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 Textbook of
ORTHODONTICS
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 Textbook of
ORTHODONTICS

SRIDHAR PREMKUMAR bds mds

Professor
Department of Orthodontics and Dentofacial Orthopedics
Head
Department of Pediatric Dentistry
Tamil Nadu Government Dental College and Hospital
Chennai
INDIA
Reed Elsevier India Pvt. Ltd.
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Textbook of Orthodontics, Sridhar Premkumar

Copyright © 2015, by Reed Elsevier India Pvt. Ltd.

All rights reserved.

ISBN: 978-81-312-4035-9
e-Book ISBN: 978-81-312-4036-6

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 Dedication

In loving memory of Dr TM Graber,

the Godfather of orthodontics whose name means
everything in orthodontics to me

In honor of my mentor
to whom I am indebted, Dr MR Balasubramanian,
who strived to bring the better out of me

In gratitude to my postgraduate teacher

to whom I am grateful, Dr S Rangacharri,
who pushed me for academic excellence

v
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 Contributors

Badrinath MDS Poornima R Jnaneshwar MDS

Reader Reader
Department of Orthodontics Department of Orthodontics
Faculty of Dental Sciences SRM Dental College
Sri Ramachandra University Ramapuram, Chennai
Porur, Chennai
Sangeetha Duraiswamy MDS
Balashanmugam B MDS Associate Professor
Professor Department of Orthodontics
Department of Orthodontics SRM Dental College
Tamil Nadu Government Dental College Ramapuram, Chennai
Chennai
Thailavathy V MDS
Krishnaraj Rajaram MDS Senior Lecturer
Professor Department of Orthodontics
Department of Orthodontics SRM Dental College
SRM Dental College Ramapuram, Chennai
Ramapuram, Chennai
Umarevathy Gopalakrishnan MDS
Meera Sravankumar MDS Reader
Reader Department of Orthodontics
Department of Orthodontics Sri Venkateswara Dental College and Hospital
SRM Dental College Thalambur, Chennai
Ramapuram, Chennai

Poornachitra BDS
Dental Surgeon
Private Practice
Chennai

vii
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 Preface
Another book on orthodontics? I am sure this is going to
be the first thought in the mind of the reader. As knowl-
edge and technology changes, so will our technique.
There is no finish line. Robert Schuller once said, “We go
from peak to peek.” We must climb to the top of the
peak of the mountain before we can see or peek at the
peaks of all other mountains out there. The art and
science of orthodontics and dentofacial orthopedics is
very complex. It had taken inexplicable evolution in
treatment philosophy and methodology over many gen-
erations put forth by various pioneers in orthodontics to
attain the present degree of success in professional ex-
pertise. This book differs from competing textbooks by
trying to uniquely combine different powerful elements:
a critical pedagogy integrated with comprehensive text,
the use of authentic clinical situations and the inclusion
of the most essential basic concepts in Orthodontics ev-
ery student must know.
This text uses the simple-to-complex approach in
teaching students clinical calculations and is, therefore,
divided into various sections in a sequential manner and
chapters are organized based on it. The sections Growth
and Development; Physiology of Stomatognathic Sys-
tem; Diagnostic Procedures, Aids and their Interpreta-
tion; Tooth Movement Principles and Philosophy; Cor-
rective Appliances; Treatment Approach to Management
of Malocclusions had been expanded further into many
chapters with addition of new accepted innovations and
facts. Space Gaining Procedures had been discussed
ix
extensively. A new chapter ‘Synopsis of Treatment Plan-
ning for Different Malocclusions’ had been included to
enable easy revision for exam preparations.
As orthodontics and dentofacial orthopedics con-
tinue to progress in various dimensions, it becomes the
duty of every student, teacher and clinician to update
themselves by preserving their curious learning spirit.
This book aims to behold its first position in any dentist’s
preference and I wish every one of the readers to use
this book judiciously and gain knowledge for crafts-
manship.
I had a diverse readership in mind while writing
this book. Clearly, my primary readership is students,
followed by practitioners and researchers in orthodon-
tics. As anyone who has a professional or academic
interest in orthodontics will be aware, the field is a
constantly changing, multidisciplinary one that draws
on developments in and insights from medicine, and
other fields of dentistry. For this reason, I have tried
to make the reader aware of those multidisciplinary
influences.
Through this column I would like to place my thanks
to all the students and faculty for the encouragement
they had given to me in my writing endeavor. The den-
tal faculties and budding dentists are welcomed to com-
municate their queries and feedbacks to my email id:
dr_premsridhar@yahoo.co.in.
Sridhar Premkumar
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 Acknowledgements

Putting together a book such as this is always a collaborative effort, and I was assisted by a number of people along
the way.
My sincere thanks go to Dr KSGA Nasser, former Principal, Tamil Nadu Government Dental College and
Hospital, for his constant support.
My special thanks to my friends, Dr K Ravi, Dean and Head, Department of Orthodontics, SRM Dental College
and Hospital, and Dr R Krishnaraj, Professor, Department of Orthodontics, SRM Dental College and Hospital, for
their constant words of encouragement.
Dr PS Haritha, Reader, Sri Ramachandra Dental College and Hospital, needs special mention for providing me
with rare clinical photographs.
A note of thanks to Mr Anand K Jha, Managing Editor for his prodding, patience and understanding and, for
being a beautiful editor; and Ms Nimisha Goswami, for being the shock absorber between the corporate structure
of Elsevier and to this writer.
The task of writing a book is made more manageable when one receives the assistance of others. I particularly
wish to thank Dr Poornachitra for her magisterial level of patience while working on artworks of this book and
providing assistance throughout.
Finally, I have been supported in this endeavor by my wife, Dr Praveena Premkumar, who has been my foremost
pillar for success; my children, Sriram and Srinidhi, for elevating my quality of life with their benevolence; all my
family members for being there for me always and the students for their amazing energy and enthusiasm. I am
grateful to them for their kind words of encouragement during my many months of writing.

xi
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 Brief Contents

Section I Section VI
An Introduction to Orthodontics Diagnostic Procedures,
1. Development of a Concept 2 Aids and Their Interpretation
18. Essential Diagnostic Aids: Case History and
Section II Clinical Examination
19. Essential Diagnostic Aids: Study Models and
215

Model Analyses 235

Growth and Development 20. Essential Diagnostic Aids: Essential
2. Prenatal Development of Cranial, Facial and Radiographs and Clinical Photographs 253
Oral Structures 14 21. Supplemental Diagnostic Aids: Cephalometric
3. Principles of Growth and Development 24 and Digital Radiography 265
4. Controlling Factors in Growth of the Skull 31 22. Supplemental Diagnostic Aids: Hand–Wrist
5. Postnatal Growth of Craniofacial Structures 43 Radiographs, Cervical Vertebrae, 3D Imaging
6. Dynamics of Facial Growth 58 and Computerized Cephalometric Systems 300
7. Development of Dentition 23. Supplemental Diagnostic Aids:
and Occlusion 67 Electromyography and Biostatistics 314
8. Normal Occlusion 89
Section VII
Section III
Principles of Orthodontic
Physiology of the Tooth Movement
Stomatognathic System 24. Biological Principles of Tooth Movement 319
9. Functional Osteology 102 25. Biomechanical Principles of Orthodontic
10. Myology 109 Tooth Movement 338
11. Temporomandibular Joint 121
12. Functions of the Stomatognathic System 125
Section VIII
Section IV Treatment Philosophy, Orthodontic
Incidence and Recognition Materials and Care during
of Malocclusion Orthodontic Treatment
13. Epidemiology of Malocclusion 134 26. Orthodontic Treatment Philosophy and
14. Recording of Malocclusion 145 Development of Appliances 353
27. Materials Used in Orthodontics 364
28. Complications Encountered and Dental Care
Section V during Orthodontic Therapy 397

Etiology of Malocclusion
15. Etiology of Malocclusion: General Factors 175
16. Etiology of Malocclusion: Local Factors 191
17. Unfavorable Sequelae of Malocclusion 206

xiii
xiv BRIEF CONTENTS

Section IX Section XI
Early Orthodontic Treatment Surgical Orthodontics
29. Preventive Orthodontics 408 37. Minor Surgical Procedures 595
30. Interceptive Orthodontics 428 38. Major Surgical Orthodontics 606
31. Serial Extraction 459 39. Cleft Lip and Palate and Orthodontics 626

Section X Section XII

Limited Corrective Orthodontics Approach to Management of Malocclusion
32. Removable Appliances 472 40. Treatment Planning: General Considerations 646
33. Functional Appliances 509 41. Space Gaining Procedures 656
34. Extraoral Appliances 549 42. Treatment of Malocclusions 676
35. Fixed Appliances: Basic Techniques 562 43. Retention after Orthodontic Therapy 710
36. Expansion Appliances 580 44. Synopsis of Treatment Planning for Different
Malocclusions 722
 Detailed Contents

Contributors vii
Preface ix
Acknowledgements xi

Section I An Introduction to Orthodontics

1. Development of a Concept 2
■ History of Orthodontics 2 ■ Definitions and Divisions of Orthodontics 2 ● Tissue Systems 5 Goals of
Orthodontics 9 ● Changing Paradigms of Goals of Orthodontics 10 ● Health-Related Quality of Life 10
● Psychosomatic Norm 10

Section II Growth and Development

2. Prenatal Development of Cranial, Facial and Oral Structures 14
■ Differences Between Growth and Development 14 ■ Prenatal Development of Cranial, Facial and Oral
Structures 15 ● Period of the Ovum 15 ● Embryonic Period 15 ● Fetal Period 18 ■ Growth of the Palate 19
■ Growth of the Tongue 20 ■ Growth of the Mandible 21 ■ Growth of the Cranium 22 ■ Growth of the
Temporomandibular Joint 22

3. Principles of Growth and Development 24

■ Bone Growth 24 ● Endochondral Bone Formation (Synonyms: Indirect Ossification/Cartilaginous Bone
Formation) 24 ● Intramembranous Bone Formation (Synonyms: Direct Ossification/Membranous Bone Formation) 25
■ Features of Craniofacial Growth 26 ● Cephalocaudal Growth 26 ● Growth Pattern 27 ● Scammon’s Growth
Gradient 27 ● Remodeling 27 ● Growth Movements 28 ● The ‘V’ Principle 28

4. Controlling Factors in Growth of the Skull 31

■ Controlling Factors of Craniofacial Growth 31 ■ Site vs Center 31 ■ Theories of Growth 32 ● Genetic
Theory by Allan Brodie 33 ● Van Limborgh Hypothesis 33 ● Sutural Theory by Sicher and Weinmann 33 ● Scott
Hypothesis/Nasal Septum Theory/Cartilaginous Theory/Nasocapsular Theory 34 ● Functional Matrix Hypothesis
(FMH)—Melvin Moss 35 ● Functional Matrix Revisited 38 ● Van Limborgh’s Composite Hypothesis 38
● Servosystem Theory 39

5. Postnatal Growth of Craniofacial Structures 43

■ Postnatal Growth of Cranial Vault/Brain Case 43 ● Fontanelles 43 ● Formation of Diploe and Frontal
Sinus 44 ● Increase in Width, Length and Height of Cranium 44 ● Deposition and Resorption Sites in Cranial Vault
Growth 45 ■ Growth of the Cranial Base 45 ● Functions of Cranial Base 45 ● Mechanisms of cranial base
growth 45 ● Growth of Anterior Cranial Fossa 45 ● Growth of Middle Cranial Fossa 46 ● Growth of Posterior Cranial
Fossa 47 ■ Growth of the Facial Skeleton 48 ● Nasomaxillary Complex 49 ● Growth of Maxilla with Regards to
Sutural and Cartilaginous 51 ● Growth of Maxilla and Functional Matrix Theory 52 ■ Mandible 53 ● Mandibular
Growth in First Year of Life 53 ● Condylar Growth 53 ● Mandibular Growth after the First Year of Life 53 ● Growth
of Mandible with regards to Functional Matrix Theory 56 ● The Chin 56 ■ Temporomandibular Joint 56

6. Dynamics of Facial Growth 58

■ Differential Growth 58 ■ Increments and Order of Completion of Growth 58 ● Order of Completion of
Growth 58 ● Amount of Growth 58 ■ Growth Spurts 59 ■ Clinical Implications 60 ● Safety Valve Mechanism 60
● Timing of Orthodontic Treatment 60 ■ Measurement of Growth 62 ● Craniometry and Anthropometry 63 ● Vital
Staining 64 ● Implant Radiography 64 ● Impressions and Study Casts 64 ● Photographs 65 ● Radioautographs 65
● Radiographs 65 ● Serial Cephalometric Radiography and Implantation 66

xv
xvi DETAILED CONTENTS

7. Development of Dentition and Occlusion 67

■ What is Occlusion? 67 ■ Stages of Development of Occlusion 67 ● Predental/Gum Pads Stage 67 ● Primary
Dentition 69 ● Mixed Dentition Stage—The Transitional Years (6–12 Years of Age) 74 ■ Eruption of Teeth 82
● Stages of Eruption 82 ● Mechanisms of Tooth Eruption 83 ● Theories of Tooth Eruption 83 ● Factors Affecting
Eruption of Teeth 84 ■ Clinical Applications of Growth and Development Data 85 ● Arch Expansion
Considerations 85 ● Space Considerations 85 ● Growth and Tooth Eruption 86 ● Ugly Duckling Stage/Broadbent
Phenomena/Physiologic Median Diastema 86 ● Overbite and Molar Relation 86

8. Normal Occlusion 89
■ Transient Malocclusions 90 ■ Development of the Concept of Occlusion 90 ● Fictional Period 90 ● Hypothetical
Period 91 ● Factual Period 92 ● Andrew’s Six Keys to Normal Occlusion 93 ■ Dynamic Occlusion 96 ● Compensating
Curves 97 ● Roth’s Keys of Occlusion 98 ● Ramjford’s Three Components of Occlusion 98 ● Functional Occlusion
Concept by Donald Rinchuse 99 ● Forces of Occlusion 99 ● Stomatognathics 101 ● Components 101

Section III Physiology of the Stomatognathic System

9. Functional Osteology 102
■ Facts about Bone 102 ■ Bone Turnover 102 ● Bone Modeling and Remodeling 103 ● Regulatory Factors in
Bone Turnover 103 ■ Mechanically Mediated Bone Adaptation Theories 104 ● Trajectorial Theory of Bone
Formation 104 ● Law of Orthogonality and Law of Transformation of Bone 104 ● Roux’s Observations 105 ● Stress
Trajectories/Benninghoff Lines 105

10. Myology 109

■ Types of Muscle 109 ● Skeletal Muscle 109 ● Smooth Muscle 109 ● Cardiac Muscle 110 ■ Properties of
Muscle 110 ● Elasticity 110 ● Contractility 110 ● Principle of Electromyogram 111 ■ Jaw Reflex Types 111
■ Buccinator Mechanism 112 ■ Tongue 113 ■ Equilibrium Theory 114 ■ Functional Movements 115
● Opening of Mandible 115 ● Mandible Closure 115 ● Mandible Protraction 115 ● Mandible Retrusion 115
● Lateral Movement 115 ● Bennett Movement 116 ● Bennett Angle 116 ■ Positions of Mandible 116
● Postural Resting Position (Postural Vertical Dimension) 116 ● Centric Relation 117 ● Initial Contact 117
● Centric Occlusion (Occlusal Vertical Dimension) 117 ● Most Retruded Position (Terminal Hinge Position) 117
● Maximum Opening of Mouth 118 ● Most Protruded Position 118 ● Posterior Tooth Relationship during Lateral
Excursions 118 ● Habitual Resting Position 118 ● Habitual Occlusal Relation (Occlusal Vertical Dimension) 119

