Development, decay, changing of teeth, and malposition of teeth and jaws, part I

By: Hermann Hoffmeister

JAM Vol. 11(4), Winter 1994

Phenomena, problems, potential for treatment "What does it mean in terms of our knowledge of the human being?" is a question I am asked over and over again in my position as dentist and orthodontist when it comes to the many and varied phenomena to be observed on individual teeth, the whole dentition, and the oral cavity. Before we can have a clear answer - and in most cases we are still far from getting it - we need to have thorough knowledge of the facts known to science and the connections between them, and we must also have practical experience as dentists in treating dental conditions and their sequels. The same applies to the vast field of malposition affecting both teeth and jaws, which is the field of orthodontics. The whole requires detailed discussion if we are to avoid the danger of adding to the many misconceptions that exist already. 

The dentist specially needs to consider the questions that are so often put in the Waldorf School context. He cannot, of course, say he will be able to answer them all in terms of our knowledge of the human being, particularly with regard to the transformation of the bodily form through repeated incarnations. Much still remains to be discovered in this area. Below, the subject will be presented above all from the point of view of a dentist who has been working with Waldorf School children from many decades. 

Dental development 

Let us first of all consider how a tooth develops. We distinguish between root and crown. This might make us think that - rather as in the case of a tree - there is a seed from which the crown grows upwards and the root downwards. In reality growth begins at the crown, in fact exactly at the border between dental enamel and dentin. The whole occurs in a hollow space within the dental follicle. Enamel develops from the inside towards the periphery. When the crown is fully developed, only a fine cuticle remains of enamel-producing cells which have ceased to produce enamel. This is why a hole in the enamel will never heal - the first non-healing aspect of teeth, which is also due to the fact that finished enamel is about 95% mineral substance, and therefore the hardest but also the deadest tissue in the whole organism. Its mechanical hardness thus means biological weakness. Dentin on the other hand develops from the outside inwards, starting with the marginal cells of the pulp, which is the live tissue inside the tooth containing afferent and efferent vessels and nerve fibers. It is often just called the "nerve", to simplify matters. For as long as the pulp is alive and there is room inside the tooth, additional dentin may form, for instance in response to an external stimulus. This, however, represents the limit of the tooth's self- protective potential. 

Diseases of teeth 

Caries is the major threat to teeth. To find out about it and about ways of preventing it, please read what I have written under the heading: "Zahnverfall - kein unabwendbares Schicksal" (dental decay - not an inevitable fate) in Weleda Nachrichten. Reprints are available free of charge from Weleda. There I referred to the second non-healing aspect of teeth. People generally only discover they have caries when a hole has developed or they experience pain. At that point it is often too late to keep the tooth alive. It is therefore advisable to have regular check-ups at the dentist so that the condition may be detected early, possibly even by means of special X-rays (bite-wing X-rays) and treated. 

Let me comment briefly on fillings and the materials generally used today. We have shown that wounds in teeth do not heal naturally. They therefore need to be closed up with foreign materials, which cannot be done without some compromise. Plastics can be colored to match teeth very well, but the pulp has to be protected from them by putting in an intermediary filling. They are also not sufficiently resistant to friction and dimensionally stable to be suitable as long-term fillings in the lateral areas. Amalgams, which are also molded, essentially consist of mercury and a silver and tin alloy. Like all metals they need to be isolated from the pulp because they conduct heat. Their silvery gray color may also be undesirable. A very few individuals do not tolerate them because of their mercury content. The expenditure of time and money in preparing them is reasonable, which is why they are still practically irreplaceable. Inlays, that is, casts made with precious metals, require much time, material and money, though in the long term they give the best results. One thing to be avoided is to have two metals in the oral cavity, especially if they are close together, as electric currents may develop between them. Unfortunately there is no ideal material for fillings. Another problem is that they are all sensitive to moisture and have to be protected from saliva whilst working with them. People who feel their fillings are causing harm should try and have a test, using electro- acupuncture, for instance, which can also be a help in detecting hidden foci of infection. 

In the first half of life, teeth are usually lost through caries, in later life through periodontopathy, i.e. diseases of the tissues investing and supporting the teeth. One hardly ever sees these in school-age children. The most would be inflammation of the gingival margins due to plaque, causing the gingiva to bleed at the slightest touch. If calcium salts have been deposited in plaque and dental calculus results, a tooth brush alone will no longer suffice, and the teeth have to be cleaned "professionally" by a dentist. 

