Introduction and

History of Orthodontics

Presented by :Dr. Rajesh GyawaliResident,Department of Orthodontics and Dentofacial OrthopaedicsFaculty of Dentistry,Institute of Medicine, Kathmandu

Guided by :Dr. Basant Kumar ShresthaAssociate Prof. and HeadDepartment of Orthodontics and Dentofacial Orthopaedics

Faculty of Dentistry, Institute of Medicine, KathmanduIntroduction

Orthodontics is a branch of dentistry concerned with prevention, interception and correction of malocclusion and other abnormalities of dentofacial region. The word – orthodontics is derived from Greek word –Orthos (which means - to correct) and Odontos (which means - teeth). In simple term, it is a branch of dentistry which deals with alignment of teeth. The term “Orthodontics” was coined by Le Felon.

Various definitions of Orthodontics have been proposed. Some of them to list are-1. By Salzmann (1943) :

“A branch of science and art of dentistry which deals with the developmental and positional anomalies of the teeth and the jaws as they affect oral health and the physical, esthetic and mental well being of the person.”

2. By Noyes (1911) : “The study of the relation of the teeth to the development of the face, and the correction of arrested and perverted development.”

3. British Society of Orthodontics (1922) : “Orthodontics includes the study of growth and development of the jaws and face particularly and the body generally, as influencing the position of the teeth; the study of action and reaction of internal and external influences on the development, and the prevention and correction of arrested and perverted development.”

4. American Board of Orthodontics (ABO) : “Orthodontics is that specific area of the dental profession that has its responsibility the study and supervision of the growth and development of dentition and its related anatomical structures from birth to dental maturity, including all preventive and corrective procedures of dental irregularities requiring the repositioning of teeth by functional and mechanical means to establish normal occlusion and pleasing facial contours.”

Branches of Orthodontics :Orthodontics can be broadply classified into 4 branches –

1. Preventive Orthodontics It is defined as the –‘Actions taken to preserve the integrity of what appears to be normal.’ It includes the procedures undertaken prior the onset of malocclusion. Eg: Elimination of deleterious habits affecting dentofacial structures, correction of general contributory causes like abnormal posture, malnutrition, maintainence of tooth form by

proper restoration of individual tooth, timely removal of the retained deciduous teeth, use of space maintainers after premature loss of primary tooth.

2. Interceptive Orthodontics It is defined as ‘That phase of the science and art of orthodontics, employed to recognize and eliminate potential irregularities and malpositions in the developing dentofacial complex. It includes the procedures undertaken at an early stage of malocclusion to eliminate or reduce the severity of the same. E.g.: Caries control, anatomic dental restoration, space maintenance, transitory oral habit correction.

3. Corrective Orthodontics It includes the procedures undertaken to correct the fully established malocclusion.

4. Surgical Orthodontics It includes the surgical procedures done in conjunction with or as an adjunct to the orthodontic treatment. It can prevent or correct periodontal problems, facilitate and hasten orthodontic treatment, reduce relapse, add to post orthodontic stability and improve esthetics and function in the patients.

Aims of orthodontic treatment:The aims of orthodontic treatment has been summarized by Jackson and called as

Jackson’s Triad. The 3 main objectives are-1. Functional efficiency

The teeth along with the surrounding structures are required to perform certain important functions. The orthodontic treatment should increase the efficiency of the functions performed by the stomatognathic system.

2. Esthetic harmony The orthodontic treatment should increase the overall appearance .The aim is to get results which match with the patient’s personality and make him look more esthetic.

3. Structural balance The structures affected by the orthodontic treatment include not only the teeth but also the surrounding soft tissue envelope and the associated skeletal structures. The treatment should maintain a balance between these structures, and the correction of one should not be detrimental to the health of the another.

Scopes of Orthodontic TreatmentThe scopes of orthodontic treatment is aimed at alteration in tooth position, skeletal

pattern and soft tissue envelope.

1. Alteration in tooth position:

Many malocclusion involving the dental system can be effectively treated by moving teeth into more ideal location by applying appropriate force on them. How efficiently this can be performed and to what extent, depends upon the nature of the malocclusion and the capability of each individual.

2. Alteration in the skeletal pattern: Using functional appliances and orthognathic surgeries, it is possible to position the jaws in more favourable position or to direct/ restrict the growth of jaws in certain direction. It can bring about changes in all the three planes of space i.e. sagittal, transverse and vertical.

3. Alteration in soft the envelope: The soft tissue that envelop the dentition are greatly influenced by the placement of the dentition. It is possible to bring about the favourable changes in the soft tissue pattern by orthodontic treatment.

Goals of Orthodontic Treatment:Angle introduced the hard tissue or Angle paradigm where in the primary goal of

orthodontics is to establish an ideal dental occlusion is followed by jaw relationship as a secondary goal. He was of the opinion that establishing proper dental occlusion produces an ideal soft tissue pattern. He was against the extraction concept.