11. Temporomandibular Joint 121

■Anatomy of Temporomandibular Joint 121 ■ lubrication of TMJ 123 ■ Response of TMJ to
Abnormalities 124

12. Functions of the Stomatognathic System 125

■ Development of Reflexes 125 ■ Respiration 125 ■ Mastication 126 ● Stages of Mastication 126 ● Child
and Adult Chewing Patterns 127 ■ Swallowing or Deglutition 127 ● Suckling 127 ● Infantile Swallow 128
● Mature Swallow 128 ● Stages of Deglutition 129 ■ Speech 130 ● Subsystems of Speech 130 ● Types of
Speech 130

Section IV Incidence and Recognition of Malocclusion

13. Epidemiology of Malocclusion 134
■ Prevalence of Malocclusion 134 ● Ethnic Variations in Malocclusion 134 ■ Arch Form 135 ● Bonwill Arch
Form 135 ● Bonwill–Hawley Arch Form 135 ● Izard Arch Form 136 ● Catenary Curve Arch Form 138 ● Brader
Arch Form 139 ■ Variations in Size, Form, Number and Position of Teeth 139 ● Size of Teeth 140 ● Form of
Teeth 141 ● Number of Teeth 142 ● Tooth Position 143
 DETAILED CONTENTS xvii

14. Recording of Malocclusion 145

■ Glossary of Terms Concerning Malposition 145 ■ Dysplasias 145 ● Dental Dysplasias/Dental Malocclusions
147 ● Skeletal Dysplasias/Skeletal Malocclusions 147 ■ Recording of Malocclusions 148 ● Method of
Classification of Malocclusion 148 ● Need for Classification 148 ● 1. Qualitative Methods of Classification 148
● Simon’s Classification 149 ● Angle’s Method of Classification 150 ● Dewey’s Modification of Angle’s
Classification 163 ● Ackerman–Proffit Classification System 164 ● British Standards Institute Classification
(1983) 165 ● 2. Quantitative Methods of Classification 166 ■ Index of Malocclusion 166 ● Irregularity
Index 168 ● Treatment Priority Index 168 ● Index of Orthodontic Treatment Need 170 ● PAR Index (An Index of
Treatment Outcome) 170 ● Index of Complexity, Outcome and Need (ICON) 172

Section V Etiology of Malocclusion

15. Etiology of Malocclusion: General Factors 175
■ Methods of Classification of Etiologic Factors 175 ● Moyers’ Classification 175 ● Graber’s Classification 176
■ General Factors 177 ● Heredity 177 ● Genetic Studies 177 ● Molecular Basis of Heredity 177 ● Heredity and
Specific Dentofacial Morphologic Characteristics 178 ■ Congenital Defects 178 ● Cleft Lip and Palate 178 ● Other
Congenital Defects 180 ■ Environment 182 ● Prenatal Influences 182 ● Postnatal Influences 184 ■ Predisposing
Metabolic Climate and Disease 184 ■ Dietary Problems (Nutritional Deficiency) 185 ■ Abnormal Pressure
Habits/Functional Causes 185 ● Head Posture 186 ● Finger Sucking Habit 186 ● Tongue Posture 186 ● Tongue
Thrusting 186 ● Mouth Breathing 187 ● Other Functional Causes 187 ● Psychogenic or Idiopathic Functional
Aberrations: Clenching and Bruxism 188 ● Adenoids and Tonsils 188 ● Tongue Size 188 ■ Posture 189 ■ Accidents
or Trauma 189

16. Etiology of Malocclusion: Local Factors 191

■ Anomalies in Number of Teeth 191 ● Extra Tooth/Hyperodontia/Supernumerary Tooth/Supplemental Tooth 191
● Missing Teeth 193 ■ Anomalies of Tooth Size 194 ■ Anomalies of Tooth Shape 196 ■ Abnormal Labial
Frenum 196 ■ Premature Loss of Deciduous Teeth 197 ■ Prolonged Retention and Abnormal Resorption
of Deciduous Teeth 199 ■ Delayed Eruption of Permanent Teeth/Dentitio Tarda 199 ■ Abnormal Eruptive
Path 201 ■ Ankylosis 202 ■ Dental Caries and Improper Dental Restorations 203

17. Unfavorable Sequelae of Malocclusion 206

■ Malocclusion and Unfavorable Psychological and Social Behavior 207 ■ Poor Appearance 208 ■ Interference
with Normal Growth and Development 208 ■ Improper or Abnormal Muscle Function 208 ● Adaptation 208
● Associated Muscle Habits 209 ● Bruxism 209 ■ Improper Mastication 209 ■ Speech Defects 209 ● Effects
of Malocclusion on Speech 210 ● Effects of Cleft Lip or Palate 210 ■ Dental Caries and Malocclusion 210
■ Periodontal Disease and Malocclusion 210 ■ Temporomandibular Joint Disorders 210 ■ Accidents and
Malocclusion 211 ■ Impacted Unerupted Teeth 211 ■ Complications in Prosthetic Rehabilitation 212
● Essential Diagnostic Criteria 214 ● Supplemental Diagnostic Criteria 214

Section VI Diagnostic Procedures, Aids and Their Interpretation

18. Essential Diagnostic Aids: Case History and Clinical Examination 215
■ Essential Diagnostic Criteria 215 ● Case History 215 ● Clinical Examination 217

19. Essential Diagnostic Aids: Study Models and Model Analyses 235
■ Plaster Study Casts 235 ● Impression Technique 236 ● Wax Bite Records 237 ● Study Cast 237 ● Information
Obtainable from Study Casts/Uses of Study Casts 241 ■ Mixed Dentition Analyses 243 ● Moyers’ Mixed Dentition
Analysis 244 ● Tanaka–Johnston’s Prediction Method 244 ● Radiographic Method 245 ● Staley and Kerber’s
Analysis 245 ■ Permanent Dentition Analyses 246 ● Bolton’s Tooth Size Analysis 246 ● Ashley Howe’s
Analysis 247 ● Pont’s Index/Pont’s Analysis 248 ● Linderhearth’s Analysis 248 ● Carey’s Analysis 249 ● Diagnostic
Setup/Kesling’s Diagnostic Setup 249 ■ Digitization of Study Models 250 ● Occlusogram 250
xviii DETAILED CONTENTS

20. Essential Diagnostic Aids: Essential Radiographs and Clinical Photographs 253
■ Intraoral Radiographs 253 ■ Panoramic Radiography 254 ● Principle of Panoramic Radiography 254
● Digital Panoramic Radiography 255 ● Interpretation of Panoramic Radiograph 255 ■ Facial Photographs 256
■ Digital Photography in Orthodontic Practice 260 ● Principle of Digital Photography 260 ■ Analysis of
Smile 261 ● Components of Smile11 262 ● Types of Smile 262 ● Analysis of Smile in the Frontal Dimension14 262
● Analysis of Smile in Oblique Dimension 263 ● Analysis of Smile in Sagittal Dimension 263

21. Supplemental Diagnostic Aids: Cephalometric and Digital Radiography 265

■ Cephalometric Radiography 266 ● Technique of Cephalometric Radiography 266 ■ Applications of
Cephalometric Radiographs 266 ● Growth and Development 266 ● Craniofacial Abnormalities 267
● Classification of Malocclusion 267 ● Prediction of Growth and Treatment Changes 268 ● Study of Post-treatment
Changes by Superimposition 268 ■ Cephalometric Landmarks 269 ● Hard-tissue Landmarks 269 ● Soft-tissue
Landmarks 270 ■ Cephalometric Planes 271 ■ Cephalometric Analyses 272 ● Limitations and Drawbacks of
Cephalometrics 274 ● Steiner’s Analysis 274 ● Wits Appraisal 277 ● Tweed’s Analysis/Tweed’s Diagnostic
Triangle 278 ● Ricketts’ Analysis 281 ● McNamara’s Analysis 286 ● Soft-Tissue Analysis 289 ● H Angle 291
● Functional Analysis 292 ● Sassouni Analysis 293 ● Jarabak Ratio 293 ● Indian Cephalometric Norms 293
■ Other Special X-Ray Views 293 ● The 45° Lateral Projections 293 ● Frontal Cephalometrics 296 ● Occlusal
Intraoral Film 296 ■ Digital Radiography 296 ● Principle of Digital Radiography 297 ● Direct Digital
Imaging 297 ● Digitization 298

22. Supplemental Diagnostic Aids: Hand–Wrist Radiographs, Cervical Vertebrae, 3D Imaging

and Computerized Cephalometric Systems 300
■ Types of Age 300 ■ Hand–Wrist Radiograph 301 ● Principle of Bone Age Assessment 301 ● Anatomy of
Hand–Wrist Region 302 ● Björk, Grave and Brown Method 303 ● Hagg and Taranger Method 305 ■ Cervical
Vertebrae Maturation As Skeletal Maturity Indicator 306 ● Clinical Application of Skeletal Maturity
Indicators 307 ■ Basal Metabolic Rate and Other Endocrine Tests 308 ■ Three-Dimensional Imaging 308
● Computed Tomography 308 ● Cone Beam Computed Tomography 308 ● Magnetic Resonance Imaging (MRI) 311
■ Computerized Cephalometric System 311 Components of Computerized Cephalometric System 311

23. Supplemental Diagnostic Aids: Electromyography and Biostatistics 314

■ Electromyographic Examination 314 ● Procedure 314 ● Orthodontic Interpretations 314
■ Biostatistics 315 ● Types of Data 315 ● Types of Biostatistics 316 ● Steps in Statistical Testing 316

Section VII Principles of Orthodontic Tooth Movement

24. Biological Principles of Tooth Movement 319
■ Basic Principles of Tooth Movement 319 ■ Physiologic Tooth Movement 320 ● Movement During
Mastication 321 ● Eruption of Tooth 321 ● Migration of Teeth 321 ● Response to Physiologic Forces 321
■ Orthodontic Tooth Movement 321 ● Role and Structure of the Periodontal Ligament 322 ● Theories of Tooth
Movement 323 ● Pathways of Tooth Movement 326 ● Optimal Orthodontic Force 327 ● Tissue Response to
Orthodontic Force 327 ● Stages of Tooth Movement 331 ● Types of Force Based on Magnitude and Force
Decay 331 ● Role of Genes on Orthodontic Tooth Movement 332 ● Root Resorption and Deleterious Effects of
Orthodontic Tooth Movement 333 ● Age Factor in Tooth Movement 335 ● Orthopedic Force 336 ● Effects of
Drugs on the Response to Orthodontic Force 336

25. Biomechanical Principles of Orthodontic Tooth Movement 338

■ Definition of Anchorage 338 ■ Types of Anchorage 339 ● Simple Anchorage 339 ● Stationary
Anchorage 339 ● Reciprocal Anchorage 340 ● Intraoral Anchorage 340 ● Extraoral Anchorage 340
● Intramaxillary Anchorage 341 ● Intermaxillary Anchorage 341 ● Multiple Anchorage 342 ● Cortical Bone/
Cortical Anchorage 342 ● Muscular Anchorage 342 ■ Implant as Anchorage Units/Absolute Anchorage/
Temporary Anchorage Devices (TADs) 342 ■ Biophysical Considerations 343 ● Spring Characteristics 346
● Activation and Deactivation Systems 347 ■ Types of Tooth Movement 347 ● Tipping 348 ● Pure
Translation 349 ● Root Movement 349 ● Rotation 350
 DETAILED CONTENTS xix

Section VIII Treatment Philosophy, Orthodontic Materials and Care during

Orthodontic Treatment
26. Orthodontic Treatment Philosophy and Development of Appliances 353
■ Changing Concepts of Treatment Philosophy 353 ● Expansion Concept 353 ● Extraction Concept 353 ● Soft
Tissue Concept 354 ● Contemporary Therapeutic Concept 354 ■ Removable Appliances 354 ● Use of Appliance
Force 355 ● Use of Muscular Force 355 ■ Fixed Appliances 356 ● Development of Fixed Appliances 356
● Preadjusted Edgewise Brackets 359

27. Materials Used in Orthodontics 364

■ Impression Materials 365 ● Alginate 365 ● Elastomeric Impression Materials 367 ■ Bite Registration
Materials 367 ● Requirements of Bite Registration Materials 367 ● Materials Used 368 ■ Gypsum
Products 368 ■ Brackets and Bracket Materials 369 ● Plastic Brackets 371 ● Ceramic Brackets 372 ■ Materials
Used for Enamel Preparation before Bonding 373 ● Phosphoric Acid Etching 373 ● Sulfated Polyacrylic
Acids 373 ● Sandblasting 373 ● Bonding to Unconventional Surfaces 373 ■ Bonding Materials used in
Orthodontics 373 ● Ideal Properties of an Adhesive 373 ■ Composite Resins 374 ● Glass Ionomer Cement
Adhesives 375 ● Resin-Modified Glass Ionomer Cement2 375 ■ Cements Used in Orthodontics 375 ● Zinc
Phosphate Cement 375 ● Zinc Polycarboxylate Cement 375 ● Glass Ionomer Cement 376 ■ Orthodontic
Wires 376 ● Desirable Properties of Orthodontic Wires 376 ● Classification of Orthodontic Archwires 377
● Stainless Steel Archwires 378 ● AJ Wilcock Archwires 380 ● Braided or Twisted Wires 380 ● Elgiloy 381
● Nickel–Titanium Alloy 382 ● BioForce Wires 384 ● Beta-titanium and Other Titanium Alloys 384 ■ Elastics
and Elastomerics 385 ● Clinical Application of Elastics and Elastomerics 385 ● Chemical Composition 386 ● Force
Characteristics of Elastomers 387 ● Merits of Elastics and Elastomerics 387 ● Demerits of Elastics and
Elastomerics 387 ■ Magnets 387 ■ Materials Used In Soldering and Welding 388 ● Welding 388 ● Soldering
and Brazing 388 ■ Mini-Implants 390 ● Mini-Implant Materials 390 ● Types of Anchorage 390 ● Types of Mini-
Implant Retention 392 ● Selection of Mini-Implant 393 ■ Sterilization and Disinfection In Orthodontics 393
● Definitions 393 ● Modes of Transmission of Infection 393 ● Route of Transmission 393 ● Protection of Operators
and Patients 394 ● Procedures BeforeSterilization 394 ● Classification of Instruments to be Sterilized 394
● Sterilization of Orthodontic Materials 394 ● Monitoring Sterilization 394

28. Complications Encountered and Dental Care during Orthodontic Therapy 397
■ Caries and Decalcification During Therapy 397■ Loose or Deformed Bands 398 ■ Care of Soft
Tissue 398 ● Necessity for Proper Oral Hygiene 399 ● Methods of Home Care 399 ■ Dangers To Appliance
Integrity 402 ■ Emergency Orthodontic Appointments 403 ● Loose Bands 403 ● Displaced or Broken
Archwires and Attachments 403 ● Nickel Hypersensitivity 404 ■ Removable Appliances 405 ● Abrasion 405
● Retainer Repair 405 ■ Caries Repair During Orthodontic Therapy 405

