Orthodontics: Diagnosis and

Management of Malocclusion and

Dentofacial Deformities 3rd Edition Om
Prakash Kharbanda
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 Section lll: Growth of face and
craniofacial complex

7. Development of teeth, dentition e

and occlusion (e-only) ................109
Section l: Historical aspects of A. Mathur, S.S. Rana, O.P. Kharbanila
orthodontics: ancient, yesteryears,
yesterdays, today and tomorrow 8. Prenatal development of the foetus e
concerning the craniofacial
region (e-only)....... ......................111
1.1. History of dentistry and significant events that Neeraj Wadhawan, Ram S. Nanda,
revolutionised dentistry ................3 O.P. Khqrbanda
O.P. Kharbanda

1.2. History of orthodontics.................................... 9

9. Concepts of growth and development ..........113
O.P. Kharbanda, Neeraj Wadhawan,
1.3. History of orthodontic speciality in India .....22 Ram S. Nanda

10. Postnatal growth of face and craniofacial

Section ll: Fundamentals of orthodontics region......... ............. 133
O.P. Kharbanda, Ram S. Nanda,
2. Adverse consequences of malocclusion Neeraj Wadhawtn
and benefits of orthodontic treatment........... 35
'11. Functions of stomatognathic system
O.P. Kharbanda
and their implications on occlusion .............151
3. Epidemiology of malocclusion O.P. Kharbanda, Shailendra Singh Rana,
and orthodontic treatment needs.................... 5l Anurag Gupta
O.P. Kharbanda

4. Classification and methods of recording

malocclusion ................ ...............62 Section lV: Orthodontic diagnosis
O.P. Kharbanda

5. Recording the severity of malocclusion: 12. Clinical evaluation.. ................... 169

orthodontic indices .....................85 O.P. Kharbanda
O.P. Kharbanda
13. Diagnostic records and their evaluation...... 195
6. Psychological implications of malocclusion
O.P. Kharbanda
and orthodontic treatment............................. 99
O.P. Kharbqnda, Rajesh Sagar 14. Practical clinical photography................. ......279
Ahhter Husain
 Contents

29. Three-dimensional imaging in

Section V: Radiation and non-radiation
orthodontics ................. ............. 369
imaging in orthodontics
O.P. Kharbanda, Sunil D. Kapila,
Rajiv Balachandran
15. Cephalometrics: historical perspectives,
methods and Iandmarks.............. ..,.,............ 233 30. Three-dimensional cephalometry................. 387
Rajiu Balachandran, Abhisheh Gupta,
O.P. Kharbanda
Viren Sardana, O.P. Kharbanda
16. Downs'analysis ......249
O.P. Kharbanda
31. 3D volumetric analysis, and clinical o
implications of the upper airway and
17. Tweed's analysis...... ...................253 sinuses (e-only) .......4O3
O.P. Kharbanda Bala Chakrauarthy Neelapu, Harish K Sarilana,
18. Steiner's analysis...... ..................257 Rajiu Balachandran, O.P. Kharbanda, Karthik S
O.P. Kharbanda

'19. Ricketts' l2-factor analysis ........263 Section Vll: Removable orthodontic

O.P. Kharbanda appliances
20. Vertical linear dimensions of face
and Sassouni's analysis ..............221 32. Role of removable appliances
O.P. Kharbanda
in contemporary orthodontics ..................... 4O7
z',t. Cephalometric analysis of the soft tissue O.P. Kharbanda
of the face ............ ...222 33. Invisible removable appliances: The Clear
O.P. Kharbanda
Aligners..... ..............423
22. Posteroanterior cephalometric analysis ....... 289 Maria Orellana Valvekens
O.P. Kharbanda

23. Interpretation and clinical applications

Section Vlll: Orthodontic armamentarium
of cephalometric data in diagnosis,
treatment planning and prognosis................301
O.P. Kharbanda, Rajiu Balachandrqn 34. Concept of orthodontic operatory
design (e-only)
e
........437
24. Lateral, PA and 3D Cephalometric
Prabhat Kumar Chaudhai, O.p. Kharbanda
superimposition ........... ..............311
O.P. Kharbanda 35. Instruments and equipment
in orthodontic use (e-only)
e
........439
25. Errors in cephalometrics .............................. 329
Prabhat Kumar Chaudhari, O.p. Kharbsnda
O.P. Kharbanda
35. Components of fixed orthodontic E
appliance ........,........441
Section Vl: Digital orthodontics O.P. Kharbands

37. Orthodontic archwires: material and their

E ZO. Digital and computerised cephalometrics...33g properties.. .............. 459
O.P. Kharbanda O.P. Kharbanila, Anurag Gupta
27. 3D data acquisition and 38. Rubber and synthetic elastic accessories. ..... 472
orthodontic triad........... ............34g O.P. Kharbanila
Rajiu Balachandran, O.p. Kharbanila
39. Bonding orthodontic appliances.................. 4g5 E
E ZA. 3D digital models ...352 O.P. Kharbanda, Priyanha Kapoor,
O.P. Kharbanila, Rajiv Balachandran Anurag Gupta

xvi
 Contents

Section lX: Contemporary orthodontic Section Xl: Class ll malocclusion

treatment
50. Class II division I malocclusion: features
40. The biological basis for orthodontic and early intervention of grorving maxillary
tooth movement.......... .............. 505 excess ...737
Vinod Krishnan O.P. Kharbanda

41. Principles of biomechanics and appliance 51. Evolution of functional appliances

design......... ..............519 and treatment with one piece removable
Varun Kalra appliances. ..............753
O.P. Kharbanda
42. Preservation of normal occlusion and
interception of malocclusion during 52. Treatment approaches with twin block E
early mixed dentition .................531 appliance ................767
O.P. Kharband& O.P. Kharbanda

43. Orthodontic treatment with contemporary 53. Interception and treatment of mandibular
fixed appliance Phase I: laying the retrusion with non-compliant fixed
foundation. .............549 functional appliances ................809
O.P. Kharbanda O.P. Kharbanda

44. Anchorage in orthodontic practice............... 563 54. Mode of action of functional appliances.....827
O.P. Kharbanda O.P. Kharbanda

E 4s. Tweed philosophy, biomechanics 55. Dentofacial orthopaedics for class II

and principles of treatment.............. .............571 malocclusion with vertical maxillary
O.P. Kharbanda, Mugdha Mankar excess ...837
O.P. Kharbando
E 46. Orthodontic treatment with contemporary
fixed appliance Phase II: maior tooth 55. Management of class II malocclusion
movements ..............607 with fixed appliance ...................851
O.P. Kharbanda O.P. Kharbanda

47. The pre-adjusted edgewise appliance ........... 645 57. Class II division 2 malocclusion.................. 865
O.P. Kharbanda O.P. Kharbanda

48. Orthodontic treatment with self-ligating

bracket systems...... .................... 669 Section Xll: Class lll malocclusion
Shailesh Deshmukh, Vilas Samrit,
O.P. Kharband&
58. Class III malocclusion in growing children..88l
MA Darendeliler, O.P. Kharbanda, S. Karthih

Section X: Non-extraction treatment 59. Orthodontic treatment of borderline

class III malocclusion .................................... 91 Z
Gauri Vichare, O.P. Kharbanda
49.1. Non-extraction treatment with maxillary
expansion and interproximal reduction ...... 68z
O.P. Kharbandu
Section Xlll: Newer trends
in orthodontics
49.2. Non-extraction treatment with non-compliance
molar distalisation ..................... 711
O.P. Kharbanda
60. Temporary anchorage devices....................... 935 E}
O.P. Kharbanda, Vilas Samrit

xvtl
 Contents

61. Surgically facilitated rapid tooth 71. Asymmetry of occlusion ...........1085 ,

movement (SF-RTM).... ..............957 O.P. Kharbanda

Priyanka Sethi Kumar, O.P. Kharbanda
72. Cant of occlusal plane in transverse
62. Orthodontic considerations direction ................1097
of inter-disciplinary treatment ......................971 George Anka, O.P. Kharbanda
Parul Taneja, Lohesh Suri
73. Asymmetries of the face (e-only).................. 1115 e
@ os. Evidence-based orthodo ntics (e - only) ........... 9 8f Mithran Goonewarilene, O.P. Kharbanda
NG Tbshniwal
74. Temporomandibular disorders
and orthodontics........... ...........1112
Section XIV: lmpactions Sanjivan Kandasamy, Charles S. Greene,
and transpositions Donald J. Rinchuse

64. Orthodontic aspects of impacted Section XVll: Expanding role of

anterior teeth.......... ................... gg5 orthodontist and inter-disciplinary care
O.P. Kharbanda

65. Transposition of teeth .............. l0ll 75. Inter-disciplinary management

O.P. Kharbanda
of cleft lip and pa1ate......... .......1122
e OO. Auto-transplantation of teeth O.P. Kharbanda, Nitiha Monga
in orthodontic practice (e-only)................... 101 7 76. Orthodontist's roles in upper airway sleep
Rajiu Balachandran, O.P. Kharbanda
disorders.... ............1162
Balakrishnsn I ayan, Abhijeet Kadu,
O.P. Kharbanda

Section XVlll: Steps in conclusion

67. Ortho-surgical management of skeletal of orthodontic therapy
malocclusions............... ............ 1021
O.P. Kharbanda, M. Ali Darendeliler 77. Orthodontic treatment with contemporary
68. Maxillomandibular distraction fixed appliance Phase III: finishing
osteogenesis for orthodontist ..1rO4Z and detaiIing................. ............tl89
Balahrishnan layan, Nand.a Kishore Sahoo, O.P. Kharbanda
Abhijeet Kailu
78. Deband, debracketing and delivery
of reiention appliance ............. l2O5
Section XVI: Treatment of complex O.P. Kharbanda
malocclusions 79. Post-orthodontic care and management
of white spot lesions ................1213
69. Malocclusion and asymmetries of Srideui Psdmanabhan, O.p. Kharbanda
the face...... .............tO62 80. Maintenance of the outcome results,
O.P. Kharbanda retention and relapse ................1219
E zo. Dental midline deviations.. ...... tOTl
O.P. Kharbanda
Prashanti Bollu, O.p. Kharbanda Index ..............1237

xvill
 Section lrl
H istorica I aspects of orthodontics:
a ncient, yesteryea rs, yesterdays,
today and tomorrow

1.1. History of dentistry and significant events that

revolutionised dentistry 3
1.2. History of orthodontics 9
1.3. History of orthodontic speciality in lndia 27
 Chapter 1.1

History of dentistry and signif icant events that

revol ution ised dentistry
A.P. Kharbanda

CHAPTER OUTLINE

The origin of the term Orthodontia 3 Discovery of X-rays 5

Orthodontosie and orthodontia 3 Dentistry in 19th century 5
Orthodontics and dentofacia I orthopaedics 3 Bonding in dentistry 6
Orthodontics and dentofacial deformities 3 High-speed dentistry 6
History of dentistry before Christ was born (BC) 4 Branemark era 6
The beginning of dentistry as a profession: early Dentistry in 20th century 6
to middle ages (AD) 4 Advances in restorative materials 6
The development of dentistry as a science 4 Regenerative dentistry 6
Pierre Fauchard, 'The 5urgeon Dentist' 4 Multi-detector row CT and CBCT 6
World's first dental journal 5
Dentistry in 21st century 8
Professionalisation of dental education 5
Application of 3D technology and CAD-CAM 8
The dental drill 5 Key Points 8

1976by B. F. Dewel, has been added to better describe the

whole compass of an orthodontist's bailiwick.'?

Orthodontosie and orthodontia Orthodontics and dentofacial deformities

The term Orthodontosie was coined by joachim Lefoulon,
a Frenchman in 1841, in his book Nouueau traite de l'art
du dentiste. The term roughly translates into 'Orthodontia'.
Ioachim Lefoulon used an elastic gold archwire on the
palatal side to trear crowding and irregular teeth. The gold
arch piano wire exerted shaping effect on alveolar process
and spring effect on teeth, which is an essential concept of
orthodontics.'
Orthodontics and dentofacial orthopaedics
An English philologist, Sir lames Murray ( 1909), realised that
the suf6x 'ia' appropriately referred to a medical condition
(e.g. amnesia) and suggested the term orthodontics. It took
manyyears, till 1930s, before the term Orthodontics was used
by professionals.'Dentofacial Orthopaedics', suggested in
'lb represent the extended role of orthodontics in treating and
contributing to the management of developing and devel-
oped, mild to complex dentofacial deformities' the Centre for
Dental Education and Research at All India Institute of Medi-
cal Sciences chaired by Professor O.p. Kharbanda preferred to
use the term Orthodontics and Dentofacial Deformities. The
term Dentofacial Deformities was coined to be added with or-
thodontics to avoid confusion for medical professionals, who
considered dentofacial orthopaedics qmonyrnous to maxillo-
facial trauma and referred jaw fracture patients to the ortho-
dontic department. The first textbook, with the title Diagnosis
and Management of Malocclusion and Dentofacial Deformities,
was published by Elsevier India in 2009.
The story of orthodontics and its development is closely
linked to the history of dentistry. Here are some notable
excerpts.
@|r|Historica|aspectsoforthodontics:ancient,yesteryears,yesterdays,todayandtomorrow
History of dentistry before Christ
was born (BC)
Historical evidence on dental ailments and descriptions can
be found in Indus valley, Greece, and Egyptian civilisations.
The Indus Valley Civilisation has yielded evidence for the
earliest form of dentistry which dates back to 7000 BC. The
oldestproof of a dental fillingwas found in 2OI2in Slovenia. A
6,500-year-old jawbone demonstrated a deep cavity impacting
the dentin layer of the tooth which was packed with beeswax.3'o
5000 BC. Tooth decay was thought to have been caused by
worrns and this belief continued to prevail as late as 1300s. Dur-
ing these years a French surgeon, Guy de Chauliac, continued to
promote the belief that worrns caused tooth decay.
2600 BC. The earliest known reference to a person identi-
fied as a dental practitioner was the description on the tomb
built following the death of Hesy-Re, an Egyptian scribq
called the first 'dentist'. An inscription on his tomb includes
the title'the greatest of those who deal with teeth, and of phy-
sicians'. The Egyptians bound replacement teeth together with
gold wires (Fig. 1.1.1A ).
1700-f 550 BC. The Ebers papyrus, the ancient medical trea-
tise written sometime before 3000 BC, provides detailed advice
on treating wounds in the mouth. Of the 11 recipes, which per-
tain to oral issues, 4 relate to remedies for loose teeth.n'6
700 BC. Pre-Roman Civilization: The Etruscans (a pre-Ro-
man civilisation in Italy) travelled far across seas and gathered
new information. Both human and animal teeth were used as
the first prosthetics, beginning around 700 BC? (Fig. 1.1.1B).
500-300 BC. Creek and Roman Dentistry: Around 500-
300 BC, both Hippocrates and Aristotle wrote about dentistry
including how teeth erupt, treatment of cavities, gum disease,
extraction, and even an early form of orthodontics involving
the use of wire to help secure loose teeth.
At the same time, one ancient Greek mummy, with a mouth
full of cavities, such that it caused a sinus infection which
eventually killed hirn was found. Fortunately, they continued
to advance in dentistry and in 100 B(,, Celsus, a Ronlan medi-
cal r,r'riter, described oral h1'giene, and rnethocls to stabilise
teeth, as well as how to treat toothaches, teething pain, and
iaw fractures.8
The beginning of dentistry as a profession:
early to middle ages (AD)
The Etruscans prepared crowns and fixed bridgework with
gold. A medical text in China mentions the use of 'silver
paste', a type of amalgam for filling cavities in teeth sometime
in 700 AD.
In 1530, l.rtzney Buchlein published The Linle Medicinal
Book for All Kinds of Dkeases and Infirmities of the Teeth, the first
book devoted entirely to dentistry in Germany. The tart was
written for barbers and surgeons who treated diseases of the
mouth.
In 1575, Ambroise Pare, famous French surgeon, published
his Compleu Worlu. His text included practical information
about dentistry such as tooth extraction and the treatment of
tooth decay and jaw fractures.
Pierre Fauchard, 'The Surgeon Dentist'
Pierre Fauchard, a French surgeon (Fig. 1.1.2A), published The
Surgeon Dentist, A Tieatise on Teeth (Le Chirurgien Dentiste) in
1723. Dr Pierre Fauchard is credited as being the Father of
Modern Dentistry because his book was the first to describe
a comprehensive system for the practice of dentistry includ-
ing basic oral anatomy and function, operative and restorative
techniques, and denture construction.

* --l-
, ,.h4* ffi
t,;lt"ui
,,
"''
!

* t

(B)

Figure 1'1'1 (A, B). This image is from The National Museum of Dentistry in Baltimore. The "treatment,,
in the mandible shown here was done at the
turn of the 20th century. Vincenzo Guerini, who wrote A History of Dentistry and who made models
of ancient dentistry examples which he supposedly
saw in his travels to Egypt rhe Egyptian mummy was supposedly 2000 years old. Source:
https://commons.wikimedia.org/wikilFile:Ancient_Egypt_Den-
tistry.jpg, https://de.wikipedia.org/wiki/Datei:Ancient_Egypt_Dentistry2.jpg

4
 Historyofdentistryandsignificanteventsthatrevo|utioniseddentistry@t'''|l
In 1746, Dr Claude Mouton was the first to suggest gold
crown and post to be retained in the root canal. The first
commercial production of non-metal porcelain teeth was
introduced by Samuel Stockton (1825). His S.S. White Den-
tal Manufacturing Company supplied commercially manu-
factured porcelain teeth and established and dominated the
dental supply market throughout the 19th century.

World's first dental journal

World's first dental joumal began publication in 1839. It
was named the "American ]ournal of Dental Science". The pro-
cess of mlcanisation invented by Charles Goodyear during
the same years greatly influenced the dental profession owing
to low cost, and ease of moulding rubber to the mouth. The
vulcanised rubber soon became the denture base material of
choice for making false teeth. In 1864, the moulding process
for vulcanite dentures was patented; that meant an onerous li-
censing fee. Dental profession continued to fight it for the next
25 years.

Professionalisation of dental education

The opening of the first dental school with DDS (Doctor of
Dental Surgery) degree in 1840 at Baltimore, USA, marked
the professionalisation of dental education. The Baltimore
College of Dental Surgery was founded by Horace HMen
and Chapin Harris in 1840 and this School awarded the
first professional dental school degree, the DDS degree. This
school later merged with the Llniversity of Maryland in 1923.
The American Society of Dental Surgeons, the world's first na-
tional dental organisation, was also founded in 1840 and was
dissolved in 1856.
Between 1845 and the turn of the 19th century major in-
ventions in chemistry and physics changed the world of medi-
cine and dentistry like the successful demonstration of tooth
extraction using ether, discovery ofX-rays and synthesis oflo-
cal anaesthesia. The dental drills, foot engine and electric drill
were discovered during this time.
In 1845, Dr Horace Wells, a dentist had conducted a dem-
onstration of dental extraction under general anaesthesia
with nitrous oxide, the laughing gas, but it was regarded a fail-
r--_r
ure when the patient cried out. A year later, in 1846, another
dentist, William Morton, conducted the first successful public
demonstration of the use of ether anaesthesia for surgery.
fiEure'l "1.? (A) Perre Faucharrl the Father of Modern Dentstry (1678
The dental drill March22, 1761 ) (B) Prototype of bandeau used to al qn teeth byty nq them
on rgid plate. Reproduced vttth pcrnssron. Source ttt/ahl N arthoclontics
The first dental drill, the foot engine was firsr commercially in 3 millennia. Chapt-.r 1; Antrquity to the mrd 1gth century. An I Orthod
manufactured as a foot-treadle dental engine under patent by Dentofacial Orthap. 2005 Feb, 1 27(2).255-9.
lames B. Morrison in 1871. Morrison's inexpensive, mecha-
nised tool supplied with dental burs with enough speed to
cut enamel and dentin smoothly and quickly, revolutionising dertt;rl X-ray of ir living person itr LISA rvirs taken in 1E9(r bv a
the practice of dentistry (Fig. 1.1.3). Much later, anAmerican, pronrirrent Ner,r, ()rleans dentist, C. Edrntrnd Kells.
Ceorge F. Creen, received a patent for the first electric dental
engine, a self-contained motor and handpiece (Fig. 1.1.4).

