“LINEAR ARCH DIMENSION AND TOOTH SIZE”

AN EVALUATION OF THE BONE AND DENTAL STRUCTURES IN CASES INVOLVISG

THE POSSIBLE REDUCTION OF DENTAL UNITS IN TREATMENT

C. W. CAREY, D.D.S., PALO ALTO, CALIF.

INTRODUCTION

T HE question of the reduction of tooth structure as a treatment procedure

in orthodontics has been a controversial one. It is not objected that teeth
should be eliminated and the ideal complement unaltered, but, specifically, the
controversy centers on how far we should go and what the dividing line between
extraction and nonextraction is.
For those of us who have years of practice behind us, the answer lies in the
assessment of the work that has been done. Few have taken the time and trouble
which this entails. Those to whom a protrusive appearance is pleasant will
arrive at a different conclusion than those to whom it is objectionable. A minor
relapse in alignment may be a calamity to some and to others a natural resolu-
tion. The work of Dr. Hays Nance has given us a key to the solution of this
problem. He has studied, over a period of years, the work of many prominent
orthodontists and has demon&rated the limitations to which we are confined
by the extent to which their best efforts were able t,o stand the test of time. Dr.
Charles Tweed has also demonstrated, by courageously exhibiting casez, that
eventually resulted in failure followin g his own very capable treatment, the
folly of attempting the impossible. We are all familiar with the work of Brodie,
Broadbent, Schour, Margolis, and others who have given us more information
on the basic reasons for our treatment limitations.
The work I am about to present is based upon the study and evaluation of
the past eighteen years of work, largely from my own practice. The assessment
of this material came about as a result of conferences with Dr. Nance and my
attempt to justify the treatment of mild deficiency cases with the sliding section
technique. These cases were treated with such ease and facility that I was en-
couraged to include the even more extreme deficiencies with optimistic en-
thusiasm, where formerly I had resorted to extraction. Retention did not seem
to be much of a problem. In the second year of retention, retainers were worn
one night per week, which seemed adequate; and, in many instances, patients
voluntarily continued at this rate for years, and I did not dissuade them. At
the suggestion of Dr. Nance, it was decided to remove them entirely and see what
happened. Within a few months, some of them relapsed while others did not.
It was easy enough now to obtain a creditable result which was not protrusive ;
Read before the Pacific Coast Society of Orthodontists, San Francisco, Calif.. Feb. 23,
1949; also read before the American Association of Orthodontists, New York, N. Y., May, 1949.
762
 “LINEAR ARCH DIMENSION AND TOOTH SIZE” 763

but if it could not be maintained without support, it was judged that a dis-
balance existed and there was good reason for not repeating these same pro-
cedures. From these cases we were able to draw certain conclusions as to the
prognosis in b,bne deficiencies treated in this manner and grade them accordingly.
Measurements taken from casts were compiled to set down a working basis
for determining when and when not to reduce tooth structure as a treatment
procedure. This work is patterned after the methods of Nance, but deviates
to allow a simple working formula which is used to make an accurate determina-
tion of the amount of tooth structure which can be accommodated by the quan-
tity of bone nature has provided and still remain stable without weakening the
supporting structure.
The necessity for reducing tooth structure in patients exhibiting a pre-
ponderance of dental tissue and deficient bony base I will assume is generally
conceded in light of evidence presented in the past ten years. We have passed
through the dark ages of orthodontics, the era of men striving desperately to
obtain a more perfect mechanism which would accomplish the impossible. It
was the pride in immediate accomplishment and an unwillingness to face the
long-range issue which retarded orthodontic progress. We have learned that
there are definite limitations in treatment involving both extraction and non-
extraction cases, and we are prepared to accept, to some degree at least, the
premise that extensive bone changes not inherent cannot be wrought by ortho-
dontic mechanisms. Furthermore, in view of the cephalometric evidence, main-
tenance of mass distal movement is possible only when these teeth have migrated
mesially b,eyond their normal positions. Nance has compiled data from measure-
ments on casts of hundreds of completed cases in which many types of appliances
were used, to arrive at the conclusion that maintenance of lateral expansion is
extremely limited.
To those of us who recognized the significance of the work of such men as
Tweed, Nance, Brodie, Broadbent, Schour, Margolis, and others, acceptance of
this concept meant admitting the fallacy of our previous thinking and a good
share of the sincere, meticulous treatment which we had diligently employed
as a result of our convictions, then generally accepted as scientifically sound.
It entailed revising the ultimate objective in our treatment and the mechanical
procedures as well.
With the change in our basic concept of the orthodontic correction and
plan of treatment came the necessity for adequate and efficient mechanics. This
factor has’long been neglected by those who were extracting teeth routinely in
extreme cases. Their inability to treat these cases efficiently placed this plan
of treatment in disrepute with dentists, the public, and their fellow practitioners.
It has been demonstrated that these cases can be corrected very creditably by
skilled operators who have been able to produce a balanced dentition, with the
teeth in favorable functional inclined plane relationship, proper axial position-
ing of the buccal teeth, esthetic inclination of the anterior teeth, and complete
and permanent space closure. To do this requires an exacting and difficult
technique and extremely careful treatment planning. If the operator is unable
764

