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Chicago, Illinois Anything like a comprehensive review of the literature or a survey of clinical results reveals the fact that treatment of Class III malocclusion, unless started at a very early age, meets with less success than that of the other two great classes. In fact, many operators consider failure inevitable if an attempt at correction of a Class III deformity is made on the permanent denture. These same operators will undertake, with the expectation of good results, the treatment of Class I and Class II cases for patients formerly considered beyond the orthodontic age. The same methods of treatment so successful in other deformities of the arches and jaws seem impotent when applied to the Class III case. This has led to the growth of a doctrine intimating that in these cases we are faced with obscure factors not present in Class I and II and vague generalities of 'Heredity' and 'Constitutional Factors' are thrown around these malocclusions as an excuse for their neglect. The comparative rarity of this deformity has made its neglect still easier to cultivate but neglect it must be termed, for, in spite of the failures encountered, no apparent effort has been made to change the method of treatment since the introduction of Baker Intermaxillary Anchorage. It is not the purpose of this paper to belittle any efforts made to study the problem from the angle of heredity or constitutional factors but it should be remembered that these researches are still in their infancy and have not yet reached a point where they may be used as a basis for clinical procedure. All through the history of orthodontia we find the same thing, namely, that cases which did not respond to the method of treatment in vogue at the time, were considered to be under the influence of heredity or other littleunderstood factors, and failures were thus excused. Steady progress in the interpretation of biological laws and their application to mechanical treatment have thrown these claims back upon their supporters, insofar as the vast majority of cases of the Class I and Class II type is concerned, for it has been proved that these can be treated successfully. This paper seeks to raise the question of whether we are even now using our full store of available knowledge in thinking upon this subject. In an effort to answer
*Read before the Eighth Annual Meeting of the Edward Orthodontia, Pasadena, California, March 9th, 1932. H. ~ngle Society of
We know that each bone has attained a certain typical form over centuries and that this form will continue to be handed down until long continued function of a different sort demands a change. namely. to point out the startling fact that after the sixth year the main sites of growth in the maxilla and the mandible were posteriorly. I believe. first. so far. Thus we may say that bones. It would be impossible to' give you an idea of all the work that has been done along these lines or of the methods used in studying the growth problems. Research work in recent years on bone growth has yielded some very significant data. a subsequent spurt on the part of these backward sites follows. It is a complex operation and. In the case of bone the machinist is function and the nature and the amount of this function will endow the bone with an individuality.this we will point out. Thus we must consider two forces in the life of any bone. Humphrey verified this and it was then apparently lost sight of until recently 220 THE ANGLE ORTHODONTIST . Among these must be mentioned the discovery that the head and face do not grow equally in three planes of space and that at the end of growth the parts assume an entirely different relation to each other than they bore at the beginning. It has been found. There is grave doubt as to whether function has a very noticable bearing on a real young bone. are dependent on a factor which we shall call the inherited growth force. in an effort to determine whether these same precepts are being followed in the latter cases. This femur or this mandible might be considered as a rough shaped casting that is to be finished by the machinist. but a few of the findings are necessary for the comprehension of the picture as a whole. Since ours is a bone problem we shall have to start with a discussion of this tissue. up to a certain age. for instance. Thus a femur is always distinguishable as a femur and a mandible as a mandible. no means have been discovered to determine the borderline between the normal and the deformed. that it is an uneven process. that vast changes take place in certain areas in a short period of time with an apparent arrest in others. At times we find a picture of apparent deformity that gradually' works itself back into balance. In the middle of the nineteenth century. Hunter was the first. The early life of all animals is a story of dependence upon factors over which they have no control and they seem to be pushed along in their development to the point where they can shift for themselves. heredity and function. the fundamental concepts that underlie successful treatment of other types of malocclusion and then critically examine the present day treatment of Class III. and there are rest periods at intervals throughout the entire process.
