage
nations assert and believe that they adhere to their institutions after
an impartial consideration of all alternatives and in full exercise of
wisdom, whereas analysis regularly reveals them as astonishingly
resistive to alteration whether for better or worse.
If our capital letters had been purposely superadded to the small
ones as a means of distinguishing certain kinds of words, a modern
claim that they were needed for this purpose could perhaps be
accepted. But since the history of the alphabet shows that the capital
letters are the earlier ones, that the small letters were for centuries
used alone, and that systems of writing have operated and operate
without the distinction, it is clear that utility cannot be the true motive.
The employment of capital letters as initials originated in a desire for
ornamentation. It is an embroidery, the result of a play of the
æsthetic sense. It is the use of capitals that has caused the false
sense of their need, not necessity that has led to their use.
144. Gothic
Another exemplification of how tenaciously men cling to the
accustomed at the expense of efficiency, is provided by the “Black-
Letter” or “Gothic” alphabet used in Germany and Scandinavia. This
is nothing but the Roman letters as elaborated by the manuscript-
copying monks of northern Europe toward the end of the Middle
Ages, when a book was as much a work of art as a volume of
reading matter. The sharp angles, double connecting strokes, goose-
quill flourishes, and other increments of the Gothic letters
undoubtedly possess a decorative effect, although an over-elaborate
one. They were evolved in a period when a copyist cheerfully
lettered for a year in producing a volume, and the lord or bishop into
whose hands it passed was as likely to turn the leaves in admiration
of the black and red characters as to spend time in reading them.
When printing was introduced, the first types were the intricate and
angular Gothic ones customary in Germany. The Italians, who had
always been half-hearted about the Gothic forms, soon revolted.
Under the influence of the Renaissance and its renewed inspiration
from classical antiquity, they reverted as far as possible to the
ancient shapes of the characters. Even the mediæval small letters
were simplified and rounded as much as possible to bring them into
accord with the old Roman style. From Italy these types spread to
France and most other European countries, including England,
which for the first fifty years had printed in Black-Letter. Only in north
central Europe did the Gothic forms continue to prevail, although
even there all scientific books have for some time been printed in the
Roman alphabet. Yet Germans sometimes complain of the “difficulty”
of the Roman letters, and books intended for popular sale, and
newspapers, go into Gothic. There can be little doubt that in time the
Roman letters will dispossess the Gothic ones in Germany and
Scandinavia except for ornamental display heads. But the
established ways die hard; Gothic letters may linger on as the “old-
style” calendar with its eleven-day belatedness held out in England
until 1752 and in Russia until 1917.
Fig. 30. The spread of alphabetic writing. Course of Occidental alphabets in dotted
lines; West Asiatic, continuous lines; Indic, broken lines. The numbers stand
for centuries: with hollow circles, before Christ; with solid circles, after Christ.
Crossed circle, point of origin, Phœnicia, 11th century B.C. Abbreviations:
Aram, Aramæan; Bl L, Black Letter (Gothic); Cyr, Cyrillic; Est, Estrangelo; Etr,
Etruscan; Go, Gothic (Runes); Gr Min, Unc, Greek Minuscule, Uncial; In Ba,
Indo-Bactrian (Kharoshthi); I, Israelite; R Min, Unc, Roman Minuscule, Uncial;
Sc, Scandinavian (Rune). The flow was often back and forth; compare the
2,000 year development from Phœnician to Ionian to Athens to Alexandria
(Uncial) to Constantinople (Minuscule) to Russian; or from Phœnician
northward to Aramæan, thence south to Nabathean and Arabic, east to
Pehlevi and back west to Armenian.
145. Hebrew and Arabic

