Power, William B.

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A CONSIDERATION OF FREQUENT CAUSES OF MAL·OCCLUSIONBy WILLIAM B. POWER, D.D.s., SEATTLE, \VASH.I N a paper which I read before the King County Dental Society April 2, 1918,published in the August issue of the JOURN AL of the same year, I took up in ageneral way some of the most frequent causes of malocclusion, as I observedthem in my own practice. The publication of that paper caused some little dis--cussion by men who read it, and to further substantiate some of the conditionswhich I have mentioned, I am writing this paper, illustrated with a number ofmalocclusions which I believe present positive etiologic factors that are so clearthat they can not be misinterpreted for anything else.Under the head of constitutional conditions, I stated "rickets" was a dis-ease that was very liable to cause malocclusion and which produced typicalconditions that could be very easily recognized in most cases. Rickets is a dis-ease which may manifest itself at any time in the life of the individual, the maloc-dusion will present certain characteristics depending upon what time the childacquires the disease. One of the earliest symptoms of rickets is that the decidu-ous teeth are lost early and the permanent teeth erupt late. Given such a clinicalhistory in any case, malocclusion is always sure to develop, and when the twoconditions go together, complicated by the constitutional disturbance as found inrickets, malocclusion of the most severe type is very liable to occur. WithFig. I.-A condition resulting from rickets. Fig. 2.-ShoW5 superior arch of same caseas in Fig. 1.children that have the disease only to a limited extent, the malocclusion IScharacterized by a lack of development of the upper arch with more or lessbunching of the upper anterior teeth and a tendency for the overdevelopment ofthe lower arch. Fig. 1 shows such a casco Fig. 2 shows the occlusal view ofthe upper dental arch in which will be noticed the large well-developed rugceof the palate which also is associated with rickets. The alveolar process is thickand spongy and the alveolar ridge is thick and the teeth will move quite easily.The tardy eruption of the teeth from any cause will, of course, produce a rnaloc-240 International Journal of Orthodo ntia and Oral Sur,qeryelusion, but in the major ity of those cases where this tar dy eruption occurs,r ickets will probably be prese nt. Fig. 3A show s the fr ont view of th e case inwhich there is a spacing betwee n the central incisor s that has been produced bythe abnormal development of the fr enum, but thi s spacing is fur ther au gmentedby th e fa ct that the upper lateral incisor s are un erupt ed and are really lat e inerupting. Owing to the lack of approximal contact, the action of the lip and theabno rmal frenum, th e upper cent ral incisor s ha ve drif ted apart, and taken alingual position. The whole case is one which will prese nt a very compl icatedcondition and one which will grow worse as the indi vidual grows older. It isanother case which dema nds immediate tre at ment and is one which by no mean sshould be allowed to wait, neith er should the parent s be told the case can be treat eda littl e later as easily as it can now. Fig. 3B show s the result that has been ac-compli shed by treatm ent, and could be more easily obtained at that tim e thanF ig, 3:-A,A . e.This shows superior centra ls in lingual occlusion, with right la ter al un eru pted. B . A resultin sam e case easily obt ained.A. B.Fig. 4.-Anteri or te et h in wrong position due to in terlocki ng of inclined planes of teeth.it could ever be obtained at any later period in the individual's life. I am show-ing this case not only as a poss ible factor of etiologic int erest, but also one whichemphas izes the importan ce of treating certain typ es of malocclusion immediatelyand to discourage the idea of telling patients to wait .In the study of norm al occlusion, we have been told that the for ce of theinclined plane was one of the fac tors which cau sed teeth to assume and main-tain their proper position in th e line of occlusion. NQw the force of the inclin edplane is acti ve and normally produces norm al occlusion but when for any reasonsthe force becomes abnormal it will cause the malocclusion to become mor e ex-treme as the indi vidual advances in age. The model on the left of Fig. 4 showsa case in which the abnormal lockin g of th e inclined plane of the central inci sor ,as well as the abnormal approximal compact in both the upper and lower teethare produ cing a type of malocclusion which will gro w worse the older the ind i-vidual becomes. In other words, the incisor s are so locked that malocclusion isthe only thin g that can possibly exist and is th e only development which willFrequent Causes of Malocclusion 241occur following the subsequent eruption of the other teeth. We might say theentire treatment of this case lies in getting the two forces of occlusion that areabnormal to act properly, namely, the force of the inclined plane and approximalcompact. If these forces are corrected and continue to act as they should, themalocclusion, of course, will be necessarily corrected and normal developmentwill progress from this point.The loss of any deciduous teeth will produce malocclusion, and when givena certain deciduous tooth that is lost, we can absolutely portray the future maloc-clusion that will develop. The loss of a deciduous tooth produces malocclusion inat least two ways, first, by destroying and interfering with the mastication ofthe teeth which in turn disturbs the mechanical stimulation of the supportingstructures. Secondly, the loss of the tooth interferes with approximal contactwhich in turn allows the dental arch to collapse and that in turn produces in-harmony in the size of the arches, which has an influence on the opposing archand eventually destroys the force of the inclined plane, In Fig. 5 we have theloss of the lower right canine and the lateral incisor has drifted lingually andFig. 