Casey CastaldiCRD 118Fall 2013The Evolution of Dental BracesHuman beings have historically been characterized as being a particularly inventive species. Throughout history, we have invented technologies to meet out basic human needs in creative ways. However, the inventive capacity of human beings is not limited to necessity. In his book about the evolution of technology, George Basalla states, If technology exists to meet basic human needs any complexity that goes beyond the basic fulfillment of needs could be judged superfluous and would need to be explained on ground other than necessity.(Basalla, 1988). The desire for straight teeth did not originate from a direct human need. In fact, human beings survived and thrived for thousands of years without any form of intervention. However, at a certain point in human history, standards of beauty forever changed in a way that produced a desire for straight symmetrical teeth. Over the years, other standards of beauty have changed significantly; with different clothes, sizes, and looks drifting in and out of fashion. However, despite these changes, straight teeth have remained an intrinsic part of our idea of beauty, specifically in U.S society. So much so in fact, that an entire field of medicine was created in its name. Dental braces and have become a pivotal technology in the United States due to their ability to create the beautiful straight smiles that we revere so dearly in this culture. What this paper will attempt to do is explore the evolution of dental braces as a technology by first examining the progression of materials and mechanisms used in the practice and then by looking at the social forces behind the acceptance and adoption of the technology. By examining the evolution of this technology through both physical material and socio-cultural lenses, I hope to illuminate the connections and relationships that exist between braces technology and the larger cultural trends of our society. Evolution of Materials:

Figure 1: Pierre Fauchards bandeauWhile a lot of modern orthodontic development occurred in the United States during the 20th century, the idea and practice of straightening crooked teeth has been around for centuries. Ancient historical figures such as Hippocrates, Aristotle, Celcus, and Pliny the Elder have all been cited discussing the appearance and structure of teeth dating back all the way to 460 B.C. (Wahl, 2005: Chpt 1). These figures hypothesized the different reasons and causes behind crooked teeth, and proposed manual ways to correct them; including the application of pressure, extraction, and filing teeth down to improve their alignment (Wahl, 2005: Chpt 1). It wasnt until the 18th century that the first physical mechanism was invented with the sole purpose of correcting malocclusion, otherwise known as crooked teeth. Pierre Fauchard, referred to by many as the father of orthodontia, invented an instrument know as the bandeau (see fig. 1). The device was made of a band of precious metal, either gold or silver, and a series of silk ligatures which were tied to individual teeth (Asbell, 1994). Fauchard used the precious metals due to their malleability and the ligatures to try and pull individual teeth towards the preformed metal band. The concept behind this device was to pull teeth into the desired symmetrical U shape, while avoiding the extraction of permanent teeth, as was a common practice for many dentists at the time. (Wahl, 2005: Chpt 1). For years, the bandeau was the norm in the practice what would later be known as orthodontics. Other orthodontists, including Etienne Bourdet who was the personal dentist to the King of France, would expand and adjust his device in order to expand the arch more efficiently to make room for more teeth (Wahl, 2005: Chpt 1). The majority of initial development to orthodontic devices and methods occurred in Europe, however in the beginning of the 19th century, the United States became a major player in dentistry and subsequently orthodontics. The devices being used by American orthodontists were similar to their European counterparts and were made primarily out of gold and silver, although some did experiment with different types of wood (Asbell, 1994). Due to their malleable consistencies, the gold and silver brackets and devices needed constant adjustments that were often times very uncomfortable for patients. In 1839 however, Charles Goodyear invented a remarkable new material called vulcanite that drastically changed the design and nature of orthodontic devices. The softer material allowed orthodontists to create new bite plates that were substantially cheaper and lighter than their metal counterparts (Wahl, 2005: Chpt 1). Professionals also used the new material to make rubber bands, which are still used today in orthodontia to reduce discomfort and correct malocclusion. The introduction of vulcanite into braces technologies allowed for more experimentation and combinatory technologies that would help advance the technology in many ways.While the invention of vulcanite was extremely important to the development of orthodontic technology, dentists still relied primarily on metal wires and brackets. As mentioned before, the precious metals were not only highly malleable, but were also extremely expensive. This issue was addressed in the early 1900s with the introduction of a new material, stainless steel. While this metal had been around for years, it was first introduced into mainstream U.S production in the first two decades of the 1900s and orthodontists quickly adopted the material. Stainless steel was cheaper and stronger than gold or silver, while still being malleable enough to be molded and adjusted to custom fit patients needs (Stainless Steel, 2013). After its adoption into braces technology, many dentists started to change the construction of their devices, because they could now use more metal with every patient without paying higher costs. As a result, around the same time that stainless steel made its first appearance in orthodontics the individual bracket also debuted. Brackets were circular metal devices that encircled each individual tooth and then connected those teeth to larger wires (Indian Dental Academy, Feb 2013; fig 2).