Only a small part of the history of the alphabet was unfolded in
Europe, where the seemingly so different forms of writing that have
been discussed are after all only fairly close variants of the early
Greek letters. In Asia the alphabet underwent more profound
changes.
The chief modern Semitic alphabets, Hebrew and Arabic, are
considerably more altered from the primitive Semitic or Phœnician
than is our own alphabet. The Hebrew letters were slowly evolved,
during the first ten centuries after Christ, under influences which
have turned most of them as nearly as possible into parts of squarish
boxes. B and K, M and S, G and N, H and CH and T, D and V and Z
and R are shaped as if with intent to look alike rather than different.
Arabic, on the other hand, runs wholly to curves: circles, segments of
circles, and round flourishes; and several of its letters have become
identical except for diacritical marks. If we put side by side the
corresponding primitive Semitic, the modern English, the Hebrew,
and the Arabic letters, it is at once apparent that in most cases
English observes most faithfully the 3,000-years old forms. The
cause of these changes in Hebrew and Arabic is in the main their
derivation from alphabets descended from the Aramæan alphabet, a
form of script that grew up during the seventh century B.C. in Aram
to the northeast of Phœnicia. The Aramæans were Semites and
therefore kept to the original value of the Phœnician letters more
closely than the Greeks and Romans. On the other hand, they
employed the alphabet primarily for business purposes and rapidly
altered it to a cursive form, in which the looped or enclosing letters
like A, B, D were opened and the way was cleared for a series of
increasing modifications. Greek and Roman writing, on the other
hand, were at first used largely in monumental, dedicatory, legal, and
religious connections, and preserved clarity of form at the expense of
rapidity of production.
One feature of primitive Semitic, most Asiatic alphabets retained
for a long time: the lack of vowel signs. In the end, however,
representation of the vowels proved to be so advantageous that it
was introduced. Yet the later Semites did not follow the Greek
example of converting dispensable consonantal signs into vocalic
ones. They continued to recognize consonant signs as the only real
letters, and then added smaller marks, or “points” as they are called,
for the vowels. These points correspond more or less to the grave,
acute, and circumflex accents which French uses to distinguish
vowel shades or qualities, é, è, ê, and e, for instance; and to the
double dot or diæresis which German puts upon its “umlaut” vowels,
as to distinguish ä (= e) from a. There is this difference, however:
whereas European points are reserved for minor modifications,
Hebrew and Arabic have no other means of representing vowels
than these points. The vowels therefore remain definitely subsidiary
to the consonants; to the extent of this deficiency Hebrew has
adhered more closely to the primitive Semitic system than have we.
The reason for this difference lies probably in the fact that Hebrew
and Arabic have retained virtually all the consonants of ancient
Semitic. Hence the breaths and stops could not be dispensed with,
or at least such was the feeling of their speakers. In the Indo-
European languages, these sounds being wanting, the
transformation of the superfluous signs into the letters needed for the
vowels was suggested to the Greeks. The step perfecting the
alphabet was therefore taken by them not so much because they
possessed originality or specially fertile imagination, as because of
the accident that their speech consisted of sounds considerably
different from those of Semitic. Perhaps the Greeks once
complained of the unfitness of the Phœnician alphabet, and adjusted
it to their language with grumblings. Had they been able to take it
over unmodified, as the Hebrews and Arabs were able, it is probable
that they would cheerfully have done so with all its imperfection. In
that case they, and after them the Romans, and perhaps we too,
would very likely have gone on writing only consonants as full letters
and representing vowels by the Semitic method of subsidiary points.
In short, even so enterprising and innovating a people as the Greeks
are generally reputed to have been, made their important
contribution to the alphabet less because they wished to improve it
than because an accident of phonetics led them to find the means.
Such are the marvels of human invention when divested of their
romantic halo and examined objectively.
146. The Spread Eastward: the Writing of

India
The diffusion of the alphabet eastward from its point of origin was
even greater than its spread through Europe. Most of this extension
in Asia is comprised in two great streams. One of these followed the
southern edge of the continent. This was a movement that began
some centuries before Christ, and often followed water routes. The
second flow was mainly post-Christian and affected chiefly the inland
peoples of central Asia.
India is the country of most importance in the development of the
south Asiatic alphabets. The forms of the Sanskrit letters show that
they and the subsequent Hindu alphabets are derivatives, though
much altered ones, from the primitive Semitic writing. Exactly how
the alphabet was carried from the shore of the Mediterranean to
India has not been fully determined. By some the prototype of the
principal earliest Indian form of writing is thought to have been the
alphabet of the south Arabian Sabæans or Himyarites of five or six
hundred years B.C. As the Arabs were Semites, and as there was a
certain amount of commerce up and down the Red Sea, it is not
surprising that even these rather remote and backward people had
taken up writing. Between south Arabia and India there was also
some intercourse, so that a further transmission by sea seems
possible enough. Another view is that Hindu traders learned and
imported a north Semitic alphabet perhaps as early as during the
seventh century, from which the Brahmi was made over, from which
in turn all living Indian alphabets are derived. Besides this main
importation, there was another, from Aramæan sources, which gave
rise to a different form of Hindu writing, the Kharoshthi or Indo-
Bactrian of the Punjab, which spread for a time into Turkistan but
soon died out in India.
147. Syllabic Tendencies

