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An Introduction to Orthodontics
An Introduction
to Orthodontics
F IF TH EDITION

Simon J. Littlewood
MDSc, BDS, FDS (Orth) RCPS (Glasg), M. Orth RCS (Edin), FDSRCS (Eng)
Consultant Orthodontist, St Luke’s Hospital, Bradford, UK
Honorary Senior Clinical Lecturer, Leeds Dental Institute, Leeds, UK

Laura Mitchell MBE

MDS, BDS, FDSRCPS (Glasg), FDSRCS (Eng), FGDP (UK),
D. Orth RCS (Eng), M. Orth RCS (Eng)
Retired. Previously, Consultant Orthodontist, St Luke’s Hospital, Bradford, UK
Honorary Senior Clinical Lecturer, Leeds Dental Institute, Leeds, UK

With contributions from

Benjamin R. K. Lewis
BDS, MFDS RCS (Eng), MClinDent, M. Orth. RCS (Eng), FDS (Orth) RCS (Eng)
Consultant Orthodontist, Wrexham Maelor Hospital & Glan Clwyd Hospital, Rhyl, UK
Honorary Clinical Lecturer, University of Liverpool, UK

Sophy K. Barber
BDS, MSc, M. Orth RCS (Edin), PG Cert. Health Res.
Post-CCST Registrar in Orthodontics, Leeds Dental Institute and St Luke’s Hospital,
Bradford, UK

Fiona R. Jenkins
MDSc, BDS, MFDS RCS (Eng), FDS (Orth) RCS (Eng), M. Orth RCS (Eng)
Consultant Orthodontist, St Luke’s Hospital, Bradford, UK
Honorary Senior Clinical Lecturer, Leeds Dental Institute, Leeds, UK

1
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Preface for fifth edition
Orthodontics is both an art and a science, and, like most great works of art, at its best orthodontics can appear
both deceptively simple and wonderfully aesthetic. The reality is of course that behind that apparent simplicity,
there is real complexity that takes years to master. Gaining expertise in any subject requires sound foundations
on which to build on, and we hope that this introduction to orthodontics provides these foundations.

In this new, significantly updated edition, we have tried to stay true to the ethos of the previous editions, pro-
viding key basic science and clinical information that is based on the best current evidence. We hope it will be
useful to anyone involved in the treatment of orthodontic patients: undergraduate dental students, postgradu-
ate students specializing in orthodontics, dentists with an interest in orthodontics, orthodontic therapists and
orthodontic nurses, and perhaps even those more experienced orthodontists who would welcome a succinct
evidence-based, sensible, and contemporary update on the subject of orthodontics.

We hope you enjoy it!

Simon J. Littlewood and Laura Mitchell

Acknowledgements
We would like to thank everyone who has assisted in completing this book, in particular our new contributing
authors, Benjamin R. K. Lewis, Sophy K. Barber, and Fiona R. Jenkins. It has been a pleasure to work with these
talented orthodontists on this project. We would also like to thank all those authors who have contributed to
previous versions. Individual credits to clinicians who have provided figures for this edition are provided in the
respective legends throughout the book. We would also like to sincerely thank all those patients who have
provided consent to show their photos.

Working with busy authors is not always easy, so we would like to thank all those clinical and support staff who
work with us on a daily basis.

For all those inspiring clinicians, teachers, and colleagues who have shared with us their knowledge, ideas, and
experience throughout our careers, thank you.

We would also like to thank the staff of Oxford University Press for their help, patience, and expertise in guiding
us through the publishing process.

And finally, to our respective families—Emma and Jack Littlewood, and David Mitchell—this book is dedicated
to you.

Simon J. Littlewood and Laura Mitchell

Online Resources
Further reading and references (including Cochrane Reviews) can also be found at:

www.oup.com/uk/orthodontics5e.

Where possible, these are presented as active links which direct you to the electronic version of
the work, to help facilitate onward study. If you are a subscriber to that work (either individually
or through an institution), and depending on your level of access, you may be able to peruse an
abstract or the full article if available.
Brief contents
1 The rationale for orthodontic treatment (S. K. Barber) 1

2 The aetiology and classification of malocclusion (L. Mitchell) 11

3 Management of the developing dentition (L. Mitchell)21

4 Craniofacial growth and the cellular basis of tooth movement (F. R. Jenkins)37

5 Orthodontic assessment (S. J. Littlewood)51

6 Cephalometrics (S. K. Barber)71

7 Treatment planning (S. J. Littlewood)85

8 Class I (Benjamin R. K. Lewis)101

9 Class II division 1 (S. J. Littlewood)115

10 Class II division 2 (S. K. Barber)123

11 Class III (Benjamin R. K. Lewis)137

12 Anterior open bite and posterior open bite (Benjamin R. K. Lewis)151

13 Crossbites (Benjamin R. K. Lewis)163

14 Canines (L. Mitchell)175

15 Anchorage planning (Benjamin R. K. Lewis)185

16 Retention (S. J. Littlewood)203

17 Removable appliances (L. Mitchell)215

18 Fixed appliances (Benjamin R. K. Lewis)225

19 Functional appliances (S. J. Littlewood)245

20 Adult orthodontics (S. J. Littlewood)261

21 Orthodontic aligners (S. K. Barber)275

22 Orthodontics and orthognathic surgery (S. J. Littlewood)287

23 Hypodontia and orthodontics (S. K. Barber)307

24 Cleft lip and palate and other craniofacial anomalies (L. Mitchell)325

25 Orthodontic first aid (L. Mitchell)337

Definitions 345
Orthodontic assessment form 347
Index  349
Detailed contents
1 The rationale for orthodontic treatment 5 Orthodontic assessment (S. J. Littlewood) 51
(S. K. Barber) 1 5.1 Introduction to orthodontic assessment 52
1.1 Orthodontics 2 5.2 Taking an orthodontic history 52
1.2 Malocclusion 2 5.3 Clinical examination in three dimensions 54
1.3 Rationale for orthodontic treatment 2 5.4 Extra-oral examination 55
1.4 Potential benefits to dental health 3 5.5 Intra-oral examination 59
1.5 Potential benefits for oral health-related 5.6 Diagnostic records 61
quality of life 5
5.7 Forming a problem list 64
1.6 Potential risks of orthodontic treatment 6
5.8 Case study: example case to demonstrate
1.7 Discussing orthodontic treatment need 9 orthodontic assessment 64
2 The aetiology and classification of 6 Cephalometrics (S. K. Barber) 71
malocclusion (L. Mitchell) 11
6.1 The cephalostat 72
2.1 The aetiology of malocclusion 12
6.2 Indications for cephalometric evaluation 73
2.2 Classifying malocclusion 13
6.3 Evaluating a cephalometric radiograph 74
2.3 Commonly used classifications and indices 13
6.4 Cephalometric analysis: general points 75
2.4 Andrews’ six keys 18
6.5 Commonly used cephalometric points and
3 Management of the developing dentition reference lines 75
(L. Mitchell) 21 6.6 Anteroposterior skeletal pattern 77
3.1 Normal dental development 22 6.7 Vertical skeletal pattern 79
3.2 Abnormalities of eruption and exfoliation 24 6.8 Incisor position 80
3.3 Mixed dentition problems 26 6.9 Soft tissue analysis 81
3.4 Planned extraction of deciduous teeth 33 6.10 Assessing growth and treatment changes 81
3.5 What to refer and when 34 6.11 Cephalometric errors 83

4 Craniofacial growth and the cellular basis 6.12 3D cephalometric analysis 83

of tooth movement (F. R. Jenkins) 37 7 Treatment planning (S. J. Littlewood) 85
4.1 Introduction 38 7.1 Introduction 86
4.2 Early craniofacial development 38 7.2 General objectives of orthodontic
4.3 Mechanisms of bone formation and growth 40 treatment86
4.4 Control of craniofacial growth 40 7.3 Forming an orthodontic problem list 86
4.5 Postnatal craniofacial growth 40 7.4 Aims of orthodontic treatment 88
4.6 Growth rotations 43 7.5 Skeletal problems and treatment planning 88
4.7 Growth of the soft tissues 44 7.6 Basic principles in orthodontic
4.8 Growth prediction 45 treatment planning 89
4.9 The cellular basis of tooth movement 45 7.7 Space analysis 90
4.10 Cellular events associated with excess force 48 7.8 Valid consent and the orthodontic
4.11 Cellular events during root resorption 48 treatment plan 95
4.12 Summary 48 7.9 Conclusions 96
x Detailed contents

7.10 Case study: example case to demonstrate 14 Canines (L. Mitchell) 175
treatment planning 97 14.1 Facts and figures 176
8 Class I (Benjamin R. K. Lewis) 101 14.2 Normal development 176
8.1 Aetiology 102 14.3 Aetiology of maxillary canine displacement 176
8.2 Crowding 102 14.4 Interception of displaced canines 177
8.3 Spacing 105 14.5 Assessing maxillary canine position 178
8.4 Early loss of first permanent molars 106 14.6 Management of buccal displacement 180
8.5 Displaced teeth 106 14.7 Management of palatal displacement 180
8.6 Vertical discrepancies 107 14.8 Resorption 182
8.7 Transverse discrepancies 108 14.9 Transposition 182
8.8 Bimaxillary proclination 108 15 Anchorage planning (Benjamin R. K. Lewis) 185
8.9 Trauma 109 15.1 Introduction 186
9 Class II division 1 (S. J. Littlewood) 115 15.2 Assessing anchorage requirements 186
9.1 Aetiology 116 15.3 Classification of anchorage 188
9.2 Objectives of treating Class II division 1 15.4 Intra-oral anchorage 191
malocclusions118 15.5 Extra-oral anchorage 196
9.3 Treatment planning for Class II division 1 15.6 Monitoring anchorage during treatment 199
malocclusions119 15.7 Common problems with anchorage 199
10 Class II division 2 (S. K. Barber) 123 15.8 Summary 199
10.1 Aetiology 124 16 Retention (S. J. Littlewood) 203
10.2 Common features of Class II division 2 16.1 Introduction 204
malocclusion126
16.2 Definition of relapse and post-treatment
10.3 Aims of treatment 127 changes204
10.4 Treatment methods 130 16.3 Aetiology of post-treatment changes 204
11 Class III (Benjamin R. K. Lewis) 137 16.4 How common are post-treatment changes? 206
11.1 Aetiology 138 16.5 Consent and the responsibilities of retention 206
11.2 Occlusal features 139 16.6 Retainers 206
11.3 Treatment planning in Class III malocclusions 140 16.7 Adjunctive techniques used to reduce
11.4 Treatment options 141 post-treatment changes 212
16.8 Conclusions about retention 212
12 Anterior open bite and posterior open
bite (Benjamin R. K. Lewis) 151 17 Removable appliances (L. Mitchell) 215
12.1 Definitions 152 17.1 Mode of action of removable appliances 216
12.2 Aetiology of anterior open bite 152 17.2 Designing removable appliances 217
12.3 Management of anterior open bite 155 17.3 Active components 217
12.4 Posterior open bite 159 17.4 Retaining the appliance 219
17.5 Baseplate 221
13 Crossbites (Benjamin R. K. Lewis) 163
17.6 Commonly used removable appliances 221
13.1 Definitions 164
17.7 Fitting a removable appliance 222
13.2 Aetiology 164
17.8 Monitoring progress 223
13.3 Types of crossbite 165
17.9 Appliance repairs 224
13.4 Management 167
 Detailed contents xi

