Zähnen Anhang 2
Zähnen und Miasmen
Phenomena, problems, potential for treatment "What does it mean in terms of our knowledge of the human being?" is a question I am asked over and over again
in my position as dentist and orthodontist when it comes to the many and varied phenomena to be observed on individual teeth, the whole dentition, and the oral cavity. Before we can have a clear answer - and in most cases we are still far from getting it - we need to have thorough knowledge of the facts known to science and the connections between them, and we must also have practical experience as dentists in treating dental conditions and their sequels. The same applies to the vast field of malposition affecting both teeth and jaws, which is the field of orthodontics. The whole requires detailed discussion if we are to avoid the danger of adding to the many misconceptions that exist already.
The dentist specially needs to consider the questions that are so often put in the Waldorf School context. He cannot, of course, say he will be able to answer them all in terms of our knowledge of the human being, particularly with regard to the transformation of the bodily form through repeated incarnations. Much still remains to be discovered in this area. Below, the subject will be presented above all from the point of view of a dentist who has been working with Waldorf School children from many decades.
Let us first of all consider how a tooth develops. We distinguish between root and crown. This might make us think that - rather as in the case of a tree - there is a seed from which the crown grows upwards and the root downwards. In reality growth begins at the crown, in fact exactly at the border between dental enamel and dentin. The whole occurs in a hollow space within the dental follicle. Enamel develops from the inside towards the periphery. When the crown is fully developed, only a fine cuticle remains of enamel-producing cells which have ceased to produce enamel. This is why a hole in the enamel will never heal - the first non-healing aspect of teeth, which is also due to the fact that finished enamel is about 95% mineral substance, and therefore the hardest but also the deadest tissue in the whole organism. Its mechanical hardness thus means biological weakness. Dentin on the other hand develops from the outside inwards, starting with the marginal cells of the pulp, which is the live tissue inside the tooth containing afferent and efferent vessels and nerve fibers. It is often just called the "nerve", to simplify matters. For as long as the pulp is alive and there is room inside the tooth, additional dentin may form, for instance in response to an external stimulus. This, however, represents the limit of the tooth's self- protective potential.
Diseases of teeth
Caries is the major threat to teeth. To find out about it and about ways of preventing it, please read what I have written under the heading: "Zahnverfall - kein unabwendbares Schicksal" (dental decay - not an inevitable fate) in Weleda Nachrichten. Reprints are available free of charge from Weleda. There I referred to the second non-healing aspect of teeth. People generally only discover they have caries when a hole has developed or they experience pain. At that point it is often too late to keep the tooth alive. It is therefore advisable to have regular check-ups at the dentist so that the condition may be detected early, possibly even by means of special X-rays (bite-wing X-rays) and treated.
Let me comment briefly on fillings and the materials generally used today. We have shown that wounds in teeth do not heal naturally. They therefore need to be closed up with foreign materials, which cannot be done without some compromise. Plastics can be colored to match teeth very well, but the pulp has to be protected from them by putting in an intermediary filling. They are also not sufficiently resistant to friction and dimensionally stable to be suitable as long-term fillings in the lateral areas. Amalgams, which are also molded, essentially consist of mercury and a silver and tin alloy. Like all metals they need to be isolated from the pulp because they conduct heat. Their silvery gray color may also be undesirable. A very few individuals do not tolerate them because of their mercury content. The expenditure of time and money in preparing them is reasonable, which is why they are still practically irreplaceable. Inlays, that is, casts made with precious metals, require much time, material and money, though in the long term they give the best results. One thing to be avoided is to have two metals in the oral cavity, especially if they are close together, as electric currents may develop between them. Unfortunately there is no ideal material for fillings. Another problem is that they are all sensitive to moisture and have to be protected from saliva whilst working with them. People who feel their fillings are causing harm should try and have a test, using electro- acupuncture, for instance, which can also be a help in detecting hidden foci of infection.
In the first half of life, teeth are usually lost through caries, in later life through periodontopathy (diseases of the tissues investing and supporting the teeth).
One hardly ever sees these in school-age children. The most would be inflammation of the gingival margins due to plaque, causing the gingiva to bleed at the slightest touch. If calcium salts have been deposited in plaque and dental calculus results, a tooth brush alone will no longer suffice, and the teeth have to be cleaned "professionally" by a dentist.
The change of teeth
It is a feature of R.S.’ teaching on the nature of the human being that he repeatedly emphasized this stage of development. The most important references have been compiled by Matthiolius, who for many years was school doctor at the Stuttgart Uhlandshoehe Waldorf School, and published in 1970 under the title Die Bedeutung des Zahnwechsels in der Entwicklung des Kindes (Significance of the Changing of the Teeth in Childhood Development). I had been examining children at this stage at the School and its nurseries from 1968 to 1976, and as a professional was asked to write a postscript to the collection, in which I considered in some detail what R.S. meant by "the changing of the teeth". Meanwhile Wolfgang Schad has written on the subject, and the second edition of the compilation includes the comments of its editor, Helmut von Kuegelgen. He has come to the same conclusion as myself, which is that Rudolf Steiner meant the onset of the process, but he also refers to a statement made at a teacher's conference that cannot have been reported correctly; I have discussed this in detail in my postscript. Unfortunately the postscript written for the second edition was not included, nor Wolfgang Schad's preface, probably because our views diverge to some extent. What follows is a revised version of that postscript.
R.S. generally uses the term "the changing of the teeth" as an expression of time, e.g. "from birth to the changing of the teeth". Considering the context, and especially the age he mentions, he can only be referring to the beginning of a process that takes years, the eruption of the first permanent teeth. These are the
lower central incisors, which generally erupt at age 6 or 7 when a phenomenon occurs in the lower jaw that is visible to all.
A statement made by Rudolf Steiner on 11 May 1919 in Stuttgart in the first of three lectures published as A Social Basis for Primary and Secondary Education, appears to contradict this: "For someone who knows the nature of the human being, it is evident that this education should not intervene in the system of human evolution for any growing child until about the time when the changing of the teeth is complete. That is as scientific a law as any other. If instead of going by rote we were to take the nature of the human being as our guide, it would become the rule that children start school at the (completion) changing of the teeth.”
R.S. is therefore using "at completion of the changing of the teeth" in the same sense here as "the changing of the teeth". The only explanation I can think of is that to him, the process is already completed when it becomes visible. In Boundaries of Natural Science he also spoke of the "point of the changing of the teeth" on 29 September 1920 in Dornnach, comparing it to the melting and boiling points. It is probably right to take his statement that the first epoch of human life extents "to the sixth, seventh, eighth year, until the end of the changing of the teeth" in the same sense.
This interpretation finally becomes the only possible one if we consider that in Oxford Rudolf Steiner referred to the same period of time like this on 16 August 1922: "Inwardly the child is essentially quite a different creature up to about the 7th or 8th year, when the changing of the teeth begins, than later on in life, from the changing of the teeth until about the 14th, 15th year and puberty", and like this on 19 August: "If one has to educate the child during the time that follows the changing of the teeth, that is, after about the 7th year."
R.S. really means the visible phenomenon and not, as Wolfgang Schad suggests, the change from deciduous tooth to permanent enamel which is not immediately apparent, and could in fact only be seen on X-ray pictures, which were after all hardly feasible at the time. We know this from, among other things, the statement made in The Spiritual-Scientific Aspect of Therapy: "Now, however, we have an equally significant change, though this time more in an inward direction and not as immediately apparent as, the changing of the teeth, for instance, or learning to speak which anyone can observe; those two come to outward expression.
According to statistics available from Rudolf Steiner's time, the first molars were the first permanent teeth to erupt. Today's latest statistics from Duesseldorf say that sequence occurs in only about half the children, and those from Munich that slightly more than half the children have the lower incisors erupting first. I suspect this indicates a change in the relationship between the different aspects of the human being, probably with the nerves and senses becoming more dominant. [This kind of one-sided development is well known in the animal world: rodent incisors that never stop growing (emphasis on nerves and senses); pointed canines of predators (emphasis on rhythmic system); millstone-like molars of ruminants (emphasis on metabolism and limbs)]. Unfortunately it has not yet been possible to substantiate this. What I have been able to establish is that the change in sequence has nothing to do with acceleration, i.e. children whose permanent teeth come very early may well have a first molar erupting first. We should really call it a fifth-year rather than sixth-year molar. On examination of school and preschool children I did not always find it easy to establish if the first tooth to erupt had been a sixth-year molar or a replacement-incisor. It would really have been necessary to observe the developing dentition at intervals shorter than the 6 months that were possible. The earliest permanent teeth I have seen were in children aged 41/2, and they certainly were not ready for school. Those were always lower central incisors.