5.-A condition resulting from the lossof the lower right deciduous cuspid.Fig. G.-Superior central deflected into mal-position.to the right until it is in contact with the first deciduous molar. The result ofthis is the lower arch is smaller by the width of one tooth which has resulted inthe bunching of the upper arch, and which will result in the impaction of thelower canine or the premolar, depending upon which of those teeth attempt toerupt last. The only treatment for this case is to restore the normal sizes ofthe upper and lower arch and make the proper space for the permanent teethin the lower arch so they can come in and occupy the normal approximal con-tact. This is another case in which it was very unwise to delay the treatment be-cause of the condition that will simply be postponed from one tooth to the otheras each succeeding tooth erupts, even though the malocclusion does not becomeapparent in early life. We see a large number of these cases in which the parentfailed to realize that one tooth was short in the lower arch and they come tous to have only the upper arch straightened because that is the only one whichto them shows any malocclusion. We have even known dentists who are so un-familiar with the dental anatomy as to overlook the missing tooth in the lowerarch until their attention was called to it.242 International J ournal of Orthodontia and Oral S urgeryIn or der to more thoroughly show the force of the inclined plane as a factorin producing normal occlus ion or malocclusion, I am showing Fig. 6 which wasanother simple case but the whole etiologic features lie in the fact that the uppercentral inci sor has become deflected and from now on will continue to oc-cupy a malposed position , unl ess th e mechanical int erference is instituted to cor-rect it.\ Ve have mentioned th e fact that the early loss of the deciduous teeth is anetiologic factor in the production of malo cclu sion , but it must also be re-membered that the prolonged retention of the deciduous tooth or even the reten-tion of a small port ion o f a decidu ous tooth will produce va rio us type s of mal oc-clusion. In Fig. 7 we find the upper central inci sor s wedged between the cen-trals and laterals, and th e deciduous root is, still in position. The position ofth e upper central is without question the result of for ce of inclined plane, duringthe time it erupted aga ins t the retained deciduous root. As a prophylacticmeasure in the preventi on of malocclusion it is very imperative that the child 'smouth be examined at various intervals and the decidu ous roots be extracted·F ig. i .....:....-Superio r central wedged crosswise be-tween low er central and lateral. D eci du ou s root sstill in place.F ig. 8-T he re moval of th e frenum labium an da sma ll amount of treat ment obtained a sa tis fac toryresu lt in this case .so as to avoid such con ditions as are shown in Fig. 7. As to the possible timewhen a deciduous root should be extracted so as not to produce a malpositionof the permanent teeth, that can only be decided by fre quent study of the con-ditions after the teeth have been radiographed.In the maj or ity of th ose cases where all th e upper teeth are in normal ap-pr oximal contact , and we find a large space betw een the centra l incisors, thi sspaci ng is generally the result o f the abnormal developm ent of the frenum-labium .The exact cause of th e developm ent of the fr enum or . abnormal size of thefrenum is still a disputed point and in some type of the maldevelopment th emost logic treatment beyond th e question of a doubt , is the surgical removal ofth e frenum and th en the drawing of the incisor s togeth er. F ig. 8 shows such acase before the removal of the frenum and also the same case after the frenumwas removed and th e central incisor s brought int o pos ition. It must be remem-bered th at every case of the separation of the upper central incisors is not anabnormal fr enum case, and consequently the condition must be very carefullyFrequent Causes of M alocclusion 243observed, before making a prognosis as to the outcome of the case or also a diag-nosis as to the etiologic factors involved.Another common type of malocclusion or rather another common condi-tion which will produce malocclusion is supernumerary teeth. Supernumeraryteeth may make quite a spectacular malocclusion, but as a rule such malocclusionsare comparatively easily treated by the removal of the supernumerary teethand the bringing of the normal teeth into occlusion. I wish to say that missingteeth are also factors in the production of malocclusion, but of the two, super-numerary teeth are much more easily treated from the standpoint of permanency,because all the tooth material is present that is necessary to produce the normalFig. 9.-A very unsightly form of malocclusioncaused by a supernumerary tooth.Fig. ll-A.-A frenum labium case.Fig. 10.-The g-rowth spaces are easily seen,with the lower centrals erupting in a lingual posi-tion. Teeth thus erupting are often mistaken formalocclusion.Fig. ll-B.