18 Fixed appliances (Benjamin R. K. Lewis) 225 22 Orthodontics and orthognathic

18.1 Principles of fixed appliances 226 surgery (S. J. Littlewood) 287
18.2 Indications for the use of fixed appliances 229 22.1 Introduction 288
18.3 Components of fixed appliances 229 22.2 Indications for treatment 288
18.4 Treatment planning for fixed appliances 235 22.3 Objectives of combined orthodontics and
orthognathic surgery 290
18.5 Practical procedures 236
22.4 The importance of the soft tissues 290
18.6 Fixed appliance systems 236
22.5 Diagnosis and treatment plan 290
18.7 Demineralization and fixed appliances 241
22.6 Planning 295
18.8 Starting with fixed appliances 242
22.7 Common surgical procedures 296
19 Functional appliances (S. J. Littlewood) 245 22.8 Sequence of treatment 298
19.1 Definition 246 22.9 Retention and relapse 300
19.2 History 246 22.10 3D developments in orthognathic surgery:
19.3 Overview 246 planning, simulation, and guided surgery 302
19.4 Case study: functional appliance 246
23 Hypodontia and orthodontics (S. K. Barber) 307
19.5 Timing of treatment 250
23.1 Definition 308
19.6 Types of malocclusion treated with
23.2 Aetiology 309
functional appliances 250
23.3 Features of hypodontia 310
19.7 Types of functional appliance 254
23.4 Impact of hypodontia 312
19.8 Clinical management of functional appliances 257
23.5 Treatment in the primary dentition 313
19.9 How functional appliances work 258
23.6 Treatment in the mixed dentition 313
19.10 How successful are functional appliances? 259
23.7 Treatment in the permanent dentition 313
20 Adult orthodontics (S. J. Littlewood) 261
24 Cleft lip and palate and other craniofacial
20.1 Introduction 262
anomalies (L. Mitchell) 325
20.2 Comprehensive, adjunctive, or limited
24.1 Prevalence 326
treatment orthodontics 262
24.2 Aetiology 326
20.3 Specific challenges in adult orthodontic
treatment263 24.3 Classification 326
20.4 Orthodontics and periodontal disease 264 24.4 Problems in management 327
20.5 Orthodontic treatment as an adjunct to 24.5 Coordination of care 329
restorative work 265 24.6 Management 330
20.6 Aesthetic orthodontic appliances 265 24.7 Audit of cleft palate care 333
20.7 Obstructive sleep apnoea and mandibular 24.8 Other craniofacial anomalies 333
advancement splints 270
25 Orthodontic first aid (L. Mitchell) 337
21 Orthodontic aligners (S. K. Barber) 275 25.1 Fixed appliance 338
21.1 Definition of orthodontic aligners 276 25.2 Removable appliance 340
21.2 History of aligners 276 25.3 Functional appliance 340
21.3 Tooth movement with aligners 278 25.4 Headgear 341
21.4 Clinical stages in aligner treatment 278 25.5 Miscellaneous 341
21.5 Digital aligner construction 282
Definitions 345
21.6 Uses for aligners 283
21.7 Advantages and limitations of Orthodontic assessment form 347
orthodontic aligners 283 Index  349
1
The rationale
for orthodontic
treatment
S. K. Barber
Chapter contents
1.1 Orthodontics 2
1.2 Malocclusion 2
1.3 Rationale for orthodontic treatment 2
1.3.1 Need for orthodontic treatment 2
1.3.2 Demand for orthodontic treatment 3
1.4 Potential benefits to dental health 3
1.4.1 Localized periodontal problems 3
1.4.2 Dental trauma 3
1.4.3 Tooth impaction 3
1.4.4 Caries 4
1.4.5 Plaque-induced periodontal disease 4
1.4.6 Temporomandibular joint dysfunction syndrome 5
1.5 Potential benefits for oral health-related quality of life 5
1.5.1 Appearance 5
1.5.2 Masticatory function 5
1.5.3 Speech 5
1.5.4 Psychosocial well-being 5
1.6 Potential risks of orthodontic treatment 6
1.6.1 Root resorption 6
1.6.2 Loss of periodontal support 7
1.6.3 Demineralization 8
1.6.4 Enamel damage 8
1.6.5 Intra-oral soft tissue damage 8
1.6.6 Pulpal injury 8
1.6.7 Extra-oral damage 8
1.6.8 Relapse 8
1.6.9 Failure to achieve treatment objectives 8
1.7 Discussing orthodontic treatment need 9

Principal sources and further reading 9

2 The rationale for orthodontic treatment

Learning objectives for this chapter

• Gain an understanding of the differences between need and demand for treatment.
• Gain an appreciation of the benefits and risks of orthodontic treatment.
• Gain an appreciation of the importance of discussing the risks and benefits of treatment with patients and their families.

1.1 Orthodontics
Orthodontics is the branch of dentistry concerned with facial growth,
development of the dentition and occlusion, and the diagnosis, inter-
ception, and treatment of occlusal anomalies.

1.2 Malocclusion
‘Ideal occlusion’ is the term given to a dentition where the teeth are in
Table 1.1 England, Wales, and Northern Ireland Child
the optimum anatomical position, both within the mandibular and max-
Dental Health Survey 2013
illary arches (intramaxillary) and between the arches when the teeth are
in occlusion (intermaxillary). Malocclusion is the term used to describe Age band
dental anomalies and occlusal traits that represent a deviation from the 12 years 15 years
ideal occlusion. In reality, it is rare to have a truly perfect occlusion and Children undergoing orthodontic 9% 18%
malocclusion is a spectrum, reflecting variation around the norm. treatment at the time of the survey
The prevalence of malocclusion and particular occlusal anomalies Children not undergoing treatment 37% 20%
depends on the population studied (e.g. age and racial characteristics), but in need of treatment
the criteria used for assessment, and the methods used by the examiners (IOTN dental health component)
(e.g. whether radiographs were employed). In the UK, it is estimated 9% Source data from Child Dental Health Survey 2013, England, Wales and Northern
of 12-year-olds and 18% of 15-year-olds are undergoing orthodontic treat- Ireland, 2015, Health and Social Care Information Centre.
ment, with a further 37% of 12-year-olds and 20% of 15-year-olds requiring
treatment (Table 1.1). This suggests the overall prevalence of moderate–
severe malocclusion is around 40–50% in adolescents (Table 1.1).

1.3 Rationale for orthodontic treatment

Malocclusion may cause concerns related to dental health and/or
oral-health-related quality of life issues arising from appearance, func-
Table 1.2 Risk–benefit analysis for orthodontics
tion, and the psychosocial impact of the teeth. The need for treatment Benefits of treatment versus Risks
depends on the impact of the malocclusion and whether treatment is
Improved dental health Worsening of dental
likely to provide a demonstrable benefit to the patient. To judge treat-
Improved oral health- health
ment need, potential benefits of treatment are balanced against the related quality of life Failure to achieve
risk of possible complications and side-effects in a risk–benefit analysis (OHRQoL) aims of treatment
(Table 1.2). Improved aesthetics Relapse
Improved function
1.3.1 Need for orthodontic treatment
Health and well-being benefits are the most appropriate determinant countries, indices are also used to manage demand and support prior-
of treatment need. Orthodontic indices have been developed to help itization through some form of rationing. For example, in the UK accept-
objective and systematic evaluation of the potential risk to dental health ance for NHS orthodontic treatment is predominantly based on need
posed by the malocclusion and the possible benefits of orthodon- for treatment determined by the Index of Orthodontic Treatment Need
tic treatment (see Section 2.3). While indices were largely developed (IOTN) (see Section 2.3.3). Similarly, in Sweden treatment priority is esti-
to measure treatment need, due to high treatment demand in many mated using a Priority Index developed by the Swedish Orthodontic

Board and the Medical Board, which aims to identify and treat the
malocclusions judged to be most severe.
Unmet treatment need varies within and across countries, depend-
ing on individuals’ desire for treatment and organizational factors, such
as availability of treatment, access to services, and cost of treatment.
In the UK, the unmet orthodontic treatment need for children from
deprived households is higher than average; 40% for 12-year-olds and
32% for 15-year-olds. Similar patterns of inequality in access to treat-
ment are seen in other countries.
1.3.2 Demand for orthodontic treatment
It can readily be appreciated that demand for treatment does not neces-
sarily reflect objective treatment need. Some patients are very aware of
minor deviations, such as mild rotations of the upper incisors, whilst oth-
ers refuse treatment for malocclusions that are considered to be severe.
1.4 Potential benefits to dental health
To determine whether orthodontic treatment is likely to carry a dental
health benefit, it is necessary to consider first whether the malocclu-
sion is likely to cause problems to dental health and secondly, whether
orthodontic treatment is likely to address the problem.
There are specific occlusal anomalies where evidence suggests
orthodontic treatment may provide a dental health benefit (Box 1.1).
For other dental conditions, such as caries, plaque-induced periodontal
disease, and temporomandibular joint dysfunction syndrome (TMD),
there is currently insufficient evidence to suggest orthodontic treat-
ment is beneficial. These conditions are complex and multifactorial in
origin and as such, direct causal relationship with malocclusion is dif-
ficult to measure effectively.
1.4.1 Localized periodontal problems
Certain occlusal anomalies may predispose individuals to periodontal
problems, particularly where the gingival biotype is thin, and in these
cases orthodontic intervention may have a long-term health benefit.
These include:
Box 1.1 Occlusal anomalies where evidence suggests
orthodontic correction would provide long-term dental
health benefit
Localized periodontal problems
• Crowding causing tooth/teeth to be pushed out of the bony
trough, resulting in recession
• Periodontal damage related to tramatic overbites
• Anterior crossbites with evidence of compromised buccal peri-
odontal support on affected lower incisors
• Increased overjet with increased risk of dental trauma
• Unerupted impacted teeth with risk of pathology
• Crossbites associated with mandibular displacement
Potential benefits to dental health 3
Research shows awareness of malocclusion and willingness to undergo
orthodontic treatment is greater in females and those from higher socio-
economic backgrounds. Demand is also higher in areas with a smaller
population to orthodontist ratio, presumably due to increased aware-
ness and acceptance of orthodontic appliances.
The demand for treatment is increasing, particularly among adults
who are attracted by the increasing availability of less visible appliances,
such as ceramic brackets and lingual fixed appliances (see Section 20.6)
and orthodontic aligners (see Chapter 21). Orthodontic treatment has
a useful adjunctive role to restorative work and as people are keeping
their teeth for longer, this is contributing to more requests for interdis-
ciplinary care (see Section 20.5). Increasing dental awareness and the
desire for straight teeth, combined with the acceptability of orthodontic
appliances and awareness of different types of orthodontic treatment
means many adults who did not have treatment during adolescence are
now seeking treatment.
• Crowding where one or more teeth are pushed buccally or lingually
out of the alveolar bony trough, resulting in reduced periodontal sup-
port and localized gingival recession.
• Class III malocclusion where lower incisors in crossbite are pushed
labially (Fig. 1.1).
• Traumatic overbites, which occur when teeth bite onto the gingiva,
can lead to gingival inflammation and loss of periodontal support
over time and this is accelerated by suboptimal plaque control.
1.4.2 Dental trauma
There is evidence that increased overjet is associated with trauma to the
upper incisors. Two systematic reviews have found that the risk of injury
is more than doubled in individuals with an overjet greater than 3 mm
and the risk of injury appears to increase with overjet size and lip incom-
petence. Surprisingly, overjet is a greater contributory factor in girls than
boys despite traumatic injuries being more common in boys. Orthodontic
intervention may be indicated where assessment and history indicate the
young person is at increased risk of dental trauma (see Section 9.2.2).
Mouthguards are also important in reducing the risk of dental trauma,
particularly for those participating in contact sports (see Section 8.9).
1.4.3 Tooth impaction
Tooth impaction occurs when normal tooth eruption is impeded by
another tooth, bone, soft tissues, or other pathology. Supernumerary
teeth can cause impaction and if judged to be impeding normal dental
development, orthodontic input may be required (see Section 3.3.6).
Ectopic teeth are teeth that have formed, or subsequently moved, into
the wrong position; often ectopic teeth become impacted. Unerupted
impacted teeth may cause localized pathology, most commonly resorp-
tion of adjacent roots or cystic change. This is most frequently seen in
relation to ectopic maxillary canine teeth, which can resorb roots of the
incisors and premolars (Fig. 1.2). Orthodontic management of impacted
teeth may be indicated to reduce the risk of pathology (see Section 14.8).
4 The rationale for orthodontic treatment

1.4.4 Caries
Caries experience is directly influenced by oral hygiene, fluoride expo-
sure, and diet; however, research has failed to demonstrate a significant
association between malocclusion and caries. Caries reduction is there-
fore rarely an appropriate justification for orthodontic treatment and
placement of orthodontic appliances in an individual with uncontrolled
caries risk factors is likely to cause significant harm.
In caries-susceptible children, for example those with special needs,
malalignment may reduce the capacity for natural tooth cleansing and
potentially increase the risk of caries. In these cases, an orthodontic
opinion may be sought regarding methods for reducing food stagnation,
(a) such as extraction or simple alignment to alleviate localized crowding.

1.4.5 Plaque-induced periodontal disease

The association between malocclusion and plaque-induced periodon-
tal disease is weak, with research indicating that individual motivation
has more impact than tooth alignment on effective tooth brushing. In
people with consistently poor plaque control, inadequate oral hygiene
is more critical than tooth malalignment in the propagation of perio-
dontal disease. Although patients report increased dental awareness
and positive habits around diet and oral hygiene patients following
­orthodontic treatment, poor plaque control is a contraindication for
orthodontic treatment. It is essential that oral hygiene is satisfactory and
(b) any periodontal disease is controlled prior to considering orthodontic
treatment to prevent worsening of dental health.

