ORTHODONTICS: THE NECESSITY OF HISTORIES TO ESTABLISH ETIOLOGY; THE NECESSITY OF EXTRA FUNCTION IN RETEN-

TION; THE NECESSITY OF PRESERVING SPACES CAUSED BY PREMATURE LOSS OF. DECIDUOUS TEETH”

BY HAROLD CHAPMAN, L.D.S. (ENG.), LONDON, ENGLAND

THE NECESSITY OF COMPLETE HISTORIES TO ESTABLISH ETIOLOGY

I HAVE for some time felt that the causation of any particular case of mal- occlusion as given in the textbooks was not in the least convincing or that

the author had proved his point. A year or so ago I began the etiologic investigations of some forty cases, some of which have normal occlusion; the detailed results are embodied in a paper,l but briefly they may be stated to be :

1. Normal occlusion occurs in many cases where so-called “causes” of malocclusion have been operative.

2. The causes referred to in (1) are not sufficient in themselves to cause malocclusion.

3. The only cause operating after birth, which might have had a harmful effect on the occlusion, seemed to be feeble mastication.

4. Antenatal causes appeared to be the factors of importance in bringing about malocclusions. These may be :

a. Heredity. There is evidence to support ,this view. b. Causes other than heredity. There is evidence to support this view

also and it is believed these causes will ultimately be proved to be the important ones in the majority of cases.

Antenatal causes, other than heredity, may be any harmful influence act- ing on (1) the germ cells of either parent before they unite, or (2) acting on the fetus. These influences are referred to by Murk Jansen in his book2 and in a paper3 and, if there is any truth in these views, which it seems impossible to doubt, then malocclusion is a form of “Feebleness of Growth” as referred to by Jansen, and where there is malocclusion it will usually be found that there is other evidence of feebleness of growth, frequently physical defects, which are not difficult to discover.

In the time at my disposal it is not possible to go into greater detail; in fact, this has already been done, l but since that time notes of additional cases have been obtained and the histories of two brothers are presented below. One, the elder, has normal occlusion (Figs. 1, 2, 3, 4, 5), and the younger one was Class II, Div. 1 (Figs. 6, 7, 8, 9, lo), though not a bad case, as his lower dental arch was good. His history shows that he had several other physical defects in early life, which his parents (who are well-to-do) have done all in

*Read at the Congress of the European Orthodontological SoCicty. 768

Odhodontics

TABLE I ~__ .-. .-___

CASE HISTORIRR

1. ~;;;nof case

2. IAge. Sex :I)ate of exam.

“.\. llifference in age cf ) with next child old(‘

2. iOcclusion

4. Type of intlividnal *Height

3. sitting total

ti. ,*Weiglit in clothes

!I. Walked at 111. Knock knrxos 11. Flat feet

Ii. L&cnatal faCtor

13. IFactors at birth

lti. IOther physical defect

17. Weight at birth 19. Diet first year

22. Mastication 23. Comforter 24. Breathing,

1 night day am

25. [Adenoids

25. Habits

29. Rickets 30. Illnesses

r:

S

/

411 March 12, 1972 13 years. Male Januarv 19?:5 * Y

2 years 5 nloutlis Rormal

Lateral

- ~~~ 475 Oct. 1, 1913

i 115/12 years. Malt IJanuary, 1925

‘1 vear 7 months Cl&s II, Div. 1 originally; has

been treated for 31 years previous to exam.

1,ateral

- ii::0 mm. at llll/ years i ft. S:: in. at 12:l vears 4 ft. 53 in. at Tli years ist. 41 Ibs. (28/l/2$) = 40.14 i st. 2f lbs. (27/l/25) at 111

kg. years = 32.77 kg. 1x months 16 months so Slight so Very pronounced when young,

improved with age, not very noticeable at present time

Father ‘s hcialth normal. Moth ,Father ‘s health normal. Mother cr’s health normal. Had re- rather run down after 5 sum- turned from holiday in Japan mers in Hong Kong 10 months before his birth

Sormal. Born at Hong Kong. Sormal. Born in Hong Kong. Good English doctor and Good English doctor and nurse. nurse.

- Sails very thin during first 3-4 years. Almost normal now

ii: 1,. (*X97 kg.) if lb. (3.4 kg.) Natural 2 weeks. Had excellent Natural 2 weeks. Very small

nurse, with first-class experi. quantity of undiluted cow’s ence of feeding all first year. milk with citrate of soda. Perfect digestion Digestion never very good

Good Good NO SO

Sormal Normal Removed at age of 6 at 1%. No

toria, B. C. Sucked left thumb for 2 years. Sucked thumb for first year

Very obstinate SO Y Wlooping cough at 7 years. iit to get slight dysentery dur-

Mumps (slight) at 9 years. ing first two years. Whoop- Chicken pox at 10 years. Ger- ing cough at 6 years. Chicken man measles at 11 years. pox at 9 years. German Gets headaches from con- measles (slight) at 10 years. gestcd liver, cold or rich food Very apt to have styes on

eyes up to 8 pears. So head- aches

mf ~~8~s 911 and 475 compared with statistical tables:<

No. 911 I Age 122 j No. 475 1 Age 113

Standing height 1,X: mm. Sitting height (age 1111/j3)’ Weight with clothes 1 40.11kg. ! 31).I)<S kg. i ::-?.77kg. 1 32.00 kg.

NO. 475 is 0.71 kg. below normal v&gilt (without clothm) for his sitting heighP. (The clothes would increase the deficiency, but the weight is taken eight months earlier than the sitting height and probably nrutralizes the error.) too short and his weight 0.77 kg. too much.

For his we his sitting height is 8 mm.

deficiency as regards On these figures this boy only exhibits a small

sittin g height and a small excess as regards weight; it must be remem- bered that he has received very careful nurture all his life. According to Whipple’s figur&

No. 911 (the normal occlusion boy) is 9 rmn. taller and 2.06 kg. heavier than the standard; it III&~ be said that, according to these figures, he has slight advantages over his brother.

770 Harold Chapman

their power to counteract. There is only one year and seven months differ- ence in t.heir ages; their environment has been the same. Their detailed his- tory is given in Table I.

Unfortunately these boys have not been tested with Friel’s dynamom- eters,4 nor have t,heir heights, weights, chest capacities, etc., been compared,

Fig. I.--Case No. 911. Right side in occlusion. Fig. 2.-Case No: 911. Front view in occlusion. Fig; 3.-Case No. 911. Occlusal view. Fig. 4.-Case No. 911. Right pro!lle (photograph). Fig. 5.-Case No. 911. Full face (photograph). Fig. B.-Case No. 475. Right side in occlusion. Fig. 7.-Case No. 475. Front view in occlusion. Fig. &--Case No. 475. OccIusal view. Fig. Y.-Case No. 475. Right proiile (photograph). Fig. lO.-Case NO. 475. Full face (photograph). The photographs of Case 475 were

taken three and one-half years after treatment commenced. The lips do not yet function correctly.

as is desirable, but in the writer’s mind there is no doubt, aft.er making allow- ances for the difference in age, that the elder brother would in all these phys- ical respects be the superior of his brother.

The British Society for the Study of Orthodontics has asked it,s mem- bers to take part in an invest.igation of this subject and has drawn up two questionnaires, one of which is to be filled in b>T the parents and the other b! the dentist, for each family examinrtl. ‘IVie questions are more numerous thall those iu the case of the boys reported on in this paper. It is expected that :I copy of the questionnaires will be publishetl in the 7’~rnsccc+~~ of the British Society for the St.udy of Orthodoutiw, IW5.

THE liEC’ESS:ITY OF ESTKA FUNC’TIOS IS KETENTIOX

