Potentials In The PatternABRAHAM GOLDSTEIN, D.D.S., M.S.Chicago, IllinoisThe persistence and the potential ofthe growth pattern of the human headand jaws continue to intrigue me.Therefore, I am constantly on thealert for additional evidence to sup-port or refute my contention that themorphogenetic pattern is unique foreach individual and persists over anytreatment procedure. The pattern is:( 1 ) spatial, ( 2) morphogenetic, (3)functional niid (4) psychologic.By pattern I mean a conglomera-tion (or juxtaposition) of factors whichare fixed for the individual. These fac-tors are multidimensional in that notonly is the pattern spatial in extent,but also morphogenetic in that her-edity puts its permanent stamp on it.It is also functional and psychologic.By psychologic I refer to the patient'stion. The concept is broad but its em-phasis is on limitations. Furthermore,its potential is not known until fullgrowth and development are achieved.For quite some time a good deal ofthought and discussion has been giv-en to the contention that, in order toachieve a successfully treated case, an-chorage must first be prepared. Thisthought seems to be even more preva-lent in extraction cases. This prepar-ing of anchorage and its results wereassessed cephalometrically in a casewhich I treated in 1940 and gave toDr. Brodie to report in his paper onthe extraction pane1.l Subsequently Iwas fortunate enough to secure addi-tional records some years later which Iwish to present here.beiidvioidi ieSpoiiSe, iiaiidy ~~~pei.2-Read before the Midwestern Component ofthe Angle Society, Chicago, Jan. 19, 1959.Case L.L. was a severe Class 11,Division I malocclusion as seen by thetracing taken from a lateral head x-ray(solid line) showing the case beforetreatment (Fig. 1).For the first four months the lowerteeth were subjected to tip-back bendstogether with ligature traction andarch expansion. Figure 1 represents asuperposed tracing of the original andme made at the end of that phase oftreatment. All superpositions havebeen on the SN plane registered atS. This reveals that, although the lowerincisor has been tipped lingually, themolar crown has not gone back, butthe root apices have come forwardto an appreciable degree. It shows fur-ther that the arch has been shortenedanteroposteriorly, which shorteningexpansion. The Hawley arch formwasused as the guide to the shape of thearch.At this period Class I11 elastics wereapplied to complete the distal move-ment. After one month the clinicalevidence of forward movement of theupper was so pronounced that a head-cap with occipital force was appliedto this arch. Figure 2 shows what wasxcomplished over the next three anda half months. It will be noted that themaxillary molar has been elevated, theusual response to pull of Class I11elastics. The maxillary incisor has beenietracted somewhat through a shorten-ing of this arch. The posterior endof the occlusal plane has opened thebite as indicated by the new position(posteriorly) of the mandible. Thiscompleted the first phase or anchoragepreparation.could liiive "veii gaiiied GGEY bjkit~?~!2 06 Vol. 29, No. 4 Potentials 207The next and final phase of treat-ment called for the setting back of themaxillary arch. This was accomplishedwith second order bends and Class I1intermaxillary elastics with a headcapworn against the uppcr at night to sup-port the elastics. This required ap-proximately six months and is repre-sented by the findings at age 14-5-27.Although the mesiodistal correction hadbeen accomplished, another three tofour months were used in settling andfinishing the case.Figure 3 represents a comparison be-tween the first tracing and one madeat the end of active treatment. It re-veals that both molars are slightly for-ward of their original positions, thelower mor2 than the upper. The upperincisors have been carried downwardand linyually. The ccclusal plane hasbeen tipped down in front, and themandible has been forced inferiorly andposteriorly.The lower molar, on the other hand,has gone upward one-third of its crownheight and forward one-third of itsmesiodistal width. The arch has beenshortened by expansion and the molarnow occupies a more unfavorable posi-tion than it did originally. Thus, at theend of n long period of treatment,LL13-1-9........... ....II- 14-5-27I \Fig. 3. 208 Coldstein October, I959with considerable disturbance of axialinclinations, we find the case in a moreunstable condition than it would havebeen had it been treated in an orthodoxmanner.Figure 4 is a composite of two trac-ings showing the case two years laterat the end of the retention period.We see here a downward and for-ward growth of the mandible of con-siderable extent. There is a downwardand forward position of the lower in-cisor which has mahtained practicallyits same axis.The lower molar which at the endof active treatment was apparentlytipped distally, is now beginning toassume a more upright position as itmoves downward and forward underthe growth influence.There is a distinct change of theaxis of the upper incisor, with thecrown down and forward and theroot apex pointing lingually again. Theupper molar shows il similar changeof its axis with the crown down andforward. Notice the recovery of theocclusal plane, the result of the im-proved axes of the teeth.We note also a tremendous surgein overall growth with parallel down-ward and forward growth of the nasalfloor and a forward position of nasionwith an tccompanyitig increase in thesize of nzal bone and the nose.Figure 5 is a comparison betweenthe tracing of 16 years; 6 months andone taken at 23 years, 6 months, andshows a continuation of the overallgrowth picture which is a male char-acteristic. The occlusal plane has re-mained nearly parallel, as have theaxes of the incisors and molars. Noticethe combiiied forward growth of nasionwith a tremendous increase in the sizeof the nasal bone and the nose, andobserve hcw the nasal floor has main-tained a parallel position.Figure 6 represects cephalometrictracings or' the mandibles of Case L.L.superimposed on the symphyses. Theresuit of active treatment (upper ieitjshows that the occlusal plane has beenelevated; the molar has gone forwardFig. 