hereditary or evolutionary factors." Now both sides have a legitimate claim on our attention and each can furnish plenty of proof. no work of which I am aware. On the side represented by functional development. He has piled up a goodly amount of evidence to prove his contentions. as yet. the subject from a different Briefly stated. He strives to interpret all deformities in terms of unbalance and bases his contentions on Wolff's Law which. between it and the cranium. comes to view all deviations from normal in terms of constitutional. has been done to tell us whether there is an even lowering of the occlusal plane of the denture or whether there is a reorientation of this plane. taking place at the back of the maxillae. Campion. And this is the viewpoint in which we are most interested. There is a great increase in this dimension throughout the entire face but. there is almost a complete lack of material on its growth in relation to the rest of the head and face. is: "The amount of growth in a bone depends upon the need for it. For this conception we are indebted to Todd. stated simply. so far as the forward direction is concerned. as an individual bone. in relation to the skull. The baby face conceals a baby pharynx which must grow to adult proportions. In a study of both Class II and Class III we are primarily interested in the development of the mandible bub when we search for facts about this bone we find very few that are at all helpful. we find evidence being amassed by scientific workers who use a different approach. This swing is of greater extent than is the actual growth. The . While the mandible.Keith. through uneven rates of growth. In most cases the orthodontic clinician may be found in this group.anthropologist. has been studied considerably. We know that there are vast changes taking place in the vertical direction during growth. however. is apparently balanced by a downward and forward swing of the face out from under the cranium. The face itself needs to grow only enough to accommodate the three permanent molars but the entire denture must be carried forward sufficiently to make room for this growing pharyngeal vault which lies in back. the facts are that this growth. maintaining that form is the result of function. approaching angle. owing to his method of attack. Hellman and others. called our attention to it again. Brash and others. No thoughtful person could doubt for a moment the part that inherent growth plays in bringing any structure to either a normal or abnormal maturity but it is equally true that no one could watch THE ANGLE ORTHODONTIST 221 .
He would produce case after case of dental deformity successfully treated to prove that by mechanical intervention he had restored a physiological balance which in turn led to a perfecting of form. His demonstrations would. When it comes to a consideration of contact points 222 THE ANGLE ORTHODONTIST . I am going to eliminate all but those forces that are pretty generally accepted as necessary mechanical elements to the building of a normal denture. we have those cases where abnormal environmental forces or factors. usually by the simplest of measures. Considering first of all the teeth themselves. To still further complicate the question. on the other hand. so that by the end of all growth the two factors have exchanged places of importance. with equal success? Taking then the point of view of the clinician. acting on normally growing bones. be limited to Class I and Class II malocclusions and were you to ask him of Class III results. If. our puny efforts would not avail. we must remember inclined planes. regardless of the time. while the growth force dictates up to the eruption of the six year molars. In the case of the bones in which we are most interested it seems safe to assume that. The deformity is easily overcome at an early age. at an advanced age. if we examine these facts carefully we find that there is really no conflict. let us examine the precepts upon which orthodontia stands. Now is Class III different? It seems to your essayist that the orthodontist has deserted his well-proven precepts in this type of case.an orthodontic practise for any length of time without being compelled to admit that functional forces were potent factors in gaining a complete development. if it were even suggested that he had no right to his existence since he could not overcome the handicap that Nature had laid on a child's face. contact points and axes of inclination. from then on its dominance starts to diminish and function begins to play an increasingly important part. Only from this basis can we proceed. However. The role played by the locking of the inclined planes is too well known to need explanation here. the other can claim that the growth force ultimately dies out but that this loss does not inhibit the reaction of bone to mechanical stimulation. Each of these is important. have led to extreme deformities. why cannot we treat them as we do other types. he would probably say that it was different. which characteristic continues throughout life. in most cases. If one side claims that we have no control over the growth force. For purposes of clarity. they can be traced to mechanical causes. Surely if the etiology were entirely of a constitutional or hereditary nature. There is not an orthodontist worthy of the name who would not rise up in wrath.