to accomplish all these objectives, then it would be far better to concentrate on

preserving the full complement, of teeth and be satisfied with an irregularit)
of the lower anterior teeth as an end result as the lesser of two evils. When t,hercb
is no extreme disbalancr of tooth t,o bone structure, the chances of producinp
a poor result are greater. These arc borderline cases in which there may be an
excess of tooth structure amounting to but a few millimeters. There is danger
of producing a loss of faGal dimension and of eventual spacing as a result ot
excess of basal bone.
The decision to extract must be preceded by a great deal of thought and
study. What is the approximate amount of basal bone deficiency? This can
be closely determined by a met,hod of measuring the linear dimension over t,he
buccal cusps and over the anterior ridge and comparing this with the sum of the
mesiodistal diameters of the teeth. Tf t,he excess of tooth structure is less than
2.5 mm. in the lower arch, the advantages of extraction arc doubtful. The same
t,ype of calculation can be made in the mixed dentition, a.s demonstrated by 1114.
Hays Nance in ascertaining the potentialities of the jaw structure for accommo-
dation of the full romplement of teeth in alignment. If it is found to he greatly
deficient, the first premolars may be extracted before the secondary dentition is
complete, to allow more favorable eruption of the cuspids. The only mecahanics
required at this stage is a simple mechanism to preserve the arch length.
If, according to Tweed, the ll‘rankfort-nlarldibular angle is greater than
35’, the esthetic result might be unpleasant,. If there is but little deviation in
alignment of the teet,h in a dental and alveolar protraction (himaxillary prog-
nathism) and the mouth is exceptionally wide and labial tissues flexible, ex-
traction can only result in very objectionable spacing in later gears. When the
deficiency is only a few millimeters, it is generally good practice to extract thr
second premolars. Frequently we find large upper first premolars and small
lower first premolars accompanied b,v small upper second premolars and large
lower second premolars. It must be planned so that the remaining teeth will
function in good inclined plane relationship. If the anterior teeth are in lingua-
version and t,he irregularity is not est,rcmc. extraction usually is not indicated.
If the sum of the diameters of the lower lateral incisors is greater than that oi’
the upper lateral incisors, extraction of a lower central incisor may be indicated.
The decision may be assisted by referring to the calculator (Fig. 2) 1 which in-
cludes the diamebrrs of the upper central and lateral incisors. A definite pro-
portion of tooth structure exists between the small are of the lower anterior
teeth and the large are of t,he upper anterior teeth. By reducing the measure-
ment of the lower arc by 5 mm. (the width of a lower central incisor), the same
average proportion must exist when the reduced are is compared with the actual
measurement of the upper anterior teeth, if the two anterior arch segments are
to be in harmonious relation after space closure. The removal of the lower
central incisor, when indicated, will obviate placing crowns on the upper lateral
incisors and requires considerably less mechanical treatment than extraction of
premolars would entail.
If the crowded condition has been a result of early loss of’ deciduous teeth,
the molars are tipped mesially, and x-raps reveal t,he third molars not in contart
 “LINEAR ARCH DIMENSION AND TOOTH SIZE” 765

