American Journal

Of

ORTHODONTICS
(822 rights ~eserucd)

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VOL. 44 L)ECE~IBER, 1958 No. 1”

Original Articles
TKXATMENT PI,ANNING AND THE TECHNICAL PROGRAM IN
THE FOUR FUNDAMENTAL TREATMENT FORMS

C. W. CAREY, D.D.S., Pnr,o ALTO, CALIF.

PART I

T HE diagnosis having been made, our att,ention is now directed to t,reatment

planning. This is as important as the diagnosis, and it, must be coordinated
with the latter and set down in outline form. It is imperative that we make full
use of all diagnost,ic material in order that, WC may recognize the etiology, charac-
teristics, classification, and extent of the malocclusion. It also follows Ihat,
having given this much time and attention t,o an accurate assessment of the
material, we should take full advantage oi’ it. Diagnosis and treatment a~‘(:in
t hv same family; t,hey are closely tied toget,her.
The treatment program should bc designed so that specific sequential steps
a IV laid out. and dire&d toward a definite objective. It is technically simple1
to band all the teeth, correct irregularities, and coordinate occlusal relationships.
lmt doing this would mean ignoring the tliagnosis and using a single t,reat,tncrlI,
1)lan t,o tit all cases.
Treatment planning, simply express&, should take into account (‘where we
are, where we are going, and how we arc going to get there and stay there.”
Easically, t,he attention that Charles Tweed paid to the position of t.hti
lower incisors is fundamentally sound and has stood the test of t,imc. E’or
many years since Tweed introduced this to the profession, I have bclicved th;lt,
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Presented before the Northeastrrn Society of O!‘tlmdontists. Buffalo. Nrw York,. Oct. 21
am1 22. 1957.
 CAREY Am. J. Olrhoduntics
December, t 958

if we can position and maintain the lower incisors on the anterior ridge in their
correct axial relationship ant1 coordinate the rest of the dental structure to
this the best possible profile and occlusion for each indiviclual patient will
result. The pot,ential growtZh of the condyle of the Inandible must be c(m
sidercd. Evidence has been p~~~tlu~d by Twectl and others that this can bc
accomplished by setting up strong anehoragc in the mandibular arch, putting
the brakes on the upper arch, and using strong Class II mechanics.
The judicious use of headgear produces distal positioning of Ihc upper
arch when anchorage from t,he mandibular arch is not indicated, it may be
applied to the lower arch for srtting up anchorage or for dist,al positionitlg
of this portion of the denture, or it may 1~ usc~l t,o suplmrt the up~)(‘r stabilized
arch when Class III mechanics are used to move the lower dental units distally.
When teeth arc extracted in discrepancy cases, t,hc t.reatmcnt planning
must take into account the extent of the discrepancy so that anchorage from
posterior units may be conserved in proportion.
In this connection, I should like to rcvicw the analysis of the dental cast
in tooth measurement and linear arch dimension, for the discrepancy factor
has a vital influence on our treatment plan and the mechanics to be employed
in the treatment program (Fig. 1). This factor, which is generally misunder-
stood and poorly applied, is the complcmcnt to our ccphalomctric: analysis.
The method used is not entirely my own. ‘l’h~ basic principles were bor-
rowed from Dr. Hays Nancc.la * My contribution was to study casts from fifty
patients in the mised dcntition and of the same pat,icnts in the permanent
dentition. These casts wcrc untreated during the intcrrcning years. The
method consists of a wire measurement, f’rorn the mesial of the first molat*,
around the arch occlusally in the contact point region, biscct,ing the lingual
inclined planes of the buccal cusps of the deciduous molars or prcmolars
parallel to the occlusal plane over the incisal edges of the lower incisors at a
point, where! we judge they belong, and to the opposite side and incsial of
the molar. The 020 soft brass wire should bc symmetrical in arch form-
not curved to occlusal relationship and not adapted to tooth position. It
is held in place by a piece of soft \~a~ 011 the o~cl~lsill surface of the premolar
or the deciduous molars. This is an accurate surTey of the linear dimension
of boric that is to accommodate t,hc teeth I’rom molar to molar. Against this
figure we must measure the combined dintnctcrs of the teeth to occupy t,his
area. If the premolars arc not prcscnt, WY’ Itlcasut’c only the lower incisors
and refer to a chart that I devisccl frottl the mc~asurcmcnts on 100 casts to
predict the size of the erupting prcmolars ant1 c~:l~tin(~s.Jrcasureltmt itmy also
be taken from accurate rocntgcnograms of thchsc!teeth. In the event that the
wire measurement is taken on a m&d dcntition, WC deduct 3.4 mm. from this
figure to compensate for the 1.7 mm. nlesixl tlrift of molars which follows
shedding of the deciduous teeth.
Thus, if the combined tliamcters of th(> teeth from molar to molar arc
72 mm., and the wire measurement is 67 mm., we have a discrepancy of 5 mm.,
or insufficient room for 5 mm. of tooth structure (Fig. 2).
TREATM EiUT CAR0