The change of teeth 

It is a feature of Rudolf Steiner's teaching on the nature of the human being that he repeatedly emphasized this stage of development. The most important references have been compiled by Matthiolius, who for many years was school doctor at the Stuttgart Uhlandshoehe Waldorf School, and published in 1970 under the title Die Bedeutung des Zahnwechsels in der Entwicklung des Kindes (Significance of the Changing of the Teeth in Childhood Development). I had been examining children at this stage at the School and its nurseries from 1968 to 1976, and as a professional was asked to write a postscript to the collection, in which I considered in some detail what Rudolf Steiner meant by "the changing of the teeth". Meanwhile Wolfgang Schad has written on the subject, and the second edition of the compilation includes the comments of its editor, Helmut von Kuegelgen. He has come to the same conclusion as myself, which is that Rudolf Steiner meant the onset of the process, but he also refers to a statement made at a teacher's conference that cannot have been reported correctly; I have discussed this in detail in my postscript. Unfortunately the postscript written for the second edition was not included, nor Wolfgang Schad's preface, probably because our views diverge to some extent. What follows is a revised version of that postscript. 

Rudolf Steiner generally uses the term "the changing of the teeth" as an expression of time, e.g. "from birth to the changing of the teeth". Considering the context, and especially the age he mentions, he can only be referring to the beginning of a process that takes years, the eruption of the first permanent teeth. These are the lower central incisors, which generally erupt at age 6 or 7 when a phenomenon occurs in the lower jaw that is visible to all. 

A statement made by Rudolf Steiner on 11 May 1919 in Stuttgart in the first of three lectures published as A Social Basis for Primary and Secondary Education, appears to contradict this: "For someone who knows the nature of the human being, it is evident that this education should not intervene in the system of human evolution for any growing child until about the time when the changing of the teeth is complete. That is as scientific a law as any other. If instead of going by rote we were to take the nature of the human being as our guide, it would become the rule that children start school at the (completion) changing of the teeth.”(1) (Words in parentheses not included in the quote given by Lindenberg(2)) Steiner is therefore using "at completion of the changing of the teeth" in the same sense here as "the changing of the teeth". The only explanation I can think of is that to him, the process is already completed when it becomes visible. In Boundaries of Natural Science he also spoke of the "point of the changing of the teeth" on 29 September 1920 in Domach,(3) comparing it to the melting and boiling points. It is probably right to take his statement that the first epoch of human life extents "to the sixth, seventh, eighth year, until the end of the changing of the teeth"(4) in the same sense. 

This interpretation finally becomes the only possible one if we consider that in Oxford Rudolf Steiner referred to the same period of time like this on 16 August 1922: "Inwardly the child is essentially quite a different creature up to about the 7th or 8th year, when the changing of the teeth begins, than later on in life, from the changing of the teeth until about the 14th, 15th year and puberty", and like this on 19 August: "If one has to educate the child during the time that follows the changing of the teeth, that is, after about the 7th year."(5) 

Rudolf Steiner really means the visible phenomenon and not, as Wolfgang Schad suggests, the change from deciduous tooth to permanent enamel which is not immediately apparent, and could in fact only be seen on X-ray pictures, which were after all hardly feasible at the time. We know this from, among other things, the statement made in The Spiritual-Scientific Aspect of Therapy: "Now, however, we have an equally significant change, though this time more in an inward direction and not as immediately apparent as, the changing of the teeth, for instance, or learning to speak which anyone can observe; those two come to outward expression.(6) 

According to statistics available from Rudolf Steiner's time, the first molars were the first permanent teeth to erupt. Today's latest statistics from Duesseldorf say that sequence occurs in only about half the children, and those from Munich that slightly more than half the children have the lower incisors erupting first. I suspect this indicates a change in the relationship between the different aspects of the human being, probably with the nerves and senses becoming more dominant. [This kind of one-sided development is well known in the animal world: rodent incisors that never stop growing (emphasis on nerves and senses); pointed canines of predators (emphasis on rhythmic system); millstone-like molars of ruminants (emphasis on metabolism and limbs)]. Unfortunately it has not yet been possible to substantiate this. What I have been able to establish is that the change in sequence has nothing to do with acceleration, i.e. children whose permanent teeth come very early may well have a first molar erupting first. We should really call it a fifth-year rather than sixth-year molar. On examination of school and preschool children I did not always find it easy to establish if the first tooth to erupt had been a sixth-year molar or a replacement-incisor. It would really have been necessary to observe the developing dentition at intervals shorter than the 6 months that were possible. The earliest permanent teeth I have seen were in children aged 4 1/2, and they certainly were not ready for school. Those were always lower central incisors. 