Figure 2: Angle's Ribbon Arch: individual bracket useThe bracket changed the way that orthodontists attempted to correct crooked teeth, and it was only possible with the introduction of a cheaper lighter weight metal. However, despite the major advances that stainless steel created for orthodontic mechanisms, there were some drawbacks. After orthodontists realized that some of their patients had allergies to the Nickel found in steel, they needed to find a new alternative solution and were not willing to revert to silver or gold. Instead, they were able to offer titanium as an alternative once it was commercially produced in the mid 1930s (Titanium, 2013). Titanium was a lighter and equally strong metal and thus provided consumers with a valid alternative to steel. However, due to the nature of its production, it came at a higher cost.Along with the production of new cheaper and lightweight metals like titanium and steel, the 20th century also marked the evolution of various other technologies that greatly advanced the field of orthodontics in different ways. Firstly, the evolution and widespread use of x-ray technology throughout the entire medical and dental field provided orthodontists with a new view into the mouths of their patients. X-rays enabled dentists and orthodontists to better treat and predict the natural movements of teeth like they had never been able to before (Wahl, 2005: Chpt 6). As dentists and orthodontists began to study the root structure of their patients, they were able to understand the physical causes of malocclusion and could treat patients accordingly. Secondly, the 20th century also marked big changes in the evolution of adhesive technologies or cements used in orthodontics. Since the end of the 19th century, dental cements had been used in order to bond the different brackets to teeth. With the changes to bracket shape and use in the 1930s and 1940s, existing cements were not providing orthodontists with strong enough bonds to hold brackets to individual teeth. However in the 1960s adhesive technologies evolved dramatically, with the creation of a dental cement that incorporated the natural make up of tooth enamel into the boding process (Ewoldsen & et.al. 2001). Orthodontists would have to prime the teeth with a phosphoric acid and then would later apply a zinc polyacrylate cement to bond the metal brackets directly to teeth. Over the years the bonding technology has evolved even further to incorporate resins and glass ionomers in order to improve both the strength of the bonds as well as the negative effects of some original cements. These new adhesive cements were stronger, clearer, and healthier for patients than previous versions. They allowed orthodontists to use smaller amounts of adhesives to receive the same strength of bonds, thus enabling them to use smaller brackets with no loss in corrective power (Al-Munajed, 2000) These changes reduced not only the overall discomfort level of many consumers, but also drastically improved the overall aesthetic appearance of braces.

Figure 3: Ceramic BracketsDespite the aesthetic improvements that adhesive technology provided for braces technology, consumers were still off put by the overall appearance of braces. In response, there has been a drastic increase within the past twenty years in new braces technologies. New materials are now being used primarily to lessen the harsh physical appearance of braces, and in some cases make them completely invisible. The first move away from the traditional use of metals in orthodontia came in the 1980s with the use of ceramic brackets and wires. These tooth colored devices camouflaged the braces and gave consumers the benefits of an improved smile without having to live with large amount of metal in their mouths for years at a time (Archwired, 2005; fig. 3). Even more recently the development of Invisalign technology has made correcting crooked teeth even less intrusive. The removable retainers are made out of a thermoplastic material and are created using 3-D imaging of an individuals teeth (Invisalign, 2013). Patients go through a series of different retainers that gradually shift the alignment of their teeth. Lingual braces, or braces that go around the inside of teeth as opposed to the outside, have also been around the orthodontic field for years and have advanced dramatically in recent years. However, due to the advanced training that orthodontists need to properly apply the devices, many dont offer the service to their patients (Wahl, 2005: Chpt 6). While both these new materials have allowed consumers to have braces without dealing with the aesthetic consequences, it should be noted that they are also more expensive options.