Akermann and Profitt believe that soft tissue determine therapeutic modifiability. So, soft tissue are recognized as both: major limitation and major consideration in orthodontic treatment. So, the change in goals of treatment represents a paradigm shift, away from an emphasis on skeletal and dental relationship and towards greater consideration of the oral and facial soft tissue.

Angle versus Soft tissue paradigm:

Parameter Angle’s Paradigm Soft tissue ParadigmPrimary treatment goal Ideal dental occlusion Normal soft tissue

proportions and adaptationsSecondary treatment goal Ideal jaw relation Functional occlusionHard and Soft tissue relationship

Ideal hard tissue proportions produce ideal soft tissues

Ideal soft tissue proportions define ideal hard tissue

Diagnostic emphasis Dental casts, cephalometric radiographs

Clinical examination of intra oral and facial soft tissue

Treatment approach Obtain ideal dental and skeletal relationships, assume the soft tissue will be OK

Plan ideal soft tissue relationship and then place teeth and jaws as needed to achieve this

Function emphasis TM joint in relation to dental Soft tissue movement in

occlusion relation to display of teethStability of the result Related primarily to dental

occlusionRelated primarily to soft tissue pressure/equilibrium effects

Roth and William have suggested a goal oriented treatment plan. Quality of life of a person is defined as the “sense of well being” that arises from satisfaction or dissatisfaction with the areas of life that are important to that person. Health of a person is a principal contributor to the quality of life and the impact of health and disease in the quality of life is known as health –related quality of life (HRQL).

Functional Occlusion

Periodontal Esthetics Health

TMJ health Facial Harmony Patient Long term Satisfaction stability

Roth Williams’ concept of goals of orthodontics

Abdul Kader introduces the term psychosomatic norm in orthodontics. Psychosomatic norm is an individual perception of norms developed unconsciously and seated in the subconscious. The sense of psychosomatic norm differs between races and generations, and by socioeconomic status and educational norm. Conflict may arise between patient and orthodontist if the orthodontist fails to understand the psychosomatic norm of the patient. Hence, psychosomatic norm also should be considered while deciding the orthodontic treatment.

Hence, today’s concept of goals of orthodontic treatment includes a wider horizon of establishing a normal esthetic and functional occlusion within the framework of balanced oral and facial soft tissues; and to maintain the health of teeth and supporting tissues with due consideration to long term stability of treatment.

History of OrthodonticsThe term “Orthodontics” was coined by Jacques Lefoulon in 1839. The term

“Orthopedics” was first used by Bunon in the year 1743 with regards to correction of teeth. Finally, A.F. Talma used the terms “Orthodontics and Dental Orthopedics” together.

The history of orthodontics has been intimately interwoven with the history of dentistry for more than 2000 years. Dentistry, in turn, had its origins as a part of medicine.

To properly study our orthodontic origins, we must return to the Greek civilization. The Greek physician Hippocrates (460 to 377 BC) is considered as a pioneer in medical science, chiefly because of his medical authorship. He was the first to separate medicine from fancy or religion, and with his reports of critical observation and experience, he established a medical tradition based on facts. This collected information was gathered into a text known as the Corpus Hippocraticum, the medical testament of the pre-Christian era.

This treatise does not discuss the dental art independently but contains many references to the teeth and the tissues of the jaws as part of the medical text. An example:

The first teeth are formed by the nourishment of the fetus in the womb. The shedding of the first teeth generally takes place about seven years of age. Children who cut their teeth in winter time get over the teeth period best. Among those individuals whose heads are long-shaped, some have thick necks, strong

members and bones; others have strongly arched palates; thus teeth are disposed to irregularity, crowding one on the other and they are molested by headaches and otorrhea. (Epidemics, chapter: de carnibus.)

Aristotle (384 to 322 BC), the Greek philosopher, was the first writer who studied the teeth in a broad manner, examined them in relation to the dentitions of various types of animals. He may be regarded as the first comparative dental anatomist because, in his famous work entitled De Partibus Animalium (On the Parts of Animals), he compared the various dentitions of the known species of animals of that time. He noted that there were marked differences between human teeth and those of animals and, in fact, differences between the different species of animals. He described the dental apparatus of the viviparous animal, distinguishing between teeth, tusks, and horns.

Aulius Cornelius Celsus (25 BC to AD 50), Roman medical author, wrote in De Re Medicina (On Medicine): When in a child a permanent tooth appears before the fall of the milk tooth, it is necessary to dissect the gum all around the latter and extract it. The other tooth must then be pushed with the finger, day by day, toward the place that was occupied by the one extracted; and this is to be continued until it reaches its proper position.

