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page 11y Proceedi)ngs of the Royal Society of Medicine Vo1 XlXVII


7

Section of Odontology
President-HAROLD CHAPMAN, L.D.S.Eng.
[October 25, 1943]
Prognosis in Orthodontics
PRESIDENT'S ADDRESS
By HAROLD CHAPMIAN, L.D.S.Eng.
(Dental Sutrgeoni to the Lonidoni Hospital.)
ONE of the most important aspects of orthodontic treatment to-day is prognosis, which
may be defined as the knowledge of what movements of teeth and jaws will be permanent
after, say, three years' treatment, sometimes longer, sometimes less.
The dental profession and the public have such confidence in our ability to obtain a
perfect result in every case that it is embarrassing to have to explain that in many a com-
promise is the only solution. By perfect result is meant one which is permanent and
leaves nothing to be desired as regards alignment and occlusion: the two latter are fre-
quently obtainable but their permanency cannot be judged till appliances have been
discarded several years, when the ultimate result will be apparent. It is this ultimate
result which is so important: unfortunately it is rarely available to the specialist ortho-
dontist, who has to rely on fortuitous circumstances to bring it to his notice. This is a
reason why it requires the combined resources of manv practices to accumulate the records
from which to draw conclusions; it is more likely that these records will be forthcoming
from private practice than from any form of public orthodontic service.
The study of these ultimate results is valuable in that we learn from them what is the
best treatment for any particular case. I have been able to collect some such records and
have supplemented them by others from which conclusions can be drawn (see illustrations).
Much orthodontic literature gives the impression that the perfect result can always be
attained. T'hough this may be so in many cases there are numerous exceptions. In somr
the perfect result can be obtained but not retained, and sooner or later relapse occurs,
undoing years of work. How much better for patients and profession to recognize these
exceptions and to adopt what may be called a compromise treatment that will be both
beneficial and permanent, zestheticallv and functionally, though falling short of the
elusive perfect result.
One frequently hears criticism of a compiromise treatment, involving, say, the loss of
an upper incisor, as if it were unwarranted. Actually it mav be the best solution in the
circumstances though the implication is that something better could have been done. The
critics, however, overlook the fact that the imnmediate result, however excellent, may not
be permanent and that our aim must be an ultimate resuilt showing a definite and lasting
improvement on the original condition. The result which is permanent is the better
though it fall short of perfection, but it must satisfy aesthetic and functional demands in
so far as the original condition permits. This latter is so variable in degree that it is un-
reasonable to expect an equally good permanent result in every case.
FEB.-ODONT. 1
174 Proceedings of the Royal Society of Meditcine 12
Cases of relapse are not uncommon and reflect no credit on the practitioner. They are
best avoided by adopting a type of treatment with a good prognosis. If this is not possible,
it is better not to begin treatment. This orthodontic problem, entirely different from
any other in dentistry, requires all one's care and ingenuity for its solution, bearing in
mind that it is not sufficient to align and occlude teeth but the teeth must reman in
alignment and occlusion. If I cannot foresee a reasonable degree of permanent improve-
ment, I prefer not to undertake a case. While it is not possible ta eliminate all failures
they should be reduced to the minimum. Failu'res in orthodontics are an enormous
waste.
Experience alone teaches what type of treatment will be successful; it is a matter of
trial and error. The combined experience of many should be available to enable each
practitioner to say what procedure will be beneficial. -Few practitioners have published
ultimate results, but from time to time one comes across straws which show the way the
wind is blowing. These may advise something other than the usual directions for tooth
movement, thus suggesting that previous directions of movements had not given the
desired result, or they may be the confessions of an unusually communicative ortho-
dontist. Reading between the lines one concludes that it is not possible, in every case,
to keep all the teeth and get a good result. From this it would appear that treatment
must not be based on theory or research alone, but also on clinical experience: new
methods of treatment must bear the test of clinical experience before adoption as a
routine. This test takes years in some instances, yet one hears of new treatments being
praised after a brief trial.
Research workers have added to our knowledge of many aspects of orthodontic practice,
e.g. the effect on the bone of force applied to teeth may cause it to be absorbed in some
areas and deposited in others, but one is forced to the conclusion that such changes
may not be permanent or the relapses known to every orthodontist would not occur.
This simple illustration is given 'to emphasize that clinical results, obtained in actual
practice and not effects seen in the laboratory, are the basis for orthodontic treatment:
all new methods of treatment must be studied critically, and it must not be assumed
that- all are advances.
-Illustrations of five cases are used to amplify the text; they are arranged according to
(Angle Classification) arch relation, and are described in the legends. The important
points are:
Class I: In those cases in which the arches. are not large enough for the teeth, extrac-
tion of upper teeth is essential because the bones cannot be enlarged. Prognosis is un-
favourable if all the teeth are kept, though it is often necessary to compromise as regards
the lower teeth and to leave them in their original state.
Classes II and III: Prognosis is favourable for the correction of the position of the
mandible: if the arches are too small the considerations as'for Class I apply in addition.
In some cases of Class III type in which the error is slight and the maxilla relatively
smaller than the mandible, the prognosis is not so good as in true prenormal occlusion.
All cases with good- arches, which implies normal-sized maxillary bones, give better
results than cases with small arches.
The prognosis as regards errors of individual teeth is uncertain but usually the earlier
these are corrected the better.
The first case was a typical Class I (Angle) small arches in normal relation (boy), treated
by- enlarging the arches at age 7 years 8 months, showing a good result at age 13 years
10 months, but considerable relapse at age 29 years. There is no record of the condition
between 14 and 29 years. This case has already been published -in the Transactions of
the British Society for the Study of Orthodontics, 1938, p. 23.
Fig. 1.-No. 3246. Male, aged 12 years 6 rnonths Diagnosis-Small arches' in normal
relation. 2 diminutive; extracted. I 12 have been moved to the right. 3246 A, the
same case aged 14 years 6 months. If 2 had been a normal tooth but rotated,
prognosis would be best if it or L2 had been removed. No treatment-not even extrac-
tion-advised for lower arch. Loss of (i[1 may allow arch to contract a little; this may not
be harmful as there is slight spacing of the upper teeth. Prognosis good.
Fig. 2.-No. p527. Female, aged 7 years: Diagnosis-Class II, Division I. Good lower
arch.
Aged 7 years 8 months: Treatment- begun with fixed appliances and- intermaxillary
traction to bring the mandible forward.
13 Section of Odontology 175