yet it must be examined carefully before we place all our reliance on it. through inclined planes and all of the other forces of occlusion. the same load is placed in a direction that is not in line with usual demands. say. it will be strengthened. In the case of the jaws we consider this adequate stimulation to be occlusion and these bones can be built up to a. on. to think that this function is operative THE ANGLE ORTHODONTIST 223 . Thus we must consider the teeth as indispensable to a full development of these bones. bring about development is only deluding himself. We have but to look at the principles of orthodontic treatment to realize that its sole purpose is to reestablish function and the man who believes that his appliances. There is not a thinking orthodontist who does not feel that full. rearrangement of the internal architecture takes place to withstand the stress. It has led to some careless thinking and men have used it without understanding its limitations. contributed to the balance and growth of bone are too well known to need elaboration here. point where they will sustain a closure of 150 to 250 pounds. deformity is the result but. Axial inclination plays a part that seems to be but indifferently understood. Angle.and axial inclination there seems to be a haziness in the minds of many as to their importance. It is possible. if we restrict our observations to Class I malocclusion. Contact points are the determining factors in the length of an arch and. that normal occlusion of the teeth was a basis of normal jaw development at once lifted orthodontia from empiricism to the beginnings of a science. of themselves. How do they act? They are fastened into the bone by a fibrous connection. are very potent influences in development. they are suspended in sockets in the bone so that the blow struck by occlusion is translated into a pull stimulation on the bone. Thus we must consider that each bone has a stimulus that is normal or adequate for it and that this stimulus is the functional force that leads to the highest degree of development of that bone. is gradually increased along lines it was phylogenetically designed to withstand. This statement we hear made constantly. If the stress. And his further discovery of the manner in which function. It must be remembered that each bone is capable of responding to mechanical stimulation and does so by a rearrangement of its internal architecture as well as its general conformation. by Dr. a long bone. Bone is built against this pull and the building is in line with the long axis of the tooth. nevertheless. If. The recognition. as will be shown. Better stated. vigorous function is a prime requisite to complete development and there is not an orthopedist worth the name who will not agree to this same precept. however. But if we exert three pounds of pressure in a lateral direction we quickly get deformity.
so that abundant growth appears. so that teeth tipped distally will usually straighten up. It has been mandible in these cases is underdeveloped lation with the head. we begin to realize the important part that axial inclination of the teeth plays in determining the lines of development. by a deep overbite. If we study the progress of a Class much that we can learn. that lateral function is almost completely inhibited. without help. individually. 224 THE ANGLE ORTHODONTIST . but teeth tipped mesially seldom regain correct axial positions. When we stop to analyze why this procedure succeeded when the actual tipping forward of the mandibular teeth failed. it is readily seen how the blow thus struck would act as a hindrance instead of an aid to growth. Granting the part life. function is depended on to bring the entire denture forward to its correct position of balance. Quite frequently it is so thoroughly locked in its anterior portion. But when we consider the results of successful Class II treatment we are forced to the realization that something has occurred to this mandible other than mere alveolar growth. yet the actual precedure cans for the setting back of the maxillary teeth to proper occlusal relationship with their mandibular antagonists. whereas. it seems that this bone comes to II case from its inception. The Class II mandible is weak and its function is well below par.only in building alveolar bone and that it will have little or no effect on the basal bone which supports this. Here we see not only a widening going on but also a lengthening and a deepening process. The resultant of occlusal forces is in a forward direction. This takes a comparatively short time to do and after this is accomplished. there is pretty definitely proved that the and is posterior to its normal rethat growth plays during its early depend considerably on function. Angle to completely change his system of treatment in this type of case. The recognition of this fact led Dr. The occlusion of the molars brings the main load on the anterior half of the lower molar teeth which not only is mechanically inefficient and unnatural but also precludes proper growth stimulation from acting upon this portion of the mandible. With mandibular teeth leaning mesially. for a moment. is responsible for the complete development of that portion of the bone which surrounds its root. If we consider. with the lines of stress vertically placed or tipped slightly in an opposite direction. Although the aim of treatment is to develop the mandible forward. It is remarkable how quickly this takes place. the very nature of bone demands that this load be supported and bone makes haste to get under it. that each tooth. every blow struck is in a backward direction prohibiting forward growth.