Lantern slides were shown of the photomicrographs which illustrate Oppenheim’s two paper9, 6s 7 on the changes in bone as a result of moving teeth. Briefly, the first series of slide+ (i showed that normally the bone on

772 Harold Chapman

the labial and palatal sides of an incisor is arranged SO that the spicules or laminae of bone are vertical; in other words they are arranged parallel to the forces of mastication, which are chiefly vertical. When a tooth has been moved by gentle pressure for from three to six months these bone spicules on both sides are found to have rearranged t.hemselves in a plane at right angles to their original plane and to be horizontal. The same thing may be expressed by saying that the bone spicules arrange themselves to be parallel to the

Fig. Il.--Same case as Fig. 9, twenty months later; l&and with it Ifihas moved con- siderably forward in this time.

Fig. IL-Buy, aged ten years am1 .qe\-en months. Class ,II, Div. 1. 4 I

no spaces for* ;

414 are erupted ,

this is the condition that arises from the early caries and eXtraCtionS

exemplifled in the two previous cases.

forces acting on the tooth. During the movement of these teeth by ortho- dontic appliances the forces or pressures, developed by means of the appli- ances, a&d horizontally, and the bone spicules rearranged themselves to be parallel to these forces. It is not to be inferred that no vertical pressures are

Orthodoniics 773

applied, but in the case of teeth being moved by appliances it is possible tha.t they become of secondary importance; in fact Yrie14 has shown that the wr- tical pressures which can be exerted by teeth undergoing orthodontic treat- ment are less than those exerted before treatment started.

These slides were followed by others’ in which were shown the rrsults of t.he experiments some six months after the teeth hat1 been retained in their II~IV positions. It n-as IIOW seett that the bone sl~iculrs were reforming them- selves parallel to the long axes of tire teeth, that is to say in the direction of the more powerful force, mastication (not appliances), that is being applied 10 them at this time. It would appear, then, that retention depends? among other things, on the reformation of the bone sljicules parallel to the long axes of the teeth. iIlld one factor in this ])roccss 7vo111~1 npl)ear to be pressnrc at)-

Fig. 16.---Roy agr,l thirtwn ~IYL~S ;tnd tw months. Class II, IN\-. 1. Thr final clinicd !

plied to t.he teeth in a vertical direction; ant1 if these pressures can br ap- plied to a great.er degree than is likely in ordinary mastication, may we not expect those spicules to be rearranged more rapidly and more solidly (t,he latter word is used for want of a better expression). Friel has designed exercisers’ for this purpose, but I have used rubber in the form of a rubber dog bone (such as is sold in the shops), which is cut lengthways into two or three so as to be a suitable thickness. At the time of retention, or when the appliances are removed, I instruct the child t,o bite on the rubber in the molar, canine and incisor regions as hard as possible; then t,he exercise is repeated, but this time the free end of the rubber bone is pulled as hard as possible by

774 Hcwold Chnpnznn

the child, i.e., the arm is pitted against the teeth. The exercise is continued an increasing number of times night and morning until, say, fifty of each kind are performed. I am unable to speak of actual results, but I am satis- fied that the procedure is a rational one, and I am adopt’ing it in my practice to an increasing degree.

THE NECESSITY OF PREiERVIKG SPAC’ES (‘AUSED I1Y PREMATIJRE LOSS OF DEVIDUOUS

TEETH

To illustrate this note a series of slides of four cases were shown, in order to trace graphically the origin of so-called impacted second premolars from a very simple beginning; this beginning is the early caries of the approximal surfaces of t.he deciduous molars followed by early loss of one or both of these; it. is believed that these particular “impactions” arise only in this simple way.

The first case, Class I (Figs. 11 and la), aged six years and seven months,

le shows slight medial movement of __ el

as a result of approximal caries of

-I_rl d I

