See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/279513073

The origins and evolution of fixed orthodontic appliances

Article · September 2014

DOI: 10.12968/denn.2014.10.9.524

CITATION READS

1 5,698

1 author:

James I J Green
Great Ormond Street Hospital for Children NHS Foundation Trust
50 PUBLICATIONS   33 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Auricular Reconstruction View project

All content following this page was uploaded by James I J Green on 01 July 2015.

The user has requested enhancement of the downloaded file.

 Professional

The origins and evolution of fixed

orthodontic appliances
Orthodontics became a discipline in its own right in the late 19th century but the use of
appliances to straighten teeth dates back more than 3,000 years. Appliances evolved a great
deal over the past two centuries and digital technology means this progress should continue

A lthough orthodontics became a recognised

dental specialty only in the 1880s, the
concept of aligning teeth with fixed
appliances dates back to around 1000 BC.
Evidence gathered from Egyptian mummies shows
that ancient civilisations fitted appliances to teeth,
presumably to correct malocclusions. Archaeologists
have discovered several mummies with simple metal
bands wrapped around individual teeth, indicating
that the ancient Egyptians knew that pressure could
be used to move teeth over a period of time.
This article examines how these early ideas evolved
to become the fixed orthodontic appliances of today. Figure 1 (left). Hippocrates, engraving by Peter Paul
Rubens, 1638. Figure 2 (right). Aulus Cornelius Celsus
Ancient origins
The earliest evidence of appliances being used to Teeth bound with a gold wire, presumably an
straighten teeth is from around 1000 BC (Weinberger, ancient precursor to modern ligature wire, have been
1934). The Etruscans, an ancient civilisation predating found in a Roman tomb in Egypt (Ruffer, 1921).
the Romans, buried their dead with appliances that The Romans saw teeth as precious—the first code
were used to maintain space and prevent collapse of of Roman law (450 BC) stated that ‘special penalties
the dentition (Guerini, 1909). [would be exacted] for knocking out the teeth of an
The ancient Greek physician Hippocrates individual, either freeman or slave’.
(c460 BC–370 BC; Figure 1), considered to be one of Roman philosopher and physician Aulus Cornelius
the most exceptional figures in the history of medicine, Celsus (c25  BC–c50  AD; Figure 2) recommended
published his ideas regarding the correction of tooth extracting deciduous teeth to allow the eruption of
irregularities in 400 BC (Hippocrates, 400 BC). the permanent dentition in his medical encyclopedia
De Medicina. In addition, Celsus was the first to
record the use of finger pressure for the treatment of
James Green is a Maxillofacial and Dental incorrectly positioned teeth and said that this finger
Laboratory Manager for Great Ormond Street pressure should be applied to new teeth every day to
Hospital and the North Thames Cleft Centre, ensure correct tooth alignment.
a supraregional managed clinical network that
treats children and adults with clefts of the The Renaissance
© 2014 MA Healthcare Ltd

lip and palate from north London, Essex and The evidence suggests that no further developments
south and west Hertfordshire. were made until the 18th century. However, the
European Renaissance of the 14th–17th centuries
Email: [email protected] heralded scientists who studied dental anatomy, most
notably the Italian Renaissance polymath Leonardo

524 Dental Nursing September 2014 Vol 10 No 9


 Professional

(From left to right) Renaissance era: Figure 3. Leonardo da Vinci, a presumed self-portrait, Biblioteca Reale, Turin,
c1512. Figure 4. Ambroise Paré, a 19th century portrait by William Holl. Figure 5. Andreas Vesalius, an engraving
from a picture by Tintoretto, c1540. Figure 6. Gabriele Falloppio, a 16th century portrait by an unknown artist