The Social Construction of Braces:As mentioned in the introduction of this paper, braces did not become a part of our society and culture our of an inherent human need. Although some young adults might argue that having crooked teeth is the equivalent of committing social suicide, that way of thinking is a derivative of the social construction of beauty rather than an innate biological need. According to Basalla, We cultivate technology to meet our perceived needs, not a set of universal ones legislated by nature(Basalla, 1988). Like many technologies, braces were created and developed due to a socially constructed belief that a straight smile and nice teeth were defining characteristics of beauty. Throughout its evolution the physical technology of braces was directly influenced by the feedback of the consumers themselves. In the article The social construction of facts and artifacts: Or how the sociology of technology and sociology of science might benefit each other written by Trevor Pinch and Wiebe Bijker, the relationship between society and technology is explored in detail. Some of the key methods they identify as useful when examining technology through this lens are the identification of relevant social groups involved, as well as using a multidirectional model to track the chronological evolution of a technology (Pinch & Bijker, 1987).

The Evolution of Mechanisms and SCOT:When the idea of correcting crooked teeth first started to manifest itself through physical technologies, there was very little background information or study that had been put into the biological and physical causes of malocclusion. As a result, the methods used to straighten teeth were highly variable. Braces technology remained subjective to each respective orthodontics up until the mid 20th century when the technology began to steady with the introduction of new metals and bonding cement (Ewoldsen & et.al. 2001). It is difficult to determine exactly which technologies taken from different mechanisms in orthodontic history have gone into the contemporary version of dental braces that we are familiar with today. However by using the SCOT method of multidirectional modeling, we see how many different technologies that might not appear in a linear model of the evolution played a part in developing contemporary braces.What braces technology shows us is that after the introduction of the bandeau in the 1700s there were very few new technologies until nearly 100 years later. Orthodontists around Europe made small adjustments to the existing technology, however it wasnt until the invention of vulcanite in the mid 1800s that braces technology did more than target the movement of individual teeth with the use of ligatures (Wahl, 2005: Chpt 1). After its invention, different dentists and orthodontists explored different types of arch expanders and bite plates made out of vulcanite that both improved the understanding of arch expansion and created the foundation for many orthodontic technologies still in use today (Whal, 2005: Chpt 2). Many of these vulcanite-based technologies worked to improve the knowledge base surrounding orthodontics, but are not directly linked to the technology used in contemporary braces. In fact, they most closely resemble retainers that are used as post-braces treatments by many orthodontists (Whal, 2005: Chpt 2). While the vulcanite devices were not directly involved in bracket technology that dominates the field today, the ideas they presented were instrumental in the development of current braces technology. When orthodontists started experimenting with vulcanite, they realized the importance of expanding the arch in order to more easily move teeth. Dr. Edward Angle took this knowledge and made a series of metal mechanisms known collectively as the E-arch. This technology was based off of the mechanisms found in previous V-arch designs, as well as the arch expansion concepts of the vulcanite plates (Civen, 2004). The E-arch, created in 1907, was improved upon in 1910 with the Pin an Tube arch. Both of these were meant to perform the same function as the vulcanite mechanisms by expanding the palate, however they were not removable. Many orthodontists in the field had decided that removable devices were not optimal for producing long-term straightening effects (Indian Dental Academy, Feb 2013). Eventually, the Pin and Tube arch would lead to Figure 4: Edgewise BracketsEdgewise brackets that were the dominant braces technology until 1956. At that point in time, the Begg bracket was introduced and would prove to be the basis for most proceeding braces models; fitting into the more linear model of technological evolution we are accustomed to exploring. (Indian Dental Academy, Feb 2013; fig. 4). What the SCOT model encourages us to do is examine the evolution of technology through a more critical lens. It acknowledges that there is a much richer history behind the evolution of a technology than we usually see by only looking retrospectively at the successful versions. While the vulcanite bite plates resemble modern day retainers much more so than they resemble metal braces, they still contributed to the evolution of the technology. By including them in the evolution of braces, we gain a new insight into not only the development of the technology, but also the development of the entire orthodontic practice. Relevant Social Groups:In their article, Pinch and Bijker also stress the importance of identifying the relevant social groups within the evolution of any technology. They argue that in order to understand how and why a technology developed in the way it did, it is important to look at who exactly had a vested interest in its advancement (Pinch & Bijker, 1987). As discussed