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The origins and evolution of fixed orthodontic appliances

Article · September 2014

DOI: 10.12968/denn.2014.10.9.524

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 Professional

The origins and evolution of fixed

orthodontic appliances
Orthodontics became a discipline in its own right in the late 19th century but the use of
appliances to straighten teeth dates back more than 3,000 years. Appliances evolved a great
deal over the past two centuries and digital technology means this progress should continue

A lthough orthodontics became a recognised

dental specialty only in the 1880s, the
concept of aligning teeth with fixed
appliances dates back to around 1000 BC.
Evidence gathered from Egyptian mummies shows
that ancient civilisations fitted appliances to teeth,
presumably to correct malocclusions. Archaeologists
have discovered several mummies with simple metal
bands wrapped around individual teeth, indicating
that the ancient Egyptians knew that pressure could
be used to move teeth over a period of time.
This article examines how these early ideas evolved
to become the fixed orthodontic appliances of today.
Ancient origins
The earliest evidence of appliances being used to
straighten teeth is from around 1000 BC (Weinberger,
1934). The Etruscans, an ancient civilisation predating
the Romans, buried their dead with appliances that
were used to maintain space and prevent collapse of
the dentition (Guerini, 1909).
The ancient Greek physician Hippocrates
(c460 BC–370 BC; Figure 1), considered to be one of
the most exceptional figures in the history of medicine,
published his ideas regarding the correction of tooth
irregularities in 400 BC (Hippocrates, 400 BC).
James Green is a Maxillofacial and Dental
Laboratory Manager for Great Ormond Street
Hospital and the North Thames Cleft Centre,
a supraregional managed clinical network that
treats children and adults with clefts of the
Figure 1 (left). Hippocrates, engraving by Peter Paul
Rubens, 1638. Figure 2 (right). Aulus Cornelius Celsus
Teeth bound with a gold wire, presumably an
ancient precursor to modern ligature wire, have been
found in a Roman tomb in Egypt (Ruffer, 1921).
The Romans saw teeth as precious—the first code
of Roman law (450 BC) stated that ‘special penalties
[would be exacted] for knocking out the teeth of an
individual, either freeman or slave’.
Roman philosopher and physician Aulus Cornelius
Celsus (c25  BC–c50  AD; Figure 2) recommended
extracting deciduous teeth to allow the eruption of
the permanent dentition in his medical encyclopedia
De Medicina. In addition, Celsus was the first to
record the use of finger pressure for the treatment of
incorrectly positioned teeth and said that this finger
pressure should be applied to new teeth every day to
ensure correct tooth alignment.
The Renaissance
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lip and palate from north London, Essex and
south and west Hertfordshire.
Email: jamesgreen@nhs.net
The evidence suggests that no further developments
were made until the 18th century. However, the
European Renaissance of the 14th–17th centuries
heralded scientists who studied dental anatomy, most
notably the Italian Renaissance polymath Leonardo

524 Dental Nursing September 2014 Vol 10 No 9


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(From left to right) Renaissance era: Figure 3. Leonardo da Vinci, a presumed self-portrait, Biblioteca Reale, Turin,
c1512. Figure 4. Ambroise Paré, a 19th century portrait by William Holl. Figure 5. Andreas Vesalius, an engraving
from a picture by Tintoretto, c1540. Figure 6. Gabriele Falloppio, a 16th century portrait by an unknown artist

da Vinci (1452–1519; Figure 3). His drawings Chirurgien Dentiste (Fauchard, 1728). He described
included detailed studies on body proportions and the use of ligature wires to straighten teeth, as well as
he used details such as lip–dental relationship, facial the first expansion appliance, known as a bandeau
proportions and tooth size ratios in his paintings. (Figure 8).
Other scientists of the time who studied the Bourdet, another Frenchman and dentist to the
anatomy and shape of the teeth included Ambroise king of France, published The Dentist’s Art (1754),
Paré (c1510–1590; Figure 4), Andreas Vesalius (1514– which, like Fauchard’s book, included a chapter
1564; Figure 5), and Gabriele Falloppio (1523–1562; dedicated to tooth alignment. Bourdet was the first
Figure 6). recorded dentist to recommend the extraction of
premolar teeth to improve jaw growth and reduce
Eighteenth century crowding.
Pierre Fauchard (1678–1761; Figure 7), a French
dentist widely seen as the father of modern dentistry, Nineteenth century
described methods of straightening teeth and devoted The term orthodontics was coined by Joachim
a chapter Lefoulon, who used the word ‘orthodontosie’ in 1841.
to the subject – the In 1880, American dentist Norman Kingsley (1829–
first comprehensive 1913) published his Treatise on Oral Deformities,
dis c ussion of which was the most comprehensive book on the
orthodontic appliances subject at the time (Lufkin, 1948).
– in his book Le In 1888, A Treatise on the Irregularities of the Teeth
and Their Corrections by John Farrar was published.
Figure 7. Pierre Farrar described the basic concepts of biological tooth
Fauchard, engraving movement and was the first to suggest using mild
by J Le Bel; Figure 8. force to move teeth at timed intervals. Both Kingsley
Fauchard’s expansion and Farrar have since been described as ‘the father of
arch
Historical images: wikimedia commons; diagrams: peter lamb

orthodontics’.
Orthodontics in the latter part of the 19th century
was led largely by American dentist Edward Angle
(1855–1930), who was widely regarded as ‘the father
of modern orthodontics’. His expansion arch, the
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E  arch, was introduced in 1887 (Figure 9). This

appliance used a wire on the labial surface of the teeth,
supported by clamp bands on the molar teeth, which
were ligated to the other teeth. Fauchard’s arch had
only given tipping control but, with the E arch, teeth

