COORDINATING THE PREDETERMINED PATTERN AND TOOTH

POSITIONER WITH CONVENTIONAL TREATMENT

H. D. KESLING, D.D.S., M.D.S.? L-4 PORTE, IND.

T SHOULD be the ambition and determination of every orthodontist to treat

I each of his patients in such a manner as to produce the best possible results
in tooth arrangement with the least inconvenience to himself and his patient.
Any discussion among arthodontists is sure to reveal numerous theories con-
cerning the proper age for treatment and the mechanics for producing any
given result. Orthodontic literature presents a variety of techniques for the
management of the different types of cases. Colleges offer specialized courses
covering the mechanics of various appliances. Nevertheless, much of each o’rtho-
dontist’s time is consumed making appliance adjustments which will contribute
little or nothing definite to the final result. There is no way of measuring the
inefficiency of orthodontic operations, but a fair estimate would reveal that
not more than 15 per cent of the time is spent on operations that are necessary
and which will contribute directly to’ t,he final result. In the past, it was the
common practice to make adjustments weekly, or even daily. This did not allow
sufficient time for the tissues to repond fully to the pressures which were being
exerted by the appliance before additional ,changes were administered. With
the materials and appliances available today it, is possible to make adjustments
that will be active over a, period of weeks. Barring accidents, so long as these
adjustments are carrying the teeth toward the desired results, there is :no need
for more frequent adjustments.
Calvin Case developed stationary anchorage by preparing rigid attachments
for groups of teeth and pinning this anchorage against individual teeth for
movement. Using these mechanics, he attempted to move only individual teeth
but did not attempt to coordinate group tooth movements. Angle, Ketcham,
Mershon, and others visualized the possibilities of group tooth movements.
Through appliances which these men developed, we are able to treat cases in
much less time through reciprocal too,th movements. Among Tweed’s many con-
tributions was his technique for successfully developing and using dynamic or
complete arch stationary anchorage. This anchorage paved the way for success-
ful mass movements of teeth. A further step forward, in line with these pre-
vious developments in orthodontics, is possible when we develop a predetermined
pattern of the proposed tooth positioas prior to treatment and coordinate this
pattern with treatment. This pattern can be used as a guide for basic treatment
with conventional appliances and later ut,ilized for the construction of the
Positioner.
Read before a meeting of the Southern Society of Orthodontists. Jan. 28 and 29, 1946.
285
286 H. D. KESLING

Temptation to start treatment before the permanent canines and premolars

have erupted is prompted by the idea that more space is needed for these
erupting teeth. If this space could be created, it would allow these teeth to
assume. better positions as they erupt. However, in the writer’s experience,
this course of treatment has invariably led to disappointment. In crowded
arches, unless the first molars are tipped forward, space is gained only by
“ballooning out” the teeth and supporting alveolar process, either labially or
buceally, without any development or modification of the apical base. This
seems to hold true regardless of the age at which treatment is undertaken. Clin-
ical experience proves that it is more practicable to close wide spaces caused by
removing teeth than to attempt to create even slight spaces.
Since treatment during the transitional period cannot be considered final,
it would seem advisable to undertake major tooth movements after the per-
manent canines and premolars have erupted into the mouth, Only emergency
cases should have earlier treatment. In these cases the early treatment should
be considered only as an attempt to aid Nature through the developmental stage.
To complete treatment successfully, not infrequently these cases will need
major tooth movements after the premolars and permanent canines have
erupted.

I . II
II III I I
I I
I
ilI---,’ FlI- - - -’
Fig. 1. Fig. 2.
Fig. l.-Diagram of case showing vertical and horizontal saw cuts.
Fig. Z.-Diagram of individual teeth, dotted line showing desirable trimming on mesial.
distal, and root end.