Claudius Galenus, commonly known as Galen (AD 130 to 200?) described dental anatomy and embryology by specifically identifying the origin, growth, and development of the teeth and enumerating the functions of each. He believed the teeth to be true bones. Because dissection was performed on animals rather than on human beings, he erroneously applied some of his findings to human beings (e.g., the presence of an intermaxillary bone and the insensibility of teeth).

Middle Ages (476 - 1450 A.D.)An Arabic physician, Paulus Aegineta (Paul of Aegina)( 625 to 690), wrote:

When supernumerary teeth cause an irregularity of dental arches, they may be corrected by resection of such teeth or by extraction. In case one projects above the level of others, the part protruding should be removed by means of a file (epitome).

He also stated that irregular teeth were “displeasing in women.”

R Renaissance Period (14 th to 16 th Century) nice period (fourteenth to sixteenth century) TOP

During the Renaissance, one of the greatest geniuses of history, Leonardo da vinci (1452 to 1519), is remembered because he painted a smile on the lips of Mona Lisa. Her smile remains most provocative; yet the brush was only one of the many tools he mastered.

He was the first artist to dissect the human body for the acquisition of anatomic knowledge and the first to draw accurate pictures of these dissections.

Leonardo was the first to recognize tooth form and the first to realize that each tooth was related to another tooth and to the opposing jaw as well, thus perceiving the articulation of the teeth.

He described the maxillary and frontal sinuses and established their relationship to facial height.

He determined and made drawings of the number of teeth and their root formations.

He noted that “those teeth that are the farthest away from the line of the temporomandibular articulation are at a mechanical disadvantage as compared with those that are nearer.”

Those (teeth) that act most powerfully, the mascellari (molars) have broad flattened crowns suitable for grinding the food, but not for tearing or cutting it; those that act less powerfully, the incisors, are suitable for cutting the food but not for grinding it; while the maestre (canines) are intermediate between these two sets, their function being presumably that of tearing the food.

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Andreas Vesalius (1514 to 1564), was a Belgian physician and anatomist. In his book-“On the Fubric of the Human Body”, he described the minute anatomy of the teeth, particularly the dental follicle and subsequent pattern of tooth eruption:“We believe that only the teeth among the bones are given the perceptible faculty of sensationby certain small soft nerves, propagated by the third pair of cranial nerves and implanted at their roots ... the Almighty Artificer of things deservedly is to be praised Who, we believe, liberally bestowed the noteworthy faculty of sensation on the teeth alone among the rest of the bones. For He knew that they will frequently encounter objects which might cut, break, or scratch them, unduly heat or chill them, or affect them in some other way... . Consequently, had they no power of sensation, Man would not be warned by pain and would not protect the tooth by avoiding the injurious agent before the threatened teeth are damaged. There are usually thirty-two teeth in all, a single series of sixteen in each jaw, most fittingly placed in the form of a semi-circle. The first four front teeth, because they cut, are called incisors; next come the canines placed singly at each side, to have torn apart that not done by the incisors. They receive their name because of their resemblance to the outthrust of dogs. After them are the maxillares, or molars, five on each side, rough, broad, hard and large by means of which food cut by the incisors and broken up by the canines can be ground to perfect smoothness.”

Ambrose Paré (1517? to 1590), a French surgeon, paid specific attention to dentofacialdeformities, especially to the cleft palate. He was the first surgeon to devise an obturator for treatment.

Gabriele Fallopio (1523 to 1562), commonly known as Fallopius, an Italian anatomist, wrote in his Observationes Anatomica (Anatomic Observations) a detailed description of the dental follicle. He also gave us the terms hard and soft palate. A membranous follicle is formed inside the bone furnished with two apices, one posterior (that is to say, deeper down, more distant from the gums), to which is joined a small nerve, a small artery and a small vein; the other anterior (that is, more superficial) which terminates in a filament ... inside the follicle is formed a special white and tenacious substance, and from this the tooth itself, which at first is osseous only in the part nearest the surface, whilst the lower part is still soft, that is, formed of the above mentioned substance. Each tooth comes out traversing and widening a narrow aperture ... bare and hard; and in process of time the formation of its deeper part is completed.

Bartholomaeus Eustachio (1520 to 1574), commonly known as Eustachius, also an Italian anatomist, wrote Libellus de Dentibus (Book on the Teeth) in 1563, which is the first important specialized monograph on the anatomy of the teeth. In this book, he collected the writings of various authors from Hippocrates to Vesalius, added the results of his own researches, and gave the first accurate account of the phenomenon of the sequential development of the first and second dentitions. He described the eruption and the function of the teeth, contending that there was no analogy between the deciduous and permanent dentitions. Eustachius devoted more attention to the teeth than most anatomists, giving full descriptions of the different forms, number and varieties. He indicated the manner of articulation of the teeth and gave a somewhat ambiguous explanation of the nature of the attachment of the teeth to the socket and the gingival tissues, comparing the latter to the attachment of the nails to the skin. His explanation of the internal structure of the teeth differentiated the two layers and compared the enamel with the bark of trees.