with the second molars, it may be quite possible to make the correction without
extraction by moving the posterior crowns distally, or by simply placing these
teeth in their normal upright positions.
When the deficiency is confined t.o the maxilla, two upper premolars may be
extracted and the secondary occlusion established with satisfactory functional
relation. More frequently, however, the deficiency is in the mandible. If only
two lower premolars are removed, the esthetics might be excellent, but the oc-
clusion is in poor relation and the upper second or third molars will have to be
removed because of the absence of occlusion with the lower teeth in this area.
In any deficiency confined to the mandible, the result is a compromise because
the upper teeth must be moved farther distally than their normal positions in
the jaw in order to be in occlusal relation with the lower teeth, unless the man-
dible can be advanced by rectifying the pseudoposition of the eondyle in the
glenoid fossa. This is especially true in short mandible cases which are in distal
relation. Here the upper teeth must be moved distally far beyond their normal
positions. It is especially apparent in the upper anterior region where, if simple
anchorage is used, these teeth would be in extreme linguoversion. Their axial
positions must be changed radically to allow esthetics and to permit cuspal inter-
digitation of the posterior teeth. These cases exhibit very little facial improve-
ment. They are generally the wide mandibular angle cases.
For making our decision we must first determine the degree of discrepancy
between bone and tooth structure. For this computation we use the linear di-
mension evaluation. If the discrepancy is 2.5 mm. or less, we do not extract.
If it is 2.5 to 5.0 mm., we extract the second premolars, whenever possible, to
obtain better esthetics. If it is more than 5 mm., we extract the first premolars.
If the discrepancy is extreme (5 mm. or more), in the lower arch and mild in
the upper, we extract the lower first and upper second premolars, and vice versa.
When the discrepancy is confined to the maxillary arch, two upper first or second
premolars are removed, the choice depending upon the degree of the deficiency.
Esthetics is a most important consideration-a primary objective in treat-
ment and the outstanding value which motivates the patient to seek orthodontic
service. If the appearance cannot be improved by treatment, there is not suf-
ficient justification for the time, effort, and expense required. Better function
and oral health may be produced, but these factors alone are not enough to
warrant the effort, except in rare instances. The typical American girl, whom
we judge to have a beautiful face, is not depicted as a thin-lipped individual,
but one having a slightly protrusive full-lipped physiognomy with a wide,
generous smile, prominently displaying a good, healthy set of teeth. We im-
mediately associate a handsome man or, if not handsome, a friendly, likable
person with a good, wholesome, generous, confident smile. These are the people
who have a definite physical advantage in their social and economic life, and
it would be, indeed, unfortunate if this should be taken from them.
For years the lower third molar was our number one alibi for failures. It
ranked before heredity, endocrines, and poor patient cooperation. It was, in
fact, the last stand, and x-rays were a perfectly obvious support for our con-
tentions. Fortunately, our efforts were sympathetically regarded by patients
 C. W. CAREY