4, Left. Fig. 5, Right. Vol. 29. No. 4 Potentials209Fig. 6. Mandibular soperpositions.and rotated on its axis. Note that, al-though the incisor is elevated, the axialinclination is practically unchanged.The anchorage preparation which wassupposed to tip back the incisor ap-pears to have succeeded only in dis-placing the molar.What hks like anchorage prepara-tion may tx a distal positioning or tip-ping of th? mandible, giving an up-right flat appearance to the incisorarea.During retention (upper right) wesee a definite return of the molar toits former axial position. The incisoraxis has been practically maintained.The occlisal plane 113s returned to amore lev4 position 2nd has elevated.In the lower left composite is de-picted the changes !rom 16 years, 6months to 23 years, 0 @s. Thereis some growth at thewstenor border.while the occlusal plane moved up- years later.i\,The lower 'is forwardFig. 7. Dotted, before trmtment; solid, ten 210ColdsteinOctober, 1959Fig. 8. Right to left, models before treatment, at completion of retention, and sevenyears after treatment.ward chiefly in the molar area.We now go one step farther andexamine the original cane at age thir-teen before treatment and at agetwenty-three. Figure '7 represents acomposite of the tracings of those yearsand reveals the follQwing:(a) An enormous overall growth,especially in the mandible; a down-ward and forward growth of the en-tire face along the Y axis.(b) Extreme fonv; rd position ofnasion, together with marked increaseir, nasal bone.(c) Downward mwement of therasal floor ir* a distinctly parallel man-ner.(d) The occlusal plane has return-ed almost to the Qrigid. In fact ithas opened slightly in the anteriorregion.(e) The axes of the molars and in-cisors are nearly identical; in fact, theincisor at the end oi this ten year in-terval is slightly mor? upright than itwas at the beginning of treatment.Figure 8 represents original models,those at the end of retention, and thosetaken 7 years later :it oge 23 years 6months; they illustrate how the casehas maintained itself. In fact, themodels taken at age sixteen years canbe transposed on thosc taken at agetwenty-three years. Figure 9 showsphotos originally, at end of activetreatment and at end of retention.Figure 10 is a profile photograph at23 years - the frontal photograph wasnot available. The balanced face speaksfor itself. Vol. 29, No. 4PotentialsFig. 9. Above, original photographs; middle, at end of active treatment;bottom, at the end of retention.21 1 21 2Coldstein October, 1959Fig. 10. Seven years after retention.The findings in this case bear outalmost completely the findings reportedin the first cephalometric appraisal oftreated cases by the staff at Illinois,published in 1938, namely:1. Tipping is the predominantmovement.2. In all cases in which elastics wereworn there was a disturbance ofthe occlusal plane.3. There is a tendency for the oc-clusal plane to return following treatment.4. Axial inclinatior! of teeth, dis-turbed by orthodontic manage-ment, tends to correct itself fol-lowing treatment.5. There seems to Le a definite cor-relation between success in treat-ment and growth.The second case (M.R.) is also amale, age 13-6-3, at the onset of treat-ment. The case is classified as a Class11, Div. 1 Sub. The left side is in a fullClass I1 re!ation, while the right sideis somewhat forward of a Class I. Theupper incisors are in ;evere overjet withan increased overbite. The lower in-cisors are in supraocclusion. Facialmusculature is hypertonic. Case pre-sents a somewhat pmtrusive type den-tition.Figure 11 is a tracing of the lateralhead x-ray, at beginning of treatment;the facial photograrjhs are in Figure12, and in Figure 13 are the modelsat the beginning of active treatment.The case was treated with a com-plete edgewise mechanism with all theteeth banded including the secondmolars. Treatment in this case wascarried out in a more or less orthodoxmanner. Anchorage was not prepared.However, approximately from four tosix months were used in establishinga good lower arch which consisted ofleveling the occlusal plane and correct-ing nearly all rotations. Slight tip backbends to reverse the curve of Speewere used in the lower arch and thearch was tied hack. In achieving theabove some expansion was resorted to.Fig. 11. Vol. 29. No. 4Potentials21 3Fig. 12.In the meantime, bracket control andsome rotations were taken care of inthe upper arch.The next phase consisted of correct-ing the mesiodistal relationship. Thiswas accomplished as follows: The up-per archwire was cut on each sidemesial to the canines. Hooks for inter-maxillary elastics were soldered to restFig. 