Fig. 1.1 (a) A 12-year-old male presented with gingival recession on

the left mandibular central incisor resulting from an anterior crossbite
pushing the tooth labially. (b) Orthodontic treatment was indicated
to prevent further damage to the periodontal tissues. Initially upper
arch alignment was provided to correct the anterior crossbite. A small
improvement was noted in the gingival recession. (c) Comprehensive
treatment was provided and following treatment, the gingival condition
of the left mandibular central incisor is similar to the other mandibular
(c) incisors.

(a) (b)
Fig. 1.2 (a) Periapical radiograph from a 14-year-old female patient who presented with resorption of the left maxillary first premolar caused by a
transposed and ectopic canine. (b) Cone-beam computed tomography shows the extent of the root resorption of the first premolar more clearly.
 Potential benefits for oral health-related quality of life
For people with reduced dexterity or restricted access for cleaning,
it is possible that irregular teeth may hinder effective brushing. In these
cases, orthodontic alignment may aid plaque control but appliance
treatment must be approached carefully to minimize the risk of peri-
odontal damage during treatment.
1.4.6 Temporomandibular joint dysfunction
syndrome
The aetiology and management of TMD has caused considerable con-
troversy in all branches of dentistry. TMD comprises a group of related
disorders with multifactorial aetiology including psychological, hormo-
nal, genetic, traumatic, and occlusal factors. Research suggests that
depression, stress, and sleep disorders are major factors in the aetiology
of TMD and that parafunctional activity, for example bruxism, can con-
tribute to muscle pain and spasm. Some authors maintain that minor
occlusal imperfections can lead to abnormal paths of closure and/or
bruxism, which then result in the development of TMD; however if this
1.5 Potential benefits for oral health-related quality of life
The other key area where orthodontics may be beneficial is in improving
oral health-related quality of life (OHRQoL). Research focussing on the
effect of malocclusion suggests OHRQoL can be negatively affected by
issues relating to dental appearance, masticatory function, speech, and
psychosocial well-being.
1.5.1 Appearance
Dissatisfaction with dental appearance is often the principal reason
people seek orthodontic treatment and, in most cases, treatment is
able to deliver a positive change. Although improved dental appear-
ance may be cited as the main goal of treatment by patients, it is likely
that the perceived benefit is not a change in appearance per se, but the
anticipated psychosocial benefit associated with improved appearance.
1.5.2 Masticatory function
Patients with significant inter-arch discrepancy including anterior open
bites (AOB) and markedly increased or reverse overjet often report
­difficulty with eating, particularly when incising food (Fig. 1.3). This may
manifest as avoidance of certain foods, such as sandwiches or apples, or
embarrassment when eating in public. Patients with severe hypodontia
may also experience problems with eating due to fewer teeth to bite
on and concerns about dislodging mobile primary teeth and prosthetic
teeth (see Chapter 21). Limited masticatory function rarely results in a
complete inability to eat, but it can contribute to significant quality of
life issues and this may be a driver for orthodontic treatment.
1.5.3 Speech
Speech is a complex neuromuscular process involving respiration, pho-
nation, articulation, and resonance. Articulation is the formation of dif-
ferent sounds through variable contact of the tongue with surrounding
structures, including the palate, lips, alveolar ridge, and dentition. It is
unlikely that orthodontic treatment will significantly change speech
in most cases, as speech patterns are formed early in life before the
5
were the case, a much higher prevalence of TMD would be expected to
reflect the level of malocclusion in the population.
The role of orthodontics in TMD has been extensively debated, with
some authors claiming that orthodontic treatment can cause TMD,
while others advocate appliance therapy to manage TMD. After consid-
erable discussion in the literature, the consensus view is that orthodon-
tic treatment, either alone or in combination with extractions, cannot
be reliably shown to either ‘cause’ or ‘cure’ TMD.
The alleged success of a wide assortment of treatment modalities
for TMD highlights both the multifactorial aetiology and the self-lim-
iting nature of the condition. Given this, conservative and reversible
approaches are advised to manage TMD in the first instance. It is advis-
able to carry out a TMD screen for all potential orthodontic patients,
including questions about symptoms, examination of the temporoman-
dibular joint and associated muscles, and a record of the range of open-
ing and movement (see Section 5.4.6). Where signs or symptoms of TMD
are found it is wise to refer the patient for a comprehensive assessment
and specialist management before embarking on orthodontic treatment.
permanent dentition is present and the teeth are only one component
in the complex system. However, where patients cannot attain contact
between the incisors anteriorly, this may contribute to the production
of a lisp (interdental sigmatism). In these cases correcting the incisor
relationship and reducing interdental spacing may reduce lisping and
improve confidence to talk in public.
1.5.4 Psychosocial well-being
Extensive research has been undertaken to examine the effect of
malocclusion on psychosocial well-being in terms of self-perception,
quality of life, and social interactions. Malocclusion has been linked to
reduced self-confidence and self-esteem, with more severe malocclu-
sion and dentofacial deformities causing higher levels of oral impacts.
However, other research suggests visible malocclusion has no discern-
ible negative effect on long-term social and psychological well-being.
A possible explanation for this is that self-esteem is a mediator in the
response to malocclusion, rather than a consequence of malocclusion.
Furthermore, self-reported impact of malocclusion may not always
reflect objective measurement of the severity of occlusal deviations; this
has been attributed to an individual’s resilience, ability to cope, as well
as social and cultural factors.
Dental appearance can evoke social judgements that affect peer
relations and childhood emotional and social development. People
with an attractive dentofacial appearance have been judged to be
friendlier, more interesting and intelligent, more successful, and more
socially competent. On the other hand, deviation from the norm can
cause stigmatization and a high correlation has been found between
victimization, malocclusion, and quality of life. The incidence of peer
victimization in adolescent orthodontic patients with untreated maloc-
clusion has been estimated to be around 12% in the UK. The extent of
malocclusion may not be proportionate to the psychosocial impact, for
example, more severe forms of facial deformity can elicit stronger reac-
tions such as pity or revulsion, while milder malocclusions can lead to
ridicule and teasing.
6 The rationale for orthodontic treatment

Table 1.3 Potential risks of orthodontic treatment

Problem Avoidance/Management of risk
Intra-oral damage
Root resorption Avoid treatment in patients with resorbed,
blunted, or pipette-shaped roots
In teeth judged to be at risk, roots should be
monitored radiographically and treatment
terminated if root resorption is evident
Loss of Maintain high level of oral hygiene
periodontal Avoid moving teeth out of alveolar bone
(a) support
Demineralization Diet control, high level of oral hygiene,
regular fluoride exposure
Abandon treatment
Enamel damage Avoid potentially abrasive components e.g.
ceramic brackets where there is a risk of
occlusal contact
Use of appropriate instruments and burs to
remove appliances and adhesives
Soft tissue Avoid traumatic components
damage Orthodontic wax or silicone to protect
against ulceration
Manage allergic reaction promptly
Loss of vitality If history of previous trauma to incisors,
counsel patient
Extra-oral damage
Worsening facial Careful treatment planning and appropriate
profile mechanics
Soft tissue Use of appropriate safety measures with
damage headgear
Manage allergy promptly

(b) Ineffective treatment

Relapse Avoidance of unstable tooth positions at end
Fig. 1.3 A significant skeletal discrepancy can impact on masticatory of treatment
function. This 28-year-old female patient reported that her Class III Long-term retention
incisor relationship and bilateral buccal crossbite made incising and
Failure to achieve Thorough assessment and accurate diagnosis
chewing food difficult.
treatment Effective treatment planning
objectives Appropriate use of appliances and mechanics

1.6 Potential risks of orthodontic treatment

Like any other branch of medicine or dentistry, orthodontic treatment is
not without potential risks. These risks need to be explained to patients Box 1.2 Recognized risk factors for root resorption
during the decision-making process and where possible, steps taken to during orthodontic treatment
manage the risk (Table 1.3). Patients should be made aware of their role • Shortened roots with evidence of previous root resorption
in treatment and any self-care or behaviour required to achieve success,
such as modifications to diet, oral hygiene practice, or use of a sports
• Pipette-shaped or blunted roots

guard for participation in contact sports.
1.6.1 Root resorption
It is now accepted that some root resorption is inevitable as a conse-
quence of tooth movement, but there are factors that increase the risk
of more severe root resorption (Box 1.2).
• Teeth which have suffered a previous episode of trauma
• Patient habits (e.g. nail biting)
• Iatrogenic—use of excessive forces, intrusion, and prolonged
treatment time
 Potential risks of orthodontic treatment 7

On average, during the course of a conventional 2-year fixed-appli-
ance treatment, around 1 mm of root length will be lost and this amount
is not usually clinically significant. However, this average finding masks
a wide range of individual variation, as some patients appear to be more
susceptible and undergo more marked root resorption. Evidence would
suggest a genetic basis in these cases. In teeth with periodontal attach-
ment loss or already shortened roots, the impact of root resorption will
be higher (Fig. 1.4).
1.6.2 Loss of periodontal support
An increase in gingival inflammation is commonly seen following the
placement of fixed appliances as a result of reduced access for cleaning
and if oral hygiene is consistently poor, gingival hyperplasia may develop
(Fig. 1.5). This normally reduces or resolves following removal of the appli-
ance, but some apical migration of periodontal attachment and alveolar
bony support is usual during a 2-year course of orthodontic treatment.
In most patients this is minimal but in individuals who are susceptible
to periodontal disease, more marked loss may occur. Removable appli-
ances may also be associated with gingival inflammation, particularly of
the palatal tissues, in the presence of poor oral hygiene.
Orthodontic movement of teeth outside the envelope of alveo-
lar bone can result in loss of buccal or less commonly lingual bone,
increasing the risk of bony dehiscence and gingival recession. The risk
is higher in patients with a narrow alveolus, thin gingival biotype, or
existing crowding where teeth have been pushed outside the alveolar
bone (Fig. 1.6).

(a) (b) (c)

Fig. 1.4 (a) A patient with a shortened right maxillary central incisor root pre-treatment. A risk–benefit analysis is necessary to determine whether
the risk of further resorption is justified by the potential benefit of treatment. (b) A monitoring periapical radiograph of the right central and lateral
incisor 6 months into treatment shows little further resoprtion of the central incisor root; however, some resoprtion of the apical tip of the lateral
­incisor root was noted. (c) A further radiograph of the incisors 6 months later confirmed there was no significant progress in the root shortening.

Fig. 1.5 Gingival hyperplasia in the upper

labial segment during fixed appliance treat-
ment (a) and at the time of appliance removal
(b). The gingival hyperplasia is expected to
fully resolve following removal of the
(a) (b) appliance.