Section IX Early Orthodontic Treatment

29. Preventive Orthodontics 408
■ Rationale for Early Orthodontic Treatment 408 ● Early Diagnosis 409 ■ Preventive Orthodontic
Procedures 411 ● Preventive Procedures without Appliances 411 ■ Space Control In Deciduous and Mixed
Dentition 415 ● Definitions 415 ● Planning for Space Maintainers 415 ● Space Maintenance in Maxillary and
Mandibular Anterior Segments 417 ● Space Maintenance in Buccal Segment 417 ■ Space Retaining Appliances
417 ● Indications for Space Maintainers 417 ● Prerequisites for Space Maintainers 418 ● Classification of Space
Maintainers 418 ● Choice of Space Maintainers 418 ■ Mouth Guards 426 ● Classification 426 ● Materials
Used 426 ● Fabrication 426

30. Interceptive Orthodontics 428

■ Classification of Interceptive Orthodontic Procedures 428 ■ Management of Non-Skeletal Problems 429
● Equilibration of Occlusal Disharmonies 429 ● Management of Incisor Crowding 431 ● Orthodontic Management
of Hypodontia 432 ● Orthodontic Management of Hyperodontia 432 ● Early Detection and Treatment of Eruption
Problems 433 ● Space Regaining in the Transitional Dentition/ Space Regainers/Active Space Maintainers 434
● Anterior Diastema 436 ■ Management of Functional Problems 438 ● Management of Deleterious Oral
Habits 438 ● Muscle Exercises 448 ■ Management of Dentoskeletal Problems 449 ● Developing Anterior
Crossbite 449 ● Need for Early Diagnosis and Treatment of Posterior Crossbites 451 ● Interception of Developing
Sagittal Skeletal Problems 454 ● Management of Vertical Problems 457
xx DETAILED CONTENTS

31. Serial Extraction 459

■ Definition of Serial Extraction 459 ■ Historical Development 459 ■ Rationale of Serial Extraction 459
■ Factors to Be Considered 461 ■ Investigations 461 ● Clinical Examination 461 ● Diagnostic Discipline 462
■ Indications or Clues for Serial Extraction 462 ■ Contraindications of Serial Extraction 463 ■ Dewel’s
Technique of Serial Extraction (CD4 Technique) 463 ● Removal of Deciduous Canines 464 ● Removal of the First
Deciduous Molars 465 ● Removal of the Erupting First Premolars 466 ■ Tweed’s Technique of Serial Extraction
(D4c Technique) 467 Disadvantages/Problems In Serial Extraction 467

Section X Limited Corrective Orthodontics

32. Removable Appliances 472
■ Classification of Orthodontic Appliances 473 ■ Advantages and Disadvantages of Removable Appliances 473
● Advantages 473 ● Disadvantages 473 ■ Components of Removable Orthodontic Appliances 474 ● Retentive
Components of Removable Appliance 474 Baseplate 479 ■ Active Components of Removable Appliance 480
● Springs 480 ● Labial Bows 486 ■ Clinical use of Removable Appliances 490 ■ Technical Considerations 490
● Fabrication of Wire Components of the Appliance 491 ● Fitting of Removable Appliance/Removable Appliance
Insertion 492 ■ Treatment With Removable Appliances 493 ● Problems of Excessive Overbite/Deep Bite 493
● Opening and Closing of Spaces and Retraction of Incisors with Removable Appliances 496 ■ Modifications of the
Basic Hawley Appliance 498 ● Expansion Screws 500

33. Functional Appliances 509

■ Historical Happenings in Dentofacial Orthopedics 511 ■ Classification of Functional Appliances 511
● Proffit’s Classification 511 ● Graber’s Classification 512 ● Based on the Nature of Removability 512 ● Based on
the Way Muscle is Used 512 ■ Principles of Functional Appliances 512 ● Force Application 512 ● Force
Elimination 513 ● Neuromuscular Response 513 ■ Effects of Functional Appliances and Their Modus
Operandi/Common Mechanisms By Which Functional Appliances Work 513 ● Dentoalveolar Changes 513
● Skeletal Changes 513 ● Remodeling Changes in TMJ 515 ■ Ideal Requirements of Functional Appliances 515
■ Advantages and Limitations of Functional Appliances 515 ● Advantages 515 ● Limitations 516
■ Indications and Criteria For Functional Appliance Therapy 516 Description of Appliances 517 ● Upper
Anterior Flat Bite Plane 517 ● Upper Anterior Inclined Plane 517 ● Lower Inclined Planes/Catalan’s Appliance 518
● Vestibular Screens/Oral Screens 519 ● Lip Bumper 521 ● Andresen Activator 522 ● Bionator 527 ● Various
Modifications of Activator 531 ■ Frankel Appliances 533 ● Rationale of Functional Regulator 533 ● Philosophy
of Frankel Appliance/Mechanism of Action of Frankel Appliance 534 ● Indications of Functional Regulator 535
● Functional Regulator (FR) I 536 ● Functional Regulator III 539 ● Functional Regulator IV 541 ● Twin
Block 542 ● Fixed Functional Appliances 544 ● Herbst Appliances 545 ● Jasper Jumper 547

34. Extraoral Appliances 549

■ Indications for use of Extraoral Force 550 ■ Changing the Growth Pattern of Dentomaxillary
Complex 550 ● Location of Center of Resistance of the Dentomaxillary Complex 550 ■ Components of
Headgear 551 ■ Types of Headgear 552 ● Cervical Headgear 552 ● High-Pull Headgear 553 ● Straight-Pull
Headgear/Combi-Pull Headgear 554 ● Vertical-Pull Headgear 554 ■ Headgears for Incisor Retraction 555
■ Reverse-Pull Headgear/Face Mask 556 ● Hickham 556 ● Delaire 557 ● Petit Face Mask 557 ● Turbinger 557
● Indications for Face Mask 558 ● Intraoral Device 558 ● Elastic Traction 559 ■ Protraction with Face-Bow and
Headgear 559 ● Biomechanics of Force Application 559 ● Force Parameters 559 ● Advantages 560 ■ Chin
Cup 560 ● Side Effects of Chin Cup 561

35. Fixed Appliances: Basic Techniques 562

■ Advantages of Fixed Appliances 562 ■ Limitations of Fixed Appliance 562 ■ Orthodontic Band 563
■ Fabrication of Molar Bands 564 ● Fabrication 564 ● Separation 564 ● Adaptation of Bands 565 ● Attachments
for Orthodontic Band and Tooth Surface 568 ● Cementation 568 ■ Bonding Attachments 570 ● Direct Bonding 570
● Indirect Bonding 573 ● Crystal Growth 573 ■ The Archwire 574 ■ Assisting Elements 575 ● Uprighting
Spring 575 ● Rotation Springs 575 ● Coil Spring 576 ● Crimpable Hooks 576 Elastomeric Modules 576 ● Kesling
Separators 577 ● Elastics 577 ● Lock Pins 578

36. Expansion Appliances 580

■ Types of Expansion 580 ● Orthodontic Expansion 580 ● Orthopedic Expansion 581 ● Passive Expansion 581
● Rapid Maxillary Expansion 581 ● Indications of Rapid Maxillary Expansion Appliances 581 ● Contraindications of
Rapid Maxillary Expansion Appliances13 582 ● Applied Anatomy 582 ● Effects of Rapid Maxillary Expansion
Appliances 583 ● Types of Rapid Maxillary Appliances 584 ● Basic Steps in Fabrication 585 ● Appliance
Management 585 ■ Slow Maxillary Expansion Appliances 587 ● Classification of Slow Expansion Appliances 588
■ NiTi Palatal Expander 28 589 ■ Fan-Shaped Maxillary Expander 591 ● Mechanism 591 ■ Comparison of
Effects of Slow and Rapid Expansion 591 ■ Surgically Assisted Maxillary Expansion 592 ● Indications 592
■ Mandibular Expansion Appliances 592
 DETAILED CONTENTS xxi

Section XI Surgical Orthodontics

37. Minor Surgical Procedures 595
■ Frenectomy 595 ● Maxillary Labial Frenum 595 ● Mandibular Midline Frenum 596 ■ Gingival Enlargement
During Orthodontic Tooth Movement 596 Circumferential Fiberotomy/Pericision 596 ● Principle of the
Supracrestal Fiberotomy Surgery 596 ● Procedure 596 ● Alternative Method/Papilla Dividing Procedure 597
● Time of Surgery 597 ■ Surgical Uncovering of Impactions and Positioning 597 ● Impacted Teeth 597
● Methods of Treatment 598 ■ Corticotomy-Assisted Orthodontics 600 ■ Transpositioning of Teeth/
Autotranspositioning/Surgical Repositioning of Teeth 601 ■ Microimplants In Orthodontics 602 ● Procedure
of Microimplant Placement 604

38. Major Surgical Orthodontics 606

■ Indications 606 ● Skeletal Class II Malocclusion 606 ● Skeletal Class III Malocclusion 607 ● Severe Dentoalveolar
Problem 607 ● Appearance and Function 607 ● Vertical Problems 607 ● Transverse Discrepancies 607 ● Patients
with Facial Asymmetry 607 ■ Contraindications 607 ■ Diagnosis and Treatment Planning 607 ● Medical and
Dental History 607 ● Cephalometric and Study Model Evaluation 610 ● Diagnostic Features of Common Dentofacial
Deformity 611 ● Epker’s Envelope of Discrepancies 611 ■ Approach To Treatment 613 ● Timing of Orthognathic
Surgery 614 ● Presurgical Orthodontics 614 ● The Surgical Treatment Objective (STO) 615 ● Mock Surgery 616
● Postsurgical Stabilization 616 ● Postsurgical Orthodontics 617 ● Should Teeth be Extracted? 617 ■ Surgical
Procedures 618 ■ Soft-Tissue Changes Following Orthognathic Surgery 619 ■ Distraction Osteogenesis 619
● Role of Orthodontist 619 ● Distraction Devices 621 ● Distraction Procedure 621 ● Biological Basis of
Distraction 622 ● Distraction Osteogenesis and Functional Matrix 623 ● Indications 623 ● Advantages of
Distraction Osteogenesis 623 ● Disadvantages of Distraction Osteogenesis 623

39. Cleft Lip and Palate and Orthodontics 626

■ Epidemiology and Incidence 627 ■ Prenatal Development of Lip and Palate 627 ● Development of Lip and
Primary Palate 627 ● Development of the Nose 627 ● Development of Secondary Palate 627 ● Cleft Lip with/
without Cleft Palate (CL and CLP) 628 ● Isolated Clefts of Secondary Palate 628 ● Oblique Facial Clefts 628 ● Median
Cleft Lip 628 ■ Anatomy and Function in Cleft Situations 628 ● Lip 629 ● Nose 629 ● Upper
Alveolus 629 ● Mandible 629 ● Hard Palate 629 ● Soft Palate 630 ■ Growth in Cleft Patients 630 ● Growth
in Operated and Unoperated Cleft 630 ● Dental Development in Cleft 630 ● Development of Occlusion in
Cleft 631 ■ Etiology of Clefts 632 ● Genes Responsible for Clefting 632 ● Environmental Influences 633
■ Prenatal Diagnosis of Clefts 633 ● Advantages of Prenatal Diagnosis (Graber and Vanarsdall) 633
● Disadvantages of Prenatal Diagnosis 633 ● Methods Employed 633 ■ Classification of Cleft Lip and
Palate 633 ● Fogh-Anderson Classification 633 ● Davis and Ritchie Classification 633 ● Veau’s Classification
(1931) 634 ● The Internationally Approved Classification Based on Embryological Origin 634 ● Kernohan’s
Stripped ‘Y’ Classification 634 ■ Team Management 635 ■ Protocols and Timing of Treatment 635 ● The
Oslo Protocol 636 ■ Presurgical Orthopedics 637 ● Nasoalveolar Molding (NAM)/Presurgical Nasoalveolar
Molding 638 ● Orthodontic Management 639 ■ Alveolar Bone Grafting 639 ● Orthodontic Treatment before
Grafting 640 ■ Surgical Management 641 ● Surgical Correction 641 ● Timing of Orthognathic Surgery 641
● Velopharyngeal Function and Orthopedic Procedure 642 ● Modifications of Osteotomies in Cleft Lip Palate
Patients 642

Section XII Approach to Management of Malocclusion

40. Treatment Planning: General Considerations 646
■ Indications for Orthodontic Treatment 646 ■ Sequence in Treatment Planning 647 ● Elimination of
Pathology 647 ● Establishing Treatment Goals 647 ● Ascertaining the Severity of the Problem 648 ● Treatment
Possibilities 648 ● Age Considerations in Treatment Planning/Treatment Timing 650 ■ Functional Appliance 654
■ Adult Treatment 654 ■ Conclusion 655

41. Space Gaining Procedures 656

■ Extraction as a Method to Gain Space 656 ● Extraction versus Nonextraction Controversy 656 ● Extraction
Choice 657 ■ Interproximal Enamel Reduction 661 ● Indications 661 ● Contraindications 661 ● Steps
Involved in Interproximal Reduction 661 ● Techniques for Enamel Reduction 661 ■ Derotation of Posterior
Teeth 663 ■ Uprighting of Tilted Posterior Teeth 663 ■ Proclination of Anterior Teeth 664 ■ Arch
Expansion 664 ■ Molar Distalization 664 ● Upper Molar Position 664 ● Influence of Second Molar on
Molar Distalization 664 ● Indications and Contraindications 665 ● Complications of Molar Distalization 665
● Classification 665
xxii DETAILED CONTENTS

42. Treatment of Malocclusions 676

■ Treatment of Class I Malocclusions 676 ● Arch Length Deficiency and Expansion 676 ● Arch Length Deficiency
and Extractions 677 ● Treatment Sequence for Class I Malocclusion Correction 678 ■ Treatment of Class II
Division 1 Malocclusions 696 ● Concept of Apical Base/Stimulation and Retardation of Growth 696 ● Role of
Extraoral Force 698 ● Use of Functional Appliances 698 ● Camouflage Treatment for Class II Malocclusion 700
● Correction by Differential Anteroposterior Tooth Movement Using Extraction Spaces 703 ● Role of Extraction 703
● Surgical Correction of Class II Malocclusion 703 ■ Treatment of Class II Division 2 Malocclusions 704
● Treatment Procedures 705 ■ Treatment of Class III and Open Bite Malocclusions 705 ● Treatment
Problems 705 ● Types of Appliances Used 707

43. Retention after Orthodontic Therapy 710

■ Causes of Post-Treatment Relapse/ Need for Retention 710 ● Forces from the Periodontal and Gingival
Tissues 710 ● Forces from the Orofacial Soft Tissues 711 ● Occlusal Factors and Occlusal Forces 712 ● Post-
treatment Facial Growth and Development 712 ■ Planning the Retention Phase 712 ● Original Malocclusion and
Patient’s Growth Pattern 713 ● Types of Treatment Performed 713 ● Soft- and Hard-Tissue Adjunctive Procedures
to Enhance Stability 714 ● Types of Retainer 714 ● Duration of Retention 714 ■ Theorems on Retention 714
■ Requirements of Retaining Appliances 715 ■ Retention Appliances 715 ● Removable Retainers 715 ● Fixed
Retention Appliances 717 ■ Active Retainers 718 ■ Raleigh Williams Keys to Eliminate Lower Incisor
Retention 719