the result of this growth is a swinging downward and forward of the face. of the reaction of the bone to occlusal stress and of the growth force to all of these. here put down. this bone is immediately placed under abnormal conditions. namely. When the mandible is thrown forward. as we have stated. if our reasoning on the mandible's reliance on this stimulation is correct. led to a working hypothesis. Unquestionably there are constitutional factors that can cause like results. The mandible's only connection with this rapidly changing part is through the occlusion of the teeth and if this connection is lost at this age it slows up the mandibular growth to a perceptible degree. which. it deserves serious consideration. on the other hand. are not affected to a like extent. but as stated in the beginning of this paper. has lead to a logical plan of treatment. The maxillae. and we find the molar bite closing. made possible a very large percentage of success in the treatment of Class II and when any hypothesis does that. It is this protrusion and not the tonsils. in the bones of the head have little.even during the later stages of deciduous dentition and that from this time on it becomes increasingly dependent on the maxillae for its stimulation. The observations. but more from above downward. effect on it. that is the cause of this deformity. of axial inclination. are intimately associated with cranial parts that are growing regardless of function and. being crowded by cranial growth from behind. Thus mouth-breathing acts in its well known way. Functional stimulation is removed from the posterior teeth and. if any. All they lose is functional stimulation. Have we used a like plan of attack in our consideration of the Class III problem? Do the symptoms of this deformity belie our precepts if we look at them from the same angles? The two most generally accepted causes for the beginning of Class III are hypertrophied or painful tonsils and imitation. It is a floating bone suspended in a mesh of musculature and changes. The maxillae. with the maxillary tuberosity and last maxillary molar THE ANGLE ORTHODONTIST 225 . the condyle is carried forward and downward on the articular eminence. a voluntary protrusion of the mandible. not only because of the change in the respiratory function. in turn. but because of the loss of occlusal relations. we are eliminating them for the sake of clearness. In this manner we have established the beginning of the occlusal plane which is so characteristic of this type of case. opening the occlusion in the molar region. Thus we might state that our knowledge of occlusal relations. that is. the maxillary teeth doing most of the traveling. one which appears low in the mandible molar region and high in the incisor region. Both of these produce a like reaction. not evenly.
immoderately. The stage is now set for the junctional development of a typical Class III malocclusion and the forces that will evolve it are only those that would ordinarily serve to bring this denture to a normal maturity. constantly increasing the deformity. in so doing. we find the tongue taking its position in the floor of the mouth and withdrawing its support from the vault and upper teeth. Other changes that take place concern the dental arches and teeth themselves. there are others equally as important. In addition to all of these changes. and this change is unquestionably accompanied by a shifting of their apices. Let us examine these perverted forces and see whether they produce the results which. as to the teeth themselves: For purposes of clarity it is again necessary to consider each factor by itself. as they are in the initial stage. we find the mandibular teeth tipping distally and the maxillary teeth mesially. The stress on these teeth is immediately made abnormal and we begin to see changes in their axial inclinations. First. Instead of the mandible striking an upward and forward blow. temporal and internal pterygoid muscles are the power plants that bring the teeth together and it is the force of occlusion that stimulates the growth of bone to support this shock. It is a well known fact that posterior teeth are necessary for the development of the angle of the mandible. a lateral functional movement in mastication is well nigh impossible and the case develops a habit of vertical function that almost invariably persists. from a knowledge of fundamentals. two dental factors are immediately brought to play. More often it is kept forward. With the condyles protruded from the fossae. that all of these are operating at the same time and that each modifies the others. in the case of 226 THE A_/\7GLE ORTHODONTIST . The other is the fact that with the condyles already protruded. This change in the occlusal plane is not the only one that is taking place at this time. these same muscles act as warpers or deformers instead of builders and the angle is gradually flattened out. Thus. permitting the condyle to slide back into the fossa where it may remain if the irritant has been removed or the habit corrected. If the occlusal contact is lost. but it must be remembered. we would expect them to. Starting with the protrusion of the mandible we have two well rounded arches brought into edge-to-edge and cusp-to-cusp relation with each other. The masseter. Recalling our earlier assertion that bone is built to resist stresses and. The first of these is the carrying of the lower denture forward from a normal lingual position with the upper teeth to one that is in cusp-to-cusp relationship in the buccal regions. the direction is upward and backward and the teeth begin to orient themselves to meet it.seeming to hang down in the mouth.