and parents, and the third molars were credited with a wickedness beyond all
sense of justice. When premolars are removed, t,hcse teeth usually erupt earlier
and in more favorable position.
The most esthetic location and position for anterior teeth should be deter-
mined at the outset. This position also will be the correct anatomic position on
the bony support, because balance and function must be harmonious with esthet-
ics. We must then determine how much of the space created by the extraction
will be utilized for distal movement of the ant,erior teeth and how much for
mesial movement of the posterior teeth. The treatment mechanics then must
be capable of producing the correct balance, or the result will be unesthetic and
unstable. We also must be able to produce mesial or distal root movement of
the teeth adjacent to the spaces so that, at the conclusion of treatment, axial
root relation is anatomically correct. Unless it is we will not be able to attain
good cuspal interdigitation and function. Under the most favorable circum-
stances, treatment of these cases is difficult--far more so than treatment, with-
out extraction, except in t,he most extreme malocclusions.
If the treatment effort has been rewarded by a good result, an additional
dividend will accrue from the ease of its maintenance, for the retention factor,
so often a source of worry, annoyance, and disappointment, will give LIS con-
siderably less trouble and embarrassment.
In evaluating t,he available bone structure to accommodate the permanent
dentition, it is necessary that we make certain calculations in the mixed dentition.
This method, patterned after Nance, is used as a basis for a calculation which
takes into account the degree of rotation or displacement of the lower anterior
teeth, so that a complete survey and an accurate determination can be made of
the amount of space available and required in the entire lower dental arch. The
same calculation is applied to secondary dent,itions which might or might not
require the removal of dental units in treatment.
The method is as follows (Fig. 1, A and B). An 0.012 brass wire is adapt,ed
to the lower mixed dentition model so that one end engages the mesiobuccal line
angle of the lower left first permanent molar near the marginal ridge. The
wire then passes over the buccal cusps of the deciduous molars, through their
greatest diatneters, over the normal cuspal position of the cuspids, then over the
anterior teeth at ridge center where the incisal edges of the lower anterior teeth
are normally found, t,hen around the same course on the opposite side, ending
in the mesiobuccal line angle of t,he lower right first permanent molar. The
wire is cut at this point, measured, and recorded. Then the mesiodistal di-
ameters of the lower anterior teeth are measured and their sum taken. From
measurements made on the casts of a hundred cases of primary and secondary
dentitions of the same patients, we have found that a definite relationship exists
between the size of these teeth and the unerupted cuspids and two premolars,
and have devised a table for quickly making this determination* (Table 1).
From the sum of the lower anterior diameters we arrive at the actual measure-
ment of the objective tooth area with a possibility of error not exceeding 0.5
*Presented 1944, Angle Society meeting in Berkeley. Calif.
 “LINEAR ARCH DIMENSION AND TOOTH SIZE” 767

mm. in ‘76 per cent of the cases, which is probably less than errors encountered
from measurement on x-rays. Fig 2 illustrates a clinical calculator which has
been devised to enable the operator to have an instrument readily accessible for
making this determination.

A. B.
Fig. 1.-A, Appraisal of mixed dentition; B, appraisal of permanent dentition.

Fig. S.-Clinical calculator to determine quickly the size of unerupted cuspids and Pre-
mohrs (window 1)). Windows A. B, and 0 express the sum of the diameters Of the uPPer
anterior teeth in their variation from large, average, to smallest.

The figure relating to the estimated size of the two premolars and cuspid
we will call X; the length of the wire, linear dimension, L.D. The sum of the
lower anterior teeth we will call L.A. Now we have a workable formula:
L.A. + 2X + 3.4 = L.D.
The plus 3.4 applies to the inevitable mesial drift (approximately 1.7 mm.*)
of the first permanent molars on each side following exfoliation of the deciduous
molars (Fig. 3). Example : If we have a linear dimension of 6.5.2 and the
*iVance.
768 C. W. CAREY

TABLE 1”