Professor Roland Bay in Basel has established that the sequence of eruptions changed between the period of the great migrations and late medieval times.(7) Before, the second molars would immediately follow the incisors, whereas today, they normally erupt only as twelfth-year teeth, when the changing of the teeth is complete. The old sequence can still be seen today, but only very rarely, though signs of it are still quite common. In some children, the second molars erupt when they still have one or more deciduous teeth. So far, no one has been able to explain this to me. 

The terms "sixth-year" and "twelfth-year" molar indicate that on average the changing of the teeth occurs between those ages today. We are therefore dealing with a 6-year and not a 7-year period. There are children in whom the change begins at 4 1/2 and ends at about 9 years of age, so that it is highly premature and accelerated. Others start only at about 8 years of age and finish are about 14 or 16, so that the process is late and retarded. 

With reference to Waldorf education, we have to ask the following questions. Is a child whose teeth begin to change at age 41/2 actually ready to start school? Is another who does not yet have a single permanent tooth at age 8 not ready? For a number of reasons the answer generally has to be in the negative. It is possible that in border-line cases the harmony of development is upset. In less extreme cases children who change early or late may be quite generally early or late developers. Parents frequently report that children who change early also had their deciduous teeth early, and vice versa. We would, of course, never make it a rule that children are ready for school on the basis of just a single developmental criterion such as the changing of the teeth. 

When I examined teeth in 26 first-year classes at different Waldorf Schools (1 in Berlin, 1 in Braunschweig, 2 in Bremen, 4 at Engelberg School, 1 in Salzburg, 14 at Uhlandshoehe School, 2 at Wien-Mauer School, 1 in Wuerz- burg) I would on average find one child per class that did not have a new tooth and, as one would expect, more often boys than girls. An experienced class teacher once referred to such a girl(!) as a "typical class 1 child" (6 years 8 months). The examination was mostly done in the first half of the school year and sometimes only in the second half, but never at the beginning of the year. An example of the range seen is Marko H. who was 7 years and 7 months old when first examined and had only deciduous teeth; he had not progressed any further when examined again at the age of 8. In the same class was Katharina N. who at 7 years and 2 months had all four sixth-year molars and all 8 incisors. At 9 years and 3 months this child showed the extremely rare feature of the upper canines erupting as the first "lateral teeth," with the lower canines erupting only six months later, statistically a highly improbable sequence. Surprisingly, the change was not complete until she was 11 years and 10 months old. That was also the time when the two lower molars appeared. Marko still had two lower deciduous teeth when I last saw him at age 13 years 9 months. 

To get a clearer picture we would need longitudinal as well as transverse studies, so that individual characteristics are not lost by calculating averages. It would be necessary to start at age 41/2 and continue at least until all second molars have erupted. All major medical, dental and educational development data would have to be collected at intervals of not more than 3 months, and evaluated on each occasion. I have been able to do this for 7 years at the Uhlandshoehe School and its nurseries at Uhlandshoehe and Stuttgart-Sillenbuch, though only at 6-month intervals. In the end the problems that arose were such that I had to discontinue the long-term project, one reason being that the Medical Educational Research department at the German Federation of Independent Waldorf Schools was closed down. In my experience it would be best to limit oneself to a single year at school. It is particularly difficult to obtain data for preschool children, as this requires the cooperation of parents and nursery staff. Ideally, parents would keep detailed records of major steps in development, height, weight, teething, and changing of teeth. Special attention would need to be given to the time interval between losing a deciduous tooth and eruption of its permanent replacement. The differences are enormous, yet to my knowledge nothing is known about it. Specimen record sheets like those in A Guide to Child Health6 or those available from baby food companies are helpful. 

The sequence in which teeth appear is easiest to establish and record. The sequences given in tables are based on averages and even so do not always agree. For our knowledge of the human being, however, data which do not fit in with the statistics, the "runaways," can be extraordinarily important. Examples are unusual and asymmetrical features in space and time, such as first eruption upper, lower, left, right or crosswise, and unusual sequence, especially if this is not in line with the statistical frequency. It may be possible to gain indications from this on potential connections between individual teeth and specific organs. It is important to realize that the appallingly widespread caries seriously interferes with all development of dentition (and beyond). Fortunately it does not affect the eruption of deciduous teeth, but it will occasionally interfere with the eruption of permanent teeth and, above all, lateral teeth. 

