Lines of Disharmony

Skeletal Malocclusions and Aesthetics in the Development of American Orthodontic Practice

This exhibit examines the development of orthodontics and oral surgery in the United States, specifically the corrective practices for Class I, Class II and Class III skeletal malocclusions, using rare books, artifacts, and archival materials from OHSU Historical Collections & Archives. In addition, the exhibit highlights the psychosocial stigma patients faced in regards to beauty standards and descriptions within early medical literature. 

Development of a Specialty

"Occipital Apparatus" for correction of Class II malocclusion. Case, Calvin. A practical treatise on the technics and principles of dental orthopedia, 1908. Chicago: C.S. Case Company. History of Dentistry Collection.

Orthodontia, the treatment of irregularities in teeth and jaw, was the first concentration created within the dentistry profession. In the later part of the 19th century, the introduction of electricity to dentistry, along with the use of local anesthesia, spurred the evolution of oral surgical procedures. In conjunction with orthodontic treatment, orthognathic surgery is an essential form of correction for abnormalities related primarily to jaw structure rather than teeth placement. Orthognathic surgery is an operative procedure involving the manipulation of the dentofacial skeleton to restore functional properties.

A number of orthodontic pioneers contributed to the development of the field as it is today. Norman W. Kingsley (1825 –1896), known best as a painter and sculptor,was one of the first orthodontic pioneers. His emphasis was primarily on correcting the alignment of teeth by removing the back molars and pulling the anterior teeth back, and experimentation with the treatment of cleft palates. Edward H. Angle (1855-1930), known as the "Father of Modern Orthodontics," advocated for orthodontics to be separated from dentistry and recognized as its own specialty. Calvin S.Case (1847 –1923) pioneered the use of rubber elastics and light wires for the bodily movement of teeth.

Class I and Class II Malocclusions

Class I malocclusion after eighteen months of treatment. Fig. 365. Angle, Edward. Treatment of Malocclusion of the Teeth: Angle's System, 1907 (7th ed.). Philadelphia: S.S. White Dental Manufacturing. History of Dentistry Collection.

Skeletal malocclusions occur when the mandible (lower jaw) and maxilla (upper jaw) do not align when closed. A Class I malocclusion is the least severe – the molars of the occlusion can be properly aligned, but the other teeth are over-erupted, crowded or unevenly spaced. A Class I can also manifest in a cross bite or abimaxillary protrusion, the forward projection of the maxilla and mandible. Treatments for a Class I malocclusion can include tooth extraction, anchorage and surgical palatal expansion. A skeletal Class II malocclusion, also known as maxillary retrognathia, is caused by the recession of the mandible, which creates an overbite.

Class III Malocclusions

Class III malocclusions. Figs. 29 and 30. Angle, Edward. Treatment of malocclusion of the teeth and fractures of the maxillæ: Angle's system, 1900 (6th ed.). Philadelphia: S.S. White Dental Manufacturing. History of Dentistry Collection.

A skeletal Class III malocclusion, or mandibular prognathism, occurs when the mandible protrudes past the maxillary teeth, which manifests as an under-bite. Bone removal, palatal expansion and orthodontic prepatory work are included in correction of Class II and Class III.

Oral Surgery

Splint, slide from the American Dental Institute, 20th century. Wilbur Nelson Van Zile Collection. Post-surgery, a plastic split is attached to the upper teeth to keep the corrected bite stable during healing.

As with orthodontia, there have been several individuals designated "Father of Oral Surgery" title. Simon P. Hullihen (1810–1857) was the first known oral surgeon to conduct orthognathic surgery to correct a jaw deformity during the years before modern anesthesia. His most famous case reported was the surgical correction of an elongated mandible using a method called bilateral sagittal split osteotomy. This method involved cutting the jaw bone bilaterally to move it either forward or backward for facial alignment. James Edmund Garretson (1828 –1895), also known as the founder of oral surgery, created a new department for the practice at the Philadelphia Dental College where he served as dean. Garretson published A Treatise on the Diseases and Surgery of the Mouth, Jaws and Associate Parts (1869), which helped to establish oral and maxillofacial surgery as a medical concentration.

Beside bone removal from the jaw, expanding an overly narrow palate (also known as RME - rapid maxillary expansion), can contribute to the correction of a Class II or Class III Malocclusion. Emerson C. Angell (1822 - 1903) is known as the founder of RME, and he was the first to use a split plate worn by the patient to keep a median incision on the palate expanded during healing. RME appliances are still used to this day.

Cultural aesthetic values and skeletal malocclusions

Face of Apollo. Fig. 42. Angle, Edward. Treatment of Malocclusion of the Teeth: Angle's System, 1907 (7th ed.). Philadelphia: S.S. White Dental Manufacturing. History of Dentistry Collection. "The face is a study of symmetry and beauty of proportion in the fully developed nose and nostril, the full rounded, finely curved lips, squarely chiseled chin, etc. Every feature is in balance with every other feature and all the lines are wholly incompatible with mutilation or malocclusion."

Class II and Class III skeletal malocclusions can be a medical liability, with potential issues such as gum disease, arthritis of the jaw, breathing and chewing difficulties. However, entries within the literature from the late 19th and early 20th century emphasized the significance of appearance, facial beauty and in some cases, intelligence. The second chapter of Norman W. Kingsley's A Treatise on Oral Deformities (1880) weighs the idea that oral irregularities could possibly correlate with "idiocy"and the "jaws of cretins." Kingsley sets the stage for stigma by frequently comparing the "higher" and "lower" orders of society in relation to malocclusions.

In his text Malocclusion of the Teeth and Fractures of the Maxillae (6th ed.), Edward H. Angle dedicates a chapter to the objective of correcting "one of the evil effects of malocclusion": the "ugliness," "inharmony," and "deformity" of the face. Angle expounds on the ideal of Apollo Belvidere, a Greco-Roman marble sculpture located in Vatican City, as the ideal that many artists of the classical era replicated. Like the artists of antiquity with Apollo, Angle believed that orthodontists could use the law of normal occlusion as their guide. And while acknowledging that orthodontists must put the functionality of a corrected occlusion at the highest level of importance, Angle states that patients wouldn't reach out for correction if it weren't for the way their faces appeared.

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By Sylvie Huhn, Historical Collections & Archives student assistant

Sylvie holds a B.A. in Fine Art from Humboldt State University and is currently completing her MLIS with a concentration in archives through Emporia State University's distance-learning program. In addition to her work at HC&A, she is also a student worker at the UO Portland Library and Learning Commons, and an archives assistant at the City of Portland Archives and Records Center.