^” _.._. ______ _^- I.-. _---w

 These data arc used in treatment planning as follows: If the discrepancy
is less than 2.5 mm. and there arc no complications t,o consider in roentgeno-
grams or facial lines, then there is no hesitation or uncertainty in treating with-
out extraction. If the discrepancy is 2.5 to 5 mm. and the lips are not pro-
trusive, or are only mildly so, a maximum of 1.5 mm. of distal movement of

Fig. P.-Assessing the discrepancy between arch length and combined tooth diameters on the
plaster casts.

canines is required and second-premolar extraction will produce a more

esthetic, nicely balanced, and harmonious result. A discrepancy of more than
5 mm. requires more than 1.5 mm. of distal movernent of canines; the first
premolar is the logical choice, as we will riced all the distal movement that
\~,,lume 14 FOUR FUNl?AMENTAJ, TREATMEXT FORMS 891
vlimher12

we can muster to our command. It is well to remember that if the teeth are
crowded but the profile and facial lines are good, second-premolar extraction
will not appreciably alter these important facial lines. First-premolar extrac-
tion, however, unless very carefully handled, may depress the labial and dental
structures to the point of transforming what was a beautiful face into a thin-
lipped, senile physiognomy whose only benefit, I’rotn t,hc treatment is a nice
(‘vct1 t’o\v of tcrth.

The diagnosis has been made, the analysis has been completed, and we
klrclw where we want t,o go. Now WC want to know how to get there.
F’or this strategic program, we have divided treatment int,o four funda-
tnc~utal forms, based largely upon the amount of bone arca that we have upon
hvhich to build a solid, stable dcntition. The application of these forrns will
yat*l\r, of course, depending upon other such factors as facial lines, relative size:
>Itltl shape of the bones of the face, racial type. pathology of tissues, habits
(tongue thrust, in particular), missing teeth, malposcd or embedded teeth, etc.
E’orm C applies to those cases that have good skeletal structure but ma.y
have a superior labial prominence. They have a good lower arch with normal
tooth-to-bone balance, or they may have a discrrpancy of up to I.5 mm. The
maxillary teeth may be in Class II cuspal rclat,ionship, with the canines
L)artia.lly blocked out or the antcrior teeth irregular. The bite is not extremely
closed. Thcsc cases represent. a small segment of our practice and can 1~
nllttilated b>- too much treatment mechanics.
Form A applies to those canes which cshibit more complications but which,
I)onrlwisc. are in fair shape. They have a good skeletal pattern, but they may
hn~c conxidcrable supcbrior labial prot,rusion, inferior labial sulcus, a deep bitt,
lmstcrior cross-bites, blocked-out canines, upper anterior protrusions, crowd-
ing, or spaced teeth. FIowovcr, they do have a fair lower arch with acceptable
iltcisor inclination and a clisc~rcpancy of 1~s than 2.5 mm.
F’orm B I applies to those cases t,hat exhibit. good or poor fa,cial balance
if tr(l skol(+al structurcb. Th(ly lllay bc protrusive or not, with deco, bites ot
opclt-hit’cs. blocked-out, teeth, ctwwdtd teeth, cross-bitq dysplasias, or Class
ITT, (!LUSRII, Division 1 or Division 2, or Class III malocclusions. The prin-
cipal criterion, from a treatment standpoint, is that they have a discrepancy
of 5 mm. OP more in bone-to-tooth nlaterial. Thus, they require reduction of
considerable tooth material. and the first prcmolars are the logical choice for
extraction. These cases demand our most careful and exacting approach and
offer the possibility of changes and benefits which are both great and reward-
ing to all concerned.
Form B II applies to those cases that have good facial balance and skeletal
pattern, although they may bc slightly protrusive. They arc Class I cases, but.
they may be in Class JT cuspal rclat,ionship. The teeth may be crowded; the
second premolars ma.y be structural.ly poor or congenitally missing. The prin-
 CAREY

SLIDING RIBBON
SECTION

SLIDING RIBBON
SECTION

f ,,,,_,,....
.,...‘-
Fig. 3.-Sliding ribbon section appliance.