The predetermined pattern, or setup, for the case should be developed as

a part of the preliminary study and used as a guide in diagnosis. Nothing an
operator can do can be as enlightening for this purpose as the preparation of
,such a setup. In treatment we strive to coordinate tooth anatomy with the
existing basal bone. There is no better way to visualize this coordination than
through the predetermined pattern prepared before treatment is undertaken..
If the technique of the setup is carefully executed and care is taken to preserve
the tooth anatomy on the plaster models, the result will be sufficiently clear-
cut as to leave no doubts as to the most desirable course of treatment.
The predetermined pattern is made by dissecting the teeth from a plaster
model, and, after trimming them, rearranging the teeth in wax into the de-
sired arch form, axial positioning, and interdigitation (Figs. 1 and 2). The
operator is free to move the teeth, within reason, to any position yhich he thinks
 TOOTH POSITIONER AND CONVENTIONAL TREATMENT 287

they should assume in the patient’s mouth. He should, of course, bear in mind
the movements that are possible considering the anchorage available. Also he
must know and respect the biologic limitations of tooth movements. With ex-
perience he will soon realize the possibilities and limitations of the mechanics
used in orthodontics. He will position the teeth on the predetermined pattern
into positions which are practical to create in the mouth.
Each case presents a fixed amount of tooth anatomy and a,lso a fixed amount
of apical base for its support. If the arch of teeth is crowded or the anterior
teeth tipped forward, it is only wishful thinking to hope to create space for their
proper positions without carrying some teeth off the apical base. The only
alternative is moving the buccal teeth distally, and this is possible only to the
extent that the first molars are tipped mesially. If these teeth are upright, any
distal movement is a difficult procedure and invariably causes impingement on
the space required for the eruption of the third mola,rs. If the apical, or bony,
base is narrow in the premolar area, it is reasonable to, expect that the arch of
teeth will also be narrow and, regardless of the treatment instigated, Nature
will again bring these teeth back to about the original relationship. .When we
recognize our limitations so far as bony development is concerned, we will never
attempt tooth movements which will leave teeth off the apical base or in axial
positions that are not stable. This makes the problem of elimination. of some
dental units quite simple and, whether we like it or not, we must admit that it is
necessary to remove some units in a high percentage of all cases of malocclusion,
and especially in Class I cases.
When repositioning the teeth in wax they should be kept upright over the
[Link] base. It is possible when constructing the predetermined pattern to
eliminate some teeth and position the others. Before truly efficient treatment
can be instigated, such fundamental decisions must be made. What could be
a more dependable guide for reaching such decisions than an exact reproduction
of the teeth coordinated with the existing apical base? When decisions are
based on such concrete evidence, percentages of successful treatment will mount
as compared with cases treated by those wishful thinkers who are still hoping
to create basal bone where it is not.
If two premolars are removed from the mandibular arch, it is very poor
technique to draw back the six anterior teeth, positioning them off the apical
base in order to place the canines in contact with the second premolars (Figs. 3
and 4). Such tooth positioning is almost impossible to reproduce in the mouth,
because reciprocal action will carry the buccal teeth forward to some extent
while moving the anterior teeth to the posterior. In most cases it would even be
advantageous to have these buccal teeth move mesially in such treatment. In
accordance with the movements desired and the movements possible with pres-
ent mechanics, we would, on the predetermined pattern, position the buccal
teeth forward as well as the anterior segment toward the posterior (Figs. 5 and
6). Therefore, by making a predetermined pattern, an operator has a. better
concept of the treatment desired for a particular case and can more efficiently
plan and execute active treatment..
 Fig. 3.-Left side of original and setup models showing cuspid moved into the space of
the first premolar, throwing [Link] anterior teeth too much to the lingual.
Fig. 4.-Occlusal view of models shown in Fig. 3.

Fig. 5.-Left side of original and setup models showing correct positioning of the teeth
over basal bone.
Fig. 6.-Occlusal view of models shown in Fig. 5.
 TOOTH POSITIONER AND CONVENTIONAL
~. ‘;
TREA’kMENT 289

By knowing the exact movements necessary for completion of treatment,

anchorage problems become simplified. In order to control the teeth, it is neces-
sary to have some rigid attachment to each individual tooth.- At the present
time there is no practical means of attaching to the teeth other than by banding.
Perfect bands do not necessarily mean good orthodontics nor the most (desirable
finished result. At the best, bands and attachments can only be considered
temporary and as a means, during treatment, of attaching to the individual
teeth. Many operators overestimate the necessity of making and placing perfect
bands and devote more time to this part of the technique than to the more im-
portant part-the manipulation of the appliance. Usually the leveling off and
lining up of the teeth can be accomplished with one adjustment, by applying
a very small high-tempered arch wire. This is only possible if enough time is
allowed for the tissues to repond to this light force.

Fig. T.-X-ray showing second premolar and cuspid roots after treatment.