especially in the molar region. namely growth above and occlusion below. did the bone carry the teeth to these positions or is the bone picture a reflection and response to tooth position? Without lateral function no denture can attain its normal width. there is little or no lateral function in this denture. we find bone has been placed to support teeth that are in wrong axial inclinations. The upper _teeth incline outward and forward while the lowers assume a direction that is backward and inward. The buccinators act as retaining walls to the buccal portions of the dental arches and they are completed and connected around the anterior region by the lips.. and these are fastened to bone quite remote from their insertion into the lips. Our first question is. we would expect to see a flow of stimulation traveling downward and forward from the teeth and building its final resistance at the symphysis instead of at the angle. naturally. being held between two forces. Add THE ANGLE ORTHODONTIST 227 . If we suddenly place the lower jaw ahead of the upper we increase the tension on the crowns of all the lower teeth. again. a most important consideration. in line with these stresses. hold these tissues tight and the lower lip is drawn up over these teeth toward the maxillary base that is none too broad as it is. these muscles form a wide band around the arches which is balanced by the mass of the tongue from within. of which more will be said later. such as the canini. below. there are just as valid reasons to explain them. have other contributors to their makeup. In all cases of vertical function there is a flattening of the lateral halves of the dental arch and the denture assumes a more or less carniverous shape as it takes on this carniverous type of function. attached to an immovable base. When we examine the maxillary bones we find a very marked constriction. The alveolar height here is usually as exaggerated as it is in the incisor region. zygomatici. Under ordinary conditions. This may be the starting point of a change in axial direction in the teeth but there are other factors equally important and sufficiently powerful to do the same thing. is built vertically to an abnormal degree. The muscles of the maxillae. As to the marked constriction of the upper jaw and the wide flare of the lower border of the mandible. triangulares. as is usual. Here. The muscles that make up the cheeks and lips comprise one of the most complex groups of the entire body. One of these is the cuspto-cusp relationship at the beginning of the abnormality and the other is musculature. As we have noted above. but helping to control the lower cheek and lip. etc. but in addition to this we find the mesial tipping of the teeth so that this jaw. however.teeth. quadrati. The lips. This is what we actually see in the typical Class III mandible with its greatly exaggerated height at the symphysis and its lack of molar height.
Resection of the mandible has never been so successful that many men were willing to try it. acting as a trip for the mandibular teeth and you have a very reasonable explanation for this perverted axial position. this need not necessarily be true. On the other hand it is equally possible that we would find an actual increase in bulk. unquestionably. we see at once that the condition has been aggravated by such treatment. the labial muscles. It has always been stated that it is overdeveloped. The teeth anterior to the break are pulled back but the forces which pull them back. are acting only on their crowns. but this does not stamp it as a bigger bone. if we were to account for the overgrowth at the symphysis and the undergrowth in the molar region. if we but examine the factors enumerated above. It is only through function on these teeth when standing in their correct axial positions. That it is greater in length and in the lower border width is. the position of the tongue in the floor of the mouth. The chin cap has been used extensively but with very little success. The abnormal position assumed and held by this mandible could conceivably demand a greater amount of bone to sustain an equal or even less amount of occlusal stress. With extraction. If we are convinced that faulty axial relations are a big factor in the original deformity. for instance. But from the physiological aspect there cannot be more bone in that mandible than the maximum demanded by its function.to this. And now let us examine the methods that have been and are being tried in the treatment of this deformity and see if they reveal a cognizance of the forces they have to overcome. In spite of its appearance. Were it possible to subject this bone to a water displacement test. By size we refer to bulk. there are at least two interesting possibilities. As to the actual bulk of bone in this mandible. 228 THE ANGLE ORTHODONTIST . we are throwing away one of our most valuable allies when we do this. we can readily see the reason for this. Likewise the extraction of a molar will be of no avail. This is merely another way of stating Wolff's Law. in fact. the case. the integrity of the arch is immediately lost and a tooth shifting begins. that we can hope for a development of the angle of the mandible. and unless the other forces were made normal it would end in failure. namely. so that the movement is a tipping one that results in an even worse inclination than before. it is conceivable that we might find that it contained no greater amount of bone than did a normal mandible but we would have to admit that its substance had been distributed differently. Extraction of the mandibular bicuspids has been repeatedly resorted to without success and.
