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CONTEMPO
ORTHODONTICS
MOSBY
ELSEVIER

11830 Westhe Industrial Drlve

St. Louis, Mlssouri 63146

CONTEMPORARY ORTHODONTICS, FOURTH EDITION

Copyright O 2007,2000,1993, 1986 by Mosby, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any mformation storage and retrieval
system, without permission in writing from the publisher.
Permissions may be sought d~rectlyfrom Elsevier's Health Sciences Rights Department in Philadelphia, PA,
USA: phone: (+I) 215 239 3804, fax: (+I) 215 239 3805, e-mail: [email protected] may also
complete your request on-line vla the Elsevier homepage (http://www.elsevier.com),by selecting "Customer
Support" and then "Obtaining Permissions':

Notice

Neither the Publisher nor the Authors assume any respons~bdityfor any loss or injury and/or damage
to persons or property arising out of or related to any use of the material contained in this book. It 1s the
responsibility of the treatmg practitioner, relying on independent expertise and knowledge of the patient,
to determine the best treatment and method of application for the patient,
The Publisher

Pubhshing Director: Linda Duncan

Senfor Edrtor: John Dolan
Developmental Edltor: Julie Nebel
Publrshmg Services Manager: Pat Joiner
Senior Project Manager: Karen M. Rehwinkel
Design Direction: Iulia Dummitt
Cover Deszgner: Julia Dummitt

Prmted in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
 %is edition is dedicated to our wives
Sara, Anne, and Valerie, respectively,
whose tolerance is best described as remarkable
 PREFACE

s in previous editions, the objectiveof Contemporary accessto the book's own website.The E-dition provides a
Orthodonticsis to provide a comprehensiveoverviewof searchabletext, which makes it easier to quickly find the
this subjectthat is accessibleto students,usefulfor residents, answer to clinical questions.For dental students,this has
and a valuablereferencefor practitioners.Our goalhasbeen proved to be a major advantageof electronic editions. In
to put information into a perspectivethat facilitatesclinical addition, the E-dition placesselectedillustrationsfrom the
use in a rational way.In eachsectionof the book, and often book in a downloadableformat for easieruse in teaching
in individual chapters, basic background information and continuing education.The websiteis updatedfrequently
that every dentist needs is covered first, followed by to provide evaluationand commentary on current ortho-
more detailed information for orthodontic residentsand dontic literature.
specialistpractitioners. In addition, the book is supplementedwith extensive
This fourth edition differs from its predecessorsin being computer-basedteachingmaterialsthat arecompatiblewith
full color, but it follows the basic outline of previous edi- deliveryto studentsvia high-speedInternet access. They are
tions.New aspectsinclude a discussionof orthodonticsasan also available in CD/DVD format for both Windows and
enhancementtechnology(an important new way of think- Macintoshoperatingsystems,and havebeen evaluatedwith
ing about need for treatment in all medical fields), an both dental students and advancedgeneraldentistry resi-
increasedemphasison soft tissueconsiderationand clinical dents.Theseprogramsare most usefulwhen they serveas a
examinationin diagnosisand treatment planning, a partic- major part of the background for interactivesmall group
ular focus on basingclinical decisionson data insteadof on seminars.Suggested outlines and visualsfor theseseminars
anecdoteand opinion, new material on the use of implant also are available.All of the teaching programs now include
anchorageand possibleapplicationsof distractionosteoge- computer self-tests(for instruction, not evaluation).These
nesis,and considerationofthe changesin orthodontic tech- self-tests not only tell students if they have correctly
nique as computer applicationsto appliancedesignbecome answeredquestionsabout the materialthey just studied,but
more widespread. also they tell them why answersare correct or incorrect and
Literature citations in this book are of two types: the displayappropriategraphics(e.g.,graphs,clinicalphotos)to
classicpapersin orthodontics that are the backgroundfor reinforcethe message.
current concepts,and recentcontributions to the literature Further information about thesesupplementalteaching
that not only provide current information but cite the pre- materials,including computer teachingprogramsand com-
vious publicationsin this particular area.Thesepaperscan puter self-tests,seminar outlines and visuals,and testsfor
open the door to a more detailedevaluationof the literature evaluation,can be obtained by contactingthe Department
on important subjects, and are cited partly for that of Orthodontics, University of North Carolina School
purpose-which reduceswhat would otherwisebe a volu- of Dentistry, Chapel Hill, NC 27599-7450,or by visiting
minous number of references. the department's website at www.dent.unc.edu/depts/
For usein the dentalcurriculum and residencyprograms, academic/ortho/.
the book now is availablein an "E-dition," which provides

vtl
 Ramona Hutton-Howe for outstanding pho- scanningcolor slides.Orthodontic residentsin the classes
of
ic support and preparation of the image files 2004-2007at Ohio Statewere a valuable resourcein helping
(which contain nearly 1000 new color images for this procure clinical illustrative material. Thanks also go to
edition), and Faith Patterson for careful organization and a number of individuals who have reviewed areas of the
management of the revision. Particular thanks also go to manuscript and kindly contributed illustrations; specific
Drs. William Gierie and Dirk Weichmann for their generous acknowledgmentis provided at appropriate points through-
sharing of clinical experienceand illustrations, to Drs. Steve out the book.
Dickens,Eric Bednar,and JaredBlackerfor assistanceduring
their orthodontic residencyprograms in locating photos Wrr,r,reuR. Pnorrrr
and radiographs in the UNC files, and soon-to-be Drs. HnNnyW. Frnr.os,fn.
Kenneth Miller and Elizabeth Kelly for diligent work in Devro M. Senvnn

tx
 CONTENTS

SECTIONI
THE ORTHODONTICPROBLEM

I Malocclusion Deformityin Contemporary

and Dentofacial Society
WilliamR.Proffit

SECTIONII
THE DEVELOPMENT OF ORTHODONTIC PROBLEMS

2 Concepts of Crowthand Development 27

WilliamR.Proffit
3 EarlyStagesof Development 72
WilliamR.Prffit
4 LaterStagesof Development 107
WilliamR.Profit
5 The Etiologyof OrthodonticProblems 130
WiIIiamR.Proffit

SECTIONIII
DIAGNOSIS AND TREATMENT PLANNING

6 OrthodonticDiagnosis: of a ProblemList
The Development 167
William R. Profit, David M. Sarver,JamesL. Ackerman

7 Orthodontic
Treatment FromProblemListto SpecificPlan
Planning: 234
WiIIiam R. Proffit, Henry W. Fields,David M. Sarver

8 Orthodontic
Treatment
Planning:
Limitations, and SpecialProblems
Controversies, 258
William R. Profft, Henry W Fields,David M. Sarver

SECTIONIV
BIOMECHANICS, MECHANICS, AND CONTEMPORARY
ORTHODONTIC APPTIANCES

9 The BiologicBasisof Orthodontic

Therapy 331
WilliamR.Prffit
f0 Mechanical Principles
in OrthodonticForceControl 359
WilliamR.Proffit
11 Contemporary Appliances
Orthodontic 395
WiIIiamR.Proffit

XI
 CoNrrurs

SECTIONV
TREATMENTIN PREADOLESCENT
CHILDREN

t2 Treatmentof NonskeletalProblemsin Preadolescent

Children 433
HenryW.Fields
r3 Treatmentof SkeletalProblemsin Children
495
HenryWFields,William
R.Prffit

SECTIONVI
COMPRXHENSIVE ORTHODONTICTREATMENT
IN THE EARLYPERMANENTDENTITION

14 The Firststageof comprehensive

Treatment:Alignmentand Leveling 55r
WlliamR.Prffit
15 The SecondStageof Comprehensive
Treatment:Correctionof Molar Relationship
and
SpaceClosure
WilliamR.Proffit
16 TheThirdStageof Comprehensive
Treatment:
Finishing 6oz
WilliamR.Proffit
17 Retention 6't7
Wliam R.Profft

SECTIONVII
TREATMENTIN ADULTS

l8 SpecialConsiderations
in Treatmentfor Adults 6ls
WilliamR.Prffit
19 CombinedSurgicaland OrthodonticTreatment 586
WilliamR.Prffit, DayidM. Sarver
Index
719
OoNTEMPo RY
ORTHODO
 SECTION

Trru ORTHoDoNTTcPnoBtEM
 CHAPTER

CHAPTER
OUTLINE
The ChangingGoals of OrthodonticTreatment
The Usual Orthodontic Problems:Epidemiologyof
Malocclusion
Crowded, irregular, and protruding teeth have been a
Why ls MalocclusionSo Prevalentl
problem for some individuals since antiquity, and attempts
Need and Demand for OrthodonticTreatment
to correct this disorder go back at leastto 1000BC. Primi-
Need for OrthodonticTreatment
tive (and surprisingly well designed)orthodontic appliances
Demand for OrthodonticTreatment
have been found in both Greek and Etruscan materials.l
As dentistry developed in the eighteenth and nineteenth
centuries, a number of devices for the "regulation" of the
teeth were describedby various authors and apparentlyused
sporadicallyby the dentists of that era'
After 1850, the first texts that systematicallydescribed
orthodontics appeared, the most notable being Norman
Kingsley's Oral Deformities.2Kingsley, who had a tremen-
dous influence on American dentistry in the latter half of the
nineteenth century,was among the first to useextraoral force
to correct protruding teeth. He was also a pioneer in the
treatment of cleft palate and related problems.
Despite the contributions of Kingsley and his contempo-
raries, their emphasis in orthodontics remained the align-
ment of the teeth and the correction of facial proportions'
Little attention was paid to bite relationships, and since
it was common practice to remove teeth for many dental
problems, extractions for crowding or malalignment
were frequent. In an era when an intact dentition was a
rarity, the details of occlusal relationships were considered
unimportant.
In order to make good prosthetic replacement teeth, it
was necessaryto develop a concept of occlusion' and this
occurred in the late 1800s.As the conceptsof prosthetic
occlusion developed and were refined, it was natural to
extend this to the natural dentition. Edward H. Angle (Figure
 SrctroN I TnE OnrnoooNrrc Pnonrnu

EdwardH. Anglein his fifties,as the proprietor

of theAngleSchoolof Orthodontia.Afterestablishing himselfas
the firstdentalspecialist,
Angleoperatedproprietary orthodon-
Line of Occlusion
tic schoolsfrom r9o5to i9z8 in St. Louis;New London,Con-
necticut;and Pasadena,California,
in whichmanyof the pioneer The line of occlusionis a smooth (catenary)
American orthodontists
weretrained. curvepassing throughthecentralfossaofeachuppermolarand
a c r o s st h e c i n g u l u mo f t h e u p p e rc a n i n ea n d i n c i s otre e t hT. h e
s a m el i n e r u n s a l o n gt h e b u c c a cl u s p sa n d i n c i s ael d g e so f
the lowerteeth,thus specifring the occlusal as wellas interarch
r e l a t i o n s h iopns c et h e m o l a rp o s i t i o ni s e s t a b l i s h e o .
1-l), whose influence began to be felt about 1890,can be
credited with much of the development of a concept of
occlusionin the natural dentition. Angle's original interest
was in prosthodontics,and he taught in that departmentin ClassI: Normal relationshipof the molars,but line of occlu-
the dental schools at Pennsylvaniaand Minnesota in the sion incorrect becauseof malposedteeth, rotations, or
1880s.His increasinginterestin dental occlusionand in the other causes
treatment necessaryto obtain normal occlusion led directly Class II: Lower molar distally positioned relative to upper
to his development of orthodontics as a specialty, with molar, line of occlusionnot specified
himself as the "father of modern orthodontics." ClassIII: Lower molar mesially positioned relative to upper
The development of Angle's classification of malocclu- molar, line of occlusionnot specified
sion in the 1890swas an important stepin the development Note that the Angle classificationhas four classes:normal
of orthodonticsbecauseit not only subdividedmajor types occlusion,ClassI malocclusion,ClassII malocclusion,and
of malocclusion but also included the first clear and simple ClassIII malocclusion(seeFigure l-3). Normal occlusion
definition of normal occlusion in the natural dentition. and ClassI malocclusion sharethe same molar relationship
Angle'spostulatewas that the upper first molars were the key but differ in the arrangement of the teeth relative to the line
to occlusion and that the upper and lower molars should of occlusion.The line of occlusion may or may not be correct
be relatedso that the mesiobuccalcusp of the upper molar in ClassII and ClassIII.
occludesin the buccal groove of the lower molar. If the teeth With the establishmentof a concept of normal occlusion
were arranged on a smoothly curving line of occlusion and a classification scheme that incorporated the line of
(Figure I-2) and this molar relationship existed (Figure occlusion,by the early 1900s,orthodontics was no longer
1-3), then normal occlusionwould result.3This statement, just the alignment of irregular teeth. Instead,it had evolved
which 100 years of experiencehas proved to be correct- into the treatment of malocclusion,defined as any deviation
except when there are aberrations in the size of teeth- from the ideal occlusalschemedescribedbyAngle. Sincepre-
brilliantly simplified normal occlusion. cisely defined relationships required a full complement of
Angle then describedthreeclasses of malocclusion,based teeth in both arches,maintaining an intact dentition became
on the occlusalrelationshipsof the first molars: an important goal of orthodontic treatment. Angle and his
 Cneprrn r Socrrw
MeroccrusroN AND Drxror,qcr,qrDrronurrv rN CoNtrrurpoRARY