Treatment of both arches can be carried on together, bearing in mind that.

the mandibular teeth should advance toward the predetermined pattern. and
stationary anchorage somewhat ahead of the maxillary teeth. Adjustments
should be [Link] which will definitely cause the teeth to progress toward the pre-
determined pattern and which will not cause unnecessary tooth movements in
any other directions. With the mechanisms we have at hand for creating such
movements, it is quite possible to make adjustments that will be active over a
period of three or four weeks. Such an adjustment need not be unusually severe
but of such a nature that the action will be continuous. Too frequent ad-
justments are a waste of time and a source of discomfort to the patient. Most
orthodontists have had experiences where it has been impossible to see a patient
for a period of eight to ten weeks because of illness. When the patient returned,
the changes that had taken place in the absence of regular appliance adjustments
were surprisingly good.
,. We must learn the possibilities of our treating mechanism. We must make
 H. D. KESLfNG

Fig. %-Tooth-positioning appliance.

Fig.. S.-Front view. .Upper left, original. Upper right, setup model. Lower left, basic treat.
ment. Lower right, flnished case.
 TOOTH POSITIONER AND CONVENTIONAL TREATMENT 291
i :

Fig. IO.- -Rig :ht side. Upper left, original. Upper right, setup model. Lower left, basic reat-
merit. Lower right, finished case.

Fig. ll.- -Lef :t side. Upper left, original. Upper right, setup model. Lower left, trest.
ment. Lower right, flnished case.
292 H. D. KESLING

Fig. 12.-Upper occlusal. Upper left, original. Upper right, setup model. Lower left, basic
treatment. Lower right, finished case.

Fig. lg.-Lower oc@$?.;al. Upper left, original. Upper right, setup model. Lower left, basic
ri _ -tPeatment. Lower right, flnished case.
 TOOTH POSITIONER AND CONVENTIONAL TREATMEST 293

adjustments accordingly and allow enough time for this stored-up energy to
create tissue changes and desired tooth movements, There is less damage to
tissue when we know by a predetermined pattern the desired position of each
tooth and through the mechanism carry the tooth only toward that prede-
termined position.
Major tooth movements are completed when the teeth are properly rotated
and approaching their normal axial inclination and interdigitation. It seems
entirely unnecessary to prolong conventional treatment after these positions
have been accomplished. It is necessary, however, in the [Link] of .extractions, to
parallel the roots of the teeth that are being moved into the space of an extracted
tooth (Fig. 7).
During basic treatment the predetermined pattern should be duplicated in
artificial stone and these models used to fabricate a tooth-positioning appliance
for the final artistic positioning (Fig. 8). As the end of conventional treatment
approaches, the function of the tooth-positioning appliance should be explained,
both to the parents and to the child. The patient should be informed of his
responsibility with regard to the wearing of this finishing appliance. The
operator, the patient, and the parents should collaborate on a definite schedule
for the patient’s wearing of the Positioner. The patient should practice: four
hours of exercise wearing-daily as well as wearing the Positioner while sleeping
at night. To be most effective, the appliance should be placed immediately
after the removal of the conventional appliance. At this time the teeth are
unstable from active treatment and are susceptible to the gentle forces of the
tooth-positioning appliance.
If the Positioner is worn as directed, slight rotations will be corrected, spaces
will be reduced, and the arch form and axial positioning of the teeth will ap-
proach that of the predetermined pattern in three or four weeks’ time. At’this
time it will be necessary to decide whether the patient is to wear the Positioner
as a retainer for a few weeks or whether it is a case that is going to require pro-
longed retention. If it is the latter, a conventiona. type of retainer should be
constructed and cordinated with the Positioner.
Orthodontic treatment should be instigated at the most opportune time.
With the exception of emergency cases this would be when the premolars and
permanent canines are erupted. At this time it is possible to develop a pre-
determined pattern of the case. This will serve as a valuable diagnostic aid, as
a guide through basic treatment, and as a form over which the tooth-positioning
appliance can be constructed. With the predetermined pattern the operator can
more efficiently plan and execute the major tooth movements with fewer ap-
pointments and less inconvenience to himself and the patient. Many of the
one hundred results to be shown in the clinic session of this meeting have been
accomplished with from fifteen to eighteen basic treatment appointments. It
seems well within the realm of possibility that in the future most orthodontic
cases can be successfully treated with twelve to fifteen basic treatment appoint-
ments. This can be accomplished, however, only if the operator first determines
his goal and then coordinates all of his efforts toward that end.
910 INDIANA AVENUE