da Vinci (1452–1519; Figure 3). His drawings Chirurgien Dentiste (Fauchard, 1728). He described
included detailed studies on body proportions and the use of ligature wires to straighten teeth, as well as
he used details such as lip–dental relationship, facial the first expansion appliance, known as a bandeau
proportions and tooth size ratios in his paintings. (Figure 8).
Other scientists of the time who studied the Bourdet, another Frenchman and dentist to the
anatomy and shape of the teeth included Ambroise king of France, published The Dentist’s Art (1754),
Paré (c1510–1590; Figure 4), Andreas Vesalius (1514– which, like Fauchard’s book, included a chapter
1564; Figure 5), and Gabriele Falloppio (1523–1562; dedicated to tooth alignment. Bourdet was the first
Figure 6). recorded dentist to recommend the extraction of
premolar teeth to improve jaw growth and reduce
Eighteenth century crowding.
Pierre Fauchard (1678–1761; Figure 7), a French
dentist widely seen as the father of modern dentistry, Nineteenth century
described methods of straightening teeth and devoted The term orthodontics was coined by Joachim
a chapter Lefoulon, who used the word ‘orthodontosie’ in 1841.
to the subject – the In 1880, American dentist Norman Kingsley (1829–
first comprehensive 1913) published his Treatise on Oral Deformities,
dis c ussion of which was the most comprehensive book on the
orthodontic appliances subject at the time (Lufkin, 1948).
– in his book Le In 1888, A Treatise on the Irregularities of the Teeth
and Their Corrections by John Farrar was published.
Figure 7. Pierre Farrar described the basic concepts of biological tooth
Fauchard, engraving movement and was the first to suggest using mild
by J Le Bel; Figure 8. force to move teeth at timed intervals. Both Kingsley
Fauchard’s expansion and Farrar have since been described as ‘the father of
arch
Historical images: wikimedia commons; diagrams: peter lamb

orthodontics’.
Orthodontics in the latter part of the 19th century
was led largely by American dentist Edward Angle
(1855–1930), who was widely regarded as ‘the father
of modern orthodontics’. His expansion arch, the
© 2014 MA Healthcare Ltd

E  arch, was introduced in 1887 (Figure 9). This

appliance used a wire on the labial surface of the teeth,
supported by clamp bands on the molar teeth, which
were ligated to the other teeth. Fauchard’s arch had
only given tipping control but, with the E arch, teeth

Dental Nursing September 2014 Vol 10 No 9 525

 Professional

endorsement from dental clinicians and soon became

the most popular fixed appliance.

Post-war developments
The concept of directly bonding brackets to the
surface of the teeth was first described by Newman in
1965 and meant that brackets could be fitted to teeth
without metal bands for the first time.
Not long after, indirect bracket bonding was first
reported (Silverman et al, 1972). Indirect bonding
aims to improve accuracy and efficiency by positioning
Figure 9. The Angle E arch—the first expansion arch brackets on a model; the brackets are located on the
teeth using a custom-made transfer tray.
could be rotated for the first time. Self-ligating brackets were first proposed by
Angle limited his practice to orthodontics in 1899 Alexander Wildman (1972). As the name suggests,
and formally established the specialty at the Angle self-ligating brackets do not require ligatures to hold
School of Orthodontia in St Louis, Missouri, which he the archwire in the bracket but, instead, have a metal
founded in 1900. He devised the term malocclusion to facing that forms a tube and can be opened and closed
describe irregular tooth positions, as well as Angle’s for the archwire to be fitted and removed. Self-ligating
classification to categorise jaw anomalies. systems have risen in popularity with the introduction
Angle described his standardised appliances in a of the Damon bracket (Damon, 1998).
series of books and pamphlets, including The Angle In 1979, Lawrence Andrews developed archwires
System of Regulation and Retention of the Teeth, that could be used to deliver three-dimensional
and Treatment of Fractures of the Maxillae (Angle, control of the teeth without needing to be adjusted
1899) and Treatment of Malocclusion of the Teeth and —the straight wire appliance. At the same time,
Fractures of the Maxillae: Angle’s System (Angle, 1900). lingual orthodontics was first proposed (Fujita, 1979).
Lingual appliances are fitted on the palatal and lingual
Early 20th century surfaces of the teeth and are intended to be less
Angle continued to dominate orthodontics into the conspicuous than conventional appliances.
early 20th century. Developments in metal technology
at this time facilitated the creation of bands with 21st century
soldered attachments that could control rotations. The adoption of 3D computer imaging in orthodontics
Angle’s pin and tube attachment (Figure 10), has been the most fundamental development of the
developed in 1911, was popular with orthodontists of 21st century. As well as using the technology to plan
the time but required a high level of dexterity and was
soon replaced by the ribbon arch bracket (Figure 11), Figure 10.
which he introduced in 1916. The ribbon arch bracket Angle’s pin
provided good control in two dimensions; this was and tube
also the first time an orthodontic appliance had a attachment;
bracket that had a name (Renfroe, 1960). Figure 11. The
At the time that the ribbon arch bracket was ribbon arch
unveiled, Angle was already developing another bracket, which
replaced the
bracket, mainly as a supplement to his ribbon arch
pin and tube
bracket. This new component, the edgewise bracket,
took more than 10 years to develop and slowly
evolved with several versions (Figure 12).
© 2014 MA Healthcare Ltd

Angle noticed that the edgewise appliance would

be able to move all teeth simultaneously in all
three planes of space and he carried out several
modifications before he settled on the number 447
in 1928 (Figure 13). It received early and enthusiastic

526 Dental Nursing September 2014 Vol 10 No 9


 Professional

peter lamb
Figure 12. Evolution of the Angle edgewise bracket
© 2014 MA Healthcare Ltd

Dental Nursing September 2014 Vol 10 No 9 527

 Professional

become the appliances we know today (Figure 14).