-The abnormally large frenum labiumwas removed in this case. No appliance was usedto move the teeth which were widely apart, yet thiswas the result at the end of two years.occlusion. In cases produced by missing teeth the tooth material is lost and itconsequently follows that in the correction of the malocclusion present the resultis never entirely satisfactory, owing to the missing tooth material, which makesthe attaining of normal occlusion or normal masticating efficiency impossibleTherefore, I would say that of the two evils, the case produced by the super-numerary tooth lends itself to more satisfactory treatment than the case pro-duced by the missing tooth.In considering the causes of the malocclusion, it is very necessary to takeinto consideration the age of the patient, for in some instances a malposition at244 International]ournal of Orthodontia and Oral Surger3'a certain age may be corrected by a normal growth, associated with normalforces of occlusion; provided all forces of occlusion are normal. In Fig. 10 isshown the upper arch of a child in which spaces are seen to be present betweenthe deciduous incisors which indicate the upper arch is developing to accommo-date the permanent teeth. However, for some reason or other in this particularindividual, the growth was not rapid enough to accommodate the eruption ofthe lower permanent teeth, and we find the lower central incisors occupy aslight position of linguoversion. Some of these cases demand treatment, whileothers when present in children that are assuming an active period of growth,will be carried out to the proper position by the normal tongue action. If achild is a normal breather with normal lip and tongue action and the properphysical development at that time, the natural forces of occlusion and naturalFig. 12.-As the occlusion should be.growth may overcome the slight deficiency shown in Fig. 10. However, with aslight malocclusion occurring we may just have the reverse, in which case thegrowth will stop at this point, Fig. 10, nothing will be carried any further, andthe mechanical interference will have to be instigated to produce the develop-ment that nature has failed to get up to this time. The question of the treat-ment of such cases as shown in Fig. 10 is one which has to be very carefullyconsidered and the child kept under close observation in order to see whetherthe normal development is going to take place, or whether mechanical interfer-ence must be started to supply what nature has failed to do up to this time.Fig. 11 also shows a very interesting case but you will have to take myword for the condition, as this case was one in which an abnormally large fre-num was removed. No appliance was used to move the teeth together, whichwere very wide apart, still the results as shown in this model occurred at theend of two years. I am showing this case to substantiate the fact that someman claimed that abnormal frenums are not etiologic factors and that the re-moval of them does no particular good. From clinical observation I am con-vinced that the spacing between the teeth as originally present was the result ofthe abnormal frenum and after the frenum was removed the etiologic factorsTeaching Orthodontia 245were gone, and nature was able to care for the rest by establishing normal forcesof occlusion.I might further say that any type of malocclusion which develops is theresult of the forces of occlusion going wrong, and if all the forces of occlusionact normally there is a normal occlusion as shown in Fig. 12, which is the idealfor every type of malocclusion treated.TEACHING ORTHODONTIA*By W. E. STOFT, D.D.S., OMAHA, NEBR.TH E teaching of orthodontia is a difficult proposition, especially in the dentalcollege, where it is presented with the idea that the course is not expectedto fit the student to practice this branch of dentistry with any degree of successand only gives him the theory which he mayor may not retain after he passes'the final written examination of the college and the state board, and which then,will have to be worked out in practice attended by the usual difficulties, incidentto initial attempts at the correcting of malocclusion. That student-dentist isan exception, who succeeds in spite of these conditions and the percentage isindeed small. There being a number of teachers in the alumni association andprobably some among the present graduation class, I offer these suggestions.Since there is so much malocclusion to be corrected, I believe we shouldendeavor to give the students under us as much practical knowledge as wepossibly can.The following, I offer mainly because I believe many colleges are not givingorthodontia the attention that Creighton gives. The junior class gets the usualthirty-two weeks of lectures during the year, while the seniors are handled alittle differently.Each senior is required to handle one case all through the year, the clinicbeing ample for this. Besides treating this practical case he is required to writea paper on it and read it before the class, during the regular lecture period: theschedule for these papers being so arranged that the student has had time to geta working knowledge of his case and, too, that each will have time to preparewell. I usually have two papers each period and that allows us a little time forgeneral discussion and "fill-in" explanations by the lecturer. This gives the en-tire class a good insight into all the orthodontia cases, widening their scope ofexperience, etc.The system used to prepare the students to handle their cases and whichhelps them materially in writing their papers was suggested to me by Dr. Bradyand consists of three diagrams illustrating, on the first, themalpositions of theteeth being drawn with black ink and over this the correct positions in red ink.'Read before the Alumni of the International School of Orthodontia, Kansas City, Mo.. July 9, 1918.

A consideration of frequent causes of malocclusion

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A consideration of frequent causes of malocclusion

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