Eustachius described the dental follicle and its blood supply. He refuted the doctrine that roots of the deciduous dentition served to form the permanent teeth. He maintained that the germs of the permanent teeth are too small to be seen in the fetus. He also mentioned that the teeth are nourished differently than other bones, as witnessed by their inability to repair when fractured.

The first book in the German language to have reference to the teeth was entitled Arzei Buchlein (A Book of the Surgical Art) and was published in 1530 (author unknown). It contains the following comment:When teeth begin to drop out ... push the new one every day toward the place where the first one was until it sits there and fits among the others, for if you neglect to attend to this, the old teeth (deciduous) will remain and the young ones (permanent) will be impeded from growing straight.

Eighteenth Century: Pierre Fauchard (French scientist) is referred to as the “Founder of Modern Dentistry.”

He gave to this new branch of medicine a scientific and sound basis for the future. The results of his labors are reflected in the publication of his two-volume book entitled Le Chirurgien Dentiste, ou Traite Des Dents (The Surgeon Dentist, A Treatise on the Teeth). With reference to orthodontics, as early as 1723, he developed what is probably the first orthodontic appliance. It was called a bandolet. It was designed to expand the arch, particularly the anterior teeth and was the forerunner of the expansion arch of modern times. If the teeth are much out of line and cannot be corrected by means of threads, it is necessary to use a band of silver or gold. The width of the band should be less than the height of the teeth to which it is applied. The band must neither be too stiff nor too flexible. Two holes are made at each end, a thread passing partially through forms a loop in the middle of each thread ... by the pressure and support given the band the inclined teeth will be made upright for a short time.

Another important French dental surgeon was Robert Bunon (1702 to 1788), who wrote in his book, entitled “Essay on the Teeth”:I claim that a good formation of the teeth can be procured if care is given them from the earliest age. I even go further and I say that the tooth germs and the tooth materials are favorably disposed by the regimen of the prospective mother. One child, by the state of his teeth, appears too young at fifteen or sixteen years of age for certain operations, which for him may be premature, and another child of eleven or twelve years old, may sometimes have waited so long for a remedy that, in this case, it is already too late.

In 1757 Etienne Bourdet (1722 to 1789), the dentist to the King of France, advocated the Fauchard method but went a step further by recommending only gold strips on the labial surface for the upper arch and on the lingual surface for the lower arch. He wrote in his Recherches et Observationes sur Toutes les Parties de L'art du Dentiste (Researches and Observations on Every Branch oftheArt ofthe Dentist):

The strings should be removed and retightened twice a week, until the teeth have resumed their proper position—that is to say, until the teeth of the upper jaw are drawn forward so that no part of them is hidden behind those of the lower jaw.

Bourdet differed with Fauchard in that he recommended the extraction of the first premolars to preserve symmetry of the jaws. In children who had protruding chins, Bourdet corrected this by extracting the mandibular first molars shortly after eruption.

In England, John Hunter (1728 to 1793), a great teacher of anatomy, published “The Natural History of the Human Teeth: Explaining Their Structure, Use, Formation, Growth and Diseases”. It was published in 1771 and initiated a new era in dentistry by placing dentistry on the basis of scientific observation at a time when empiricism was rampant. Hunter's descriptions of the formation and the growth of the teeth and jaws excelled anything previously published. He demonstrated the growth, development, and articulation of the maxilla and mandible with the attached musculature and outlined the internal structure of the teeth (enamel) and bone (dentin) and their separate functions. His innumerable experiments and observations of case histories established the difference between bone and teeth for the first time. Because he improperly prepared the specimens, in that he had failed to inject disclosing material in teeth during a series of experiments, he erroneously concluded that teeth were “nonvascular.” For the nomenclature of dentistry, he labeled incisors, bicuspids, and molars.

Robert Blake, a disciple of Hunter, followed in his footsteps of scientific inquiry, as demonstrated by his thesis presented to the University of Edinburgh entitled “On the Structure and Formation of the Teeth in Man and Various Animals.” It was published in 1798. The following is an excerpt from the text:“I feel myself justified that the alveolar arches continue to increase during the entire progress of the formation of the teeth. It is, however, sufficiently evident that the greatest increase of the jaws is backward ... we frequently meet with disproportions between the jaws and teeth,

and in such that the permanent teeth never would become regular without the assistance of the art.”

In Germany during the eighteenth century, little attention was paid to the dental art. However, we should note that Gottfried Janke attributed the shedding of deciduous teeth to the obliteration of their vessels by the compression of the erupting permanent teeth. Adam A. Brunner (1737 to 1810) advised that “miLk teeth should never be extracted unless there be manifest signs of the presence of the corresponding permanent teeth, or when it is painful or decayed.”