Investigations of this kind offer the additional benefit of early detection of caries. Yet in my experience indifference to this is sometimes difficult to understand, even in Waldorf Schools. It is possible that people do not consider it important to maintain deciduous dentition. Yet with a deciduous molar, loss of substance in the area of contact with a neighboring tooth makes the latter move up, which reduces the space available to the molar's successor, making it difficult if not impossible for it to erupt. If such a molar is lost prematurely, two consequences are possible that go in opposite directions. If destruction due to caries causes long-term suppuration, the bone above the successor may be dissolved, causing the permanent tooth to erupt years too early, with root development incomplete. If the deciduous tooth is removed as soon as pain arises because the pulp has become inflamed or decayed, a hard bone layer may develop in the gap and delay eruption of the successor for years, which increases the risk of losing the space. If a deciduous tooth is dead, with or without dental treatment, and remains in situ, it is often not properly resorbed and may cause problems of time or space for eruption of the successor. All it needs sometimes are small remnants of the root, though on the other hand these can also help to preserve space. The deciduous teeth are therefore important not only as childhood organs of mastication and speech, but also because they keep the space needed for the permanent teeth. 

Anomalies 

If dentures are already narrow in themselves, it may happen that the permanent lateral incisor is obstructed by the deciduous canine and causes it to be lost, using its space to find its own place in the denture. The permanent canine has then lost most if not all of its allotted space. In many of these cases there will later be insufficient space for the permanent teeth, and a balanced dental arch is usually obtained by removing premolars. 

Occasionally problems may arise even when the first permanent teeth appear. The upper sixth-year molar may be sharply tilted forward, getting caught up under the deciduous molar anterior to it, undermining it and finally causing both it and the space for its successor to be lost. A less serious situation arises when a permanent incisor erupts behind, or less frequently in front of, the deciduous incisor. If the latter is removed and there is sufficient space, the permanent tooth responds to pressure from tongue and lip and assumes its proper place. I have seen this abnormality with remarkable frequency in families where susceptibility to disorders of dental development is hereditary. I was able to prove that the above-mentioned undermining and resorption are part of this hereditary element. 

The most common and serious form of hereditary disposition to abnormal development is hypodontia, which affects about 9% of girls and 8% of boys in our population. Hyperdontia is seen in only 2 or 3 per cent. On very rare occasions one also sees hyper- and hypodontia in one and the same mouth. Teeth missing from the permanent dentures are usually the upper lateral incisors and/or second premolars; rarely lower middle incisors and first molars, and very rarely canines and second molars. It is highly uncommon for many and different teeth to be missing, and in severe cases this may be linked with other constitutional problems. If there are too few or too many deciduous teeth or else twin teeth, the total number of teeth in the permanent denture is usually also incorrect. Hyperdontia is more common that hypodontia in deciduous dentures, both usually occurring in the frontal region. Wisdom teeth are not included in these calculations, and, as already mentioned, hypodontia is common in their case. It is not yet clearly established if this relates to the other anomalies described, but it is probable. 

Inherited tendency to anomalies certainly also includes any type and degree of displacement, a condition seen especially with canines and second premolars which then remain partly in the jaw or erupt at an angle, often even in the wrong place. In the case of the upper lateral incisors the hereditary tendency often also involves a precursor of absence, i.e. a reduction in size that may go so far that only pointed, conical peg teeth remain, which also tend to be late in developing. The upper lateral incisors tend to be the normal shape in this case, but are often rotated in position, as are the premolars. In their case, retarded development is common, another feature of inherited tendency to anomalies. 

A particularly strange phenomenon in this context, the origins of which are only partly known, is infraposition, also known as infraocclusion or depression, of deciduous molars. In the upper jaw such a tooth has its occlusal surface above the occlusal plane, in the lower jaw below it, so that it does not reach its opposite, though originally it usually occluded with it. This kind of infraposition develops gradually and gets worse in time. It is an important anomaly because anyone can observe it without needed special aids. If it is found, the child in question, its siblings and cousins should be examined for hypodontia, hyperdontia and displacement, which will, of course, require X-rays. It is possible to take pan-oral radiographs where the radiation dose is very low. 

These, then, are inherited characteristics that may occur in different form and degree in both deciduous and permanent dentures but generally appear in the permanent denture only. Rudolf Steiner has frequently stated that deciduous teeth are inherited, but not the permanent teeth. He would sometimes make the statement less decisive, e.g. in the first lecture of Waldorf Education/or Adolescence(9) where he said: "as we have our first teeth as a kind of inheritance from our parents", and before that, "the first teeth, which are more due to inheritance from our ancestors". Three days later, in Man, Hieroglyph of the Universe,(10) he said: "Dentition, insofar as the deciduous teeth are concerned, is essentially due to heredity". On November 7,1910 he put it as follows: "The first teeth are inherited; they come from the organisms of our ancestors and are their fruits, we might say; and only the second teeth develop according to our own physical laws."(11) A little later he said in the same lecture: "On the first occasion the teeth are inherited directly; on the second, the physical organism is inherited and this in turn produces the second teeth." 