Normalocclusion Class I malocclusion

N o r m a l o c c l u s i o na n d m a l o c -
clusionclassesas specifiedby Angle.This clas-
s i f i c a t i o nw a s q u i c k l ya n d w i d e l ya d o p t e de a r l y
in the twentieth century. lt is incorporated
w i t h i n a l l c o n t e m p o r a rdy e s c r i p t i v a
end classi-
ficationschemes. Classll malocclusion Classlll malocclusion

followersstrongly opposedextractionfor orthodontic pur- computer imaging methods that allow the orthodontist
poses.With the emphasison dental occlusionthat followed, to share facial concerns with patients in a way that was
however,lessattention cameto be paid to facialproportions not possibleuntil recently;
and esthetics.Angle abandonedextra-oralforce becausehe 2. Patientsnow expectand are granted a greaterdegreeof
decided this was not necessaryto achieveproper occlusal involvement in planning treatment. No longer is it
relationships. appropriate for the paternalistic doctor to simply tell
As time passed,it became clear that even an excellent patientswhat treatment they should have.Now patients
occlusion was unsatisfactoryif it was achievedat the expense are given the opportunity to participate in selecting
of proper facial proportions. Not only were there esthetic among treatmentoptlons-a processthat is facilitatedby
problems,it often provedimpossibleto maintain an occlusal computer imaging methods;and
relationshipachievedby prolonged use of healy elasticsto 3. Orthodontics now is offered much more frequently to
pull the teeth together as Angle and his followershad sug- older patients as part of a multidisciplinary treatment
gested.Extraction of teethwas reintroducedinto orthodon- plan involving other dental and medical specialties.The
tics in the 1930sto enhancefacialestheticsand achievebetter goal is not necessarilythe best possibledental occlusion
stability of the occlusalrelationships. or facialestheticsbut the bestchancefor long-term main-
Cephalometricradiography,which enabledorthodontists tenance of the dentition. This increasedemphasison
to measurethe changesin tooth and jaw positionsproduced treatment coordinated with other dentists has the effect
by growth and treatment, came into widespreaduse after of integratingorthodonticsback into the mainstreamof
World War II. Theseradiographsmade it clear that many dentistry, from which Angle's teachings had tended to
ClassII and ClassIII malocclusionsresultedfrom faulty jaw separatelt.
relationships,not just malposedteeth. By use of cephalo- All three of theserecent developmentsare reflectedin the
metrics,it also was possibleto seethat jaw growth could be later chaptersof this book. The changein the goalsof treat-
alteredby orthodontic treatment.In Europe,the method of ment representsa paradigm shift, awayfrom an emphasison
"functional jaw orthopedics" was developed to enhance skeletaland dental relationships and toward greater consid-
growth changes,while in the United States,extraoral force eration of the oral and facialsoft tissues.The soft tissuesnow
cameto be usedfor this purpose.At present,both functional are recognizedas both the major limitation on orthodontic
and extraoralappliancesare used internationallyto control treatmentand the major considerationin whethertreatment
and modifr growth and form. can be judged to be successful.n't Thble 1-l contraststhe
In the early 2l't century,orthodontics differs from what Angle paradigm that dominated 20'hcentury orthodontics
was done previously in three important ways: with the soft tissueparadigmthat is replacingit' The impact
1. Thereis more emphasisnow on dental and facialappear- on diagnosisand treatmentplanning that the new paradigm
ance.This reflectsa greaterawarenessthat parentsand requiresis readily apparent,and is emphasizedin the clini-
patientsseektreatmentlargelybecauseof concernabout cal chaptersthat follow.
facialappearance, and that psychosocialproblemsrelated It must be kept in mind that orthodontics is shapedby
to appearancecan have major effectson an individual's biological,psychosocial, and cultural determinants.For that
quality of life. The advent of orthognathic surgery has reason,in defining the goalsof orthodontic treatment,one
made it possible to correct facial disproportions that hasto considernot only morphologicand functional factors'
previously were not treatable,and the developmentof but a wide rangeof psychosocial and bioethicalissuesaswell.
 Srcrrow I Tnr OntnoooNrrc PnosrrNl

Teern r-r
AngleversusSoft TissueParadigms:A NewWayof Lookingat TreatmentGoals
Parameter Angle paradigm Soft tissue paradigm
Primary
treatmentgoal ldealdentalocclusion Normalsofttissueproportions
and adaptations
Secondary
goal ldealjaw relationships Functional
occlusion
Hard/softtissuerelationshipsldealhardtissueproportions
produceideal ldealsofttissueproportions
defineidealhard
soft tissues IISSUCS

Diagnosticemphasis Dentalcasts,cephalometric
radiographs Clinicalexamination
of intra-oral
and facialsoft
IISSUCS

Treatmentapproach Obtainidealdentaland skeletal relationships,Planidealsofttissuerelationshipsand then place

assumethe softtissueswill be OK teethand jawsas neededto achievethis
Function
emphasis TM joint in relation
to dentalocclusion Softtissuemovementin relationto displayof
teeth
Stabilityof result Relatedprimarily to dentalocclusion Relatedprimarilyto soft tissuepressure/
equilibriumeffects

Theseare discussedbriefly in the sectionsof this chapteron needs in the United Statesin 1989-1994(National Health
need and demand for treatment, and in greater detail in and Nutrition EstimatesSurveyIII, abbreviatedas NHANES
Chapters6-8. III), estimatesof malocclusionagain were obtained. This
The treatmentsequence shownin Figures1-4 through l-7 study of some 14,000individuals was statisticallydesigned
demonstratesthe facial as well as dental changesthat can to provide weightedestimatesfor approximately150million
be attained through orthodontics. The focus of modern personsin the sampled racial/ethnicand age groups. The
orthodontic treatmentis on improving not only dental and data provide current information for U.S. children and
skeletalbut alsosoft tissueaspectsof orthodontic problems, youths and include the first good data set for malocclusion
in combination with other dental treatment as needed. in adults,with separateestimatesfor the major racial/ethnic
groups.t't
The characteristics of malocclusion evaluated in
NHANES III included the irregularity index, a measureof
incisor alignment (Figure 1-8), the prevalenceof midline
diastema>2mm (Figure 1-9), and the prevalenceof poste-
What Angle defined as normal occlusion more properly rior crossbite (Figure 1-10). In addition, overjet (Figure
should be consideredthe ideal, especiallywhen his criteria 1-11) and overbite/openbite (Figure l-12) were measured.
are applied strictly. In fact, perfectly interdigitating teeth Overjet,which reflectsAngle'sClassII and ClassIII molar
arrangedalong a perfectlyregularline of occlusionare quite relationships,can be evaluatedmuch more preciselyunder
rare.For many years,epidemiologicstudiesof malocclusion epidemiologic evaluation conditions, so molar relationship
sufferedfrom considerabledisagreementamong the investi- was not evaluateddirectly.
gatorsabout how much deviation from the ideal should be Current data for thesecharacteristicsof malocclusionfor
acceptedwithin the bounds of normal. As a result,between children (age8 to 11),youths (age12 to 17) and adults (age
1930and 1965,the prevalenceof malocclusionin the United 18 to 50) in the U.S.population, taken from NHANES III,
Stateswasvariouslyestimatedas35o/o to 95ol0.
Thesetremen- are shown in Thblesl-2 and 1-3 and are displayedgraphi-
dous disparitieswere largelythe result of the investigators' callyin Figures1-13to 1-16.
differing criteria for normal. Note that in the age8- 11 agegroup,just over half of U.S.
By the 1970s,a seriesof studiesby public health or uni- children have well-aligned incisors. The rest have varying
versity groups in most developedcountriesprovided a rea- degreesof malalignment and crowding. The percent with
sonably clear worldwide picture of the prevalenceof various excellentalignment decreases in the age 12-17group as the
occlusal relationships or malrelationships.In the United remaining permanent teeth erupt, then remains essentially
States,two large-scalesurveyscarried out by the Division of stablein the upper arch but worsensin the lower arch for
Health Statisticsof the U.S.Public Health Service(USPHS) adults. Only 34o/oof adults have well-aligned lower incisors.
coveredchildren ages6 to ll between 1963 and 1965 and Nearly l5o/o of adolescentsand adults have severelyor
youths ages12 to 17 between 1969 and 1970.6'7 As part of a extremelyirregularincisors,so that major arch expansionor
large-scalenational survey of health care problems and extraction of some teeth would be necessaryto align them.
 Crr.c.ptrnr MaroccrusroN AND DEllror.q.crerDrronurty rw CotrrupoRARy Socrsry

Pre-treatment facialand dentalviewsofan rr-year-oldgirl. Sheand her parentswere concernedabout her facialappear-
ance, especiallythe "no teeth" appearanceon smile, and her difficultyin eating.A, On the frontal view of the face, short lower face
h e i g h ti n p r o p o r t i o nt o f a c i a lw i d t h ,a s h o r t u p p e rl i p a n d m i n i m a ld i s p l a yo f t h e v e r m i l i o nb o r d e r so f t h e l i p s ,a n d a d e e pl a b i o m e n t a l
f o l d w e r e a p p a r e n tB . , O n s m i l e ,t h e r e w a so n l y r m m d i s p l a yo f t h e u p p e ri n c i s o r sw , h i c hw e r e m a l f o r m e da n d q u i t e s m a l l .C , O n t h e
profileview,an evertedupper lip, short face height and incompletedevelopmentof the nose were noted. D-E, Intraoralexamination
revealedmalformed maxillaryincisorsand short crown heights.Note the deep bite anteriorly.

A wide spacebetweenthe maxillarycentralincisors(midline 23% of children, l5o/oof youths, and l3o/oof adults. Reverse
diastema)often is presentin childhood (260/ohave >2 mm overjet, indicative of Class III malocclusion,is much less
space).Although this spacetendsto close,over 60loof youths frequent. This affects about 1oloof American children and
and adultsstill havea noticeablediastemathat compromises increasesslightly in youths and adults. SevereClass II and
the appearanceof the smile. Blacksare more than twice as ClassIII problems, at the limit of orthodontic correction,
likely to have a midline diastema than whites or Hispanics occur in about 4o/oof the population, with severeClass II
(p < .001). much more prevalent. SevereClass II problems are less
Posterior crossbitereflectsdeviations from ideal occlu- prevalent,and severeClassIII problemsare more prevalent,
sion in the transverseplane of space,overjet or reverse in the Hispanic than the white or black groups.
overjet indicate antero-posterior deviations in the Class Vertical deviations from the ideal overbite of 0-2 mm are
II/ClassIII direction, and overbite/openbite indicateverti- less frequent in adults than children but occur in half the
cal deviations from ideal. As Table l-2 shows, posterior adult population, the great majority of whom have excessive
crossbiteis relativelyrare at all ages.Overjet of 5mm or overbite. Severedeep bite (overbite > 5 mm) is found in
more, suggestingAngle's Class II malocclusion,occurs in nearly 20o/oof children and l3o/oof adults, while open bite
 SEcrroN I Tnr OntnopoNrrc PnosnN4

The beginningoftreatment was deferreduntil age tz'l,,when she was judged to be close to her adolescentgrowth
spurt, and then was directedtoward extrusionof posteriorteeth to gain greaterface height.The improvementin verticalfacial pro-
portionsand incisordisplayon smile at age14,after r8 months of treatment,is shown in A and B. Three months later,she was ready
for initial restorations.At that point, the bracketson the upper incisorswere removed(C) so that temporarylaminatescould be placed
to improvethe height-widthrelationshipsof the incisorsand further increaseincisordisplay(D), then the bracketswere replacedat a
more gingivallevel (E) and treatmentcontinued.
 Cnaptrn r MeroccrusroN AND DrNrorecrer Dtronurtv rN CoNTEMpoRARy
Socrrrv

After another9 months of treatment,the orthodonticappliancewas removedat age r5, with further improvementin
the facialappearanceand incisor position.With the temporarylaminatesstill in place,the smile arc (describedin detail in Chapter6)
was more flat than ideal.In the cephalometricsuperimposition(D), the increasein face height and eruption of posteriorand anterior
teeth that occurredduring treatmentcan be seen.
;;"g*
:,iffi

k
 CnaptEn r Socrrrv
MaroccrusroN AND DrNtorecu,r Drronlrrty rN CoNTEMpoRARy

Overbite

Posteriorcrossbiteexistswhen the maxillary

posteriorteeth are linguallypositionedrelativeto the mandibu- Open bite
lar teeth,as in this patient.Posteriorcrossbitemost often reflects
a narrow maxillarydental arch but can arisefrom other causes.
This patient also has a one-tooth anterior crossbite,with the
l a t e r a il n c i s o rt r a p p e dl i n g u a l l y .

Overbite is defined as verticaloverlap of the

incisors. Normally,the lower incisal edges contact the lingual
surface of the upper incisors at or above the cingulum (i.e.,
n o r m a l l yt h e r e i s r t o 2 m m o v e r b i t e ) I. n o p e n b i t e ,t h e r e i s n o
vertical overlap, and the vertical separationof the incisors is
measuredto quantifr its severity.

