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<p>SPECIAL ARTICLES</p><p>Edward H. Angle versus Calvin S. Case: Extraction</p><p>versus nonextraction. Historical revisionism. Part II</p><p>Leonard Bernstein, DMD*</p><p>Brook/ine, Mass.</p><p>S i n c e Angle had a school for training ortho-</p><p>dontists, his philosophy became the predominant one</p><p>and such was the power accorded him, none dared to</p><p>say otherwise. Not only did he dominate the philosophy</p><p>of treatment, but his students and disciples carried it</p><p>on. This idea is substantiated by Pollock who points</p><p>out that "Many of Angle's followers became teachers</p><p>in dental schools, and for years the doctrine of the full</p><p>complement of teeth was widely disseminated. ''3t</p><p>I remember being told that this power carried over</p><p>to his widow who exerted great influence in seeing that</p><p>the teachings and principles of her deceased husband</p><p>remained inviolate.</p><p>Jackson, as late as 1952, still had to defend his use</p><p>of extractions for in describing his treatment of a case</p><p>says, "Fortunately, we have as one of our greatest allies</p><p>the natural unaided readjustment of the tissues them-</p><p>selves which follows that most controversial [emphasis</p><p>mine] of all subjects, the 'judicious extraction' of</p><p>teeth.,'J-'</p><p>He also probably recognizes the influence of Angle-</p><p>trained people dominating the universities as evidenced</p><p>in his lengthy espousal of preceptorship training. This</p><p>is accompanied by a frontal assault on university-dom-</p><p>inated orthodontic training as exemplified by the fol-</p><p>lowing statements:</p><p>"The teaching field is naturally besieged by individuals</p><p>of this type who in many cases are very clever in creating</p><p>outward impressions of their qualifications as teachers. It is</p><p>actually very easy to do this by writing papers on any of the</p><p>highly scientific aspects of the orthodontic problem but which</p><p>have little practical application. Individuals of this type would</p><p>welcome nothing better than to win for themselves positions</p><p>of 'full-time professorships' which would provide sinecures</p><p>for their financial needs in lieu of their precarious private</p><p>practices and at the same time establish them in the profes-</p><p>sional esteems which they so urgently desire."</p><p>"In the first place, it is inconceivable that any man should</p><p>be allowed to be in charge of any of the orthodontic depart-</p><p>*Clinical Professor of Orthodontics, Boston University School of Graduate �9</p><p>Dentistry.</p><p>8/1/34613</p><p>546</p><p>merits of any of the universities in the country other than a</p><p>man of long practical experience and recognized personal</p><p>professional ability and standing in the specialty."</p><p>"Are we orthodontists going to allow this heritage to be</p><p>lost and taken over by a group of clinical ineom~petents who</p><p>are interested primarily in their own personal careers in the</p><p>teaching field rather than in the broad interests of orthodontics</p><p>itself?."</p><p>Jackson is less strident in evaluating Angle when</p><p>he states, "As a pioneer, Angle may possibly be for-</p><p>given for the fact that his whole concept of orthodontics</p><p>and his methods of dealing with its basic problems were</p><p>based on a very obvious but devastatingly fatal fallacy.</p><p>This fallacy is the absolute impossibility of harnessing</p><p>infinite variation as found in anything as fantastically</p><p>complex as orthodontics to a definite set schematic clas-</p><p>sification and 'system' of mechanical therapy, which in</p><p>its broad sense is out of harmony with many of the</p><p>basic biological principles of nature. ''3"- But further, in</p><p>regard to Angle's personality, he states, "In Angle's</p><p>original groups there naturally happened to be some</p><p>mature intelligent, free thinkers, some of whom, ex-</p><p>ercising the prerogatives of free thought and speech,</p><p>promptly found unceremonious exits through his back</p><p>door."</p><p>One would be hard-pressed to find other negative</p><p>references to Angle in the literature even as late as 1952;</p><p>such was the nature of the purported power of the man,</p><p>his disciples, and his widow.</p><p>The Dental Cosmos, in its section, "Proceedings of</p><p>Societies," published "A Memorial Meeting to the Late</p><p>Edward Hartley Angle," which was held by The Eastern</p><p>Association of Graduates of the Angle School of Or-</p><p>thodontia, in the Vanderbilt Hotel, New York City, on</p><p>Jan. 26, 1931.</p><p>One of the principal speakers was Professor Ed-</p><p>mund H. Wuerpel t7 who delivered a paean to Angle,</p><p>his friend of 31 years. One should read this paper to</p><p>get a sense of Angle the person, while keeping in mind</p><p>that this address was in the nature of a eulogy for an</p><p>old, good friend. Even in this lengthy paean, it is pos-</p><p>sible to pick out comments that shed light on the nature</p><p>of Angle. I quote part of a reconstructed conversation</p><p>between Angle and Wuerpel as follows: "After I got to</p><p>Volume 102 Special article 547</p><p>Number 6</p><p>know him bet ter- -and I think it was not over 2 years</p><p>before I got to know him as well as ever I d id--1 re-</p><p>marked, 'You have a vision, but you have a mighty</p><p>obstinate one.' 