I have also found it impossible to reconcile the statements made in Pastoral Medicine,(12) for instance, with the above phenomena in order to explain these references. I know from the literature and from my own investigations that the inherited tendency to dentition anomalies comes to expression mainly in the permanent dentures. The inherited disposition to certain types of anomaly of the jaws is usually apparent at first dentition but only shows itself hilly in the permanent teeth. The greatest German expert in the field. Professor Christian Schuize in Berlin, has the following to say on hereditary factors in lacteal and permanent dentition: "in fact their role is usually crucial."(13) When Rudolf Steiner gave his lectures, no one was able to ask him about these things, as they were still largely unknown. What is more, it usually needs X-rays to show the characteristics of the disposition, and in his day radiology was little used in dentistry. 

Some of the things Rudolf Steiner has said about teeth therefore continue to puzzle us, especially his comments on the connection between caries and the fluorine or magnesium process.(14) Professor Oskar Roemer, who was an expert and heard the lectures himself, has published Ueber die Zahnkaries oder Zahnfaeule mit Beziehung auf die Ergebnisse der Geis tesforschung Dr Rudolf Steiners (Caries in Relation to Dr. Rudolf Steiner's Discoveries in Spiritual Science), but this did not make the matter clearer to me. Two people who know Rudolf Steiner's works extremely well, the pediatrician Wilhelm zur Linden and Erwin Meyer-Steinbach,(15) have told me that in their opinion the passage has not been correctly recorded. In the final instance it is a matter of what Rudolf Steiner means by "dull" and "clever". Wolfgang Gueldenstem, dentist, suggests that clever means that the individual is not sufficiently earthy and lacks the necessary amount of dumbness to be an earthly human being (that is, a spiritual entity in a physical body). Dull means, in his view, that the individual relates too strongly to the earth and is too intellectual (materialistic). Rudolf Steiner did say: "We develop bad teeth so that we won't get too dull," because this would interfere with the "fluorine-absorbing ... action of the teeth."(14) Dr. Otto Wolff on the other hand considers the phenomenology to be as follows: "It is definitely not the case that fluorine makes us dull in the sense of feeble-minded." For him, it is-the "abstract thinker" who is dull, someone divorced from reality who may nevertheless be highly intelligent, like an absent-minded professor. Unfortunately we can no longer ask Rudolf Steiner what he really meant. 

Another passage that I have always had my doubts about has since been clarified. It is in Curative Education, where a "not" has been omitted in the description of the first boy in paragraph 3 of the sixth lecture. The publishers have confirmed this. The correct version would be: "His mouth is slightly open, which is not due to dental development.. .."(16) Considering that this was a course where Rudolf Steiner specially asked for "loving attention to detail, even the smallest detail,"(16) one would hope, as a dentist, to find useful statements relating to teeth. But for that, of course, dentists would have had to be present. 

In Pastoral Medicine,(12) Rudolf Steiner said on September 11, 1924 how important it is for people "that they do not have to get a third set of teeth". Wolfgang Schad made his first attempt at interpreting Rudolf Steiner's concept of "changing of the teeth" in connection with this. He quotes a passage not included in Matthiolius's collection: "until the sixth, seventh, eighth year, until the end of the changing of the teeth."(4) have already given my own explanation of a similar statement by Rudolf Steiner. Schad also quotes another passage in his Erziehung ist Kunst (Education is Skilled Work)." 

Rudolf Steiner says in this passage that the first three months after birth are really part of the embryonic period. If we add another year, so that the individual would be 15 months old by the usual way of reckoning, "he will be approximately at the stage where he gets his milk teeth." Before that he said, "we have to think in terms of the arithmetic mean, of course, but approximately that is how it is."(18) Schad's comment is that this is about the stage when the enamel crowns "for all the milk teeth are complete". In his illustration, however, the roots are already beginning to develop for all the teeth at age 1 year + 3 months, so that the times are different. However, the arithmetic mean for the period of eruption for all deciduous teeth was between 14.26 and 14.97 months according to 1934 German statistics. H. Ehlers gave 15.68 months as the mean in 1967.19 