Professor Roland Bay in Basel has established that the sequence of eruptions changed between the period of the great migrations and late medieval times.
Before, the second molars would immediately follow the incisors, whereas today, they normally erupt only as twelfth-year teeth, when the changing of the teeth is complete. The old sequence can still be seen today, but only very rarely, though signs of it are still quite common. In some children, the second molars erupt when they still have one or more deciduous teeth. So far, no one has been able to explain this to me.
The terms "sixth-year" and "twelfth-year" molar indicate that on average the changing of the teeth occurs between those ages today. We are therefore dealing with a 6-year and not a 7-year period. There are children in whom the change begins at 4 1/2 and ends at about 9 years of age, so that it is highly premature and accelerated. Others start only at about 8 years of age and finish are about 14 or 16, so that the process is late and retarded.
With reference to Waldorf education, we have to ask the following questions. Is a child whose teeth begin to change at age 41/2 actually ready to start school?
Is another who does not yet have a single permanent tooth at age 8 not ready? For a number of reasons the answer generally has to be in the negative. It is possible that in border-line cases the harmony of development is upset. In less extreme cases children who change early or late may be quite generally early or late developers. Parents frequently report that children who change early also had their deciduous teeth early, and vice versa. We would, of course, never make it a rule that children are ready for school on the basis of just a single developmental criterion such as the changing of the teeth.
When I examined teeth in 26 first-year classes at different Waldorf Schools (1 in Berlin, 1 in Braunschweig, 2 in Bremen, 4 at Engelberg School, 1 in Salzburg, 14 at Uhlandshoehe School, 2 at Wien-Mauer School, 1 in Wuerzburg) I would on average find one child per class that did not have a new tooth and, as one would expect, more often boys than girls. An experienced class teacher once referred to such a girl(!) as a "typical class 1 child" (6 years 8 months). The examination was mostly done in the first half of the school year and sometimes only in the second half, but never at the beginning of the year. An example of the range seen is Marko H. who was 7 years and 7 months old when first examined and had only deciduous teeth; he had not progressed any further when examined again at the age of 8. In the same class was Katharina N. who at 7 years and 2 months had all four sixth-year molars and all 8 incisors. At 9 years and 3 months this child showed the extremely rare feature of the upper canines erupting as the first "lateral teeth," with the lower canines erupting only six months later, statistically a highly improbable sequence. Surprisingly, the change was not complete until she was 11 years and 10 months old. That was also the time when the two lower molars appeared. Marko still had two lower deciduous teeth when I last saw him at age 13 years 9 months.
To get a clearer picture we would need longitudinal as well as transverse studies, so that individual characteristics are not lost by calculating averages. It would
be necessary to start at age 41/2 and continue at least until all second molars have erupted. All major medical, dental and educational development data would have to be collected at intervals of not more than 3 months, and evaluated on each occasion. I have been able to do this for 7 years at the Uhlandshoehe School and its nurseries at Uhlandshoehe and Stuttgart-Sillenbuch, though only at 6-month intervals. In the end the problems that arose were such that I had to discontinue the long-term project, one reason being that the Medical Educational Research department at the German Federation of Independent Waldorf Schools was closed down. In my experience it would be best to limit oneself to a single year at school. It is particularly difficult to obtain data for preschool children, as this requires the cooperation of parents and nursery staff. Ideally, parents would keep detailed records of major steps in development, height, weight, teething, and changing of teeth. Special attention would need to be given to the time interval between losing a deciduous tooth and eruption of its permanent replacement. The differences are enormous, yet to my knowledge nothing is known about it. Specimen record sheets like those in A Guide to Child Health or those available from baby food companies are helpful.
The sequence in which teeth appear is easiest to establish and record. The sequences given in tables are based on averages and even so do not always agree.
For our knowledge of the human being, however, data which do not fit in with the statistics, the "runaways," can be extraordinarily important. Examples are unusual and asymmetrical features in space and time, such as first eruption upper, lower, left, right or crosswise, and unusual sequence, especially if this is not in line with the statistical frequency. It may be possible to gain indications from this on potential connections between individual teeth and specific organs. It is important to realize that the appallingly widespread caries seriously interferes with all development of dentition (and beyond). Fortunately it does not affect the eruption of deciduous teeth, but it will occasionally interfere with the eruption of permanent teeth and, above all, lateral teeth.
Investigations of this kind offer the additional benefit of early detection of caries. Yet in my experience indifference to this is sometimes difficult to understand, even in Waldorf Schools. It is possible that people do not consider it important to maintain deciduous dentition. Yet with a deciduous molar, loss of substance in the area of contact with a neighboring tooth makes the latter move up, which reduces the space available to the molar's successor, making it difficult if not impossible for it to erupt. If such a molar is lost prematurely, two consequences are possible that go in opposite directions. If destruction due to caries causes long-term suppuration, the bone above the successor may be dissolved, causing the permanent tooth to erupt years too early, with root development incomplete. If the deciduous tooth is removed as soon as pain arises because the pulp has become inflamed or decayed, a hard bone layer may develop in the gap and delay eruption of the successor for years, which increases the risk of losing the space. If a deciduous tooth is dead, with or without dental treatment, and remains in situ, it is often not properly reabsorbed and may cause problems of time or space for eruption of the successor. All it needs sometimes are small remnants of the root, though on the other hand these can also help to preserve space. The deciduous teeth are therefore important not only as childhood organs of mastication and speech, but also because they keep the space needed for the permanent teeth.
If dentures are already narrow in themselves, it may happen that the permanent lateral incisor is obstructed by the deciduous canine and causes it to be lost, using its space to find its own place in the denture. The permanent canine has then lost most if not all of its allotted space. In many of these cases there will later be insufficient space for the permanent teeth, and a balanced dental arch is usually obtained by removing premolars.
Occasionally problems may arise even when the first permanent teeth appear. The upper sixth-year molar may be sharply tilted forward, getting caught up under the deciduous molar anterior to it, undermining it and finally causing both it and the space for its successor to be lost. A less serious situation arises when a permanent incisor erupts behind, or less frequently in front of, the deciduous incisor. If the latter is removed and there is sufficient space, the permanent tooth responds to pressure from tongue and lip and assumes its proper place. I have seen this abnormality with remarkable frequency in families where susceptibility to disorders of dental development is hereditary. I was able to prove that the above-mentioned undermining and reabsorption are part of this hereditary element.
The most common and serious form of hereditary disposition to abnormal development is hypodontia, which affects about 9% of girls and 8% of boys in our population. Hyperdontia is seen in only 2 or 3%. On very rare occasions one also sees hyper- and hypodontia in one and the same mouth. Teeth missing from the permanent dentures are usually the upper lateral incisors and/or second premolars; rarely lower middle incisors and first molars, and very rarely canines and second molars. It is highly uncommon for many and different teeth to be missing, and in severe cases this may be linked with other constitutional problems. If there are too few or too many deciduous teeth or else twin teeth, the total number of teeth in the permanent denture is usually also incorrect. Hyperdontia is more common that hypodontia in deciduous dentures, both usually occurring in the frontal region. Wisdom teeth are not included in these calculations, and, as already mentioned, hypodontia is common in their case. It is not yet clearly established if this relates to the other anomalies described, but it is probable.
Inherited tendency to anomalies certainly also includes any type and degree of displacement, a condition seen especially with canines and second premolars which then remain partly in the jaw or erupt at an angle, often even in the wrong place. In the case of the upper lateral incisors the hereditary tendency often also involves a precursor of absence, i.e. a reduction in size that may go so far that only pointed, conical peg teeth remain, which also tend to be late in developing. The upper lateral incisors tend to be the normal shape in this case, but are often rotated in position, as are the premolars. In their case, retarded development is common, another feature of inherited tendency to anomalies.
A particularly strange phenomenon in this context, the origins of which are only partly known, is infraposition, also known as infraocclusion or depression, of deciduous molars. In the upper jaw such a tooth has its occlusal surface above the occlusal plane, in the lower jaw below it, so that it does not reach its opposite, though originally it usually occluded with it. This kind of infraposition develops gradually and gets worse in time. It is an important anomaly because anyone can observe it without needed special aids. If it is found, the child in question, its siblings and cousins should be examined for hypodontia, hyperdontia and displacement, which will, of course, require X-rays. It is possible to take pan-oral radiographs where the radiation dose is very low.