44. Synopsis of Treatment Planning for Different Malocclusions 722

■ Management of Intra-Arch Problems 723 ● Crowding 723 ● Spacing 724 ● Median Diastema/Midline
Diastema 725 ● Transposition 727 ● Rotation 728 ■ Management of Transverse Malocclusions 728 ● Types
of Crossbites 728 ● Anterior Crossbite 729 ● Posterior Crossbite 730 ● Facial Asymmetry 731 ■ Management
of Vertical Malocclusions 732 ● Deep Bite 732 ● Open Bite 735 ● Short Face/Low Angle Cases/Hypodivergent
Face 736 ● Long Face/Hyperdivergent Face/Features of High Angle Case 736 ■ Management of Sagittal
Malocclusions 737 ● Class II Division 1 Malocclusion 737 ● Incisor Edge–Centroid Relationship/Edge–Centroid
Relationship 741 ● Class II Division 2 Malocclusion 741 ● Class III Malocclusion 743 ● Pseudo-Class III
Malocclusion 746 ● Bimaxillary Protrusion 746

Index 749
 S E C T I O N I

An Introduction to Orthodontics
S E C T I O N O U T L I N E

Chapter 1. Development of a Concept 2

1
 C H A P T E R
1
Development of a Concept
C H A P T E R
History of Orthodontics 2 Soft tissue paradigm
Definitions and Divisions of Orthodontics 2 Health-related quality of life
Tissue systems 5 Psychosomatic norm
Goals of Orthodontics 9 Learning Exercises
Jackson’s triad 9
Changing paradigms of goals of orthodontics 10
Hard tissue or Angle paradigm 10
HISTORY OF ORTHODONTICS
Orthodontics, the oldest specialty in dentistry, dates
back to the turn of the twentieth century. The Angle
School of Orthodontia was founded in St Louis in the
year 1900 and in the following year that the American
Society of Orthodontists was formed.1
An awareness of unsightly appearance of ‘crooked
teeth’ many centuries before has been reported in
the literature.2 It is mentioned in the writings of
Hippocrates (460–377 BC), Aristotle (384–322 BC), and
Celsus and Pliny, contemporaries of Christ. Celsus noted
in 25 BC that teeth could be moved by finger pressure.
Pierre Fauchard, often called the father of modern den-
tistry, is generally given the credit for the first compre-
hensive discussion of ‘regulating teeth’. In his Treatise
on Dentistry, published in 1728, Fauchard discusses
the ‘bandelette’, now called the expansion arch. Since Fau-
chard, many pioneers in orthodontics have written about
irregularities of the teeth. Names such as Hurlock, Hunter,
Fox, Delabarre, Harris, Kingsley, Brown, Mortimer,
Farrar and Talbot are associated with the development of
orthodontics in the United States during the nineteenth
century.3,4
Edward H. Angle (1855–1930), who is regarded as
the ‘Father of modern Orthodontics’ was the most com-
manding, most influential and prominent person in
orthodontics. Almost as important were Calvin Case
2
O U T L I N E
10
10
10
11
and Martin Dewey. The constant battles among Angle,
Case and Dewey, in the contemporary literature and in
and out of society meetings, only served to enhance in-
terest in orthodontics and increase the dedication and
devotion of their disciples.
The name of the specialty, ‘orthodontics’, comes from
two Greek words: ‘orthos’, meaning right or correct, and
‘dons’, meaning tooth. The term ‘orthodontia’ was ap-
parently used first by the Frenchman LeFoulon in 1839.
Sir James Murray (1909) realized that the suffix ‘ia’
properly referred to medical conditions (e.g. amnesia)
and, therefore, suggested the term orthodontics. Subse-
quently, in 1976, ‘Dentofacial orthopedics’, suggested by
BF Dewel, was included to depict the entire ambit of an
orthodontist’s domain of authority.5 The contributions
of various pioneers to the field of orthodontics are given
in Table 1.1.
DEFINITIONS AND DIVISIONS OF
ORTHODONTICS
Angle5 in 1907 stated that the objective of the science of
orthodontics is ‘the correction of the malocclusions of
the teeth’. In 1911, Noyes6 defined orthodontics as “the
study of the relation of the teeth to the development of
the face, and the correction of arrested and perverted
development”.
 CHAPTER 1. DEVELOPMENT OF A CONCEPT 3

TABLE 1.1 Contributions of various pioneers in orthodontics

Pioneers Contributions
Pierre Fauchard He introduced bandeau, an expansion arch consisting of a horseshoe-shaped strip of precious metal to which
(1678–1761) the teeth were ligated

John Hunter Hunter, a British anatomist and surgeon had a special interest regarding teeth and jaws’ anatomy and
(1728–1793) was also the first to explain normal occlusion and to attempt classification of teeth. His article, The natural
history of the human teeth (1771) showcased the first transparent statement on principles of orthopedics.
He was the first to describe the growth of the jaws, not as a hypothesis, but as a sound, scientific
investigation

Joseph Fox He was the first to classify malocclusion (1803). He was one of the foremost to observe that beyond molars,
(1776–1816) the mandible grows by distal extension with no or little increase in the anterior region. Used bite blocks
to open the bite. His other appliances included an expansion arch and a chin cup

Joachim LeFoulon He coined the name Orthodontosie (1839) which approximately means orthodontia. He was the first to bring
labial arch with a lingual arch as a combination.

Christophe-François He introduced the crib and the principle of the lever and the screw
Delabarre (1787–1862)

JM Alexis Schange He published the first work confined to orthodontics.

(1807–1865) He introduced a modification of the screw, the clamp band and also coined the term anchorage

Friedrich Christoph He was the first to record malocclusion by using plaster models and used chin strap for his prognathic
Kneisel (1797–1847) patient (1836)

JS Gunnell (1822) He invented occipital anchorage in 1822

EG Tucker (1846) He was the first American to use rubber bands (1846)

Norman W Kingsley He was honored for perfecting a gold obturator and artificial soft rubber velum when he experimented with
(1825–1896) cleft palate treatment (1859).
He introduced many innovations which also included occipital traction (1879). At first, he performed teeth
extraction and moved the anterior teeth behind into the extracted space. Later, he discontinued extraction
and added an inclined vulcanite plane in his mechanism to ‘jump the bite’

Emerson C Angell He was the first to open the median palatal suture with a split plate (1860)
(1823–1903)

William E Magill He was the first to cement (platinum) bands (1871)

(1825–1896)

CR Coffin (1871) He designed an expansion appliance that still bears his name. Into a vulcanite plate that is separated in the
middle, he embedded W-shaped spring-action piano wire and activated the spring so that the two halves
pressurized the alveolar process to the outside.

John Nutting Farrar He laid the foundation for ‘scientific’ orthodontics by doing studies on biology of tooth movement.
(1839–1913) He originated the theory of intermittent force.
He was among the first to use occipital anchorage for retracting anterior teeth (1850) and recommended
bodily movement of teeth (1888).
His Treatise on irregularities of the teeth and their correction (1888) is regarded as the first enormous work
that was dedicated exclusively to orthodontics.
Hence forth, he is called the ‘Father of American Orthodontics’

Henry A Baker He introduced intermaxillary rubber bands to correct protrusions. His method came to be known as
(1848–1934) ‘Baker anchorage’

Calvin S Case He was the first to attempt bodily movement and to use light wires (0.016 and 0.018 in.)
(1847–1923) He advocated extraction to correct facial deformities
In contrast to Angle’s dependence on occlusion, he emphasized facial esthetics and also used different type
of appliance. He advised changing the specialty name to ‘Facial orthopedia’

Edward H Angle He is regarded as the ‘Father of Modern Orthodontics’. His contributions

(1855–1930) include Key of occlusion, Classification of malocclusion, Ribbon arch and Edgewise appliances

Holly Broadbent Introduced cephalometric radiography which combined longitudinal approach with the anthropologic
and Hoffrath (1931) mensuration of the underlying bony structures of the living bony structures

Melvin Moss Introduced functional matrix hypothesis which received international recognition.
(1923–2006) He also introduced finite element analysis in the modeling of craniofacial growth and orthodontic treatment
effects

Lawrence Andrews Developed straight wire appliance that would apply 1st, 2nd and 3rd order movements to the teeth without
(1972) making changes in the wire
4 SECTION I AN INTRODUCTION TO ORTHODONTICS

In 1922, the British Society of Orthodontists proposed

the following definition: Orthodontics includes the study of
growth and development of the jaws and face particularly, and
the body generally, as influencing the position of the teeth; the
study of action and reaction of internal and external influ-
ences on the development, and the prevention and correction
of arrested and perverted development.
The general field of orthodontics can be divided7 into
four categories:
1. Preventive orthodontics
2. Interceptive orthodontics
3. Corrective orthodontics
4. Surgical orthodontics.
1. Preventive orthodontics, as the name implies, is
action taken to preserve the integrity of what appears to be the
normal occlusion at a specific time (Graber). Under the
heading of preventive orthodontics are any procedures
that attempt to ward off untoward environmental
attacks or anything that would change the normal
course of events. The early correction of carious lesions
(particularly in proximal areas) that might change the
arch length (Fig. 1.1A), proper restoration of mesiodistal
dimensions of the teeth, early recognition and elimina-
tion of oral habits that might interfere with the normal
development of the teeth and jaws, the placing of a
space maintainer (Fig. 1.1B) that is designed to maintain
proper positions of contiguous teeth—all these are
examples of preventive orthodontics. The dentition is
normal at this time, and it is the goal of the dentist to see
that it stays that way.
2. Interceptive orthodontics implies that an abnor-
mal situation exists. The definition given by the Ameri-
can Association of Orthodontists, Council on Orthodon-
tic Education, is ‘that phase of the science and art of
orthodontics employed to recognize and eliminate potential
irregularities and malpositions in the developing dentofacial
complex’.8 When there is an establishment of developing
malocclusion due to hereditary pattern or intrinsic and
FIGURE 1.2 An anterior open bite is developing as a result
of a finger sucking habit coupled with abnormal lip and
tongue activity. This is an example for interceptive problem
extrinsic factors, specific procedures may be undertaken
to reduce its severity and in some cases to eradicate its
cause (Fig. 1.2). A good example would be a planned
program of serial extraction and space regainer in case
of space loss in conditions where space maintenance
was not initiated. Recognizing the discrepancy between
the amount of tooth material and the space available
for teeth in the dental arches and the properly timed
removal of deciduous teeth (and ultimately the first
premolar teeth) can allow considerable autonomous
adjustment.
3. Corrective orthodontics, like interceptive ortho-
dontics, recognizes the existence of a malocclusion and the
need for employing certain technical procedures to reduce or
eliminate the problem and the attendant sequelae. These pro-
cedures are usually mechanical and of broader scope
than techniques used in interceptive orthodontics. It is
in this type of problem that demands for special training
are greatest (Figs 1.3–1.5).
4. Surgical orthodontics, as the name denotes,
includes the surgical procedures that are carried out before,

A B
FIGURE 1.1 Preventive orthodontic problem: (A) Loss of arch length due to proximal carious lesions. (B) Preventive orthodontic
procedure—space maintainer
 CHAPTER 1. DEVELOPMENT OF A CONCEPT 5

FIGURE 1.3 Corrective orthodontic problem Class II type problem, with arch length deficiency. Study models before treatment.

FIGURE 1.4 A corrective orthodontic problem that needs to be handled by a properly trained orthodontist. Unerupted and
impacted tooth has been corrected.

during, or after active orthodontic treatment. Surgical pro-
cedures can prevent or correct periodontal problems,
facilitate and hasten orthodontic treatment, reduce re-
lapse, add to post-orthodontic stability, and improve
esthetics and function in the patients.
Tissue Systems
There are four tissue systems recognized in dentofacial
development: the bone system, the muscle system, the
nerve system, and the tooth system. Only the laboratory
technician deals with the tooth system. It is essential
that the dentist recognizes at the outset that the tissue
system orientation requires a thorough knowledge of
the bone system (two-thirds of malocclusions treated by
orthodontists involve basal bone abnormalities) and of
the vital and dynamic roles of the nerve and muscle
systems. Equally important is an appreciation of facial
esthetics—the relationship of the parts of the face to
each other and to the face as a whole. The position the
6 SECTION I AN INTRODUCTION TO ORTHODONTICS

A B
A B

C D
FIGURE 1.5 (A) Frontal and (B) profile views before orth-
odontic treatment, showing muscle imbalance and lack of C D
facial harmony; (C) Frontal and (D) profile views after mecha-
notherapy, illustrating the establishment of a normal facial
contour and pleasing esthetics.

dentition assumes in the face and its effect on the total

profile become vital considerations. Facial balance, both
at the postural resting position and with the teeth in oc-
clusion, is important. Is the dentition complementary to
facial appearance? Is it contributing harmony and bal-
ance to the face (Figs 1.6 and 1.7), or is the reverse true?
Do the lips close effortlessly or with obvious strain
when the teeth are placed in centric occlusion (Fig. 1.8)?
E
FIGURE 1.6 Facial changes that can be achieved in a rela-
tively short time by properly guided orthodontic procedures.
(A, B) At beginning of treatment. (C, D) During orthodontic
treatment. (E) After orthodontic treatment.
CLINICAL SIGNIFICANCE
Goals of Orthodontics
Would a change in the anteroposterior position of
1. Create the best possible occlusal relationship
the dentition contribute greater harmony and balance
2. Within the framework of acceptable facial esthetics
to the face? And what of the relationship of the maxilla
3. Create a stable occlusal result
and mandible to each other and to the cranial base
(Figs 1.9–1.12)?
 CHAPTER 1. DEVELOPMENT OF A CONCEPT 7

B
FIGURE 1.7 Perverted perioral muscle function. A hypotonic upper lip and a redundant lower lip require a plan of mechano-
therapy that utilizes growth increments, maximum control of individual teeth and possible tooth sacrifice to achieve the desired
result. (A) Before treatment. (B) Two years out of all appliances.

FIGURE 1.8 Facial views of patient taken before and after treatment, demonstrating gratifying facial changes associated with
proper orthodontic guidance. Significant increments in favorable facial growth and a reduction in the excessive apical base dys-
plasia contribute to the profile improvement (see Figs 1.9–1.11).
8 SECTION I AN INTRODUCTION TO ORTHODONTICS

FIGURE 1.9 Class II type malocclusion, deep bite, and arch length deficiency go with pretreatment facial photos of top row,
Figure 1.8. This is a difficult case to treat because of need for tooth sacrifice, despite deep bite and steep mandibular plane.