The next case, Fig. 13, aged six, also Class I, shows the condition shortly after extraction of 1 d. Fig. 14 shows the same case twenty months later, when considerable forward movement of 1 e had taken place as the result of loss of 1 d; I 6 also has come forward anequal amount. These two cases _-

54145 show how the spaces for 5 4 , 4 5 are or may be very gradually but very con-

siderably reduced. Preventive treatment should be undertaken to 0bviat.e this loss of the premolar spaces as soon as it is liable to occur; if t.he condi-

54145 tion cont,inues unchecked the A

54~45 spaces will be still smaller at nine t,o

eleven years of age, and we msy confident,ly expect there to be room for only one premolar instead of for two,

Fig. 15 shows the maxillary and mandibular arches of a Class II Div. 1 41 case in which there is only space enough for __ 414

where the spaces should be

large enough to accommodate * (x-rays’show that g a

are present).

Fig. I6 shows t,he final stage of the clinical condition, the eruption of .__ 515

entirely lingual t,o the arch; this is a Class Tl, Div. 1 case in a boy aged t,hir- teen years and ten mont.hs.

It should be noted what serious occlusal results supervene from very small beginnings in approximal caries of deciduous molars. In these cases the parents would doubtless have been willing and eager to have the necessary steps taken to prevent the serious malocclusion which has arisen had the necessity and value of doing so been pointed out t.o them. A stitch in time saves nine.

IZEYEKEI;('ES i L

~Chapman, Harold: Orthodontics: Investigations in Etiology, Transactions British Society for the Study of Orthodontics, 1925, J)ental Record, August, 1925.

%Jansen, Murk : Feebleness of Growth and Congenital I)warfism, Oxford Press. :%Jansen, Murk: Some of the Life Properties of Bone Substance, Trausactious Europeail

Orthodontological Society, 192-l, IJental Record, June, 1925. .i I*‘ricl, Sheldon : Muscle Testing and Muscle Training, Transactions British Society for the

Study of Orthodontics, 1924, Ikntal Record, April, 19%. ~XcCoy, J. I).: Applied Orthodontia, Kimpton, Lontlon, 1922, 1’. 159. sA\ngle, E. H.: Okklusions Anomilics clcr Zahnc~, ed. 2, Chapter on ‘ ’ J3011e c1lan!gx ’ ’ 1lV

Oppenlieim. 7()lll)t~llllcinx, Albill : I)ic: \‘&nde~unget~ tier Gc~wrlw u%hrru,l dcr Retrilticti~, \Vietl, I!) 1;:. \\\:lrilrple, Guy Moutrose: Manual of Mental antI Physical Tests, I%t,t I : Hilnlllrr I’rovWrW

11. 67, \Varwick & York, Inc::, Baltiuu~re, 1lll-C. $11 lrcyel,, C?. : The Assessment of Physical E’itilcss, (‘a?;st~ll & Co.. 1912.

IIISC’YSSIOX

Hr. Priel said there was one pint Jvhich Mr. Chapman brought out which was int,errst,- ing, and that was the exercises to try to stiniulate the growth of bone. It was quite impos- sible to tell what effect those exercises had, but certainly one increased the powers of nlastication. The exercises would giyc the child n1ore confidence, but he did not know of any way of telling whether you had made the bone clc~-r~lop in the proper vvap except lly kill iug the child and examining sections of tlw bone.

34~. Wat7& referred to the idea of’ retaining the spaces when deciduous teeth had to 1~ lost. He had several models he could sl~ow \vhwe there was no question about it that the malocclusion later on had been caused entirely by the early extraction; otherwise it was a case of Class I and normal developme~~t. alll the treatment would have been unuccssary if, when extraction became necessary, a little 1~~01~ hat1 JWP~ put between the teeth on eith<xr sick to maintain the spaces until tlw rulwqueirt c~ru1ltion of the lwmanent teeth.

UT. Cnle Yatthews saitl Ire had only to thank Mr. (%al)nmn for his contribution.

Mt-. Xorthcroft said he would like to have iuformation on one point, and that was the device he used for keeping the spactss open.

MT. Ch,apmavL replied that ho was glad to know that Mr. Frirl could approve of the exercises from another point of view, lvhicli made him feel he was more than justified in adopting that method. As regartlcd the &v-ice for retaining the spaces, he had on a fcx occasions used a vulcanite plate to be worn at night only-. At other times he banded a tooth, preferably a deciduous one, approxirual to tlw sln~ce and from it arrwlged a wire extension to the other tooth apl~roximal to the space. The wiw exteusion ih designed to reduce the possibility of displacement to a mininluni aud nc)t to intc~rfcrc with teeth that may be erupting.