These, then, are inherited characteristics that may occur in different form and degree in both deciduous and permanent dentures but generally appear in the permanent denture only. Rudolf Steiner has frequently stated that deciduous teeth are inherited, but not the permanent teeth. He would sometimes make the statement less decisive, e.g. in the first lecture of Waldorf Education/or Adolescence where he said: "as we have our first teeth as a kind of inheritance from our parents", and before that, "the first teeth, which are more due to inheritance from our ancestors". 3 days later, in Man, Hieroglyph of the Universe, he said: "Dentition, insofar as the deciduous teeth are concerned, is essentially due to heredity". On November 7,1910 he put it as follows: "The first teeth are inherited; they come from the organisms of our ancestors and are their fruits, we might say; and only the second teeth develop according to our own physical laws."
A little later he said in the same lecture: "On the first occasion the teeth are inherited directly; on the second, the physical organism is inherited and this in turn produces the second teeth."
I have also found it impossible to reconcile the statements made in Pastoral Medicine, for instance, with the above phenomena in order to explain these references. I know from the literature and from my own investigations that the inherited tendency to dentition anomalies comes to expression mainly in the permanent dentures. The inherited disposition to certain types of anomaly of the jaws is usually apparent at first dentition but only shows itself hilly in the permanent teeth. The greatest German expert in the field. Professor Christian Schuize in Berlin, has the following to say on hereditary factors in lacteal and permanent dentition: "in fact their role is usually crucial." When R.S. gave his lectures, no one was able to ask him about these things, as they were still largely unknown. What is more, it usually needs X-rays to show the characteristics of the disposition, and in his day radiology was little used in dentistry.
Some of the things R.S. has said about teeth therefore continue to puzzle us, especially his comments on the connection between caries and the fluorine or magnesium process. Professor Oskar Roemer, who was an expert and heard the lectures himself, has published “Über die Zahnkaries oder Zahnfäule mit Beziehung auf die Ergebnisse der Geistesforschung Dr Rudolf Steiners” (Caries in Relation to Dr. Rudolf Steiner's Discoveries in Spiritual Science), but this did not make the matter clearer to me. Two people who know Rudolf Steiner's works extremely well, the pediatrician Wilhelm zur Linden and Erwin Meyer-Steinbach, have told me that in their opinion the passage has not been correctly recorded. In the final instance it is a matter of what Rudolf Steiner means by "dull" and "clever". Wolfgang Gueldenstem, dentist, suggests that clever means that the individual is not sufficiently earthy and lacks the necessary amount of dumbness to be an earthly human being (that is, a spiritual entity in a physical body). Dull means, in his view, that the individual relates too strongly to the earth and is too intellectual (materialistic). Rudolf Steiner did say: "We develop bad teeth so that we won't get too dull," because this would interfere with the "fluorine-absorbing ... action of the teeth." Dr. Otto Wolff on the other hand considers the phenomenology to be as follows: "It is definitely not the case that fluorine makes us dull in the sense of feeble-minded." For him, it is-the "abstract thinker" who is dull, someone divorced from reality who may nevertheless be highly intelligent, like an absent-minded professor. Unfortunately we can no longer ask Rudolf Steiner what he really meant.
Another passage that I have always had my doubts about has since been clarified. It is in Curative Education, where a "not" has been omitted in the description of the first boy in paragraph 3 of the sixth lecture. The publishers have confirmed this. The correct version would be: "His mouth is slightly open, which is not due to dental development.. .." Considering that this was a course where Rudolf Steiner specially asked for "loving attention to detail, even the smallest detail," one would hope, as a dentist, to find useful statements relating to teeth. But for that, of course, dentists would have had to be present.
In Pastoral Medicine, R.S. said on September 11, 1924 how important it is for people "that they do not have to get a third set of teeth". Wolfgang Schad made his first attempt at interpreting Rudolf Steiner's concept of "changing of the teeth" in connection with this. He quotes a passage not included in Matthiolius's collection: "until the sixth, seventh, eighth year, until the end of the changing of the teeth." have already given my own explanation of a similar statement by R.S. Schad also quotes another passage in his Erziehung ist Kunst (Education is Skilled Work)."
R.S. says in this passage that the first three months after birth are really part of the embryonic period. If we add another year, so that the individual would be 15 months old by the usual way of reckoning, "he will be approximately at the stage where he gets his milk teeth." Before that he said, "we have to think in terms of the arithmetic mean, of course, but approximately that is how it is." Schad's comment is that this is about the stage when the enamel crowns "for all the milk teeth are complete". In his illustration, however, the roots are already beginning to develop for all the teeth at age 1 year + 3 months, so that the times are different. However, the arithmetic mean for the period of eruption for all deciduous teeth was between 14.26 and 14.97 months according to 1934 German statistics. H. Ehlers gave 15.68 months as the mean in 1967.19
These figures agree very well with R.S.'s "mean (= durchschnittlich)". Thus there is no reason to take up Wolfgang Schad's suggestion and concentrate instead
on the stage of development reached by the enamel crowns of unerupted teeth both at first dentition and at the changing of the teeth, which can be radiologically assessed.
He is, of course, right in saying that this is also the time when the first permanent teeth erupt and the enamel crowns of the permanent teeth are complete, except for the wisdom teeth, i.e. the time when the body has managed to create the hardest substance of all, since the enamel of deciduous teeth is somewhat softer. In Schad's opinion, this change in substance is more important to understanding the human being than the change in position, and Rudolf Steiner's references to the changing of the teeth must relate to this, particularly in passages that seem more contradictory. Schad also assumes, therefore, that X-rays would be helpful if there is doubt about a child being ready for school, with no visible evidence as yet that the change is coming. I am unable to confirm this, particularly as development of the last of the crowns is often greatly delayed by a hereditary disposition to abnormal dental development. I hope to have clearly established that in spite of some passages that appear to be contradictory, Rudolf Steiner meant the beginning of the process when he spoke of the changing of the teeth. It would be helpful if this insight into his teaching and the literature could be unanimously and consistently presented. I do not know any physician or dentist who considers any other explanation either necessary or meaningful.
More than 10 years ago, Armin Johannes Husemann drew attention to an illustration by Stratz first published in 1909. This shows the changes in bodily form by representing total body height in relation to the height of the head at different ages. The figure has also been included in the second edition of Husemann's Der musikalische Bau des Menschen, with minor corrections reflecting the current state of knowledge. Ten years ago I immediately realized that human beings are five times the height of the head when five teeth have developed on one side of the jaw, and six, seven or eight times the height of the head when as a rule six, seven or eight teeth are present. This remarkable numerical relationship may have further significance.
I suspect that relationships exist between dental development and the macro- and microcephaly R.S. spoke of. This cannot yet be proved. Perhaps it will be possible after all to evaluate the data from my investigations in this respect. They are lodged with the Medical Educational Research Department in Stuttgart.
On the other hand I do not expect much to come of further research into the relationship between the shape of the front teeth and Kretschmer's constitutional types. Wolfgang Schad reported on this at the School Doctor's Conference held in Dornach in 1980. This refers to work done by the late K. Hoerauf, dentist.
His descriptions are supposed to help us find the right kind of teeth for edentate patients. A major denture producer based their designs for front teeth on those descriptions ("type-related system"). Doing the opposite, which Schad recommended, i.e. to draw conclusions from the shape of a child's teeth as to its future constitution, does not seem justifiable. To my knowledge, Hoerauf's findings have never been confirmed by follow- up. It is, of course, extraordinarily difficult to recognize the defined shapes of teeth in a mouth and fit them into a system. My friend and colleague, Hermann Lauffer and I once made the attempt to establish the effects of polar opposite formative principles, i.e. those due to the magnesium as compared to the fluorine processes, in my large collection of denture casts, but we did not succeed.
The relationship of dental and jaw positions to the essential nature of the human being was extensively investigated by Professor Wilhelm Balters (1893 -1973), who was the most important of my teachers. He also spoke about this to Waldorf school teachers. He would sometimes give amazing details after merely looking at denture casts from individuals who were not known to him personally. On the one hand he was an extraordinarily careful observer, noting details that others failed to see, and on the other hand he clearly had intuitive gifts. I will try and include aspects of this in the section on orthodontics but would warn readers not to draw the wrong conclusions. The words the doyen of modern orthodontics wrote beneath a picture of a well- developed human denture still apply today: secretum apertum - "open secret."
This brings us to the field of orthodontics, the purpose of which is to correct malocclusion and malposition, or rather train the teeth to assume the right position.