FIGURE 1.10 Plaster study casts after treatment of patient in FIGURE 1.11 Intraoral views, 5 years after active treatment.
Figures 1.8 and 1.9. Torque demands with overbite control A stable result has been achieved, with elimination of exces-
provided a major challenge in treatment. sive overbite and arch length deficiency.
 CHAPTER 1. DEVELOPMENT OF A CONCEPT 9

FIGURE 1.12 Cephalometric tracings of lateral cephalogram of a treated patient. Despite excessive apical base difference, steep
mandibular plane, and need to remove four first premolars, overbite and overjet are completely normal and well out of retention.
Significant growth increments with counter-clockwise mandibular rotation contributed to the excellent orthodontic result.

efficiency and esthetic harmony as orthodontic objec-

GOALS OF ORTHODONTICS
Jackson’s Triad
Among the myriad definitions of objectives of ortho-
dontics, the most concise and clear is that of Jackson
who had listed the triad of structural balance, functional
tives (Box 1.1). It was believed that the basic goal of or-
thodontics is to either move the teeth or change the basic
shape of the jaw. Correction of malocclusion will elimi-
nate all the unfavorable sequelae present in it. Thereby,
functional efficiency of the masticatory apparatus is re-
stored. A balance between the hard and soft tissues

BOX 1.1 JACKSON’S TRIAD

JACKSON’S TRIAD

Functional efficiency Structural balance Esthetic harmony

10 SECTION I AN INTRODUCTION TO ORTHODONTICS
should be achieved. Failure to achieve structural
balance will lead to relapse or loss of correction achieved.
Achieving structural balance maintains stability of
the correction. The single, most common reason for
the patients to approach an orthodontist is to improve
the facial appearance. Therefore, improvement of
facial esthetics is also a prime objective of orthodontic
treatment.
Changing Paradigms of Goals of Orthodontics
Hard Tissue or Angle paradigm
Angle introduced the hard tissue or Angle paradigm,
wherein the primary goal of orthodontics is to estab-
lish an ideal dental occlusion, followed by jaw rela-
tionship as the secondary goal. Angle was of the
opinion that establishing proper dental occlusion
produces an ideal soft tissue, and he was against the
extraction concept.
Soft Tissue Paradigm
Orthodontists have traditionally viewed structural dis-
crepancies as the major limitation of treatment. But
Ackerman and Proffit9 believe that it is the soft tissues
that determine curative modifiability. The extent of dental
compensation for an existing jaw discrepancy are enacted
by lips, tongue and cheeks; limitations of the periodontal
attachment; mandibular position by neuromuscular
influence; soft tissue contours of the facial mask on the teeth
as pressures over them. The adaptive ability of the soft
tissues for tooth–jaw relationships is far lesser than the
anatomic limits in correcting occlusal relationships. The
adaptive ability of the soft tissues for tooth–jaw positions
[i.e. physiologic limits of orthodontic treatment] is far
lesser than the anatomic limits of treatment. While correct-
ing severe malocclusion in a growing patient, it is not
uncommon to create 7–10 mm change in overjet, overbite
or molar relationship. However, the endurance of adapta-
tion of soft tissue from the stand point of equilibrium,
facial balance, temporomandibular joint (TMJ) and peri-
odontium for expansion of the lower arch are more in the
range of 2–3mm and even lesser for condylar position
changes. In more ways, the crucial step in orthodontic
decision making is the analysis of soft tissue effects. Thus,
the concept of soft tissue paradigm as the main goal of
orthodontics, which includes placing jaws and teeth in a
functional occlusion within the framework of ideal soft-
tissue proportions and adaptation, has become an impor-
tant factor now. There is paradigm shift in giving impor-
tance from skeletal and dental relationships to oral and
facial soft tissues.
The traditional Angle’s concept of establishing proper
dental occlusion without extraction in all cases does not
hold well in the present scenario. The contemporary
philosophy of treatment is that correction of the maloc-
clusion with non-extraction treatment is preferred, if
this can be accomplished within the soft-tissue limita-
tions discussed earlier. With appropriate extractions,
crowding can be relieved without excessive arch expan-
sion, and greater change in tooth positions by retraction
of incisors is possible; but this should be done only if
esthetic guidelines are not compromised.
Health-Related Quality of Life
Roth and Williams have suggested a goal-oriented
treatment plan (Fig. 1.13). Quality of life of a person is
defined as the ‘sense of wellbeing’ that arises from sat-
isfaction or dissatisfaction with the areas of life that are
important to that person. Health of an individual is the
fundamental contributor to life quality. The impact of
healthy and disease on the life quality is termed as
health-related quality of life (HRQL).10 Hence, health
care profession has evolved from a disease-oriented
focus to a wellness model. Similar to medical profes-
sion, the goal of orthodontics today is to improve pa-
tients’ life by enhancing dental and jaw function and
dentofacial esthetics. Hence, orthodontics today is con-
sidered more as a part of medical service dedicated to
establish both physical and mental health as orthodon-
tic treatment is bound to improve the HRQL. Ortho-
dontics in the present world is offered more frequently
to older patients primarily as a part of multidisci-
plinary treatment, and less frequently as only a form of
treatment.
Psychosomatic Norm
Abdul Kader10 introduced the term psychosomatic
norm in orthodontics. Psychosomatic norm is an indi-
vidual’s perception of norm developed unconsciously and
seated in the subconscious. The sense of psychosomatic
norm differs between races and generations, and by
socioeconomic status and educational level. It also dif-
fers from anatomic norm, which is based on objective
assessment of the facial norm. Conflict may arise be-
tween orthodontist and patients, if the orthodontist fails
to understand the psychosomatic norm of the patients
and their parents. Hence, psychosomatic norm also
should be considered while deciding the goal of orth-
odontic treatment.
Today’s concept of goals of orthodontic treatment
includes a wider horizon of establishing a normal es-
thetic and functional occlusion within the framework of
balanced oral and facial soft tissues; balance between
the hard tissues and maintenance of the health of teeth
and supporting tissues with due consideration to long-
term stability of treatment (Fig. 1.14).
 CHAPTER 1. DEVELOPMENT OF A CONCEPT 11

FIGURE 1.13 Roth Williams concept of goals of orthodontics. A goal-oriented orthodontic treatment is advised.

CLINICAL SIGNIFICANCE
Clinical Judgment
In orthodontic practice, clinical judgment involves
integration of clinical experience and a systematic as-
sessment of relevant scientific evidence in the context
of the patient’s orthodontic condition, treatment
needs, and preferences. Clinical judgment is a skill
(art), using the best available evidence (science) with
societal and patient values (Ackerman, 1974).

LEARNING EXERCISES
1. Define orthodontics and what are the divisions of
orthodontics?
2. Who coined the words orthodontia, orthodontics
and dentofacial orthopedics?
3. History of orthodontics
4. Goals of orthodontic treatment
FIGURE 1.14 This patient had come for a treatment to im- 5. Hard and soft tissue paradigm
prove her profile. Examination showed that she had acceptable 6. Jackson’s triad
dental features. This highlights the changing paradigm of goal
of orthodontics toward a balanced soft-tissue feature.
12 SECTION I AN INTRODUCTION TO ORTHODONTICS
References
1. Angle EH. The Angle system of regulation and retention of the teeth and
treatment of fractures of the maxilla. 5th ed. Philadelphia: S S White
Manufacturing Co; 1897.
2. Weinberger BW. Orthodontics: a historical review of its origin and evolu-
tion. St. Louis: Mosby; 1926.
3. Shankland WM. The biography of a specialty organization. St. Louis:
The American Association of Orthodontists; 1971.
4. Angle EH. The Angle system of regulation and retention of the teeth.
1st ed. Philadelphia: S S White Manufacturing Company; 1887.
5. Angle EH. Treatment of malocclusion of the teeth. 7th ed. Philadelphia:
S S White Manufacturing Company; 1907.
6. Noyes FB. What should be the relation of the orthodontist and the
dentist? Dental Cosmos 1911;13:69-70.
7. Moore AW. A critique on orthodontic dogma. Angle Orthodont
1969;39:69-82.
8. Orthodontics: principles and policies; educational requirements; orga-
nizational structure – council on orthodontic education. St. Louis:
American Association of Orthodontists; 1971.
9. Ackerman JL, Proffit WR. Soft tissue limitations in orthodon-
tics: treatment planning guidelines. Angle Orthodont 1997;5:
327-36.
10. Hussam M Abdul Kader. Psychosomatic norm in orthodontics –
problems and approach. World J Orthodont 2006;7:394-98.
 S E C T I O N I I

Growth and Development

S E C T I O N O U T L I N E

Chapter 2. Prenatal Development of Cranial, Facial and Oral Structures 14

Chapter 3. Principles of Growth and Development 24
Chapter 4. Controlling Factors in Growth of the Skull 31
Chapter 5. Postnatal Growth of Craniofacial Structures 43
Chapter 6. The Dynamics of Facial Growth 58
Chapter 7. Development of Dentition and Occlusion 67
Chapter 8. Normal Occlusion 89

13
 C H A P T E R
Prenatal Development of Cranial,
Facial and Oral Structures
C H A P T E R
Differences between Growth and
Development
Prenatal Development of Cranial, Facial
and Oral Structures
Period of the Ovum
Embryonic Period
Fetal Period
Growth was conceived by an anatomist, born to a biologist, deliv-
ered by a physician, left on a chemist’s doorstep, and adopted by a
physiologist. At an early age, she eloped with a statistician, divorced
him for a psychologist, and is now being wooed, alternately and
concurrently, by an endocrinologist, a paediatrician, a physical
anthropologist, an educationalist, a biochemist, a physicist, a math-
ematician, an orthodontist, a eugenicist and the Children’s Bureau!
This humorous expression by Krogman1 illustrates
the complex nature of the biologic process of growth
and development. Like two Siamese twins joined at
the head, growth and development are practically in-
separable. According to Todd, “Growth is an increase in
size; development is progress toward maturity”.2 Meredith
defines growth as “The entire series of anatomic and
physiologic changes taking place between the begin-
ning of prenatal life and the close of senility.” Various
other definitions for growth and development are given
in Box 2.1.
DIFFERENCES BETWEEN GROWTH
AND DEVELOPMENT
s The fundamental difference between growth and
development is that growth can be considered an
‘anatomic phenomenon’, whereas development is a
‘physiological and behavioral phenomenon’.
2
O U T L I N E
Growth of the Palate 19
14 Growth of the Tongue 20
Growth of the Mandible 21
15 Growth of the Cranium 22
15 Growth of the Temporomandibular Joint 22
15 Learning Exercises 23
18
s Growth is quantitative, i.e. it is a measurable aspect
of biologic life. The units of growth are inches per
year or grams per day. Characteristically, growth is
equated with enlargement. But sometimes there are
instances in which there is a decrease in size during
growth, e.g. thymus gland after puberty. Growth
highlights the normal dimensional changes over a
period of time. Growth might cause change in form
or proportion, increase or decrease in size, and change
in texture and complexity. In simple words, growth is
change or difference in quantity.
s Development includes all the changes in the life of a
subject from his or her origin as a single cell till death.
It comprises sequential events from fertilization till
death. Development: growth ! differentiation ! trans-
location where differentiation means change in quality
and translocation means change in position (Fig. 2.1).
During the prenatal period, the height increase is
5000-fold as opposed to only a three-fold increase during
the entire postnatal period. The weight increase, accord-
ing to Krogman,1 is 6.5 billion-fold from ovum to birth
and only 20-fold from birth to adulthood. By the end
of the fourth month of life, birth weight has doubled.
If growth continued at this rate, human size would be
astronomical.
14
 CHAPTER 2. PRENATAL DEVELOPMENT OF CRANIAL, FACIAL AND ORAL STRUCTURES
BOX 2.1 OTHER
DEFINITIONS OF GROWTH
AND DEVELOPMENT
Growth
s Krogman: Increase in size, change in spatial propor-
tion over time.
s Huxley: Self-multiplication of the living tissues.
s Moss defines growth as any change in morphology
which is within measurable parameter.
s Moyer defines growth as the biologic process by
which living matter gets larger.
Development
s Melvin Moss: “Development can be considered as
a continuum of causally related events from the
fertilization of ovum onwards.”
Even if we project only the absolute increase of
7 pounds during the four postnatal months, a man would
weigh 1000 pounds and would be 50 feet tall at 50 years
of age. But the accomplishment of normal human propor-
tions is not due merely to a general slowing down. Differ-
ent tissues grow at different rates and at different times.
Although growth is an orderly process, there are
times when ‘spurts’ occur. As more information is avail-
able on growth processes, there is a certain amount
of predictability with respect to growth and develop-
mental phenomena. With the increasing importance of
orthopedic concepts and growth guidance, the clinical
application of this information is quite apparent. A thor-
ough knowledge of postnatal growth particularly is
essential for the dental surgeon and orthodontist who
work with the growing child, if he or she is to make
significant clinical application of this information.
FIGURE 2.1 Components of development.
15
PRENATAL DEVELOPMENT OF CRANIAL,
FACIAL AND ORAL STRUCTURES
Prenatal life may be arbitrarily divided into three periods
(Box 2.2).
Period of the Ovum
Fertilization of oocyte by sperm results in the formation
of zygote that undergoes rapid mitosis on its passage
along the fallopian tube to form a cluster of cells called
blastomere (Fig. 2.2). Continuation of mitosis results in
a 16-cell stage called morula. The center of morula
cavitates to form a structure called blastocyst. The
fluid-filled space in the blastocyst is called blastocystic
cavity surrounded by single layer of cells called tropho-
blastic layer. Inside the blastocyst is the inner cell mass
called the embryoblast. The trophoblastic layer forms
the embryonic part of the placenta and the inner cell
mass develops into the embryo. By the starting of sec-
ond week of IUL, the blastocyst is implanted into the
uterine endometrium. This period of about 2 weeks
consists primarily of cleavage of the ovum and its at-
tachment to the uterine wall. At the end of this period,
the ovum is only 1.5 mm in length and cephalad dif-
ferentiation has not begun.
Embryonic Period
As early as 21 days after conception, when the human
embryo is little more than 3 mm in length, the head be-
gins to take shape.3 At that time, just before the connec-
tion exists between the oral cavity and the foregut,
the head is primarily made up of the prosencephalon
(Fig. 2.3). The most inferior portion of the prosencepha-
lon is to become the frontal prominence, which over-
hangs the developing oral groove. Bounding the oral
groove laterally is the rudimentary maxillary processes.4
These processes will migrate toward the midline
and ultimately join with the medial and lateral nasal
components of the frontal process (Fig. 2.4). Below the
oral groove is the broad mandibular arch. The primitive
B O X 2 . 2 S TA G E S I N
P R E N ATA L L I F E
1. The period of the ovum (from fertilization to the
end of the fourteenth day).
2. The period of the embryo (from the fourteenth day
to about the fifty-sixth day).
3. The period of the fetus (from about the fifty-sixth
day until the two hundred and seventieth day birth).
16 SECTION II GROWTH AND DEVELOPMENT

FIGURE 2.2 The stages of development of blastocyst as the fertilized ovum traverses through the fallopian tube.

FIGURE 2.3 Midsagittal section of 3 mm embryo. Oral groove and foregut still separated.

oral cavity (bounded by the frontal process), the

two maxillary processes and the mandibular arch are
together called the stomodeum.