1 Per Cent 27 Per Cent 18 Per Cent 17 Per Cent 14 Per Cent
20-18.5 25-22 26-24
23.22..5 25-22 26-23.5
8 Per Cent 23-21.5 25-22.5 26-23.5
21-19 25-22.5 26-24
21-20.5 25-24 26-24
21-19 2522.5 26-23
21-20 25-23 26-23.5
21-20.5 25-22.5 26-23
21-19.5 25-23 26-24
21-20 23-22.5 25.23 26-24
21-19.5 23-21.5 25-23.5 26-24
Average 19.75 23-2 1.5 25-23.5 26-24
23-21.6 25-22.5 26-22.5
13 Per Cent 522.5 26-23
22-21.5
25-22 .4verage 23.65
22-19.5 O‘j.02
_t Y .
5 24-22.5 25-23
22-21 23-22.5 2 Per Cent
22-21 23-21.5 24-23
"$2" d 27-24
23-21 Average 22.75
22-21 27-24
22-20.5 dverage 22.25
Average 24
22-21
22-21
22-19.5
23-22.5
22-19.5
22-21
22-20.5
22-21
Average 20.66

“Table prepared from measurement of the sum of mesiodistal diameters of the lower
lateral incisors and Central incisors and the corresponding sum of the cuspids ad two pre-
molars on one side, indicating a definite relationhip which may be used instead of x-rays its a
reliable guide to unerupted tooth dimension.

L.A. is 23.4, which, according to our table, gives the X value as 21.8, then
L.A. (23.4) + 2X (43.6) + 3.4 = 70.4 This means that, there is 5.2 mm. less
than enough space or bone fundation to accommodate the full complement of
teeth, so we know that any mechanical interference would result in lost effort
and that extraction of premolars is inevitable. If the deficiency of linear dimen-
sion is -2.5 mm. or Icss, there is some possibility that a treatment to maintain
spaces might be of value in preserving alignment and giving enough alveolar
buccal and labial bone diversion to make up the deficiency without impairing
the esthetics or weakening the supporting structures. If it is more t,han 2.5 mm.,
treatment in the mixed dentition to preserve the full complement is not indi-
cated, and tooth structure will have to be reduced after eruption of the pre-
molars. These measurements may be made on the casts of all patients reporting
for consultation in the mixed dentition, and an accurate prognosis may be made.
Even though we are certain that treatment shouId b.e delayed, these casts are
valuable to our experience and our understanding of the transitional changes
occurring at this important stage in the development of dentition, and they will
serve to prepare us for the treatment program of the case at hand with a more
complete and graphic record than our memory would be capable of affording.
Photographs may be taken at this time; however, a study of the profile and
Frankfort-mandibular angle would rarely influence our decision in this early
 “LINEAR ARCH DIMENSION AND TOOTH SIZE ” 769

TABLE II*

I I I I SUMOF I I I

NO. 1 L.A. 1 TEETH / X ) DENT. 1 SPACE 1 SPACE ) SPACE

772 22.3 31.1 20.7 21.4 67.1 ti5.0 63.3 JiX
273 23.4 29.0 21.8 20.5 70.4 65.2 63.3 Ex
561 25.0 32.6 22.7 22.1 73.8 75.0 il.0 N-EX
537 24.0 31.4 22.2 Zl.6 71.8 70.5 68.U N-&x
659 23.1 29.6 21.8 21.i TO.1 62.5 56.7 EX
956 23.0 33.1 21.x 22.0 70.0 6X.9 66.7 N-Ex
983 23.x 35.0 22.2 2% 9 71.6 66.6 63.1
533 21.7 28.6 20.5 19:s 66.1 66.9 66.9
510 21.6 29.3 20.5 20.4 66.0 64.1 62.0 N-Ex
722 24.0 33.0 22.2 21.9 71.8 ti5.u 65.0 EX
895 26.2 33.8 23.6 22.9 76.8 68.0 59.1 EX
998 26.8 35.4 24.0 24.1 78.2 75.1 69.5 EX
365 23.4 32.4 21.9 21.7 70.6 72.2 70.1 N-Lx
690 23.6 33.2 22.0 22.1 71.0 65.2 63.5 Ex
816 23.1 27.G 21.8 21.1 70.1 67.5 63.8 EX
789 24.2 30.6 22 . 3 22.9 72.2 66.5 64.1 J3X
592 23.1 33.0 21.8 22.1 70.1 74.2 70.4 N-Ex
563 23.6 33.7 22.0 21.5 71.0 67.1 64.7 Ex
773 24.0 33.4 2212 8” 4 71.8 72.1 71.5 N-Ex
657 24.2 31.4 22.3 2i::! 72.2 69.5 67.1 N-Ex
*Table of’ tooth measurement and calculation of arch dimension on models of mixed
dentition and permanent dentition of the sitme case.