Fig. 1.6 Teeth that are buccally positioned

outside the alveolar bone due to crowding (a)
are at increased risk of gingival recession dur-
ing orthodontic alignment (b). At-risk patients
must be informed of potential worsening of
the gingival recession prior to commencing
(a) (b) orthodontic treatment.
8 The rationale for orthodontic treatment
1.6.3 Demineralization
Demineralized white lesions are an early, reversible stage in the devel-
opment of dental caries, which occur when a cariogenic plaque accu-
mulates in association with a high-sugar diet. If white spot lesions are
not managed early and effectively they can cause permanent dam-
age and even progress to frank caries. The presence of a fixed appli-
ance predisposes to plaque accumulation, as tooth cleaning around
the components of the appliance is more difficult. Demineralization
during treatment with fixed appliances is a real risk, with a reported
prevalence of between 2% and 96% (see Section 18.7). Although there
is evidence to show that the lesions regress following removal of the
appliance, patients may still be left with permanent ‘scarring’ of the
enamel (Fig. 1.7).
1.6.4 Enamel damage
Enamel damage can occur as a result of trauma or wear from the
orthodontic appliances. Band seaters, band removers, and bracket
removal can cause fracture of enamel, or even whole cusps in heavily
restored teeth. During removal of adhesives, the debonding burs can
cause enamel damage, particularly if used in a high-speed handpiece.
Certain components of orthodontic appliances can cause wear to
opposing tooth enamel if there is heavily occlusal contact during func-
tion. This is a particular concern if ceramic brackets are used in the
lower arch in cases with a deep overbite or where buccal crossbites
are present.
1.6.5 Intra-oral soft tissue damage
Ulceration can occur during treatment as a result of direct trauma from
both fixed and removable appliances, although it is more commonly
seen in association with fixed components as an uncomfortable remov-
able appliance is usually removed. Lesions generally heal within a few
days without lasting effect.
Intra-oral allergic reactions to orthodontic components are rare
but have been reported in relation to nickel, latex, and acrylate.
Fig. 1.7 Demineralization on the buccal surfaces of the incisor and
canine teeth during fixed appliance treatment. After repeated attempts
to control risk factors, treatment was abandoned to prevent further
enamel damage.
Management depends on the location and severity of the allergic reac-
tion and the scope for modifying treatment.
1.6.6 Pulpal injury
Excessive apical root movement can lead to a reduction in blood supply to
the pulp and even pulpal death. Teeth which have undergone a previous
episode of trauma appear to be particularly susceptible, probably because
the pulpal tissues are already compromised. Any teeth that have previ-
ously suffered trauma or that are judged to be at risk of pulpal injury require
thorough examination prior to orthodontic treatment, and any orthodon-
tic treatment should be delivered with light force and careful monitoring.
1.6.7 Extra-oral damage
Some authors have expressed concern over detrimental effects to the
facial profile as a result of orthodontics, particularly retraction of anterior
teeth in conjunction with extractions. While a number of studies have
shown little difference in profile between extraction and non-extraction
treatment, it is important that when treatment planning to correct mal-
occlusion, the impact on overall facial appearance is considered.
Contact dermatitis is reported in approximately 1% of the population
and allergic reactions may be seen on facial skin in response to compo-
nents of appliances, usually nickel. This may be managed by covering
metal components with tape to prevent contact, or alternative treat-
ment methods may be sought depending in the severity of the reaction.
Recoil injury from the elastic components of headgear poses a rare
but potentially severe risk of damage to the eyes. This is discussed in
more detail in Chapter 15 (see Section 15.5.3). Iatrogenic skin damage,
such as burns from acid etch or hot instruments, are avoidable using the
usual precautions employed in other fields of dentistry.
1.6.8 Relapse
Relapse is defined as the return of features of the original malocclusion
following correction. Retention is a method to retain the teeth in their
corrected position, and it is now accepted that without retention there
is a significant risk the teeth will move. The extent of relapse is highly
variable and difficult to predict but any undesirable tooth movement fol-
lowing orthodontic treatment will reduce the net benefit of orthodontic
treatment. Relapse and retention are covered in detail in Chapter 16.
1.6.9 Failure to achieve treatment objectives
When deciding whether orthodontic treatment is likely to be benefi-
cial it is important to consider the effectiveness of appliance therapy
in correcting the malocclusion. There are a number of operator- and
patient-related factors that may prevent treatment achieving a worth-
while improvement (Table 1.4).
Errors in diagnosis, treatment planning, and delivery can lead to
poor selection of appliances and ineffective treatment. It is essential
to determine whether planned tooth movements are attainable within
the constraints of the skeletal and growth patterns of the individual
patient, as excessive tooth movement or failure to anticipate adverse
growth changes will reduce the chances of success (Chapter 7). There
is evidence that orthodontic treatment is more likely to achieve a pleas-
ing and successful result if the operator has had some postgraduate
 Discussing orthodontic treatment need 9

training in orthodontics, as this supports appropriate appliance selec-

Table 1.4 Failure to achieve treatment objectives
Operator factors
Errors of diagnosis
Errors of treatment planning
Anchorage loss
Technique errors
Poor communication
Inadequate experience/
training
Patient factors
Poor oral hygiene/diet
Failure to wear appliances/elastics
Repeated appliance breakages
Failure to attend appointments
Unexpected unfavourable growth
tion and use.
Patient co-operation is essential to achieve a successful outcome.
Patients must attend appointments, look after their teeth and appli-
ances, and comply with wear and care instructions. Patients are more
likely to co-operate if they, and their family, fully understand the process
and their role from the outset. This should be explicitly stated during the
consent process. It is important to establish that the patient and f­ amily
feel willing and able to adhere to the agreed treatment plan before
commencing treatment. Long-term effectiveness of treatment depends
on patients’ commitment to life-long retainer wear and this must be
stressed at the beginning of discussions about orthodontic treatment
(see Chapter 16).

1.7 Discussing orthodontic treatment need

It is important that patients and families are involved in the discussion
about whether orthodontic treatment is needed and justified. Patients
and their families have a key role in providing information about the
impact of malocclusion, expectations from treatment, and their desired
outcome. The clinician’s role is to provide unbiased information about
the potential risks and benefits of treatment based on best available
evidence and their own clinical experience. General information should
be tailored to the individual’s clinical presentation and personal circum-
stance. Patients and families should be supported to participate in the
decision about whether treatment is likely to provide sufficient ben-
efit to outweigh any risks. Patients also have a vital role in determining
whether they are likely to be able to comply with treatment adequately
to achieve a satisfactory outcome. Treatment planning and consent are
covered in more detail in Chapter 7.

Key points

• The decision whether to embark on orthodontic treatment is essentially a risk–benefit analysis.

• The perceived benefits of orthodontic intervention should outweigh any potential risks associated with treatment.
• Patients and families have an important role in determining whether treatment is likely to address issues caused by the malocclusion.

Relevant Cochrane reviews

Benson, P. E., Parkin, N., Dyer, F., Millett, D.T., Furness, S., and Germain, P. (2013). Fluorides for the prevention of early tooth decay (demineralised white
lesions) during fixed brace treatment. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD003809. DOI: 10.1002/14651858.CD003809.pub3.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003809.pub3/full
The authors report that (1) fluoride varnish applied every 6 weeks provided moderate-quality evidence of around 70% reduction in demineralized
white lesions, and (2) no difference was found between different formulations of fluoride toothpaste and mouth rinse on white spot index, visible
plaque index, and gingival bleeding index.

Principal sources and further reading

American Journal of Orthodontics and Dentofacial Orthopedics, 1992,
101(1).
This is a special issue dedicated to the results of several studies set up
by the American Association of Orthodontists to investigate the link
between orthodontic treatment and the temporomandibular joint.
Davies, S. J., Gray, R. M. J., Sandler, P. J., and O’Brien, K. D. (2001). Orthodon-
tics and occlusion. British Dental Journal, 191, 539–49. [DOI: 10.1038/
sj.bdj.4801229] [PubMed: 11767855]
This concise article is part of a series of articles on occlusion. It contains
an example of an articulatory examination.
10 The rationale for orthodontic treatment
DiBiase, A. T. and Sandler, P. J. (2001). Malocclusion, orthodontics and bully-
ing. Dent Update, 28, 464–6. [DOI: 10.12968/denu.2001.28.9.464] [Pub-
Med: 11806190]
An interesting discussion around bullying and the ‘victim type’.
Egermark, I., Magnusson, T., and Carlsson, G. E. (2003). A 20-year follow-up
of signs and symptoms of temporomandibular disorders in subjects with
and without orthodontic treatment in childhood. Angle Orthodontist,
73, 109–15. [DOI: 10.1043/0003-3219(2003)73<109:AYFOSA>2.0.CO]
[PubMed: 12725365].
A long-term cohort study, which found no statistically significant dif-
ference in TMD signs and symptoms between subjects with or without
previous experience of orthodontic treatment.
Guzman-Armstrong, S., Chalmers, J., Warren, J. J. (2011). Readers’ forum:
White spot lesions: prevention and treatment. American Journal of
Orthodontics and Dentofacial Orthopedics, 138, 690–6. [DOI: 10.1016/j.
ajodo.2010.07.007] [PubMed: 21171493]
An interesting and informative read on decalcification during ortho-
dontic treatment.
Helm, S. and Petersen, P. E. (1989). Causal relation between malocclu-
sion and caries. Acta Odontologica Scandinavica, 47, 217–21. [DOI:
10.3109/00016358909007704] [PubMed: 2782059]
A historic paper that demonstrates no link between malocclusion and
caries.
Joss-Vassalli, I., Grebenstein, C., Topouzelis, N., Sculean, A., and Katsa-
ros, C. (2010). Orthodontic therapy and gingival recession: a system-
atic review. Orthodontics and Craniofacial Research, 13, 127–41. [DOI:
10.1111/j.1601-6343.2010.01491.x] [PubMed: 20618715]
Kenealy, P. M., Kingdon, A., Richmond, S., and Shaw, W. C. (2007). The Car-
diff dental study: a 20-year critical evaluation of the psychological health
gain from orthodontic treatment. British Journal of Health Psychology, 12,
17–49. [DOI: 10.1348/135910706X96896] [PubMed: 17288664]
An interesting paper highlighting the complexities of self-esteem.
Luther, F. (2007). TMD and occlusion part I. Damned if we do? Occlusion the
interface of dentistry and orthodontics. British Dental Journal, 202, E2.
Luther, F. (2007). TMD and occlusion part II. Damned if we don’t? Functional
occlusal problems: TMD epidemiology in a wider context. British Dental
Journal, 202, E3.
These two articles are well worth reading.
Maaitah, E. F., Adeyami, A. A., Higham, S. M., Pender, N., and Harrison, J.
E. (2011). Factors affecting demineralization during orthodontic treat-
ment: a post-hoc analysis of RCT recruits. American Journal of Ortho-
dontics and Dentofacial Orthopedics, 139, 181–91. [DOI: 10.1016/j.
ajodo.2009.08.028] [PubMed: 21300246]
A useful study that concludes that pre-treatment age, oral hygiene, and
status of the first permanent molars can be used as a guide to the likeli-
hood of decalcification occurring during treatment.
Mizrahi, E. (2010). Risk management in clinical practice. Part 7. Dento-legal
aspects of orthodontic practice. British Dental Journal, 209, 381–90.
[DOI: 10.1038/sj.bdj.2010.926] [PubMed: 20966997].
References for this chapter can also be found at: www.oup.com/uk/orthodontics5e. Where possible, these are presented as active links
that direct you to the electronic version of the work to help facilitate onward study. If you are a subscriber to that work (either individually or
through an institution), and depending on your level of access, you may be able to peruse an abstract or the full article if available.
Murray, A. M. (1989). Discontinuation of orthodontic treatment: a study of
the contributing factors. British Journal of Orthodontics, 16, 1–7. [DOI:
10.1179/bjo.16.1.1] [PubMed: 2647133].
Nguyen, Q. V., Bezemer, P. D., Habets, L., and Prahl-Andersen, B. (1999).
A systematic review of the relationship between overjet size and trau-
matic dental injuries. European Journal of Orthodontics, 21, 503–15. [DOI:
10.1093/ejo/21.5.503] [PubMed: 10565091].
Petti, S. (2015). Over two hundred million injuries to anterior teeth attribut-
able to large overjet: a meta-analysis. Dental Traumatology, 31, 1–8. [DOI:
10.1111/edt.12126] [PubMed: 25263806]
Two systematic reviews that demonstrate the relationship between
increased overjet and dental trauma.
Roberts-Harry, D. and Sandy, J. (2003). Orthodontics. Part 1: who
needs orthodontics? British Dental Journal, 195, 433. [DOI: 10.1038/
sj.bdj.4810592] [PubMed: 14576790]
A summary of the potential benefits of orthodontic treatment.
Seehra, J., Newton, J. T., and Dibiase A. T. (2011). Bullying in schoolchildren
– its relationship to dental appearance and psychosocial implications:
an update for GDPs. British Dental Journal, 210, 411–15. [DOI: 10.1038/
sj.bdj.2011.339] [PubMed: 21566605]
A useful summary of bullying and its relationship to malocclusion.
Steele, J., White, D., Rolland, S., and Fuller, E. (2015). Children’s Dental Health
Survey 2013. Report 4: The burden of dental disease in children: England,
Wales and Northern Ireland. Leeds: Health and Social Care Information
Centre.
Tsakos, G., Hill, K., Chadwick B., and Anderson, T. (2015). Children’s Dental
Health Survey 2013. Report 1: Attitudes, behaviours and Children’s Dental
Health: England, Wales and Northern Ireland. Leeds: Health and Social
Care Information Centre.
The reports from the 2013 Child Dental Health Survey, highlighting
orthodontic treatment need.
Travess, H., Roberts-Harry, D., and Sandy, J. (2004). Orthodontics. Part 6:
Risks in orthodontic treatment. British Dental Journal, 196, 71–7. [DOI:
10.1038/sj.bdj.4810891] [PubMed: 14739957]
A follow-up to the previous article by the same authors to outline the
risks of orthodontic treatment, illustrated with cases.
Weltman, B., Vig, K. W., Fields, H. W., Shanker, S., and Kaizar, E. E. (2010). Root
resorption associated with orthodontic tooth movement: a systematic
review. American Journal of Orthodontics and Dentofacial Orthopedics,
137, 462–76. [DOI: 10.1016/j.ajodo.2009.06.021] [PubMed: 20362905]
Wheeler, T. T., McGorray, S. P., Yurkiewicz, L., Keeling, S. D., and King, G.
J. (1994). Orthodontic treatment demand and need in third and fourth
grade schoolchildren. American Journal of Orthodontics and Dentofacial
Orthopedics, 106, 22–33. [DOI: 10.1016/S0889-5406(94)70017-6] [Pub-
Med: 8017346]
Contains a good discussion on the need and demand for treatment.
Zhang, M., McGrath, C., and Hägg, U. (2006). The impact of malocclusion and
its treatment on quality of life: a literature review. International Journal of
Paediatric Dentistry, 16, 381–7. [DOI: 10.1111/j.1365-263X.2006.00768.x]
[PubMed: 17014535]
2
The aetiology and
classification of
malocclusion
L. Mitchell
Chapter contents
2.1 The aetiology of malocclusion12
2.2 Classifying malocclusion13
2.2.1 Qualitative assessment of malocclusion 13
2.2.2 Quantitative assessment of malocclusion 13
2.3 Commonly used classifications and indices13
2.3.1 Angle’s classification 13
2.3.2 British Standards Institute classification 13
2.3.3 Index of Orthodontic Treatment Need (IOTN) 13
2.3.4 Peer Assessment Rating (PAR) 15
2.3.5 Index of Complexity, Outcome and Need (ICON) 15
2.3.6 Index of Orthognathic Functional Treatment
Need (IOFTN) 15
2.4 Andrews’ six keys18