earlier, one of the strongest driving forces behind the evolution of dental braces were the standards of beauty that have existed historically, and have continued to develop within our society. Therefore, when examining the technological evolution of braces, it is important to look at who exactly was most active in the perpetuation and creation of the standards that emphasized having straight, symmetrical teeth. Through my research, I have determined that the two main actors involved in the evolution of braces in the broadest sense, were patients and orthodontists. However, within the patient group, there are various different subcategories that have effected and supported the evolution of braces in different ways. Specifically, the relevant groups within patients are women, individuals with high socio-economic standing, and most recently adults. Beginning by examining the group of women, it is clear by examining historical trends braces use that women have always been more interested in using braces to straighten their teeth. Even before the technology began to stabilize in the 1970s and became more aesthetically pleasing, women were willing to undergo many different kinds of orthodontic treatments to straighten their teeth. Due to the increased pressure by society to conform to standards of beauty, women have gone to great lengths throughout history to change their natural appearance even if that meant undergoing painful procedures or wearing heavy metal appliances in their mouths (Jensen, 2013). Even in ancient Etruscan cultures, only female remains were found with the remnants of some sort of corrective dental device (Wahl, 2005: Chpt 1). A more recent study done in 2009 amongst a group of children showed that girls were generally more critical of their own smiles and thought they needed to get braces, even if they did not have a definite treatment need (Christopherson & et.al, 2009). What this case demonstrates is the constructed need to have straight teeth and consequential social pressure to conform to those social constructions being felt by young women today. While men have also expressed an interest in braces, women have historically and currently do experience a larger pressure to have straight teeth and have therefore always been important actors in the evolution of braces technology.In more recent history, the incorporation of new materials into braces technology has turned adults into a new relevant social group. Before the introduction of ceramic brackets and Invisalign technology, braces did not attract many adults due to the association of braces with adolescence (Rosvall & et.al, 2009). Forty-year old executives with metal braces were not likely to be taken very seriously. Therefore, when ceramic brackets and Invisalign type technologies began to develop, adults were quick to involve themselves in the process. Merely by typing Invisalgn or ceramic braces into a search engine, one can see that the many of the companies and organizations that are found advertise to adult consumer groups. As the materials have changed and the technology has evolved, adults now have a way to get straight teeth without having to go through the humiliating process of metal braces. While the social groups vary based on gender and age, there is one characteristic that has remained relatively constant throughout the entire evolution of braces and that is socioeconomic status. Since their inception when they were made out of pure gold and silver, braces have always been an expensive technology. It does not come as a surprise then, that the majority of patients come from relatively affluent backgrounds. Original patients who were the test subjects of the worlds first orthodontists, included kings and princes in France who could afford to pay their dentists to create devices out of precious metals (Wahl, 2005: Chpt 1). Today, the class divide still exists in orthodontics, although now you dont have to be a King or Queen to receive treatment. This being said, braces still remain a technology only available to those with comprehensive dental plans and large savings accounts. Traditional metal braces run between $3,500 and $6,000 dollars, which, for families and individuals belonging to lower socio-economic groupings are far too expensive (Proctor and Gamble, 2013). While some dental plans do cover braces at least partially and some orthodontists offer payment plans for patients, the price of braces generally limits the patient base to relatively wealthy sectors of society. In fact, one of the reasons that the new aesthetically pleasing braces technologies (which cost between $5,000 and $8,000 dollars) have been allowed to develop and succeed is because the social group most directly involved in their production typically have the financial means to afford them. In effect, braces have always been a technology paid for and influenced by the most elite groups of society.Lastly, as I will expand upon in the near future, orthodontists themselves are another relevant social group in the evolution of braces. When the first orthodontists began to distinguish themselves in the dental community, they were more like specialized dentists than anything else. Due to the fact that no official discipline of orthodontics had yet been established, the original orthodontists had no foundation to base their work upon therefore they had a vested interest in creating completely new technology that could serve as an example for generations to come. Once the specialty and technology had been established, orthodontists had much more economically fueled interest in the evolution of the technology. When orthodontists decided that they were not interested in going through extra training to use lingual braces, the