One trait of Indian alphabets leads back to their direct Semitic
origin: they did not recognize the vowels. The Hindus speaking Indo-
European were confronted with the same difficulty as the Greeks
when they took over the vowelless Semitic alphabet. But they solved
the difficulty in their own way. They assumed that a consonantal
letter stood for a consonant plus a vowel. Thus, each letter was
really the sign for a syllable. The most common vowel in Sanskrit
being A, this was assumed as being inherent in the consonant. For
instance, their letter for K was not read K, but KA. This meant that
when K was to be read merely as K, it had to be specially
designated: something had to be done to take away the vowel A. A
diacritical sign was added, known as the virama. This negative sign
is a “point” just as much as the positive vowel points of Hebrew; but
was used to denote exactly the opposite.
There are of course other vowels than A in Sanskrit. These were
represented by diacritical marks analogous to the virama. Thus while
this is a diagonal stroke below the consonant, U is represented by a
small curve below, E by a backward curve above, AI by two such,
and so on.
If a syllable had two consonants before the vowel, these were
condensed into one, the essential parts of each being combined into
a more complex character. This was much as if we were to write “try”
by forcing t and r into a special character showing the cross stroke of
the t and the roll or hook of the r, and superposing a diæresis for the
vowel. This process reduced every syllable to a single though often
compound letter. If the syllable ended in a consonant, this carried
over as the beginning of the next syllable. Even the end consonant

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Basic Guide to Orthodontic Dental

Nursing 2nd Edition Fiona Grist

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging‐in‐Publication Data

Cover Design: Wiley

Set in 10/12.5pt Sabon by SPi Global, Pondicherry, India

Foreword to Second Edition ix

1 Definition of orthodontics and factors influencing orthodontic treatment 1

22 Mandibular advancement devices 249

Professor P.J. Sandler BDS (Hons), MSc, PhD, FDSRCPS, MOrthRCS

Basic Guide to Orthodontic Dental Nursing, Second Edition. Fiona Grist.

Figure 1.1 Cephalometric tracing.

When assessing occlusion there are two aspects to classification:

I n c iso r cla ssific ation

Bu cca l se gmen t oc c lusion

Figure 1.3 Large overjet. Source: Reproduced by kind

Figure 1.4 Side view of severe overjet. Source: Reproduced by kind

Figure 1.5 Bite stripping lower gingivae. Source:

Figure 1.6 Damage to labial gingivae caused by the

Figure 1.8 Class III. Source: Reproduced by

Class I ½ unit Class II Class III

THE MIXED DENTITION

Figure 1.10 Hypodontia. Source: Reproduced by kind

INDICATIONS FOR TREATMENT

Clinical indications for orthodontic treatment may be because the teeth:

Figure 1.11 Lower incisor trapped outside the bite.

Figure 1.12 Scissors bite. Source: Reproduced by kind

• which look unattractive and affect the smile

UNDERLYING CAUSES OF MALOCCLUSION OF THE TEETH

There may also be:

Mu lt id iscip lin ar y approac h

PROBLEMS WHEN THE ARCH IS NOT INTACT

Figure 1.13 Anterior open bite due to digit sucking.

Figure 1.14 Leaflet on digit sucking. Source: Reproduced by kind

Some problems are caused by:

Upper right upper left

Deciduous dentition (as the clinician looks at the patient)

• lower left is 3, so lower left wisdom tooth would be 38

And in the deciduous dentition

CONDITION OF THE SURROUNDING SOFT TISSUES

Figure 1.15 Tongue tie. Source: Reproduced by kind

Basic Guide to Orthodontic Dental Nursing, Second Edition. Fiona Grist.

THE CLINICAL ASSESSMENT RECORDS

The first appointment

INCS REL CL 1 CL11/1 CL2/2 type CL111

OVERJET normal increased (mm) reduced e/e reversed

OVERBITE norm increased reduced e/e open (mm)

UPPER INCS average proclined retro sl crowded sl spaced CL L/R

UPPER CANINES average mesial distal buccal palatal high

LOWER INCS average proclined retro sl crowded sl spaced

LOWER CANINES average mesial distal lingual erupting unerupted

MOLAR REL right left

CROSS/SCISSOR BITE left / right displacement init contact on

GEN DENTAL CONDITION

OPT supplied by GDP dated

Complaint Social Details

AP 1 2 3 Vertical ↑ ↓ Average Lateral Asymmetry Yes No

Soft Tissue Pattern

Foreword to Second Edition ix

1 Definition of orthodontics and factors influencing orthodontic treatment 1

22 Mandibular advancement devices 249