Principal sources and further reading19

12 The aetiology and classification of malocclusion
Learning objectives for this chapter
• Be aware of current understanding of the aetiology of malocclusion.
• Achieve an insight into classifying malocclusion.
• Gain an understanding of the commonly used classifications and indices.
2.1 The aetiology of malocclusion
An ideal occlusion is defined as an anatomically perfect arrangement
of the teeth. While previously orthodontists may have concentrated on
achieving a static, anatomically correct occlusion, it is now accepted that
a functional occlusion is more important (see Box 2.1). It is important
to realize that malocclusion is not in itself a disease; rather, it describes
variation around the ideal.
The aetiology of malocclusion is a fascinating subject about which
there is still much to elucidate and understand. Theoretically, malocclu-
sion can occur as a result of genetically determined factors which are
inherited, or environmental factors, or a combination of both inherited
and environmental factors acting together. For example, failure of erup-
tion of an upper central incisor may arise as a result of dilaceration fol-
lowing an episode of trauma during the deciduous dentition which led
to intrusion of the primary predecessor—an example of environmental
aetiology. Failure of eruption of an upper central incisor can also occur
as a result of the presence of a supernumerary tooth—a scenario which
questioning may reveal also affected the patient’s parent, suggesting an
inherited problem. However, if in the latter example, caries (an envi-
ronmental factor) has led to early loss of many of the deciduous teeth
then forward drift of the first permanent molar teeth may also lead to
superimposition of the additional problem of crowding.
While it is relatively straightforward to trace the inheritance of syn-
dromes such as cleft lip and palate (see Chapter 24), it is more difficult to
determine the aetiology of features which are in essence part of normal
variation, and the picture is further complicated by the compensatory
mechanisms that exist. Evidence for the role of inherited factors in the
aetiology of malocclusion has come from studies of families and twins.
The facial similarity of members of a family, for example, the prognathic
mandible of the Hapsburg royal family, is easily appreciated. However,
more direct testimony is provided in studies of twins and triplets, which
indicate that skeletal pattern and tooth size and number are largely
genetically determined.
Examples of environmental influences include digit-sucking habits
and premature loss of teeth as a result of either caries or trauma. Soft
tissue pressures acting upon the teeth for more than 6 hours per day can
also influence tooth position. However, because the soft tissues includ-
ing the lips are by necessity attached to the underlying skeletal frame-
work, their effect is also mediated by the skeletal pattern.
Crowding is extremely common in Caucasians, affecting approxi-
mately two-thirds of the population. As was mentioned above, the size
of the jaws and teeth are mainly genetically determined; however, envi-
ronmental factors, for example, premature deciduous tooth loss, can
precipitate or exacerbate crowding. In evolutionary terms both jaw size
and tooth size appear to be reducing. However, crowding is much more
prevalent in modern populations than it was in prehistoric times. It has
been postulated that this is due to the introduction of a less abrasive
diet, so that less interproximal tooth wear occurs during the lifetime
of an individual. However, this is not the whole story, as a change from
a rural to an urban lifestyle can also apparently lead to an increase in
crowding after about two generations.
Although this discussion may at first seem rather theoretical, the aeti-
ology of malocclusion is a vigorously debated subject. This is because if
one believes that the basis of malocclusion is genetically determined,
then it follows that orthodontics is limited in what it can achieve.
However, the opposite viewpoint is that every individual has the poten-
tial for ideal occlusion and that orthodontic intervention is required to
eliminate those environmental factors that have led to a particular mal-
occlusion. It is now acknowledged that the majority of malocclusions
are caused by both inherited polygenic and environmental factors and
the interplay between them. Malocclusion is not a single disease, but a
collection of abnormal traits. These traits can be the result of complex
interactions between different genes, interactions between genes and
the environment (epigenetics), and distinct environmental factors.
When planning treatment for an individual patient, it is often helpful
to consider the role of the following in the aetiology of their malocclu-
sion. Further discussion of these factors will be considered in the forth-
coming chapters covering the main types of malocclusion:
1. Skeletal pattern—in all three planes of space
2. Soft tissues
3. Dental factors.
Of necessity, the above is a brief summary, but it can be appreciated
that the aetiology of malocclusion is a complex subject. The reader
seeking more information is advised to consult the publications listed
in the section on ‘Principal sources and further reading’ at the end of
this chapter.
Box 2.1 Functional occlusion
• An occlusion which is free of interferences to smooth gliding
movements of the mandible with no pathology.
• Orthodontic treatment should aim to achieve a functional
occlusion.
• But there is a lack of evidence to indicate that if an ideal
functional occlusion is not achieved that there are deleterious
long-term effects on the temporomandibular joints.

2.2 Classifying malocclusion
The categorization of a malocclusion by its salient features is helpful
for describing and documenting a patient’s occlusion. In addition, clas-
sifications and indices allow the prevalence of a malocclusion within
a population to be recorded, and also aid in the assessment of need,
difficulty, and success of orthodontic treatment.
Malocclusion can be recorded qualitatively and quantitatively.
However, the large number of classifications and indices which have
been devised are testimony to the problems inherent in both these
approaches. All have their limitations, and these should be borne in
mind when they are applied (Box 2.2).
2.2.1 Qualitative assessment of malocclusion
Essentially, a qualitative assessment is descriptive and therefore this cat-
egory includes the diagnostic classifications of malocclusion. The main
drawback to a qualitative approach is that malocclusion is a continu-
ous variable so that clear cut-off points between different categories do
not always exist. This can lead to problems when classifying borderline
malocclusions. In addition, although a qualitative classification is a help-
ful shorthand method of describing the salient features of a malocclu-
sion, it does not provide any indication of the difficulty of treatment.
Qualitative evaluation of malocclusion was attempted historically
before quantitative analysis. One of the better-known classifications
was devised by Angle in 1899, but other classifications are now more
2.3 Commonly used classifications and indices
2.3.1 Angle’s classification
Angle’s classification was based upon the premise that the first perma-
nent molars erupted into a constant position within the facial skeleton,
which could be used to assess the anteroposterior relationship of the
arches. In addition to the fact that Angle’s classification was based
upon an incorrect assumption, the problems experienced in categoriz-
ing cases with forward drift or loss of the first permanent molars have
resulted in this particular approach being superseded by other classi-
fications. However, Angle’s classification is still used to describe molar
relationship, and the terms used to describe incisor relationship have
been adapted into incisor classification.
Angle described three groups (Fig. 2.1):
• Class I or neutrocclusion—the mesiobuccal cusp of the upper first
molar occludes with the mesiobuccal groove of the lower first molar.
In practice, discrepancies of up to half a cusp width either way were
also included in this category.
• Class II or distocclusion—the mesiobuccal cusp of the lower first
molar occludes distal to the Class I position. This is also known as a
postnormal relationship.
• Class III or mesiocclusion—the mesiobuccal cusp of the lower first
molar occludes mesial to the Class I position. This is also known as a
prenormal relationship.
Commonly used classifications and indices 13
Box 2.2 Important attributes of an index
• Validity—can the index measure what it was designed to
measure?
• Reproducibility—does the index give the same result
when recorded on two different occasions and by different
examiners?
• Acceptability—is the index acceptable to both professionals
and patients?
• Ease of use—is the index straightforward to use?
widely used, for example, the British Standards Institute (1983) clas-
sification of incisor relationship.
2.2.2 Quantitative assessment of malocclusion
In quantitative indices, two differing approaches can be used:
• Each feature of a malocclusion is given a score and the summed total
is then recorded (e.g. the Peer Assessment Rating (PAR) Index).
• The worst feature of a malocclusion is recorded (e.g. the Index of
Orthodontic Treatment Need (IOTN)).
2.3.2 British Standards Institute classification
This is based upon incisor relationship and is the most widely used
descriptive classification. The terms used are similar to those of Angle’s
classification, which can be a little confusing as no regard is taken of
molar relationship. The categories defined by British Standard 4492 are
shown in Box 2.3 (see also Figs 2.2, 2.3, 2.4, and 2.5).
As with any descriptive analysis, it is difficult to classify borderline
cases. Some workers have suggested introducing a Class II intermediate
category for those cases where the upper incisors are upright and the
overjet increased to between 4 and 6 mm. However, this approach has
not gained widespread acceptance.
2.3.3 Index of Orthodontic Treatment
Need (IOTN)
The IOTN was developed as a result of a government initiative. The
purpose of the index was to help determine the likely impact of a maloc-
clusion on an individual’s dental health and psychosocial well-being. It
comprises two elements.
Dental health component
This was developed from an index used by the Dental Board in Sweden
designed to reflect those occlusal traits which could affect the function
14 The aetiology and classification of malocclusion

Box 2.3 British Standards incisor classification

• Class I—the lower incisor edges occlude with or lie immedi-

ately below the cingulum plateau of the upper central incisors.
• Class II—the lower incisor edges lie posterior to the cingulum
plateau of the upper incisors. There are two subdivisions of this
category:
• Division 1—the upper central incisors are proclined or of
average inclination and there is an increase in overjet.
• Division 2—the upper central incisors are retroclined. The
overjet is usually minimal or may be increased.
• Class III—the lower incisor edges lie anterior to the cingulum Fig. 2.2 Incisor classification—Class I.
plateau of the upper incisors. The overjet is reduced or reversed.

 ermission to reproduce extracts from British Standards is granted by

P
BSI. British Standards can be obtained in PDF or hard copy formats
from the BSI online shop: www.bsigroup.com/Shop or by contacting BSI
Customer Services for hardcopies only: Tel: +44 (0)20 8996 9001, Email:
cservices@bsigroup.com

Fig. 2.3 Incisor classification—Class II division 1.

Fig. 2.4 Incisor classification—Class II division 2.