CLINICAL SIGNIFICANCE
Neural Crest Cells
th
s On the 28 gestational day, the germ disk closes
and forms a neural tube by induction from the
notochord. At the cranial end of this neural tube,
edges are formed by the neuroectoderm at the
inner aspect and the surface ectoderm at the outer
aspect. From different areas on these edges, cells
start migrating anteriorly and form the cranium,
face, and dentition. The migrating cells are called
the neural crest cells. These cells migrate from
different parts of the neural crest to different parts
of the cranium and dentition with a well-defined
sequence. The migration of neural crest cells was
first described by Le Douarin and Teillet (1974).
s Disturbances in the migration of neural crest cells A B
result in various congenital abnormalities.
FIGURE 2.4 Drawing of 3 mm embryo. (A) Frontal and (B)
lateral view before the formation of nasal pits.
 CHAPTER 2. PRENATAL DEVELOPMENT OF CRANIAL, FACIAL AND ORAL STRUCTURES
Between the third and eighth weeks of intrauterine
life, a major part of the development of the face takes
place. The primitive oral cavity deepens, and the oral
plate, which is made up of two layers (the endodermal
lining of the foregut and the ectodermal floor of the
stomodeum) ruptures. During the fourth week, when
the embryo is only 5 mm long, it is easy to see the
ectodermal proliferations on either side of the frontal
prominence. These nasal placodes or thickenings
will ultimately form the lining of the nasal pits and the
olfactory epithelium.
The maxillary processes grow forward and unite
with the frontonasal process to form the maxillary jaw.
Since the medial nasal processes grow downward more
rapidly than the lateral nasal processes, the latter do
not contribute to the structures that ultimately form
the upper lip. The depression that forms in the midline
of the upper lip is called the philtrum and indicates
the line of fusion of the medial nasal and maxillary
processes.
Those primordia responsible for facial development
are readily observed by the fifth week of life. Inferior
or caudal to the stomodeum and the maxillary pro-
cesses, which are growing toward the midline to form
the lateral parts of the upper jaw, are the four pharyn-
geal pouches (and possibly a transitory fifth pharyn-
geal pouch), which form the branchial arches and
furrows (Fig. 2.5). The lateral walls of the pharynx are
divided both inside and outside into branchial arches.
Only the first two arches are named; these are the
mandibular and the hyoid. The arches are divided
by grooves, which are usually identified by number.
Special visceral efferent nuclei of the central nervous
system supply the branchial arches and activate the
visceral muscles.
Embryonic development actually begins relatively
late, after the primordia of other cranial structures (brain,
FIGURE 2.5 Internal representation of the pharyngeal
pouches (numbered) in a somite period embryo.
17
CLINICAL SIGNIFICANCE
Six Main Fields of Migration
of Neural Crest Cells
s Cerebellar and cervical spine (notochordal field)
s Theca (induced from notochord and/or from neural
crest cells)
s Frontonasal (anteroneural crest field)
s Maxillary (anteromedian neural crest field)
s Palatine (posteromedian neural crest field)
s Mandibular (posterior neural crest field)
cerebral nerves, eyes, muscles, etc.) have already devel-
oped. At this time, between and around these structures,
mesenchymal tissue condensations appear, providing a
shape that we recognize as the skull. Mesenchyme also
appears in the branchial arch area. By the fifth week of
life of the human embryo, the mandibular arch is quite
distinct, bounding the caudal aspect of the oral cavity.
Over the next 2–3 weeks of embryonic life, the medial
notch that signifies the area of the union of the paired
primordia gradually disappears so that by the eighth
week, there is little to indicate the region of merging and
fusion.
The medial nasal process and the maxillary processes
grow toward each other and are almost in contact.
The fusion of the maxillary processes occurs in the
14.5 mm embryo during the seventh week. The eyes
migrate medially.
Condensed mesenchyme in the area of the cranial
base, and also in the branchial arches, differentiates
into cartilage. The cartilaginous skull primordium, the
chondrocranium, thus develops (Fig. 2.6). As Limbo-
rgh points out, the condensed mesenchyme reduces
to a thin layer, the perichondrium, which covers the
cartilage.5 The base of the skull is part of the chondro-
cranium, joining the nasal capsule in front and otic cap-
sules laterally. The first centers of endochondral ossifi-
cation appear, with cartilage being replaced by bone,
leaving only the synchondroses or cartilaginous growth
areas.
About the same time, the mesenchymal condensations
of the calvarium and facial areas appear and intramem-
branous bone formation takes place. As with cartilage,
there is condensation of the mesenchyme to form the
periosteum. In addition, the sutures with proliferating
mesenchyme remain between the bones.
At the beginning of the eighth week, the nasal sep-
tum has narrowed further, the nose is more prominent,
and the external ear may be seen forming (Fig. 2.7).
The embryo has quadrupled in length by the end of the
18 SECTION II GROWTH AND DEVELOPMENT
FIGURE 2.6 Schematic drawing of the skull of a 12-week-old embryo. The developing skull has two components. The neuro-
cranium includes the calvaria and the base of the skull, and the viscerocranium includes the facial skeleton and associated
structures.
A B
FIGURE 2.7 Drawing of 18 mm embryo, eighth week. Nasal
septum narrowed down, nose more prominent; external ear
may be seen forming.
eighth week. The nasal pits have broken through into
the upper part of the oral cavity and may now be called
the nostrils. At this time also, the cartilaginous septum
is being constructed from the mesenchymal cells of
the frontal prominence and the medial nasal process.
Simultaneously, it will be noted that there is a sharp
demarcation between the lateral nasal and the maxillary
processes (the nasolacrimal groove). As this closes over,
it is converted into the nasolacrimal duct.
The primary palate has formed and actual communi-
cation exists between the nasal and oral cavities through
the primary choanae. The primary palate develops into
the premaxilla and the alveolar process underlying it
and part of the inside of the upper lip.
The lidless eyes start migrating toward the midsag-
ittal plane. Even though the lateral halves of the man-
dible have fused by the time the embryo is 18 mm long,
the mandible is still relatively short. It is recognizable
in shape by the end of the eighth week of intrauterine
life. At this time, the head starts to assume human
proportions.
Fetal Period
Between the eighth and twelfth weeks, the fetus triples
in length from 20 to 60 mm; the eyelids and nostrils
form and close. There is relatively greater increase
in mandibular size, and the anteroposterior maxillo–
mandibular relationship approaches that of the new-
born infant. Great changes have taken place in the facial
structures (Fig. 2.8). But the changes seen during these
last two trimesters of intrauterine life, arbitrarily la-
belled the fetal period, are largely an increase in size and
a change in proportions. Tremendous acceleration is the
theme. During prenatal life, the body weight increases
several billion times, but from birth to maturity, rate of
 CHAPTER 2. PRENATAL DEVELOPMENT OF CRANIAL, FACIAL AND ORAL STRUCTURES 19

BOX 2.3 CHANGES IN

A B
FIGURE 2.8 Drawing of 60 mm embryo, twelfth week. Embryo
has tripled in length in 4 weeks. Maxillomandibular relationship
more nearly normal, nostrils closed, and eyelids formed and
closed. Face approaches human proportions. Adult face has
approximately same division as embryonic precursor.
MANDIBLE
1. The alveolar plate (ridge) lengthens more rapidly
than does the ramus
2. The ratio of alveolar plate length to total mandibu-
lar length is reasonably constant
3. The width of the alveolar plate shows a more rapid
increase than does total width
4. The ratio of the width between the mandibular
angle to the total width is relatively constant dur-
ing fetal life

increase is only 20-fold. The rate slows down apprecia- B O X 2 . 4 C O M PA R I S O N

bly before birth (Table 2.1), which indicates the ratio OF GROWTH OF MAXILLA
of weight increase within each of the 10 lunar months AND MANDIBLE
(28 days), arrived at by taking the weight at the end of Structures related Developmental
each month as compared with the weight at the begin- to developing jaws elements
ning of the same lunar month.3
More specifically in the area of the developing denti- Mandible
tion, the maxilla and mandible are of concern. Dixon6 1. Inferior dental nerve 1. Neural
divides the maxilla, arising as it does from a single 2. Meckel’s cartilage 2. Alveolar
center of ossification, into two areas, based on the rela- 3. Tooth germs 3. Ramal
tionship to the infraorbital nerve: 4. Muscular
1. Neural and alveolar areas 5. Cartilaginous
2. Frontal, zygomatic and palatal processes.
Maxilla
With the exception of the paranasal processes of the 1. Infraorbital nerve 1. Neural
nasal capsule and the cartilaginous areas at the alveolar 2. Nasal capsule 2. Alveolar
border of the zygomatic process, the maxilla is essen- 3. Tooth germs 3. Zygomatic
tially a membranous bone. This is important clinically, 4. Palatal
because of the apparent difference in responses of 5. Cartilaginous
membranous and endochondral bones to pressure. In
the last half of the fetal period, the maxilla increases in
height through bone growth between the orbital and
the alveolar regions.7
Freiband8 has described the pattern of fetal growth of indices, he showed that the form of the palate is quite nar-
the palate. In numerous measurements taken to establish row in the first trimester of fetal life, of moderate width in
the second trimester of pregnancy, and wide in the last
fetal trimester. Palatal breadth increases more rapidly
TABLE 2.1 Ratio of weight increase during prenatal period
than length, which accounts for the morphologic change.
Lunar Month Ratio of Weight Increase Palatal height changes are less dramatic. For the mandi-
First lunar month 8000 ble, the changes are summarized by Ingham9 (Box 2.3).
Second lunar month 499 Box 2.4 shows a comparison of the maxilla with the
Third lunar month 11.0 mandible, which was made by Dixon.7
Fourth lunar month 4.0
Fifth lunar month 1.75
Sixth lunar month 0.82
Seventh lunar month 0.67 GROWTH OF THE PALATE
Eighth lunar month 0.60
Ninth lunar month 0.50 The main part of the palate arises from that part of
Tenth lunar month 0.33
the upper jaw which originates from the maxillary
20 SECTION II GROWTH AND DEVELOPMENT

processes. Also contributing to the formation of the pal-
ate is the medial nasal process, the deeper aspects of
which give rise to a small triangular medial portion of
the palate, identified as the premaxillary segment. The
lateral segments arise from shelf-like projections of the
maxillary processes, which grow toward the midline by
differential proliferations (Fig. 2.9).
As the nasal septum proliferates downward and
backward, the shelf-like palatal ridges take advantage
of the rapid mandibular growth, which allows the
tongue to drop caudally. With the tongue mass no
longer interposed between the palatine processes, the
oronasal communication is narrowed down. The pala-
tine processes continue to grow toward each other ante-
riorly and unite with the downward proliferating nasal
septum to form the hard palate. This fusion progresses
from anterior to posterior and reaches the soft palate.
Failure of fusion of the palatine processes with each
other and the nasal septum gives rise to one of the most
frequent congenital defects known—the cleft palate. It
would appear that perforation of the epithelial covering
of the processes is essential. There is some evidence to
substantiate the thesis that failure of mesodermal perfo-
ration of the resistant epithelial covering and the reten-
tion of epithelial bridges can cause cleft palate.10–14
GROWTH OF THE TONGUE
Because of the importance of the tongue in the func-
tional matrix and its role in the epigenetic and environ-
mental influences on the osseous skeleton, as well as its
possible role in dental malocclusion, the development of
the tongue is of considerable interest.
Patten refers to the tongue initially as a sack of mu-
cous membrane that becomes filled with a mass of
growing muscle.10 The surface of the tongue and the
lingual muscles are from different embryonic origins
and undergo changes that make it desirable to consider
them separately.
During the fifth week of embryonic life, rapidly
proliferating mesenchymal swellings, covered with a
layer of epithelium, appear on the internal aspect of the
mandibular arch (Fig. 2.10). These are referred to as the

A B

C D
FIGURE 2.9 Drawings of four successive stages of palatal development. (1) External nares; (2) median nasal process; (3) median
palatal process; (4) nasal cavity; (5) nasal septum; (6) lateral palatal processes.
 CHAPTER 2. PRENATAL DEVELOPMENT OF CRANIAL, FACIAL AND ORAL STRUCTURES
FIGURE 2.10 Schematic paramedian section of a 5-week-old
embryo, illustrating development of the ventral wall of the
oropharynx and the path of migration of the occipital-somite
myotomes forming the tongue muscles.
lateral lingual swellings. A small medial projection rises
between them, the tuberculum impar. Caudal to this is
the copula, which unites the second and third branchial
arches to form a midcentral elevation extending back-
ward to the epiglottis. Mesodermal tissue from the sec-
ond, third and fourth arches grow on either side of the
copula and contribute to the tongue structure. The point
at which the first and second branchial arches merge is
marked by the foramen caecum just behind the sulcus
terminalis. This serves as a boundary line between the
base or root of the tongue and its active portion.
Since the mucosal sac or covering of the body of the
tongue originates from the first lateral lingual swellings
of the mandibular arch, part of its innervation comes
from the mandibular branch of the fifth cranial nerve.
The hyoid or second arch contributes the taste bud
innervation, or the seventh nerve.
FIGURE 2.11 Schema of the origin of the mandible. The center of ossification is lateral to Meckel cartilage at the bifurcation of
the inferior alveolar nerve.
21
The largest part of the tongue is covered with tissue
that originated from the stomodeal ectoderm. The papil-
lae of the tongue are seen as early as 11 weeks of fetal
age. By 14 weeks, the taste buds can be observed in the
fungiform papillae, and they appear in the circumvallate
papillae at about 12 weeks. Beneath the ectodermal cov-
ering is a kinetic mass of specialized and well-developed
muscle fibers, admirably prepared well before birth to
cope with the manifold functional demands being made
on it by deglutition and suckling. In no other area of the
body is precise muscle activity as far advanced.
GROWTH OF THE MANDIBLE
There is a marked acceleration of mandibular growth
between the eighth and twelfth weeks of fetal life. As a
result of the mandibular length increase, the external
auditory meatus appears to move posteriorly. The de-
velopment of a slender cartilage rod (Meckel cartilage)
during the second month serves as a precursor of the
mandibular mesenchyme that forms around it and is
responsible for mandibular growth activity. At its proxi-
mal aspect, nearest to the chondrocranium, it is actually
possible to discern the incus, the malleus and the stapes
of the ear. The form of the incus, malleus and stapes at
the end of 3 months is essentially complete.
Bone begins to develop lateral to Meckel cartilage dur-
ing the seventh week and continues until the posterior
aspect is covered with bone (Fig. 2.11). Ossification stops
at the point that will later become the mandibular lingula,
and the remaining part of Meckel cartilage continues
on its own to form the sphenomandibular ligament and
the spinous process of the sphenoid. The part of Meckel
cartilage that has been encapsulated with bone appears
to have served its purpose as a splint for the intramem-
branous ossification, and it largely deteriorates.
22 SECTION II GROWTH AND DEVELOPMENT
The early development and ossification of the bones
of the stomatognathic system are quite evident in a
lateral radiograph of a 69 mm fetus taken at 14 weeks.
Ossification in the downward proliferating condylar
cartilage does not appear until the fourth or fifth month
of life. There is good evidence that final ossification in
this center does not occur until the twentieth year of life.
GROWTH OF THE CRANIUM
Early cranial base growth is due to proliferation of car-
tilage and its replacement by bone, primarily at the
synchondroses. In the cranial vault or desmocranium,
growth is accomplished by proliferation of connective
tissue between the sutures and its replacement by bone.
The periosteum also grows but it is a limiting mem-
brane, of course, determining the size and shape
changes. Despite the rapid ossification of the cranial
vault in the terminal stages of fetal life, the bones of the
desmocranium are separated from each other by the
fontanels when the child is born (Fig. 2.12).
The changes that occur during the first three months
in utero are the most important. Those that continue for
the balance of intrauterine life are largely growth in size
and change in position. Patten points out the impor-
tance of the underlying developmental mechanisms that
few anatomists discuss.10 As important as the surface
configurations are known to be, beneath the ectodermal
covering lie masses of developing mesenchymal cells,
which arise from mesoderm and migrate, aggregate,
and differentiate to form structures.
FIGURE 2.12 Fontanels, fissures and sutures in the newborn skull.
GROWTH OF THE
TEMPOROMANDIBULAR JOINT
There are four main pairs of branchial arches and fur-
rows. These differentiate into a number of structures,
with the mandibular and hyoid arches forming the man-
dible, malleus, incus, stapes, styloid process, and so forth.
The proximal ends of the first and second branchial
arches provide the articulation for the mandible.
The temporomandibular joint may be seen in an
embryo of 7–8 weeks, with the condyloid process being
formed shortly thereafter, and is situated between the
superior end of Meckel cartilage and the developing
zygomatic bone.14 By the end of the eleventh week, the
two joint cavities are formed.
The articular disk and the external pterygoid mus-
cle are seen in the second trimester. Pterygoid muscle
fibers have actually been traced to the retrodiskal por-
tion of the joint. Cartilaginous concentrations appear
in the head of the mandible and are first seen during
the tenth week. They may also be observed in the ar-
ticular portion of the temporal bone. The fibrous tissue
covering of the articular surfaces is already present
at birth. As the embryo grows, the pouches and
branchial arches differentiate into a number of organs
(Fig. 2.13). The tympanic cavity of the middle ear and
the eustachian tube come from the first pouch. The
palatine tonsil rises, in part, from the second pouch.
The thymus and parathyroids arise from the third and
fourth pouches. It is of interest to note that neither the
pharyngeal nor the lingual tonsils are of pharyngeal
pouch origin.
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throughout the school year, not because he disliked him or wanted to
be troublesome, but because the teacher could not perceive that
Cleaver had a mania for approbation which needed to be guided into
better channels.