treatment planning, but would certainly be taken into account when active
treatment is undertaken.
In patients reporting after eruption of the permanent teeth, when there is
a question of the advisability of reducing the amount of tooth structure, the same
calculation is made to assist in making a decision. The wire is adapted in the
same manner and the length in millimeters recorded. We then either measure
just the lower anterior teeth and refer to the table for the X value, or we measure
the actual diameters of the cuspids and premolars. In the secondary dentitions
we do not include the plus 3.4 mm., because the mesial molar drift has already
occurred. The variation in linear dimension in the permanent dentition, when
extraction is indicated, will be from -2.5 to -14. The latter figure represents
the complete obliteration of premolar spacing, and the former a fraction of a
tooth diameter bone deficiency. By this means treatment can be planned so that
the amount of distal movement of the anterior segment and the amount of mesial
movement of the posterior anchorage unit may be determined in advance and
the strategy outlined for its accomplishment.
Table II indicates the measurements of the mixed dentition casts and the
permanent casts of the same case untreated. In most cases, treatment was de-
layed until the eruption of the premolars and cuspids. Measurements were
taken, as indicated in the chart, on 20 cases for the first studies of the accuracy
of this method of evaluation. The figure in the first column is the sum of the
lower central incisors and lateral incisors. In the second column (for com-
parison only) is the sum of the upper anterior teeth. The third column gives
770 C. W. CAREY

the X value or calculation of the combined widths of unerupted cuspids and

premolars on one side. The next column gives the actual measurement,s of these
same permanent teeth taken from the casts simply to compare with our caleula-
tion. The next column (2X + LA. + 3.4) gives the amount of space required
for accommodation of the permanent teeth on ridge center in the lower dental
arch. The next column is the amount of space available in the lower mixed
dentition cast. This figure should be equal to or greater than the figure in the
preceding column in order that the permanent teeth may have space to erupt
in alignment. If it is smaller by 2.5 mm. or less, a lingual arch treatment is
justified before loss of the deciduous molars in order to accomplish a satisfactory
result in treatment without extraction of premolars. In the last column is in-
dicated the linear dimension of the permanent dentition which, in most instances,
is considerably less than either of the two preceding columns. In general, not
considering early 10~3 of deciduous molars, it should be approximately 3.4 mm.
less than the linear of the mixed dentition because of the molar mesial drift.
To clarify this formula as applied to cases, we will select three sets of casts.
In Fig. 3 we have an L.D. of 65.2 mm.; the required space (2X + L.A. +
3.4) is 70.4 mm. This leaves a deficiency of 5.2 mm., which precludes extraction.
When the permanent dentition erupted, the L.D. was 63.3 mm. The required
space is 3.4 mm. less than 70.4 because mesial drift of molars has already oc-
curred. The deficiency is 3.7 mm. Treatment of any kind in the mixed den-
tition is contraindicated.
The next case (Fig. 4) has a mixed dentition L.D. of 75.0 mm. The L.A.
is 25.0 mm., which gives an X value of 22.7 mm. The required space, L.A. +
2X + 3.4 = 73; therefore, the lower arch has 1.2 mm. more t,han enough space
for the permanent dentition. In this case some treatment was instituted in the
mixed dentition and, after a rest period and eruption of the permanent teeth,
treatment was completed. The measurements show that a loss of arch dimension
resulted, probably caused by unstable anchorage and migration of the lower
teeth forward to an incorrect anatomic position. The result of this migration
is the unstable location of t,he lower anterior teeth and the tendency for the lower
left central incisor to be crowded out labially. In spite of the unsightly appear-
ance, Class II relationship, and impacted upper left central incisor, a better and
more stable result would have been attained had we waited for eruption of the
permanent teeth, or simply placed a lingual retaining arch before loss of the
deciduous molars.
The next case (Fig. 5) has a mixed dentition L.D. of 70.5 mm. ; the L.A. is
24.0 mm. ; the X value, 22.2 mm. The required space, L.A. + 2X + 3.4 = 71 mm.
The lower arch has a deficiency of only 1.9 mm. in spite of the apparent great
lack of space in the cuspid area. The deciduous molars are apparently over-
sized, as the calculations indicate. A retention lingual arch is indicated before
loss of deciduous molars. This was done, followed by a minor treatment in the
permanent dentition. No relapse was experienced following a brief retention
period of four months, which was occasioned by loss of retention devices and
failure to report until a year later. The L.D. of the permanent dentition, after
 “LINEAR ARCH DIMENSION AND TOOTH SIZE”