Key points The increased use of digital technology means that
this progress should continue for years to come. DN
The basic principle of the orthodontic bracket has
n
remained largely unchanged since it was first developed
by Angle in the early 20th century. James Green will present ‘A Review of Indirect Bracket
Bonding Techniques’ at the 28th British Orthodontic
Andrews developed the straight wire appliance in 1979,
n Conference at the Edinburgh International Conference
which enables three-dimensional control of the teeth
without having to adjust the archwire. Centre on 20 September 2014.

Other key developments in the 20th century included

n Andrews LF (1979) The straight wire appliance. Br J Orthod 6(3):
direct and indirect bracket bonding, self-ligating brackets 125–43
and lingual orthodontics. Angle EH (1899) The Angle System of Regulation and Retention of
the Teeth, and Treatment of Fractures of the Maxillae. University
3D computer imaging technology can now be used to
n
of California Libraries, California, US. http://bit.ly/1BtoGDN
create custom-made brackets.
(accessed 18 August 2014)
Angle EH (1900) Treatment of Malocclusion of the Teeth and
Fractures of the Maxillae: Angle’s System. University of California
Libraries, California, US. http://bit.ly/1n1pF4k (accessed 18
August 2014)
Bourdet L (1754) The Dentist’s Art. Paris, France
Damon DH (1998) The Damon low friction bracket: a biologically
compatible straight-wire system. J Clin Orthod 32(11): 670–680
Farrar JN (1888) A Treatise on the Irregularities of the Teeth and
Their Corrections. The De Vinne Press, New York, US. http://bit.
ly/1tfkkug (accessed 18 August 2014)
Fauchard P (1728) Le Chirurgien Dentiste. Paris, France
Fujita K (1979) New orthodontic treatment with lingual bracket
Figure 14. Today’s fixed orthodontic and mushroom archwire appliance. Am J Orthod 76(6): 657–675
Figure 13. The Angle Green J (2013) Orthodontic appliances for patients with a nickel
edgewise bracket allergy. Dent Nurs 9(9): 504–508
Guerini V (1909) A History of Dentistry. Lea and Febiger,
treatment and create virtual study models, computer- Philadelphia, US. http://bit.ly/1mbSWcx (accessed 18 August
aided design and computer-aided manufacture can be 2014)
used to design and create custom-made brackets to Hippocrates (400  BC) Of the Epidemics. http://classics.mit.edu/
make appliances more comfortable and enable more Hippocrates/epidemics.html

accurate results. Kingsley NW (1880) Treatise on Oral Deformities as a Branch of

Mechanical Surgery. D Appleton and Company, New York, US.
There has also been an emphasis on improving
http://bit.ly/1oJmbZR (accessed 18 August 2014)
the biocompatibility of materials. Nickel is present
Lufkin AW (1948) A History of Dentistry. Lea & Febiger,
in many orthodontic components; it is also the Philadelphia, US
metal that is most likely to cause an allergic Newman GV (1965) Epoxy adhesives for orthodontic attachments:
reaction, so brackets and archwires twhat are nickel- A progress report. Am J Orthod 51(12): 901–912
free or low in nickel content have been developed Renfroe EW (1960) Technique Training in Orthodontics. 1st edn.
(Green, 2013). Edwards Brothers Inc, Michigan, US
With the aim of making appliances less visible, Ruffer MA (1921) Studies in the Paleopathology of Egypt. University
ceramic, tooth-coloured brackets have been developed of Chicago Press, Chicago, US. http://bit.ly/1teT3cq (accessed 18
in recent years; these are also suitable for people with August 2014)
a nickel allergy. Silverman E, Cohen M, Gianelly AA, Dietz VS (1972) A universal
© 2014 MA Healthcare Ltd

direct bonding system for both metal and plastic brackets. Am J

Orthod 62(3): 226–244
Conclusion Weinberger BW (1934) Historical résumé of the evolution and
After more than 3,000 years of advancements,
growth of orthodontia. J Am Dent Assoc 21: 2001–2021
orthodontic appliances have come a long way and Wildman AJ (1972) Round table—the Edgelok bracket. J Clin
have developed quickly over the last two centuries to Orthod 6(11): 613–623

528 Dental Nursing September 2014 Vol 10 No 9



View publication stats