CONSTRUCTIVE TREATMENT

The pupil who does evil for approbation will do good for the same
cause, if approbation for good can be secured. In this case, Mr.
Fraser might have turned Cleaver’s talent for making cartoons and
doggerel into less personal use, utilizing the admiration of his
classmates as a spur to accomplishment. If he had asked Cleaver, for
instance, to illustrate some event in current history with an original
cartoon, to accompany a talk to be given in opening exercises, even
Cleaver’s vanity would have been satisfied at the flattery of having his
talent taken so seriously. At the same time the narrow personal
nature of Cleaver’s interests would have been broadened by a
knowledge of affairs outside his immediate world.

COMMENTS

Wise teachers do not allow the rudeness, crudeness and

childishness of their pupils to disturb their serenity. They know that
good manners and consideration are the result of training, and with
“a fine disregard of personalities” they set about giving this training.
The great art in such cases is to substitute a good activity for the bad
one which has heretofore gained the approbation sought.

ILLUSTRATION 1 (RURAL SCHOOL)

Mary Costello had fiery red hair, which Red Hair

swirled around her freckled face in a way
that would have delighted Titian, but which her pupils in District 27
found only surpassingly funny. She unburdened herself one night to
her mother, who was just a generation more Irish than herself.
 “That Thad Burrows thinks he’s so funny,” she stormed. “Today he
said to me, ‘Say, Miss Costello, do you wear a hat in winter?’ and I
said of course I did, and why shouldn’t I? And he said he should
think it would have to be lined with asbestos. Then they all bellowed,
and if he ever mentions it again I’ll lambast him for it,” and Mary’s
eyes snapped with indignation.
“There now, Mary, don’t be after letting a fool kid upset ye so,” her
wise old mother advised. “That Thad Burrows is a bright boy, and if
it was someone else’s thatch he said it about ye’d be laughing with
him altogether. I’ll bet that if you’ll win the heart of him, he’ll lick
anyone that dares to think of a white horse when you’re around.”
Mary pondered this advise and took it. She showed no resentment
toward Thaddeus, but rather sought ways of being especially kind to
him. She discovered that he was eager to earn money, and helped
him find work in town on Saturdays; she lent him books and
deferred to his opinion in matters of stove-tending and mouse-
catching. He came to connect his leadership with the teacher, who
found so many little ways of giving him the prominence his soul
craved. The red hair ceased to be a joke, and by the term’s end the
prophecy of Mary’s mother had come to pass.

ILLUSTRATION 2 (SIXTH GRADE)

Raymond Smith had just taken up boxing. He was accustomed to

hang around a gang of street idlers and would-be sports and when
any of the number ventured to put on the gloves he was fully alive to
every move they made.
Not having funds to purchase a pair of gloves he began
pummelling smaller boys, getting some little skill in certain
movements imitated from his larger associates. There was a great
deal of bluff and bluster in his actions and not a small amount of
teasing.
Ellen Moore, teacher, knew boy nature Shaking Fist
fairly well. She was strict in conduct but
rarely was caught firing her guns at a mere decoy. Raymond broke
over bounds in a harmless fashion in that as she was passing his desk
one afternoon, he doubled up his fist and shoved it in her direction—
an excellent opportunity for rigid discipline. But this is what
happened:
“My, what a large, solid fist you have,” she said in a quiet voice,
quickly moving on to her next duty.
The hand fell. The boy had no clear motive and yet was in a mood
where belligerency would be easily aroused and deeply relished.
No reference was again made to this incident by either, although
Miss Moore took occasion in a few other matters to draw the lines
closely on Raymond that he might clearly sense the limitations that
school life laid upon him.

CASE 90 (THIRD AND FOURTH GRADES)

(3) Practical jokes—a more serious kind Toy Mouse

of teasing. Imogene and Charles Rogers
were two orphans, living with elderly relatives who wanted to bring
them up wisely, but did not know how. They were full to overflowing
of animal spirits, bubbling with fun, restlessly eager to fill every
moment with good times. Miss Spires, their teacher, was somewhat
short-sighted, and that is why, when a little mechanical mouse ran
from the second row of chairs right up to her feet, she thought it a
live one and jumped and screamed.
Imogene and Charles, who had bought the mouse at the ten-cent
store, were delighted past all bounds, and all the children laughed.
Miss Spires thought she had been insulted, and without much
ceremony put the two children behind the piano. They were not at all
resentful, for here they had a good chance to plan more mischief, and
made a conspiracy to secure a repetition of the entertaining panic of
the morning by putting two of their pet rabbits into Miss Spires’ desk
at noon. This great joke worked as well as the first—even better. Miss
Spires sent the “dreadful children” to the principal for correction,
with a message which made the principal look at the young
scapegraces gravely. But she was a wise principal. She said:
“What did Miss Spires do when you made the mouse run up to her
feet?”
“She just screeched!” gurgled Imogene in reminiscent delight.
 “She jumped as high as my head!” Charles had a good imagination.
“Did she screech when you put the rabbits into her desk?”
“She hopped all around like a chicken, and asked who did that.”
“What did you say?”
“I said we did, and she didn’t think it a good joke, but she said we
were bad children and sent us to you.”
“Do you think you are bad? What is it, to be bad?”
“Swearing.”
“Biffing people that ain’t as big as you are.”
“And telling lies. That’s ’specially bad.”
“Yes, that’s all true. But do you know, good things are sometimes
bad, when they are put in the wrong places, and done at the wrong
times.” The principal had a long talk with the children, in which she
discovered that their attitude toward control was very good, but that
their ideas of appropriateness were very primitive. This was because
their elders had tried to repress them instead of guiding them, and
being made of irrepressible stuff they had simply overrun
boundaries.
“Why don’t you try to guide those play instincts that are so strong
in Imogene and Charles?” she asked Miss Spires later. Miss Spires’
reply shows just why she failed as a teacher:
“It’s not my business to study their ‘instincts.’ I’m here to teach
them to read and write and cipher.”

CONSTRUCTIVE TREATMENT

Laugh with the children at your own silliness. At their age it would
have seemed as funny to you as it now does to them.
Pick up the mouse, examine it with interest, and say, “He is a
funny little fellow, isn’t he! (Approval.) But he hasn’t very good
manners to interrupt us so in school time. Let’s put him up here on
the teacher’s desk, where he can learn to be more polite.” (Suggestion
—that the act was rude.)
“Charles, you may read next. Imogene, see if he reads just right.”
(Substitution.)
COMMENTS

A teacher who is so infantile as to scream at a tiny, frightened

mouse, even though it were a live one, should not blame the pupils
for indulging in less marked exhibitions of arrest of development.
Teachers meet pupils sanely on the play question when they
sympathize with their desire to play, but see clearly why and how
these impulses must be controlled for the child’s future good. Play is
a good servant but a poor master; no human being is more pitiful
than the amusement drunkard. Play in its right place is a wonderful
renovator of health and spirits; play in the wrong place stunts
character and makes for selfishness and littleness. The ideal teacher
wants his pupils to play, helps them to realize the great values that lie
in play, but shows them clearly that play must be indulged in at right
times and places, and rigidly excluded from work hours, except
where it can be made to help on the work. In short, he leads his
pupils as they grow older to play with reason and to plan play
intelligently, rather than blindly to follow impulses.

ILLUSTRATION (HIGH SCHOOL)

In a certain large high school the teachers Play in Study

had had much trouble with the students in Hour
the assembly room. A spirit of uncontrolled play seemed to take
possession of the room a few minutes after the hour had begun.
Instead of settling down to work, the boys and girls wrote notes,
played little tricks on each other, whispered and made endless
meaningless trips to dictionary and bookcase. They seemed to think
the hour was given to them for social purposes.
Many teachers had failed to remedy this condition, before Miss
Stansbury was relieved of two classes that she might take hold of the
assembly room.
“Do you give me permission to do whatever I think is wise?” she
asked the harassed principal.
“Go ahead,” said he. So she did.
 She had been in the room about five minutes, and was busily
marking papers, when a hard lemon came rolling up the aisle toward
her desk. She went to it, picked it up, and saw that two boys, the only
two who could have thrown it up that aisle, were looking at her under
lowered lids. Very quietly, so as not to be overheard except by those
hard by, she asked who had thrown the lemon, and the doer
acknowledged at once—lying was not a fault in this school.
“You don’t seem to know what a study period is for. You may take
your books and go home, and study your lessons there. I shall call up
your mother on the telephone and tell her why you are coming
home.”
“But I have a class this next hour, and I live clear across the city!”
exclaimed the student, in dismay. “I can’t go home!”
“But you can’t stay here, since you don’t know how to use a
common study hall. Please go at once, and I’ll report to your teacher
why you are gone. I have work to do, and can’t spend my time
policing the room.”
The puzzled boy rose slowly and left the room. Miss Stansbury
went to the high school office, called up his mother, and told her that
her son would be home shortly, as he had been playing in the
assembly room and would therefore have to do his studying at home
that day.
“But he can’t study at home. We live a mile and a half across the
city. What was he doing? Was it anything dreadful?”
“Not at all. He merely rolled a lemon up the aisle, a very innocent
performance at any other time—but this happened to be study hour.”
“Well, you may be very sure he won’t do it again!” and the
indignant mother hung up her receiver with a snap.
When Miss Stansbury reached the assembly room again she saw a
group standing around a boy near the center of the room. They were
giggling and peering over his shoulder at something on the desk—
which, when she reached them, Miss Stansbury discovered to be the
last copy of Life.
“Don’t go to your seats yet. I want to talk to you a moment, and I
don’t want to disturb those who are studying by talking very loud.
You six people also seem not to have learned what a study hour is for.
Play and fun and Life belong to other times and places. I shall write
your names on slips, and send them to the teachers of your various
classes, so that if you are absent or tardy they may know why. And
now you six may take whatever study books you need and go home.
You can not stay here unless you study, for this is a study period. I
shall call up your homes and tell your parents why you are coming
home.”
“Will you give us an excuse for absence from physics next hour?”
one boy asked.
“Why, no. You have excuses only for necessary absences.”
“But then we’ll get a zero for the recitation!”
“Yes, I suppose so. But a high school boy is supposed to know
enough to study during study hours.” Miss Stansbury was smiling
and implacable.
The six passed out, grumbling and almost rebellious. Miss
Stansbury went again to the telephone, and told five mothers (the
sixth one being out) why their children were coming home.
“Why don’t you make him study?” said one mother.
“I am doing so,” was the reply.
When she returned to the assembly room all was quiet. Not one of
the students who were left cared to play, or write notes, or roll
lemons. Here was a teacher who meant business. Miss Stansbury did
not reform the students altogether, for they often slid back into their
old habits when the younger and weaker teachers had charge of the
room. But when she was in charge, there was quiet and industry, and
no attempt at ill-timed fun.
By the time they have reached the high school, pupils know what is
expected of them during school hours in a general way; but they also
know that teachers vary greatly in their standards. Some tolerate
play during work time, some do not. Those who will tolerate it
usually have to. Miss Stansbury simply and quietly defined her stand,
which was one of absolute adherence to a work-while-you-work
program. Neither did she fall into the error of a certain high school
teacher who dallied around a note writer, neither asking what he was
doing nor demanding that he work. She reasoned that if a study
period is for study, there is no sense in having it spoiled by
interpolated fun. She did not scold, she did not lecture, she did not
entreat, she did not moralize; she just eliminated the disturbers, and
after two examples of her method everyone understood her and did
as she demanded. She assumed differentiation between working and
play hours. If she had used this method with untrained, little
children in the lower grades it would have been a stupid and harmful
mistake, for such children have not yet learned to control their play
impulses. High school students know how; they will do it if held up
to a standard of action.

CASE 91 (HIGH SCHOOL)

The sophomore class in a high school decided to do something to

call public attention to the valor and general high qualities to be
found in its members. As students their record was good. As to
conduct no member had suffered any extreme penalties, although
the superintendent’s son had often skirted the boundaries of the
unendurable.
 The class played the following pranks: Buildings
during the night the school bell was Disfigured
rendered useless by removal of the rope and clapper; a donkey was
taken up the steps into the assembly room and left there until
morning; class emblems were painted in class colors in a score of
forbidden places.
This second offense aroused the ire of the superintendent. In a few
days the class was called to meet him and another member of the
faculty. Mr. Webster, the superintendent, at once asked the following
questions:
“I would like to know what members of this class took part in the
disfigurement of the buildings and grounds.” His manner was not
offensive, yet his firmness was very evident and a degree of anxiety
was betrayed in his voice.
No answer was given. The superintendent then questioned each
member of the class as follows: “Were you on the school grounds the
night of the 14th? Did you assist in disfiguring the property? Do you
know who did the work?” All but two members of the class declared
they were under obligations not to give any answers that would
reveal who was guilty; the two others answered these questions
truthfully; but as they knew no pertinent facts about the incident,
nothing was gained.
The superintendent’s next step was to say: “Do you know any
reason why the members of this class, except these two, should not
be suspended until the desired information is given?” A few protests
were heard, but they all affirmed the right of a pupil to maintain
silence when asked to incriminate a fellow pupil. The superintendent
then announced the suspension to take effect at once.
At the end of two weeks a compromise was brought about and a
majority of the class returned to school. The rebellious members had
declared they would not open negotiations with the superintendent.
He had declared that they must inform him who were guilty of the
offenses. Both of these demands were laid aside. The superintendent
was known to have changed his decision and the offenders were
publicly taunted with backing down on the boast.
Some of these boys never re-entered the school; others found their
places soon, in another high school. The memory of the incident is a
sad one for all concerned.

CONSTRUCTIVE TREATMENT

Release the donkey from his “embarrassing situation,” but leave

other details of the mischief for a day or two. Some inkling of who
the perpetrators are will probably leak out in that time.
Meanwhile, have the damages appraised by the school board.
Next have a private talk with the president and other officers of the
class, stating to them the amount of the damages, the fact that you
will present the bill to the class and that you will then turn it over to
them for collection; also that you will expect their hearty coöperation
in seeing that all damages are repaired and paid for.
Finally, address the class as a whole. Say to the class, “I appreciate
the funny side of your pranks the other evening, but there are some
damages that some one has to pay. Two or three members of the
board, in whom all of us have confidence, have appraised them at ten
dollars. You have made a good record as a class. I shall expect you to
live up to your reputation by doing the fair and square thing in this
instance also. That means that you will authorize your president or
some other member of the class to see that damages are repaired and
expenses paid. You had lots of fun, but if the fun is ‘worth the
candle,’ why, now, the only manly course to pursue is to ‘pay for the
candle.’
“I think it will not be necessary for me to speak of this episode
again. I leave the matter in your hands. I will ask your class president
to report to me when the work is completed.”