50

c40
(g

3an
6- "-
o_
Overjetis definedas horizontal overlapof the
i n c i s o r sN. o r m a l l yt h, e i n c i s o r a
s r e i n c o n t a c tw, i t h t h e u p p e r E20
o)
i n c i s o ras h e a do f t h e l o w e rb y o n l yt h et h i c k n e sosf t h e i ri n c i s a l o

e d g e s( i . e . 2
, - 3 m mo v e r j e its t h e n o r m a lr e l a t i o n s h i pl f) .t h e (6L 1 0
lowerincisorsarein frontof the upperincisors, the conditionis
calledreverse overjetor anteriorcrossbite.
0to1 21o3 4to6 7to10 >10mm
ldeal Mild Moderate Severe Extreme

(negativeoverbite >-2mm) occurs in lessthan lol0.There Incisorlrregularity(mm)

are striking differencesbetween the racial/ethnic groups in I n c i s o ri r r e g u l a r i tiyn t h e U . S . p o p u l a t i o n ,
vertical dental relationships.Severedeep bite is nearly twice thirdof the population haveat leastmoderately
asprevalentin whitesasblacksor Hispanics(p < .001),while crowded)incisors,
irregular(usually and nearlyt57ohavesevere
open bite >2 mm is five times more prevalent in blacks than or extremeirregularity.
in whites or Hispanics(p < .001).This almost surelyreflects
the slightly different craniofacial proportions of the black
population groups (seeChapter 5 for a more completedis- haveAngle's normal occlusion.ClassI malocclusion(500/o
cussion).Despitetheir higher prevalenceof antero-posterior to 550/o)is by far the largestsingle group; there are about
problems,vertical problems are lessprevalentin Hispanics half as many ClassII malocclusions (approximately 15olo)as
than either blacksor whites. normal occlusions;and ClassIII (lessthan 1%) representsa
From the survey data, it is interesting to calculate the very small proportion of the total.
percentageof American children and youths who would fall Differences in malocclusion characteristicsbetween the
into Angle'sfour groups.From this perspective,307oat most United Statesand other countrieswould be expectedbecause
 Srcrrow I THr Onrnopourrc Pnonrrvr

TAnr,sr-z
Percent of U.S. Population Wth Incisor Crowding/Malalignment

TOTALPOPULAIION,BY AGE
AGE8-II AIGE12-17 AGE 18-50

Irregularity index Max Mand Max Mand Max Mand

0- I [ideal] 52.7 qA q
42.3 43.7 43.2 33.7
2-3 [mild crowding] 25.3 25.O 26.8 25.2 26.5 27.3
4-6 [moderate] 13.3 r59 18.4 18.5 19.1 233
7- l0 [severe] 6.2 3.5 9.4 8.9 8.0 1 1. 4
>10 fextreme] 2.5 1.2 3.2 3.6 2.7 4.3
Midlinediastema>2 mm 26.4 6.6 6.4

RACIAL/ETHNIC GROUPS. AGES COMBINED

WHITE BLACK HISPANIC

Irregularity index Max Mand Mand Max Mand Max Mand

0-l [ideal] 438 35.6 48.1 45.6 35.9 58.8 44.O 3-7.1
2-3 [mild crowding] 26.3 26.9 27.O 27.2 26.5 23.O 26.4 26.8
4-6 [moderate] t9.t 22.6 15.-7 17.1 22.5 23.8 r8.8 21.9
7-10 [severe] 8.0 10.8 6.7 7.2 12.1 9.6 8.0 10.3
>10 [extreme] 28 4.O 2.5 3.0 3.0 4.8 2.8 3.9
Midlinediastema>2 mm 7.O r8.9 6.7 8.5

Data from NHANES III.

40 =40
c

(g
6
=30 f,an

(L
o2.,
cZV
c q)
c)
o
Sro t10

>10 7-10 5-6 3-4 1-2 0 -1 to-2-3to 4> 4mm > 4 4to-3 -2to0 0to2 3to4 5to7 >7mm
Extreme Severe Modercte Mild Mitd Moderate Severe Extrcme Extreme Severe Moderate Moderate Severe Extreme

Overjet (mm) IncisorOverlap(mm)

O p e n b i t e / d e e pb i t e r e l a t i o n s h i pisn t h e U . S .
in the U.S. population,t989-'t994.Only one-thirdof the popula- p o p u l a t i o n t, 9 8 9 - t 9 9 4 .H a l f t h e p o p u l a t i o nh a v ea n i d e a lv e r t i -
t i o n h a v ei d e a la n t e r o - p o s t e r i o
i nrc i s o rr e l a t i o n s h i p sb,u t o v e r j e t cal relationship o f t h e i n c i s o r sD. e e pb i t e i s m u c h m o r e p r e v a -
i s o n l y m o d e r a t e l yi n c r e a s e di n a n o t h e r o n e - t h i r d .I n c r e a s e d lent than open bite, but vertical relationshipsvary greatly
overjea t c c o m p a n y i nC g l a s sl l m a l o c c l u s i o ins m u c h m o r e p r e v a - betweenracialgroups (seeTabler-z).
lent than reverseoverjetaccompanyingClasslll.
 CHeptEnr MeroccrusroN AND DrNrorecrnr Drponurty rrq CoxrtvrpoRARySocrrrv

Tenr,nr-3
Percentof U.S.PopulationWth OcclusalContactDiscrepancies
8 - 1l * l2-17* l8-50* whitel Hispanict
PosteriorCrossbite 7.1 9.5 9.1 9.6 9.1

Overjet (mm)
Classll
>']0
-7-10 [extreme] o.2 o.2 o.4 0.3 o.4 o.4 0.5
Icerrercl 3.4 3.5 3.9 3.8 4.3 2.2 3.8
5-6 Imoderate] lB.9 11 . 9 9.1 t0.t I 1.8 6.5 10.6
3-4 Imild] 45.2 39.5 37.7 58.0 39.8 49.O 38.8

ldeal
t-z 29.6 39.3 43.O 42.4 35.6 33.6 41.1

Closslll
0 Imild] 2.2 4.6 4.8 4.1 6.1 6.7 4tr.

-1 Io -2 Imoderate] o.7 0.5 o.-7 0.5 1.5 0.9 0.6

-3 to -4 Icevprcl 0.0 0.6 o.2 o.2 o.4 o.4 0.3
>-4 [extreme] 0.0 0.0 0.1 0.1 0.1 0.3 o.2

Overbite(mm)
Openbite
>-4 [extreme] 0.3 o.2 0.1 0.r o.7 0.0 0.1
-3 lo -4 0.6 0.5 0.5 AA 0.0 0.5
[severe] t.J

0to-2 Imoderate] 2.7 2.8 2.-7 2.4 4.6 2.1 2.7

Ideal
o-2 40.2 45.O 49.O ./l q. tr
56.4 s6.5 4-7.5

Deepbite
3-4 Imoderate] 36.2 34.-7 32.5 34.O 28.5 32.6 33.1
E1
[severe] 18.8 15.5 13.4 15.7 7.5 8.7 14.2
>7 [extreme] 1.2 1.5 1.8 r.9 0.9 0.0 1.7

Data from NHANES III.

*All racial/ethnic groups
tAll ages.

ldealAlignment

I
t
MandibularArch
I
V
SevereCrowding

Excess Overjet
+
OpenBite

sion from childhoodto adult life, UnitedStates,r989-1994.Note the

increasein incisorirregularityand decreasein severeoverjetas chil-
dren mature,both of which are relatedto mandibulargrowth.
 SrcrroN I THE OnrHoooNtrc Pnonrrvr

Mandibulardental archesfrom Neanderthalspecimensfrom the Krapinacavein Yugoslavia, estimatedto be approx-

. , C r o w d i n ga n d m a l a l i g n m e nat r e s e e ni n t h i s s p e c i m e n ,
i m a t e l yr o o , o o o y e a r so l d . A , N o t e t h e e x c e l l e nat l i g n m e n ti n t h e s p e c i m e nB
which had the largestteeth in this find of skeletalremainsfrom approximately8o individuals.(From WolpoffWH. Paleoanthropology.
New York:Alfred A Knopf;r998.)

of differencesin racial and ethnic composition. Although the fectedby modern development:crowding and malalignment
availabledata are not as extensiveas for American popula- of teeth are uncommon, but the majority of the group may
tions, it seemsclear that ClassII problems are most preva- havemild antero-posterioror transversediscrepancies, as in
lent in whites of northern Europeandescent(for instance, the Classltl tendencyofSouth Pacificislandersr2 and buccal
25o/oof children in Denmark are reported to be ClassII), crossbite(X-occlusion)in Australianaborigines.rl
while Class III problems are most prevalent in Oriental Although 1000 years is a long time relative to a single
populations (3o/oto 5o/oin Japan, nearly 2o/oin China with human life, it is a very short time from an evolutionary per-
another 2o/oto 3olo pseudo-ClassIII [i.e., shifting into spective.The fossil record documents evolutionary trends
anterior crossbite because of incisor interferences]).I0 over many thousands of years that affect the present denti-
African populationsareby no meanshomogenous,but from tion, including a decreasein the size of individual teeth, a
the differences found in the United Statesbetween blacks decreasein the number of the teeth, and a decreasein the
and whites, it seemslikely that Class III and open bite are sizeof the jaws.For example,there hasbeen a steadyreduc-
more frequent in African than European populations and tion in the sizeof both anterior and posterior teeth over at
deep bite lessfrequent. least the last 100,000years (Figure 1-18). The number of
teeth in the dentition of higher primates has been reduced
comparedwith the usualmammalian pattern (Figure 1-19).
The third incisor and third premolar have disappeared,as
has the fourth molar. At present, the human third molar,
second premolar, and second incisor often fail to develop,
Although malocclusionnow occursin a majority of the pop- which indicates that these teeth may be on their way out.
ulation, that does not mean it is normal. Skeletalremains Compared with primitive peoples,modern human beings
indicate that the presentprevalenceis severaltimes greater have quite underdevelopedjaws.
than it was only a few hundred years ago. Crowding and It is easyto seethat the progressivereduction in jaw size,
malalignment of teeth was unusual until relativelyrecently,tr if not well matched to a decreasein tooth size and number,
but not unknown (Figure l-17). Becausethe mandibletends could lead to crowding and malalignment. It is less easy
to becomeseparatedfrom the rest of the skull when long- to see why dental crowding should have increased quite
buried skeletalremains are unearthed, it is easierto be sure recently, but this seems to have paralleled the transition
what has happenedto alignment of teeth than to occlusal from primitive agricultural to modern urbanized societies.
relationships.The skeletalremainssuggestthat all members Cardiovasculardiseaseand relatedhealth problems appear
of a group might tend toward a ClassIII or, lesscommonly, rapidly when a previously unaffected population group
a Class II jaw relationship.Similar findings are noted in leavesagrarian life for the city and civilization. High blood
presentpopulation groups that haveremainedlargelyunaf- pressure,heart disease,diabetes,and severalother medical
 Csnptrn r MeroccrusroN AND Druroracrar Drronrurry rN ColltrupoRARy Socrrry

Past and PresentToothSize

2
o)
6 200
E
E
o
5 150
U) I
-rar-
E- .A
I Qafzeh
\o- ---+--- Neanderthal
T h e g e n e r a l i z edde c l i n ei n t h e s i z eo f /
h u m a n t e e t h c a n b e s e e n b y c o m p a r i n gt o o t h s i z e s English
E-
from the anthropologicalsite at Qafzeh,datedroo,ooo
years ago; Neanderthalteeth, ro,ooo years ago; and
m o d e r nh u m a n p o p u l a t i o n s(.R e d r a w n f r o m K e l l yM A ,
P1 P2 M1 M2 M3
LarsenCS,eds.Advancesin DentalAnthropology.New
Y o r k :W i l e y - L i s sr ;9 9 r . ) Toothcategory

AAAA US\
Basic
Mammalian

M-3 PM-3 t-z Prosimian

M-3 PM-2 t-z HigherApe

PM-2 t-z Man

R e d u c t i o ni n t h e n u m b e ro f t e e t h h a s b e e na f e a t u r eo f p r i m a t ee v o l u t i o n I. n t h e p r e s e n th u m a n p o p u l a t i o nt,h i r d
molarsare so frequentlymissingthat it appearsa further reductionis in progress,and the variabilityof lateralincisorsand secondpre-
molars suggestsevolutionarypressureofthese teeth.

problems are so much more prevalent in developedthan with uncooked or partially cooked meat and plant foods.
underdevelopedcountries that they have been labeled Watching an Australian aboriginal man using every muscle
"diseasesof civilization."There is some evidencethat mal- of his upper body to tear off a pieceofkangaroo fleshfrom
occlusionincreaseswithin well-definedpopulations after a the barely cookedanimal, for instance,makesone appreci-
transition from rural villages to the city. Corrucini, for ate the decreasein demand on the masticatory apparatus
instance,reports a higher prevalenceof crowding,posterior that has accompaniedcivilization (Figure l-20).
crossbite,and buccal segment discrepancyin urbanized Determining whether changesin jaw function have in-
youths compared with rural Punjabi youths of northern creasedthe prevalenceof malocclusionis complicatedby the
India.lnOne can arguethat malocclusionis another condi- fact that both dental cariesand periodontal disease,which
tion made worseby the changingconditionsof modern life, are rare on the primitive diet, appear rapidly when the diet
perhapsresulting in part from less use of the masticatory changes.The resulting dental pathology can make it difficult
apparatus with softer foods now. Under primitive condi- to establish what the occlusion might have been in the
tions, of course,excellentfunction of the jaws and teethwas absenceof early loss of teeth, gingivitis, and periodontal
an important predictor of the ability to survive and repro- breakdown.The increasein malocclusionin modern times
duce.A capablemasticatoryapparatuswas essentialto deal certainly parallels the development of modern civilization,
 SEcrrou I TrrE OnrrroooNtrc Proerrl4

tion or pain), temporomandibularjoint dysfunction(TMD),

and problemswith mastication,swallowingor speech;and
(3) greatersusceptibilityto trauma, periodontal diseaseor
tooth decay.