Dental Nursing September 2014 Vol 10 No 9 525

 Professional
Figure 9. The Angle E arch—the first expansion arch
could be rotated for the first time.
Angle limited his practice to orthodontics in 1899
and formally established the specialty at the Angle
School of Orthodontia in St Louis, Missouri, which he
founded in 1900. He devised the term malocclusion to
describe irregular tooth positions, as well as Angle’s
classification to categorise jaw anomalies.
Angle described his standardised appliances in a
series of books and pamphlets, including The Angle
System of Regulation and Retention of the Teeth,
and Treatment of Fractures of the Maxillae (Angle,
1899) and Treatment of Malocclusion of the Teeth and
Fractures of the Maxillae: Angle’s System (Angle, 1900).
Early 20th century
Angle continued to dominate orthodontics into the
early 20th century. Developments in metal technology
at this time facilitated the creation of bands with
soldered attachments that could control rotations.
Angle’s pin and tube attachment (Figure 10),
developed in 1911, was popular with orthodontists of
the time but required a high level of dexterity and was
soon replaced by the ribbon arch bracket (Figure 11),
which he introduced in 1916. The ribbon arch bracket
provided good control in two dimensions; this was
also the first time an orthodontic appliance had a
bracket that had a name (Renfroe, 1960).
At the time that the ribbon arch bracket was
unveiled, Angle was already developing another
bracket, mainly as a supplement to his ribbon arch
bracket. This new component, the edgewise bracket,
took more than 10 years to develop and slowly
evolved with several versions (Figure 12).
Angle noticed that the edgewise appliance would
be able to move all teeth simultaneously in all
three planes of space and he carried out several
modifications before he settled on the number 447
in 1928 (Figure 13). It received early and enthusiastic
526

endorsement from dental clinicians and soon became
the most popular fixed appliance.
Post-war developments
The concept of directly bonding brackets to the
surface of the teeth was first described by Newman in
1965 and meant that brackets could be fitted to teeth
without metal bands for the first time.
Not long after, indirect bracket bonding was first
reported (Silverman et al, 1972). Indirect bonding
aims to improve accuracy and efficiency by positioning
brackets on a model; the brackets are located on the
teeth using a custom-made transfer tray.
Self-ligating brackets were first proposed by
Alexander Wildman (1972). As the name suggests,
self-ligating brackets do not require ligatures to hold
the archwire in the bracket but, instead, have a metal
facing that forms a tube and can be opened and closed
for the archwire to be fitted and removed. Self-ligating
systems have risen in popularity with the introduction
of the Damon bracket (Damon, 1998).
In 1979, Lawrence Andrews developed archwires
that could be used to deliver three-dimensional
control of the teeth without needing to be adjusted
—the straight wire appliance. At the same time,
lingual orthodontics was first proposed (Fujita, 1979).
Lingual appliances are fitted on the palatal and lingual
surfaces of the teeth and are intended to be less
conspicuous than conventional appliances.
21st century
The adoption of 3D computer imaging in orthodontics
has been the most fundamental development of the
21st century. As well as using the technology to plan
Figure 10.
Angle’s pin
and tube
attachment;
Figure 11. The
ribbon arch
bracket, which
replaced the
pin and tube
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Dental Nursing September 2014 Vol 10 No 9
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peter lamb
Figure 12. Evolution of the Angle edgewise bracket
© 2014 MA Healthcare Ltd

Dental Nursing September 2014 Vol 10 No 9 527

 Professional
Key points
The basic principle of the orthodontic bracket has
n
remained largely unchanged since it was first developed
by Angle in the early 20th century.
Andrews developed the straight wire appliance in 1979,
n Conference at the Edinburgh International Conference
which enables three-dimensional control of the teeth
without having to adjust the archwire.
Other key developments in the 20th century included
n Andrews LF (1979) The straight wire appliance. Br J Orthod 6(3):
direct and indirect bracket bonding, self-ligating brackets
and lingual orthodontics.
3D computer imaging technology can now be used to
n
create custom-made brackets.
Figure 14. Today’s fixed orthodontic
Figure 13. The Angle
edgewise bracket
treatment and create virtual study models, computer-
aided design and computer-aided manufacture can be
used to design and create custom-made brackets to
make appliances more comfortable and enable more
accurate results.
There has also been an emphasis on improving
the biocompatibility of materials. Nickel is present
in many orthodontic components; it is also the
metal that is most likely to cause an allergic
reaction, so brackets and archwires twhat are nickel-
free or low in nickel content have been developed
(Green, 2013).
With the aim of making appliances less visible,
ceramic, tooth-coloured brackets have been developed
in recent years; these are also suitable for people with
a nickel allergy.
Conclusion
After more than 3,000 years of advancements,
orthodontic appliances have come a long way and
have developed quickly over the last two centuries to
528

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become the appliances we know today (Figure 14).
The increased use of digital technology means that
this progress should continue for years to come. DN
James Green will present ‘A Review of Indirect Bracket
Bonding Techniques’ at the 28th British Orthodontic
Centre on 20 September 2014.
125–43
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