COMMENTS

The superintendent lost ground with the school in assuming a

belligerent attitude, in trying to force a confession, and in punishing
innocent pupils because they were unwilling to incriminate their
classmates. The weakness of his position is shown in the fact that in
the end he was obliged to compromise.
ILLUSTRATION (HIGH SCHOOL)

The room was full of pupils. A Carbon

representative of one of the numerous book Bisulphide
companies was present. Everything was moving smoothly and in
order, when suddenly the room began to fill with the disagreeable
odor of carbon bisulphide. It grew worse and worse. Pupils were
holding their noses to keep out the smell, and some were covering
their mouths to keep in the laughter.
The situation was trying for the teacher. He was embarrassed by
the presence of the visitor, under such odoriferous circumstances.
What was to be done? It would be useless to hold a public inquiry. It
was a time both for thought and tact. Finally the teacher evolved his
plan.
Going on with the work, just as if nothing had happened, the
teacher conducted the remaining recitations of the day, as usual.
Meantime he kept his eyes open. The odor gradually grew less
offensive and most of the pupils quietly resumed their customary
work.
The vigilance of the schoolmaster was finally rewarded. One of the
boys seemed to be enjoying the situation to a greater degree than the
rest. He was unable to entirely conceal his enjoyment and this was
the teacher’s clue. He kept his eye innocently on this boy.
Just as school was about to close for the day, the teacher said:
“Frank, I’d like to see you a few moments after dismissal.”
Frank remained. His countenance paled slightly and he no longer
had difficulty in suppressing his enjoyment.
“Frank,” began the principal, “where did that preparation that
made such a disagreeable odor here this afternoon come from?”
Frank looked guilty.
“I didn’t have it here in the room,” he replied.
“Yes, Frank, but that’s not answering my question,” responded the
inquisitor severely.
“Well, I had some bisulphide down on the playground, but I didn’t
bring it into the school-room,” Frank finally admitted.
“What did you do with it?”
 “I gave it to Harry.”
“What did he do with it?”
“I don’t know.”
“Very well, you are excused for the present, till we can see Harry.”
The next night Frank and Harry were both asked to remain. The
superintendent was present. Two pale boys appeared before the
teachers.
“Harry, what did you do with the bottle of bisulphide you got from
Frank yesterday?” inquired the superintendent.
“I kept it down on the playground awhile and then threw it here in
the wastebasket,” was Harry’s candid response.
“Didn’t you know what was in the bottle?” resumed the teacher.
“No, sir, I didn’t.”
“Didn’t Frank tell you?”
“No, sir, he didn’t.”
“Is that right, Frank?”
“I guess that’s right,” said Frank seriously.
Evidently Harry was innocent for the most part. After sound
admonition by the superintendent the boys were dismissed. Frank
was very careful thereafter and Harry was always an exemplary
pupil. No further disturbances of this nature occurred during the
year.
A little tact and patience on the part of the teacher will often be
highly rewarded in the school-room.
(4) Teaching children how to play rightly. All playgrounds, while
in use, should be supervised by one or more responsible teachers.

CASE 92 (SEVENTH GRADE)

A big snow had fallen, but the weather had soon turned warmer
and the snow had softened just enough to make snowballing good.
“You may snowball all you want to as long Snowball Contest
as you keep above the row of trees,” said the
superintendent to the boys.
 A fierce battle was going on within the prescribed bounds. The
contest increased in fury and finally one side was driven back.
“Remember the limits!” cautioned one of the pupils.
Most of the boys either forgot to stop or kept running in the
excitement of the game, and rushed far beyond the limits. Then
several more were crowded beyond the limits, and unfairly engaged
in the contest from their new position.
“You’d better quit now or get over with the rest all of you!” shouted
the head of the schools.
Charles stopped for a short time, but in a few moments threw
again from outside of the limits.
“Charles, you go upstairs at once!” were the decisive words of the
superintendent, hurled at the offending boy in a way not to be
mistaken.
Charles mounted the stairs without delay and entered the office.
The superintendent soon appeared.
“What did you mean by throwing after I cautioned you, Charles?”
asked he sternly.
“Well—I don’t know. I got lost in the game and didn’t notice what
you said, I guess.”
“Well, what do you think, now?”
“I think we should obey the regulation.”
“Will it be necessary to speak to you more than once the next
time?”
“No, it won’t!” said Charles decisively.
“Then you may go.”
Charles left the office, glad to get off as easily as he did. Thereafter
the superintendent watched this boy, but Charles was careful to obey
whatever the teacher told him if the superintendent was within
reach.

CONSTRUCTIVE TREATMENT

Some one must attend these children when at play on the school
grounds. Organize the game, mark the boundaries carefully and
coach the children just as in athletics. Have a comrade to attend
them when they are running bases. Call the group together before the
game opens; explain the chief points in the rules. Show what comes
of neglecting the rules—confusion and several other bad things.
Prove that just as much pleasure can be had by following some sort
of system as if one goes at play in a helter-skelter fashion.

COMMENTS

All children must be taught how to play despite the fact that they
have an insatiable appetite to engage in it. Scattering hints will often
suffice and save not only injuries but open infractions of school
regulations.
Self-control is acquired only gradually, hence the orderly play that
is so delightful for pupils in the teens is preceded by a period of
learning.
Most first grade children are afraid to snowball, but in the second
grade boys begin to want to do brave things and in consequence can
do some damage by snowballing. Snowballing should not be
considered an offense. Every teacher knows how he has enjoyed the
sport. It is only the carelessness that may creep into the play that
may cause a window to be broken or some child to be hurt in the
eyes, ears, or about the face or body. It is really necessary that a
teacher should teach the pupils how to snowball, when there is snow
on the ground. She should go with them and enjoy the sport.

ILLUSTRATION (SECOND GRADE)

“One, two, three,” and all the boys and Limitations in

girls passed out of the room, Miss Play
O’Gorman following. “Remember now, Phil, no hard snowballs, as I
told you in the school-room.” “Now wait until we get out of reach of
the windows before you begin.” “Are we divided up evenly, just the
same number on both sides? Let’s count and see. Yes, just fifteen on
each side.” “Now, ready, everybody.”
 Miss O’Gorman let her ball fly along with the others, as she was to
play a few minutes on each side. She kept a keen eye for illegal
conduct and spurred all of them on in the fine fun.
This had been prearranged with parents’ consent to occur just at
the close of school so that the children could go home and dry up
their clothes at once if it became necessary.
By the end of twenty minutes one side gave away and yielded the
honors to the others and the game ended. On her way home Miss
O’Gorman remarked:
“I like to have the snow come because then I can snowball, but
children, I never make hard balls or throw at a building. I never
throw at anyone’s head. It would make me feel very sad to hurt
someone or break a window.”
Directing the sport of snowballing is far better and wiser than
prohibiting it. The discreet teacher will not even try to suppress it,
but will use every occasion to get into the snow with the boys and
girls and have fun and frolic.

CASE 93 (SIXTH GRADE)

“Come on, Mr. Frank, first batter!” Quarrelsome

“Pitcher!” “Catcher!” “First base!” Soon Play
every position was filled as the boys and the teacher of the eighth
grade streamed out of the schoolhouse.
“Come on, Mr. Frank, play with us.”
“No, not today, boys. I have something else to do now, I can’t.”
This was the third and last time for the season that the boys of
Mount Holly School urged this young man to enter into his privilege
in play. He stood off and for a few moments closely observed the
outcome. The game started after some parleying, but was soon
interrupted by dissension.
“He’s out.” “You’re out.” “Throw him out.” “I won’t do it,” and
scores of chopped-off utterances filled the air. Ten minutes were lost
in hot argument out of which no one gained the least value. Big boys
squeezed smaller ones out of their turn and these, lacking any
opportunity for play, stood about occupied with gloomy thoughts.
 “They don’t get on well together—I wonder what the matter is with
these fellows,” Mr. Frank remarked.

CONSTRUCTIVE TREATMENT

Accept the invitation to play. As a player, take only a player’s part.

No pedagogical authority need be used; but as a private person
exercise a control that will give tone to the whole performance. See
that something like justice is done to all and that the foolish delays
are eliminated.

COMMENTS

Boys little by little acquire a sense of order and often become

deeply offended at the unruly procedure of their comrades. They
welcome the presence of an older hand that steadies affairs and
prevents one or two reckless boys or girls from spoiling the fun of all
the rest.
An occasional participation may be all that is needed to institute a
noticeable improvement. Such aid should be given heartily as it is
due to the children in every school.

ILLUSTRATION (FIFTH GRADE)

How a child looks upon this matter is Boy’s Letter

seen in the following extract taken from a
boy’s letter:

“We’re having a bully time at school. At recess time teacher plays

with us and after school, too, sometimes.
“We play baseball, and he says we can have a match game if we
practice hard. I’m second baseman. Teacher made the boys let in the
little fellows if they can keep up.
 “I hain’t going to miss school nary a day if I can help it. Play’s lots
of fun. We don’t play much in school because we have work to do.
“Hope you’re all well.

Sam.”

CASE 94 (SEVENTH AND EIGHTH GRADES)

The Cloverdale Grammar School gave much attention to athletics

and especially tried to encourage the baseball team which had been
organized from the seventh and eighth grades. Mr. Tilden, the
principal, was sincere in his desire that his pupils should engage in
the sport, but having given his verbal encouragement and assistance,
it did not occur to him that his personal presence on the playground
was in any degree necessary to the welfare of the school. He
interpolated but on restriction into the fun: “In order to safeguard
our school buildings,” he said to the boys, “I am going to make one
ruling, namely, that you must not send the balls toward the school
building. Any boy who does that, accidentally or otherwise, must
drop out of the game.”
All went well for a few days. The less aggressive among the boys
adhered to the rule strictly. But one day one of the leading boys,
Reginald Coleman, happened to hit the stone foundation of the
school building. In this particular instance the stone foundation was
surmounted by brick walls up to about one-third or one-half the
height of the building, then finished off for the remainder of the
distance with wood.
Reginald argued with much boyish eloquence that “the foundation
was not a part of the building, no possible harm would result from
hitting it with the ball, hence it could not be that Mr. Tilden intended
to include that in his prohibition.”
So much in earnest was Reginald in pleading his case that the
other boys were soon won to his way of thinking, and he was allowed
to continue in the game.
For the next few days Reginald’s modification of Mr. Tilden’s rule
was the law of the playground. Then came another issue. Carl Story
lost his balance slightly just as he raised his bat to strike, the result
being that the ball glanced sidewise, striking the brick wall of the
school building. It was now Carl’s turn to present a plea for leniency
in the application of the law.
“Aw, ’tain’t fair to throw that out! It don’t do no more harm to hit
the brick than it does ter hit the stone. That brick’s a part of the
foundation. Didn’t you fellers say the other day that we could hit the
foundation? It’s all foundation up to the top of brick.”
Now Carl happened to be playing in the same nine as Reginald,
and Reginald naturally espoused his cause.
“That’s right, kids,” he joined in, “Carl didn’t hit the building; he
only hit the brick foundation. Let him play on! We don’t want to lose
this game. Go on, Carl”—and Carl finished the game notwithstanding
the protests of the opposing nine.
Thus the modifications of the rules went on from day to day,
always in favor of the larger and stronger and more aggressive boys
and always to the disadvantage of the younger and smaller ones of
the opposite side.

CONSTRUCTIVE TREATMENT

Be on the ground when a new game is launched. Study the

possibilities for unfair playing (silently, of course), and make every
effort to establish rules that will be just to all.
Do not stop at this point, however. Play with the children
frequently enough to learn at first hand whether strict rules of honor
are being observed or whether the leaders are taking unfair
advantage wherever opportunity offers.
Say to Reginald and Carl, “If one of the boys on the other side had
made that play would you have wished to count it?”
If the boys can not be converted to a desire for strictly honest play,
then see to it that the ringleader gets no advantage from his
trickiness. Say, “We’ll have to throw out this whole game because it
wasn’t played quite fairly. Tomorrow we’ll have another game to take
the place of this one.”
COMMENTS

Boys are not unlike adults in that they are quick to make rulings
favorable to themselves or their party and unfavorable to others. The
surest way to make men honest is to make dishonesty unprofitable. A
state inspector of weights and measures, remarking recently upon
the fact that a certain town in Michigan had “fewer cases of short
weights and measures than any other town visited,” accounted for
the fact by saying, “It is an inland town with a settled population. The
grocers depend year after year upon the same group of persons for
customers. Under such conditions any habitual shortage would
certainly be discovered and in the end would work harm to the
business. Hence all the grocers are honest there. It doesn’t pay to be
dishonest.”
The “paying” side of honesty may not seem a very high motive to
hold before children; but with the habit of honesty once formed, the
altruistic ideal will be much surer of lodgment when the children are
old enough to appreciate it. On the other hand the high ideal without
the habit is simply another expression for hypocrisy.
Much is said today regarding play as a means of training for the
higher duties of life. It may indeed be so, but on the other hand play
may be the most effective training possible for trickery, selfishness,
and every anti-social instinct. The remedy is supervision of play and
participation in it by leaders who know how to suppress the evil
impulses which there find opportunity for expression, while
stimulating the good. Such a leader will study individually the pupils
under his supervision and be quick to adapt his regulations to
changes, not only in place and time, but also to the personnel of his
group.

ILLUSTRATION (EIGHTH GRADE)

From scraps of conversations floating in Modify Rules

through the open window near which Mr.
Tilden was accustomed to sit correcting papers, as well as from
sundry complaints coming to him from the defeated “nine,” Mr.
Tilden got an inkling after a while that all was not as it should be on
the ball ground.
“I’ll come down and play with you after school this afternoon,” he
replied one day to a seventh grade boy, who had come in to tell him
that he wanted to give up his place in the baseball nine.
“We can’t win no games, Mr. Tilden,” said he, “coz the other team
ain’t square. They kid us all the time.”
Mr. Tilden, true to his word, joined hands in the game, purposely
taking a place in the losing team. Next to the ball ground was a tennis
court. Between the two fields was a high wire fence. Presently over
the fence went a ball, sent thither by a batter of the opposing nine. Of
course there was vexatious delay while one of the boys went to hunt
it up and bring it back. Before the game had proceeded very far
another ball flew over the high wire fence, and later another.
“Oho! I believe I can see through that game,” thought Mr. Tilden.
“The boys on the other team are heckling these boys, wasting their
time and strength and confusing them more or less by sending the
balls over the fence in order to place these fellows at a disadvantage.
That needs a bit of attention.”
The game over, he called all the boys to him. “Well, boys, we had a
fine game and I’m glad I came in if my side did get beaten. But
there’s just one rule I’d like to change a little. Some of you fellows
need to practice striking so as to hit squarer than you did today. It’s a
great nuisance to have the balls go over that fence. We’ll have it the
rule hereafter that whoever can’t do better than send his ball over
there will choose someone else to take his place while he drops out
for the remainder of the game. Probably he needs to rest his arms a
little. Anyhow we can’t have the fun spoiled just for a few boys who
haven’t practiced enough.”
This arrangement solved the immediate problem, but Mr. Tilden
found that new ones successively presented themselves as one side or
the other worked out new devices for outwitting the opposite side.
He did not make the mistake again, however, of leaving the boys to
themselves entirely, but kept in touch with the players and
readjusted the rules as occasion required.

CASE 95 (HIGH SCHOOL)