It is indeed miraculous how the individual teeth growing within the jaws combine to form well-balanced dental arches, providing all goes well. "Normal" does not mean "according to statistical norms" today; for most dentures are irregular today. Major investigations have shown only about 8% to be normal. If we accept the "minor deviations" seen in about 22% of cases, this gives us about 30% of "proper" dentures. Occlusion and tooth positions are so poor in about 25 - 30% of children that orthodontic treatment is necessary or desirable. These figures were given by Rudolf Hotz, Professor of Orthodontics in Zurich, a sound man, who unfortunately has died since, in the 5th edition of his textbook (1980). In practice the situation is as follows: Parents will almost always only take their children to see an orthodontist because they don't like the look of the denture. They hardly ever notice, for example, that a tooth may be missing laterally or that the teeth do not occlude properly. The dentist must first of all establish the present situation (diagnosis), the history, and the prospects with treatment given now or later (prognosis). The first impression a child makes, a few words spoken, a look in the mouth, will tell much to the expert. He also needs to know things that are not immediately apparent, especially if the unerupted teeth are all present and pointing in the right direction for successful eruption. This is best established by taking a panoramic X-ray, a tomogram with minimal radiation exposure. Evaluation of about 50,000 such X-rays at the big school dentistry clinic in Zurich, where this picture is taken of every boy and girl in the third grade, showed that on average, two teeth are not preformed in about 8 % of boys and 9% of girls. This does not include the wisdom teeth, which are frequently missing, as their buds are often not visible at this age. By the way, it is quite unknown why the gender difference exists. (See earlier details of hereditary dental development disorders). Recent investigations by Karl Ulrich, orthodontist in Stendal, have shown that some harmless abnormalities in the skin (ectoderm, with the dental enamel also deriving from this) remarkably often go hand in hand with hereditary dental development disorders. Skin abnormalities of this kind include freckles and irregular eyebrows - joined up, sparse, or shortened eyebrows (usually the lateral third missing).
Anomalies of the jaws may also be hereditary. The most common of these is prognathism, with the lower front teeth projecting well in front of the upper teeth, even in the case of the deciduous teeth. This anomaly may be marked in some, and only minor in other members of the same family. Major regional differences have also been noted, with prognathism about three times as common in Stuttgart as in Hamburg. The condition occurs even in the best families. Well-known individuals with prognathism were Dante, Richard Wagner, Stefan George, and above all the Habsburg family, where prognathism evidently occurred through many generations.
Overbite, a condition where the upper (middle) incisors extend well below the incisal ridges of the lower incisors, is also hereditary. It causes shortening of the lower face, with distinct dimples in the chin, as in the case of Abraham Lincoln, for instance, and the German actor Hans Albers. Experience has shown that the condition if severe cannot be entirely corrected, and at most made more balanced. It may be a comfort to those affected to know that Professor Balters spoke of the "intelligent overbiter" (the upper part, i.e. the upper jaw, being specially developed).
The most important aspect of orthodontic diagnosis is to make an accurate assessment of the present situation. This is done by taking plaster casts of the denture which can then be observed and measured at leisure, without being impeded by lips, cheeks, tongue and poor light. Putting the upper and lower casts together, it is even possible to look into the denture from behind, and again and again I am surprised to discover things I had not realized when looking into the patient's mouth.
It was a very sad experience some time ago, when numerous statements relating to the study of man made by our Dutch colleague Hooghoudt proved untenable, for they were entirely based on inspection of the mouth. More accurate information had since become available from casts and X-rays. It goes without saying that apart from analyzing the model, it is important to examine the mouth and its functions in detail, one main reason being that we must diagnose existing caries and institute treatment where indicated, and inspect the gingiva and the quality of dental and oral care.
If the relation of the denture to the facial skull is abnormal, anterior and lateral photographs must be taken to investigate this. Distant lateral X-rays provide further information. To come as close as possible to parallel projection, the distance should be not less than 150 cm. These X-rays also permit some degree of prediction as to the growth direction of the face. If it is important to know if there will be any appreciable further growth, especially in girls who have reached puberty, and X-rays taken by hand will provide fairly reliable information. The use of apparatus to stimulate and guide growth is only indicated whilst growth is still in progress, i.e. when the mandible and temporomandibular joint are still developing. Intervention needs to be early, and we have to work with the growth process.
A key factor with malocclusion and malposition, and therefore also the outcome of orthodontic treatment, is whether closure of the mouth and breathing through the mouth are possible, or if the patient breathes through the mouth, which tends to be open, and possibly even with the incisors positioned on the lip. A balanced bite is only possible if closure of the mouth is normal and natural, for otherwise pressures are not normal in the mouth. I always explain to the patient: The nose is meant for breathing, the mouth only in emergencies, m the nose, and only in the nose, we smell the air, and the fine hairs inside the nose clean it (the dust ends up in your handkerchief); the air is also warmed up in the nose, and actually given life because of the form of the air passages. It is easy to make someone realize how cold air inhaled through the mouth actually is if we ask them to pant with the mouth open like a dog. You can easily catch a cold if you keep your mouth open, and then, with the nose blocked, need to keep the mouth open even more in order to breathe. How do we break this vicious circle? I first of all show the children that they do not look nice and rather stupid if they leave the mouth open. We used to call this "gaping". You hardly ever see adults walk around with their mouths open. Almost all of them manage to close them. But the sooner you leam, the easier it will be. I then often show them a series of denture models taken from a patient whose dreadfully displaced upper teeth and regressed lower jaw could initially be corrected, but then deteriorated again because she always had her mouth open. m the end the position of the teeth was worse than it had been to begin with.
It needs practice and patience to change to nasal breathing. I know only one activity where the mouth is naturally kept closed because of the concentration required: balancing. It does not need a beam; a tree trunk or curbstone will do just as well. Otherwise we have to make a conscious effort. I tell the children to watch all the time if the mouth is closed. If it is not, they must close it immediately. Memory is aided by pictures put up in rooms where they spend a lot of their time, of a nicely closed mouth, for instance, or an open one looking far from nice that is crossed out, like the cigarette in a non-smoking sign. Signals may also be put on the covers of exercise or textbooks, blotting paper or even a finger nail: C for Close your mouth, or a red L for red Lips closed! I also ask friends and family to give signals if the mouth is left open inadvertently: making the V sign, for instance, and then bringing the fingers together, pointing to the mouth, etc. This can be done very discreetly, so that others won't notice.
A simple exercise is to take a sip of water and keep it in the mouth for as long as possible without swallowing it or spitting it out. One can also get the children to hold something in their lips during some quiet occupation - a wooden spatula like those used by ENT specialists, for instance, or a file for ampules, a button or a coin, using bigger and heavier ones as time goes on. Anything where the breath is used can be helpful, e.g. playing a wind instrument, blowing out candles, making soap bubbles, "shooting a goal" by blowing bits of cotton wool across the table. Other methods are to breathe in slowly for as long as possible, the outward sign of this a leaf or a piece of gauze held across the nostrils by the negative pressure, or doing the opposite, which is to take a deep breath to fill chest and abdomen and then exhale as slowly as possible, external evidence being provided by talking, counting, singing, whistling or, more tolerable for anyone else who happens to be around, humming. If the nasal passages are not clear, an ENT specialist has to be consulted who will remove any greatly enlarged pharyngeal tonsil (preferably not the visible palatine tonsils), also known as adenoids.
A common contributory cause to open mouths is a denture so badly out of shape due to sucking that the lips cannot be closed. Children will suck not only their fingers and a pacifier, but also a comer of their blanket or a piece of clothing. The upper front teeth are generally pushed forward and the whole mandible is pushed back in the process, resulting in the typical open bite. The sucking gesture is one of definite introversion, withdrawing into one's shell before an unkind world; it may also be regression, wanting to go back to the protection enjoyed in early infancy, for instance, when a younger brother or sister suddenly appeared and attracted most of the family's love and attention.
What can be done to overcome these and other undesirable habits (chewing nails, for instance)? We must help the child to take the necessary developmental steps, e.g. not to put their hands into their mouths but use them in the outside world. There is no point in shouting at them, but ignoring the habit may sometimes help.
A doctor's wife once told me she suddenly realized she had stopped sucking when she left her parent's home at the age of 20. To have such a habit drop away like
a ripe fruit is, of course, the ideal, except that in her case it was much too late. It is generally easier to wean children off their pacifier than their fingers, by "losing" it, for instance. If one has to give them a pacifier, it is best to use a specially shaped one that will at least prevent some of the damage.