Fig. 3.

Fig. 4.
Fig. S.-Measurement indicates deficiency of bone structure 5.2 mm. and precludes e‘x-
tralction of premolars in secondary dentition. Lower arch has lost 1.9 mm. linear dimension in
tralwition, despite lingual arch treatment to preserve space.
Fig. 4.-Measurements indicate an excess of 1.2 mm. in arch dimension, allowing latitu Ide
for full complement of teeth. A loss of 4 mm. arch dimension resulted in the transition.
 C. W. CAREY

Fig. 5.

Fig. 6.
‘ig. 5.-Measurement indicates a deficiency of 1.9 mm. linear arch dimension in spi 1te of
oblit Ltel d cuspid slxxe. A lingual retention arch was justified in the mixed dentition.
‘ig. B.-Measurement on the permanent dentition cast indicates a deficiency of 2.1 mm.
linea an zh dimension. This is within the bounds for treatment without extraction. The
treal ci tse (right) is six years out of retention. Age, 2.2. No relapse has occurred.
 ‘I LINEAR ARC?3 DIMENSION &ND TOOTH SIZE ” 773

retention, was 29.0 mm., or a loss of 1.5 mm. from the mixed dentition, and 2.8
mm. less than that required in the computation. The loss is apparent in the
poor lower premolar contact point relat,ion in the permanent dentition casts.
The next case (Fig. 6) is a permanent dentition, aged 12. The L.D. is
64.5 mm.; the L.A. is 23.0 mm. ; the X value is 21.8, and the required space,
L.A. plus 2X (omit plus 3.4), is 66.6 mm. The lower arch has a deficiency of
2.1 mm., which is just &thin the boundary of treatment without extraction.
The case was treated for twelve months and retained for fifteen months. No
relapse was experienced. Third molars were removed following their complete
eruption. The casts at right show the case six years after retention, at age 22.
The L.D. has held an increase of 2.0 mm., which approaches the limit of linear
arch dimension increase without endangering the health of the investing tissues
at the labial and buccal crest of the alveolar process.

Fig. 7.--Measurement indicates a bone deficiency of 5.5 mm. Treatment attempted without
extraction. Case two years out of retention (right).

I have searched the records of my colleagues, hoping that someone among

them could produce one single case which would give us hope that more latitude
existed. The one notable exception to the treatment possibilities without ex-
traction in bone deficiency exceeding 2.5 mm. is a case treated by Dr. X of San
Francisco. The measurements (Fig. 7) give a 5.5 mm. bone deficiency in the
lower jaw. This case was treated without extraction ; the casts were made two
years out of retention. The patient was 18 years of age, The protrusion in the
treated case is very minor and the esthetics is good. There is some gingival
recession, and in place of crowding some spacing has occurred. There is a
4 mm. increase in the linear dimension of the treated casts over that of the mixed
dentition.
The figures are as follows: anterior teeth, 24.0 mm. L.A. plus 2X plus
2 equals 70.5 (2 mm. are allowed for molar drift because part of the drift had
already occurred with loss of the deciduous cuspid and first molar). The mixed
774 C. W. CAREY

dentition linear dimension is 65.0 mm. 70.5 minus 65.0 equals 5.5 mm. bone
deficiency.
I was so excited about this case that I asked for recent photographs. When
the patient reported, photographs were not, taken because in the ensuing four
years the case had completely relapsed and the bone at the alveolar crests was
badly broken down (E’ig. 8).