the lower buccal teeth continue to lean inward. Let us see why this should be. Were it possible to take this load on the external pterygoids. also. The symptoms outlined in this THE ANGLE ORTHODONTIST 229 . at their distal ends. so far as occlusal relations are concerned. Unless we go to occipital anchorage. In this position we could scarcely expect a change in the conformation of the face. The lower incisors are leaning back to a very marked degree and the upper incisors are standing almost straight out and give the appearance of just managing to hold on. there does not appear to be any way around this difficulty at present. This however. Indeed. What of the future-is there any hope? I believe there is and offer you my suggestions for what they may be worth. In brief.There are two or three reasons why we should not expect too much of it. we begin to find some measure of encouragement. In the first place. If you will recall some of those cases you have seen after treatment. it is used intermittently and it is off more than it is on. When we come to consideration of the methods of treatment that stress the occlusal relations of the teeth. As everyone knows who has tried it. while anteriorly they are pulling upward on a part of the arch already too high. The first thing necessary is a comprehension of our problem. with a face-bow attached to the archwire. but this would only be possible through a conscious control at all times. gets steadily worse. while helping to shift the teeth. their roots flared out. just what conditions do we face in Class III. you will recognize the description. sometimes. Unquestionably the intermaxillary elastic has contributed more to this type of treatment than has any other single thing. Likewise. When we apply this device we are actually trying to modify the entire angle of the mandible and we are using only the thin plate of bone that forms the roof and posterior wall of the glenoid fossa as the point of resistance. Here we find cases treated in the permanent denture and some of these cases have held. but I know of no case where the facial deformity has been eradicated. The dragging and tipping backward of the mandibular teeth through the use of simple anchorage in this dental arch increases the abnormal lean of these teeth and the very condition that should be corrected. this is the point that breaks down first and the patient complains of severe pains in this region. This covers the main points in symptoms and present day methods of treatment. is not the most important reason for its ineffectiveness. are fighting the denture in its efforts to regain balance. The intermaxillary elastics. These elastics are attached. it is a miracle that these occlusal relations hold as they do. to the maxillary molars which are already below their proper place in the occlusal plane. there might be a chance of making the cap an effective instrument in the modification of the body of the bone.
we place our appliance. your essayist believes that this treatment must be based on the restoration of normal occlusal relations but that this calls for a consideration of several factors that are being generally neglected. deglutition and speech. Basing his conclusions on the observations stated. No bands are placed on the incisors during this phase of treatment and the archwire is adjusted to stand away from with the Edgewise Arch 230 THE ANGLE ORTHODONTIST . As in all cases. After these have been studied and the treatment planned. Strang. we must look to a more scientific and accurate method of examination. I shall not go over the exact procedure but shall merely try to indicate how we attempt to meet the demands of this type of treatment. The stepping back of the lower buccal teeth is accomplished by means of second order bends. providing the break is anywhere but at the cuspid. The placing of the brackets and tubes must be strictly in accordance with the dental anatomy or complications will arise very early in the treatment. the first prerequisite is complete recording of all significant factors. The next is an analysis of the type of case with which we have to deal. In the meantime cases are going to present themselves for treatment. except the third molars and staples must be very carefully planned and placed. One of the first objectives is gaining of the integrity of the arches. The first procedure is best accomplished by means of the vertical loop designed by Dr. the state of development of the platysma. Merely placing the inclined planes under the influence of their normal antagonists will not suffice in these cases. This is usually a problem of opening spaces for teeth that have been locked lingually in the upper or the stepping back of buccal segments of the lower where they have broken contact in the cuspid regions and the teeth have drifted forward. In fact when this stage is reached we have only started. the presence of irritants which might induce a protrusion of the tongue and mandible and defects in respiration. For a verification or denial of these.paper are based only on clinical observations. There is no case that calls for so close an adherence to principle as does Class III. the lips and the buccal musculature. Treatment of Class III Malocclusion Mechanism The Edgewise Arch Mechanism has given us a means of perfecting the treatment of these cases that is far in advance of those formerly at our command. Every tooth must be banded. Class III presents many variations and each type possesses certain elements which differ from the others. Especially should we note the position of the tongue in the mouth at rest.