If a child has only been sucking for a short period, is able to close the mouth easily, and there is sufficient room for all the teeth, the defect due to sucking may correct itself. If sucking continues for such a long time that the permanent dentition is also affected, orthodontic intervention is usually required. In simple cases, it is often enough to use a ready-made atrial plate; difficult cases require individually fitted appliance. An activator is most commonly used, or the greatly reduced form called a "bionator". It may be said to be a sucking body that acts in reverse. It lies loosely in the mouth, has a guide surface for the lower teeth and a wire brace above the projecting upper front teeth. Every time the mouth is closed, e.g. when swallowing saliva, the mandible moves forward, wants to go back again and takes the upper teeth back.
This is known as a reciprocal action (going back, re-, and forward, -pro-), and is particularly effective. A seriously malformed denture has of course responded particularly well to the original sucking bodies and will therefore also respond well to the appliance which acts the other way round. The use of appliances lying loose in the mouth is the functional method. It does not impose force but offers an opportunity to change position which influences the jaws, teeth and joints via the muscles. Apart from the above-mentioned classic activator and the smaller "bionator", a number of similar appliances are available.
In my experience, the 'function regulators' designed by Professor Fraenkl in Zwickau (Germany) are the best appliances for effecting functional changes.
With distoclusionantero-mesioclusion, or prognathism, structural reversal), the mandible is made to move in an anterior direction to avoid a wire arch or tongue shield. These appliances are attached to cheek shields positioned in the atrium or "cheek pouches." Small additional pads positioned behind the lower lip help to block external pressure from the muscles of the cheeks and lower lip. Internal pressure from the tongue muscles is thus given dominance and can help to widen and round out a narrow dental arch. The special advantage of the regulator is that there are no impediments inside the mouth apart from a few wires and perhaps
a tongue shield. Speech is possible, and it is important to speak while wearing it, speech being the primary oral function. To achieve a different position for the teeth and jaws it is necessary to wear the regulator while the mouth is functioning, i.e. speaking. We do most of our talking during the day and little at night, and this means that the regulator is intended mainly for daytime use. Once one has gotten used to it, it is helpful to wear it at night as well. The treatment can be supported by doing lip exercises, asking the patient to pull the upper Up down and bite it. This is particularly effective with the head tilted back. Many children do, however, find this exercise difficult.
It would be nice if such exercises were all that is required to correct a distoclusion, but experience has proved otherwise. The same applies to eurythmy therapy.
I have found that years of experimentation with this meant orthodontic treatment was not initiated at the right time, causing more space to be lost in the dentition as the gaps left by prematurely lost deciduous teeth were not kept open. Eurythmy therapy will, however, be useful as a baseline treatment. Even if money is no object, it is important to remember that any additional treatment may demand too much of a child's time and energies, causing him to lose interest and not comply where it is most important, and that is to wear the appliance - usually for years. I usually tell them that in orthodontics the saying is: "The end is always the hardest" be- cause person's patience tends to wear thin.
If there is lack of space, no matter where and in which direction, there are essentially two possible solutions: either we manage to stimulate growth and enable
the dental arches to develop fully or stretch and expand them so that room is found for all the teeth, or we must redistribute the available space, i.e. dispense with some teeth. The latter is unpopular with orthodontists and their patients and is a method chosen only after careful investigation and thought. It is good to remember Wilhelm Balters' words, saying that with a vault it does not matter if it consists of 12 or 14 stones but only that it is a good arch.
I can understand people's concern over the probable relationship of certain teeth to specific organs, but so far I have seen no evidence of this. We are dealing with extremely hard facts in the case of teeth. They cannot be compressed to fit a gap that is too narrow. Sadly, the need to remove teeth is often people's own fault, having failed to save a full denture of deciduous teeth (with fillings). The size of teeth and that of the jaws are inherited separately, and conditions may be so unbalanced that it is impossible to accommodate all the teeth. The opposite may also be the case: large arches and small teeth, resulting in gaps.
I have never actually regretted having removed teeth, but I have often been sorry I did not make my demand more urgent. The premolars are usually removed first, which provides space for the front and lateral teeth. In the upper jaw the premolars tend to have two roots and be among the most susceptible to disease. One often sees crowns, gaps and bridges in that area. The lower premolars are more resistant. Sometimes the second lower premolars are also removed. Unfortunately their posterior neighbors, the first molars (six-year molars) are sometimes so bad that they cannot be kept alive in the long run. There is no good orthodontic reason for their extraction, which can only be an emergency measure to deal with caries and usually has serious consequences, as neighboring teeth are apt to tilt. As one of the most renowned orthodontists has said, planned removal of teeth requires the greatest expertise in the field.
A word on the removal of wisdom tooth buds (germectomy), which is being done more and more frequently. It has to be advised if the X-ray shows that the wisdom teeth are very badly positioned and cannot possibly emerge and find a space. This includes situations where they are tilted forward at an angle, with the teeth generally packed tightly together, so that they will cause even more serious overlapping once they emerge. Removal is easiest at the time when the roots are just beginning to develop. Once they are fully developed and curved like a postillion's horn, which is common with wisdom teeth, extraction is difficult and time-consuming even for an experienced orthodontist, and the wound heals less easily. Unfortunately, full dentures rarely include well-positioned wisdom teeth. One would obviously only extract these after careful investigation and assessment of their potential value, remembering the words of the above-quoted orthodontist: "Where would I be in my old age without my wisdom teeth" (as bridge piers)? Teeth that have failed to erupt should not be left in situ, however. Their enamel is part of the skin organ and/ therefore, belongs on the outside. Teeth retained in the jaw can act as foci of pathologicpremolars and wisdom teeth are quite often missing. disorder. Nature actually shows us that fewer teeth can be adequate, for removal of the first premolars sometimes involves long-term planning, starting with the removal of all deciduous canines. The incisors will then usually erupt spontaneously and be well positioned. Later the first deciduous molars are removed and then their successors. The process is known as extraction-guided eruption of permanent dentures. I felt it was important to know that Rudolf Hotz, the main protagonist of the method, also used it with two of his three children.
Another, equally acceptable reason for extractions of this type is that in earlier times, when the food was coarser, containing particles of ground millstone, for instance, not only the occlusal surfaces of the teeth were worn down, but also contact areas between teeth, so that a row of teeth would be reduced by about the width of one tooth and could be accommodated more easily in a jaw that had grown smaller. The extractions are done to make up for the absence of this kind of wear and tear.
To return to prognathism. In both deciduous and permanent dentures it is normal for the upper teeth to lie anterior to and partly enclose the lower teeth. If the opposite is the case, we speak of prognathism. It is important to diagnose this early as it will become more serious unless treated. Treatment should start not later than the changing of the incisors, taking care that the permanent incisors are in the correct position. It is, however, better to start at nursery school age. A regulator of reverse construction functioning like the one used for teeth displaced by sucking is often fitted. Marked prognathism can be very disfiguring and is the most frequent indication for orthodontic interventions. The surgical procedure is to split the ascending rami of the mandible longitudinally to change their relative positions. In most cases, preoperative and postoperative orthodontic treatment is also needed to adjust the dental arches to each other. The procedure is difficult, protracted and expensive, but it harmonizes the facial features as well as improving mastication. Prognathism also presents extremely difficult problems at the later stage when the upper front teeth need to be replaced, which is another reason for early prevention. Early treatment gives lasting results, except in a few cases where a new growth phase of the lower jaw occurs in puberty - something which cannot be predicted. I have treated a girl with severe prognathism whose front teeth were reversed, and in her case there was no recurrence. Her brother had only a mild degree of prognathism that appeared to have been overcome by the age of twelve. During puberty his lower jaw grew inexorably forward, so that surgical intervention became necessary at school-leaving age, fortunately with a positive outcome.
Crossbite is a form of malocclusion where the mandibular teeth are unilaterally or bilaterally outside the maxillary teeth, one arch crossing the other. It needs to be treated as early as possible, especially if unilateral and, therefore, asymmetric, which may also be due to a displacement of the whole mandible. Treatment will prevent the malocclusion becoming fixed, and with the deciduous teeth this is relatively easy to achieve. Individual teeth hooked over the other arch on the inside or outside should also be corrected as early as possible. Working in collaboration with the Michaelshof/Hoefle, we found that overcoming the problem of caught-up teeth may also help to resolve an inner situation in which a young person is caught up. It is also desirable to have the centers of the jaws properly aligned, again also in relation to curative education. All these treatments should be given as early as possible, as they are much easier then. Curative Education Institution, under the medical supervision of Dr. Crowding of frontal teeth generally means waiting until all incisors have erupted, so that their exact size and therefore need for space can be established. On the other hand, it has proved effective to start earlier in cases where it is perfectly obvious that there will be problems.