Fig. 2.1 Angle’s classification. Fig. 2.5 Incisor classification—Class III.


and longevity of the dentition. The single worst feature of a malocclu-
sion is noted (the index is not cumulative) and categorized into one of
five grades reflecting need for treatment (Box 2.4):
• Grade 1—no need
• Grade 2—little need
• Grade 3—moderate need
• Grade 4—great need
• Grade 5—very great need.
(The Index of Orthodontic Treatment Need (IOTN) is the property of The University
of Manchester. © The University of Manchester 2018. All rights reserved.
Reproduced by kind permission of The University of Manchester.
The SCAN scale was first published in 1987 by the European Orthodontic Society
(Ruth Evans and William Shaw, Preliminary evaluation of an illustrated scale for rat-
ing dental attractiveness. European Journal of Orthodontics 9: 314 – 318.)
A ruler has been developed to help with assessment of the den-
tal health component (Fig. 2.6), and these are available commer-
cially. As only the single worst feature is recorded, an alternative
approach is to look consecutively for the following features (known
as MOCDO):
• Missing teeth
• Overjet
• Crossbite
• Displacement (contact point)
• Overbite.
Aesthetic component
This aspect of the index was developed in an attempt to assess the aes-
thetic handicap posed by a malocclusion and thus the likely psycho-
social impact upon the patient—a difficult task (see Chapter 1). The
aesthetic component comprises a set of ten standard photographs (Fig.
2.7), which are also graded from score 1, the most aesthetically pleas-
ing, to score 10, the least aesthetically pleasing. Colour photographs are
available for assessing a patient in the clinical situation and black-and-
white photographs for scoring from study models alone. The patient’s
teeth (or study models), in occlusion, are viewed from the anterior
aspect and the appropriate score determined by choosing the photo-
graph that is thought to pose an equivalent aesthetic handicap. The
scores are categorized according to need for treatment as follows:
• Score 1 or 2—none
• Score 3 or 4—slight
• Score 5, 6, or 7—moderate/borderline
• Score 8, 9, or 10—definite.
(Reproduced from Evans, R. and Shaw, W. C., A preliminary evaluation of an
illustrated scale for rating dental attractiveness. European Journal of Orthodontics,
9, pp. 314–318. Copyright (1987) with permission from Oxford University Press.)
An average score can be taken from the two components, but the
dental health component alone is more widely used. The aesthetic
component has been criticized for being subjective—particular diffi-
culty is experienced in accurately assessing Class III malocclusions or
anterior open bites, as the photographs are composed of Class I and
Class II cases, but studies have indicated good reproducibility.
Commonly used classifications and indices 15
2.3.4 Peer Assessment Rating (PAR)
The PAR index was developed primarily to measure the success (or oth-
erwise) of treatment. Scores are recorded for a number of parameters
(listed below), before and at the end of treatment using study mod-
els. Unlike IOTN, the scores are cumulative; however, a weighting is
accorded to each component to reflect current opinion in the UK as to
their relative importance. The features recorded are listed as follows,
with the current weightings in parentheses:
• Crowding—by contact point displacement (×1)
• Buccal segment relationship—in the anteroposterior, vertical, and
transverse planes (×1)
• Overjet (×6)
• Overbite (×2)
• Centrelines (×4).
The difference between the PAR scores at the start and on completion
of treatment can be calculated, and from this the percentage change in
PAR score, which is a reflection of the success of treatment, is derived. A
high standard of treatment is indicated by a mean percentage reduction
of greater than 70%. A change of 30% or less indicates that no appreci-
able improvement has been achieved. The size of the PAR score at the
beginning of treatment gives an indication of the severity of a malocclu-
sion. Obviously it is difficult to achieve a significant reduction in PAR in
cases with a low pre-treatment score.
2.3.5 Index of Complexity, Outcome and
Need (ICON)
This index incorporates features of both the IOTN and the PAR.
The following are scored and then each score is multiplied by its
weighting:
• Aesthetic component of IOTN (×7)
• Upper arch crowding/spacing (×5)
• Crossbite (×5)
• Overbite/open bite (×4)
• Buccal segment relationship (×3).
The total sum gives a pre-treatment score, which is said to reflect
the need for, and likely complexity of, the treatment required. A score
of more than 43 is said to indicate a demonstrable need for treatment.
Following treatment, the index is scored again to give an improvement
grade and thus the outcome of treatment.
Improvement grade = pre-treatment score – (4 × post-treatment score)
This ambitious index has been criticized for the large weighting
given to the aesthetic component and has not gained widespread
acceptability.
2.3.6 Index of Orthognathic Functional
Treatment Need (IOFTN)
Although the IOTN has proved a reliable method of assessing malocclu-
sion, like any index, it does have its limitations. Many of these relate to
16 The aetiology and classification of malocclusion

Box 2.4 The Index of Orthodontic Treatment Need

Grade 5 (Very Great)

5a Increased overjet greater than 9 mm.

5h Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics.

5i Impeded eruption of teeth (with the exception of third molars) due to crowding, displacement, the presence of supernumerary teeth,
retained deciduous teeth, and any pathological cause.

5m Reverse overjet greater than 3.5 mm with reported masticatory and speech difficulties.

5p Defects of cleft lip and palate.

5s Submerged deciduous teeth.

Grade 4 (Great)

4a Increased overjet 6.1–9 mm.

4b Reversed overjet greater than 3.5 mm with no masticatory or speech difficulties.

4c Anterior or posterior crossbites with greater than 2 mm discrepancy between retruded contact position and intercuspal position.

4d Severe displacement of teeth, greater than 4 mm.

4e Extreme lateral or anterior open bites, greater than 4 mm.

4f Increased and complete overbite with gingival or palatal trauma.

4h Less extensive hypodontia requiring pre-restorative orthodontic space closure to obviate the need for a prosthesis.

4l Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments.

4m Reverse overjet 1.1–3.5 mm with recorded masticatory and speech difficulties.

4t Partially erupted teeth, tipped and impacted against adjacent teeth.

4x Supplemental teeth.

Grade 3 (Moderate)

3a Increased overjet 3.6–6 mm with incompetent lips.

3b Reverse overjet 1.1–3.5 mm.

3c Anterior or posterior crossbites with 1.1–2 mm discrepancy.

3d Displacement of teeth 2.1–4 mm.

3e Lateral or anterior open bite 2.1–4 mm.

3f Increased and complete overbite without gingival trauma.

Grade 2 (Little)

2a Increased overjet 3.6–6 mm with competent lips.

2b Reverse overjet 0.1–1 mm.

2c Anterior or posterior crossbite with up to 1 mm discrepancy between retruded contact position and intercuspal position.

2d Displacement of teeth 1.1–2 mm.

2e Anterior or posterior open bite 1.1–2 mm.

2f Increased overbite 3.5 mm or more, without gingival contact.

2g Prenormal or postnormal occlusions with no other anomalies; includes up to half a unit discrepancy.

Grade 1 (None)

1 Extremely minor malocclusions including displacements less than 1 mm.

The Index of Orthodontic Treatment Need (IOTN) is the property of The University of Manchester. © The University of Manchester 2018. All rights reserved. Reproduced
by kind permission of The University of Manchester. The SCAN scale was first published in 1987 by the European Orthodontic Society (Ruth Evans and William Shaw,
Preliminary evaluation of an illustrated scale for rating dental attractiveness. European Journal of Orthodontics 9: 314–318).
Another random document with
no related content on Scribd:
 FOOTNOTES:
[5] Atlantic Monthly, August, 1894.
 V
PHASES OF STATE LEGISLATION[6]

THE ALBANY LEGISLATURE.

Few persons realize the magnitude of the interests affected by
State legislation in New York. It is no mere figure of speech to call
New York the Empire State; and many of the laws most directly and
immediately affecting the interests of its citizens are passed at
Albany, and not at Washington. In fact, there is at Albany a little
home rule parliament which presides over the destinies of a
commonwealth more populous than any one of two thirds of the
kingdoms of Europe, and one which, in point of wealth, material
prosperity, variety of interests, extent of territory, and capacity for
expansion, can fairly be said to rank next to the powers of the first
class. This little parliament, composed of one hundred and twenty-
eight members in the Assembly and thirty-two in the Senate, is, in
the fullest sense of the term, a representative body; there is hardly
one of the many and widely diversified interests of the State that has
not a mouthpiece at Albany, and hardly a single class of its citizens—
not even excepting, I regret to say, the criminal class—which lacks
its representative among the legislators. In the three Legislatures of
which I have been a member, I have sat with bankers and
bricklayers, with merchants and mechanics, with lawyers, farmers,
day-laborers, saloonkeepers, clergymen, and prize-fighters. Among
my colleagues there were many very good men; there was a still
more numerous class of men who were neither very good nor very
bad, but went one way or the other, according to the strength of the
various conflicting influences acting around, behind, and upon them;
and, finally, there were many very bad men. Still, the New York
Legislature, taken as a whole, is by no means as bad a body as we
would be led to believe if our judgment was based purely on what we
read in the great metropolitan papers; for the custom of the latter is
to portray things as either very much better or very much worse than
they are. Where a number of men, many of them poor, some of them
unscrupulous, and others elected by constituents too ignorant to hold
them to a proper accountability for their actions, are put into a
position of great temporary power, where they are called to take
action upon questions affecting the welfare of large corporations and
wealthy private individuals, the chances for corruption are always
great; and that there is much viciousness and political dishonesty,
much moral cowardice, and a good deal of actual bribe-taking in
Albany, no one who has had any practical experience of legislation
can doubt; but, at the same time, I think that the good members
generally outnumber the bad, and that there is not often doubt as to
the result when a naked question of right or wrong can be placed
clearly and in its true light before the Legislature. The trouble is that
on many questions the Legislature never does have the right and
wrong clearly shown it. Either some bold, clever parliamentary
tactician snaps the measure through before the members are aware
of its nature, or else the obnoxious features are so combined with
good ones as to procure the support of a certain proportion of that
large class of men whose intentions are excellent, but whose
intellects are foggy. Or else the necessary party organization, which
we call the “machine,” uses its great power for some definite evil
aim.

THE CHARACTER OF THE REPRESENTATIONS.

The representatives from different sections of the State differ
widely in character. Those from the country districts are generally
very good men. They are usually well-to-do farmers, small lawyers,
or prosperous store-keepers, and are shrewd, quiet, and honest.
They are often narrow-minded and slow to receive an idea; but, on
the other hand, when they get a good one, they cling to it with the
utmost tenacity. They form very much the most valuable class of
legislators. For the most part they are native Americans, and those
who are not are men who have become completely Americanized in
all their ways and habits of thought. One of the most useful members
of the last Legislature was a German from a western county, and the
extent of his Americanization can be judged from the fact that he
was actually an ardent prohibitionist: certainly no one who knows
Teutonic human nature will require further proof. Again, I sat for an
entire session beside a very intelligent member from northern New
York before I discovered that he was an Irishman: all his views of
legislation, even upon such subjects as free schools and the
impropriety of making appropriations from the treasury for the
support of sectarian institutions, were precisely similar to those of his
Protestant-American neighbors, though he was himself a Catholic.
Now a German or an Irishman from one of the great cities would
probably have retained many of his national peculiarities.
It is from these same great cities that the worst legislators come. It
is true that there are always among them a few cultivated and
scholarly men who are well educated, and who stand on a higher
and broader intellectual and moral plane than the country members,
but the bulk are very low indeed. They are usually foreigners, of little
or no education, with exceedingly misty ideas as to morality, and
possessed of an ignorance so profound that it could only be called
comic, were it not for the fact that it has at times such serious effects
upon our laws. It is their ignorance, quite as much as actual
viciousness, which makes it so difficult to procure the passage of
good laws or prevent the passage of bad ones; and it is the most
irritating of the many elements with which we have to contend in the
fight for good government.

DARK SIDE OF THE LEGISLATIVE PICTURE.

 Mention has been made above of the bribe-taking which
undoubtedly at times occurs in the New York Legislature. This is
what is commonly called “a delicate subject” with which to deal, and,
therefore, according to our usual methods of handling delicate
subjects, it is either never discussed at all, or else discussed with the
grossest exaggeration; but most certainly there is nothing about
which it is more important to know the truth.
In each of the last three legislatures there were a number of us
who were interested in getting through certain measures which we
deemed to be for the public good, but which were certain to be
strongly opposed, some for political and some for pecuniary reasons.
Now, to get through any such measure requires genuine hard work,
a certain amount of parliamentary skill, a good deal of tact and
courage, and above all, a thorough knowledge of the men with whom
one has to deal, and of the motives which actuate them. In other
words, before taking any active steps, we had to “size up” our fellow-
legislators, to find out their past history and present character and
associates, to find out whether they were their own masters or were
acting under the directions of somebody else, whether they were
bright or stupid, etc., etc. As a result, and after very careful study,
conducted purely with the object of learning the truth, so that we
might work more effectually, we came to the conclusion that about a
third of the members were open to corrupt influences in some form
or other; in certain sessions the proportion was greater, and in some
less. Now it would, of course, be impossible for me or for anyone
else to prove in a court of law that these men were guilty, except
perhaps in two or three cases; yet we felt absolutely confident that
there was hardly a case in which our judgment as to the honesty of
any given member was not correct. The two or three exceptional
cases alluded to, where legal proof of guilt might have been
forthcoming, were instances in which honest men were approached
by their colleagues at times when the need for votes was very great;
but, even then, it would have been almost impossible to punish the
offenders before a court, for it would have merely resulted in his
denying what his accuser stated. Moreover, the members who had
been approached would have been very reluctant to come forward,
for each of them felt ashamed that his character should not have
been well enough known to prevent anyone’s daring to speak to him
on such a subject. And another reason why the few honest men who
are approached (for the lobbyist rarely makes a mistake in his
estimate of the men who will be apt to take bribes) do not feel like
taking action in the matter is that a doubtful lawsuit will certainly
follow, which will drag on so long that the public will come to regard
all of the participants with equal distrust, while in the end the
decision is quite as likely to be against as to be for them. Take the
Bradly-Sessions case, for example. This was an incident that
occurred at the time of the faction-fight in the Republican ranks over
the return of Mr. Conkling to the United States Senate after his
resignation from that body. Bradly, an Assemblyman, accused
Sessions, a State Senator, of attempting to bribe him. The affair
dragged on for an indefinite time; no one was able actually to
determine whether it was a case of blackmail on the one hand, or of
bribery on the other; the vast majority of people recollected the
names of both parties, but totally forgot which it was that was
supposed to have bribed the other, and regarded both with equal
disfavor; and the upshot has been that the case is now merely
remembered as illustrating one of the most unsavory phases of the
once-famous Halfbreed-Stalwart fight.