Dentistry in 19th century

Discovery of X-rays
Wilhelm Roentgen, a German physicist, in 1885, discovered Nineteenth century witnessed major changes with scientific
X-rays which had a great impact on medical practice. The 6rst discovery of formulation of local anaesthesia, the first bonding
 Section Irl

tl
@
{b'
Figure 1.1.3 First foot dental drill was commercially available in
1871. This foot engine is a proud possession of the author who
All Cord'Ifue
the Riltcr I)ental €ngiu

Figure '1.1.4 The dental electric drill that revolutionised restorative

dentistry. (http://mcnygeneatogy.com/pics/picture.php?/21 3lcateqories).
used it in 70s as a dental student.

system, the acid etch, high-speed air drills and the mosr
technology. The first commercial home tooth bleaching prod-
significant being the concept ofosseointegration. In 1905, AI_
uct was marketed in 1989.
fred Einhorn, a German chemist, formulated the local anaes_
thetic procaine, later marketed under the trade name Novocain.
Advances in restorative materials
Bonding in dentistry A year larer in 1990, a new era of aesthetic dentistry began
with the introduction of tooth-corour restorative materiils,
Oskar Hagger, a Swiss chemist, developed the first system of
veneers/ increased usage ofbleaching, and implants. ln 1992,
bonding acrylic resin to dentin in 1949 and a few years larer,
FDA (Food and Drug Administration) approved the erbium
in 1 955, a simple method of increasing the adhesion of acryl_
YAC laser, the first for use on dentin, to treat tooth decay.
ic fillings to enamel was described by Michael Buonocore us_
The need for broad research base in dentistry led to
ing acid etch technique.
renaming The National Institute of Dental Research, to
'National Institute of Dental and Craniofacial Research,.
High-speed dentistry in
1 998.
iohn Borden (1952) first inrroduced a high_speed air_driven con_
tra-angle handpiece. The Airotor attained speed up to 300,000 Regenerative dentistry
rotations per minute and was an immediate commercial success,
launching a new era of high-speed dentisuye,r,, (Box 1.1.1 By 2000, regenerative dentistry and stem cell research,
includ-
). ing banking of primary tooth pulp tissue for regeneration
Branemark era turned out to be the most exciting and promising area
of
dentistry. Regenerating a functional ind living tooth is
The history of modern one of
dentistry will always be remem_ th-e most promising therapeutic strategies forihe
replacement
bered as before and after Branemark era. ln 1980, per_lngvar of a diseased or damaged tooth.il
Branemark described techniques for the osseoinregratioi
of
dental implants and this was perhaps the most thrilling
and
usefirl innovation that had influenced the practice of den"tistry
Multi-detector row CT and CBCT
and patient satisfaction in the century. Discovery of computed tomography added new
dimensions in
maglng of living strucrures. Computed axial tomography
JO_f

Dentistry in 20th Century

The 20th century saw the advances and refinements
in ma_
I {CT), which changed the world of medical imaging nom-ZO
I t"y_r to 3D imaging was invented by British engineer, God_
frey Hounsfield of EMI Laboratories, England and
Africa-born physicist AIan cormack of tifts
sachusetts in 1922. Discovery of cone beam
by South
universiw, Mas-
comput"d i;;;;_
terials, aesthetic dentistry and induction of sophisticated
raphy (CBCT) originated at a small town named
Verona in
6
 History of dentistry and significant events that revolutionised dentistry |11 II
@E
Box 1 .1 .1 Landrnark events in the history of dentistry from FC to 20!0

BC The first and most enduring explanation for what causes tooth decay was the tooth worm, as depicted in the ivory
sculptures, which was first noted by the Surnerians.
2600 BC The earliest known reference to a person identified as a denlal practitioner was the description on the tomb built following
the death of Hesy-Re, an Egyptian scribe, often called the first'dentist'.
1700-1 550 BC The Edwin Smith PapyruVEbers Papyrus is an ancient Egyptian medical text. lt is the oldest known surgical treatise on
trauma. This contains 1 1 recipes, which pertain to oral issues
700 BC Human and animal teeth were used as the first prosthetics, beginning around 700 BC. The Etruscans (a pre-Roman
civilization in ltaly) actually made some basic leaps in dentrstry
500-300 BC Hippocrates and Aristotle wrote about dentistry including how teeth erupt, treatment of cavities, gum disease, extraction,
and even an early form of orthodontics involving the use of wire to help secure loose teeth
166-201 AD The Ftruscans practiced dental prosthetics using gold crowns and fixed bridgework.
700 A medical text in Chrna mentions the use of 'silver paste', a type of amalgam ior filling cavities in teeth.
1210 A Guild of Barbers was established in France.
1530 Artzney Buchletn published The Little Medicinal Book for All Kinds of Diseases and lnfirmities of the Teeth the first book
devoted entirely to dentistry, in Germany.
1575 In France, Ambroise Pare. known as the Father of Surgery, published his Complete Works.
1723 Pierre Fauchard, a French surgeon published The Surgeon Dentist, A Treatise on feeth (Le Chirurgien Dentiste). Surgeon
Pierre Fauchard is credited as being the Father of Modern Dentistry.
1746 Claude Mouton described a gold crown and post to be retained in the root canal.

1825 Samuel Stockton began commercral manufacture of porcelain teeth under 5. S. White Company.
1839 The American Journal of Dental Science, the world s f irst dental journal, began publication.
1840 Horace Hayden and Chapin Harris found the world s first dental school, the Baltimore College of Dental Surgery and
established the Doctor of Dental Surgery (DDS) degree. (The school merged with the University of Maryland in 1923).
1846 Dentist William Morton conducted the first successful public demonstration of the use of ether anaesthesia for surgery.
1871 James B. Morrison patented the first commercially manufactured foot-treadle dental engine.
'1895 Wilhelm Roentgen, a German physicist, discovered the X-ray. In 1896, prominent New Orleans dentist, C. Edmund Kells,
took the first dental X-ray of a living person in the US.
1899 Edward Hartley Angle classified the various forms of malocclusion. Credited with makinq orthodontics into a dental
specialty.
1905 Alfred Finhorn, a German chemist, formulated the local anaesthetic procaine, later marketed under the trade name Novocain.
1955 Michael Buonocore described the acid etch technique, a simple method of increasing the adhesion of acrylic fillings to
enamet.
1957 John Borden introduced a high-speed air-driven contra-angle handpiece. The Airotor obtained speed up to 300,000 rotations
per minute and was an immediate commercial success, launching a new era of high-speed dentistry
1980 Per-lngvar Branemark described techniques for the osseointegration of dental implants
1990 New tooth-coloured restorative materials plus increased usage of bleaching, veneers, and implants inaugurated an era of
aesthetic dentistry.
1972, 1988, 1996 Discovery of multi-detector row CT (MDCT) added new dimensions in 3D imaging of living structures. Computed axial
tomography (CT) was invented in 1972 by British engineer, Godfrey Hounsfield of EMI Laboratories, England and by South
Africa-born physicist, Allan Cormack of Tufts University, Massachusetts. Discovery of CBCT originated at a small town named
Verona in ltaly in 1988. The NewTom or maxiscan was the first CBCT system in the world, installed in 1996.
1990 .... First dental CAD-CAM was invented in Zurich by Siemens and sold by SIRONA.
1997 FDA approved the erbium YAG laser, the first for use on dentin, to treat tooth decay.
'1998 National Institute of Dental Research was renamed National Institute of Dental and Craniofacial Research to more accuratelv
reflect the broad research base.
2000.... Regenerative dentrstry and stem cell research including banking of primary tooth pulp tissue for regeneration, proposeg rn
the new millennium.
2010 3D printing in dentistry oral and maxillofacial surgery and orthodontics.
 Section Irl
Italy in l9BB." The NeWTom or maxiscan was the first CBCT
system in the world, installed in 1996.13
Dentistry in 21st Century
Application of 3D technology and
CAD-CAM
Frangois Duret, in the 1970s, conceptualised and adapted
the use of digital technology used in industry to dentistry.
The most significant and useful application was digital im-
pression making either directly in the mouth or indirectly
on a model. These clinical applications were the outcomes
of research as a part of his thesis exercise having the title The
optical imprint'.
The 3D scan of impressions is transferred to production
milling machines through a process of computer-assisted
manufacturing (CAM) to create dental restorations such as in-
lays and crowns. First dental CAD-CAM was invented in Zurich
by Siemens and sold by SIRONA.1a.r5 Dr Anderson developed
Procera System. He attempted to fabricate titanium copings
by spark erosion and introduced CAD-CAM technology into
the process of composite veneered restorations. This system
later developed as a processing centre networked with satellite
digitizers around the world for the fabrication of all ceramic
frameworks.16'r7 Dr Mormann developed CEREC System, an
innovative approach to fabricate same day restorations at the
chair side in the dental office.r8
With the induction of 3D printing in dentistry particu-
larly in the streams of oral and maxillofacial surgery and or-
thodontics, future dentists and patients are now looking at
quality control in rehabilitation, and customised lingual and
labial appliances. 3D printing has numerous applications in
dentistry although the full potential of this technology is yet
to be explored.'e'20
Key Points
I
'fhe art and science of dental practice has evolved
since
ancient Egyptians times to modern era of high speed,
precision and lately digitalisation. The science of den-
tistry has contributions from the fields of medicine, engi-
neering, computer sciences, material sciences and many
more.

. References
L

References for this chapter are found on the companion website wwwmedenact.com.

Suggested reading
Weinberger BW. Historical rdsumd of the evolution and groMh of orthodonti
a. I Am Dent Assoc 1934;21:2OOl_21. Cited
from wahl N. orthodontics in 3 milrennia. chapter 16. Late 2'th-century
fixed applianc es. Am I orthod Dentofaciar orthop
2008; r34(6): 827 -30. PMID: 19061 811.
il. Dewel BF Editorial: orrhodontosie, orrhodontics, or dentofacial orthopedics.
Am I orthod r9z6;zo(3):32g. pubMed pMID:
1066971.
III. Mozzo P' Procacci c, Tacconi A, Martini Pr, Andreis IA. A new volumetric
cr machine for dental imaging based on the cone
beam technique: preliminary results. Eur Radiol rgg8;8(9):1558-64. pubMed pMID:
9866261.

8
 Chapter 1.2

H istory of orthodontics

CHAPTER OUTTINE

Orthodontics in ancient times Orthodontics during 1960-70

Orthodontics in 17-18th century and European Contributions of Charles H. Tweed
dominance 9 (June 1 895-January 1 970) 21
Pierre Fauchard father of modern dentistry Orthodontics during'1970-80: pre-adjusted
and first fixed appliance 9 appliances 22
Contributions of Joachim Lefoulon 10 Evolution of pre-adjusted appliances and bonding:
American dentistry and orthodontics hallmark of contemporary orthodontics 22
in mid-19th century 10 Orthodontics during 1980-90: clinical success with
Contribution of Edward Hanley Angle to the twin block popularised functional
orthodontic profession (1 855-1 930) 11 appliance
Edward Angle's inventions and teachings 14 Temporary anchorage devices: major game
changer in orthodontic practice
The first three decades of 20th century, 1900-30:
beginning of biological foundation of orthodontics 15 Auto-transplantation of teeth in the management
of space 24
Orthodontics during 1930-40: Functional appliance
and cephalometrics 't8 Orthodontics during 2000-1 8 24
Orthodontics during'l 940-50: Tweed's Robotic orthodontics 24
concepts of growth 19 Orthodontics beyond 2020 24
Orthodontics during 1950-60: emphasis Key Points 25
on cephalometrics 20

Galen (129-199), suggested treatment of irregular teeth by

Orthodontics in ancient times filing of the teeth to gain space. It was Fabricius (1619) who
suggested extraction of teeth in
case of crowding.t Follow-
In Ancient times, irregular teeth have been located in the ing years saw some evolutionin dental profession in France
skulls of Neanderthal man who existed about 50,000 BC. An- where dental surgeons could undergo formal training and
cient Creeks and Etruscan artefacts exhibit designed devices/ practice correction of dental irregularities.
appliances to exert pressure on teeth. Archaeologists have dis-
covered Egyptian mummies with crude metal bands wrapped
around individual teeth. It is speculated that catgut was used Orthodontics in 17-18th century and
to close the gapsl (Fig. 1.1.1B).
European dominance
Hippocrates era, 400 BC to 16th century. Ancient Greek l

physicians mentioned dental irregularities as early as 400 BC.

Celsus (in Rome, 25 BC-50 AD) advised the removal of de-
ciduous teeth once the permanent teeth have erupted and treat-
ment of crooked or irregular teeth could be attempted by pres-
sure exerted by the finger. He stated, 'lf a second tooth should
happen to grow in children before the first has fallen out, that
ought to be shed is to be drawn our, and the new one daily
pushed toward its place by means of the finger until it arrives
at its iust proportionl' In all probability, Pliny the Elder was
the first to use (AD 23-79), mechanical rreatment, which was
filing elongated teeth to bring them into proper alignment.l
Pierre Fauchard, father of modern dentistry
and first fixed appliance
Pierre Fauchard (1678-March 22, 1767), a French physician is
known as 'father of modem dentistry' for his innumerable scien-
tific contributions. He is also known for the first description of
'brace'the'bandeau', the forerunner of Angle's E Arch appliance
(Fig. 1 . 1 .2 A, B). The bandeau was made of gold. Ir was used as
a firm arch to which irregular teeth were tied using waxed linen
or silk threads. He discovered that the teeth position could be
corrected, as the teeth would follow the pattem of the brace.
9
 Section lrl Historical aspects of orthodontics: ancient, yesteryears, yesterdays, today and tomorrow
Dr Fauchard, The Surgeon Dentist, is also known for writ-
ing the first complete scientific description of dentistry 'Le
Chirurgien Dentiste', published as early as 1728. Dr Fau-
chard who worked in Royal French Nary, ioining, Alexander
Poteleret, at the age of 15, was greatly influenced by surgeon
maior, Alexander Poteleret, and got interested in diseases of
the mouth, which caused much suffering in sailors on long
voyages. Dr Fauchard studied medicine and later practised at
Angers University Hospital. He moved to Paris in 1723, at the
age of 45 years, where he completed the first 600-page manu-
script. Next 5 years were spent on modifting and updating
the text based on feedback from his peers; by the time it was
published in 17 28 in two volumes, it swelled to 783 pages.'
'Le Chirurgien Dentiste' is considered to be the first major
description of dentistry. It described the basic oral anatomy,
and function, signs and symptoms of oral pathology, op-
erative methods for removing tooth decay and restorations,
periodontal disease, orthodontics, replacement of missing
teeth, and tooth transplantation. Dr Fauchard described a
labial arch made of ivory for use in orthodontics.2
The second edition was published in 1746, and the third
one in 1786. In 1733, the book was translated into German
language.
Dr Fauchard collected examples of treatment of inegular
teeth to describe them particularly well, concerning the erup-
tion of teeth, he wrote: '... teeth empt sooner or latet depend-
ing on the children's forces', with their'temperament'being
possibly so big as to present with teeth already at the time
of birth. He described, among other things: a rddressement
force using a'pelican', where the tooth was moved within the
socket. He then ligated the tooth to its neighbours until heal-
ing took place. At that time, most attention was paid only to
the alignment of teeth almosr exclusively in the maxilla. He
also suggested interproximal polishing and splinting of the
tooth with a follow-up trearmenr bringing about the desired
result within a week.t,'
During these years (1222-66), phillip pfaff, a surgeon den_
tist, for the first time described taking the impression with
sealing wax. However, he denied that milk teeth have roots,
which was later contradicted by Iohn Hunter (1728_93), a
British surgeon, inspector-general of hospitals, also worked in
orthodontics and found our thar milk teeth do have roots. His
observations included that, once they have erupted, they no
longer grow in width, but that crowding is the result of tooth
movement. He determined that milk molars are bigger than
premolars, but front milk teeth are smaller than permanent
teeth.2
fohn Hunter (1728-93) was first to investigate the growth
in animals, using pigs' mandibles. A metal ring that was in_
serted at the front edge of the ascending mandibular ramus
in growing animals that moved to the centre due to the op_
position ar the front edge and resorption at the hind edge of
the mandible.
The inclined plane. John Hunter was first to use an inclined
plane made of silver in the anterior tooth_bearing area of the
jaws to treat prognathia and a metal arch with
ligatures. Adam
Anton Brunner was first to use an inclined plane in l77l.
However, it was L. I. Catalan who propagated an inclined
plane around 180B as its construction. The inclined plane
is
now named after him.
10
First plaster models. In 1836, Friedrich Christoph Kneisel,
a German dentist, was first to use plaster models to record
malocclusion. He used chin straps for correction of prognath-
ic mandible and hence, became the first to use a removable
appliance. Kneisel (1797-1887) also wrote the 2l-page'Der
Schiefstand der Ziihne, dessen Ursachen und Abhilfe einer neuen,
sicheren und schmerzlosen H eilmethode' lD ental malposition-
ing, its causes and remedies using a novel, safe and painless
method]. The first regulatory plate was made by Christopher
Starr Brewster in 1840; it was made of caoutchouc.
Contributions of Joachim Lefoulon
The year 1841 is perhaps one of the historic years in the den-
tal profession, when Joachim Lefoulon, in his book Nouueau
traite de I'art du dentiste, used the term Orthodontosie, which
the Americans simplified to 'orthodontia' and, later, to 'or-
thodonticsln
An elastic gold archwire was ried on the palatal side to treat
dental crowding. The wire has dual effect on relief of dental
crowding and also a moulding shaping effect on the alveolar
process, it can be said that this appliance was the first step
towards'orthodontics'.'
Lefoulon, suggested malocclusion can be caused by these
factors:
(1) Constitutional differences brought about by social,
economic, and geographic conditions
(2) Prenatal conditions
(3) A disease process, such as scrofula and
(4) Abnormal pressures during the speech.
The first molar band was fixed with a screw in 1g4l by I. U.
Afexis Schang€. His book Prdcis sur le Redressement des Dents
described an adaptable band clamp rhat was fixed to the tooth
using a screw. He was also the first to mention a need for a
period of retention after the treatment.
The first classification of malocclusion. Georg Carabelli
in 1842 presented first ever classification of malocclusion. He
presented a novel classification ofvarious types ofocclusion,
which was highly regarded in the German-speaking world for
quite some time.
William Henry Dwinelle (1819-96) was the firsr to use
screws and the first elastic rubber for orthodontics
in 1g46.
The first report on bone remodelling (1g59). Iohn Tomes
was the first to show remodelling processes in the alveolar
bone with bone resorption in the direction pressure is exerted,
and bone apposition on the side of relief.,
American dentistry and orthodontics in
In the United States before the 1g30s, there was no formal
professional education or a dental degree. The physicians,
barbers, or charlatans performed the woik and procedures in
mouth. The literature has little contributions from American
authors related to orthodontics until 1Bg0r and the term Mal,
occlusion was not known.
During mid-19th century significant developments took
place which contributed to evolving a dental profession
with
l History of orthodontics
formal education and uaining. In 1839, the American Joumal of
Dentnl Science, the world's first dental joumal, had begun pub-
lication and a year later, the world's first dental school, the Bal-
timore College of Dental Surgery was founded. The first formal
dental degree, DDS degree was awarded from Baltimore.
It is at Baltimore College of Surgery that the first lectures on
'irregularities' of the teeth were given to undergraduates by
Chapin Harris. Norman Kingsley, who is considered'Father of
Orthodontia in the USA, lectured students on the causes and
correction of malocclusion ( 1 872).
Before 1910, orthodontics was taught as a branch of pros-
thetics, the techniques for correction of irregular teeth with
little or no emphasis on science.
Norman William Kingsley, 1866. Dr Kingsley suggested
prosthetic treatment of cleft lip and palate and introduced
extraoral traction device. His student, Walter Harris Coffin,
in 1B8l (Fig. t.2.t), found an innovative method for regula-
tion of irregular teeth using a bent W spring made of piano
wire embedded on both sides into l.ulcanite, later replaced by
acrylic. The spring is free to expand in the middle and thereby
used as expansion appliance to move two sides of the alveolar
process in the maxilla.
fohn Nutting Farrar (1839-1913). Dr Farrar authored text
on orthodontics 'lnegularities of the Teeth and TheirTreatment'
first in 1888, which went through six editions; and more rhan
90 articles on gingival pathologies and irregularities of the teeth.
Fanar opined that forces for moving the teeth should not be
continuous and suggested the theory of intermittent force. He
developed a screw to deliver this kind of force in controlled in-
crements by activating the device 'about7l24O inch every mom-
ing and the same in the evening'.
Around the same years Dr George B. Crozat (1S93-1966)
developed a universal wire device, which is more popularly
known as Crozat appliance and Crozat retainer (Fig. 1.2.2;
Box 1.2.1A, B, C).
Contribution of Edward Hartley Angle to
the orthodontic profession (1855-1930)5-8
'lt is well known that Dr Edward H. Angle is the nestor of
orthodontia. To him, more than to any other individual is
Figure 1.2.1 The W spring made of piano wire by Walter Harris Cof-
fin (1881). Source: Wahl N. Orthodontics in 3 millennia. Chapter 2:entering
the modern era. Am J Orthod Dentofacial Ofthop 2005 Apr,127(4):51A5.
@112r I
ffi
ll ,,
Figure 1.2.2 Dr George B. Crozat (1893-1956) developed a univer-
sal wire device. which is more popularly known as Crozat appli-
ance and Crozat retainer. Source: Wahl N. Orthodontics in 3 millennia.
Chapter 5: the American Board of Orthodontics, Albert Ketcham, and
early 20th-century apphances. Am J Orthod Dentofacial Orthop 2005
Oct;128(4):53540.
this science indebted. His life has been spent nursing and de-
veloping it',
Cited from A Biographical Portrait of Edward Hartley An-
gle, the First Specialist in Orthodonrics', written by Peck S.6 in
a three part series and the Editorial for the first issue of The
International Journal of Orthodontia in 1915 by Martin Dewey,
DDS, MD, one of his most accomplished students, the follow-
ing write-up gives a brief record of E. H. Angle.
"No personality central to the history of orthodontics stim-
ulated as much progress, excitement, and polarity as Edward
Hartley Angle, MD, DDS (1855-1930), the acknowledged
founder of this clinical speciality. Early in the 20th century
he dominated the emergence of 'orthodontia as a science and
a specialityi This inventive doctor gave malocclusion the pri-
macy and order it needed."
Edward Hartley Angle spent his boyhood on his parents'
farm in District, 'Ballibay', Herrick Township, Bradford Coun-
ty, Pennsylvania. His mother Isabel, in the year 1874, intro-
duced HART (Angle's nickname) at age lB years to a nearby
dentist to learn dentistry as an office apprentice. Later, Angle
enrolled himself at College of Dental Surgery in Philadel-
phia for the DDS programme. The DDS programme was then
arranged in two 6-month terms spaced over a nominal two
years.
In 1878, Edward Angle initiated his profession by setting
up a general practice of dentistry in the centre of town at
Bradford County seat, Towanda. In 1881, his health dete-
riorated, and he decided to abandon dentistry on his phy-
sician's advice to live in an outdoor environment. Angle
moved to live in Minneapolis, Minnesota where his health
improved. While Angle was contemplating to abandon den-
tistry to avoid physically demanding dental profession, he
set up a lucrative sheep-raising business in Montana with his
friends and brother. Unfortunately, a record-breaking deep
freeze that year killed off the entire herd and he lost all his
savings.
By mid-1882, he moved back to practice again. His curiosi-
ty, attention and indulgence in 'regulating'the'irregular teeth'
continued to flourish. The breaking point in his career was his
11
Section I f i Historical aspects of orthodontics: ancient, yesteryears, yesterdays, today and tomorrow