Pierre Fauchard is referred as the “Father of Modern Dentistry.” He developed the first orthodontic appliance – bandolet, designed for arch expansion, particularly the anterior teeth and was the forerunner of the expansion arch of modern times. If the teeth are much out of line and cannot be corrected by means of threads, it is necessary to use a band of silver or gold. The width of the band should be less than the height of the teeth to which it is applied. The band must neither be too stiff nor too flexible. Two holes are made at each end, a thread passing partially through forms a loop in the middle of each thread ... by the pressure and support given the band the inclined teeth will be made upright for a short time.

In 1757 Etienne Bourdet (1722 to 1789), the dentist to the King of France, advocated the Fauchard method but went a step further by recommending only gold strips on the labial surface for the upper arch and on the lingual surface for the lower arch.

He wrote in his Recherches et Observationes sur Toutes les Parties de L'art du Dentiste (Researches and Observations on Every Branch oftheArt ofthe Dentist): The strings should be removed and retightened twice a week, until the teeth have resumed their proper position—that is to say, until the teeth of the upper jaw are drawn forward so that no part of them is hidden behind those of the lower jaw. Bourdet differed with Fauchard in that he recommended the extraction of the first premolars to preserve symmetry of the jaws. In children who had protruding chins, Bourdet corrected this by extracting the mandibular first molars shortly after eruption.

John Hunter (1728 to 1793), an English anatomist, placed dentistry on the basis of scientific observation at a time when empiricism was rampant. He demonstrated the growth, development, and articulation of the maxilla and mandible, and their relation with the attached musculature. He experimentally established the difference between bone and teeth for the first time. Because he improperly prepared the specimens, in that he had failed to inject disclosing material in teeth during a series of experiments, he erroneously concluded that teeth were “nonvascular.” For the nomenclature of dentistry, he labeled incisors, bicuspids, and molars.

Gottfried Janke attributed the shedding of deciduous teeth to the obliteration of their vessels by the compression of the erupting permanent teeth.

Adam A. Brunner (1737 to 1810) advised that “milk teeth should never be extracted unless there be manifest signs of the presence of the corresponding permanent teeth, or when it is painful or decayed.”

Friedrich Christopher Kneisel was first to use plaster models to record malocclusion and first to attempt to classify malocclusion. He introduced modern impression trays. He wrote the book- “Der Scheifstand Der Zahn”.

Baltimore College of Dental Surgery is the first dental college in the world. It opened its doors to a class of 5 students on Nov 3rd, 1840.

Norman W. Kingsley is considered as “Father of Orthodontics”. He experimented with appliances for the correction of cleft palate. He fabricated gold obturator and artificial velum made of soft rubber. He introduced a technique known as jumping the bite with the use of a bite plate. It was the treatment for protrusion of the maxilla, not necessarily with extractions, shaping the dental arches to be in harmony with each other. He used vulcanite in conjunction with ligatures, elastic bands made of rubber, jackscrews, and the chincap. In 1880 he published A Treatise on Oral Deformities, which remained a textbook for many years. He, too, emphasized the importance of the relationship between mechanics and biology as the principle on which orthodontics should be based. His book was the first to recommend that etiology, diagnosis, and treatment planning were the acceptable bases of practice. “Much success in treating irregularities will depend upon a correct diagnosis and prognosis.”

E.G. Tucker (1846) was the first American to use rubber bands for tooth movement.

Emerson C. Angell was probably the first person to advocate the opening of the median suture to provide space in the maxillary arch In 1860, he used a jack screw type of device between the maxillary premolars in 14 yrs old girl and achieved an increase in arch width by 1/4th inch in 14 days. He is also called Father of Rapid Maxillary Expansion. Walter Coffin in 1877 introduced Coffin spring for arch expansion.

William E. Magill (1871) was the first to cement bands. Henry A. Baker (1893) introduced intermaxillary rubber bands to correct protrusions. It is now known as “Baker’s anchorage”

Edward Hartley Angle (1855-1930) is considered as Father of Modern Orthodontics. Angle’s original interest was in Prosthodontics, and he taught in that department in the dental schools at Pennsylvania and Minnesota in the 1880s. His increasing interest in dental occlusion and in the treatment necessary to obtain normal occlusion led directly to his development of orthodontics as a specialty. He established Angle School Of Orthodontics in St. Louis ,Connecticut in 1900 and Pasadena in 1920. He founded American Society Of Orthodontics in 1901.

The publication of Angle's classification of malocclusion in the 1890s was an important step in the development of orthodontics because it not only subdivided major types of

malocclusion but also included the first clear and simple definition of normal occlusion in the natural dentition.