These figures agree very well with Rudolf Steiner's "mean". Thus there is no reason to take up Wolfgang Schad's suggestion and concentrate instead on the stage of development reached by the enamel crowns of unerupted teeth both at first dentition and at the changing of the teeth, which can be radiologically assessed. He is, of course, right in saying that this is also the time when the first permanent teeth erupt and the enamel crowns of the permanent teeth are complete, except for the wisdom teeth, i.e. the time when the body has managed to create the hardest substance of all, since the enamel of deciduous teeth is somewhat softer. In Schad's opinion, this change in substance is more important to understanding the human being than the change in position, and Rudolf Steiner's references to the changing of the teeth must relate to this, particularly in passages that seem more contradictory. Schad also assumes, therefore, that X-rays would be helpful if there is doubt about a child being ready for school, with no visible evidence as yet that the change is coming. I am unable to confirm this, particularly as development of the last of the crowns is often greatly delayed by a hereditary disposition to abnormal dental development. I hope to have clearly established that in spite of some passages that appear to be contradictory, Rudolf Steiner meant the beginning of the process when he spoke of the changing of the teeth. It would be helpful if this insight into his teaching and the literature could be unanimously and consistently presented. I do not know any physician or dentist who considers any other explanation either necessary or meaningful. 

More than 10 years ago, Armin Johannes Husemann drew attention to an illustration by Stratz first published in 1909. This shows the changes in bodily form by representing total body height in relation to the height of the head at different ages. The figure has also been included in the second edition of Husemann's Der musikalische Bau des Menschen, with minor corrections reflecting the current state of knowledge.(20) Ten years ago I immediately realized that human beings are five times the height of the head when five teeth have developed on one side of the jaw, and six, seven or eight times the height of the head when as a rule six, seven or eight teeth are present. This remarkable numerical relationship may have further significance. 

(GRAPHIC, PG 42) I suspect that relationships exist between dental development and the macro- and microcephaly Rudolf Steiner spoke of. This cannot yet be proved. Perhaps it will be possible after all to evaluate the data from my investigations in this respect. They are lodged with the Medical Educational Research Department in Stuttgart. 

On the other hand I do not expect much to come of further research into the relationship between the shape of the front teeth and Kretschmer's constitutional types. Wolfgang Schad reported on this at the School Doctor's Conference held in Dornach in 1980. This refers to work done by the late K. Hoerauf, dentist.(21) His descriptions are supposed to help us find the right kind of teeth for edentate patients. A major denture producer based their designs for front teeth on those descriptions ("type-related system"). Doing the opposite, which Schad recommended, i.e. to draw conclusions from the shape of a child's teeth as to its future constitution, does not seem justifiable. To my knowledge, Hoerauf's findings have never been confirmed by follow- up. It is, of course, extraordinarily difficult to recognize the defined shapes of teeth in a mouth and fit them into a system. My friend and colleague, Hermann Lauffer and I once made the attempt to establish the effects of polar opposite formative principles, i.e. those due to the magnesium as compared to the fluorine processes, in my large collection of denture casts, but we did not succeed. 

The relationship of dental and jaw positions to the essential nature of the human being was extensively investigated by Professor Wilhelm Balters (1893 -1973), who was the most important of my teachers. He also spoke about this to Waldorf school teachers. He would sometimes give amazing details after merely looking at denture casts from individuals who were not known to him personally. On the one hand he was an extraordinarily careful observer, noting details that others failed to see, and on the other hand he clearly had intuitive gifts. I will try and include aspects of this in the section on orthodontics but would warn readers not to draw the wrong conclusions. The words the doyen of modern orthodontics wrote beneath a picture of a well- developed human denture still apply today: secretum apertum - "open secret." 

Orthodontics 

This brings us to the field of orthodontics, the purpose of which is to correct malocclusion and malposition, or rather train the teeth to assume the right position. It is indeed miraculous how the individual teeth growing within the jaws combine to form well-balanced dental arches, providing all goes well. "Normal" does not mean "according to statistical norms" today; for most dentures are irregular today. Major investigations have shown only about 8% to be normal. If we accept the "minor deviations" seen in about 22% of cases, this gives us about 30% of "proper" dentures. Occlusion and tooth positions are so poor in about 25-30% of children that orthodontic treatment is necessary or desirable. These figures were given by Rudolf Hotz, Professor of Orthodontics in Zurich, a sound man, who unfortunately has died since, in the 5th edition of his textbook (1980). In practice the situation is as follows: Parents will almost always only take their children to see an orthodontist because they don't like the look of the denture. They hardly ever notice, for example, that a tooth may be missing laterally or that the teeth do not occlude properly. The dentist must first of all establish the present situation (diagnosis), the history, and the prospects with treatment given now or later (prognosis). The first impression a child makes, a few words spoken, a look in the mouth, will tell much to the expert. He also needs to know things that are not immediately apparent, especially if the unerupted teeth are all present and pointing in the right direction for successful eruption. This is best established by taking a panoramic X-ray, a tomogram with minimal radiation exposure. Evaluation of about 50,000 such X-rays at the big school dentistry clinic in Zurich, where this picture is taken of every boy and girl in the third grade, showed that on average, two teeth are not preformed in about 8 % of boys and 9% of girls. This does not include the wisdom teeth, which are frequently missing, as their buds are often not visible at this age. By the way, it is quite unknown why the gender difference exists. (See earlier details of hereditary dental development disorders). Recent investigations by Karl Ulrich, orthodontist in Stendal, have shown that some harmless abnormalities in the skin (ectoderm, with the dental enamel also deriving from this) remarkably often go hand in hand with hereditary dental development disorders. Skin abnormalities of this kind include freckles and irregular eyebrows - joined up, sparse, or shortened eyebrows (usually the lateral third missing). 