Box 1 .2.1A Origin and worldwide contributions in orthodontics from 400 BC to 19th tentury

Years Events

400 Bc Hippocrates era: Dental irregularities mentioned the first time

25 BC-50 AD Celsus recommended the removal of milk teeth once the permanent teeth have erupted, and the straightening of crooked or
irregular teeth by pressure exerted with the finger
129-199 Galen suggested treatment of the irregular teeth by filing of the teeth to gain space
1 619 Fabricius suggested extraction of teeth in case of crowding
1678-1761 First description of 'brace' or the 'bandeau', the forerunner of Angleb E Arch appliance given by Pierre Fauchard. Bandeau was
used as a firm arch to which inegular teeth were tied using waxed linen or silk threads
1722-1766 Phillip Pfaff, a surgeon dentist, forthe firsttime described taking the impression with sealing wax
1728-1793 John Hunter, a British surgeon, inspector-general of hosprtals, also worked in orthodontics and found out that milk teeth do
have roots. He was also the first to investigate growth of mandible in animals
Adam Anton Brunner was the first to use an inclined plane in 1 771 . However, it was L. J. Catalan who propagated an inclined
plane around 1808 as his own construction
1 836 Friedrich Christoph Kneisel, a German dentist, was first to use plaster models to record malocclusion. He used chin straps for
correction of prognathic mandible and hence, became the first to use a removable appliance
Joachim Lefoulon, in his book Nouveau traite de l'aft du dentiste, used the term 'Orthodontia'. He used an elastic qold archwire
on the palatal side to treat crowding
M. Alexis Schang6 described an adaptable band clamp that was fixed to the tooth using a screw; he was probably the first to
realise that treatment should be followed by a period of retention
1842 Georg Carabelli presented a novel classificatron of types of occlusion
1846 Claude Lachaise and Elisha Gustavus Tucker were the first to use the elasticity of rubber straps for orthodontic purposes
1 859 John Tomes was the first to show remodelling processes in the alveolar bone
1872 Norman Kingsley, considered as the 'Father of orthodontia in USA, lectured students on the causes and correction of
malocclusion at Baltimore College of Dental 5urgery
1 878-1 930 Edward H. Angle's contributions are listed in Box 1.2.2
'1881
Walter Harris Coffin found an innovative method for regulation of irregular teeth using a bent W spring made of piano wire
embedded on both sides into vulcanite, later replaced by acrylic
1 888 John Nutting Farrar wrote on irregularities of the teeth and their treatment
1 890 Intermaxillary elastics proposed by Dr Case and Dr Baker However it became popular as Baker's Anchoraoe

Box 1 2.1 B origin and worldwide contributions in orthodontics, 20th century

Events

George B Crozat developed a universal wrre device, which is more popularly known
as Crozat appliance and Crozat retainer
charles A Hawley published 'Determination of Normal Arch and rts Application
to orthodontia, and introduced the retainer
appliance that bears his name: Hawleys appliance
191 1 Albin oppenheim, an Austrian-Hungarian born physician turned orthodontist, was
the first to report tissue changes more so in
bone during orthodontic tooth movement. His flrsi article on this subject *ui'prlilin"o
in Vienna
Albert H Ketcham. one of the first to introduce the roentgenogram and photography
into orthodontic practice
fhe lnternational lournal of Orthodontia and Oral Surge4l was started in 19i 5
John v Mershon introduced the removable lingual arch based on the principle
that teeth must be free and unrestricted for
adaptatton to normal growth
19'18 Alfred Rogers introduced the concept of myofunctional tnerapy
1921 Dr case published his maiorwork, 'A Practical Treatise on the Techniques
and principle of Dental orthopedia and prosthetic
Correction of the Cleft palate,
1924 concept of orientation of face beyond teeth was introduced. paul
simon,s Gnathostatics
1931
orthodontia'rhrs pioneerins technique tead to a new era or understandins
t1):IJi:?J:.',:[T:#,i;:J:i::.t'",.to or
Bolton s polnt: In recognition of Mrs chester c. Bolton
and her son charles B. Bolton who funded manufacture of
cephalostat head holder and x-ray apparatus, which was installed first
at anatomical taboratory of the western Reserve university
1 933 Dr' Andressen revrved Monoblock appliance first
developed by Piene Robin in 1902 to new appliance called
Dr Robert E Moyers and sam Pruzansky inducted electromyography Activaror.
to study the effect of musculature on occlusion
Biorks study on normal variations and mechanism of prognathrsm
as well as relationship between facial build and
representative materral the bite in
 Historyof orthodonr,.,
@ lr.2l I
Years Events
1946 Dr Kooper established first dedicated interdisciplinary clinic for patients with cleft lip and palate and craniofacial anomalies;
what is now famous as Lancaster Cleft Centre
1 950-1 960 Key contributions of Dr Charles H. Tweed: Induction of cephalometry in cilnical practice and the emphasis by a number of
authors like William B. Downs in 1952 followed by C. C. Steiner 1953, C. H. Tweed 1953, S. E. Coben 1955
1952 Textbook of Functional Jaw Orthopaedics' was released by Karl HSupl
1 960-1 970 Standardization of edgewise mechanism by Charles J. Tweed and popularization of extraction philosophy treatment with light
wire appliance by P R. Begg at Adelaide, Australia. Dr Begg promoted reduction of tooth substance by extractions and created
modified Ribbon Arch bracket, and multiple-loop light-force wire appliance, known as Begg's Light wire technique. His book
was first published in 1965
'r970s Robert Murray Ricketts greatly influenced orthodontic thinking by his critical evaluation of existing cephalometric analysis. He
evolved bracket modification towards building prescription in .018 inch slot 1 970s. The f irst cephalometric analysis diagnostic system
to project treatment plus groMh in treatment planning (WO) and computer generated method for projecting growth was also
developed by him
Ricketts also developed the quad helix, utility arches, sectionalisation and most significantly, bioprogressive philosophy, a
biological approach to diagnosis and treatment. He recognised and used facial proportions to treat dental and skeletal problems
called the Divine Proportion
CF Andrews introduced straight wire appliance
1969 Newman introduced bonding in orthodontics
1 980-1 990 The duo of clinicians Mclaughlin and Bennett, made the MB (McLaughlin-Bennett) appliance popular. The MB prescription was
later further modified by Trevisi and is now widely known as MBT prescription
1987 Ceramic brackets first introduced in the market
'1990s Temporary anchorage devices (TADs) another game changer in orthodontic practice with a successful case report by Creekmore
and Eklund
1 990 DlGl-CEPH, computerised cephalometric analysis system, developed at All lndia Institute of Medical Sciences in collaboration
with Indian Institute of Technology (llT) New Delhi

BOX '1 .2.'1C Origin and worldwide contributions in orthodontics, 21st century

Years Events

2000 onwards Concept of 3D printing emerged in Nagoya, Japan by Hideo Kodama who invented the first fabricating technology and
methodology for rendering plastic into 3D with a polymer that was exposed to ultraviolet rays
2006 The integration of CBCT (cone beam computed tomography) skull, CBCT models, non-radiation 3D facial scanning put to use
for 'real life' like planning more so the effects of orthodontic treatment on facial profile
2006 Dolphin lmaging company introduced its 3D module which is able to import and process 3D datasets from MDCT, CBCT, MRI
and high definitjon facial camera systems
2007 'Universal Connector' Developed at AIIMS by O.P Kharbanda for indirect Miniscrew anchorage.
Around 2010 The first commercial venture with robotic wire bended wire supplies in the United States with the name SureSmile/Orametrix
201 0 Auto-CEPH, the advanced computerised cephalometric system, was developed as a collaborative work by O.P Kharbanda and H. S.
Sardana working at All lndia Institute of Medical Sciences, New Delhi and Central Scientific Instrument Organisation, Chandigarh
Around 20 0 1 Plaster-free clinrcs wherein intraoral scanners are in use which allow 3D scanning of dental structures; this helps to produce
digital models, virtual planning and print plastic models
201 5 'CollobDDS' a network enabled digital diagnosis and interactive platform developed by a team of clinicians and scientists from
various disciplines. Orthodontics and Radiology at AllMS, imaging scientists at CSIO Chandigarh and llT Mumbai and
lT team at NIC New Delhi
201 8 Algorithm for automated 3D cephalometric analysis and automated volumetric analysis through CBCT developed at CSIO AIIMS
collaboration. Lead scientists. H. S. Sardana and O.P Kharbanda, A. Gupta and B. C. Neelapu

announcement that he would be practising orthodontia and
no other forms of dental treatment or therapy. 'With this deci-
sion, he became the first acknowledged exclusive specialist in
orthodontics in the worldi
Dr Angle was lecturing orthodontics in several schools'
In 1886, 31-year-old Edward Angle was appointed a pro-
fessor of histology and lecturer on comparative anatomy
and orthodontia at Minnesota Hospital College in Min-
neapolis.
In 1887, Angle was the youngest of the speakers at Ninth
International Medical Congress in Washington DC in the
section on 'Dental and Oral Surgery'. His talk titled Notes
on Orthodontia with a New System of Regulation and Retention,
demonstrated his classification of tooth movements and his
13
 I t I Historical aspects of orthodontics: ancient, yesteryears, yesterdays, today and tomorrow
novel orthodontic devices, such as piano wire in a soldered
'pipe' (tube) and the jackscrew and traction screw. He used
'lantern slides' to show his presentation, a new lecturing aid
in those days. His presentations led to some passionate and
inflammatory discussions with eminent dentists accusing
Angle of presenting old stuff with his claims. Transactions
of the Ninth International Medical Congress contained his
edited paper titled 'Notes on Orthodontia', commonly re-
ferred as 'First Edition' of his classic textbook on the treat-
ment of malocclusion. However, Angle considered that his
first edition was his 14-page chapter appended to Loomis P.
Haskell's new book on dental laboratory procedures pub-
lished in 1887, Extracts of Notes on Orthodontia with a New
System by [sic] Regulation and Retention.
Edward Angle's inventions and teachings
(Figs. 1.2.3 and 1.2.4)
With his talent of mechanical innovations and his zeal to treat
patients and teach, he continuously evolved new methods
and appliances. He had 46 patents to his credit, 45 during his
lifetime, and 46th appearing after his death. Angle continued
to edit his book, adding his experience and innovations. The
seventh and last edition of the 628-page text was published
in 1907. His contribution and events are given in Box 1.2.2.
He initiated the first formal exclusive school in orthodontia,
Figure 1.2.3 Edward Hartley Angle's model of ideal occlusion was
based on this ancient skull which he called ,Old Glory,. Th js skull had
been presented to Angle by Richard Summa, one of AnqLe,s first students
and an amateur archaeologist. Source; Wahl N. Orthodontics in 3 millen-
nia. Chapter 12: Two controversies: early treatment and occlusion. Am l
Orthod Dentofacial Orthop 2006 Dec,l 30(6):799_804.
14
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tlliNltt, u!:flttrlr{r 1}a riltt} t,{trr tgrJt
A tr@a{tilly olnil'1*rl l)ctrtrl 5rlrool. A iiuirr,l nuolrr of rluda[tr f$rnajgtl
Itrrsonrl rtleollotr trorr ll,. l..clrrrr.
Spcclel Prcperation glvtn Studcntr lor ell Stetc Ermirlng Bolrdr
' l'rtrttnr rBl nri,'{,rhi!, nirr,$
'trt
Figure 1.2.4 The newspaper advertisement of Angle School of
Orthodontia. Source: Wahl N. Orthodontics in 3 millennia. Chap-
ter 2: entering the modern era. Am J Orthod Dentofacral Orthop 2005
Apr,1 27(4):51 0- | 5.
'The Angle School of Orthodontia' at 1023, N. Crand Av-
enue, Saint Louis, MO, USA in 1903. Angle organised the
first orthodontic society (1900) meeting, the American Soci-
ety of Orthodontists, which is now the American Association
of Orthodontists (AAO). He developed several appliances
(Figs. 1.2.5 and 1.2.6), Pin and tube (Fig. 1.2.7), Ribbon arch
(Fig. 1.2.8) and finally the best gift to orthodontic profession,
the Edgewise appliance (Fig. 1.2.9). The edgewise appliance
with its modifications is still in use as the mainstay fixed ap-
pliance around the world.
Angle (Figs. 1.2.10 and 1.2.11) taught orthodontics to 198
disciples which includes Charles H. Tweed. Most of them
(185) completed formal training with him and received cer-
tificates of course completion and 13 had some training. Dr
Angle was very choosy to accept a dentist for training in or-
thodontia; not everyone who applied were lucky enough to
work under him. His disciples included 6 Canadians and 27
from 15 countries outside North America and were leaders
Figure 1.2.5 Angle's non-compliance functional Class ll correc_
tor. Source: Wahl N. Orthodontics in 3 millennia. Chapter 9: functional
1ppli9!:9:.
to mid-century. Am J Orthod Dentofacial Orthop 2006
lun;1 29(6):829-33.
 Historyof orthodon,i.,
@ 11.2 | I

Figure 1.2.6 E arch appliance by E. H. Angle was introduced in 1887. The adjustable clamp bands closely adapted to the teeth. The E arch appliance
was used to expand the arches.

Figure1.2.7 Pinandtubeappliance(1910)wasdevelopedtocontrol movementof thetoothroot Thewirewasinsertedfromocclusal direc-

tion and held in a vertical tube with pins soldered on wire. Source: Wahl N. Orthodontics in 3 millennia. Chapter 5: the American Board of Orthodontics,
Albeft Ketcham, and early 2}th-century appliances. Am I Orthod Dentofacial Orthop 2005 Oct,128(4):535-40.

lr
Figure 1.2.8 Ribbon arch appliance in '1915 replaced cumbersome pin and tube appliance, where soldering was replaced with brass pins in
a slot cut in the tube contemporary to edgewise bracket. The rectangular wire was held in place in a ribbon mode with pins.

15
 Section I I I Historical aspects of orthodontics: ancient, yesteryears, yesterdays, today and tomorrow

(D)

o,", (H)

a: oo
o

Figure 1.2.9 (A-J)

First edgewise appliance by Edward H. Angfe in 1928. The
edgewise appliance of 0.022,X0.028 slot was introduced
It was described in a series of articles in Dental Cosmos. 192g by Angle
and 1929.

in the fie ld in prorrroting tlrc science of or..hoc.lorrtics in their that each tooth shall be made to occupy its normal position,.
coun tr\' ( l3ox I .2 2 )
The climax of this conflict was a debate in 1911 at the
annual
meeting of the American Dental Association, which was
then
called National Dental Association. The debate led to un_
The first three decades of 20th century, pleasantness, bittemess and animosity among
those support_
19O0-30: Beginning of biological ing and not supporting the concept. However, the positive
foundation of orthodontics outcome of the debate was the initiation of thought process
towards rationalisation and oblective evaluation oiextiaction
procedure.to
The first decade of the 20th century was marked
by ,Great Ex_ ln 7921, Case published his major work, A practical
traction Debate' by Angle_Case on extraction ,r"rr.r, Tiea_
non-o_ on the kchniques and principle of Dental Orthopedia
tise.
traction treatment controversy and dental manufacturers
selling and Prosthetic Correction of the CIeft palate.s He publisheJ
standardised orthodontic appliances which could
be modifieJ 123 articles and attempted bodily tooth movement
by the dentists by simple soldering and adapted and was
to fit.e also the first ro use light wires (.0i6 and.01g in.).r
Dr Calvin Suverit Case (1842_tg/:_t gig. 1.2.12), a Dyling
these years, standardised appliances was made
graduate of Ohio and professor of prosthetic aentist y available mounted on cards and sold by'dental
orthodontia at the Chicago College oiDental Surgery "na supply com_
in 1890, panies. By the use of a few simple soldering
techniques, the
devised original appliances and suggested use
of intermaxil_ dentist could make a required ,fitting,, as it "was
lary elastics. Both Dr Case and gaker;ere to called., Dur_
claim originality ing these years Charles A. Hawley
on intermaxillary elastics. Dr Case was a strong advocate
of
ltsor_rlzs)
Determination of Normal Arch and lts Application
published
the relationship of malocclusion to facial improvement to Orthodontia
and and introduced the retainer appliance that bears
'face first' approach whereby facial
improvement was a guide his name
( 1908).1r
to orthodontic treatment.e
Second decade of20th century 1911_20. This
He is known for the reintroduction of the decade was
concept that the marked by a review of the cases and thought
removal of ceftain teeth will enable the correction process on in_
of maloc_ dividual case planning from non-extractio"n to extraction in
clusion-. His suggestions_ met great opposition
from many, select cases, and the opening of formal
particularly those who orthodontic education
Angie,s philosophy whic'h rrom.men-centred private orthodontic training
stated that 'there shall _followed
be a full coriplement of teeth, and schools to in_
stitutionalised education.
16