The “Angle Orthodontist” Journal was founded in his memory in 1931…

Angle’s postulates : Upper first molars are the key to occlusion and the most stable landmark in

craniofacial anatomy. Upper & lower molars should be related so that the mesiobuccal cusp of the

upper molar occludes in the buccal groove of the lower molar. If this molar relationship existed and the teeth were arranged on a smooth

curving line of occlusion, then normal occlusion would result.

Angle then described three classes of malocclusion, based on the occlusal relationships of the first molars:

Normal occlusion: Normal relationship of the molars and the correct line of occlusion.

Class I: Normal relationship of the molars, but line of occlusion incorrect because of malposed teeth, rotations, or other causes.

Class II: Lower molar distally positioned relative to upper molar, line of occlusion not specified.

Class III: Lower molar mesially positioned relative to upper molar, line of occlusion not Specified.

Normal Occlusion Class I Malocclusion

Class II Malocclusion Class III Malocclusion

Line of occlusion: It is a smooth (catenary) curve passing through the central fossa of each upper molar and across the cingulum of the upper canine and incisor teeth. The same line runs along the buccal cusps and incisal edges of the lower teeth, thus specifying the occlusal as well as interarch relationships once the molar position is established.

Angle believed that every person has the potential for an ideal relationship of all 32 natural teeth. Angle and his followers strongly opposed extraction for orthodontic purpose. He paid less attention to the facial proportion and esthetics.

On being asked about his ‘discovery’ of the constancy of the upper first molar Angle said – “I thought about it & I thought about it & all at once it came to me. Anybody who disagrees with me must be a fool”.

Angle’s Progrression to Edgewise ApplianceWith few exceptions, the fixed appliances used in orthodontics now are based on

Angle’s design.Angle developed 4 major appliance system:

1. E- Arch2. Pin and Tube3. Ribbon Arch4. Edgewise

1. E- Arch It consists of a rigid framework of a heavy labial archwire extended around the arch. Bands were placed on the molars and individual teeth were simply ligated to this rigid framework. It can deliver only heavy interrupted force. Only tipping movement is possible and precise positioning of individual tooth is not possible.

2. Pin and Tube To overcome the difficulty in precise positioning of individual tooth, Angle placed

bands on other teeth and used a vertical tube on each tooth into which a soldered pin from a smaller arch wire was placed.

An incredible degree of craftsmanship was involved in constructing and adjusting this pin and tube appliance. Although theoretically possible of precise movement, it proved impractical. Only Angle and one of his students mastered this appliance.

3. Ribbon Arch It consisted of vertically positioned rectangular slot. A ribbon arch of 10 × 20 gold wire was placed into the slot and held with pins. It was small enough to have good spring qualities and was quite efficient in aligning malposed teeth.

The resiliency of ribbon arch wire did not allow generation of the moment necessary to torque roots to a new position.

4. Edgewise To overcome the difficulties of ribbon arch, Angle reoriented the slot from

vertical to horizontal and inserted a rectangular wire rotated 90 degree to the orientation it had with the ribbon arch. The dimension of the slot is altered to 22×28 mils and a 22×28 precious metal wire was used.

With this technique, there is excellent control of crown & root position in all three planes of space.

Martin Dewey (1881-1933) founded and became editor of International Journal of Orthodontia (now called American Journal of Orthodontics). In 1914, he wrote ‘Practical orthodontics’, a textbook on orthodontic philosophy and mechanical procedures. In 1911, he established Dewey school of orthodontia, similar to that formed by Angle in 1900.

To Extract or Not to Extract: Controversies: Angle was influenced by Rousseau & the German physiologist Wolff.

Rousseau emphasized the perfectability of man. This led Angle to believe that every person has the potential for an ideal relationship of all 32 natural teeth. He was against the extraction concept.

German physiologist Wolff discovered in early 1900s that the internal architecture of bone responds to stresses placed on that part of the skeleton. So, Angle believed that :

1. If bone remodelled when stressed, the etiology of Class II or Class III problems must be abnormal stresses on the jaws. So, different pattern of pressure associated with treatment could change growth so as to overcome the problem.

2. If the teeth were placed in proper occlusion, forces transmitted to the teeth would cause bone to grow around them & stabilize them even if a great deal of arch expansion had occurred.

Angle believed that relapse after expansion of arch or after overjet/overbite correction is because adequate occlusion has not been achieved. If the orthodontic result was not stable, it was the fault of the orthodontist, not the theory. He emphasized that (whether a person liked the outcome or not) the best facial appearance for him would be achieved when the dental arches has been expanded so that all the teeth are in ideal occlusion.

Angle believed that extraction is not necessary for stability of the result or esthetics.

Dr. Calvin Case (1847-1923) argued that although arches could always be expanded for alignment of teeth, neither esthetics nor stability would be satisfactory in long term in many patients. Case believed that facial improvement was a guide to orthodontic treatment. He was critic of Angle and opposed Angle’s philosophy of arch expansion in every case. He introduced the concept of removal of certain teeth to enable correction of malocclusion and improve facial esthetics.