Anomalies of the jaws may also be hereditary. The most common of 

(GRAPHIC, PG 44) these is prognathism, with the lower front teeth projecting well in front of the upper teeth, even in the case of the deciduous teeth. This anomaly may be marked in some, and only minor in other members of the same family. Major regional differences have also been noted, with prognathism about three times as common in Stuttgart as in Hamburg. The condition occurs even in the best families. Well-known individuals with prognathism were Dante, Richard Wagner, Stefan George, and above all the Hapsburg family, where prognathism evidently occurred through many generations. 

Overbite, a condition where the upper (middle) incisors extend well below the incisal ridges of the lower incisors, is also hereditary. It causes shortening of the lower face, with distinct dimples in the chin, as in the case of Abraham Lincoln, for instance, and the German actor Hans Albers. Experience has shown that the condition if severe cannot be entirely corrected, and at most made more balanced. It may be a comfort to those affected to know that Professor Balters spoke of the "intelligent overbiter" (the upper part, i.e. the upper jaw, being specially developed). 

The most important aspect of orthodontic diagnosis is to make an accurate assessment of the present situation. This is done by taking plaster casts of the denture which can then be observed and measured at leisure, without being impeded by lips, cheeks, tongue and poor light. Putting the upper and lower casts together, it is even possible to look into the denture from behind, and again and again I am surprised to discover things I had not realized when looking into the patient's mouth. 

It was a very sad experience some time ago, when numerous statements relating to the study of man made by our Dutch colleague Hooghoudt proved untenable, for they were entirely based on inspection of the mouth. More accurate information had since become available from casts and X-rays. It goes without saying that apart from analyzing the model, it is important to examine the mouth and its functions in detail, one main reason being that we must diagnose existing caries and institute treatment where indicated, and inspect the gingiva and the quality of dental and oral care. 

If the relation of the denture to the facial skull is abnormal, anterior and lateral photographs must be taken to investigate this. Distant lateral X-rays provide further information. To come as close as possible to parallel projection, the distance should be not less than 150 cm. These X-rays also permit some degree of prediction as to the growth direction of the face. If it is important to know if there will be any appreciable further growth, especially in girls who have reached puberty, and X-rays taken by hand will provide fairly reliable information. The use of apparatus to stimulate and guide growth is only indicated whilst growth is still in progress, i.e. when the mandible and temporomandibular joint are still developing. Intervention needs to be early, and we have to work with the growth process. 

A key factor with malocclusion and malposition, and therefore also the outcome of orthodontic treatment, is whether closure of the mouth and breathing through the mouth are possible, or if the patient breathes through the mouth, which tends to be open, and possibly even with the incisors positioned on the lip. A balanced bite is only possible if closure of the mouth is normal and natural, for otherwise pressures are not normal in the mouth. I always explain to the patient: The nose is meant for breathing, the mouth only in emergencies, m the nose, and only in the nose, we smell the air, and the fine hairs inside the nose clean it (the dust ends up in your handkerchief); the air is also warmed up in the nose, and actually given life because of the form of the air passages. It is easy to make someone realize how cold air inhaled through the mouth actually is if we ask them to pant with the mouth open like a dog. You can easily catch a cold if you keep your mouth open, and then, with the nose blocked, need to keep the mouth open even more in order to breathe. How do we break this vicious circle? I first of all show the children that they do not look nice and rather stupid if they leave the mouth open. We used to call this "gaping". You hardly ever see adults walk around with their mouths open. Almost all of them manage to close them. But the sooner you leam, the easier it will be. I then often show them a series of denture models taken from a patient whose dreadfully displaced upper teeth and regressed lower jaw could initially be corrected, but then deteriorated again because she always had her mouth open. m the end the position of the teeth was worse than it had been to begin with. 