-t
*y'#
-.
-- I
Figure 1.2.10 Angle E. H. Source: Peck S A biographical portrait of Edward
Hartley Angle, the first specialist in orthodontics, Part 1. Angle Orthodont
2009;79.1 021-7.
Two major and classical contributions were made by Mil-
lo Hellman, who was a Professor of Dentistry at Columbia
University and Research Associate and who also worked as
Research Associate in Physical Anthropology, American Mu-
seum of Natural History in New York. He showed that the
dimension of the human face, as represented by the group
studied, is greatest in width, less in height and least in depth
and that with growth, the greatest dimension increases least
and the smallest most. He linked the growth stages of the face
according to the sequence of eruption and shedding of de-
ciduous teeth and appearance of permanent teeth.r2'r3
'Since 1912, he turned his attention to research in the
science of anthropology and its relation to the growth and
development of the human dentofacial complex. Hellman
sought an explanation of the development of human den-
tal occlusion, linking the phenomenon of occlusion with
the evolution of the dentition as a whole. He introduced
craniometric measurements and a classification of dental
development'.e
Albin Oppenheim (Fig. 7.2.13), an Austrian-Hungary born
physician turned orthodontist, was the first to report tissue
changes more so in bone during orthodontic tooth move-
ment. His first article on this subject was published in Vienna
(1911). Others who contributed to the new information on
fundamentals in orthodontics included Albert H. Ketcham
( 1870- 1935), one of the first to inrroduce roentgenogram and
photography into orthodontic practice. Dr Ketcham reported
and described apical root resorption and guided creation of
History of orthodonti.,
@l I i.2l I
Figure 1.2"11 Anna Hopkins and Edward H. Angle. Source: Repro-
duced with permission from Wahl N. Orthodontics in 3 millennia. Chap-
ter 2: entering the modern era. Am I Orthod Dentofacial Orthop. 2005
Apr;127(4):510-5.
the American Board of Orthodontics (1929), which was for-
mally incorporated in 1930.
lohn V. Mershon introduced the removable lingual arch
based on the principle that teeth must be free and unrestricted
for adaptation to normal growth ( 1909 ).
Alfred Rogers introduced the concept of myofunctional
therapy (1918).
The International lournal of Orthodontia and Oral Surgery was
started in 1915.14
The invention of Edgewise appliance which provided 3D
control on tooth movement by Edward Hartley Angle ap-
peared in 1928.15 The mechanism as devised by Angle, who
died shortly after launching his invention, was only used for
a short length of time. However, all subsequently invented
therapeutic techniques incorporated the mechanical princi-
ples underpinning Edgewise, paying tribute in this way to a
great invention'.16
The most notable shift in scientific thinking during this
decade was introduced by Paul Simon which related to the
concept of the orientation of face beyond teeth in three
planes ofspace called gnathostatics (1924) (Fig. 1.2.14).
On the technological front, on August 13, 1913, Harry
Brearley in Sheffield created a steel with 12.8% chromium
and 0.24o/o carbon, argued to be the first ever stainless steel.
However, it was in 1929 that Dr Lucien de Coster, a Belgian,
used stainless steel to fabricate appliances, substituting gold
thereby bringing the orthodontic treatment within reach of
all.17
17
 Section I t I Historical aspects of orthodontics: ancient, yesteryears, yesterdays, today and tomorrow

Year Event

1 855 Edward Hartley Angle (HART) was born on June 1, 1855. His boyhood home was on his parents farm in District 1, 'Ballibay', Herrick
Township, Bradford County, Pennsylvania.
As a child, HART had an innovative mind for mechanical artefacts.
1874-1816 HART at age 18 had his training in dentistry with a nearby dentist as an office apprentice.
1818 Graduated as a dentist with DDS from Pennsylvania College of Dental Surgery in Philadelphia. The DDS programme was then
arranged in two 6-month terms spaced over a nominal 2 years.
1 878 He began practising dentistry in Towanda, the county seat of Bradford County, Pennsylvania. He was very much interested in
regulating teeth and worked on mechanical devices to that effect.
1 886 Edward Angle was appointed a professor of histology and lecturer on comparative anatomy and orthodontia. A few years later, he was
appointed to a rare position of professor of orthodontia, at the University of Minnesota which he retained till ,|892.
1887 Angles first contribution to orthodontic literature was'Notes on Orthodontia' published in the International Transacrrons
of the Medical Congress, whrch has also been called the 'First Edition' of his classic textbook on the treatment of malocclusion.
Patented a jackscrew mechanism, the first of his 46 parenrs.
First formal exclusive school in orthodontia, 'The Angle School of Orthodontia'was started at ,l023, N. Grand Avenue, Saint Louis,
MO, USA.
1892 The year was a watershed in Angles professional development: he announced that he would be practising orthodontia
to the
exclusion of all other dental therapies. With this decision, he became the first acknowledged exclusive tp"lialirt in orthodontics
in
the world.
1 892 Dr Angle continued to teach at several universities. He was a professor of orthodontia at the American College
of Dental Surgery
(1892-98) Chicago.
1 896-1 899 Professor of orthodontia in the Dental Department of Marion-Sims College of Medicine, St Louis.
1 897-1 898 He taught in the Dental Department of Washrngton University, St Louis.
1 899 Angles classification of malocclusion, pubilshed in Dental Cosmos.
1 899 June 6, 1899 patented the E-arch, hrs expansion archwire mechanism.
1 900 Founded the Angle school of orthodontia in st Louis. The course duration was 5-weers.
Early 1901 Angle organised the first orthodontic society (1900) meeting, the American Society of Orthodontists,
which is now the American
Association of Orthodontists (AAO).
190647 Dr Angle retired from active practice of orthodontia in St Louis.
1907 Released 628-page text of the seventh editron of'Treatment of Malocclusion of the Teeth,.
1907 orthodontBt, the first journal in the world devoted exclusively to orthodontics;
forerunner of the Angle
:"^T$tj#;.^terican
1910 Patented 'Pin and tube'appliance.
1916 Patented'Ribbon arch'.
1917 Latel9l6,AnglemovedtosouthernPasadena,california. lnlglT,atrequestof
JamesC.Angle(norelation),hereopenstheAngle
School of Orthodontia at his home in pasadena.
1922 His students contributed to erect exclusively devoted
building to the education and training of orthodontics.
1924 The school was chartered as the ,Angle College of Orthodontia,,
1925 appliance'. The edgewise appliance with modifications, is the one most commonty used apptiance today in
:Xit:::X,:y"wise
1927 Angle College of Orthodontja closed unofficially.
1 930 After his death, his students and followers founded Edward H.
Angle socrety of orthodontia (now ,orthodontists,).
I 930s Anna Hopkins' 'Mother Angle' became secretary of the American
Society of orthodontists. she was also appornted a founding
editor of the Angle orthodontist, and honorary chair of the co-
Angle socieiy executivecommrttee.
1 930 November 17 1930, The Angle orthodontist, a scientific journal
'
Angle's memory by the newry reorganised Edward H. Angre
devoted exclusively to orthodontics, was founded in chicago
in Dr
society or ortrooontra]

Orthodontics during 1 g3O-40: Functional
appliance and cephalometrics
During this decade and the next, a significant development
took place with an innovative appliance, the newer conceDt in
oral function and diagnosis. In Europe, the Monoblock appli_
ance introduced by pierre Robin in France (1902) resurrected
in 1909 as the forerunner of a new appliance by Andresen,
18
the Activator, and the philosophy of functional jaw orthopae_
dics was born'8 (Fig. 1.2.15).
During the next decade, Dr Robert E. Moyers and Sam pru_
zansky inducted electromyography to study the effect
of the
musculature on occlusion. This induced further investigation
in uses of the removable appliance-activators.e
..!"5.b Orthodontist, joumal volume I no. 2, 1931, pub_
lished a landmark arricle by B. Hoily Broadbent titled
A New

Figure 1.2.12 Dr Calvin Suveril Case (April 24, 1847-April 16, 1923)
is known for the reintroduction of the concept that the removal
of certain teeth will enable the correction of malocclusion. Source:
Wahl N. Orthodontics in 3 millennia. Chapter 2: entering the modern era.
Am I Orthod Dentofacial Orthop 2005 Apr;127(4):510-l5.
f"7
Vr
ry
r\ I
Figure 1.2.13 Albin Oppenheim (January 8, 1875-November 20,
1945), an Austrian-Hungary born physician turned orthodontist,
was the first to report tissue changes more so in bone during
orthodontic tooth movement. Source: Wahl N. Orthodontrcs in 3 mil-
lennia. Chapter 4: the professionalization of orthodontics (concluded). Am
I Orthod Dentofacial Orthop 2005 Aug;128(2):252-7.
X-ray Technique and Its Application to Orthodontia'. This
pioneering technique led to a new era of understanding of
face, skull and science of orthodontics. He presented a skull
holder. a head holder an instrument for accurate orientation
of head to FH (Frankfort horizontal) plane and in relation to
source of the X-ray, and the technique of cephalometry tracing
and measurements.to The cephalometric apparatus was based
on head holder developed by B. Holly Broadbent and T. Win-
gate Todd (Fig. 1.2.16).'
The very first study of facial growth was supported by the
generosity of Mrs Chester C. Bolton and her son Charles B.
Bolton who funded the manufacture of first cephalostat head
Historyof orthodon,i.,
@ t't.r l I
Figure 1.2.14 Simon's gnathostatic approach to orient the face in
three dimension given by Paul Simon (1924). Source: Wahl N. Ortho-
dontics in 3 millennia. Chapter 7: Facial analysis before the advent of the
cephalometer. Am I Orthod Dentofacial Orthop 2006 Feb;1 29(2):293-8.
Figure 1.2.15 In Europe, Viggo Andresen. in the year 1933, intro-
duced the Activator and the philosophy of functional jaw ortho-
paedics was born. Source Wahl N Orthodontics in 3 millennia. Chap-
ter 9: Functional appliances to midcentury. Am J Orthod Dentofacial
Orthop 2006; 29(6) 829-33.
1
holder and X-ray apparatus, and that was installed at the ana-
tomical laboratory of the Western Reserve University. Bolton
Point was named to recognise the donors' contribution to this
study.
Orthodontics during 1940-50: Tweed's
concepts of growth
The face and its growth studies by cephalometry remained
the mainstream research during this decade. This decade also
changed how cephalometry influenced and supported the
19
 Section I t I Historical aspects of orthodontics: ancient, yesteryears, yesterdays, today and tomorrow
.#
Figure '1.2.16 Craniostat developed by Holly B. Broadbent and T.
Wingate Todd as a precursor to the first cepahlometric head holder.
Source; Hans MG, palomo JM, Vatiathan M. History of imaging
dontics from Broadbent to
Orthod Dentofacial Orthop
cone beam computed tomography.
2 0 1 5 Dec, I 48(6) :9 1 4_2 I
treatmenr approaches from absolute and rigid philosophy of
non-extraction treatment to rationalised extraction treatment
based on incisor mandibular plane angle (lMpA) by Charles
H. Tweed (Fig. 1.2.17).
The landmark studies on facial growth were contributed
from North America and Europe. Dr Wilton M. Krogman
(1903-87), an anthropologist, made outstanding conlribu_
tions to orthodonrics. He used the principles of physical an_
thropology to the dentofacial complex wiih craniometry and
roenrgenographic cephalometry. He was the first to study
the
growth of the face and introduced a set of criteria for growth
and development of the child and adolescent. Krogman
Cent_
er for Research in Child Growth and Development at phila_
delphia is named in honour of his classical ctntributions
on
growth.20
Another major contribution to facial growth was by Allan
G. Brodie. He reported the growth patierns of the human
head from the third month of life to-the eighth year.
His re_
search was published in the American
Iourial of Anatomy in
1941 and greatly influenced orthodontic thoughi process
and
laid a foundation for future research.2t
The classical work The Face in profile: An Anthropological
X-ray Investigation on Swedish Children and
ConscriptJ by
A. Bjork also appeared these years. His study
aimed to exam_
ine normal variations and mechanism of prognathism
as well
20
Figure '1.2.'17
Charles H. Tweed (June 24, lggG_January 1970), the
man who talked about growth trends, judicious extraction based on
Tweed triangle and mastered the use of edgewise appliance intro_
duced by his guru E. H. Angle.
as the relationship between facial build and the bite in repre_
sentative material.22
in ortho_
Charles H. Tweed (1895-1920) advocated upright lower in_
Am I .
cisor positioning on mandibular base which is fundamental to
.
facial aesthetics. He introduced the judicious use of extractions
for gaining space and philosophy of an Edgewise appliance.
First multidisciplinary cleft clinic, Lancaster
In Lancaster, Phitadetphia, Dr Herbert K. Cooper (1897_
1978) founded an integrated clinic for cleft lip and palate
in Lancaster in 1938. Dr Cooper believed that an integrated
team of plastic surgeon, dentist and speech therapist i." ,"_
quired to solve the problems of the cleft palate patlents.
By
1946, the first integrated centre for treatment of oro_facial
deformities and communicative disorders was established.
Dr Cooper thus established the first dedicated interdiscipli_
nary clinic for patients with cleft lip and palate and crani_
ofacial anomalies, which is now famous as Lancaster Cleft
Centre.2l
A new form of rubber tooth positioner (Tp) was introduced
by Dr Kesling. The tooth positioner
,rr"i to finish unset_
-^,
tled occlusion after major orthodontic treatment to an ideal
cusp-fossa relationship.2a
Orthodontics during 1950-60: emphasis of
cephalometrics
Two major areas of contribution in this decade
were: First,
the induction of cephalometry in clinical practice and
the
emphasis on the same by a number of authors
like wiliam
B. Downs in 1948, 1952,7956, C. C. Steiner (1953),
C. H.

Tweed (19s3), S. E. Coben (19ss), R. M. Ri&etts (1966), V.
Sassouni (1969), H. D. Enlow (1969) and many more."''u
Second, in 1952, Ti:xtbook of Functional law Orthopaedics'
released by Karl Hdupl, MD, Professor of Dental Surgery Uni-
versity Dental School, Innsbruck, co-authored by William l.
Grossman, Orthodontic Consultant and Lecturer in Ortho-
dontics, University College Hospital Dental School, London,
and Patrick Clarkson, Consultant Plastic Surgeon, the Queen
Alexandra Hospital, [,ondon. This 408 pages book contained
an extensive 536 illustrations and 309 figures. The price was
60 shillings.2T
'I'his decade was marked by standardisation of an edgewise
mechanism by Charles f. Tweed and popularisation of ex-
traction philosophy treatment with light wire appliance
by P. R. Begg at Adelaide Australia. Dr P. Raymond Begg
(Fig. 1.2.18), Angle's student, on return to Australia worked
with a metallurgist to develop the Australian orthodontic
wires in the 1940s; which will deliver gentle forces for a
longer duration.28
He looked at occlusion of Australian Aboriginals and sug-
gested proximal wear with ageing is a phenomenon which
is missing in the modern population.'o He promoted the re-
duction of tooth substance by extractions and created modi-
r*fl j
fied Ribbon arch bracket, and multiple-loop light-force wire
appliance, known as Begg's light wire technique. His book
was first published in 1965.30-32
ft""- E ;
m
Figure 1.2.18 P. Raymond Begg in Adelaide Australia (13 October 1898-1983), Disciple of E. H. Angle from Adelaide who eventually
developed new brackets and wires to be used with light wire technique. He lustified reduction of tooth material based on his research related
toattritional occlusionof AustralianAboriginals. lmagecouftesyof theAustralasianBeggSocietyof Orthodontists.Source: http;//www.beggsociety.orgl
dr-pr-begg; [accessed 30.1 2.201 6 1 0:41 :08].
History of orthodon,i.,
@ | 1.21
I
Contributions of Charles H. Tweed
(June 1 895-Janu ary 19701
Angle gave orthodontics the edgewise bracket, but Tweed
gave orthodontists a way to use it. Tweed, the innovative and
perceptive diagnostician and master clinician, kept his prom-
ise to his mentot Edward Angle. He devoted all 42 years of
his professional life to the use and refinement of Angle's in-
vention, the edgewise appliance'.33
Dr Tweed was refused admittance to Angle school in the
first instance, in 1925. He eventually joined the course
in 1927 and they worked closely together for the last 2
years of Angle's life. Dr Tweed banded his patients with
an edgewise appliance; Angle acted as the advisor. The re-
cords were reviewed by Angle every four months. This was
a very productive time during Tweed's education and for
the evolving edgewise appliance. ln 7932, the first report
of cases treated was published in The Angle Orthodontist. lt
was titled 'Reports of Cases Treated with the Edgewise Arch
Mechanism'.34
Tweed, a true disciple of Angle held the conviction of
non-extraction treatment to adhere to the line of occlusion
concept. He noticed failures in his treated cases, after which
he re-examined the records in detail to realise that the pa-
tients who had pleasing facial balance and harmony also
had mandibular incisors that were upright over basal bone,
which was not possible to achieve in all types of cases of
malocclusion. He re-treated some of these patients with ex-
traction of first premolars, and presented at a meeting for
which he was heavily criticised. His mechanism was soon
popularised. Tweed created a study club, which later in 1947
rFr'
F.-!F
&
E
.G: rry
-qr
I
,E
21
@|lIHistorica|aspectsoforthodontics:ancient,yesteryears,yesterdays,todayandtomorrow
translbrmerl into Charles I l. Tweed Irounclatior.r for ()rtho-
clontic Rescarch. I Ie published articles on tircial triangler5 't
irnd also tr,r,o volurnes on clinical orthodontics in 19(r(r.rs

Orthodontics during 1970-80: pre-adiusted

appliances

The decade from 1970 to 1980 saw tremendous develop-

ments in the fields of facial growth, technology, appliance
philosophy and fundamental understanding of biological
processes related to orthodontic tooth movement.
Classical work by A. Bjork and V. Skiller on growth rotation
during facial growth studies after inserting implants greatly
influenced orthodontic thinking. Ame Bjork following com-
pletion of his PhD thesis in human genetics was particularly
interested in craniofacial growth. His classical work has not
and cannot be emulated and is among the few best studies
available on facial growth in humans.3e t3
During these years, Robert Murray Ricketts greatly influ-
enced orthodontic thinking by his critical evaluation of ex_
Figure 1.2.20 Charles J. Burstone, April 4, .1928-February 11,20,15,
isting cephalometric analysis. He evolved bracket modifica- extensively researched on bioengineering principles of orthodontic appliance
tion towards building prescription in 0.01g-in. slots in 1970 and introduced sectional arch mechanics, titanium molybdenum alloy wires
(Fig. 1.2.1e) and COGS analysis.
He developed the first computerised cephalometric analy_
sis diagnostic system to project treatment plus growth in
treatment planning (VTO) and computer generated method proportions to treat dental and skeletal problems called the
for projecting growth. He gave new perspectives to early or- divine proportion.44-sr'
thodontics and developed new appliances systems includ_ Charlie I. Burstone (Fig. f .2.20), who extensively re_
ing quad helix, utility arches, sectionalisation and most sig_ searched on bioengineering principles of the orthodontic
nificant, bio-progressive philosophy, a biological upprou.h appliance also introduced sectional arch mechanics, tita_
to diagnosis and treatment. He recognised and used facial nium molybdenum alloy wire in collaboration with A. I.
Goldberg that added newer dimensions to the orthodontic
mechanism. Dr Charlie Burstone in collaboration with Dr
H. Legan also developed cephalometrics for orthognathic
surgery (COCS) analysis for patients requiring orthognathic
sur8ery.
Dr Ram Swaroop Nanda (Fig. 1.2.21), a prolific writer and
researcher, sensitised the orthodontic fraternity on significant
contribution of facial growth in the success or failuie of or_
thodontic treatment.