Case was the first to stress on root movement & use rubber elastics in treatment. He was one of the first to use small gauze, light resilient wires for tooth alignment. He pioneered the use of retainers to stabilize orthodontic results.

In 1911, Annual meeting of the National Dental Association (now ADA) was held. At that meeting, debate between Angle’s student - Dewey & Case was one of the most sharpest and most heated controversies. But Angle & his followers won the day. Extraction of teeth for orthodontic purpose essentially disappeared from the orthodontic scene in the period between the two world wars.

By 1930s, relapse after non extraction treatment were frequently observed. Charles Tweed(Angle’s student) decided to re-treat these cases with extraction. First four premolars were removed and the anterior teeth were aligned and retracted. After re-treatment, the occlusion was much more stable. His presentation of consecutively treated cases with the premolar extraction caused a revolution in American orthodontic thinking and led to widespread reintroduction of extraction in orthodontic therapy.

Tweeds contributions are –• Acceptance of extraction of teeth.• Upright mandibular incisors over basal bone.• Serial extraction of primary & permanent teeth.• Tweed’s diagnostic facial triangle.• Introduced anchorage preparation.

Raymond Begg in Australia also concluded that non- extraction treatment was unstable. Like Tweed, he modified Angle’s appliance (ribbon arch) adapting it for extraction and produced what is now called the Begg appliance.

Charactristics of Begg’s appliance:1. Replacement of precious metal ribbon arch with high strength 16mil stainless steel wire.2. He retained the original ribbon arch bracket but turned it upside down so that the

bracket slot points gingivally.3. He added auxillary springs to the appliance for control of root position.

In the resulting Begg’s appliance, the friction was minimized due to small contact area between bracket and wire; and the force of the wire against the bracket was also small. Begg’s strategy for anchorage control was tipping/uprighting. It is a complete appliance in the sense that it allows good control of crown and root position in all three planes of space. Now , Begg’s appliance can be seen hybrid form with brackets that allow the use of rectangular wires in finishing.

In the 1960s, Begg appliance became widely popular because it was more efficient than the edgewise appliance. But now, edgewise appliances have been developed far beyond (retaining the basic principle of rectangular wire in rectangular slot) and is more efficient than Begg’s.

Steps in evolution of the edgewise appliance –

1. Automatic Rotation control In the original appliance, Angle soldered eyelets to the corners of the bands, so a

separate ligature could be used to control/correct rotation if needed. Now rotation control is achieved by using either twin brackets or single brackets with extension wings that contact the underside of the archwire.

2. Alteration in bracket slot dimension Original bracket slot dimension is reduced from 22 to 18 mil. Reducing bracket

slot and arch wire size reduces the friction associated with sliding of tooth along the wire.

3. Straight wire prescription Angle used the same brackets in all tooth. In 1900, Andrews developed bracket

modification for specific teeth to eliminate many repetitive bends in archwires . The result was the “straight wire appliance”.

First order bend in labiolingual direction is compensated by the base of the bracket itself.

Mesiodistal root positioning required second order bends. Angulating the bracket or bracket slot decreases or removes the necessity of these bends.

The facial surface of teeth varies in inclination with true vertical. So, a third order bends were necessary in rectangular archwire to make the wire fit passively. Now the bracket slots are inclined to compensate for the inclination of the facial surface.

Albert. H. Ketcham-(1870-1935) entered the Angle School of Orthodontia in 1902. He was first to introduce X-Ray and photography in Orthodontics. He was concerned about the possible consequences of mechanotherapy. He investigated the problem of root resorption.

Milo Hellman (1873-1947) was Angle’s student. He studied the development of the human dentition and face with precise anthropometric techniques. He demonstrated the occlusal relationship of the upper and lower molars in man and indicated the evolutionary trend of the cuspal interdigitation. He demonstrated high percentage of upper 1st molar rotation and warned in classifying malocclusion. He pioneered the use of hand- wrist radiograph to determine the growth age and status of the patient.

Parallel developments in European OrthodonticsIn America, fixed appliances were getting popular where as Europeans developed

removable and myofunctional appliances. The reasons were-

1. Angles dogmatic approach to occlusion – less impact in Europe.2. Social welfare systems developed rapidly.3. Precious metal for fixed appliances less available.

Removable appliances were differentiated into –1. Active Plate aimed at moving teeth2. Activators or functional appliances aimed at modifying growth

Activator: Kingsley in 1879 made a vulcanite plate which consisted of an anterior incline that

guided the mandible to a forward position while closing. Holtz devised a ‘Vorbissplatte’ which was a modified form of Kingsley’s plate.It is used

to treat retrognathism associated with deep bite. Pierre Robbin devised “Monobloc” made of single block of vulcanite. It is used to

position the mandible forward in patients with glossoptosis and severe mandibular retrognathism.