ANTERIOR SPACE CLOSER

’ CUSPID RETRACTOR

Fig. 4.-Auxiliary units.

Apal criterion for this group is that they exhibit a discrepancy in tooth
tnaterial to bone of 2.5 mm. or more (but less than 5 mm.) and second prcmolal’s
a 1.0to bc eliminated.
The treatment progran~ for thcsc four fundamental forms is described and
illustrated as follows :
J~‘UUILC.-These cases may be treated in the mixed dentition, at which timcx
application of a headgear to the upper molars may be sufficient. Tf they nwtl
further twatment, or if they arc seen for the first time at a later period ill
clc:\elopment, the first molars and four anterior t&h will be banded and a
sljtling-section arch will be applied with headgear mot,ivating the distal I’orw
~l~‘ig. 3). If the lower anterior teeth are crowded, they are stripped to rcdnw
I ..> 1~1111.
OF tooth struct,ure and a lower loop-lingual arch is placed. Only thtl
silllplcst mechanics should bc used. The canines and premolars may need ret,rac-
tion with a plate, or after spacing has occurred we may wish to band thcsc teeth
irll;i ~)lace the sliding section with second-order bends in t,heir brackets (Figs. 1
i111Gl 5).

For~a A.-This is a routine type of treatment in which, first, the upper and
ion-cr anterior teeth are lightly stripped to reduce the discrepancy; :& mm. oft’
wch proximal sarfacc will give us as much as 2 mm. The upper buccal teetll
and canines are banded and stabilized wit,h an arch section plus an acrylic plate.
The lower buecal teeth and canines arc banded, and, after limbering up with
894 CAREY Am. J. Orthodc
December,

Fig. B.-Form A case fifteen years out of retention. Discrepancy 2.5 mm.

Fig. ‘I.--Form R IT case. Discwpanry 4.0 mm.

 FOUR FUNDAMENTAL TREATMENT FORMS 895

light. round wires, a lower sliding section with second-order bends is placed and
(Ilass IIT rubbers and headgear are applied to the upper arch. Then the lower
antsrior teeth are banded, spaces are closed, and a rectangular arch with second-
order bends is placed. The upper plate is discontinued. An upper sliding
section with second-order bends is placed, as well as headgear plus daytime Class
I I rubbers. When cuspal interdigitat,ion is complete, anterior teeth are banded
iltltl aligned, spaces are closed, and ;I finishing arch is placed (Figs. 6 and 7).

LAMINATED LOOP
ARCH

Fig. 8.--A, Laminated loop arches.

R, Brass wire applied to graph for location of loops. stops, and hooks.

Fornt B I (Indicntion for Eztraction of First Prenrolars).-In the mixed

drntition, early extraction of deciduous rnolars or canines is frequently desirable
for relief of crowded anterior teeth. Some headgear treat,ment rnay be necessary
in extreme protrusion or Class II conditions, either before or after extraction of
lhc first premolars. It is generally advantageous to wait for near eruption of
second premolars before extraction of first premolars, in order to obviate pro-
longed passive treatment.
1-n some cases early treatment is indicated and, while waiting for eruption of
the canine and second premolar, an upper lingual arch with acrylic button is
896 CAREY Am. J. Orthodontics
December. 195 8

used. The only force employed may be tipping or rotation of molars or distal
force with headgear. The lower loop-lingual arch is used to tip back the molars.
After the canines have erupted and improved their positions sufficiently, they
are tipped back to distal axial relationship. The upper second premolar and
canine are banded and a section laminated circle loop is placed for leveling and
canine root retraction (Fig. 9). An upper impression is taken for a stabilizing
plate, usually over the occlusal surface of the posterior teeth, to relieve cuspal
interference for freedom of lower tooth movement. The lower lingual arch is re-
moved, second premolars are banded, rutations are removed with a leveling arch,
and the complete laminated circle loop arch is placed, This arch is preassembled
and is applied in the following manner: A brass wire is inserted in the molar
tubes. The stops, loops, midline, and hook areas are marked on the brass wire
with bird-beak pliers (Fig. 8, A). This is transferred to graph paper, and
the marks and dimensions are recorded. The laminated arch wire, 21 x 25,
is superimposed and the marks arc indicated. First the loops are formed, and
then the molar stops are set by pinching the small tube (Fig. 8, B) . The arch
area is incorporated with an arch former, hooks are set, buccal torque is
placed, and now the completed arch is placed in position. Second-order bends
are not used, as the brackets and molar tubes are angulated (Fig. 10, A).