Evolution of pre-adjusted appliances

and bonding: hallmark of contemporary
orthodontics
Although the beginning of the thinking process to build treat_
ment into brackets had started as early as the 1960s,57 the first
fully pre-adjusted appliance was invented after the classical
work of Dr L. F. Andrews by the publication of six keys to nor_
mal occfusion in 1972.s8 (Fig. I.2.22). The original straight
wire appliance (SWA) by Andrews was later modified bv
many clinicians including Roth in 1g76.5e,60
Bonding in orthodontics was a major game changer
that
revolutionised clinical orthodontics. attnougn Buonocore
as
early as 1?55:1 reported a simple method Jf increasing
ad_
Figure 1.2.19 Robert Murray_Ricketts (May 5, 1920_June hesion of filling materials on enamel surfaces, it was
17,ZOO3), New_
inventor of bioprogressive therapy, computerisation in
cephalom_ man who introduced bonding in orthodontics in 1969.62,63
etry, divine proportions and growth pr"diction.
The late 1970s saw the evolution ofbetter adhesives,
bracket
22

Figure 1.2.21 Ram Swaroop Nanda founded department of orthodon-
tics, Dental College at King George's Medical University and later became
Chairman at the Department of Orthodontics, University of Oklahoma,
USA. He made significant contributions to orthodontic research more so
in the field of facial growth and its implications in orthodontic treatment.
Figure 1.2.22 Lawrence Andrews known for six keys to normal
occlusion and developing the straight wire appliance (SWA). Repro-
duced with permission. Source: Andrews LE The 6-elements otthodontic
philosophy: Treatment goals, classification, and rules for treating. Am
Orthod Dentofacial Ofthop. 201 5 Dec;148(6):883-7.
base modifications and clinical studies which evolved bond-
ing technology as the acceptable merhod of attaching ortho-
dontic auxiliary on tooth surfaces. It took several years before
developing light cure self-adhesive. The first study on light-
curing appeared in 1979, but it was not until 1993 that the
first commercial product came into the market (Transbond
XT Light Cure, 3M Unitek).64
Historyof orthodonrt.,
@ 11.2 | I
Orthodontics during 1 98O-9O: clinical
success with twin block popularised
functional appliance
Reports on success of myofunctional appliance with a
new concept of 24 h of wearing time introduced by Wil-
liam Clark of Fife, Scotland surprised orthodontic frater-
nity. Twenty four hours wear of appliance was possible by
changing the very basic design of Monoblock to Twin block
(Fig. 1.2.23).
Refinement of pre-adjusted appliance continued with many
'prescriptions' appearing in the market. However, it was the
magic of duo clinicians Mclaughlin and Bennett which made
the MB (Mclaughlin-Bennett) appliance very popular. The
MB prescription was later further modified and is now widely
known as MBT prescription.65-6e The ceramic brackets were
commercially introduced in 1 987.70
During these years, Dr Tom M. Graber (May 27 , l917-June
26, 2007) remained the most revered educationist in the field
of orthodontics. He contributed 28 books including the most
popular standard reference'Orthodontics: Current Principles
and Techniques'. In 1985, he was chosen as the fifth editor-
in-chief of the American lournal of Orthodontics, a position he
held for 15 yearsTr (1990-2000).
Temporary anchorage devices: major game
changer in orthodontic practice
With a successful case report by Creekmore and Eklund,
1983 by using vitalium screw below anterior nasal spine
to open the deep bite, the possibility of skeletal anchor-
age was introduced in the clinical orthodontic literature.T2
Similar outcome was achieved for the intrusion of lower
l
Figure 1.2.23 William C. Clark, a practicing orthodontist in Fife
Scotland is known for inventing Twin block appliance in 1977.
23
@]llHistorica|aspectsoforthodontics:ancient,yesteryears,yesterdays,todayandtomorrow
Figure 1.2.24 Ryuzo Kanomi from Japan reported temporary
anchorage with mini screws of 1.2 mm diameter in 1997.
incisors by Kanomi (1997) (Fig. :r2.2q. He implanted mi-
ni-bone-screw of 1.2 mm diameter and 6 mm long in the
alveolar bone between root apices of mandibular incisors
and did intrusion of the mandibular incisors.T3 Following
years, clinicians and researchers from Korea worked and
promoted temporary anchorage devices (TADs) in clinical
practice.Tr During the same years, l. Sugawara from Sendai,
fapan worked and introduced the concept of skeletal an_
chorage system. Earlier he has reported treatment of a case
with open bite using skeletal anchorage in 199975. During
these years, the percentage of patients receiving extraction
treatment declined. The over zealous premolar extraction
treatment approach during adolescent years led to prema_
ture sagging of faces later in life76. The extraction treatment
was also linked to temporomandibular disorder (TMD) and
the subject caused much concern to orthodontists foilow_
ing a lawsuit, Brimm versus Malloy in 19g7, in which it was
claimed that orthodontic treatment has caused TMD27. The
introduction of TADs and skeletal anchorage system were
welcome armamentarium for these allowed more cases to
be treated with non-extraction approach. Secondarily, dem_
onstration of successful molar distalisation with palatal
supported anchorage systems and demand for fuller profile
has encouraged orthodontists to undertake non_extraction
treatment options.
Auto-transplantation of teeth in the
management of space
Although Hale as early as 1956 suggested auto-transplan_
tation,78 it was Andresen and his group who reported
tech_
niques and follow-up of autotransplanted premolars. premo-
lars are now considered a viable alternative for orthodontic
space management in cases of missing maxillary anterior
Te-8('
teeth.
24
Orthodontics during 2000-1 8
First cone beam computed tomogram (CBCI) machine was de-
veloped in a factory near Verona in Italy in 1996 (Fig. 1.2.25).
Turn of the century witnessed the emergence of digital technol-
ogy and automation in orthodontics as a reality.
The concept of 3D printing emerged in Nagoya, lapan by
Hideo Kodama who invented the first fabricating technology
and methodology for rendering plastic into three dimensions
with a polymer that was exposed to ultraviolet rays. Later,
in 1984, Chuck Hull, independently innovated a process by
which objects could be rendered in layers with a process of
stereo lithography which was used more often in craniofacial
model surgery. By the 2000s, 3D printers had advanced to the
point that they could print objects in various shapes not only
from plastics but metals as well. Additive manufacturing and
3D printing are synonymous today.87
With adaptation of 3D surface scanning in orthodontics,
plaster-free digital models became a reality and so is the vir-
tual treatment planning. The sophistication of software and
technology has led to 3D printing and popularised clear
alignment systems, customised bracket designs and mecha-
nised robotic wire bendins.",8e
Robotic orthodontics
Dr Rohit Sachdeva is the cofounder of Orametrix Inc.
(OraMetrix Inc., Richardson, TX, USA) who developed the
Suresmile system. OraMetrix Inc. was founded in 199g. This
was the first such commercial venture with robotic wire bent
wire supplies in the USA with the name Suresmile/Orame_
trix (Fig. 1.2.26).
The first articles that present the development and the
clinical procedure of the Suresmile system were published
in the lournal of Clinical Orthodontics and. American lournal of
Orthodontics and Dentofacial Orthopedics authored by nohit
Sachdeva.eo-e2
This century also witnessed the integration of CBCT skull,
CBCT models, non-radiation 3D facial scanning put to use
for 'real life' like planning, more so to know the effects of
orthodontic treatment on facial profile. Advancements in the
process of segmentation have allowed extraction of selected
data and image processing in volume data.
In 2006, Dolphin Imaging company introduced its 3D
module that can import and process of three_dimensional
(3D) datasets from MDCI, CBCT, MRI and high_definition
facial camera systems.e3
Orthodontics beyond 2O2O I
The current trend in orthodontics is heading towards
plaster-free clinics wherein intraoral scanners
are in use.
Intraoral scanners permit 3D scanning of dental structures,
which helps ro produce digital mod-ets, virtual planning
and print plastic models. The orthodontic appliance
can be

Figure 1 .2.25 Factory at Verona in ltaly where the f irst CBCT machine, NewTom, was invented and manufactured in 1996.
Figure 1.2.26 Rohit Lal Sachdeva, Indian-ethnic orthodontist born
in Kenya and works in usA. Hrs coilaborative research curminated in the
development of both copper nicker-titanium and titanium niobium alloys
and titanium brackets for use in orthodontics. He owns over 90 patentl.
Sachdeva co-founded the OraMetrix lnc. (OraMetix lnc., Richardson,
TX,
USA) and developed the Suresmile svstem.
History of orthodon.,.,
@ | 1.2 | I
prepared on 3D printed models either with conventional
techniques or pressure moulding material. The integration
of skeletal morphology obtained from CBCT, 3D non-ra-
diation imaging of face (3D-MD), and volume rendering
allows planning in three dimensions and permits visualisa,
tion of effects of various orthodontic/ortho surgical treat-
ment on face (Fig. I.2.27).
The modem office is also likely to use clear aligners, cus-
tomised appliances and devices to enhance the rate of ortho_
dontic tooth movement which may include the use of low-
level lasers, some vibration devices or even drugs.
Author's hypothetical concept would include developing a
micro sensor that will be placed in the mouth to monitor and
control orthodontics from a remote location by an orthodontist!
Orthodontics, the science and art of correction of dental ir_
regularities and improvement in face began since Egyptian
times. Irregular teeth are also mentioned in Hippoirates
literature. American and European clinicians have made
tremendous contributions in its evolution to sophisticat_
ed techniques based on deep understanding ofbiological
process of craniofacial development and tooth movement.
Future of orthodontics lies in knowing more about its bio_
Iogical aspects at the molecular level and in 3D technology.
25
@lr|Historica|aspectsoforthodontics:ancient,yesteryears,yesterdays,todayandtomorrow

Dr Kharbanda's hypothetical model of sensor based remotely controlled orthodontics

Patient - Visits to
orthodontic clinic.
Undergoes | 3D scanning

il:
Virtual treatment
planning and
microchip embedding l, I
G
n l=a
I Remote monito.ing of
lreatment progress -GEl!
iiqutt. i".;.27 Hypothetical model of future orthodontic treatment.

References

References for this chapter are found on the companion website wwwmedenact.com.

Suggested reading
_l
I Peck S' The students of Edward Hartley Angle, the first specialist in
orthodontics: a definitive compilation.
2O06;5 4(2):70- 6 Summer-Fall; pubMed pMI D : 1 703 9 8 63.
I Hist Dent

II' Peck S. A biographical portrait of Edward Hartley Angle, the first specialist
in orthodontics, parr l. Angte orthod
2Oo9 ;7 9 (6):1021 -7. PubMed pMID: I 9852589.
III' Peck S. A biographical
portrait of Edward Hartley Angle, the first specialist in orthodontics, part 2. Angle orthod
PubMed pMID: 1 9852590.
2OO9 ;7 9 (6):1028-33.
IV' Hellman M' An introduction to growth of the human face from infancy to adulthood
. lnt J orthod oral Surg Rad r932;lg:zzz-
98.
Angle EH. The latest and best in orthodontic mechanism. Dent Cosmos 192g;20:1143-5g.
V.
u. Tweed CH. The diagnostic facial triangle in the control of trearmenr objectives. Am I Orthod 1969;55(6):651_7. pubMed pMID:
5253959.
VII. Biork A" skieller V. Normal and abnormal growth of rhe mandible. A synthesis of
longitudinal cephalometric implant studies
over a period of25 years. Eur I Orthod 1983;5(l):l_a6. pubMed pMltj: 6572593.
VIII. Ricketts RM. Bioprogressive therapy as an answer to orthodontic needs. partl. Am
I Orthod l9Z6;ZO(3):241_6g. pubMed pMID:
786034.
x. Ricketts RM' Bioprogressive therapy as an answer to orthodontic needs. partll. Am Orthod I pubMed
l9Z6;Zo(4):359-97.
PMID: 1067757.
X. Rorh RH. Five year clinical evaluation of the Andrews straight_wire appliance. I CIin Orthod 1976;10(11):836_50. pubMed
PMID: 1069735.
XI. Kanomi R. Mini-implant for orthodontic anchorag e. ctin orthod 1997;31(17):263-7. pubMed pMlD:
I 9511584.

26
 Chapter I r.3 |

History of orthodontic speciality in India

CHAPTER OUTLINE

History of formal dental education in lndia 27 Course curriculum 29

Postgraduate dental education 27 Indian Orthodontic Society (lOS)
The first MDS orthodontics course and its role in education and faculty development 29
in lndia 29 Key Points 31

History of formal dental education

in lndia

J
The very first formal dental school in India was established
by Dr R. Ahmed in 1920 at Calcutta, West Bengal (Fig. 1.3.1).
The college started with a 1-year LDSc diploma, duration of
which increased to 2 years in 1922 and 4 years in 1936-37
(Box 1.3.1). The first dental faculty, formed at Mumbai in

b
1957, offered Bachelor of Dental Surgery course.t At present,
India has more than 300 dental colleges, recognised by Den-
tal Council of India, that offer Bachelor of Dental Surgery
(BDS) qualification.2 It was in 1933 that a series of lectures
on the sublect of orthodontics were delivered for the first time
in a teaching institution, that is, at Nair Hospital Dental Col-
lege by H. D. Merchant. In 1937, orthodontics was accepted
as a separate subject3.

Before the 1950s, facilities for postgraduate dental education

hardly existed in India. In the 1940s, Master's Degree in Den-
tistry (MDS) was awarded by the one and only college of den-
tistry De'Montmorency College of Dentistry at Lahore, now
in Pakistan. The Dental Council of India (DCI) was incorpo-
rated under The Dentists Act 1948 to regulate dental educa-
tion and the profession throughout India. In 1959, the DCI
laid down regulations and the syllabus for the Master's degree
courses. They recommended seven specialities for post-gradu-
ate education in dentistry including orthodontia.l a
Figure 1.3.1 Padma Bhushan Dr Rafiuddin Ahmed (24 December
1890-1965) is known as father of dentistry in India. In 1920, Dr
Ahmed founded the first dental college of India, which was financed
by starting the New York Soda Fountain in Calcutta. Dr Ahmed pub-
lished the first Students handbook on Operative Dentistry in 1928. Dr
R. Ahmed was the first elected President of the Dental Council of India,
serving from 1954 to 1958. Source: The lDATimes..)uly 2015, vol. Xl,
issue 7, p. 6.

27
@lr|Historica|aspectsoforthodontics:ancient,yesteryears,yesterdays,todayandtomorrow

Box 1 .3.1 Chronology of formal dental and orthodontic educatian in lndia

1924 Dr R. Ahmed established the first formal dental college in India in 1920 at Calcutta, West Bengal. The college started with a 1

year LDSc diploma. ln 1922, the duration of course was increased to 2 years.
'1933 Bai Yamunabai L. Nair Hospital Dental College started in Bombay. In 1946, it was taken over by the Municipal Corporation of
Bombay. ln 1954, it was affiliated to Bombay University.
1 933 De'Montmorency Dental College and Hospital, Lahore. Regular BDS course started with Panjab University in1936. First
postgraduate course in dentistry started in 1945. Dr K. L. Shourie was amongst the first recipients of MDS degree who
eventually headed the Dental Council of lndia as President.
1940 CEM Dental College, Bombay. 1945-Affiliated to Bombay University. 1960-Became Govt. Dental College, Bombay.
1943 'Health Survey and Development Committee' by the Govt. of India. Charrman Sir Joseph Bhore. Recommendations paved the
way for enactment of the Dentists Act '1948 and formation of the Dental Council of lndia.
March 29, 1948 Dentjsts Act (XVl of 1948) reviewed, assent of the President of India.
April 12, 1949 Dental Council of India formed by the Govt. of India by a special notification.
1 953 The first Indian Dentists Register was prepared and placed before the council.
1957 Formation of the first dental faculty in India, at the University of Bombay.
1 959 Dental Council of India laid down regulations and the syllabus for the Master's degree courses. Universities were encourageo
to establish post-graduate course in seven specialties, including Orthodontia.
1959/60 MDS Orthodontia course started at Government Dental College and Nair Hospital, Mumbai.
1 960 Approval of Govt. of India to a minimum basic qualification for appointment of teaching staff for Master's degree courses (MDS).
1 963 The Government of UP state sanctioned starting of PG courses at Lucknow Dental College.
1964 MDS Orthodontia started at Dental College and Hospital, King Georges Medical College, Lucknow University,
Lucknow.
1 965 The first formal Dental Council regulations containing syllabus of Master's degree courses were published.
1 965 Indian orthodontic Society started as a study group in Bombay (now Mumbai) way back in the year 1963. lt was
formally
established as the Indian Orthodontic Society on October 5, 1 965 by seven orthodontists.
I vbb MDS Orthodontra started at Bangalore.
1967 The lndian orthodontic society held its first conference in the year 1967 in New Delnr.
1969 MDS Orthodontia started at Government Dental College, Trivandrum.
1970 MDS Orthodontia started at Government Dental College, Ahmedabad.
1972 MDS orthodontia started at Manipal; first non-government dental institute.
1975 MD5 Orthodontia started at Government Dental College, Madras.
1978 MDS Orthodontia started at Government Dental College, Hyderabad.
1 98s MDS Orthodontia started at Government Dental College, Nagpur.
1 983 DCI course regulations for Master's programme were created.
i 986 AIIMS New Delhi starts first full time 3 years residency programme for Masters in
orthodontics.
1993 lndian orthodontic Society conducts National workshop on Postgraduate orthodontic
Education in Mumbai. Recommends
higher case load.
1 993 Dental Council of India passed a resolution (DE-1(SC)-93l206428.10.igg3)for
MDS course duration for 3 years.
1 995 with the signing of the charter of the world Federation of orthodontics at san Francisco, uSA
in 1995, the Indian orthodontic
Society became a part of the World Federatjon of Orthodontics.
1999 lndian orthodontic society established 'lndian Board of orthodontics', the first
such board in the field of dentistry rn India and
the third in the world.
2006 National workshop at All India Institute of Medical Sciences to update
curriculum in all nine specialties of dentistrv.
2007 Revised regulatrons for MDS course.
2009 First sAARC orthodontic conference held in New Delhi with Prof. o.p Kharbanda as the founder president.
2008,2012 Dental council of India released the revised regulations for MDS course
amendments.
2013 Asian Pacific Orthodontic Conference held in Delhi, 20i 3.
2014 National oral Health Programme (NoHP) launched. NoHP is an initiatrve of the Ministry
ot Health, Government ot India aimed
to strengthen the public health fa-cilities of the country for an accessible,
affordable and quality oral health care delivery
centre for Dental Education and Research, All India lnstitute of Medical sciences
was designated the Centre of Excellence for
implementation of NOHP
2014 The first WHo collaboratrng centre on oral Health was established at
centre for Dental Education and Research, All India
Institute of Medical Sciences, New Delhi.
2016 The Centre for Dental Education and Research, All lndia Institute of Medical
sciences, New Delhi became Cochrane oral Health
Global Alliance partner, as the first partner not based in a primarily English-speaking
counrry
2016 World lmplant Orthodontic Conference held in Goa, 2016.
January 2017 First formal batch admitted to. advanced fellowship in cleft orthodontics
started at Department of orthodontics centre for
Dental Education and Research, All India Institute of Medical Sciences, New
Delhi, under prof. op Kharbanda.
2017 Go-v-ernment of India approves creatton of first National Level Referral
and Research lnstitute for Higher Dental studies
(NRRIDS) at centre for Dental Education and Research,
L All India lnstitute of Medical Sciences. New Delhi
I
 Historyoforthodonticspecia|ityin|ndia@|1.3|l
The first MDS orthodontics course in India
The MDS courses in India including orthodontia were estab-
lished in 195911960 simultaneously at Nair Hospital Den-
tal College and Government Dental College and Hospital
in Mumbai. Both colleges were affiliated with University of
Bombay.''o'' MDS started at Lucknow in 1964, Bangalore
1966, Trivandrum 1969, Ahmadabad 1970, Manipal 1972,
Madras 1975, Hyderabad 1978, Nagpur 19854, AIIMS 19866
and many more colleges followed. By the 1970s, the number
increased to seven dental schools that offered MDS course in
orthodontics with 31 admissions/year. Half of these belonged
to the two dental colleges in Bombay (Fig. 1.3.2). The den-
tal profession and education showed steady growth until the
1980s and showed incredible growth during 1990s with pri-
vate entrepreneurs taking the lead. The number of postgradu-
ate departments grew to 48 in 2005, reaching an enormous
strength of 1 86 by 2O74.) Also, many Indian dental graduates
are pursuing higher dental education in orthodontics in Rus-
sia, China, Philippineshesides UK and USA. Their exact num-
ber cannot be ascertaineT-'-----
MDS orthodontics programme 3t AIIMS, New Delhi began
in 1986 as full time three years program on similar regula-
tions for MS/MD of medical disciplines.6
Course curriculum
The first formal Dental Council regulations containing sylla-
bus on Master's courses were published in 1965.? The subse-
quent detailed revision of the course regulations by the Den-
tal Council of India in 1983, contained exhaustive guidelines
in all the nine specialities of dentistry.B
Traditionally, orthodontic training in India has been wide-
ly influenced by teachers who were trained in the USA.r The
orthodontic equipment and materials were imported from
the USA. The MDS courses started at Mumbai and later at
Lucknow and Nair Hospital Dental College, were chaired by
teachers trained at North American Universities in edgewise
techniques. Dr Prem Prakash first time introduced edgewise
technique at Sir CEM Dental College in Bombay.3 However,
Figure '1.3.2 First and second batch of MDS orthodontics students
at Mumbai. Dr K. L. Shourie, Dean is seen sitting in the centre.
scarce availability of these materials and high import cost,
led to them consider other options, including Begg's ap-
pliance. While the dental school in Lucknow with profes-
sor Ram Nanda as its first chair continued to teach Tweed's
edgewise technique, there was a major drift towards the use
of Begg's appliance in other institutions in India. In 1970s,
Begg's tubes and brackets were manufactured in India. The
low cost and the ease of availability of these materials fur-
ther popularised the Begg's technique in India.
During the 1980s, the advent and popularisation of pre-
adjusted appliances have led to a gradual drift by the ortho-
dontic practitioners to adopt pre-adjusted appliance systems.
Some practitioners found a comfort zone in TIP EDGE tech-
nique, a combination of Begg's appliance with control of the
edgewise system, whereas others moved on to the so-called
'straight wire appliance' (SWA).
During the 1980-90s, many references on funcrional appli-
ances and their proven clinical efficacy in growth, modifica-
tion influenced the thinking across the USA and the Indian
orthodontic fraternity. Teaching institutions in India started
using functional appliances more ollen than before. In the
year 1990, author had a visit to Scotland to get first-hand ex-
posure with twin block from Dr William Clark. Dr Kharbanda
introduced, used and extensively researched twin block ap-
pliance at AIIMS. Slowly, twin block, percolated throughout
India. It is perhaps the most widely accepted and used func-
tional appliance (Table 1.3.1).
The DCI has made some efforts to change the curricu-
lum in all the nine postgraduate specialities of dentistry
through their revised curriculum.e,'u Subsequently, updated
guidelines on syllabus and curriculum were established in
2007. These guidelines have undergone amendments from
time to time.rr'r2 MDS course was extended to three years
duration in 1994rr''a (Box 1.3.1).
Indian Orthodontic Society (lOS) and its
role in education and faculty development
The IOS started as a study group in Bombay (now Mumbai)
way back in the year 1963. It was formally established as the
lndian Orthodontic Society on October 5, 1965 by seven or-
thodontists. Late, Dr H. D. Merchant was the founder presi-
dent and Dr Naishadh Parikh, the founder secretary and
treasurer (Fig. 1.3.3) and other founder members included
Drs A. B. Modi, Prem Prakash, H. S. Shaikh, Keki Mistry and
Mohan Das Bhatt. The Indian Orthodontic Society, is the
first dental speciality society in India.'s
The Indian Orthodontic Society held its first conference
in the year 7967 at New Delhi. This was followed by regu-
lar conferences, usually every year, which are attended by
a large number of orthodontists from within the country
and abroad. Indian Orthodontic Society held its Golden
lubilee conference in 2016 at Hyderabad. IOS publishes a
quarterly scientific journal named f ournal of Indian Ortho-
dontic Society (llOS) since 1968's and an IOS newsletter
since 2009.
'Indian Board of Orthodontics' was established in 1999,
first such board in the field of dentistry in India and the third
in the world.'s Wirh the signing of the charter of the World
Federation of Orthodontics at San Francisco, USA in 1995,
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 Historyoforthodonticspecia|ityintndia@t'.'|l
_l
I
Figure 1.3.3 Dr H. D. Merchant, Founder President of the Indian
Orthodontic Society. Source: Dtrectary of lndtan orthadontic soclety
Member's Directory 241 0.
the Irrdian Orthodontic Society became a member of the
World Federation of Orthodontics.
Irirst SAARC orthodontic conference was held in Delhi in
2009 and the first Asian Pacific Orthodontic Conference too
in Delhi in 2013 (Fig. 1.3.a). Indian Orthodontic Society in
collaboration with World lrnplant Orthodontic Society host-
Key Points
The very first formal dental school in India was established
by Dr R. Ahmed in 1920 at Calcuta, West Bengal. The first
dental faculty, formed at Mumbai in 7957, offered Bach-
elor of Dental Surgery course. The Dental Council of India
(DCI) was incorporated under The Dentisrs Act, 1948 to
regulate dental education and the profession throughout
India.
In 1959, the DCI laid down regulations and the syl-
labus for the Master's degree courses in seven speciali-
ties, including orthodontia. In 1986, All India Institute
of Medical Sciences (AIIMS), New Delhi srarted first full
time 3 years residency programme for Masiers in Ortho-
dontics. In 1993, DCI passed a resolution for MDS course
duration for 3 years throughout India.
Indian Orthodontic Society was established on October
5, 1965, in Mumbai and starred its journal in 1968. Indian
Board of Orthodontics was established in 1999. It was the
first such board in the field of dentisrry in India and the
g @
Figure 1.3.4 First SAARC orthodontics conference held at New
Delhi, 2009.
ed the Bth World Implant Orthodontic Conference in 2016. A
brief overview of orthodontic programs in the Indian Subcon-
tinent is given in Table 1.3.1.
India has a large orthodontic fraternity with a significant
presence at regional and international forums, which include
the SAARC Orthodontic Sociery Asia Pacific Orthodontic So-
ciety and World Federation of Orthodontists.
The Indian orthodontic curriculum, examination pat-
tern, education are regulated by the Dental Council of lndia
(DCI) except at All India Institute of Medical Sciences and
Post Craduate Institute of Medical Education and Research,
Chandigarh, which are immune to Dental Council of lndia
through special acts of the parliament. These act gives liberty
to create and implement their own curriculum and examina-
tion pattern in these two preeminent institutes.
third orthodontic board in the world. With the signing of
the charter of the World Federation of Orthodontics at San
Francisco, the United States of America in 1995, the Indian
Orthodontic Society became a part of the World Federation
of Orthodontics.
The first WHO collaborating centre on Oral Health in
India was established at Centre for Dental Education and
Research, AIIMS, New Delhi in 2O1.4. The Centre for Den-
tal Education and Research, AIIMS, New Delhi became
Cochrane Oral Health Global Alliance partner, as the first
partner was not based in a primarily English-speaking
country in 2016.
The first formal batch for an advanced 2 years post-MDS
fellowship in' Cleft and Craniofacial Orthodonrics' starred
at Centre for Dental Education and Research, AIIMS, New
Delhi in 2017.In the same yeat the Government of India
approved the creation of India's first National Level Refer-
ral and Research Institute for Higher Dental Studies (NR-
RIDS) at Centre for Dental Education and Research, AIIMS,
New Delhi.
31
 Section I I I Historical aspects of orthodontics: ancient, yesteryears, yesterdays, today and tomorrow