The "interceptive" method, using an appliance, will generally be indicated, but it needs to be interrupted as soon as possible in order not to overstrain the child's patience. Unfortunately, the appliance can only be removed if there is no danger of losing space in the lateral arch due to caries or even early loss of deciduous teeth, again demonstrating the importance of deciduous dentures that are healthy or at least well preserved by means of fillings.
If the crowding is moderate, it will always be best to avoid extractions if possible; if it is severe, it is definitely advisable to develop the dental arches as far as possible because it is not always sufficient to remove just one tooth from each half-jaw. Unfortunately, X-rays do not provide accurate infor- mation on the size of teeth lying within the jaw, and this is why orthodontists prefer to wait at least until the first lateral tooth has erupted before deciding for or against extraction.
It is also important to consider the background to crowding, something of which Wilhelm Balters has frequently spoken. The German term for it, Enge (closing in of walls), relates to anxiety and angina, which are typical signs of our times. People are constricted and coerced in so many ways that local measures will hardly suffice, and crowding will often develop where none has been before. It is comforting to know that crowding of the lower front teeth, which, of course, are particularly caries-resistant and tend to be retained longest, means no particular danger of caries or periodontopathy. Compared to the crowding of upper teeth, that of lower teeth is also less of an esthetic problem. It does, of course, have a distinct hereditary element.
Some functional orthodontic appliances have already been discussed with reference to malpositioning due to sucking. Others will be discussed below, starting with some that are removable. Active plates are attached to the teeth with wire clips. The active components are either sprung wires or devices with built-in male screw elements. This makes it possible to apply pressure or traction to specific teeth or parts of the dental arch, single or groups of teeth, and the relevant maxillary processes supporting them may be slowly moved as the bone is restructured. Functional appliances are thus intended to change form by changing function; the opposite is the case with active appliances. We change the form and hope function will also change. In either case, changes in form need time to stabilize.
This is achieved by means of retention, using passive appliances to support the changes achieved. This does, of course, predispose closure of the mouth, as mentioned earlier.
Active plates will achieve quite remarkable changes, especially in the upper dental arch. The lower arch is less responsive but fortunately requires only minor correction as a rule. The lower canines in particular are known to resist change once erupted. If the intention is to widen this area, functional stimuli need to be set very early and for a long period, preferably using a functional regulator. Appliances which are half-way between active and functional are also available, e.g. the double propulsion plate with guide wires that engage in grooves and thus take the mandible forward each time the mouth is closed. The Crozat appliance is half-way between the fixed wire appliances, which will be discussed below, and active plates. It consists of a wire frame attached to the teeth with flexible wires welded onto it and acts only via the teeth and not, like the plates, via the alveolar ridges as well. It takes up little room in the mouth, which means that it presents the same problems with mutual support of movements as the fixed wire appliances.
Other repositioning maneuvers are difficult if not impossible with removable appliances. This applies particularly to parallel repositioning of teeth within an arch, i.e. without tilting or rotation; extensive changes in the angle of the axis, e.g. moving the crown inwards and the root outwards (torque). Fixed appliances are used for the purpose. These are also known as multi- band appliances because the devices for holding the brackets were originally attached to the teeth with bands. Today the brackets are attached directly to the teeth in visible areas, using a caustic fusion process. This is less obvious than the metal bands, especially if plastic or ceramic brackets are used.
The action is based on the thin, highly elastic, light wires, which sometimes are also angular (edgewise arch) or twist and flex. They are fitted into the brackets and usually terminate in a small tubule on bands attached to molars. Spiral springs and elastic (rubber) rings are further energy sources in this type of precision engineering which will also deal with many of the problems that can be solved by using removable appliances.
Orthodontists are increasingly giving preference to these "fixed" methods, mainly because they can be sure that the appliance will be in the mouth. This is not to say, however, that fixed appliances require less compliance than removable ones. Patients have to be highly conscientious with dental care, for about 3 minutes after every meal because the brackets, wires and ligatures will retain food residues which may cause disastrous plaque and caries. Prevention consists in impregnating the teeth concerned with fluoride, a local protection against caries that has proved effective in this situation. As a short-term measure against caries, which after all is incurable and in the long run generally worsens, fluoride impregnation is certainly acceptable, even if its general use is regarded with skepticism. The complex orthodontic appliances affixed to the teeth make not only dental care but also eating, and especially mastication, more difficult. As a result the risk of caries is greatly increased.
To achieve certain goals it will frequently be necessary to support the appliance with headgear. This makes it possible to move upper lateral teeth posteriorly.
For the opposite situation a "face mask" supported by the chin is available. A head-chin cap with elastic rubber to pull back the mandible is much simpler.
It is mainly used for the early treatment of prognathism.
A very simple aid is the angled glide plane to align one or several wrongly interlocking teeth. It is usually cemented onto the lower front teeth for a period.
There are, of course, endless variations of the above appliances. What matters is that one knows "how to play the instrument," that is, the potential and limits of the different methods, which generally presupposes training as an orthodontist. It has no doubt become obvious that my personal preference is for the functional method, using a regulator. This does not use force but offers a possibility of change and addresses one of the main causes, which is wrong positioning and tensioning of muscles in the mouth (tongue) and around the mouth (above all lip, cheek and masticatory muscles).
Having described malpositioning and methods for its treatment, let us consider the key question of the issue: when is orthodontic treatment indicated?
Daily experience and a look in the mirror show that we shall manage even if our teeth are not the most beautiful. Still the desire for balance, beauty and efficient function of teeth is perfectly natural and also common. On one hand, we hear again and again from parents and caregivers that when they were young, the war,
the post-war period or simply lack of money - insurance companies were not paying what they do today - prevented orthodontic treatment, and they are surprised that so many children are fitted with braces today, and ask if this is really necessary. News has got around that orthodontic treatment also has its problems.
Again, younger parents and others of their generation will often say that they had orthodontic treatment, but "it has all gone back to what it was before." They will often confess that they only wore their braces at intervals. We can tell them that orthodontics has made enormous progress since then and that unfortunately it is impossible to check the reported failures because no documents are available. In most cases it was probably crowding that was the problem because the often considerable expansion that could be achieved was thought to be permanent in the past. Crowding of the lower teeth is very liable to recur, as already mentioned.
The number of orthodontic treatments has undoubtedly increased, and conditions are much more favorable today. On the other hand, why should malformations of the teeth remain at the same level at a time when disharmony is on the increase in so many other respects? We only have to think of the widespread sucking habit and of the fact mat we have not yet overcome caries. A highly experienced dentist of my acquaintance who specializes in young people has recently written that
80% of orthodontic treatments have become necessary because of caries, bad habits (sucking, mouth breathing) and "refined foods" that require little chewing, and all of this is avoidable.
Again and again we see parents who take great care over their children's mental and spiritual development seriously fail to care for the children's teeth; often they do not even notice major malpositioning of teeth and even jaws. The children are only too glad to be left in peace, since too many demands are made on them.
The question is asked again and again if malposition of teeth and jaws is a purely esthetic matter. My answer would be in the positive if it was merely a matter of minor dental rotation and mild crowding. Yet children are brought to us exactly because of such "mini-anomalies."
The real problems in the mouth are often not apparent at first sight because they are in the lateral region. Generally these are instances of misalignment, with a lower tooth engaging with one rather than two upper teeth (singular antagonism or cusp-to-cusp bite) or the bite is displaced by the width of a whole tooth. This will, of course, also mean that the front teeth do not relate properly.
In a well-developed, complete, balanced denture all parts fit well with each other despite the fact that they have developed separately, with the teeth already mineralized and unchangeable when they erupt. Everything fits, making a single whole for mastication and speech; everything is arranged around a distinct mid-point where left and right mirror symmetry. Above and below are different but designed for balanced interaction of incisor edges, cusps and grooves when the mouth is closed, that is, when closing the bite. The same holds true for both masticatory and so-called "idle" movements. It is not surprising that we rarely see such perfect dentures today, though they are the ideal to strive for. Many things that interfere with balanced denture composition can be greatly improved today even if they cannot be entirely removed. As always we have to compromise, and this is not so reprehensible if we are aware of it.
Let us now try and make a list of the most important indications for denture regulation. When should we advise orthodontic treatment for children?
• Obviously in all cases of disfiguring anomaly. When teeth protrude so far that mouth closure is prevented. Experience has shown that such teeth are 10x more at risk from accidents than normally-positioned teeth.