Fig. 9.-Sectional laminatecl loop with stabilizirncphplate. First-premolar-extraction case. Upper

Class III force is used to tip back the molars and premolars. The canines
are not included in this operation, as it is more advantageous to set up
posterior anchorage first (Fig. 10, B). The canines should now be in the same
axial relationship as the molar and premolar. Class III mechanics are con-
tinued, and the lower incisors are tipped back to the same degree, which is
approximately 80 to 85 degrees M.I.A., and banded at this point. This obviates
the condensation of the lower arch and an arch change. Lingual root torque
is incorporated in the anterior laminated arca when the arch is formed. The
mandibular unit is now ready for a stabilized solid arch (21 x 25). The lower
second molars are banded unless already included. The full laminated arch
without loops is now applied to the maxilla. Class II anchorage is applied.
During the Class III and Class II stages, occipital force supports the anchorage.
 897

A.

B.

(5.

Fig. 10.-A. Lower arch first premolar wtraction. The three units are parull~l. Thr:
case is ready for cuspid banding.
B, Lower arch after cuspid banding.
C. Lower arch in deep-bite cases with lingual arch and key loop extension.
898 Am. J.Orthodontics
December, 1958

In close-bite cases the lower lingual arch with key loop extensions to the
mesial side of the canines is used. Class III force is applied to the key loops
(Fig. 10, C). There are many cases in which it is more expedient to wait for
eruption of the second molars. The technique is the same, except that the
lingual arch may or may not be used in the lower setup.
The particular advantages of this arch are its flexibility, ease of adapta-
tion, storage of power, resistance to displacement or distortion, long-range
activation, simplicity of design, loops that do not distort, absence of solder
joints, and versatility of application. The disadvantages are in assemblage
and the more technical precision required in fabrication.
Form B II (Indication for Extraction of Second Premolars).-These cases
are treated in the same manner a.s the B I cases except that the first premolar
may be retracted first and then the canine. The lingual arch may be omitted
and a.11of the teeth anterior to the space moved en masse, depending upon the
extent of the discrepancy. When the second premolars are congenitally
missing, the treatment plan is already established in spite of the discrepancy
or lack of it. Generally, in these cases, we will wait for the second molars to
erupt so that they can be included at the start.
The same rule applies, namely, that the stabilization of the maxillary arch
precedes lower space closure to avoid cusp interference in long-cusp, Class 11,
or deep-bite cases. The loops arc set in the ccntcr of the extraction space, and
the full loop arch is used.
The central and lateral incisors are banded, and a coil spring is set mesial
to the premolar which is activated by compressing the small tube mesial to it on
the arch wire. Canine distal movement is obtained by moving and setting t,his
tube mesial to the cuspid bracket. Occasionally, the Class III stage is omitted
in this treatment form.
REFERENCES

1. Nance, Hays N.: Limitations of Orthodontic Treatment. I. Mixed Dentition Diagnosis

and Treatment! AM. J. ORTHODONTICS &ORAL SURG.~~: 177.233,1947.
2. Sante, Hays N.: Limitations of Orthodontic Treatment. TI. Diagnosis and Treatment
in the Permanent Dentition, AM. 5. ORTHODONTWS & ORAL SURG. 33: 253-301, 1947.
3. Carey, C. W.: Linear Arch Dimension and Tooth Size, AM. J. ORTHODONTICS 35: 762-775,
lQ4Q.
4. Carey, C. W.: Diagnosis and Case Analysis in Orthodontics, Anr. J. ORTHODONTICS 38:
149-161, 1952.
5. Carey, C. W.: Force Control in the Movement of Dental Structure, Angle Orthodontist
14: 47-67, 1944.
6. Carey, C. W.: Principles and Mechanics of Treatment With the Sliding Twin Section
Mechanism, AM. J. ORTHODONTICS & ORAL SURG. 33: l-20,1947.
7. Steiner, Cecil C.: Power Storage and Delivery in Orthodontic Appliances, AK J.
ORTHODONTICS 39: 859-880, 1953.
S. Carey, C. W.: Laminated Arches, the Double Ribbon and Double Edgewise, rlnf. J.
ORTHODONTICS 42: 47-53, 1956.
616 UNIVERSITY AVE.