DIFFICULTIES OF PREVENTING AND PUNISHING

CORRUPTION.
From the causes indicated, it is almost impossible to actually
convict a legislator of bribe-taking; but at the same time, the
character of a legislator, if bad, soon becomes a matter of common
notoriety, and no dishonest legislator can long keep his reputation
good with honest men. If the constituents wish to know the character
of their member, they can easily find it out, and no member will be
dishonest if he thinks his constituents are looking at him; he
presumes upon their ignorance or indifference. I do not see how
bribe-taking among legislators can be stopped until the public
conscience becomes awake to the matter. Then it will stop fast
enough; for just as soon as politicians realize that the people are in
earnest in wanting a thing done, they make haste to do it. The
trouble is always in rousing the people sufficiently to make them take
an effective interest,—that is, in making them sufficiently in earnest
to be willing to give a little of their time to the accomplishment of the
object they have in view.
Much the largest percentage of corrupt legislators come from the
great cities; indeed, the majority of the assemblymen from the great
cities are “very poor specimens” indeed, while, on the contrary, the
congressmen who go from them are generally pretty good men. This
fact is only one of the many which go to establish the curious political
law that in a great city the larger the constituency which elects a
public servant, the more apt that servant is to be a good one; exactly
as the Mayor is almost certain to be infinitely superior in character to
the average alderman, or the average city judge to the average civil
justice. This is because the public servants of comparatively small
importance are protected by their own insignificance from the
consequences of their bad actions. Life is carried on at such a high
pressure in the great cities, men’s time is so fully occupied by their
manifold and harassing interests and duties, and their knowledge of
their neighbors is necessarily so limited, that they are only able to fix
in their minds the characters and records of a few prominent men;
the others they lump together without distinguishing between
individuals. They know whether the aldermen, as a body, are to be
admired or despised; but they probably do not even know the name,
far less the worth, of the particular aldermen who represents their
district; so it happens that their votes for aldermen or assemblymen
are generally given with very little intelligence indeed, while, on the
contrary, they are fully competent to pass and execute judgment
upon as prominent an official as a mayor or even a congressman.
Hence it follows that the latter have to give a good deal of attention
to the wishes and prejudices of the public at large, while a city
assemblyman, though he always talks a great deal about the people,
rarely, except in certain extraordinary cases, has to pay much heed
to their wants. His political future depends far more upon the skill
and success with which he cultivates the good-will of certain
“bosses,” or of certain cliques of politicians, or even of certain bodies
and knots of men (such as compose a trade-union, or a collection of
merchants in some special business, or the managers of a railroad)
whose interests, being vitally affected by Albany legislation, oblige
them closely to watch, and to try to punish or reward, the Albany
legislators. These politicians or sets of interested individuals
generally care very little for a man’s honesty so long as he can be
depended upon to do as they wish on certain occasions; and hence
it often happens that a dishonest man who has sense enough not to
excite attention by any flagrant outrage may continue for a number of
years to represent an honest constituency.

THE CONSTITUENTS LARGELY TO BLAME.

Moreover, a member from a large city can often count upon the
educated and intelligent men of his district showing the most gross
ignorance and stupidity in political affairs. The much-lauded
intelligent voter—the man of cultured mind, liberal education, and
excellent intentions—at times performs exceedingly queer antics.
The great public meetings to advance certain political movements
irrespective of party, which have been held so frequently during the
past few years, have undoubtedly done a vast amount of good; but
the very men who attend these public meetings and inveigh against
the folly and wickedness of the politicians will sometimes on election
day do things which have quite as evil effects as any of the acts of
the men whom they very properly condemn. A recent instance of this
is worth giving. In 1882 there was in the Assembly a young member
from New York, who did as hard and effective work for the city of
New York as has ever been done by anyone. It was a peculiarly
disagreeable year to be in the Legislature. The composition of that
body was unusually bad. The more disreputable politicians relied
upon it to pass some of their schemes and to protect certain of their
members from the consequences of their own misdeeds. Demagogic
measures were continually brought forward, nominally in the
interests of the laboring classes, for which an honest and intelligent
man could not vote, and yet which were jealously watched by, and
received the hearty support of, not mere demagogues and agitators,
but also a large number of perfectly honest though misguided
workingmen. And, finally, certain wealthy corporations attempted, by
the most unscrupulous means, to rush through a number of laws in
their own interest. The young member of whom we are speaking
incurred by his course on these various measures the bitter hostility
alike of the politicians, the demagogues, and the members of that
most dangerous of all classes, the wealthy criminal class. He had
also earned the gratitude of all honest citizens, and he got it—as far
as words went. The better class of newspapers spoke well of him;
cultured and intelligent men generally—the well-to-do, prosperous
people who belong to the different social and literary clubs, and their
followers—were loud in his praise. I call to mind one man who lived
in his district who expressed great indignation that the politicians
should dare to oppose his re-election; when told that it was to be
hoped he would help to insure the legislator’s return to Albany by
himself staying at the polls all day, he answered that he was very
sorry, but he unfortunately had an engagement to go quail-shooting
on election day! Most respectable people, however, would
undoubtedly have voted for and re-elected the young member had it
not been for the unexpected political movements that took place in
the fall. A citizens’ ticket, largely non-partisan in character, was run
for certain local offices, receiving its support from among those who
claimed to be, and who undoubtedly were, the best men of both
parties. The ticket contained the names of candidates only for
municipal offices, and had nothing whatever to do with the election of
men to the Legislature; yet it proved absolutely impossible to drill this
simple fact through the heads of a great many worthy people, who,
when election day came round, declined to vote anything but the
citizens’ ticket, and persisted in thinking that if no legislative
candidate was on the ticket, it was because, for some reason or
other, the citizens’ committee did not consider any legislative
candidate worth voting for. All over the city the better class of
candidates for legislative offices lost from this cause votes which
they had a right to expect, and in the particular district under
consideration the loss was so great as to cause the defeat of the
sitting member, or rather to elect him by so narrow a vote as to
enable an unscrupulously partisan legislative majority to keep him
out of his seat.
 It is this kind of ignorance of the simplest political matters among
really good citizens, combined with their timidity, which is so apt to
characterize a wealthy bourgeoisie, and with their short-sighted
selfishness in being unwilling to take the smallest portion of time
away from their business or pleasure to devote to public affairs,
which renders it so easy for corrupt men from the city to keep their
places in the Legislature. In the country the case is different. Here
the constituencies, who are usually composed of honest though
narrow-minded and bigoted individuals, generally keep a pretty
sharp lookout on their members, and, as already said, the latter are
apt to be fairly honest men. Even when they are not honest, they
take good care to act perfectly well as regards all district matters, for
most of the measures about which corrupt influences are at work
relate to city affairs. The constituents of a country member know well
how to judge him for those of his acts which immediately affect
themselves; but as regards others they often have no means of
forming an opinion, except through the newspapers,—more
especially through the great metropolitan newspapers,—and they
have gradually come to look upon all statements made by the latter
with reference to the honesty or dishonesty of public men with
extreme distrust. This is because our newspapers, including those
who professedly stand as representatives of the highest culture of
the community, have been in the habit of making such constant and
reckless assaults upon the characters of even very good public men,
as to greatly detract from their influence when they attack one who is
really bad. They paint everyone with whom they disagree black. As a
consequence the average man, who knows they are partly wrong,
thinks they may also be partly right; he concludes that no man is
absolutely white, and at the same time that no one is as black as he
is painted; and takes refuge in the belief that all alike are gray. It then
becomes impossible to rouse him to make an effort either for a good
man or against a scoundrel. Nothing helps dishonest politicians as
much as this feeling; and among the chief instruments in its
production we must number certain of our newspapers who are
loudest in asserting that they stand on the highest moral plane. As
for the other newspapers, those of frankly “sensational” character,
such as the two which at present claim to have the largest circulation
in New York, there is small need to characterize them; they form a
very great promotive to public corruption and private vice, and are on
the whole the most potent of all the forces for evil which are at work
in the city.

PERILS OF LEGISLATIVE LIFE.

However, there can be no question that a great many men do
deteriorate very much morally when they go to Albany. The last
accusation most of us would think of bringing against that dear, dull,
old Dutch city is that of being a fast place; and yet there are plenty of
members coming from out-of-the-way villages or quiet country towns
on whom Albany has as bad an effect as Paris sometimes has on
wealthy young Americans from the great sea-board cities. Many men
go to the Legislature with the set purpose of making money; but
many others, who afterwards become bad, go there intending to do
good work. These latter may be well-meaning, weak young fellows of
some shallow brightness, who expect to make names for
themselves; perhaps they are young lawyers, or real-estate brokers,
or small shop-keepers; they achieve but little success; they gradually
become conscious that their business is broken up, and that they
have not enough ability to warrant any expectation of their continuing
in public life; some great temptation comes in their way (a
corporation which expects to be relieved of perhaps a million dollars
of taxes by the passage of a bill can afford to pay high for voters);
they fall, and that is the end of them. Indeed, legislative life has
temptations enough to make it unadvisable for any weak man,
whether young or old, to enter it.

ALLIES OF VICIOUS LEGISLATORS.

The array of vicious legislators is swelled by a number of men who
really at bottom are not bad. Foremost among these are those most
hopeless of beings who are handicapped by having some measure
which they consider it absolutely necessary for the sake of their own
future to “get through.” One of these men will have a bill, for
instance, appropriating a sum of money from the State Treasury to
clear out a river, dam the outlet of a lake, or drain a marsh; it may be,
although not usually so, proper enough in itself, but it is drawn up
primarily in the interest of a certain set of his constituents who have
given him clearly to understand that his continuance in their good
graces depends upon his success in passing the bill. He feels that
he must get it through at all hazards; the bad men find this out, and
tell him he must count on their opposition unless he consents also to
help their measures; he resists at first, but sooner or later yields; and
from that moment his fate is sealed,—so far as his ability to do any
work of general good is concerned.
A still larger number of men are good enough in themselves, but
are “owned” by third parties. Usually the latter are politicians who
have absolute control of the district machine, or who are, at least, of
very great importance in the political affairs of their district. A curious
fact is that they are not invariably, though usually, of the same party
as the member; for in some places, especially in the lower portions
of the great cities, politics become purely a business, and in the
squabbles for offices of emolument it becomes important for a local
leader to have supporters among all the factions. When one of these
supporters is sent to a legislative body, he is allowed to act with the
rest of his party on what his chief regards as the unimportant
questions of party or public interest, but he has to come in to heel at
once when any matter arises touching the said chief’s power, pocket,
or influence.
Other members will be controlled by some wealthy private citizen
who is not in politics, but who has business interests likely to be
affected by legislation, and who is therefore, willing to subscribe
heavily to the campaign expenses of an individual or of an
association so as to insure the presence in Albany of someone who
will give him information and assistance.
On one occasion there came before a committee of which I
happened to be a member, a perfectly proper bill in the interest of a
certain corporation; the majority of the committee, six in number,
were thoroughly bad men, who opposed the measure with the hope
of being paid to cease their opposition. When I consented to take
charge of the bill, I had stipulated that not a penny should be paid to
insure its passage. It therefore became necessary to see what
pressure could be brought to bear on the recalcitrant members; and,
accordingly, we had to find out who were the authors and sponsors
of their political being. Three proved to be under the control of local
statesmen of the same party as themselves, and of equally bad
moral character; one was ruled by a politician of unsavory reputation
from a different city; the fifth, a Democrat, was owned by a
Republican Federal official; and the sixth by the president of a horse-
car company. A couple of letters from these two magnates forced the
last members mentioned to change front on the bill with surprising
alacrity.
Nowadays, however, the greatest danger is that the member will
be a servile tool of the “boss” or “machine” of his own party, in which
case he can very rarely indeed be a good public servant.
There are two classes of cases in which corrupt members get
money. One is when a wealthy corporation buys through some
measure which will be of great benefit to itself, although, perhaps an
injury to the public at large; the other is when a member introduces a
bill hostile to some moneyed interest, with the expectation of being
paid to let the matter drop. The latter, technically called a “strike,” is
much the most common; for, in spite of the outcry against them in
legislative matters, corporations are more often sinned against than
sinning. It is difficult, for reasons already given, in either case to
convict the offending member, though we have very good laws
against bribery. The reform has got to come from the people at large.
It will be hard to make any very great improvement in the character
of the legislators until respectable people become more fully awake
to their duties, and until the newspapers become more truthful and
less reckless in their statements.
It is not a pleasant task to have to draw one side of legislative life
in such dark colors; but as the side exists, and as the dark lines
never can be rubbed out until we have manfully acknowledged that
they are there and need rubbing out, it seems the falsest of false
delicacy to refrain from dwelling upon them. But it would be most
unjust to accept this partial truth as being the whole truth. We blame
the Legislature for many evils, the ultimate cause for whose
existence is to be found in our own shortcomings.