these teeth. stationary anchorage should be enlisted in this denture. This phase of treatment should be carried on until the roots of the lower incisors may be THE ANGLE ORTHODONTIST 231 . the upper may be brought forward by second order bends if this arch is distal to normal. All of these cases should be overtreated to at least the extent of one-half of a cusp or more and at this point there will usually be considerable tip to the teeth that have been SUbjected to the second order bends. It is usually not necessary to wait until this stage of treatment before starting to correct this condition. This movement is accomplished by means of second order bends in a forward direction. we now set about to establish those conditions which will lead this denture. It goes without saying that any other tooth movement that will not interfere with these mechanics should be taken care of at the same time. This can only be attained by so placing the axes of the teeth that stimulation will be delivered to the areas that call for development and taken away from those already overdeveloped. Thus. your essayist believes that the care with which the balance of treatment is carried out will largely determine its success or failure. in fact. we find the following conditions existing. while the lower buccal segments are being tipped back. through normal function. Care must be taken to avoid dragging the incisors. back towards normal size. The incisors are tipped lingually and the buccal teeth are tipped not only lingually but distally as well. at each appointment. it is possible to do much more and. of course. however. form and proportion. So far the treatment is much like that performed with any other appliance but at this point the cases usually are freed. Assuming that the mesio-distal and bucco-lingual relations of the teeth have been corrected. With the Edgewise Arch. Class III intermaxillary elastics are adjusted mesially to the cuspids and the buccal teeth tipped back. carrying the archwire with them. If we remember the picture of the typical Class III case described earlier and think first of the mandible. that a mesial tip of these teeth does not already exist. provided. tipping the teeth en masse. This is a slow process and one which requires the continued pull of the elastics to hold the crowns while the roots are being moved. to move the archwire forward in relation to the brackets. it is necessary. As soon as the upper teeth are under the influence of the correct inclined planes we should start to throw the roots of the lower teeth lingually by torquing the archwire. any slippage of the archwire through the brackets can be avoided by tying the cuspid bracket to a spur on the archwire distally to it. To do this. At the same time the buccal teeth should be shifted so that their axes point mesially instead of distally. if not.
The persistent wearing of Class III elastics will usually overcome it but if the primary cause of this protrusion is not removed the mandible will revert to its old position as soon as this force is removed. In the upper archwire the mechanics that have been operative in correcting mesio-distal relations are gradually reversed. When both mesio-distal relation and axialinclination show overtreatment. It is not sufficient to instruct the patient at the time of retention that he or she must do so and so. Tongue position and function is another important factor and one which should always be included in our calculation. The last may seem strange to you but it is becoming more and more apparent that mouth breathing is very common in this type of case. There is another phase of treatment that must be diligently followed right from the beginning. I am not going to prescribe tongue exercises for I have found none that are satisfactory. This is a supervision of function. This organ is almost invariably found lying in the floor of the mouth and this position may be either the cause or the effect of the mandibular position. The patients should be shown the correct position of the tongue and encouraged to try and get the 'feel' of this organ filling the upper part of the mouth and supporting the vault and upper alveolar arch. the case may be retained. So much for mechanical treatment. or nasal obstructions. 232 THE ANGLE ORTHODONTIST .distinctly felt on the lingual surface of the alveolar process and the buccal teeth have assumed quite a decided mesial tilt. A close study should be made of the normal tongue and its function and this. should be the ideal sought in every case. like normal occlusion.. pharyngeal irritations. they will frequently cooperate to a surprising degree. such as tonsils. imitation. namely. by the protrusion of the mandible. In many cases this habit is still present when these cases are started. A number of things must be checked either before or during treatment. These causes seem to fall under one of three headings. They must cooperate right from the start so that correct habits are well established by the time the retention is placed. When we consider that the tongue is the mold around which the denture is formed and when we note its very unnatural position in Class III. at the inception of these malocclusions. If they can be shown how this stimulates the expansion and growth of this area. This means that the second order bends in a backward direction are applied and it seems needless to say that the elastics must be continued so that the resulting movement will be restricted to the roots. it is easy to understand its abnormal functioning. etc. Mention was made earlier in the paper of the part that was played.