Psychosocial Problems
A number of studiesin recentyearshaveconfirmed what is
intuitively obvious, that severemalocclusion is likely to be a
social handicap.The usual caricatureof an individual who
is none too bright includes protruding upper incisors.A
witch not only ridesa broom, shehas a prominent lower jaw
that would produce a ClassIII malocclusion.Well-aligned
teeth and a pleasingsmile carry positivestatusat all social
levelsand ages,whereasirregular or protruding teeth carry
negativestatus.lstt Appearancecan and doesmake a differ-
encein teachers'expectations and thereforestudentprogress
in school,in employability,and in competition for a mate.
Testsof the psychologicreactionsof individuals to various
dental conditions, carried out by showing photographsof
various mouths to the individual whoseresponsewas being
evaluated, show that cultural differences are smaller than
might havebeen anticipated.A dental appearancepleasing
to Americanswas alsojudged pleasingin Australiaand East
Germany,whereasa dental appearanceconsideredin the
United Statesto carry with it some social handicap drew
about the same responsein these other cultural settings.rE
Protruding incisorsare judged unattractivewithin popula-
tions where most individuals have prominent teeth,just as
they are within lessprotrusivegroups.t'
Sections from a r96osmovieof an Australian There is no doubt that social responsesconditioned by
a b o r i g i n aml a n e a t i n ga k a n g a r o p o r e p a r e idn t h e t r a d i t i o n a l the appearanceof the teeth can severelyaffect an individual's
f a s h i o nN. o t et h ea c t i v i toyf m u s c l e sn,o to n l yi n t h ef a c i arle g i o n , whole adaptationto life. This placesthe conceptof "handi-
b u t t h r o u g h o ut th e n e c ka n d s h o u l d egr i r d l e .( C o u r t e sM y .J. capping malocclusion" in a larger and more important
Barrett.) context. If the way you interact with other individuals is
affectedconstantly by your teeth, your dental handicap is far
from trivial. It is interestingthat psychicdistresscausedby
but a reduction in jaw sizerelatedto disuseatrophy is hard disfiguring dental or facial conditions is not directly pro-
to document,and the parallelwith stress-related diseases
can portional to the anatomicseverityof the problem.An indi-
be carried only so far. Although it is difficult to know the vidual who is grosslydisfigured can anticipate a consistently
precisecauseof any specificmalocclusion,we do know in negative response.An individual with an apparently less
generalwhat the etiologicpossibilitiesare,and theseare dis- severeproblem (e.g.,a protruding chin or irregularincisors)
cussedin some detail in Chapter 5. is sometimestreated differently becauseof this but some-
What differencedoesit make if you have a malocclusion? times not. It seemsto be easierto copewith a defectif other
Let us considernow the reasonsfor orthodontic treatment. people'sresponses to it are consistentrather than if they are
not. Unpredictableresponsesproduce anxiety and can have
strong deleteriouseffects.20
The impact of a physical defect on an individual also will
be strongly influenced by that person's self-esteem.The
result is that the samedegreeof anatomic abnormality can
be merely a condition of no great consequenceto one
individual but a genuinely severe problem to another. It
Need for OrthodonticTreatment
seemsclear that the major reasonpeople seekorthodontic
Protruding, irregular,or maloccludedteeth can causethree treatment is to minimize psychosocialproblems relatedto
typesof problemsfor the patient:( I ) discriminationbecause their dental and facial appearance.Theseproblems are not
of facial appearance;(2) problems with oral function, "just cosmetic."They can have a major effect on the quality
including difficultiesin jaw movement (muscleincoordina- of life.
 Cnaptnn r MaroccrusroN AND DrNtorncrm DEronurtv rN CoxtrvrpoRARySocrrrv

Oral Function
Adults with severemalocclusion routinely report difficulty
in chewing, and after treatment, patients usually say that
their masticatoryproblems are largelycorrected.2lIt seems
reasonablethat poor dental occlusionwould be a handicap
to function, but there is no good test for chewing ability and
no objective way to measure the extent of any functional
handicap. Methods to test for jaw function would put this
reasonfor orthodontic treatmenton a more scientificbasis.
Scoring the effrciency of mastication from video tapes of
standard tasksnow offers the possibility of doing this.22
Severemalocclusion may make adaptive alterations in
swallowing necessary.In addition, it can be difficult or
impossibleto produce certain sounds (seeChapter 6), and
effective speech therapy may require some preliminary year-oldgirl.Thereis almostonechancein threeof an injuryto
orthodontic treatment. Even less severemalocclusionstend a protruding incisor,
thoughfortunately
the damagerarelyis this
to affect function, not by making it impossible but by severe.Mostof the accidents occurduringnormalactivity, not
in sDorts.
making it difficult, so that extra effort is required to com-
pensatefor the anatomic deformity. For instance,everyone
uses as many chewing strokes as it takes to reduce a food
bolus to a consistencythat is satisfactoryfor swallowing, so shift on closure) correlatepositively with TM joint problems
if chewing is lesseffrcientin the presenceof malocclusion, while other types do not,23but eventhe strongestcorrelation
either the affected individual uses more effort to chew or coefficientsare only 0.3 to 0.4. This means that for the great
settles for less well masticated food before swallowing it. majority of patients,there is no associationbetweenmaloc-
Similarly, almost everyonecan move the jaw so that proper clusion and TMD.
lip relationships exist for speech,so distorted speechis On the other hand, if a patient doesrespondto stressby
rarely noted eventhough an individual may haveto make an increased oral muscle activity, improper occlusal relation-
extraordinaryeffort to producenormal speech.As methods ships may make the problem more severeand harder to
to quanti$r functional adaptationsof this type aredeveloped, control. Therefore, malocclusion coupled with pain and
it is likely that the effect of malocclusion on function will be spasmin the musclesof mastication may indicate a need for
appreciatedmore than it has been in the past. orthodontic treatment as an adjunct to other treatment for
The relationship of malocclusion and adaptive function the muscle pain (but orthodontics as the primary treatment
to temporomandibulardysfunction (TMD), manifestedas almost never is indicated). If the problem is a pathologic
pain in and around the TM joint, is understoodmuch better processwithin the joint itself, improving the dental occlu-
now than only a few years ago. The pain may result from sion may or may not help the patient adapt to the necessar-
pathologicchangeswithin the joint, but more often is caused ily alteredjoint function (seeChapter 18).
by muscle fatigue and spasm. Muscle pain almost always
correlateswith a history of clenchingor grinding the teeth Relationship to Injury and Dental Disease
as a responseto stressfulsituations,or of constantlypostur- Malocclusion, particularly protruding maxillary incisors,
ing the mandible to an anterior or lateralposition. can increasethe likelihood of an injury to the teeth (Figure
Some dentists have suggestedthat even minor imperfec- 1-21).There is about one chancein three that a child with
tions in the occlusion serve to trigger clenching and grind- an untreated ClassII malocclusion will experiencetrauma to
ing activities. If this were true, it would indicate a real need the upper incisors, but most of the time, the result is only
for perfecting the occlusion in everyone,to avoid the possi- minor chips in the enamelresulting in a fracture of the tooth
bility of developing facial muscle pain. Becausethe number and/or devitalization of the pulp. For that reason,reducing
of people with at least moderate degreesof malocclusion the chanceof injury when incisors protrude is not a strong
(500/oto 75o/oof the population) far exceedsthe number argument for early treatment of Class II problems (see
with TMD (50loto 30%, depending on which symptoms are Chapter 8). Extreme overbite, so that the lower incisors
examined), it seemsunlikely that occlusalpatterns alone are contact the palate, can cause significant tissue damage,
enough to cause hyperactivity of the oral musculature. A leading to loss of the upper incisors in a few patients.
reaction to stressusually is involved. Some individuals with Extreme wear of incisors also occurs in some patients with
poor occlusion have no problem with muscle pain when excessiveoverbite.
stressed but develop symptoms in other organ systems. It seemsobvious that malocclusion could contribute to
Almost never does an individual haveboth ulcerative colitis both dental decay and periodontal disease,by making it
(also a common stress-induceddisease)and TMD. Some harder to care for the teeth properly or by causing occlusal
types of malocclusion (especiallyposterior crossbitewith a trauma. Current data indicate, however, that malocclusion
has l i t b f pact on diseases of the teeth or support- need, were proposed in the 1970s. Of these, Grainger's Treat-
livridual's willingness and motivation ment Priority Index (TPI)27is the most prominent because
deteqnmgral hygyne Pouch more than how well the teeth it was used in the 1965-1970 U.S. population surveys. None
ire aenza, ind arr -rice or absence of dentaI plaque is the of the early indices were widely accepted for screening
major determinant of the health of both the hard and soft potential patients, however.
tissues of the mouth. If individuals with malocclusion are More recently, Shaw and co-workers in the United
more prone to tooth decay, the effect is small compared with Kingdom developed a scoring system for malocclusion, the
hygiene status.24Occlusal trauma, once thought to be impor- Index of Treatment Need (IOTN),28that places patients in
tant in the development of periodontal disease, now is rec- five grades from "no need for treatment" to "treatment
ognized to be a secondary, not a primary, etiologic factor. need." The index has a dental health component derived
Two studies carried out in the late 1970s, in which a large from occlusion and alignment (Box 1-1) and an esthetic
number of patients were carefully examined 10 to 20 years component derived from comparison of the dental appear-
after completion of orthodontic treatment, shed some light ance to standard photographs (Figure 1-22). IOTN grades
on long-term relationships between malocclusion and seem to reflect clinical judgments better than previous
oral health.25,26
In both studies, comparison of the patients methods.2930There is a surprisingly good correlation
who underwent orthodontic treatment years earlier with between treatment need assessed by the dental health and
untreated individuals in the same age group showed similar esthetic components of IOTN (i.e., children selected as
periodontal status, despite the better functional occlusions needing treatment on one of the scales are also quite likely
of the orthodontically treated group. There was only a to be selected using the other).
tenuous link between untreated malocclusion and major With some allowances for the effect of missing teeth, it is
periodontal disease later in life. No evidence of a beneficial possible to calculate the percentages of U.S. children and
effect of orthodontic treatment on future periodontal health youths who would fall into the various IOTN grades from
was demonstrated, as would have been expected if untreated the NHANES 111 data set.9 Figure 1-23 shows the number
malocclusion had a major role in the cause of periodontal of youths age 12-17 estimated by IOTN to have mildl
problems. moderatelsevere treatment need. Although the prevalence
Patients with a history of orthodontic treatment appear of malocclusion is similar for the three raciallethnic groups
to be more likely to seek later periodontal care than those evaluated in NHANES 111, the percentage of blacks with
who were not treated, and thus are over-represented among severe problems is higher. The TPI scores of 40 years ago
periodontal patients. Because of this, it has been suggested placed more children toward the severe end of the maloc-
that previous orthodontic treatment predisposes to later clusion spectrum than the current IOTN grades, but it seems
periodontal disease. The long-term studies show no indica- unlikely that there has been a major change in treatment
tion that orthodontic treatment increased the chance of later need. To some extent, the difference may be due to the dif-
periodontal problems. The association between early ortho- ference in the indices, but there is another factor. Many more
dontic and later periodontal treatment appears to be only children have orthodontic treatment now. The number of
another manifestation of the phenomenon that one segment white children who receive treatment is considerably higher
of the population seeks dental treatment while another than blacks or Hispanics (p < .001). Treatment almost always
avoids it. Those who have had one type of successful dental produces an improvement but may not totally eliminate all
treatment, like orthodontics in childhood, are more likely to the characteristics of malocclusion, so the effect is to move
seek another like periodontal therapy in adult life. some individuals from the severe to the mild treatment need
In summary, it appears that both psychosocial and func- categories. The higher proportion of severe malocclusion
tional handicaps can produce significant need for ortho- among blacks, who are much less l~kelyto receive treatment
dontic treatment. The evidence is less clear that orthodontic at this point than whites, probably reflects the effect of more
treatment reduces the development of later dental disease. treatment in the white group, and may not indicate the pres-
ence of more severe malocclusion in the black p ~ p u l a t i o n . ~ ~
Epidemiologic Estimates of Orthodontic How do the IOTN scores compare with what parents and
Treatment Need dentists think relative to orthodontic treatment need? The
Psychosocial and facial considerations, not just the way the (rather weak) existing data suggest that in typical American
teeth fit, play a role in defining orthodontic treatment need. neighborhoods, about 35% of adolescents are perceived by
For this reason, it is difficult to determine who needs treat- parents and peers as needing orthodontic treatment (see
ment and who does not, just from an examination of dental Figure 1-23).Note that this is larger than the number of chil-
casts or radiographs. It seems reasonable that the severity dren who would be placed in IOTN grades 4 and 5 as severe
of a malocclusion correlates with need for treatment. Thls problems definitely needing treatment, but smaller than the
assumption is necessary when treatment need is estimated total of grades 3,4, and 5 for moderate and severe problems.
for population groups. Dentists usually judge that only about one-third of their
Several indices for scoring how much the teeth deviate patients have normal occlusion, and they suggest treatment
from the normal, as indicators of orthodontic treatment for about 55% (thereby putting about 10% in a category of
 CHAPTER
I MALOCCLUSION
AND DENTOFACIAL
DEFORMITY
I N CONTEMPORARY
SOCIETY