THE OTHER SIDE OF THE PICTURE.

There is a much brighter side to the picture, and this is the larger
side, too. It would be impossible to get together a body of more
earnest, upright, and disinterested men than the band of legislators,
largely young men, who during the past three years have averted so
much evil and accomplished so much good at Albany. They were
able, at least partially, to put into actual practice the theories that had
long been taught by the intellectual leaders of the country. And the
life of a legislator who is earnest in his efforts faithfully to perform his
duty as a public servant, is harassing and laborious to the last
degree. He is kept at work from eight to fourteen hours a day; he is
obliged to incur the bitterest hostility of a body of men as powerful as
they are unscrupulous, who are always on the watch to find out, or to
make out, anything in his private or his public life which can be used
against him; and he has on his side either a but partially roused
public opinion, or else a public opinion roused, it is true, but only
blindly conscious of the evil from which it suffers, and alike ignorant
and unwilling to avail itself of the proper remedy.
This body of legislators, who, at any rate, worked honestly for what
they thought right, were, as a whole, quite unselfish, and were not
treated particularly well by their constituents. Most of them soon got
to realize the fact that if they wished to enjoy their brief space of
political life (and most though not all of them did enjoy it) they would
have to make it a rule never to consider, in deciding how to vote
upon any question, how their vote would affect their own political
prospects. No man can do good service in the Legislature as long as
he is worrying over the effect of his actions upon his own future.
After having learned this, most of them got on very happily indeed.
As a rule, and where no matter of vital principle is involved, a
member is bound to represent the views of those who have elected
him; but there are times when the voice of the people is anything but
the voice of God, and then a conscientious man is equally bound to
disregard it.
In the long run, and on the average, the public will usually do
justice to its representatives; but it is a very rough, uneven, and long-
delayed justice. That is, judging from what I have myself seen of the
way in which members were treated by their constituents, I should
say that the chances of an honest man being retained in public life
were about ten per cent. better than if he were dishonest, other
things being equal. This is not a showing very creditable to us as a
people; and the explanation is to be found in the shortcomings
peculiar to the different classes of our honest and respectable
voters,—shortcomings which may be briefly outlined.

SHORTCOMINGS OF THE PEOPLE WHO

SHOULD TAKE PART IN POLITICAL WORK.
The people of means in all great cities have in times past
shamefully neglected their political duties, and have been
contemptuously disregarded by the professional politicians in
consequence. A number of them will get together in a large hall, will
vociferously demand “reform,” as if it were some concrete substance
which could be handed out to them in slices, and will then disband
with a feeling of the most serene self-satisfaction, and the belief that
they have done their entire duty as citizens and members of the
community. It is an actual fact that four out of five of our wealthy and
educated men, of those who occupy what is called good social
position, are really ignorant of the nature of a caucus or a primary
meeting, and never attend either. Now, under our form of
government, no man can accomplish anything by himself; he must
work in combination with others; and the men of whom we are
speaking will never carry their proper weight in the political affairs of
the country until they have formed themselves into some
organization, or else, which would be better, have joined some of the
organizations already existing. But there seems often to be a certain
lack of the robuster virtues in our educated men, which makes them
shrink from the struggle and the inevitable contact with rough
politicians (who must often be rudely handled before they can be
forced to behave); while their lack of familiarity with their
surroundings causes them to lack discrimination between the
politicians who are decent, and those who are not; for in their eyes
the two classes both equally unfamiliar, are indistinguishable.
Another reason why this class is not of more consequence in politics,
is that it is often really out of sympathy—or, at least, its more
conspicuous members are—with the feelings and interests of the
great mass of the American people; and it is a discreditable fact that
it is in this class that what has been most aptly termed the “colonial”
spirit still survives. Until this survival of the spirit of colonial
dependence is dead, those in whom it exists will serve chiefly as
laughing-stocks to the shrewd, humorous, and prejudiced people
who form nine tenths of our body-politic, and whose chief
characteristics are their intensely American habits of thought, and
their surly intolerance of anything like subservience to outside and
foreign influences.
From different causes, the laboring classes, even when thoroughly
honest at heart, often fail to appreciate honesty in their
representatives. They are frequently not well informed in regard to
the character of the latter, and they are apt to be led aside by the
loud professions of the so-called labor reformers, who are always
promising to procure by legislation the advantages which can only
come to working men, or to any other men, by their individual or
united energy, intelligence, and forethought. Very much has been
accomplished by legislation for laboring men, by procuring
mechanics’ lien laws, factory laws, etc.; and hence it often comes
that they think legislation can accomplish all things for them; and it is
only natural, for instance, that a certain proportion of their number
should adhere to the demagogue who votes for a law to double the
rate of wages, rather than to the honest man who opposes it. When
people are struggling for the necessaries of existence, and vaguely
feel, no matter how wrongly, that they are also struggling against an
unjustly ordered system of life, it is hard to convince them of the truth
that an ounce of performance on their own part is worth a ton of
legislative promises to change in some mysterious manner that life-
system.
 In the country districts justice to a member is somewhat more apt
to be done. When, as is so often the case, it is not done, the cause is
usually to be sought for in the numerous petty jealousies and local
rivalries which are certain to exist in any small community whose
interests are narrow and most of whose members are acquainted
with each other; and besides this, our country vote is essentially a
Bourbon or Tory vote, being very slow to receive new ideas, very
tenacious of old ones, and hence inclined to look with suspicion
upon any one who tries to shape his course according to some
standard differing from that which is already in existence.
The actual work of procuring the passage of a bill through the
Legislature is in itself far from slight. The hostility of the actively bad
has to be discounted in advance, and the indifference of the passive
majority, who are neither very good nor very bad, has to be
overcome. This can usually be accomplished only by stirring up their
constituencies; and so, besides the constant watchfulness over the
course of the measure through both houses and the continual
debating and parliamentary fencing which is necessary, it is also
indispensable to get the people of districts not directly affected by
the bill alive to its importance, so as to induce their representatives
to vote for it. Thus, when the bill to establish a State Park at Niagara
was on its passage, it was found that the great majority of the
country members were opposed to it, fearing that it might conceal
some land-jobbing scheme, and also fearing that their constituents,
whose vice is not extravagance, would not countenance so great an
expenditure of public money. It was of no use arguing with the
members, and instead the country newspapers were flooded with
letters, pamphlets were circulated, visits and personal appeals were
made, until a sufficient number of these members changed front to
enable us to get the lacking votes.

LIFE IN THE LEGISLATURE.

As already said, some of us who usually acted together took a
great deal of genuine enjoyment out of our experience at Albany. We
liked the excitement and perpetual conflict, the necessity for putting
forth all our powers to reach our ends, and the feeling that we were
really being of some use in the world; and if we were often both
saddened and angered by the viciousness and ignorance of some of
our colleagues, yet, in return, the latter many times unwittingly
furnished us a good deal of amusement by their preposterous
actions and speeches. Some of these are worth repeating, though
they can never, in repetition, seem what they were when they
occurred. The names and circumstances, of course, have been so
changed as to prevent the possibility of the real heroes of them
being recognized. It must be understood that they stand for the
exceptional and not the ordinary workings of the average legislative
intellect. I have heard more sound sense than foolishness talked in
Albany, but to record the former would only bore the reader. And we
must bear in mind that while the ignorance of some of our
representatives warrants our saying that they should not be in the
Legislature, it does not at all warrant our condemning the system of
government which permits them to be sent there. There is no system
so good that it has not some disadvantages. The only way to teach
our foreign-born fellow-citizens how to govern themselves, is to give
each the full rights possessed by other American citizens; and it is
not to be wondered at if they at first show themselves unskilful in the
exercise of these rights. It has been my experience moreover in the
Legislature that when Hans or Paddy does turn out really well, there
are very few native Americans indeed who do better. A very large
number of the ablest and most disinterested and public-spirited
citizens in New York are by birth Germans; and their names are
towers of strength in the community. When I had to name a
committee which was to do the most difficult, dangerous, and
important work that came before the Legislature at all during my
presence in it, I chose three of my four colleagues from among those
of my fellow-legislators who were Irish either by birth or descent.
One of the warmest and most disinterested friends I have ever had
or hope to have in New York politics, is by birth an Irishman, and is
also as genuine and good an American citizen as is to be found
within the United States.
A good many of the Yankees in the house would blunder time and
again; but their blunders were generally merely stupid and not at all
amusing, while, on the contrary, the errors of those who were of
Milesian extraction always possessed a most refreshing originality.

INCIDENTS OF LEGISLATIVE EXPERIENCE.

In 1882 the Democrats in the house had a clear majority, but were
for a long time unable to effect an organization, owing to a faction-
fight in their own ranks between the Tammany and anti-Tammany
members, each side claiming the lion’s share of the spoils. After a
good deal of bickering, the anti-Tammany men drew up a paper
containing a series of propositions, and submitted it to their
opponents, with the prefatory remark, in writing, that it was an
ultimatum. The Tammany members were at once summoned to an
indignation meeting, their feelings closely resembling those of the
famous fish-wife who was called a parallelopipedon. None of them
had any very accurate idea as to what the word ultimatum meant;
but that it was intensively offensive, not to say abusive, in its nature,
they did not question for a moment. It was felt that some equivalent
and equally strong term by which to call Tammany’s proposed
counter-address must be found immediately; but, as the Latin
vocabulary of the members was limited, it was some time before a
suitable term was forthcoming. Finally, by a happy inspiration, some
gentlemen of classical education remembered the phrase ipse dixit;
it was at once felt to be the very phrase required by the peculiar
exigencies of the case, and next day the reply appeared, setting
forth with well-satisfied gravity that, in response to the County
Democracy’s “ultimatum,” Tammany herewith produced her “ipse
dixit.”
Public servants of higher grade than aldermen or assemblymen
sometimes give words a wider meaning than would be found in the
dictionary. In many parts of the United States, owing to a curious
series of historical associations (which, by the way, it would be
interesting to trace), anything foreign and un-English is called
“Dutch,” and it was in this sense that a member of a recent Congress
used the term when, in speaking in favor of a tariff on works of art,
he told of the reluctance with which he saw the productions of native
artists exposed to competition “with Dutch daubs from Italy”; a
sentence pleasing alike from its alliteration and from its bold
disregard of geographic trivialties.
Often an orator of this sort will have his attention attracted by
some high-sounding word, which he has not before seen, and which
he treasures up to use in his next rhetorical flight, without regard to
the exact meaning. There was a laboring man’s advocate in the last
Legislature, one of whose efforts attracted a good deal of attention
from his magnificent heedlessness of technical accuracy in the use
of similes. He was speaking against the convict contract-labor
system, and wound up an already sufficiently remarkable oration
with the still more startling ending that the system “was a vital cobra
which was swamping the lives of the laboring men.” Now, he had
evidently carefully put together the sentence beforehand, and the
process of mental synthesis by which he built it up must have been
curious. “Vital” was, of course, used merely as an adjective of
intensity; he was a little uncertain in his ideas as to what a “cobra”
was, but took it for granted that it was some terrible manifestation of
nature, possibly hostile to man, like a volcano, or a cyclone, or
Niagara, for instance; then “swamping” was chosen as describing an
operation very likely to be performed by Niagara, or a cyclone, or a
cobra; and behold, the sentence was complete.
Sometimes a common phrase will be given a new meaning. Thus,
the mass of legislation is strictly local in its character. Over a
thousand bills come up for consideration in the course of a session,
but a very few of which affect the interests of the State at large. The
latter and the more important private bills are, or ought to be,
carefully studied by each member; but it is a physical impossibility for
any one man to examine the countless local bills of small
importance. For these we have to trust to the member for the district
affected, and when one comes up the response to any inquiry about
it is usually, “Oh, it’s a local bill, affecting so-and-so’s district; he is
responsible for it.” By degrees, some of the members get to use
“local” in the sense of unimportant, and a few of the assemblymen of
doubtful honesty gradually come to regard it as meaning a bill of no
pecuniary interest to themselves. There was a smug little rascal in