it should be remembered that Class III presents an entirely different aspect than other types of malocclusion. You will remember that attention was called to the fact that these patients were almost invariably incapable of lateral mastication. This means more than the developing of crushing strength however. if all of this seems involved and complicated. I would call your attention to the fact. This must be broken up and the tongue made independent by speech exercises.In addition to the normal rest position. All of you have probably noticed the thickened speech of these individuals. I have yet to find a Class III case with a normal development of this muscle and when we consider its location and form this seems significant. that this severe deformity could not be heritable. The aid of a good elocutionist is frequently of great value. One treatment is a release and the other is a forcing. In the case of Class III we are forcibly changing form and function and the demand for painstaking attention to details is inexorible. And now. nose. two active functions must be checked. The first of these is deglutition and the second speech. etc. In the case of the release the natural forces from within will usually work hand-in-hand with the orthodontist and permit the slighting of some details. That it appears so strikingly in some families. There is a tendecy to mouth sounds and the mandible usually assumes the responsibiiity of moving the tongue. In addition to all this we must prescribe exercises of the platysma for the reduction and retraction of the mandible. If the individual becomes conscious of a defect of this sort. pointed out by most authorities. Now. Substances requiring a crushing and shearing action must be prescribed if we hope to get the most out of this form of aid. Correct swallowing must be taught in conjunction with tongue placement and for this I know no better method than that of demonstration. in closing. just a few words about the legitimacy of this approach. For the building up of the angle of the mandible. Much has been made of the endocrine side of the field and we know that the acromegalic exhibits an overgrown mandible. feet. But he also shows his symptoms in his hands. he or she will usually make a decided effort to correct it. Speech may prove more difficult and its correction will require considerable patience on the part of both operator and patient. we prescribe heavy mastication. In the other two classes we are usually dealing with arrests which are crying for a chance to develop normally. is easily explained by the fact that it can and often does· have its inception in imitation. In derangements of the endocrine mechanism the removal of the hyperactive glands and the feeding of ex- THE ANGLE ORTHODONTIST 233 .
Let us not sit back.tracts of underfunctioning glands have both led to recovery of balance. with our hands folded. Let us take a different view-point of this problem. must be scientifically checked. We should not fail to take all the aid we can get from allied fields but we are not living up to our responsibiiities if we make no effort in our own behalf. It is easily conceivable that a mandible might. be carried beyond limits of self-recovery. the hint has been dropped that. this paper is an endeavor to bring out the point that the treatment of Class III malocclusion is being looked upon as a hopeless problem. That a review of the items that underlie the successful treatment of other types of malocclusion makes it at once apparent that we. even though etiology may have had its inception in constitutional disorders. merely because a bone has been altered by a constitutional disturbance is no sign that it has lost. And. enumerated above. forever. last of all. Michigan Avenue 234 THE ANGLE ORTHODONTIST . These are but hints that should be considered in thinking about this subject. in a sudden spurt of growth. Emphasis has been placed on the fact that all of this reasoning is based on clinical observations which. its power to react to normal forces. In this event the normal factors. 30 N. This same point of view must be considered when we think of deformities caused by inequalities in the growth rate. and wait for a solution by the anthropologist or endocrinologist-it may never come. This is a vicious state of affairs in itself. are neglecting this logical point of attack. And remember that the Class I and Class II problems were not solved in a laboratory. This seems to point to the fact that these disturbances do not place an ineradicable. Summary To summarize. eventually. From this as a base has been pointed out the fallacy of our present modes of treatment and indications for a more logical treatment have been outlined. That our first concern is a comprehension of the conditions with which we are faced together with a knowledge of the normal factors. mark on the bones and does not prove that these contributing factors serve to hold or maintain a deformity when the cause is removed. this does not necessarily put these cases into a hopeless class. would serve to maintain and increase the abnormality. then. as clinicians. In short.
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