Box 1-1'

LI lofhl TREATMENT GRADES

- ~ r a d 5e (ExtremeINeed Treatment)
w
Grade 3 (ModerateIBorderline Ned)
5.i Impeded eruption of teeth (except third molars) due to 3.a Increased overjet greater than 3.5mm but less than or
crowding, displacement, the presence o f supernumerary equal to 6 m m with incompetent lips.
teeth, retained deciduous teeth, and any pathological 3.b Reverse overiet greater than i m m but lessrhan 01 lal
cause. to 3.5 m n
5.h Extensive hypodontia with restorative implications (more 3.c Anterior or posterior crossbit greater than I m m
than one tooth per quadrant) requiring pre-prosthetic but less than or equal to z m m ~ ~ i c r e p a n cbetween
y
orthodontics. retruded contact position and intercuspal posrtion.
5.a Increased overjet greater than g m m . 3.d Contact p o ~ n displacements
t greater than 2 m m but less
5.m Reverse overjet greater than 3.5 m m with reported than or equal t o 4 m m .
masticatory and speech difficulties. 3.e - .
Lateral or anterior open bite greater than 2 m m bu_g~bsh
e
5.p Defects o f cleft lip and palate and other craniofacial than or equal to 4 m m .
anomalies. 3.f Deep overbite complete on gingival or pal: ~ut
s Submerged deciduous teeth. no trauma. I

I Grade 4 (SevereINeed Treatment) Grade 2 (MildILittle Need)

_I

1 4.h Less extensive hypodontia requiring pre-restorative 2.a Increased overjet greater than 3.5mm but less t l
orthodontics or orthodontic snace closure (one tooth per equal to 6 m m with competent lips.
quadrant). 2.b Reverse overjet greater than o m m but less than or equal
4.a Increased overjet greater than 6 m m but less than or to 1 mm.
I equal t o g m m . 2.c Anterior or posterior crossbite with less than or equal t o I
Reverse overjet greater than 3.5rnrn with no tasticatory Im m discrepancy between retruded contact position and
or speech difficulties
-h r
Reverse overjet greater t an 1 m m but less than 3.5mm
with recorded masticatory or speech difficulties.
2.d
intercuspal position.
Contact point displacements greater than I m m but I
than or equal t o z m m .
4.c Anterior or posterior crossb~teswith greater than 2 m m 2.e Anterior or posterior openbite greater than im ut I
r, 7
discrepancy between retruded contact position and than or equal t o 2mm.

-
intercuspal position. 2.f Increased overbite greater than or equal ro
4.1 Posterior lingual crossbite with no functional occlusal without gingival contact.
contact in one or both buccal segments. 2.g Pre-normal or post-normal occlusions with no 0 t h
4.d Severe contact point displacements greater than q m m . anomalies.
4.e Extreme lateral or anterior open bits greater than 4 m m .
4.f Increased and complete overbite with gingival or palatal Grade (No
trauma. I. Extremely minor ma~occ~usions m
Partially erupted teern, tipped, and pacted against displacements less than Imrn i p
adjacent teeth.

malocclusion with little need for treatment). It appears that not recognize that they have a problem; others feel that they
they would include all the children in IOTN grade 3 and need treatment but cannot afford it or cannot obtain it.
some of those in grade 2 (Table 1-4) in the group who would Both the perceived need and demandvary with social and
benefit from orthodontics. Presumably, facial appearance cultural condition^.^^ More children in urban areas are
and psychosocial considerations are used in addition to thought (by parents and peers) to need treatment than
dental characteristics when parents judge treatment need or children in rural areas. Family income is a major determi-
dentists decide to recommend treatment. nant of how many children receive treatment (Figure 1-24).
This appears to reflect two things, not only that higher
income families can more easily afford orthodontic treat-
Demand for Orthodontic Treatment
ment, but also that good facial appearance and avoidance of
Demand for treatment is indicated by the number of patients disfiguring dental conditions are associated with more pres-
who actually make appointments and seek care. Not all tigious social positions and occupations. The higher the
patients with malocclusion, even those with extreme devia- aspirations for a child, the more likely the parent is to seek
tions from the normal, seek orthodontic treatment. Some do orthodontic treatment for him or her. It is widely recognized
 SrcrroN I Tnr OnrrroooNtrc PnosrtN4

T h e s t i m u l u sp h o t o g r a p h so f t h e I O T N e s t h e t i ci n d e x .T h e s c o r ei s d e r i v e df r o m t h e p a t i e n t ' sa n s w e rt o " H e r e i s a
set of photographsshowinga rangeof dentalattractiveness. Number r is the most attractiveand number ro the leastattractivearrange-
ment. Where would you put your teeth on this scale)" Crades 8-ro indicatedefinite need for orthodontictreatment,5-7 moderate/
b o r d e r l i n en e e d ,r - 4 n o / s l i g h tn e e d .
 Cneprrn r MaroccrusroN ANDDrrqtoracrar DEronurtv rN CowtrupoRARySocrrrv

that severemalocclusion can affect an individual's entire life orthodontic treatment by some families as a factor in social
adjustment, and every state now provides at least some and careerprogress.
orthodontic treatment through its Medicaid program, but The effect of financial constraints on demand can be seen
Medicaid and relatedprogramssupport only a tiny fraction most clearlyby the responseto third-party payment plans.
ofthe population'sorthodontic care.From that perspective, When third-party copayment is available, the number of
it is interesting that even in the lowest income group almost
5o/oof the youths and over 5o/oof adults report receiving
treatment, with l0oloto l5o/otreated at intermediate income
30
levels. This probably reflects the importance placed on

25
o- FamilyIncome
(l)Y
Severe (IOTN4,5) E o ) 20 EI E o-$1e,eee
Moderate(IOTN3) (l)E @ I $20-34,eee
PX
Mird (roTN 2)
IJ t I $35-49,999
50
c
I I >$49,999
o
640 cc) 10
f
o6
o30

E
820
o Youths12-17 Adults18-50
(L
10 The percent of the U.S. population ry89-94
who receivedorthodontic treatment, as a function of family
income. Although severe malocclusion is recognizedas an
White Black Hispanic White Black Hispanic
Need Treatment important problem and all statesoffer at leastsome coverageto
Had Treatment
l o w - i n c o m ec h i l d r e nt h r o u g ht h e i r M e d i c a i dP r o g r a mt,h i s f u n d s
Orthodontic need by severityof the problem treatmentfor a very small percentageof the population.Never-
for white, black,and Mexican-American youths age rz-r7 in the theless,nearly5/" of the lowest income group, and to/"-t5%"of
United States1989-94,and the percentofeach group who report intermediateincome groups, have had some orthodontictreat-
receivingorthodontic treatment.The greaternumber of whites ment. The increasingavailabilityof orthodonticsin recentyears
who receivetreatmentprobablyaccountsfor the smallernumber is reflectedin the largernumber of youthsthan adultswho report
of severeproblemsin the white population. beins treated.

Tlnn r-4
versus1989-1994
Percentof U.S.PopulationEstimatedto NeedOrthodontics,1965-1970
WHITE HISPANIC*X

YOUTH CHILD YOUTH YOUTH

A8e 6 - tI B - lI 12-17 6-lt 8 - ll 12-17 B-1I 12-17
Year !965-70 r989-91 r965-70 r989-91 1965-70 r989-91 1965-70 t9B9-91 1989-91 1989-91
Index TPI IOTN TPI IOTN TPI IOTN TPI IOTN IOTN IOTN
No treatmentneed 28.7 36.5 20.0 43.7 39.7 40.4 243 42.2 49.4 41.5
(TPl0-r, roTNr)
Minimalneed 33.9 t6.3 25.1 16.5 28.4 B.B 27.3 9.2 1 1. 7 8.5
(TPr2-3,IOTN2)
Moderate need 23.7 36.4 25.7 25.3 15.0 37.1 21.O 26.0 29.9 36.8
(TPr4-6, |OTN3)
Definiteneed 13.7 r0.B 292 14.5 16.9 13.7 27.4 22.6 9.0 13.2
(TPl>6, |OTN4-5)
Hadorthodontic 2.5* 10.5 10.71 27.4 3.6 6.2 1.4 11.7
treatment

Data from NHANES I and III.

*White/black combined.
+*No data for 1965-1970.
 SrcrroN I Tnr OnrHoooNrrc Pnosnr\a

individualsseekingorthodontic treatmentrisesconsiderably dental and orthodontic treatment,just as it is in other con-

(but even when all costs are covered,some individuals for texts.3s
whom treatment is recommended do not accept it-see Orthodonticshasbecomea more prominent part of den-
Table1-4).It seemslikely that under optimal economiccon- tistry in recentyearsand this trend is likely to continue.The
ditions,demandfor orthodontic treatmentwill at leastreach vast majority of individualswho had orthodontic treatment
the 35o/olevel thought by the public to need treatment. The feel that they benefited from the treatment and are pleased
NHANES III datae show that 35o/o-50o/o of children and with the result. Not all patients havethe dramatic changesin
youths in higher socioeconomicareasin the United States dentaland facialappearance shown in Figures1-4 to I -7, but
alreadyare receivingorthodontic care. nearly all recognizean improvement in both dental condi-
As late as the 1960s,95o/oor more of all orthodontic tion and psychologicwell-being.
patientswere children or adolescents. From 1975to the late
1980s,much of the growth in the orthodontic patient pop-
ulation was adults (agel8 or older). By 1990,about25o/oof RnrrnrNcEs
all orthodontic patientswere adults (18 or older). Interest-
l. Corrucini RS, PaccianiE. "Orthodontistry" and dental occlusion in
ingly, the absolutenumber of adults seekingorthodontic Etruscans. Angle Orthod 59:61-64, 1989.
treatment has remained constant since then while the 2. Kingsley NW Treatise on Oral Deformities as a Branch of Mechan-
number of youngerpatientshas grown, so by the late 1990s, ical Surgery. New York: Appleton; 1880.
the proportion of adultsin the orthodontic patient popula- 3. Angle EH. Treatment of malocclusion of the teeth and fractures of
the maxillae. In: Angle's System, ed 6. Philadelphia: SS White
tion had dropped to about 20o/o.33 Many of these adult Dental Mfg Co; 1900
patientsindicatethat they wanted treatment earlierbut did 4. Sarver DM. Esthetic Orthodontics and Orthognathic Surgery. St.
not receiveit, often becausetheir families could not afford Louis: CV Mosby; 1998.
it; now they can.Wearingbracesas an adult is more socially 5. Sarver DM, Proffit WR, Ackerman |L. Evaluation of facial soft
acceptable than it was previously, though no one really tissues. In: Proffit WR, White RP Jr, eds. Contemporary Treatment
of Dentofacial Deformity. St. Louis: CV Mosby; 2003.
knows why, and this too has made it easier for adults to
6. Kelly JE, Sanchez M, Van Kirk LE. An Assessment of the Occlusion
seektreatment. Recently,more older adults (+0 and over) of Teeth of Children. Washington, DC: National Center for Health
have sought orthodontics, usually in conjunction with Statistics;1973. DHEW Publication No. (HRA) 74-1612.
other treatment,to savetheir teeth.As the population ages, 7. Kelly J, Harvey C. An Assessmentof the Teeth of Youths 12-17
this is likely to be the fastest-growingtype of orthodontic Years.Washington, DC: National Center for Health Statistics; 1977.
DHEW Pub No. (HRA) 77-1644.
treatment.
8. Brunelle IA, Bhat M, Lipton JA. Prevalence and distribution of
Many of the children and adults who seekorthodontic selectedocclusal characteristicsin the US population, 1988-91. J
treatment today have dentofacial conditions that are within Dent Res 75:706-713, 1996.
the normal range of variation, at least by definitions that 9. Proffit WR, Fields HW, Moray LJ. Prevalence of malocclusion and
focus tightly on obvious degreesof handicap.It has been orthodontic treatment need in the United States: Estimates from
the NHANES-III survey. Int J Adult Orthod Orthogn Surg 13:97-
estimated,for instance,that only about 5oloof the popula-
106,1998.
tion have orthodontic conditions that can be considered 10. El-Mangoury NH, Mostafa YA. Epidemiologic panorama of mal-
unequivocallyhandicapping.tnDoes that mean treatment is occlusion. Angle Orthod 60:207-214, 1990.
not indicatedfor thosewith lesserproblems?Today,medical 11. Larsen CS. Bioarchaeology: Interpreting Behavior From the
and dental interventions that are intended to make the Human Skeleton. Cambridge, Mass: Cambridge University Press;
1997.
individual either "better than well" or "beyond normal" are
12. Baume LJ. Uniform methods for the epidemiologic assessmentof
calledenhancements. Examplesof typical medical and sur- malocclusion. Am J Orthod 66:251-272, 1974.
gical enhancementsare drugs to treat erectiledysfunction, 13. Brown T, Abbott AA, BurgessVB. Longitudinal study of dental arch
face lifts and hair transplants. In dentistry, a good example relationships in Australian aboriginals with reference to alternate
of enhancementis tooth bleaching. intercuspation. Am I Phys Anthropol 72:49-57, 1987.
14. Corrucini RS. Anthropological aspects of orofacial and occlusal
In this context, orthodontics often can be considered
variations and anomalies. In: Ke1ly MA, Larsen CS, eds. Advances
an enhancement technology. It is increasingly accepted in Dental Anthropology. New York: Wiley-Liss; 1991.
that appropriate care for individuals often should include 15. Shaw WC. The influence of children's dentofacial appearance on
enhancement,to maximize their quality of life. If you really their social attractiveness as judged by peers and lay adults. Am J
want it becauseyou are convincedyou need it, perhapsyou Orthod 79:399-4 I 5, 198l.
16. Mandall NA, McCord JR Blinkhorn AS, Worthington HV O'Brien
really do need it-whether it is orthodonticsor many other
KD. Perceived aesthetic impact of malocclusion and oral self-
types of treatment. Both Medicaid/Medicareand many perceptions in 14-15-year-old Asian and Caucasian children in
insurancecompaniesnow have acceptedthe reality that at greater Manchester.Eur J Orthop 22:175-183,2000.
leastsome enhancementprocedureshaveto be acceptedas 17. Shaw WC, ReesG, Dawe M, Charles CR. The influence of dento-
reimbursablemedicalexpenses. Similarly,when orthodontic facial appearance on the social attractiveness of young adults. Am
J O r t h o d 8 7 : 2 1- 2 6 , 1 9 8 5 .
benefits are included in insurance coverage,the need
18. Cons NC, Jenny L Kohout FJ, et al. Perceptions of occlusal condi-
for treatmentis no longer judged just by the severityof the tions in Australia, the German Democratic Republic, and the
malocclusion.The bottom line: enhancementis appropriate United States. Int Dent J 33:200-206,1983.
 CHlprrn r Socrrrv
MlroccrusroN AND DsNtoracrar Drronvrrty rN CorqtrvrpoRARy