It needs practice and patience to change to nasal breathing. I know only one activity where the mouth is naturally kept closed because of the concentration required: balancing. It does not need a beam; a tree trunk or curbstone will do just as well. Otherwise we have to make a conscious effort. I tell the children to watch all the time if the mouth is closed. If it is not, they must close it immediately. Memory is aided by pictures put up in rooms where they spend a lot of their time, of a nicely closed mouth, for instance, or an open one looking far from nice that is crossed out, like the cigarette in a non-smoking sign. Signals may also be put on the covers of exercise or textbooks, blotting paper or even a finger nail: C for Close your mouth, or a red L for red Lips closed! I also ask friends and family to give signals if the mouth is left open inadvertently: making the V sign, for instance, and then bringing the fingers together, pointing to the mouth, etc. This can be done very discreetly, so that others won't notice. 

A simple exercise is to take a sip of water and keep it in the mouth for as long as possible without swallowing it or spitting it out. One can also get the children to hold something in their lips during some quiet occupation - a wooden spatula like those used by ENT specialists, for instance, or a file for ampules, a button or a coin, using bigger and heavier ones as time goes on. Anything where the breath is used can be helpful, e.g. playing a wind instrument, blowing out candles, making soap bubbles, "shooting a goal" by blowing bits of cotton wool across the table. Other methods are to breathe in 

(GRAPHIC, PG 47) 

slowly for as long as possible, the outward sign of this a leaf or a piece of gauze held across the nostrils by the negative pressure, or doing the opposite, which is to take a deep breath to fill chest and abdomen and then exhale as slowly as possible, external evidence being provided by talking, counting, singing, whistling or, more tolerable for anyone else who happens to be around, humming. If the nasal passages are not clear, an ENT specialist has to be consulted who will remove any greatly enlarged pharyngeal tonsil (preferably not the visible palatine tonsils), also known as adenoids. 

A common contributory cause to open mouths is a denture so badly out of shape due to sucking that the lips cannot be closed. Children will suck not only their fingers and a pacifier, but also a comer of their blanket or a piece of clothing. The upper front teeth are generally pushed forward and the whole mandible is pushed back in the process, resulting in the typical open bite. The sucking gesture is one of definite introversion, withdrawing into one's shell before an unkind world; it may also be regression, wanting to go back to the protection enjoyed in early infancy, for instance, when a younger brother or sister suddenly appeared and attracted most of the family's love and attention. 

What can be done to overcome these and other undesirable habits (chewing nails, for instance)? We must help the child to take the necessary developmental steps, e.g. not to put their hands into their mouths but use them in the outside world. There is no point in shouting at them, but ignoring the habit may sometimes help. A doctor's wife once told me she suddenly realized she had stopped sucking when she left her parent's home at the age of 20. To have such a habit drop away like a ripe fruit is, of course, the ideal, except that in her case it was much too late. It is generally easier to wean children off their pacifier than their fingers, by "losing" it, for instance. If one has to give them a pacifier, it is best to use a specially shaped one that will at least prevent some of the damage. 

If a child has only been sucking for a short period, is able to close the mouth easily, and there is sufficient room for all the teeth, the defect due to sucking may correct itself. If sucking continues for such a long time that the permanent dentition is also affected, orthodontic intervention is usually required. In simple cases, it is often enough to use a ready-made atrial plate; difficult cases require individually fitted appliance. An activator is most commonly used, or the greatly reduced form called a "bionator". It may be said to be a sucking body that acts in reverse. It lies loosely in the mouth, has a guide surface for the lower teeth and a wire brace above the projecting upper front teeth. Every time the mouth is closed, e.g. when swallowing saliva, the mandible moves forward, wants to go back again and takes the upper teeth back. 

This is known as a reciprocal action (going back, re-, and forward, -pro-), and is particularly effective. A seriously malformed denture has of course responded particularly well to the original sucking bodies and will therefore also respond well to the appliance which acts the other way round. The use of appliances lying loose in the mouth is the functional method. It does not impose force but offers an opportunity to change position which influences the jaws, teeth and joints via the muscles. Apart from the above-mentioned classic activator and the smaller "bionator", a number of similar appliances are available. 

Hermann Hoffmeister, D.D.S. 
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Citation: Hoffmeister, H. (1994). Development, decay, changing of teeth, and malposition of teeth and jaws, part I. Journal of Anthroposophic Medicine, 11(4), 32–49.