technology faded to the background of new braces technologies. Orthodontists created an entirely new field of medicine for themselves and were driven by both professional and financial goals.The Professionalization of Orthodontics:Another very important factor in the evolution of dental braces was the professionalization of orthodontics and the emergence of accredited university and professional programs. In 1910, Dr. Edward Angle created the first university program for orthodontics in the United States known as the Angle School. The program was the first of its kind to focus specifically on the practice of orthodontics, rather than dentistry. Dr. Angle himself was one of the most influential orthodontists in the United States, and the creation of his university program enabled many of the discoveries and mechanisms of the 20th century. After the Angle school opened, other post-graduate programs began to emerge around the country. Student and graduates of these programs went on to develop their own methods and devices and even went on to publish some of the first national journals devoted to orthodontics (Wahl, 2005: Chapt 3). Before this point, orthodontics had merely been a subset of dentistry that a few dedicated individuals had devoted their lives to. The progression of orthodontic technology was slow and messy because there was no uniform curriculum or knowledge base for individuals to base their methods off of. With the introduction of schools of orthodontics, industrial knowledge and methods were able to flow freely and as a result the industry experienced a growth in industry specific knowledge and an increase in new mechanisms. (Wahl, 2005: Chpt 3; Lapsley, 2012).

Figure 5: One current Ortho AssociationAlong with the introduction of new university programs, the early 1900s also marked the first instances of nation wide orthodontic associations (Wahl, 2005: Chpt 3). These associations allowed recent graduates of orthodontic programs, as well as already established figures in the orthodontic field to organize and form networks amongst each other. One result of these new networks was a newfound sense of competition between individual orthodontists and schools of though. The majority of conflicts and debates existed between Dr. Angle and his students, and those who attended other institutions that didnt belong to the same school of thought. Like most competition within industries, the competition between Angle and others in the field did spark some controversy, but it also inspired new technologies and methods, which would go on to advance the fields as a whole (Wahl, 2005: Chpt 6; Kenney, 2013). Without the creation of university programs and orthodontic associates, the discussions and innovations formed in the wake of newly created relationships and competition would have gone unexplored. As a profession, many individuals saw a lot of potential in orthodontics for a variety of reasons. Firstly, as discussed above, the demand for straight teeth has always been, and promises to remain, relatively high especially in U.S society. Orthodontists rarely have to worry that their client base will suddenly stop desiring straight teeth; therefore their jobs are almost inherently secure. Another appeal of the profession is that orthodontists tend to make decent livings due to the relative cost of their product. It should come as no surprise that with a product literally made of gold; orthodontists were not operating within a small budget when it came to developing their technology. Even today, orthodontists are one of the top earning careers in the entire United States. In 2012, the BLS published findings that placed orthodontists at number six on the list of top earning positions, with those in the field earning an average of $186,000 a year (Locsin, 2012). With high job security and high salaries, it is not surprising that orthodontia is a competitive and highly sought after profession. Conclusion:To the dismay of millions of young adults who have lived through the experience, braces have become an important technology in U.S society. The century old desire for straight teeth has resulted in countless mechanisms and technologies made out of various different materials. As those materials and mechanisms evolved, so too did the general understanding of the underlying structure of teeth. Even in the past century, we have seen the effectiveness of braces increase exponentially. For a price, individuals are able to enter an orthodontists office one day with crooked teeth, and leave a few months or a couple years later with perfectly straight teeth. Previously, this same transformation was only possible with multiple years of therapy and gave no guarantee of success. Braces technology has found new ways to incorporate fresh materials and to address the needs of patients in successful and important ways. As a result, braces have become an important part of U.S culture and have expanded their influence into new social groups and institutions. Unless standards of beauty in this country change drastically in the near future, braces will remain to be an important technology and will continue to evolve and expand as new technologies become available. Currently, work is being done with 3-D modeling and genetic testing in order to find new ways to map and more effectively treat malocclusions. The incorporation of these new technologies, as well as the further development of existing methods will undoubtedly lead to more discrete and effective treatments for crooked teeth. Not to mention a significant decrease in the number of embarrassing school photos that entire generations of young children will have to hide from their friends.

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