FarrowAL, Zarinnia K, KhosrowA. Bimaxillaryprotrusion in black 27. GraingerRM. Orthodontic TieatmentPriority Index.Washington,
Americans-an estheticevaluationand the treatment considera- DC: National Center for Health Statistics;1967.USPHSPublica-
tions.Am J Orthod DentofacOrthop 104:240 -250,1993. tion No. 1000-Series 2, No.25.
20. MacgregorFC. Socialand psychologicalimplications of dentofa- 28. Brook PH, ShawWC. The developmentof an index for orthodon-
cial disfigurement.Angle Orthod 40:231- 233, 1979. tic treatmentpriority. Eur J Orthod Il:309-332,1989.
21. OstlerS,Kiyak HA. Treatmentexpectationsvs outcomesin orthog- 29. Richmond S, Shaw WC, O'Brien KD, et al. The relationship
nathic surgerypatients.Int JAdult Orthod OrthognathSurg6:247- betweenthe index of treatment need and consensusopinion of a
256,t99t. panelof 74 dentists.Br Dent | 178:370-374,1995.
22. FeinefS, MaskawiK, de Grandmont P,et al. Within-subject com- 30. Beglin FM, FirestoneAR, Vig KW, Beck FM, Kuthy RA, WadeD.
parisonsof implant-supportedmandibular prostheses: Evaluation A comparisonof the reliability and validity of 3 occlusalindexes
of masticatoryfunction. J Dent Res73:1646-1656,1994. of orthodontic treatment need.Am ] Orthod Dentofac Orthop
L) McNamara fA, SeligmanDA, OkesonfP. Occlusion,orthodontic 120:240-246,2001.
treatment and temporomandibular disorders.J Orofacial Pain 31. NelsonS,ArmoganV, Abel Y, BroadbentBH, Hans M. Disparity in
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24. Helm S, PetersenPE. Causalrelation betweenmalocclusionand students.I Public Health Dent 64:26-30,2004.
caries.Acta Odontol Scand47:217-22I,1989. 32. Tulloch lFC, ShawWC, Underhill C, et al. A comparisonof atti-
Sadowsky C, BeGole EA. Long-term effects of orthodontic tudestowardorthodontic treatmentin British and Americancom-
treatment on periodontal health. Am J Orthod 80:156-172, munities.Am J Orthod 85:253-259,1984.
1981. 33. Patientcensussurveyresults.Bull Am AssocOrthod 75:4,1997.
26. PolsonAM. Long-termeffectof orthodontic treatmenton the peri- 34. Morris AL, et al. SeriouslyHandicappingOrthodontic Conditions.
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Discovering Diverse Content Through
Random Scribd Documents
 According to the present style of sleeves, the ruffle should not fall
over the hand, but should be sewed at the other edge of the
wristband with the puff, on which it must fall back. For cold weather,
an undersleeve of sarsenet, made of the same dimensions as the
knitted one, and tacked under it, will be found a very great
improvement, and if of a colour that will harmonise with the dress,
will be very becoming.
Knitted Lace Ruffle.—Cotton No. 50; Needles, No. 22. Cast on
17 stitches.
1st Row.—Knit 2, m. 1, k. 2 t., k. 1, m. 1, k. 2 t., k. 1, slip 1, k. 1, pass
the slip stitch over, m. 1, k. 3, m. 2, k. 2 t., m. 2, k. 2.
2nd.—K. 3, p. 1, k. 2, p. 1, k. 3, p. 5, k. 5.
3rd.—K. 2, m. 1, k. 2 t., k. 1, m. 1, k. 2 t., k. 1, slip 1, k. 1, pass the
slip stitch over, m. 1., k. 10.
4th.—K. 2, m. 2, k. 2 t., k. 1, k. 2 t., m. 2., k. 2 t., k. 2, p. 3, k. 6.
5th.—K. 2, m. 1, k. 2 t., k. 2, m. 1, k. 3 t., m. 1, k. 4, p. 1, k. 4, p. 1, k.
2.
6th.—K. 12, p. 3, k. 6.
7th.—K. 2, m. 1, k. 2 t., k. 2 t., m. 1, k. 3, m. 1, k. 2 t., k. 2, m. 2, slip
1, k. 3 t., pass the slip stitch over, m. 2, k. 2 t., k. 2 t.
8th.—K. 3, p. 1, k. 2, p. 1, k. 3, p. 5, k. 5.
9th.—Like 3rd.
10th.—Cast off 3, k. 6, p. 2, m. 1, p. 2 t., p. 1, k. 5.

This lace should be put on rather full; and on no account should

knitted articles be ironed by the laundress. It is quite sufficient to
pull them into proper shape whilst they are drying at the fire.
 INSERTIONS IN EMBROIDERY.
[Figs. 7 & 8.]

Suitable for the fronts of shirts, and for other purposes; to be

worked in satin stitch, with embroidery cotton, No. 80. The centres
of the leaves and cups of the flowers may be done in very small
eyelet-holes. The stalks sewn over with extreme neatness.
 TABLE MAT.
[Fig. 3.]

Materials.—Shaded green and scarlet 8 thread Berlin wool; bone

crochet hook. Make a chain of six and form it into a round.
1st Round.—12 dc.
2nd.—4 ch., miss 1 sc. in 2nd. stitch; repeat all round.
3rd.—Like 2nd.
4.—Scarlet wool; 6 ch., sc. under the loop of 4 ch.; repeat.
5th.—7 ch., sc. under 6 ch. of former round; repeat.
6th.—9 ch. worked as before.
7th.—12 ch. worked as before: fasten off the scarlet and begin with
the green wool once more.
8th.—12 tc. on 12 ch. of last round, miss sc. stitch; repeat.
9th.—Sc. on 2nd. stitch, 2 ch., miss 1; repeat.
10th.—+ 1 tc., 3 ch., miss 3 +; repeat.
11th.—+ 1 tc., on tc. of last round, 4 ch. +; repeat.
12th.—+ Dc. on 4 ch. of last round, 1 ch. +; repeat.
13th.—[Scarlet wool,] 4 tc. on 4 dc. of last round, 1 ch.; repeat.
14th—+ 9 dc. on 9 stitches, of last round, 9 ch., dc. into same
stitch as the last +; repeat.
15th.—6 ch., sc. in 3rd dc. of last round; repeat this twice more; 8
ch., unite into the loop formed by 9 ch. in last round; three times
more, then repeat from the commencement of the 15th round.
16th.—Sc. in centre loop of 8 ch. in scallop; 1 ch., sc. into centre
loop of 8 ch. in next scallop, 11 ch.; repeat.
17th.—12 ch., sc. in third stitch; repeat.
18th.—12 dc. through every chain of 12 in last round.
19th.—5 ch. unite with sc. on the point of the loop; repeat.
20th—Dc. all round, and fasten off.
 GENTLEMEN’S KNITTED BRACES.
[Fig. 4.]

Materials.—Rich, dark blue, or crimson crochet silk; two knitting

needles, No. 14. Cast on 19 stitches.
1st. Row.—K. 2, m. 1, k. 1, slip 1, k. 1, pass the slip stitch over, p. 1,
k. 2 t., k. 1, p. 1, k. 1, slip 1, k. 1, pass the slip stitch over, p. 1, k. 2 t., k.
1, m,. 1, k. 2.
2nd.—P. 5, k. 1, p. 2, k. 1, p. 2, k. 1, p. 5.
3rd.—K. 2, m. 1, k. 1, m. 1, slip 1, k. 1, pass the slip stitch over, p. 1,
k. 2 t., p. 1, slip 1, k. 1, pass the slip stitch over, m. 1, k. 1, m. 1, k. 2.
4th.—P. 6, k. 1, p. 1, k. 1, p. 1, k. 1, p. 6.
5th.—K,. 2, m. 1, k. 3, m. 1, slip 1, k. 2 t., pass the slip stitch over, p.
1, slip 1, k. 2 t., pass the slip stitch over, m. 1, k. 3, m. 1, k. 2.
6th.—P. 8, k. 1, p. 8.
7th.—K. 2, m. 1, k. 5, m. 1, slip 1, k,. 2 t., pass the slip stitch over, m.
1, k. 5, m. 1, k. 2.
8th.—Purled.
Repeat this pattern until you have done the length required for one
half of the braces. Then cast on, and do another length. When made
up, they should be lined with white Petersham ribbon, and finished
with white kid trimmings.
 SMALL GIMPS IN CROCHET
[Fig. 5.]

Materials.—Crochet cotton, No. 6; crochet hook, No. 18.

No.—1.—Make a chain the length required and then work back in
dc. This is a very neat little trimming for children’s dresses; and if
required to be made of silk and purse twist be used, will be found to
answer every purpose for which a narrow gimp may be required. It
forms also an excellent substitute for the braid which is run on the
skirt of a dress, as the wools of which it should then be made, can be
procured of any shade whatever, which the braid itself cannot.
No. 2.—Make a chain of the length required, and on it work 1 dc., 1
ch, miss 1.
 JUDY’S ANTI-MACASSAR.
[Fig. 6.]