Viggo Andresen in 1908 developed a loose fitting appliance, which was a modified Hawley’s retainer on maxillary arch to which added a lower lingual horse-shoe shaped flange which helped in positioning the mandible forward. He first used this appliance in his own daughter and found marked sagittal correction and improvement in profile.

Vestibular screen: Developed by Newell in 1912. Takes the form of curved shield of acrylic placed in the labial vestibule.

Martin Schwartz in Vienna developed Split plate appliance which could produce most types of tooth movements.

Philips Adams modified arrowhead clasp made by Schwartz into the Adam’s crib, which is still the most effective clasp for orthodontic purpose.

Functional Regulator Also called as Frankel appliance, vestibular appliance and oral gymnastic appliance. Developed by Professor Rolf Frankel of Germany.

Bionator Developed by Balters during early 1950s. Similar to activator but less bulky and more elastic.

Twin Block Appliance The first twin block appliance was fitted on 7th September 1977 on a patient aged 8

years 4 months. It was comfortable to wear and over jet reduced from 9mm to 4mm in 9 months.

Herbst Appliance Developed by Emil Herbst in early 1900s. It was soon forgotten and reintroduced in 1979 by Hans Pancherz.

Jasper Jumper A flexible, fixed tooth borne functional appliance Introduced by J.J.Jasper in 1980.

John N. Farrar is referred to as the Father of American Orthodontics. He investigated the physiologic and pathologic changes occurring in animals as the result of orthodontically induced tooth movement. He also published Irregularities of the Teeth and Their Correction, in which he demonstrated the many uses of the screw as the motivating attachment and the basis of what he referred to as a system of orthodontia. He stressed the “importance of the observance of the physiologic law which governs tissues, during movement of the teeth, the subject being to prevent pain.” Farrar was the originator of the theory of intermittent force, and the first person to recommend root or bodily movement of the teeth.

Robert Ricketts(1920-2003) developed the bioprogressive therapy from a background of edgewise and Begg technique. He was the founder of American Institute of Bioprogressive Education. He introduced utility arch. He introduced the use of preformed bands. He used computerized cephalometrics for VTOs & STOs.

Melvin L. Moss ( 1923-2006): He did research in craniofacial growth and development and introduced functional matrix hypothesis. He introduced certain nontraditional biomedical engineering principles such as finite element analysis in the modelling of craniofacial growth and orthodontic treatment.

Thomas.M. Graber(1907-2007) did research in craniofacial anomalies, cleft lip and palate, temporomandibular joint antomy and disturbances, orthopaedic growth guidance of dentofacial structures and the use of magnetic forces in orthodontics. He was editor-in-chief of American Journal of Orthodontics and Dentofacial Orthopedics (AJODO) for 15yrs. He wrote 20 textbooks, 22 chapters in other textbooks, 180 publications in journals & 930 book & journal abstract reviews.

Orthodontics in Nepal As per the WHO report 1977, there were 18 dental surgeons in Nepal, now there are more

than 800 dental surgeons with 680 registered in Nepal Dental Association (NDA). At present there are 5 undergraduate dental colleges and 3 post graduate institutions providing general

dental services as well as special orthodontic treatment. Among government hospitals,

B.P.K.I.H.S was the first to provide orthodontic treatment where as in Kathmandu valley, IOM was the first.

Dr. Sambhu Man Singh (DORCS- England, 1974) is the first Orthodontist of Nepal. Dr. Praveen Mishra is the first orthodontist with MDS degree (MAHE – 1995).

Orthodontics and Dentofacial Orthopaedics Association of Nepal (ODOAN) has been established in July 2010. It is the first association among postgraduate specialities. At present there are 14 orthodontists (as registered ODOAN) in Nepal most of them are centred in Kathmandu valley. ODOAN has got affiliation to World Federation of orthodontics (WFO) as 108th member and Asian Pacific Orthodontic Society (APOS) in Feb 2010.

Post graduation in Orthodontics was started in National Academy of Medical Sciences (NAMS) in 2008 for the first time in Nepal. Later in 2010, Institute of Medicine (IOM) and People’s Dental College and Teaching Hospital also started the PG programme.

References:• Milton B. Asbell, Cherry Hill, N. J. AJODO Aug1990 •Volume 98 • Number 2, p. 176-183• Contemporary Orthodontics,, Proffit, Fields, Sarver, FourthEdition• Orthodontics: Principles and practice; Graber, Vananrsdall, Vig, Fourth Edition• Textbook of Orthodontics, Basic Principles and Practices, Sridhar Premkumar, 4th edition• Textbook of Orthodontics : Gurkeerat Singh, 2nd Edition• Orthodontics, The Art and Science: S.I. Bhalajhi , 3rd Edition