• For all misalignments that come under the heading of prognathism, that is, with lower teeth overbiting the upper teeth, in severe cases with the whole mandible projecting forward; also for misalignments such as all types of crossbite and "missed bite" - a similar situation where upper and lower lateral teeth do not come together but go past each other. All these anomalies cause unfavorable stresses on teeth and periodontal tissues and may in the long run also affect the temperomandibular joints.
• For very deep overbite, with the lower front teeth biting into the palatal tissues or the upper front teeth into the lower gingiva, especially if both are the case. Pain, inflammation and regression of gingiva may result. The teeth are subject to abnormal stresses, which may cause them to loosen.
• For open bites, where some upper and lower teeth do not meet at all, often because the tongue is again and again coming between them. Here the biting function suffers and in severe cases also speech. Absence of functional stresses is as harmful in this instance as wrong stresses are with deep overbite.
• Marked crowding, one reason being that physiologic and toothbrush cleaning have poor access to the hiding places created by the condition. Crowding of the upper front teeth may also be unsightly, while barely noticeable in the lower jaw.
• For regression of the mandible, causing wrong relation of front teeth and alignment of lateral teeth so that a lower molar does not bite between the two corresponding upper molars, with the bite displaced by the width of one or half a tooth width, with each tooth biting only against one other (singular antagonism). All this again causes harmful stresses. In severe cases the profile is markedly affected.
• For front teeth and molars displaced in the jaw, especially the canines, those vital comer-posts for the whole denture. Every effort to get a canine in position is justified.
• If the number of teeth is too small. Efforts will be made to close gaps by orthodontic measures where possible to avoid having to use prostheses for young people that soon have to be replaced.
• If the number of teeth is too large and it is not enough simply to remove excess teeth. In most cases, the remaining teeth will have been displaced.
The basic precondition for all orthodontic treatment is that child and parent are willing to cooperate, usually for years. Support at school is most important since functional methods of treatment, especially using a regulator, require the appliance to be worn all day, that is, also during school hours. Once the child is used to the appliance, it is able to speak well and must be encouraged to do so. If only the dentist is convinced that orthodontic treatment is necessary and the other parties involved do not see the need for it, the treatment does not work well and often fails. It goes without saying that the dentures - such a marvelous creation - should look, fit and function harmoniously.
In anthroposophic circles people often express concern that orthodontic treatment intervenes in destiny, a view I do not share. The idea is that it relieves the individual of the need to come to terms with an inherent physical malformation. For a physician, however, it is natural to do whatever is possible to promote me healing of physical disorders of whatever origin. By the way, health insurance companies have for some years now considered malposition of me jaws and teeth a pathologic condition and been prepared to pay for treatment.
I would also say that common dental anomalies are not usually a matter of destiny (caused by sucking or due to caries). Severe malformation of the jaws, above all cleft lip, jaw or palate, are much more likely to impress one as related to karma. But no one would think of leaving such individuals, who are at particular risk perinatally, to their fate. From the beginning they are in the care of orthodontists and surgeons and later also of speech therapists who "rehabilitate" them so that the mouth functions as well as possible and their facial appearance does not cause social problems. If this is taken as a matter of course for individuals thus severely affected, why should we not be allowed to help also those with lesser dental anomalies?
Another reproach leveled at orthodontists is that they use mechanical means. It has to be admitted that in the majority of cases we cannot manage without wires and appliances. Malposition of teeth presents us with genuinely "hard facts." In orthopedics much can be done by exercises. Orthodontics also call for exercises, above all mouth closure, but also with the unattached "functional" appliances used to correct the position of the jaw. This changes the familiar relative position of dentures and usually makes room for vertical growth, i.e. letting teeth grow into a different position. I have been using these appliances, which create the conditions for harmonious development, for more than 33 years at the Curative Education Institute in Hepsisau, where orthodontics has effectively supported curative education. Balters was evidently right in saying: "No real change unless the whole person changes." When a curative teacher is unable to help a child to progress in a real way, orthodontic treatment usually also has little effect. We also try to contribute to the overall change that is required by using the means offered by orthodontics, e.g. by influencing the positioning of the jaw. This will usually fail if the new position is not in accord with the nature of the individual.
So this is where we find our limits, an indication that there can be no unwarranted interference in the person's karma. On the other hand, orthodontic treatment also offers something that is desirable in this context - exercise of the will. It always calls for an effort of will for patients to use unattached appliances or those that clip on and can be removed by them, and we are powerless if they do not do this regularly and reliably. Orthodontic treatment requiring an appliance to be worn is unlikely to be successful in spoiled children who have never been asked to do anything that goes against the grain. Even fixed bandelette appliances are no way out. They are certainly no more comfortable and, what is more, tend to collect food residues, so that the teeth have to be cleaned thoroughly after every meal to prevent caries. This calls for a considerable effort of will several times daily.
In conclusion, some attempts will be made to explain the situation in psychosomatic and anthroposophic terms. The dental phenomena have frequently aroused the interest of researchers. Wilhelm Balters actually went so far as to draw conclusions as to me personality of the individual from a study of denture plaster casts. This provided him with more reliable evidence than merely looking in the mouth. His conclusions are often graphic. With reference to deep overbite,th regard to frontal open bite that you'd never find a surgeon with such a bite, for surgeons have to use their front teeth to probe situations. Another of his statements was that people with frontal open bite always wanted to have the last word, something I can only report without comment. for instance, he said that the individual concerned tended to cover up rather than be open about things, mat "he had let down the shutters." Conversely he spoke of a child with open bite as "open and unprotected." He also said with Wilhelm Balters' opinion that open bite might also indicate unbelief induced me to make a declaration and substantiate it at a congress of the German Orthodontics Society. I referred to the threefold organization of the mouth. The maxilla clearly relates to the upper human being. It is part of the head, with the palate a vaulted structure similar to the cranium. The mandible is connected to the head by joints and is the "limb" of the head. The middle human being may be seen in the rhythmic movement of maxilla and mandible in speaking and chewing activities, in the sinus curve of the dentition and in the mediating function of the tongue. When above and below are no longer in touch, as is the case with open bite, we have a "loss of the middle." The relationship between upper and lower is upset. I might also say "God" or "world of the spirit" rather than "upper," and "the human being on earth" instead of "lower." It is difficult to say if the interpretation is correct, but it does make sense to me.
In cases where the open bite was due to pushing the tongue between the teeth, Balters was able to offer two further interpretations. It is normal for hard tooth to meet hard tooth in a bite, but some prefer to put the tongue in between as a soft cushion; they prefer to pull their punches. On me other hand we might take the tongue pushing in between as an image. The tongue, or metaphorically speaking the individual concerned, intrudes where not wanted. When I told a mother whose daughter was always pushing her tongue between the lateral teeth, resulting in a highly uncommon lateral open bite, about these two possible interpretation, she said spontaneously, "We call her 'the wedge in our marriage'." Karin, partly because she did not continue as the only child in the family. Again, the interpretation would make sense to me. By the way, everything turned out well for
It is also graphic to speak of someone who is always clenching his teeth and does not relax them, as "dogged" or someone who has to fight tooth and nail.
If teeth are thus subject not only to pressure but also to grinding, they are evidently getting worn down, even in childhood. Grinding the teeth may also be interpreted as autoaggression, biting oneself. Conversely a relaxed jaw, someone who is too lazy to chew, would indicate that the individual does not want to be seriously involved in his food or in the environment, lacking the necessary awareness for this. Eugen Kolisko commented: "When we chew, the conscious mind goes for a walk on the food."
Balters once used a military analogy with reference to posterocclusion, where the lower jaw is too far back and the lower front teeth bite into empty space. He said: "At the front, there are no punches pulled. You (the patient) are not at the front, you are behind the lines. It is time to go forward and engage the enemy!" We use our limbs to realize the will. Everyone can push his lower jaw forward if he wants to. Posterocclusion is a matter of holding back. If, however, the lower front teeth actually bite into the palate, then, according to Balters, it is better not to damage oneself- That would indeed be masochistic.
Balters and his students, above all Fritz Bahnemann and Hubertus von Treuenfels who took over Bahnemann's practice, also established connections between jaw position and body posture, calling this the "gnatho- vertebral syndrome," and devised exercises for this. Their goal is holistic orthodontics. Fraenkel, who designed the function regulators, is of the same opinion. Years ago he wrote: "It is extremely difficult to get people to understand that we treat not only the dentures but really the whole human being. What is more, the head and face of the individual are unique, and measurement based on mean values will not serve the purpose." Some people take an oversimplified view, however, thinking it is holistic therapy just to fit a child with a Balters bionator or a Fraenkel function regulator. On the other hand, we must beware not to let our enthusiasm for a holistic approach go to extremes.