Materials.—Crochet cotton, No. 10; crochet hook, No. 16. 133 ch.
Four rows of open square crochet.
5th.—20 os., 4 dc., 3 ch., miss 3, 12 dc., 2 ch., 17 os., 1 dc.
6th.—10 os., 1 dc., 1 ch., miss 1, 16 dc., 2 ch., miss 2, 3 os., 9 dc., 1
ch., miss 1, 21 os., 1 dc.
7th.—10 os., 1 dc., 1 ch., miss 1, 59 dc., 2 ch., miss 2, 13 os., 1 dc.
8th and 9th.—The same.
10th.—11 os., 1 dc., 1 ch., miss 1, 54 dc., 1 ch., miss 1, 14 os., 1 dc.
11th, 12th, and 13th.—Like 10th.
14th.—12 os., 20 dc., 1 ch., miss 1, 32 dc., 1 ch., miss 1, 14 os., 1 dc.
15th.—Like 14th.
16th.—12 os., 20 dc., 1 ch., miss 1, 17 dc., 1 ch., miss 1, 14 dc., 1 ch.,
miss 1, 14 os., 1 dc.
17th.—12 os., 7 dc., 1 ch., miss 1, 11 dc., 1 ch., miss 1, 18 dc., 1 ch.,
miss 1, 13 dc., 2 ch., miss 2, 14 os., 1 dc.
18th.—12 os., 7 dc., 1 ch., miss 1, 11 dc., 1 ch., miss 1, 18 dc., 1 ch.,
miss 1, 11 dc., 1 ch., miss 1, 15 os., 1 dc.
19th.—12 os., 7 dc., 1 ch., miss 1, 13 dc., 1 ch., miss 1, 16 dc., 1 ch.,
miss 1, 10 dc., 2 ch., miss 2, 15 os., 1 dc.
20th.—12 os., 1 dc., 1 ch., miss 1, 7 dc., 1 ch., miss 1, 11 dc., 1 ch.,
miss 1, 16 dc., 1 ch., miss 1, 8 dc., 1 ch., miss 1, 16 os., 1 dc.
21st.—12 os., 1 dc., 1 ch., miss 1, 7 dc., 1 ch., miss 1, 11 dc., 1 ch.,
miss 1, 14 dc., 1 ch., miss 1, 9 dc., 2 ch., miss 2, 16 os., 3, 1, dc.
22nd.—13 os., 7 dc., 1 ch., miss 1, 12 dc., 1 ch., miss 1, 12 dc., 1 ch.,
miss 1, 7 dc., 1 ch., miss 1, 17 os., 1 dc.
 23rd.—13 os., 1 dc., 1 ch., miss 1, 7 dc., 1 ch., miss 1, 10 dc., 1 ch.,
miss 1, 10 dc., 1 ch., miss 1, 8 dc., 2 ch., miss 2, 17 os., 1 dc.
24th.—14 os., 35 dc., 1 ch., miss 1, 18 os., 1 dc.
25th—15 os., 40 dc., 2 ch., miss 2, 15 os., 1 dc.
26th.—17 os., 1 dc., 1 ch., miss 1, 41 dc., 2 ch., miss 2, 12 os., 1 dc.
27th.—17 os., 1 dc., 1 ch., miss 1, 12 dc., 1 ch., miss 1, 11 dc., 1 ch.,
miss 1, 16 dc., 2 ch., miss 2, 12 os., 1 dc.
28th.—17 os., 12 dc., 1 ch., miss 1, 10 dc., 1 ch., miss 1, 2 dc., 1 ch.,
miss 1, 1 os., 13 dc., 2 ch., miss 2, 12 os., 1 dc.
29th.—16 os., 1 dc., 1 ch., miss 1, 11 dc., 1 ch., miss 1, 11 dc., 1 ch.,
miss 1, 5 dc., 2 ch., miss 2, 3 os., 1 dc., 1 ch., miss 1, 3 dc., 1 ch., miss
1, 12 os., 1 dc.
30th.—15 os., 1 dc., 1 ch., miss 1, 12 dc., 1 ch., miss 1, 11 dc., 1 ch.,
miss 1, 7 dc., 2 ch., miss 2, 17 os., 1 dc.
31st.—15 os., 1 dc., 1 ch., miss 1, 10 dc., 1 ch., miss 1, 11 dc., 1 ch.,
miss 1, 10 dc., 1 ch., miss 1, 17 os., 1 dc.
32nd.—15 os., 23 dc., 1 ch., miss 1, 13 dc., 2 ch., miss 2, 16 os., 1 dc.
33rd.—15 os., 21 dc., 1 ch., miss 1, 15 dc., 2 ch., miss 2, 16 os., 1 dc.
34th.—15 os., 19 dc., 1 ch., miss 1, 15 dc., 1 ch., miss 1, 17 os., 1 dc.
35th.—15 os., 1 dc., 1 ch., miss 1, 32 dc., 2 ch., miss 2, 17 os., 1 dc.
36th.—16 os., 28 dc., 2 ch., miss 2, 18 os., 1 dc.
37th.—16 os., 1 dc., 1 ch., miss 1, 29 dc., 2 ch., miss 2, 17 os., 1 dc.
38th.—16 os., 1 dc., 1 ch., miss 1, 30 dc., 1 ch., miss 1, 17 os., 1 dc.
39th.—17 os., 25 dc., 1 ch., miss 1, 3 dc., 1 ch., miss 1, 17 os., 1 dc.
40th.—15 os., 10 dc., 1 ch., miss 1, 17 dc., 2 ch., miss 2, 19 os., 1 dc.
41st.—14 os., 14 dc., 2 ch., miss 2, 18 dc., 2 ch., miss 2, 18 os., 1 dc.
42nd.—14 os., 15 dc., 1 ch., miss 1, 17 dc., 2 ch., miss 2, 5 dc., 1 ch.,
miss 1, 16 os., 1 dc.
43rd.—14 os., 1 dc., 1 ch., miss 1, 16 dc., 1 ch., miss 1, 22 dc., 1 ch.,
miss 1, 16 os., 1 dc.
44th.—15 os., 17 dc., 1 ch., miss 1, 17 dc., 1 ch., miss 1, 17 os., 1 dc.
45th.—14 os., 20 dc., 1 ch., miss 1, 16 dc., 2 ch., miss 2, 17 os., 1 dc.
46th.—13 os., 23 dc., 1 ch., miss 1, 7 dc., 2 ch., miss 2, 4 dc., 2 ch.,
miss 2, 18 os., 1 dc.
 47th.—12 os., 1 dc., 1 ch., miss 1, 8 dc., 1 ch., miss 1, 29 dc., 2 ch.,
miss 2, 18 os., 1 dc.
48th.—13 os., 35 dc., 1 ch., miss 1, 19 os., 1 dc.
49th.—13 os., 1 dc., 1 ch., miss 1, 30 dc., 1 ch., miss 1, 20 os., 1 dc.
50th.—13 os., 1 dc., 1 ch., miss 1, 15 dc., 1 ch., miss 1, 1 dc., 1 ch.,
miss 1, 12 dc., 1 ch., miss 1, 20 os., 1 dc.
51st.—14 os., 13 dc., 2 ch., miss 2, 1 dc., 2 ch., miss 2, 1 dc., 1 ch.,
miss 1, 8 dc., 2 ch., miss 2, 20 os., 1 dc.
52nd.—14 os., 10 dc., 2 ch., miss 2, 3 os., 5 dc., 1 ch., miss 1, 21 os.,
1 dc.
53rd.—15 os., 6 dc., 2 ch., miss 2, 26 os., 1 dc.
54th to 57th inclusive.—In open square crochet.

The border to be the same as that given for Punch’s Anti-Macassar,

in part I. of this book.
 CROCHET D’OYLEY.
[Fig. 9.]

Materials.—7 shades of Berlin wool; bone hook.

Make a chain of 9, and form it into a round.
1st.—Dc., increasing 3 in the round.
2nd.—6 ch., 1 tc., miss 3. Repeat.
3rd.—Sc. on centre of 6 ch., 9 ch. Repeat.
4th.—Sc. on centre of 9 ch., 12 ch. Repeat.
5th. Sc. on centre of 12 ch., 15 ch., sc. on same stitch, and work 1
sc., 2 dc., 14 tc., 2 dc., 1 sc. in the loop thus formed. Fasten off, and
repeat in the centre of every 12 ch.
6th.—Begin on the point of the leaf with a sc. stitch; 15 ch., sc. on
point of next leaf, and so on.
7th and 8th.—Dc. all round.
9th.—✕ Sc., 6 ch., miss 2, ✕. Repeat.
10th.—✕ Sc. on centre of 6 ch., 9 ch., ✕; repeat.
11th.—✕ Sc. on centre of 9 ch., 12 ch., ✕; repeat.
12th.—✕ Sc. on centre of 12 ch., 9 ch., ✕; repeat.
13th.—Dc.
14th.—Dc., working two stitches into every one.
15th.—Sc. on the centre of one of the spaces. ✕ 12 ch., sc. in same
stitch three times, 12 ch., sc on centre of next space. And repeat from
✕.
16th.—Dc. all round.
 17th.—Sc., ✕ 5 ch., miss 2, sc. in 3rd ✕. Repeat all round, and
fasten off.
 POINT LACE STITCHES.

Point Lace is now so fashionable that very few are unacquainted

with its appearance; but perhaps some of my readers will be
surprised when told that the whole of the genuine Point Lace is the
production of the needle; not merely the close and heavy parts are so
made, but the most exquisitely delicate nets, of which, of late years,
we have had imitations from the loom, are all alike produced by the
common sewing needle.
The work of which we treat here may be regarded not as an
imitation of the valuable and beautiful work of ancient times, but
rather as an actual revival of an art which has unfortunately been
suffered to sink into oblivion. Of course, at present, I content myself
with giving very simple Point Lace patterns; but, as my fair readers
advance in knowledge, I shall give them specimens which will still
more exercise their skill and patience.
Point Lace stitches are worked on a foundation of braid or tape; or,
sometimes, cambric. At present, I chiefly use braid, it being the more
comeatable material, and answering extremely well for delicate
articles. It is the kind termed French white cotton braid, being very
closely and evenly plaited. That used for large patterns is No. 9; for
delicate work, a still narrower braid may be employed.
Very much of the beauty of Point Lace depends of course, on the
skill of the workers; but it would not be exaggeration to assert that
even more is the result of the adaptation of the materials. A very
great variety of cotton and linen thread is absolutely necessary; not
less than nine different kinds entering frequently into the
composition of one single collar: those I use are termed Evans’s
Point Lace Cottons, manufactured by Messrs. Walter Evans and Co.,
of Derby; and they are as superior to all others that I have tried as it
is possible to imagine. They are sold selected and arranged properly
for this kind of work.
The pattern being drawn in outline, on colored paper, is to be then
pasted on calico or linen; when quite dry, begin to braid it, by laying
on the braid, and running it on the paper with a fine needle and
cotton, No. 50. The stitches are to be taken through the paper, and
not very closely together, except where points of leaves and other
angularities occur. In these places the braid is sewed at each end of
the pattern and turned back; this is termed mitreing. The stitches
must be taken across the braid, as it is not liable then to become
wider.
The stitches which are used in the specimens I have hitherto made
in point lace are the following, which may be divided into three
kinds: edgings, laces, and connecting bars.
 The use of the edgings is sufficiently obvious: they form narrow
borderings to the braid or other material which is the foundation of
the lace.
The lace stitches are used to fill up open parts in the design, such
as the leaves, flowers, or fruit, the mere outlines of which are made in
the braid.
Finally, the connecting stitches unite the several parts into one
perfect mass of work.
EDGES.—Brussels Edging (No. 1).—This is merely the common
button-hole stitch, or (as it is sometimes called) glove stitch. It is
worked nearly at the edge of the braid, and differs only from the
ordinary button-hole because the stitches are taken at the distance of
the fourteenth part of an inch apart, and, as the thread is not drawn
tightly, each stitch forms a small loop. It is worked from left to right.
Venetian Edging (No. 2).—The first stitch is taken as in Brussels
edging, and in the loop thus formed, four tight button-hole stitches
are worked.
Sorrentine Edging (No. 3).—Make a stitch as in Brussels edging,
but the eighth of an inch long; work one button-hole stitch in the
loop; repeat at the distance of the sixteenth of an inch; two stitches
are thus formed, one of which is half the length of the other. Repeat.
LACES.—Brussels Lace (No. 4) is worked by doing a line of
Brussels edging in the space to be filled up, and then another line,
from right to left, putting the needle, at every stitch, through one of
the loops of the first row. These lines are to be repeated, backwards
and forwards, until the part is completed. In working the last row,
run the needle through the braid after every stitch.
Venetian Lace (No. 5).—The beautiful closely-dotted appearance,
characteristic of this lace, is obtained by working consecutive rows of
Venetian edging, not backward and forwards, but always from left to
right, fastening off after completing each line; or, if the space be very
small, running the needle in the braid back to the place where the
next line is to be begun.
English Lace (No. 6) is used principally to fill up large open
spaces. Make a series of diagonal bars across the space to be filled
up, securing the tightness of each thread by working a button-hole
stitch on the braid, before slipping the needle to the next place; cross
these bars by others, in the contrary direction, and at the same
distance (one-eighth of an inch) apart. Wherever the bars cross each
other, work a small spot, by passing the needle alternately under and
over the threads, five or six times round. Twist the threads twice
round each other in bringing the needle to the next cross, and repeat
until a spot is made at every one. Observe, that in crossing the first
bars you slip the needle alternately under and over them.
Open English Lace (No. 7) is commenced like the preceding, but
when the two lines of diagonal bars are made, a line of perpendicular
and one of horizontal threads must be added. The spot will thus be
worked on eight threads instead of four. The lines to be at the rate of
five to an inch.
English Rosettes (No. 8).—Another beautiful style of English
point. It is a kind of spot, which looks like the miniature of the
rosette on a baby’s cap, whence its name is derived. A single spot is
only used in one space, and the size is to be suited to it. The open
space is crossed with four, six or eight twisted threads; the last
thread to be twisted only to the centre, where all are to be firmly
joined by working one or two tight button-hole stitches. Make the
rosette by passing the needle round one thread and under the next,
then round that and under the succeeding; continue until you have
made a rosette as large as the space requires, working from four to
ten times round. Stop at the single thread, twist round it, and fasten
off.
Mechlin Lace (No. 9).—This is one of the most beautiful, and at
the same time, complicated stitches in the list. Those who have
worked it, however, all confess that the effect amply repays the
trouble. It is worked thus: A number of diagonal bars, each of a
single thread, cross each other in the space to be filled up, at the
distance of one quarter of an inch from each other. Then all the bars
in one direction are to be covered with button-hole stitch. Begin in
the opposite direction, in the same way, and work it nearly to the
crossing of the two. Pass the thread loosely round the cross twice,
slipping the needle under one and over another thread, so as to form
the small circle seen in the engraving. This is to be covered with
button-hole stitch; and as, from the looseness of the thread, it is
otherwise somewhat troublesome to work it, pin it down on the
paper with a second needle. In the middle of each quarter of every
alternate round, a dot is to be worked thus: instead of drawing the
thread tight, as usual, put in the loop a pin, which is to keep it about
the eighth of an inch in length. On this loop work three button-hole
stitches; and withdraw the pin, and continue the round.
Valenciennes Lace (No. 20,) has a very heavy appearance, and
contrasts admirably with lighter stitches. A space to be so filled up
has a number of radiating threads, meeting, in a common centre, to
be very closely darned with extremely fine thread.
Henriquez Lace (No. 11), is, on the contrary, a very light and
delicate stitch. It must never be done with coarser thread than
Evans’s boar’s head, 120. With this make a diagonal line across the
space to be so filled in, and return your needle to the point you began
from, by twisting the thread back again. Make another line, parallel
with this one, and not more than the tenth of an inch from it. Twist it
over four times, then on the single and double thread form a spot, by
darning the three backwards and forwards about sixteen times. To
do this, you must separate the two threads twisted together
whenever you make a spot. Continue twisting your needle round the
single thread, for the space of one quarter of an inch, when you will
form another dot. Repeat until this line is finished. Make similar
ones at one quarter of an inch apart in the entire space; and then
cross them with others, worked in precisely the same manner, in
exactly the opposite direction. Take care that where the lines cross
each other the thread is twisted between the first bar and the second,
that a small, clear square may be maintained.
Cordovan Lace (No. 12), is similar to the preceding, but less
delicate and less troublesome. Two twisted bars are made the tenth
of an inch apart, and a third single one, in going back on which the
spots are worked on two twisted threads and the single one. They are
also crossed by similar ones, the crossing of the threads forming a
diamond of four holes.
CONNECTING BARS are stitches used in the various kinds of
point lace, to unite different parts. The most simple is the
Sorrento Bar (No. 13), which is made by passing a thread from
one part to another, fastening it by a tight stitch, and twisting the
thread back on the bar thus formed; pass the thread round until it
appears as much twisted as a rope.
 Bars in Alencon Point (No. 14).—This is almost the same as our
common herring bone stitch, but the needle is passed under the last
thread after every stitch before taking another, which twists the two
together. Where the space is more than half-an-inch wide, it is
requisite to pass the needle more than once under after every stitch.
Venetian Bars (No. 15).—Pass the needle backwards and forwards
two or three times, and work the bar thus formed in close button-
hole stitch. If it be a cross bar, work the button-hole stitch half the
length; make the bar in the opposite direction, work that; and if
another is required, do the same before finishing the first bar.
Edged Venetian Bars (No. 16) are merely the above edged on
each side with Brussels or Sorrento edging.
Dotted Venetian Bars (No. 17.)—To make these bars, pass the
thread across the space two or three times, and make four button-
hole stitches on the bar thus formed; put a needle in the fourth, and
draw it out until it will allow of three or four button-hole stitches
being worked on it; continue the bar in the same way.
English Bars (No. 18) are used to connect two lines of edging.
Pass the needle backwards and forwards between two opposite
stitches four times each way, always putting the needle in the under
side of the edge. Sometimes these bars are radiated, by missing a
stitch more on one side than on the other.
The marked characteristic of Spanish Point (No. 19) is a kind of
heavy satin stitch, with which parts are ornamented. It is very much
raised, and afterwards worked in button-hole stitch with fine linen
Mecklenburgh thread.
Continuous rows of Sorrento edges worked backwards and
forwards, like Brussels Lace, form a variety represented in a corner
of the Engraving.
The lower line of edging in the Engraving is termed Little
Venetian. It is worked like the other, but with only one button-hole
stitch.
When, by means of these different stitches, the pattern is formed
into a solid mass of work, the stitches at the back are to be cut, to
detach the lace from the paper; the threads may then be picked out
and the article is complete.
 To join point lace on to cambric or muslin, make an extremely
narrow hem on either, and lay the inner line of braiding on that. Join
them together by running on the middle of the braid through the
cambric, and then working a line of Brussels edge on to the inner
part of the braid, taking every stitch through both substances.
 CROCHET COLLAR
[Fig. 1.]