References

References for this chapter are found on the companion website www.medenact.com.

Suggested reading

I, National Board of Examinations Guidelines of Competency Based Training Programme. Orthodontics; 2OOO, p. 441-438.
II. Mistry KK. Proceedings of national workshop on PG orthodontic education in India: its future directions. 1993.
III. Kumar i. Orthodontic education in India-the challenge of change. Some suggestions from Trivandrum. Base paper for the
national workshop on PC orthodontic education in India: its future directions, 1993.
IV. Kharbanda OP. Orthodontic specialty education in the Indian subcontinent. In: Eliades T, Athanasiou AE, editors. Orthodontrc
postgraduate education: a global perspectiue. Stuttgart: Thieme; 2016.

32
 Section ll
Fundamentals of orthodontics

2. Adverse conseouences of malocclusion 5. Recording the severity of malocclusion:

and benefits of orthodontic treatment 35 orthodontic indices 85
3. Epidemiology of malocclusion and orthodontic 5. Psychological implications of malocclusion and
treatment needs 57 orthodontic treatment 99
4. Classificatron and methods of recordinq
malocclusion 62
 Chapter

Adverse consequences of malocclusion

and benefits of orthodontic treatment
O.P. Kharbanda

CHAPTER OUTLINE

lntroduction 35 Oral health benefits 45

Adverse consequences of malocclusion 37 Health of temporomandibular joint 45
Consequences due to poor aesthetics 37 Critical appraisal of the benefits of orthodontic
Alteration in functions of stomatognathic treatment 45
system 37 Limits of orthodontic therapy 46
Loss of tooth substance and function 40 Orthodontic treatment 46
Increased susceptibility to dental trauma 40 Orthodontics supported with implants and
Proneness to dental diseases 41 skeletal anchorage system 46
Benefits of orthodontic treatment 41 Limits of dentofacial orthopaedic treatment 47
lmproved aesthetics/enhanced self-image 41 Orthognathic surgery 47
Reduction in trauma to maxillary anterior teeth 42 Distraction osteogenesis 49
lmproved oral functions 43 Key Points 49

the arch or a minor diastema betvveen teeth, to more severe forms

Introduction
Malocclusion is seen to be associated with adverse physical,
psychological and social effects including longevity of dentition
and oral health and therefore adversely affects the quality oflife
(QoL).' A systematic review has suggested an association, albeit
modest, between malocclusion/orthodontic treatment need
and poor health-related quality of life (HReoL), and that they
coexist in the same population.2 Most studies suggest an asso-
ciation between malocclusion/orthodontic treatment need and
oral health-related quality of life (OHReoL) scores. Anrerior
segment spacing and anterior mandibular overjet are signifi-
cantly associated with an impact on OHReoL. School children
with malocclusion are more likely to experience an adverse
impact on OHRQoL than those without malocclusion.3
Severe crowding and severe protrusion result in lower self-
esteem compared with those with mild afflictions.a Dental
aesthetics has a role in social life and finding a job. persons
with ideal smiles are perceived more intelligent and have a
greater chance of finding a job when compared with persons
with non-ideal smiles.5
Malocclusion can manifest in a wide range and variations such
as an inconspicuous rotation of a tooth, its slight malposition in
ofcrowding spacing superiorprotrusion, retrusion in isolation or
combinations of several traits of tooth malpositions and abnor-
mal dental relations. Dental malalignments may be limited to or
extended to one or more teeth, within an arch (intra-arch), or
both the arches and in improper relations of tooth/teeth between
the upper and lower arches (inter-arch) (Figs. 2.1A, 2.2 and 2.3).
The deviations in tooth or teeth positions may be local or a
consequence of architectural deviations of the underlying den-
toalveolar structures, skeletal bases of maxilla and mandible and
craniofacial structures. The imbalance in harmony of face and
occlusion is reflected through solt-tissue drape of the face which
usually follows underlying skeletal and dental architecture.
More severe forms of malocclusion are associated with
facial skeletal malrelations and constitute a group of dentofa-
cial deformities.
The common facial deformities are:
o mandibular prognathism with or without maxillary hypo-
plasia or midface deficienry;
o mandibularretrognathia;
o skeletal anterior open bite often associated with long-face
syndrome or skeletal deep bite;
o facial asymmetry.

35
Section lrl Fundamentals of orthodontics

r
./
it
[
,/\
.]itrn I
''-"-,",-- L
I
T

F
I &.' t
Rr

Figure 2.1 lmproved aesthetics and enhanced self esteem following orthodontic treatment are evident in this girl. (A) Poor facial aesthetics
in a '12-year-old girl who is unable to close her lips due to malocclusion. She had significant proclination of maxillary incisors and a lower lip trap. Both
of her maxillary central incisors and left lateral incisor are chipped. (B) She underwent comprehensive orthodontic treatment and aesthetic restoration of
fractured tips of the incisor teeth resulting in significant improvement in aesthetics.

Facial asymmetry with chin deviation associated with tem- affecting cranio-facial region. Among congenital defects
poromandibular joint (TMI) ankylosis is often seen in chil- affecting the face, clefts of the lip and palate are the com-
dren of Indian subcontinent. Facial trauma affecting TMf monest.
during early childhood, if not treated well, may cause partial Common syndromes affecting the face
or complete TMf anlcylosis, and thereby hinder the growth of o Pierre Robin sequence
the mandible. Facial asymmetry is also seen in malunited frac- . Apert syndrome
tures of the facial skeleton, tumour(s) of the condylar cartilage r Down syndrome
such as unilateral condylar hyperplasia (Figs. 2.4 and 2.5). r Crouzon syndrome
Complex deformities of the face can be a manifestation o Hemifacial microsomia/Goldenharsyndrome
of more severe forms of systemic diseases or syndromes r Treacher Collin syndrome.
36
 Adverseconsequencesofma|occ|usionandbenefitsoforthodontictreatm"n.@|zlI
Figure 2.2 Severe crowding in both the maxillary and mandibular arches, which contributes to difficulty in plaque removal leading to
gingival disease.
'-'
- (Fig. 2.6).
Figure 2.3 Erupted mesiodens causing poor aesthetics.
lldverse consequences of malocclusion
Major direct effects of malocclusion are proneness to dental
diseases and loss of tooth substance. Malocclusion leading to
an unaesthetic facial appearance may result in a low social
image and psychological disturbances. A person's QoL can be
further affected due to compromised functions of the oral cav-
ity: mastication, respiration and speech. It can also be affected
by the abnormal loss of tooth substance such as that due to
attrition of teeth. Severe forms of posterior cross-bite and deep
traumatic bite lead to reduced jaw function and masticatory
ability and occasionally problems with'fMJs.
Indirect consequences of malocclusion are connected with
proneness to periodontal diseases and increased susceptibil-
ity to dental caries. Traumatic bite can lead to occlusal trauma
while crowded dentition is associated with proneness to den-
tal caries.
In a spaced dentition, lack of tight proximal contacts
between the teeth leads to the compromised function of spill-
ways, reducing the natural cleansing action of food in remov-
ing the plaque and thereby leading to increased proneness to
dental caries and periodontal disease.
Consequences due to poor aesthetics
The face is the most exposed part of the human body, an
organ of expression and communication. When the aesthet-
ics are compromised, a patient may develop negative body
image and psychological disturbances which could manifest
as poor performance at school, poor interpersonal and work-
place relationships, lost job opportunities, poor matrimonial
alliances and consequences thereupon. It is well known that
severe deformity of the face and severe malocclusion can lead
to introverted personality behaviour and psychological stress
Children with buck teeth may get bullied at school which
may have devastating and long-lasting effects. Physical
appearance does appear to play a role in these children, which
includes facial and dental appearance, although these tend
not to be primary factors. Teasing related to dental appear-
ance appears to be particularly hurtful.6
Concern about existing deformities may vary among indi-
viduals, races, people with different socioeconomic back-
grounds and diverse ages. The individual's adjustment to his/
her imperfections in dental alignment could be variable and
there is no evidence that children with visible irregularities
will, in general, be emotionally handicapped.?
Mild to moderate malocclusion can create negative impacts
on daily performance and cause psychological stress, especially
interpersonal sensitivity and depression in young adults.8
Alteration in functions of stomatognathic
system
Essential functions of the stomatognathic system that can be
adversely affected with malocclusion are masticatory perfor-
mance, deglutition, speech and respiration.
Masticatory performance
Masticatory performance is evaluated by the ability of a per-
son to grind food and the chewing force he/she can exert. Ir
is likely to be compromised when occlusion is less than opti-
mum, more so in association with specific traits of malocclu-
sion.
The diminished number of occlusal contacts and qual-
ity of contacts lead to reduced ability to pulverise food into
smaller pafticle sizes in the same number of strokes/unit of
time compared with someone with normal abilities.e Sub-
jects with malocclusion have been found to chew food of
larger particle sizes compared with the normal occlusion
group.to English et al.r' found median particle sizes for class
I, II, and III malocclusion groups to be approximately 9, 15
and 34o/o larger, respectively, compared with those with nor-
mal occlusion.
37
Section Fundamentals of orthodontics

#
l
?.:
:.

4. rm
':j

-+-I
ffi r:
Q-_-J
Figure 2.4 lmpacted maxillary left canine in a patient with facial asymmetry of the face. Her upper and lower incisors are crowded along wrth
buccal cross-bite on the left side. This case was diagnosed with maxillary hypoplasia, unilateral hyperplasia of the mandible right side and significanifacial
asymmetry which are better appreciated on a 3-D cone beam computed tomography volumetric image.

Figure 2'5 A case of gross facial asymmetry associated with unilateral condylar hyperplasia
of the left side. Note a significant cant of occlusal
plane and adaptation of the maxilla maintaininq the occlusal contacts.

38
 AdverseGonsequencesofma|occ|usionandbenefitsoforthodontictreatm"n.@|2|I
,@.,.
/t
jI
rJ
r
F_]
Figure 2.6 Malocclusion in a patient with hemifacial microsomia, associated with bilateral absence of ears and cleft of the palate.
A team of multiple specialists is required to treat and rehabilitate such a deformity. He has been provided an implant supported ear prosthesis.
Malocclusion associated with frequent interference in nor-
mal masticatory movements shows altered activities of the
muscles involved in mastication and poor coordination of
muscle functions. Individuals with scissors bite or cross-bite
of the buccal segment show a lack of coordination of mus-
cular activities more so on the affected side. Research studies
have shown that, when measured by kinematic parameters,
dental malocclusions were associated with significantly lower
skilfulness of masticatory jaw motion.'2
Patients with anterior open bite are unable to bite using
their incisors and hold obiects between their front teeth.
Articulation and quality of speech
Speech articulation can be adversely affected in severe open
bite, skeletal class III malocclusion with negative overjet, and
in severely malpositioned teeth.13'14
Articulation errors occur primarily on the sibilans (s, z) and
(sh, ch, i, dz), which are characterised mostly by combined vis-
ual and auditory distortions. Errors on the stop consonants (p, b,
m, t, d, n) occur less fiequently and consist of isolated visual
distortions. While most subjects having class II malocclusion,
with or without open bite could assume a variety of tongue and
mandibular postures that allowed them to approimate an (s)
or (z), these compensations in subjects with class III malocclu-
sion do not occur. In these cases, the tongue remains distal to
the mandibular incisors, causing scattering of the air stream. In a
study conducted in Poland on class III patients with mandibular
prognathism, almost all patients exhibited speech disorders and
severe articulation defects.
Abnormal respiration, snoring and obstructive sleep
apnoea
Obstructive sleep apnoea (OSA) is associated with narrow-
ing of the phary.ngeal airway which is thought to arise fiom
a combination of abnormal anatomical features of the crani-
ofacial structures and functional impairment of the muscles
of the upper airway. Retroposition of the facial skeleton leads
to reduced oropharlmgeal dimensions and hence, makes a
person prone to snoring and sleep apnoea. Patients with a
retognathic/small mandible are at greater risk of developing
39
 Section I tt I Fundamentals of orthodontics
\ -;$ #r
Figure 2.7 Loss of tooth substance of the maxillary and mandibular incisors associated with deep bite.
snoring and OSA. In these patients, the tongue assumes a more
posterior and inferior position to accommodate itself in a
smaller oral caviry which further compounds the narrow exist-
ing airway. Children born with a rerrognathic mandible such as
in Pierre Robin sequence require immediate attention in hold-
ing the mandible forward to prevent asphp<ia. Orthodontists
have traditionally constructed appliances to hold the mandible
forward to assist them in breathing. patients with retrognathia
due to TMJ ankylosis do suffer from OSA and benefit signifi_
cantly after mandibular lengthening procedures."
Loss of tooth substance and function
Traumatic deep bite is one of the causes of pain in lower anterior
teeth and on the anterior palate. Supraerupted mandibular inci_
sors cause trauma on the anterior palate while retroclined upper
incisors impinge on the labial gingiva of the lower incisors.
Attrition of teeth can also be an outcome of single_tooth
malposition, which hinders normal masticatory functions.
Deep bite affects the anterior teeth causing wear on the labial/
incisal edges of mandibular incisors and the paratar surfaces
of maxillary incisors. The extent of attrition may vary depend_
ing upon the severity of deep bite and the interference it offers
during functional jaw movements (Fig. 2.7).
Loss of enamel further leads to wearing away of dentine and
can cause pain and sensitivity of the affected teeth, followed
by pulp exposure and consequent complications including
periapical abscess formation.
Many adults report with complaints of their front teeth get_
ting wom out, unaware of existing traumatic deep bite. the iate
of tooth substance wear may vary greatly fiom individual to
individual. In other situations, the attrition of tooth substance
leads to periodontal and endodontic complications.
These
patients do present difficulties for prosthetic rehabilitation
due
to lack of interocclusal space required for the placement of
the
prosthesis. Traumatic deep overbite
-uy r"ruit in unprotected
incisors, adversely affeaing the life of the dentition. Teeth
in
cross-bite also end up in attrition due to functional hindrances.
Increased susceptibitity ro dentar trauma
Proclined maxillary anterior teeth are more prone
to trau-
matic infuries' more so if the lip coverage is inadequate.
significant relationship was found betwien the severity
A with increised orrerjet, ,ug;"r, that these parients are
trauma to protrusion of maxillary incisors and the
of
amount
40
t+
of lip coverage.tu-'' The extent of dental injury does vary from
slight chipping of the incisors to avulsion, which is related to
the type of injury.
Dental trauma and overjet have been linked to increased
proneness to traumatic dental injuries (TDI) in children.
Children in primary dentition with overjet and anterior
open bite are more prone to TDL A recent systematic review
suggests thar males, older children (1-2 yearsf2_3 yearsf
3-4 years) and those with inadequate lip coverage overbite, or
overjet are more likely to have TDI in the primary dentition.22
Several other studies have linked proneness to TDI with
increased overjet in children and adolescents. Increased over_
jet with inadequate coverage increased the risk.
It has been reported that, among 6- to 13_year_old children
having fractured or traumatic injuries to anterior teeth, the
highest proportion was found with class II division 1 mal_
occlusion and inadequate upper-lip coverage.r. In general,
children with overjet of more than 3 mm with inadeq-uate lip
coverage are at a higher risk of sustaining crown fracture of
the incisors.2a There is a 13%o increase in the risk of trauma for
every millimetre of increase in overjet.2t An increase in overjet
of more than 3 mm doubled the incidence of coronal fracture
while an overjet of more than 6 mm increased the incidence
fourfold.26 Soriano et al. have suggested the critical trauma
susceptibility value of overjet of 5 mm or greater.27,28 In gen_
eral, boys with overjet are more prone to inJuries than girl.re
Recent studies have reiterated these observations.
Among ado_
lescents, the teeth most affected by dental trauma
are the maxil_
lary central incisors. Boys run a 2.03-times higher risk
of crown
fiacture than girls, and children with an ove4it size )3
mm are
178 times more likely to have dental injuries. Also, children
with inadequate lip coverage are 2.1g times more likelv to
ore_
sent TDI than children with adequate lip coverage.3o,3'
. In short, overjet, lip competence, and short lip line are
important predisposing factors to coronal fracture of
the ante-
rior teeth while the severity of the fracture was mainly
deter_
mined by increase in the overiet.,r,
f:iliT,|,Ir"*:".1"Tfl:ili:ffii:il:,J,.":"'appriance
Thefindingsofahigherincidenceofdental traumainpatients
rikely to
be benefitted with early orthodontic interventions before the
age of 11 years.
T Adversecon5equencesofmalocc|usionandbenefitsoforthodontictreatm"n.@|z|I
Figure 2.8 Severe deep bite causing trauma to the periodontium of the mandibular incisor teeth.
Proneness to dental diseases
Occlusion trauma
Occlusal trauma associated with developing cross-bite during
early mixed dentition is often seen with increased mobility
of affected mandibular incisor(s) and loss of gingival attach-
ment.
Periodontal disease
Severe crowding is seen associated with increased plaque
accumulation and gingivitis.33 Bollen et al. (2008) in a sys-
tematic review reported a correlation between the presence
of a malocclusion and periodontal disease. Subjects with
greater malocclusion have more severe periodontal disease.
Periodontal health is also dependent on the oral health sta-
tus of an individual. Therefore, malocclusion per se cannot
be implicated as the sole aetiology of periodontal disease
but suggests an association. Large overjet has been associated
with greater susceptibility to poor oral hygiene and gingivitis
caused by dryness of the mouth (Figs. 2.8-2.10).
Dental caries
Malocclusion has been implicated and associated with den-
tal caries as a result of disturbed alignment, greater plaque
formation and difficulties related to its complete removal
(Fig.2.u).
The author has come across many children and adults
seeking orthodontic treatment for several functional reasons
besides concern for aesthetics and improvement in appear-
ance. Some of the comnron concerns are:
t,
lnability to keep lips closed, which causes discomfort.
Such patients are usually associated with a superior pro-
trusion or bidental protrusion.
Problems with clarity and errors in articulation of speech,
common cause being anterior open bite.
Appearance of spacing between teeth. The spacing be-
comes progressively larger. Such patients are usually adult
females who have deep anterior traumatic bite causing
periodontal migration of teeth.
a Sensitivity to cold and hot foods in front teeth.
a Front teeth getting wom or completely worn-out front
teeth and complications thereof.
Pain in TMI and non-specific symptoms of pain in the oro-
facial region ( Box 2. 1 ).
i--=,
orthodontic treatment
The very purpose of orthodontic treatment varies from indi-
vidual case to case and so would the expected benefits which
need to be derived both in the short and long term.
The perceived benefits and measurable benefits are influ-
enced by patients'and parents'perception of malocclusion, the
motivational reasons of the patient for undergoing treatment,
the severity of malocclusion, and the complexity of disfigure-
ment and its impact on oral health (Figs. 2.1P., 2.72 and 2.13).
lmproved aesthetics/enhanced self-image
In general, orthodontic treatment aims to improve the aes-
thetics, self-image body concept and social well-being in a
majority of cases.
41
Section ] tl I Fundamentals of orthodontics