We have to keep our feet on the ground and develop a feeling for what we may ask of a child, considering the domestic and school situation. Thus it is always sad to see how an impending or completed divorce seriously puts our orthodontic efforts in jeopardy. Help comes from anything that creates order. In this sense, orthodontics is a treatment that establishes order in the meaning of the term given by Bircher-Benner. For fatherless children it is a help if the orthodontist is male.
To come back to the tongue once more: apart from pushing it between the upper and lower jaws and letting it rest there, another, more active habit is to push it in a vertical position between teeth within a row. This creates gaps. This soundless gesture of the tongue (compared to speech with its sounds) may also be regarded as body language and interpreted accordingly. The tongue is breaking through the fence (of teeth), rotating through an angle of 90 degrees. According to Bakers', and my observations confirm this, the area where the tongue is pushed through means something. In the upper jaw we are dealing more with higher elements relating to soul and spirit, in the lower jaw with the physical basis. The middle of the row of teeth indicates a central problem. The individual's general laterality probably influences me laterality of the phenomenon. Experience has shown that this kind of diastema usually disappears again in children. If it persists, an effort should be made to discover the reasons. We might try and make the individuals conscious of the mood in which they make this initially unconscious gesture (also recommended for those who grind their teeth). However, this will probably work only for individuals who are able and prepared to work on themselves. On the other hand, if a trace of former habits remains in the dentition and does not disappear of its own accord, it should be regarded as a fossil record, signifying no more for the individual than an aspect of the past that has been left behind.
"Myofunctional therapy" has been developed by the American speech pathology expert. Professor Garliner, to deal with malposition of the tongue between the jaws; it involves a program of tongue exercises that require a great deal of patient compliance. The Brazilian speech pathologist and former Waldorf teacher,
Mrs. Padovan, suspects that these problems are partly due to developmental deficiencies in early childhood. Her treatment program, therefore, includes going back to infant movements such as crawling. Another problem going back to early childhood has been pointed out by Dr. Wellmann, Waldorf school doctor in Wuerzburg, Germany. He noted that children who prefer to lie in the prone position are liable to develop crowding of teeth. He would be grateful for substantiation of this.
Finally, I'd like to emphasize that extreme caution is indicated in establishing this kind of connection and interpreting it. With interpretation, I stick as far as possible to imagery and never impose my views on others. What matters, I think, is not to have great thoughts about these things nor a theory, however magnificent, but the encounter, always unique, with human beings who may come to see me on account of their teeth but should not have a label attached to them just because of certain dental phenomena.
Let us recall the words of our doyen. Dr. Angle, who called the dentures a secretum apertum - an "open secret." It is for us to increase our understanding, not by applying "screws and levers." Goethe himself considered these inappropriate although they are justified and necessary for some of the mechanical problems that have to be solved in orthodontics. But to uncover the mysteries of human dentition we need a different tool and that is a good, Goethean way of thinking.
Note: This may mean a temptation for patients to want to and for dentists to actually 'overdo' things. To limit abuse, the insurance companies now only pay 80 percent of the cost, or 90 for additional children in the same family, with accounting done quarterly. The rest has to be paid in advance by the insured and is only reimbursed when treatment has been concluded according to plan.
In 1950 a survey of American public school teachers determined that their main concerns were gum chewing in class, speaking out of turn, and failing to raise one's hand before speaking among high school students. At that time the diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) had not been "invented" and dress codes were enforced in public schools. Ah yes, the good (?) old days.
What about the '90s? According to the latest information (a recent Time Magazine survey) between 5-7% of all American children in grades 1-4 take medicine for ADHD and this goes up to between 9-11 % of the boys. At a meeting I went to at a local public school, the statement was made that the normal incidence of the disease ADHD is 10% of the boys, and if less than 10% of the boys are on medication then the school is not doing a good enough job of diagnosing these children.
In fact, as an overall theme the health of the American children is much different than it was in the 50s (and earlier). Then, the main concerns were childhood diseases (measles, mumps, chicken pox, etc.), all fundamentally short-lived and mostly harmless. Now the main medical concerns are asthma (25% of urban elementary children carry an inhaler to school - higher in some cities), diabetes, leukemia and of course ADHD - all very serious and chronic diseases. The big unanswered (and unfortunately, unasked) question is - why?
While there is certainly no definitive answer to this question one "lead" is provided by the work of Western Price.
Dr. Price, a dentist, was concerned about another epidemic which has actually severely worsened since his time. In the '30s Dr. Price noticed that more and more of his young patients were having occlusal troubles (i.e., their teeth were not coming in straight and proper). This previously relatively rare occurrence was quickly becoming the norm to the point that currently it is 100%, that is, nobody is born today with enough room in their mouths for all the teeth including the "wisdom" teeth, to come in.
Folks, our jaws are not supposed to be bowed, our teeth crooked, the woman's pelvis too small to birth babies, our chest caved in, our hips osteoporotic.
In setting out to determine why nobody is born with enough room for their teeth, Dr. Price went all over the world looking for people with normal dental development - that is, properly spaced teeth with the absence of dental caries (cavities, which by the way are infections and are a good marker for general resistance to infection).
Dr. Price found many such groups and was able to document conclusively that the sole reason for the near perfect health of these indigenous people's teeth was their diet. For, without racial intermixing, without any significant changes in their culture but solely with the introduction of Western processed foods into their diets, within one generation their immunity to cavities was lost and their teeth became misaligned, just like us Americans.
Dr. Price also demonstrated that a reason for the changes that accompany the new diet is that the skeleton of those eating Western foods can lose up to 40% of its calcification. This means that even at birth the bones can be as much as 40% less calcified and strong as bones of indigenous people with their traditional diet. The misalignment of the teeth is the result of a weakened jaw bone bending up ( a more "stable" opposition for the weaker bone) which, however changes the angles of the erupting teeth. While this in itself may not seem important (except, of course, if you are an orthodontist), the `bending' jaw bone is really just a marker. For the pelvis is formed at the same time as the jaw, and it also is under-calcified and bowed, resulting in our C-section rate of greater than 20%. Another result of this facial bone deformity is that the nasal arches become narrow - breathing is pinched, the tonsils and adenoids move closer to the midline, closing the Eustachian tube leading to chronic ear infections and on and on.
When we also realize that the adoption of the Western diet by indigenous people led to their loss of resistance to infectious disease (including dental caries), we have a plausible explanation for a number of current health concerns.
Getting back to our discussion of food and behavior (I bet you thought I forgot the topic) there are three important additions to be made. First, modern psychiatry has made it quite clear that chemistry, particularly the chemistry of proteins, (amino acids) and fats are determinants of behavior. Truly, Prozac, anti-depressants and Ritalin, etc.
the medicines used to treat depression and ADHD, do nothing more than manipulate amino acid levels in the brain of the patient. One could ask why these amino acids are abnormal in the first place. Is there something wrong with our food, our digestion, or both?
2. R.S.: the relationship between digestion, thinking and other "mental processes." He went so far as to say that the brain is the mirror image of the intestines in its shape and function. He further pointed out that one's physical structure is the external manifestation, and in fact, the basis of an orderly thinking process and even an orderly society. Our bones are (or at least were) formed in precise mathematical relationships, which gives our subconscious the experience of form, order and even logic. Folks, our jaws are not supposed to be bowed, our teeth crooked, the woman's pelvis too small to birth babies, our chest caved in, our hips osteoporotic. If they are, one will see rampant disorder all around us, particularly in our thinking, logic, and other "inner processes."
3. (and probably most practically) in all human and animal studies that have ever been done, when a switch from an indigenous diet to a current Western processed diet is made, extreme behavioral changes occur without fail. Prison inmates fluctuate in their level of violence depending on their food, and we see it all around us every day.
Dr. Price, in his studies, detailed again and again how previously unknown behavior and emotional problems were being seen in indigenous people with the introduction of Western food. When he returned to the U.S. and set up a clinic in Cleveland to treat dental caries for disadvantaged inner city children, he noticed and documented dramatic changes in behavior, emotional life, and school performance when he put these children on a program approximating a diet used by indigenous people; i.e., a diet of fresh, vital and properly grown grains, vegetables, raw milk and select fish and meat products.
The bottom line here seems to be that a diet of sugar, caffeine, pasteurized milk, white flour and chemically grown fruits and vegetables literally enough to drive you crazy.