Materials.—Cotton, No. 30. Crotchet hook, No. 22; eagle card-

board gauge.
Chain of 180 stitches, on which work a row of dc.
2nd.—+ 3 tc., 3 ch., miss 3, +. Repeat. Finish with 3 tc.
3rd.—+ 3 dc. on 3 tc., 3 ch., +. Repeat.
4th.—+ sc. on 1st dc., 6 ch., miss 5, sc. on 6th, +. Repeat.
5th.—Sc. on the centre of first loop, +, 7 ch., sc. on centre of next
loop, +. Repeat.
6th.—Sc. on centre of first loop, + 6 ch., sc. on centre of next loop,
+. Repeat.
7th row.—Dc. on all the chain, missing every sc. stitch.
8th.—Sc. on first stitch, 9 ch., sc. on same stitch, 12 ch., sc. on
same stitch, 9 ch., sc. on same stitch, turn the work, dc. in every
chain of the 3 loops just formed, turn again, and work dc. on the
previous dc. except the first 5, 7 ch., miss 5 stitches of the 7th row, 6
dc. on the next 6, +. Repeat.
9th.—Sc. on the point of the leaf of 9, 4 ch., + sc. on point of large
leaf, 15 ch., +. Repeat. Finish the row with 4 ch., sc. on point of last
small leaf.
10th.—Dc. in every stitch of the last row working 2 in every 4th.
 11th.—+ 2 dc., 3 ch., miss 3, + until you come to the stitch over
the large leaf, then make a loop of 6 ch., dc. into the same stitch.
Repeat.
12th.—Dc. on all the rest of the line, working every loop thus—1 sc.,
4 dc., 1 sc.
15th.—Dc. in first dc. of last row, + 3 ch., miss 2, dc. in 3rd +.
Repeat, but without missing any on the loops.
16th.—Sc. on first chain of the foundation, and up the side work 4
ch., miss 2, 8 sc., sc. on every stitch of the last row, and dc. the other
end of the collar like the first.
17th.—Sc. under first loop, 5 ch., sc. under 2nd, repeat to the sc.
stitches, then + 5 ch. miss 2, sc. on 3rd, + to the end, which work
like the beginning.
 MAT WITH BORDER OF MOSS, CHERRIES,
AND LEAVES.
[Fig. 2.]

Materials.—Half-an-ounce of bright cherry-coloured Berlin wool;

two shades of green ditto, or of chenille a broder, two skeins of the
best green fleecy of different shades, or shaded Shetland will do as
well.
For the Moss.—If fleecy wool be used, it must be split, and a
thread of each shade taken, by using Pyrenees wool this trouble is
obviated. Take a pair of very fine knitting needles; cast on 16 to 20
stitches: knit a piece as tightly as possible, four times the length
required: wet, and bake or dry it before the fire. When it is quite dry,
cut off one edge throughout the whole length, and unravel all the
stitches but two at the other edge. (Take care to begin to unravel at
the end you left off knitting, or the wool will get entangled.) Fold it in
four, and sew the edges together. This will make a very full moss
fringe.
For the Cherries.—Cut a number of rounds in card, each the
diameter of a good-sized cherry. Cut a small hole in the middle of
each take a needleful of Berlin wool, three times the length of your
arm; thread it with a rug needle; pass the needle in the hole of the
card, holding the end of the wool with the left hand; pass the wool;
lay it on the edge of the card, as if you were going to wind it; pass the
needle through the hole again; repeat this until the whole needleful
of wool is used. Then make a little tuft of wool on the end of a rather
fine wire; twist the wire tight and pass the ends into the hole of the
card; take a pair of sharp-pointed scissors, cut the wool all round the
card; with a bit of waxed thread, tie as tightly as possible the little
bunch of wool in the hole of the card, tear the card off, and pare the
wool as smooth as velvet; cover the ends of wire with green wool or
silk, and each cherry is completed.
Leaves.—Make a cherry of 13 loops in green wool, and on them,
miss 4, dc. in 5th, ✕2 ch., miss 2, dc. in 3rd, twice 1 ch., miss 1, slip
on first of 13. Take a ✕piece of very fine wire and hold it in, while
working round this open hem, leaving a short piece for a stem. Work
all round in tc., except the 2 first and 2 last stitches which are to be 1
sc., 1 dc., and 1 dc., 1 sc., twist the two ends of wire together, cover
them with wool. When sufficient leaves are done, form them into a
wreath with the cherries, joining them by means of the ends of wire;
insert them in the moss, and sew the border thus made round a mat
of velvet, or work, lined with card-board, and with silk at the other
side.
This border may be used for any crochet or knitted mat; the moss
may be made more or less thick according to taste. A very full border
would require six lengths.
 INITIALS IN EMBROIDERY
[Fig. 3.]

Materials.—Ingrain red and white embroidery cotton, No. 70 for

linen, No. 80 for cambric.
These Initials should be marked on the material, and then worked
in the white cotton in raised satin stitch, after which a thread is to be
run entirely round the work, and sewed over in red very closely
indeed.
Every angle and point must be made with the utmost accuracy, as
on this the beauty of the letters greatly depends.
 AUTOUR BOUTONS.
[Fig. 4.]

Small pattern to surround shirt-studs; to be worked in embroidery

cotton, No. 80. The small rounds in eyelet-holes to be made with a
fine stiletto, and sewed over.
 A VERY PRETTY CARRIAGE BAG.
[Fig. 5.]

Materials.—White and blue Berlin wool, half-an-ounce of each;

two flat meshes, not quite a quarter of an inch broad, a piece of
French canvas, No. 24, one-half the size the bag is desired; gros-de
Naples, (the shade of the coloured wool), cord and tassels to match.
With the blue wool work on the canvass, in common cross-stitch, a
square of 6 stitches in every direction; miss an equal space and
repeat. Thus the whole space of canvass must be prepared like a
chess-board, the blue checks of one line coming between those of the
previous, the third over those of the first line, and so on. Having
completed this, take one of your meshes and a rug needle, threaded
with white wool, work immediately over each blue square of the first
line 6 stitches, thus:—Begin at the top of the stitch, lay the wool over
the mesh, take two threads for the lower part of the stitch, pass the
wool under the mesh, finish your stitch; repeat five times; leave the
mesh on the stitches; take the second mesh, work a second row
exactly alike over this; then, at the top, a third row of white stitches,
four threads long, and two broad.
 Turn the work, and in the space which is now over, but was first
under the first row of blue squares, work with the white, the rows
round the meshes, as before, and one of long white stitches.
Turn the work again, and work the next two rows of white stitches
round the meshes.
Repeat the same operation over every other line of blue squares.
Now take the work cross-way, and work in white, as before, every
space left; then cut the ends of the white wool.
Make up the bag with a top of silk, line it, add cords and tassels,
and it is complete.
If preferred without silk, have canvass the full size for a carriage
bag and work it all over.
 D’OYLEY IN SQUARE CROCHET.
[Fig. 6.]

Materials.—Cotton, No. 16; crochet hook, No. 18. Eagle card-

board gauge.
The size I have given for materials will make this d’oyley about 20
inches, as there are 88 squares, and 9 squares are equal to 2 inches.
Of course, with finer cottons and hooks, the size will be diminished.
Patterns given in square crochet are very pretty worked in two
colours of wool. The open squares should be worked in one colour,
and the close in the other; every square consisting of three dc.
stitches. Mats of this description should be tacked on a stand
previously formed of stout card or mill-board, covered with green
calico or silk.
DEEP POINT LACE, FOR A HANDKERCHIEF
OR VEIL.
[Fig. 8.]

Visitors to the London Exhibition, will recognise this pattern as

one of those in the gallery of that wondrous palace: I presume,
therefore, it will be very acceptable to my fair readers.
The pattern of the flowers is well adapted for the mandarin sleeves
which everbody wears just now. To draw the pattern for that
purpose, merely copy over and over again the two large flowers at the
bottom of the page. Draw the pattern on colored paper, and use a
fine sable brush, dipped in Indian ink for coloring the lines; paste the
paper on linen, and when dry it will be fit to be worked. A little more
management is required when a pattern for a handkerchief is to be
made. Cut a square of tissue paper, rather larger than the
handkerchief is to be,—double it twice, so as to mark the centre of
each side, and trace the three divisions of the corner flower up to a
on one side of this centre, leaving room for half of another division;
fold the paper and trace a similar piece of the flower on the other
side of the centre, and finish also the division in the middle. As it will
be seen on referring to the plate, that there are three divisions and
nearly half another up to the a, it will be evident that the centre
flower will have seven divisions. On the right of this centre draw
three of the flowers at the lower edge of the frontispiece, and at the
corner another flower, exactly like the centre one, but turned so as to
form a corner. Trace the left hand side of the centre from that already
done, and you will have a perfect side with two corners. Draw the
pattern on colored paper, from this one side, and line it with linen
before working it.
 You will observe that there are two straight lines of braid in the
inner border; the one nearest to the flowers is only to be laid on
when working the lace, and connected with the other: no edging is to
be put to it until after the hemmed cambric is laid underneath, when
it is to be run on, and then edged with Brussels edging.
a.—Sorrento edging. To be worked with Mecklenburgh thread,
120.
b.—Venice edging. Boar’s-head thread, No. 50.
c.—Brussels edge. Ditto.
d.—Bars of Venice Point. Mecklenburgh thread, 120.
e.—Rosettes worked on 4 threads: the centre ones gradually
increasing in size, towards the outer edge of the flower; the others as
small as the spots of English Point. Boar’s-head thread, No. 90.
f.—Open English lace. Ditto.
g.—Brussels lace. Ditto.
h.—English lace. Boar’s-head thread, No. 70.
i.—Sorrento bars. Mecklenburgh thread, No. 120.
j.—Rosettes. Thread No. 70.
k.—Bars in Alencon point. Ditto.