Journal of Orthodontics

Early treatment of the cleft lip and palate infant poses a number of problems. Analysis of the success of pre-surgical treatment has been difficult due to a lack of adequate records of a large number of variables applied to a statistically small sample, with a lapse of many years being required before assessment can be made. Active pre-surgical appliances frequently cause ulceration in the mouth and nasal septum, but this can be minimized following design modification. Several methods are in current use for alignment of the segments, including appliances which expand the segments and others which introduce a curvature into the greater segment or retain the arch while still allowing it to grow mesially and distally. The dilemma today is no longer whether to give pre-surgical treatment, but to what extent it should be carried out.

Pre-surgical orthodontics has certain minor undesirable influences upon the surgery. These are the slight delay in the primary lip operation and the need for anterior palate repair in the bilateral case. When balanced against the very considerable advantages however there can be few surgeons who would not willingly accept the drawbacks in the interests of achieving a relatively easy definitive lip repair at the primary operation. One wonders whether there is significance in the fact that most of the criticism of pre-surgical orthodontics has come not from surgeons but from orthodontists who are either unable or unwilling to provide this service for their surgical colleagues and through them for their patients.

The most successful autogenous tooth transplantation technique of which we have had experience in Liverpool is that described by Thonner (1969). Our results have been sufficiently encouraging to regard the technique as a normal orthodontic/surgical procedure and to be able to tell the patient that the chances of success are good. The technique consists of the removal of the tooth with the minimum of trauma and while the new socket is being prepared the tooth is kept in the patient's serum at 37°C. The tooth is not root filled at the time of operation.

The importance of correcting Angle's Class II molar relationships during orthodontic treatment is discussed and two methods of achieving this correction are described. The literature is reviewed and an investigation designed to compare the modes of action of extra-oral traction and functional appliances is described. The base line for cephalometric measurement is taken as S-N with a perpendicular axis constructed at S in order to minimize errors due to growth occurring during the investigation period. Results suggest that neither appliance has significant effects on the horizontal growth of the dental bases, but that the clinical effect of molar relationship correction is substantially due to dento-alveolar changes.

A previous objection to the cephalometric assessment of individual variations in tongue size was the difficulty of obtaining a standardized position of the tongue and the effect this may have on its apparent size.

Five different positions of the mandible were recorded on cephalometric radiographs in sixteen individuals. The tongue postures adopted were produced spontaneously for each posed position of the mandible. Measurement of the tongue area revealed a high degree of intra-individual consistency when comparing the tongue area with the mandible at rest to the area found when the teeth were edge to edge or in occlusion.

When the mouth was wide open or the mandible was maximally protruded, the tongue area measurement was significantly different (smaller).

The level of reliability of the tongue measurements has been established. It is suggested that further studies of orofacial morphology and posture could usefully incorporate tongue dimensions, provided that recordings were made while the mandible is contained by an envelope of movement limited by occlusion, rest position and incisors edge to edge.

An analysis of 1000 consecutive treated cases from a private orthodontic practice was made. Inter alia the results show: the male to female ratio was 4: 6; the mean age of first attendance was 10·7 years and the mean age at the start of active treatment was 11·6 years. 49 per cent of the cases were Angle Class I; 39 per cent Class II/1; 8 per cent Class II/2 and 4 per cent Class III. Over half the patients had an increased overbite. 21 per cent had an anterior crossbite and 11 per cent showed a posterior crossbite. Approximately 75 per cent of the cases showed crowding of the labial segments. There was crowding in 26 per cent of the upper buccal segments and in 49 per cent of the lower ones.

93 per cent of the patients received active treatment for the upper arch but only 4 per cent had appliances in the lower arch. A quarter of the cases were treated without upper extractions; in the lower arch the figure was 58 per cent. 94.1 per cent of the patients were treated with removable appliances requiring, on average, 1·5 appliances per case to complete treatment. 30 per cent of the cases received no retention. 54 per cent wore a retainer for less than 6 months.

88 per cent of the patients completed treatment and co-operation was satisfactory in 87 per cent. The mean treatment period for each patient was 13·1 months involving an average of 11·7 visits. The average active treatment time for each patients was 95 minutes. 74 per cent of the completed cases had a satisfactory result.

The discussion supports the case for relating the type of orthodontic treatment to the total dental need of the patient. This requires more knowledge of what is meant by “dental health”. A plea is made that orthodontists should not become rigid in their approach to treatment.