13.against the mesial side of the caninebrackets. Distal second order bendswere placed in the buccal arch seg-ments which were then tied in theusual manner and Class I1 elasticsstarted.The anterior arch segment was leftin place for lip protection.I have employed this procedure inClass I1 cases or wherever the mesio-distal relaiionship requires correctionfor the past twenty years. The think-ing behind this is as follows:1. Class TI intermaxillary elastics arenot employed continuously.2. Second order bends are placedand elastics worn in the buccal seg-ments for two or three appointmentsof three to four weekly intervals.3. The buccal arch segments arethen removed, `elastics discontinued,and the case allowed to settle, or re-lapse, for cne or two appointments.4. This reveals several things:(a) Anchorage is not strainedand has a chance to recover dur- 214ColdsteinOctober, I959(c) The relations of inclinedplanes of the upper and lowerteeth change to each other; oftenthis change occurring during agrowth period acts to jump thebite. This saves much tooth move-ment.5. After the rest period the archsegments are then replaced, second or-der bends checked, and intermaxillaryelastics worn.6. This procedure also serves as anexcellent check on whether the pa-tient is wearing elastics as instructed.If elastics are worn correctly, a spacenearly always opens, distal to the up-per laterals.7. This process is repeated severaltimes until the buccal segments arelocked in correct mesiodistal relation.The upper incisors are then retractedand placed in their correct positions.Figure 14 shows tracings of the case atthe beginning and the completion ofactive treatment and reveals the fol-Fig. 14. Before treatment and at the endof ac,tive treatment.ing this brief rest period.(b) Adverse distal tipping of theupper teeth is prevented. lowing:Fig. 15. Vol. 29, No. 4Potentials215Fig. 16. Left to right, original models, end of active treatment, and sixteeii yearsafter completion of treatment.1. Correction of the mesiodistal re-lationship.2. Considerable overall growth withmaxillary and mandibular growth ina downward and forward direction.3. The lower incisor has improvedits axial inclination from 100.5' tolower border in the original, to 92' atend of active treatment.4. The lower molar has a more up-right position. Any existing tipping isdue to reducing the curve of Spee.5. The xclusal plane has not beentipped. Noce the nearly parallel re-lationship.6. Nasion has moved forward whilethe nasal floor has descended in aparallel manner.7. The upper molar has moveddownward while maintaining the samerelative axial inclination. This maybe ascribed to the influence of the in-clined planes. The incisor is relativelymore upright.Photographs at end of active treat-ment are Been in Figure 15.Figure 16 shows models of the casesixteen years after the completion oftreatment and approximately fourteenyears after removal of retention. Thefour third molars were removed twoyears prior to making these models.Figures 17 and 18 represent com-posites of tracings made before start-ing treatment and sixteen years afterthe completion of active treatment, a 21 6Goldstein October, 1959/fig. 17. Tracings before treatment andeighteen years later.span of eighteen years, and reveals thefollowing:1. The excellent overall growth.p15-8-5-2. Practically parallel occlusal planes.3. The c!ose paralleling of the axesof the incisors and molars.4. The upper incisor is tipped lingu-ally.5. Note the forward movement ofnasion as well as the parallel descentof the nasal floor.Final photographs are illustrated inFigure 19.SUMMARYThe analyses of these two casesshow striking similarities : both showexcellent growth changes during theactive treatment period and evidenceof continuccl excellent growth long af-ter treatmrnt; both were treated with-out extraction.The first case, L.L., had its denti-tion subjected to severe turmoil in theprocess of setting up anchorage. Thesecond case, M.R., was not subjectedto the procw of setting up anchorage.in the finai assessment the resuits6 #'Fig. 18. Above, maxillary superpositioii mid below, mandibular superpositions. Vol. 29, No. 4Potentials21 7Fig. 19.were strikifigly similar. The occlusalplane in the first one was completelyupset and ultimately returned to aposition practically parallel to the orig-inal case before treatment.The occlusal plane in the secondcase ws maintained nearly parallelthroughout treatment and was foundparallel, or nearly so, to the originalcase many years after treatment.In the second case, after sixteenyears without appliance support, theonly evidences of relapse are brokencontact? at the lowe;. left central andupper right central, and a slight buccalmovement of the lower left first molar.There does not appear to be any rootresorption evident in the second caseon intraoral x-rays taken sixteen yearsafter treataent. The first case showedsome slight resorption about the rootsof the upper and lower incisors.It would appear, therefore, thatour greatest ally is the angel on ourshoulder, growth. It also appears thatsetting up anchorage does not appearto offer enough advantages to justifyits use.These findings are the answer tomy reluctance to give full credenceto the cephalometric findings in angu-lar measurements at the beginning oftreatment, especially between the agesof nine and twelve years.The hasic angles may remain thesame or nearly the same, but the po-tential of the pattern in a spatial re-lationship is not known for many years.It behooves us to explore this potentialto its utmost.I am fully aware that one caseproves little in orthodontics. However,were we to explore more adequatelythe potentials in the pattern, keep ade-quate treatment and follow-up records,it is not unreasonable to suppose thatwe may find many cases exhibitingthe same or similar response to liketreatments.111 No. Wabash he.