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I Section of Odontology 1-77
Aged 8 years 11 months: Upper appliance left off for five moniths with little or no
relapse. Lower appliance left in to keep pre-molar spaces.
Aged 11 years 2 months: All appliances removed.
Aged 11 years 4 months: Put in vulcanite retention plates for night wear with inter-
maxillary traction; patient was conscientious about this at first but did not wear them
continually for long; probably worn in all for six months spread over two vears; thev
were not worn for weeks at a time. Model 1527 c.
Aged 22 years 1 month: I\odel 1527 v shows post-nornmality corrected, slight imbrica-
tioin of upper and lower incisors. Prognosis good.
Fig. 3.-No. 3198 .A. Female, aged 8 years 4 months: Diagnosis-Class II, Division I
on right, Division II on left.
Aged 8 years 5 months: Treatment begun with fixed appliances and intermaxillarv
traction to bring the mandible forward: 1 moved labially into line with I
Aged 10 years 7 months. NModels two vears two months after treatment was begun.
Appliances removed.
Aged 10 years 10 months: No relapse: appliances replaced for retention. Prognosis
probably good.
Fig. 4. No. L.H. 996. Female, aged 7 years 10 months: Diagnosis Class II,
Division I on right, Division II on left. Good lower arch, 2 rotated. 1 in good
relation to lower teeth. Post-normality half a cusp bilaterally.
Age(d 7 vears 10 months: Treatment Extract 2; retract I 2 and move 1 to the
right.
Aged 9 years 4 months: Models. Retention with plain banid oni _1 carrving labial
spurs 1 2.'
A suitable case for this simple method of treatment in which the positioil of the mandible
has not been changed. Uncertain how long retention will be required and how perfect
the alignment will remain; if there is relapse it is the disadvantage of this method of
treatment. Prognosis probably good.
Compare case No. 3198 (fig. 3) in which the instanding central was moved labially into
line with the other and the mandible maved forward; this acts as a retainer for the
labially moved central and so relapse of incisor alignment is unlikelv. This case is not
so favourable for treatment with extraction as is case No. L.H. 996 (fig. 4). Neither case
has been under observation long enough to speak of the long-term results but both
methods of treatment seem to have a place.
Fig. 5.-No. 3264. Female, aged 4 years 11 months: Diagnosis-Arches
good. a abc lingual to lower teeth. Pre-normal occlusion of lower arch with (probably)deviation
to the left. Profile has slight suggestion of Class III. a a show signs of attrition on
their labial surfaces.
Aged 4vears 11 months: Headl and chin cap with intermaxillarv traction to retract the
mandible for wear both night ancd day. Lower plate with shod incline to assist a a
labially.
Aged 5 years I month: a a correct. cb bc not quite enough labial.
Aged 5 years 1 month: cba abc correct. Gradually reduced wearing of plate and head
and chin caps until
Aged 5 years 4 months, when instructed to discard all appliances.
Aged 6 years 7 months: Occlusion excellent. Are the arches large enough? Case to
be watched for this. Case corrected in three months; appliances discarded in five months.
Prognosis excellent.
The cases illustrated bring out the great value of intermaxillary traction, but it in-
volves operative procedures which have restricted its use: its value is undoubted and
before other methods replace it on a large scale, one must make sure that they have
definite advantages: t, decide this wvill take years of clinical work and observation. There-
fore, sudden and spectacular advances in treatment are not to be expected, particularly of
those irregularities-post-normal and pre-normal occlusion-which are often deformities
and form such a large part of a specialist's practice. It is well to remember that the
incidence of caries is not likely to fall during the progress of orthodontic treatment.
To ensure the best results for the patient, orthodontic and conservative work must be
d(one in close co-operation. As the practice of orthodontics increases, prognosis becomes
178 Proceedings of the- Royal Society of Medicine 16
even more important, not only from the point of view of permanency of result but also
in selecting the method of treatment. In order to foresee the ultimate result before
treatment is begun prognosis must be known and acted upon. It is often easy to pro-
duce what appears to be a brilliant result but which may be as transient as a rainbow.
Appliances are important but if the result they produce is not permanent, it matters not-
how perfect they are.
[The text has been abbreviated and seven of the cases shown, omitted; four of these
showed long-term results.]

Mrs. Lilian Lindsay, L.D.S., described a case of Bell's palsy in two sisters. It was
congenital in both and appeared to be hereditary, as it would appear from a photograph
of the father of the girls that he had the same condition.