w*]
s

f, t
=

{d

a=
!1, e
-=
l,

Figure 2.9 Occlusal trauma from a single tooth in crcss-bite has Figure 2.10 Beginning of gingival recession in the mandibular inci-
right mandibular central incisor.
caused gingival recession of the sors caused by trauma from malposed teeth and twin supernumer-
ary teeth.

Improvement in dentofacial aesthetics following ortho-
dontic treatment enhances self-confidence and self-esteem in
most patients.3n Dissatisfaction with dental appearance has a
strong predictive effect on how orthodontic treatment helps
to improve a person's self-esteem. School students who had
received orthodontic treatment showed greater self-esteem
than those who had not.r5
Assessment of the impact of aesthetic improvement as
a result of orthodontic treatinent can generate a significant
improvement in adult patients' QoL.tt' Socially, malocclusion
and its treatment can affect perceived attractiveness by oth-
ers, social acceptance and perceived intelligence. People with
abetter appearance may be perceived as socially more accept-
able and superior performers.
42
The benefits of orthodontic treatment are the outcome of
a synergy of a variety of improvements that are dental, facial
and functional in nature. Improved aesthetics is the outcome
of dental alignment, reduced proclination and improved
facial profile. The ability to keep the lips closed and overall
improvements in static and dynamic smile help a person feel
good and socially more acceptable.
Reduction in trauma to maxillary anterior
teeth
Early correction of a severe superior protrusion in class II
malocclusion helps to reduce risks of trauma to maxillary
anterior teeth. It also prevents teasing and nicknames at
 AdverseConsequencesofma|occ|usionandbenefitsoforthodontictreatm"n.@|z|I
\ those with such a condition (independent groups). OHIP-14
\t
Figure 2.11 Crowding of teeth causes difficulties in effective plaque
removal making them susceptible to dental caries and periodontal
diseases. Interproximal caries on the maxillary right central and lateral
incisors associated with crowding in this 14-year-old girl.
Box 2.1 Consequences of malocclusion
1. Consequences due to poor aesthetics
a. Negative body image
b. Psychological disturbances
2. Compromised functions of the stomatognathic system
a. Poor masticatory performance
b. Difficulty in articulation and lack of clarity of certain words
c. Altered respiration leading to snoring and obstructive sleep
apnoea (OSA)
3. Loss of tooth substance and function
a. Attrition and loss of tooth structure
b. Hypersensitivity oi teeth
c. Pulp exposure and related complications
4. Increased susceptibility to trauma
High frequency of fractures of maxillary incisors and associated
comolications
5. Proneness to dental diseases
a. Bone loss and gingival recession due to occlusal trauma
b. Poor oral hygiene and periodontal disease
c. Proneness to dental caries due to increased plaque
accumulation in crowded dentition
6. Temporomandibular joint disturbances
school and offers significant psychological benefits to the
child.
A recent Cochrane review of risk ratio analyses for new
incisor trauma showed that providing early treatment using
a functional appliance reduced the risk of trauma by 33o/o.
In other words, early treatment using functional appliances
prevents the incidence of incisal trauma in 1 out of every 10
patients. Orthodontic treatment for young children, followed
by a later phase of treatment when the child is in early adoles-
cence, appears to reduce the incidence of new incisal trauma
significantly compared with treatment that is provided in
single phase when the child is in early adolescence."
Benefits of orthodontic treatment in adult patients
requiring oral rehabilitation
In adult patients, a recent meta-analysis revealed that oral
health impact profile (OHIP-14) scores were significantly
lowet which means they had a better OHRQoL after receiving
treatment for malocclusion, as well as in individuals without
malocclusion or orthodontic treatment need, compared with
scores are valid and reliable measures of OHRQoL.38
Orthodontic treatment significantly improves patients' self-
esteem and QoL. Adult patients undergoing interdisciplinary
treatment with periodontists, prosthodontists or orthodon-
tists get psychological benefits because of the need for oral
rehabilitation as a result of the motivation for improved
occlusion and smile esthetics.3e
More severe forms of malocclusion, especially in those who
require treatment involving a combination of surgery can
be associated with greater distorted self-image. Patients who
have undergone orthognathic surgery experience psychosocial
benefits, including improved self-confidence, body and facial
image and social adjustment.40'4r General HRQoL, OHRQoL,
and psychosocial function show significant improvements
after bilateral sagittal split osteotomy, and the improvements
are stable between 2 and 5 years after surgery.n' Patients with
class III malocclusion, especially those with large mandibular
prognathism, are benefitted the most.
lmproved oral functions
Treatment of malocclusion can offer physical health benefits
such as improvement in masticatory performance, clarity in
articulation, prevention of dental and gingival trauma and
improved respiration.
lmprouement in masticatory performance: Alterations of the
occlusal contacts following orthodontic treatment produce a
significant mechanical advantage for masticatory performance.
In orthognathic surgery patients, the major changes relate to
normalisation of patients' masticatory muscle attachments
physiologically by altering sensory and proprioceptive inputs.a'
The conection of malocclusion through orthodontic treat-
ment becomes an important resource with which to improve
ocdusal contacts and, consequently, the masticatory perfor-
mance of an individual'.oo Research studies using iaw motions
measured by kinematic parameters have shown that orthodonti-
cally improved occlusion, either with or without premolar extrac-
tion, with more skilful masticatory jaw motions.r2
is associated
The intewentional procedures that are undertaken to guide
eruptingteeth and intercept incipient malocdusion are primarily
aimed at achieving a normal occlusion. Impacted and submerged
teeth when brought into alignment contribute to achieving
occlusion with proper masticatory efficiency and a need for fur-
ther actions to treat pathologies caused by their impaction.
A noticeable tendency towards normalisation in mastica-
tory patterns has been recorded after orthognathic correction
of severe class II and class III malocclusion.'s Although class
III patients after orthognathic surgery report better mastica-
a tion performance than before, it takes up to 5 years to con-
firm a significant improvement in masticatory performance'ot'
Reduction in obstructive sleep apnoea
Craniofacial abnormality is reported as one of the major
causes of OSA syndrome. The common findings are retropo-
sition of the mandible, reduced cranial base flexure meas-
43
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 Hart, Republican 385,514
McGrann, Democrat 340,269
Irish, Prohibitionist 18,471
Kennedy, Greenback 8,900

Total 753,154

An important feature of the year was the interest shown in the

question of prohibiting the manufacture and sale of intoxicating
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April, Texas voting in August, Tennessee in September, and Oregon
in November. Prohibition was defeated in each instance, but its
advocates succeeded in polling a surprisingly large vote. The poll in
these States was as follows:

For Pro. Against Pro.

Michigan 178,488 184,429
Texas 129,273 221,627
Tennessee 117,504 145,197
Oregon 19,973 27,958

Totals 445,238 579,211

Majority against prohibition 133,973

To this should be added the defeat of prohibition in Atlanta and

Fulton counties, Ga., by 1122 majority, where it had won two years
before by 228 majority. The interest shown in local option and high
license as a solution of the temperance question, and its popularity
wherever adopted, is also a marked feature of the year’s politics. In
Michigan local option succeeded the failure of prohibition, while in
Pennsylvania the people are promised a choice between high license
and prohibition.
The elections of 1887 as a whole, without removing doubts as to
the future, were generally accepted as favorable to the Republicans.
The following is a fair comparison with Rhode Island omitted, for the
plain reason that her spring result was reversed in the fall:
 1883. 1887.
Rep. Dem. Rep. Dem.
Mass 160,092 150,228 136,000 118,394
New York 429,757 445,976 452,435 469,886
New Jersey 97,047 103,856 107,026 104,407
Penna 319,106 302,031 385,514 340,269
Maryland 80,707 92,694 86,644 98,936
Ohio 347,164 359,793 356,937 333,205
Kentucky 89,181 133,615 126,476 143,270
Iowa 164,182 139,093 168,696 152,886
Nebraska 56,381 41,998 86,725 56,548
Virginia 144,419 124,080 119,380 119,806
Totals 1,888,036 1,893,364 2,025,833 1,937,607

Democratic majority in 1883 5,328

Republican majority in 1887 88,226
Gain in the Dem. vote in four years 44,243
Gain in the Rep. vote in four years 137,797

The vote in Rhode Island would probably reduce the Republican

gain of the year about 5000. But as the figures for Virginia are
disputed and not the official vote, which it is known would add
several thousand to the Republican total, the above result can be
taken as a just estimate of the gain made by the Republicans in these
eleven states, where general elections were held. It would be at least
25,000 larger if the vote of the highest candidate, instead of the head
of the ticket, were taken.
 OPENING OF THE CAMPAIGN OF 1888.

The fiftieth Congress convened in December, 1887, the Senate

consisting of 38 Republicans, 37 Democrats, and 1 Readjuster, Mr.
Riddleberger, of Virginia. In the House there were 168 Democrats,
153 Republicans, and 4 Independents—Anderson, of Iowa and
Hopkins, of Virginia, classed with the Democrats, and Smith of
Wisconsin and Nichols of North Carolina, classed with the
Republicans upon tariff and educational subjects—two questions
which in the form of Revenue measures and of the Blair educational
bill, gave early promise of becoming the issues for the campaign of
1888.
Upon the assembling of the fiftieth Congress President Cleveland,
instead of sending the usual message describing the condition of the
Nation and its relations with foreign nations, together with such
recommendations as he desired to make, sent simply a message upon
questions of revenue, and in this way gave the subject such emphasis
as to make his views the issue in the campaign to follow. The
message excited wide and varied political comment, and when Mr.
Blaine, who at the time was in Paris, permitted an answer to be wired
to the New York Tribune, the two opposing views seemed to meet the
wishes of the two great opposing parties, and they were at once
accepted as defining the tendencies of each party, at least, upon tariff
and revenue subjects.
As these two papers will prove the text for much of the discussion
incident to the campaign of 1888, we give below their text:
 President Cleveland’s Message.

To the Congress of the United States:

You are confronted at the threshold of your legislative duties with
a condition of the national finances which imperatively demands
immediate and careful consideration.
The amount of money annually exacted, through the operation of
the present laws, from the industries and necessities of the people,
largely exceeds the sum necessary to meet the expenses of the
government.
When we consider that the theory of our institutions guarantees to
every citizen the full enjoyment of all the fruits of his industry and
enterprise, with only such deduction as may be his share towards the
careful and economical maintenance of the government which
protects him, it is plain that the exaction of more than this is
indefensible extortion, and a culpable betrayal of American fairness
and justice. This wrong inflicted upon those who bear the burden of
national taxation, like other wrongs, multiplies a brood of evil
consequences. The public treasury, which should only exist as a
conduit conveying the people’s tribute to its legitimate objects of
expenditure, becomes a hoarding-place for money needlessly
withdrawn from trade and the people’s use, thus crippling our
national energies, suspending our country’s development, preventing
investment in productive enterprise, threatening financial
disturbance, and inviting schemes of public plunder.
This condition of our treasury is not altogether new; and it has
more than once of late been submitted to the people’s
representatives in the Congress, who alone can apply a remedy. And
yet the situation still continues, with aggravated incidents, more than
ever presaging financial convulsion and widespread disaster.
It will not do to neglect this situation because its dangers are not
now palpably imminent and apparent. They exist none the less
certainly, and await the unforeseen and unexpected occasion when
suddenly they will be precipitated upon us.
On the 30th day of June, 1885, the excess of revenues over public
expenditures after complying with the annual requirement of the
sinking fund act, was $17,859,735.84; during the year ended June
30, 1886, such excess amounted to $49,405,545.20; and during the
year ended June 30, 1887, it reached the sum of $55,567,849.54.
The annual contributions to the sinking fund during the three
years above specified, amounting in the aggregate to
$138,058,320.94, and deducted from the surplus as stated, were
made by calling in for that purpose outstanding three per cent. bonds
of the government. During the six months prior to June 30, 1887, the
surplus revenue had grown so large by repeated accumulations, and
it was feared the withdrawal of this great sum of money needed by
the people would so affect the business of the country that the sum of
$79,864,100 of such surplus was applied to the payment of the
principal and interest of the three per cent. bonds still outstanding,
and which were then payable at the option of the government. The
precarious condition of financial affairs among the people still
needing relief, immediately after the 30th day of June, 1887, the
remainder of the three per cent. bonds then outstanding, amounting
with principal and interest to the sum of $18,877,500, were called in
and applied to the sinking fund contribution for the current fiscal
year. Notwithstanding these operations of the Treasury Department,
representations of distress in business circles not only continued but
increased, and absolute peril seemed at hand. In these circumstances
the contribution to the sinking fund for the current fiscal year was at
once completed by the expenditure of $27,684,283.55 in the
purchase of government bonds not yet due bearing four and four and
a half per cent. interest, the premium paid thereon averaging about
twenty-four per cent. for the former and eight per cent. for the latter.
In addition to this, the interest accruing during the current year upon
the outstanding bonded indebtedness of the government was to
some extent anticipated, and banks selected as depositories of public
money were permitted to somewhat increase their deposits.
While the expedients thus employed, to release to the people the
money lying idle in the Treasury, served to avert immediate danger,
our surplus revenues have continued to accumulate, the excess for
the present year amounting on the 1st day of December to
$55,258,701.19, and estimated to reach the sum of $113,000,000 on
the 30th of June next, at which date it is expected that this sum,
added to prior accumulations, will swell the surplus in the Treasury
to $140,000,000.
There seems to be no assurance that, with such a withdrawal from
use of the people’s circulating medium, our business community may
not in the near future be subjected to the same distress which was
quite lately produced from the same cause. And while the functions
of our National Treasury should be few and simple, and while its best
condition would be reached, I believe, by its entire disconnection
with private business interests, yet when, by a perversion of its
purposes, it idly holds money uselessly subtracted from the channels
of trade, there seems to be reason for the claim that some legitimate
means should be devised by the government to restore in an
emergency, without waste or extravagance, such money to its place
among the people.
If such an emergency arises there now exists no clear and
undoubted executive power of relief. Heretofore the redemption of
three per cent. bonds, which were payable at the option of the
government, has afforded a means for the disbursement of the excess
of our revenues; but these bonds have been all retired, and there are
no bonds outstanding the payment of which we have the right to
insist upon. The contribution to the sinking fund which furnishes the
occasion for expenditure in the purchase of bonds has been already
made for the current year, so that there is no outlet in that direction.
In the present state of legislation the only pretence of any existing
executive power to restore, at this time, any part of our surplus
revenues to the people by its expenditure, consists in the supposition
that the Secretary of the Treasury may enter the market and
purchase the bonds of the government not yet due, at a rate of
premium to be agreed upon. The only provision of law from which
such a power could be derived is found in an appropriation bill
passed a number of years ago; and it is subject to the suspicion that it
was intended as temporary and limited in its application, instead of
conferring a continuing discretion and authority. No condition ought
to exist which would justify the grant of power to a single official,
upon his judgment of its necessity, to withhold from or release to the
business of the people, in an unusual manner, money held in the
Treasury, and thus affect, at his will, the financial situation of the
country; and if it is deemed wise to lodge in the Secretary of the
Treasury the authority in the present juncture to purchase bonds, it
should be plainly vested, and provided, as far as possible, with such
checks and limitations as will define this official’s right and
discretion, and at the same time relieve him from undue
responsibility.
In considering the question of purchasing bonds as a means of
restoring to circulation the surplus money accumulating in the
Treasury, it should be borne in mind that premiums must of course
be paid upon such purchase, that there may be a large part of these
bonds held as investments which cannot be purchased at any price,
and that combinations among holders who are willing to sell may
unreasonably enhance the cost of such bonds to the government.
It has been suggested that the present bonded debt might be
refunded at a less rate of interest, and the difference between the old
and new security paid in cash, thus finding use for the surplus in the
Treasury. The success of this plan, it is apparent, must depend upon
the volition of the holders of the present bonds; and it is not entirely
certain that the inducement which must be offered them would
result in more financial benefit to the Government than the purchase
of bonds, while the latter proposition would reduce the principal of
the debt by actual payment, instead of extending it.
The proposition to deposit the money held by the Government in
banks throughout the country, for use by the people, is, it seems to
me, exceedingly objectionable in principle, as establishing too close a
relationship between the operations of the Government Treasury and
the business of the country, and too extensive a commingling of their
money, thus fostering an unnatural reliance in private business upon
public funds. If this scheme should be adopted it should only be done
as a temporary expedient to meet an urgent necessity. Legislative
and executive effort should generally be in the opposite direction and
should have a tendency to divorce, as much and as fast as can safely
be done, the Treasury Department from private enterprise.
Of course it is not expected that unnecessary and extravagant
appropriations will be made for the purpose of avoiding the
accumulation of an excess of revenue. Such expenditure, beside the
demoralization of all just conceptions of public duty which it entails,
stimulates a habit of reckless improvidence not in the least
consistent with the mission of our people or the high and beneficent
purposes of our government.
I have deemed it my duty to thus bring to the knowledge of my
countrymen, as well as to the attention of their representatives
charged with the responsibility of legislative relief, the gravity of our
financial situation. The failure of the Congress heretofore to provide
against the dangers which it was quite evident the very nature of the
difficulty must necessarily produce, caused a condition of financial
distress and apprehension since your last adjournment, which taxed
to the utmost all the authority and expedients within executive
control; and these appear now to be exhausted. If disaster results
from the continued inaction of Congress, the responsibility must rest
where it belongs.
Though the situation thus far considered is fraught with danger
which should be fully realized, and though it presents features of
wrong to the people as well as peril to the country, it is but a result
growing out of a perfectly palpable and apparent cause, constantly
reproducing the same alarming circumstances—a congested national
treasury and a depleted monetary condition in the business of the
country. It need hardly be stated that while the present situation
demands a remedy, we can only be saved from a like predicament in
the future by the removal of its cause.
Our scheme of taxation, by means of which this needless surplus is
taken from the people and put into the public treasury, consists of a
tariff or duty levied upon importations from abroad, and internal
revenue taxes levied upon the consumption of tobacco and spirituous
and malt liquors. It must be conceded that none of the things
subjected to internal revenue taxation are, strictly speaking,
necessaries; there appears to be no just complaint of this taxation by
the consumers of these articles, and there seems to be nothing so
well able to bear the burden without hardship to any portion of the
people.
But our present tariff laws, the vicious, inequitable and illogical
source of unnecessary taxation, ought to be at once revised and
amended. These laws, as their primary and plain effect, raise the
price to consumers of all articles imported and subject to duty, by
precisely the sum paid for such duties. Thus the amount of the duty
measures the tax paid by those who purchase for use these imported
articles. Many of these things, however, are raised or manufactured
in our own country, and the duties now levied upon foreign goods
and products are called protection to these home manufactures,
because they render it possible for those of our people who are
manufacturers, to make these taxed articles and sell them for a price
equal to that demanded for the imported goods that have paid
customs duty. So it happens that while comparatively a few use the
imported articles, millions of our people, who never use and never
saw any of the foreign products, purchase and use things of the same
kind made in this country, and pay therefor nearly or quite the same
enhanced price which the duty adds to the imported articles. Those
who buy imports pay the duty charged thereon into the public
treasury, but the great majority of our citizens, who buy domestic
articles of the same class, pay a sum at least approximately equal to
this duty to the home manufacturer. This reference to the operation
of our tariff laws is not made by way of instruction, but in order that
we may be constantly reminded of the manner in which they impose
a burden upon those who consume domestic products as well as
those who consume imported articles, and thus create a tax upon all
our people.
It is not proposed to entirely relieve the country of this taxation. It
must be extensively continued as the source of the government’s
income; and in a readjustment of our tariff the interests of American
labor engaged in manufacture should be carefully considered, as well
as the preservation of our manufacturers. It may be called
protection, or by any other name, but relief from the hardships and
dangers of our present tariff laws should be devised with especial
precaution against imperilling the existence of our manufacturing
interests. But this existence should not mean a condition which,
without regard to the public welfare or a national exigency, must
always insure the realization of immense profits instead of
moderately profitable returns. As the volume and diversity of our
national activities increase, new recruits are added to those who
desire a continuation of the advantages which they conceive the
present system of tariff taxation directly affords them. So stubbornly
have all efforts to reform the present condition been resisted by
those of our fellow-citizens thus engaged, that they can hardly
complain of the suspicion, entertained to a certain extent, that there
exists an organized combination all along the line to maintain their
advantage.
We are in the midst of centennial celebrations, and with becoming
pride we rejoice in American skill and ingenuity, in American energy
and enterprise, and in the wonderful natural advantages and
resources developed by a century’s national growth. Yet when an
attempt is made to justify a scheme which permits a tax to be laid
upon every consumer in the land for the benefit of our
manufacturers, quite beyond a reasonable demand for governmental
regard, it suits the purposes of advocacy to call our manufactures
infant industries, still needing the highest and greatest degree of
favor and fostering care that can be wrung from Federal legislation.
It is also said that the increase in the price of domestic
manufactures resulting from the present tariff is necessary in order
that higher wages may be paid to our workingmen employed in
manufactures, than are paid for what is called the pauper labor of
Europe. All will acknowledge the force of an argument which
involves the welfare and liberal compensation of our laboring people.
Our labor is honorable in the eyes of every American citizen: and as
it lies at the foundation of our development and progress, it is
entitled, without affectation or hypocrisy, to the utmost regard. The
standard of our laborers’ life should not be measured by that of any
other country less favored, and they are entitled to the full share of
all our advantages.
By the last census it is made to appear that of the 17,392,099 of our
population engaged in all kinds of industries 7,670,493 are employed
in agriculture, 4,074,238 in professional and personal service,
(2,934,876 of whom are domestic servants and laborers,) while
1,810,256 are employed in trade and transportation, and 3,837,112
are classed as employed in manufacturing and mining.
For present purposes, however, the last number given should be
considerably reduced. Without attempting to enumerate all, it will be
conceded that there should be deducted from those which it includes
375,143 carpenters and joiners, 285,401 milliners, dressmakers, and
seamstresses, 172,726 blacksmiths, 133,756 tailors and tailoresses,
102,473 masons, 76,241 butchers, 41,309 bakers, 22,083 plasterers
and 4,891 engaged in manufacturing agricultural implements,
amounting in the aggregate to 1,214,023, leaving 2,623,089 persons
employed in such manufacturing industries as are claimed to be
benefited by a high tariff.
To these the appeal is made to save their employment and
maintain their wages by resisting a change. There should be no
disposition to answer such suggestions by the allegation that they are
in a minority among those who labor, and therefore should forego an
advantage, in the interest of low prices for the majority; their
compensation, as it may be affected by the operation of the tariff
laws, should at all times be scrupulously kept in view; and yet with
slight reflection they will not overlook the fact that they are
consumers with the rest; that they, too, have their own wants and
those of their families to supply from their earnings, and that the
price of the necessaries of life, as well as the amount of their wages,
will regulate the measure of their welfare and comfort.
But the reduction of taxation demanded should be so measured as
not to necessitate or justify either the loss of employment by the
working man nor the lessening of his wages; and the profits still
remaining to the manufacturer, after a necessary readjustment,
should furnish no excuse for the sacrifice of the interests of his
employés either in their opportunity to work or in the diminution of
their compensation. Nor can the worker in manufactures fail to
understand that while a high tariff is claimed to be necessary to allow
the payment of remunerative wages, it certainly results in a very
large increase in the price of nearly all sorts of manufactures, which,
in almost countless forms, he needs for the use of himself and his
family. He receives at the desk of his employer his wages, and
perhaps before he reaches his home is obliged, in a purchase for
family use of an article which embraces his own labor, to return in
the payment of the increase in price which the tariff permits, the
hard-earned compensation of many days of toil.
The farmer and the agriculturist who manufacture nothing, but
who pay the increased price which the tariff imposes, upon every
agricultural implement, upon all he wears and upon all he uses and
owns, except the increase of his flocks and herds and such things as
his husbandry produces from the soil, is invited to aid in maintaining
the present situation; and he is told that a high duty on imported
wool is necessary for the benefit of those who have sheep to shear, in
order that the price of their wool may be increased. They of course
are not reminded that the farmer who has no sheep is by this scheme
obliged, in his purchase of clothing and woolen goods, to pay a
tribute to his fellow farmer as well as to the manufacturer and
merchant; nor is any mention made of the fact that the sheep-owners
themselves and their households, must wear clothing and use other
articles manufactured from the wool they sell at tariff prices, and
thus as consumers must return their share of this increased price to
the tradesman.
I think it may be fairly assumed that a large proportion of the
sheep owned by the farmers throughout the country are found in
small flocks numbering from twenty-five to fifty. The duty on the
grade of imported wool which these sheep yield, is ten cents each
pound if of the value of thirty cents or less, and twelve cents if of the
value of more than thirty cents. If the liberal estimate of six pounds
be allowed for each fleece, the duty thereon would be sixty or
seventy-two cents, and this may be taken as the utmost enhancement
of its price to the farmer by reason of this duty. Eighteen dollars
would thus represent the increased price of the wool from twenty-
five sheep and thirty-six dollars that from the wool of fifty sheep; and
at present values this addition would amount to about one-third of
its price. If upon its sale the farmer receives this or a less tariff profit,
the wool leaves his hands charged with precisely that sum, which in
all its changes will adhere to it, until it reaches the consumer. When
manufactured into cloth and other goods and material for use, its
cost is not only increased to the extent of the farmer’s tariff profit,
but a further sum has been added for the benefit of the manufacturer
under the operation of other tariff laws. In the meantime the day
arrives when the farmer finds it necessary to purchase woolen goods
and material to clothe himself and family for the winter. When he
faces the tradesman for that purpose he discovers that he is obliged
not only to return in the way of increased prices, his tariff profit on
the wool he sold, and which then perhaps lies before him in
manufactured form, but that he must add a considerable sum thereto
to meet a further increase in cost caused by a tariff duty on the
manufacture. Thus in the end he is aroused to the fact that he has
paid upon a moderate purchase, as the result of the tariff scheme,
which, when he sold his wool seemed so profitable, an increase in
price more than sufficient to sweep away all the tariff profit he
received upon the wool he produced and sold.
When the number of farmers engaged in wool-raising is compared
with all the farmers in the country, and the small proportion they
bear to our population is considered; when it is made apparent that,
in the case of a large part of those who own sheep, the benefit of the
present tariff wool is illusory; and, above all, when it must be
conceded that the increase of the cost of living caused by such a
tariff, becomes a burden upon those with moderate means and the
poor, the employed and the unemployed, the sick and well, and the
young and old, and that it constitutes a tax which, with relentless
grasp, is fastened upon the clothing of every man, woman, and child
in the land, reasons are suggested why the removal or reduction or
this duty should be included in a revision of our tariff laws.
In speaking of the increased cost to the consumer of our home
manufactures, resulting from a duty laid upon imported articles of
the same description, the fact is not overlooked that competition
among our domestic producers sometimes has the effect of keeping
the price of their products below the highest limit allowed by such
duty. But it is notorious that this competition is too often strangled
by combinations quite prevalent at this time, and frequently called
trusts, which have for their object the regulation of the supply and
price of commodities made and sold by members of the combination.
The people can hardly hope for any consideration in the operation of
these selfish schemes.
If, however, in the absence of such combination, a healthy and free
competition reduces the price of any particular dutiable article of
home production, below the limit which it might otherwise reach
under our tariff laws, and if, with such reduced price, its
manufacture continues to thrive, it is entirely evident that one thing
has been discovered which should be carefully scrutinized in an
effort to reduce taxation.
The necessity of combination to maintain the price of any
commodity to the tariff point, furnishes proof that some one is
willing to accept lower prices for such commodity, and that such
prices are remunerative; and lower prices produced by competition
prove the same thing. Thus where either of these conditions exists, a
case would seem to be presented for an easy reduction of taxation.
 The considerations which have been presented touching our tariff
laws are intended only to enforce an earnest recommendation that
the surplus revenues of the government be prevented by the
reduction of our customs duties, and, at the same time, to emphasize
a suggestion that in accomplishing this purpose, we may discharge a
double duty to our people by granting to them a measure of relief
from tariff taxation in quarters where it is most needed and from
sources where it can be most fairly and justly accorded.
Nor can the presentation made of such considerations be, with any
degree of fairness, regarded as evidence of unfriendliness toward our
manufacturing interests, or of any lack of appreciation of their value
and importance.
These interests constitute a leading and most substantial element
of our national greatness and furnish the proud proof of our
country’s progress. But if in the emergency that presses upon us our
manufacturers are asked to surrender something for the public good
and to avert disaster, their patriotism, as well as a grateful
recognition of advantages already afforded, should lead them to
willing coöperation. No demand is made that they shall forego all the
benefits of governmental regard; but they cannot fail to be
admonished of their duty, as well as their enlightened self-interest
and safety, when they are reminded of the fact that financial panic
and collapse, to which the present condition tends, afford no greater
shelter or protection to our manufactures than to our other
important enterprises. Opportunity for safe, careful, and deliberate
reform is now afforded; and none of us should be unmindful of a
time when an abused and irritated people, heedless of those who
have resisted timely and reasonable relief, may insist upon a radical
and sweeping rectification of their wrongs.
The difficulty attending a wise and fair revision of our tariff laws is
not underestimated. It will require on the part of the Congress great
labor and care, and especially a broad and national contemplation of
the subject, and a patriotic disregard of such local and selfish claims
as are unreasonable and reckless of the welfare of the entire country.
Under our present laws more than four thousand articles are
subject to duty. Many of these do not in any way compete with our
own manufactures, and many are hardly worth attention as subjects
of revenue. A considerable reduction can be made in the aggregate,
by adding them to the free list. The taxation of luxuries presents no
features of hardship; but the necessaries of life used and consumed
by all the people, the duty upon which adds to the cost of living in
every home, should be greatly cheapened.
The radical reduction of the duties imposed upon raw material
used in manufactures, or its free importation, is of course an
important factor in any effort to reduce the price of these
necessaries; it would not only relieve them from the increased cost
caused by the tariff on such material, but the manufactured product
being thus cheapened, that part of the tariff now laid upon such
product, as a compensation to our manufacturers for the present
price of raw material, could be accordingly modified. Such reduction,
or free importation, would serve beside to largely reduce the revenue.
It is not apparent how such a change can have any injurious effect
upon our manufacturers. On the contrary, it would appear to give
them a better chance in foreign markets with the manufacturers of
other countries, who cheapen their wares by free material. Thus our
people might have the opportunity of extending their sales beyond
the limits of home consumption—saving them from the depression,
interruption in business, and loss caused by a glutted domestic
market, and affording their employés more certain and steady labor,
with its resulting quiet and contentment.
The question thus imperatively presented for solution should be
approached in a spirit higher than partisanship and considered in
the light of that regard for patriotic duty which should characterize
the action of those intrusted with the weal of a confiding people. But
the obligation to declared party policy and principle is not wanting to
urge prompt and effective action. Both of the great political parties
now represented in the Government have, by repeated and
authoritative declarations, condemned the condition of our laws
which permits the collection from the people of unnecessary revenue,
and have, in the most solemn manner, promised its correction; and
neither as citizens or partisans are our countrymen in a mood to
condone the deliberate violation of these pledges.
Our progress toward a wise conclusion will not be improved by
dwelling upon the theories of protection and free trade. This savors
too much of bandying epithets. It is a condition which confronts us—
not a theory. Relief from this condition may involve a slight
reduction of the advantages which we award our home productions,
but the entire withdrawal of such advantages should not be
contemplated. The question of free trade is absolutely irrelevant; and
the persistent claim made in certain quarters, that all efforts to
relieve the people from unjust and unnecessary taxation are schemes
of so-called free-traders, is mischievous and far removed from any
consideration for the public good.
The simple and plain duty which we owe the people is to reduce
taxation to the necessary expenses of an economical operation of the
government, and to restore to the business of the country the money
which we hold in the treasury through the perversion of
governmental powers. These things can and should be done with
safety to all our industries, without danger to the opportunity for
remunerative labor which our workingmen need, and with benefit to
them and all our people, by cheapening their means of subsistence
and increasing the measure of their comforts.
The Constitution provides that the President “shall, from time to
time, give to the Congress information of the state of the Union.” It
has been the custom of the Executive, in compliance with this
provision, to annually exhibit to the Congress, at the opening of its
session, the general condition of the country, and to detail, with
some particularity, the operations of the different Executive
Departments. It would be especially agreeable to follow this course at
the present time, and to call attention to the valuable
accomplishments of these departments during the last fiscal year.
But I am much impressed with the paramount importance of the
subject to which this communication has thus far been devoted, that
I shall forego the addition of any other topic, and only urge upon
your immediate consideration the “state of the Union” as shown in
the present condition of our treasury and our general fiscal situation,
upon which every element of our safety and prosperity depends.
The reports of the heads of departments, which will be submitted,
contain full and explicit information touching the transaction of the
business intrusted to them, and such recommendations relating to
legislation in the public interest as they deem advisable. I ask for
these reports and recommendations the deliberate examination and
action of the Legislative branch of the government.
 There are other subjects not embraced in the departmental reports
demanding legislative consideration and which I should be glad to
submit. Some of them, however, have been earnestly presented in
previous messages, and as to them, I beg leave to repeat prior
recommendations.
As the law makes no provision for any report from the department
of State, a brief history of the transactions of that important
Department, together with other matters which it may hereafter be
deemed essential to commend to the attention of the Congress, may
furnish the occasion for a future communication.

Grover Cleveland.

Washington, December 6, 1887.

 Mr. Blaine’s Answer to Cleveland.

By Cable to the N. Y. Tribune.

Paris, Dec. 7, 1887.—After reading an abstract of the President’s
message, laid before all Europe this morning, I saw Mr. Blaine and
asked him if he would be willing to give his views upon the
recommendation of the President in the form of a letter or interview.
He preferred an interview, if I would agree to send him an intelligent
shorthand reporter, with such questions as should give free scope for
an expression of his views. The following lucid and powerful
statement is the result. Mr. Blaine began by saying to the reporter:
“I have been reading an abstract of the President’s message and
have been especially interested in the comments of the London
papers. Those papers all assume to declare that the message is a free
trade manifesto and evidently are anticipating an enlarged market
for English fabrics in the United States as a consequence of the
President’s recommendations. Perhaps that fact stamped the
character of the message more clearly than any words of mine can.”
“You don’t mean actual free trade without duty?” queried the
reporter.
“No,” replied Mr. Blaine. “Nor do the London papers mean that.
They simply mean that the President has recommended what in the
United States is known as a revenue tariff, rejecting the protective
feature as an object and not even permitting protection to result
freely as an incident to revenue duties.”
“I don’t know that I quite comprehend that last point,” said the
reporter.
“I mean,” said Mr. Blaine, “that for the first time in the history of
the United States the President recommends retaining the internal
tax in order that the tariff may be forced down even below the fair
revenue standard. He recommends that the tax on tobacco be
retained, and thus that many millions annually shall be levied on a
domestic product which would far better come from a tariff on
foreign fabrics.”
“Then do you mean to imply that you would favor the repeal of the
tobacco tax?”
“Certainly; I mean just that,” said Mr. Blaine. “I should urge that it
be done at once, even before the Christmas holidays. It would in the
first place bring great relief to growers of tobacco all over the
country, and would, moreover, materially lessen the price of the
article to consumers. Tobacco to millions of men is a necessity. The
President calls it a luxury, but it is a luxury in no other sense than tea
and coffee are luxuries. It is well to remember that the luxury of
yesterday becomes a necessity of to-day. Watch, if you please, the
number of men at work on the farm, in the coal mine, along the
railroad, in the iron foundry, or in any calling, and you will find 95 in
100 chewing while they work. After each meal the same proportion
seek the solace of a pipe or a cigar. These men not only pay the
millions of the tobacco tax, but pay on every plug and every cigar an
enhanced price which the tax enables the manufacturer and retailer
to impose. The only excuse for such a tax is the actual necessity
under which the government found itself during the war, and the
years immediately following. To retain the tax now in order to
destroy the protection which would incidentally flow from raising the
same amount of money on foreign imports, is certainly a most
extraordinary policy for our government.”
“Well, then, Mr. Blaine, would you advise the repeal of the whiskey
tax also?”
“No, I would not. Other considerations than those of financial
administration are to be taken into account with regard to whiskey.
There is a moral side to it. To cheapen the price of whiskey is to
increase its consumption enormously. There would be no sense in
urging the reform wrought by high license in many States if the
National Government neutralizes the good effect by making whiskey
within reach of every one at twenty cents a gallon. Whiskey would be
everywhere distilled if the surveillance of the government were
withdrawn by the remission of the tax, and illicit sales could not then
be prevented even by a policy as rigorous and searching as that with
which Russia pursues the Nihilists. It would destroy high license at
once in all the States.
“Whiskey has done a vast deal of harm in the United States. I
would try to make it do some good. I would use the tax to fortify our
cities on the seaboard. In view of the powerful letter addressed to the
democratic party on the subject of fortifications by the late Samuel J.
Tilden, in 1885, I am amazed that no attention has been paid to the
subject by the democratic administration. Never before in the history
of the world has any government allowed great cities on the
seaboard, like Philadelphia, New York, Boston, Baltimore, New
Orleans, and San Francisco, to remain defenceless.”
“But,” said the reporter, “you don’t think we are to have a war in
any direction?”
“Certainly not,” said Mr. Blaine, “Neither, I presume, did Mr.
Tilden when he wrote his remarkable letter. But we should change a
remote chance into an absolute impossibility. If our weak and
exposed points were strongly fortified; if to-day we had by any
chance even such a war as we had with Mexico our enemy could
procure ironclads in Europe that would menace our great cities with
destruction or lay them under contribution.”
“But would not our fortifying now possibly look as if we expected
war?”
“Why should it any more than fortifications made seventy or eighty
years ago by our grandfathers when they guarded themselves against
successful attack from the armaments of that day. We don’t
necessarily expect a burglar because we lock our doors at night, but if
by any possibility a burglar comes it contributes vastly to our peace
of mind and our sound sleep to feel that he can’t get in.”
“But after the fortifications should be constructed would you still
maintain the tax on whiskey?”
“Yes,” said Mr. Blaine, “So long as there is whiskey to tax I would
tax it, and when the National Government should have no use for the
money I would divide the tax among the Federal Union with specific
object of lightening the tax on real estate. The houses and farms of
the whole country pay too large a proportion of the total taxes. If
ultimately relief could be given in that direction it would, in my
judgment, be a wise and beneficent policy. Some honest but