Fig. %--Same case six years out of retention.

Treatment without extraction in cases measuring deficiency of b,one in ex-

cess of 2.5 mm. is possible, providing the operator is willing to accept a com-
promise result exhibiting distortion labially and buccally of alveolar structure,
or a mild irregularity of the anterior teeth, with rotations or broken alignment,
or contact point deviations in the premolar region. In these compromises, the
linear dimension of the treated case after retention usually will show no in-
crease over that of the untreated case. The result may be acceptable in view
of the fact that t,here arc no untreated normals without some deviations and
excepting those exhibiting spacing because of excess of boric structure, their
linear dimension measures short, of their combined tooth diameters. Treat,ment
in which reduction of tooth structure has been resorted to is in itself a com-
promise and it must bc judged from the experience of a large number of cases
that have stood the test of time, which compromise offers the patient the rnost
esthetic and serviceable dentition.
SUMMARY

1. It is possible to diagnose cases reporting in the mixed dentition with a

fair degree of accuracy regarding the possibilities of treatment with or without
extraction of premolars in the permanent dentition.
2. Calculations may be made from tooth and linear arch measurements to
determine whether any retentive type of treatment in the mixed dentition will
b.e successful in obtaining a slight increase in linear dimension of the permanent.
dentition and thus obviate reduction of tooth structure in borderline cases.
 “LINEAR ARCH DIMENSION AND TOOTH SIZE” 775

3. Measurements made on mixed dentitions compared with those on perma-

nent dentitions of the same cases years later without treatment, or after treat-
ment and relapse, demonstrate that calculations can be made on the mixed den-
tition casts to practical advantage in diagnosis and treatment planning.
4. Tooth measurements made on the casts of the patient reporting in the
permanent dentition may be used in computing the relative discrepancy in bone
and tooth structure and to assist in treatment planning by offering a working
basis for determining the amount of mesial movement of t,he posterior anchorage
units permitted in treatment procedure.
5. A study of the profile and the Frankfort-mandibular angle should be
made at the initial appearance of the patient, but the calculation is not affected
by the findings, although they must ,be dealt with when the patient submits to
active treatment.
REFERENCES

Name, Hays N.: Limitations of Orthodontic Treatment. I. Mixed Dentition Diagnosis and
Treatment, AW J. ORTHODONTICS AND ORAL BURG. 33: 177-233, 1947.
Nance, Hays N.: Limitations of Orthodontic Treatment. II. Diagnosis and Treatment in
the Permanent Dentition, AM. J. ORTHODONTICS AND ORAL SURG. 33: 253-301, 1947.
Tweed, Charles H.: The Frankfort-Mandibular Plane Angle in Orthodontic Diagnosis;
Classification, Treatment Planning, and Prognosis, AM. J. ORTHODONTICS AND ORAL
SURG. 32: 175221, 1946.
Broadbent, B. Holly: Otogenic Development of Occlusion, Angle Orthodontist 11: 223-241,
1941.
Brodie, Allan G.: Some J&cent Observations on the Growth of the Mandible, Angle Ortho-
dontist 10: 63-76, 1940.
Brodie, Allan G.: On the Growth of the jaws and the Eruption of the Teeth, Angle Ortho-
dontist 12: 109-123, 1942.
Margolis, Herbert I. : The Axial Inclination of the Mandibular Incisors. AM. J. ORTHO-
DONTICS AND ORAL SURG. 29: 571, 1943.

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