'What do you mean?' 'The trouble with</p><p>you is that you want everybody's vision to agree with</p><p>your own. You will not see that very few people have</p><p>the brains necessary to have your vision, and because</p><p>they do not in intelligence come up to your standard,</p><p>you conclude they do not that they have no vision. They</p><p>have vision, but it is of lower degree than your own. '"</p><p>Later on, Wuerpel says that, "I used to plead with him</p><p>so often, 'Why don't you look at things in a bigger way?</p><p>You are a big man, you have big ideas, you understand</p><p>things so nobly. Why don't you understand humanity</p><p>better? Don't you realize that you could get along easier</p><p>if you made people understand you?' 'The trouble with</p><p>you is that the wind of misunderstanding rises, and you</p><p>wrap your mantle of pride around you, the more the</p><p>wind blows the tighter the mantle goes around you. No-</p><p>body really sees you, they just see the mantle. '" Angle's</p><p>answer to this criticism is informative of the man as he</p><p>responded, "Yes, but there is right and there is wrong.</p><p>These people have done wrong."</p><p>Wuerpel spoke of the humble background that An-</p><p>gle came from and noted that "He came from an an-</p><p>cestry, which was rather bigoted." According to Wuer-</p><p>pel, he harbored a great dislike for Germans. He goes</p><p>on to say that "And although he rose above his narrow</p><p>upbringing, he had all of the prejudices of that narrow-</p><p>ness, and he never rid himself of them. This freedom,</p><p>which we call modemism, he couldn't tolerate. He</p><p>couldn't understand it. No matter how I argued, no</p><p>matter what I said, he said, 'It is wrong. '"</p><p>Wuerpel goes on to admonish Angle and asking him</p><p>to be more tolerant of other people's ways of looking</p><p>at things; this Angle could not do and thus, "He made</p><p>enemies because he made remarks about it. People</p><p>couldn't understand. They couldn't understand because</p><p>they weren't with him; they thought he was narrow,</p><p>prejudiced, a cantankerous old fool. And he was, in</p><p>certain ways. I will grant it. He stood in his own light</p><p>in some instances, but if people had only understood,</p><p>they would have had tolerance."</p><p>Throughout his eulogy, WuerpeP 7 alludes again and</p><p>again to the high ideals and standards that Angle set</p><p>for himself and his impatience with those who did not</p><p>live up to what Angle set as the standard. It is summed</p><p>up by Wuerpel when he rhetorically asks, "Why was</p><p>it that people in the majority of cases went against him</p><p>instead of with him?" He answers himself by saying,</p><p>"It was because of this idealism, because of this insa-</p><p>tiable desire to live on the heights, and because he</p><p>required this of himself, he required it of all mankind."</p><p>If this portrait of Angle is correct, and one has to</p><p>read the whole eulogy to get the flavor of the man</p><p>Wuerpel is describing, then the more enigmatic the</p><p>mystery of the sixth edition becomes. Why did Angle</p><p>never make reference to this book? Why did he sup-</p><p>posedly have it withdrawn from publication? Why did</p><p>he not, in regard to his putative high ideals, repudiate</p><p>it? I regret that I have no definitive answers</p><p>for you.</p><p>In terms of Freudian psychology today, we can analyze</p><p>Angle in ways that were not as readily facile then as</p><p>today. If Professor Wuerpel's degree had been in psy-</p><p>chology rather than art, and were he to give an evalu-</p><p>ation of his friend today, there might be some different</p><p>conclusions as the nature of the man.</p><p>In a profile of Angle, Noyes starts off by saying</p><p>that "Dr. Angle was a genius, essentially a mechanical</p><p>[emphasis mine] genius. ''33 After reading things that</p><p>Angle himself wrote and reading what others wrote</p><p>about him, the flavor of the man that starts to emerge</p><p>is that indeed he was a genius but was not so in many</p><p>areas.</p><p>Wuerpel, t7 Noyes, 33 and Dewe123 all point out the</p><p>range of Angle's talents and far-ranging interests from</p><p>inventing appliances to woodworking and carpentry to</p><p>collecting Southwest Indian beadwork and blankets.</p><p>Even with all this, when compared to Case, Case</p><p>emerges as more of a true scientist and more of a Re-</p><p>naissance man, seemingly knowledgeable in many</p><p>areas. Indeed, Angle himself may have consciously or</p><p>subconsciously recognized his own shortcomings in</p><p>comparison with Case. Another flavor of Angle that</p><p>appears to me is that of a basically insecure man who</p><p>is working overly hard to cover his insecurities by hid-</p><p>ing behind the dogmatic, absolutist positions he takes.</p><p>This insecurity puts him in conflict with most people,</p><p>as documented by Wuerpel, ~7 and puts him into the</p><p>position of having to be always right and incapable of</p><p>accepting criticism. In a letter to me dated Apr. 4, 1991,</p><p>Graber points out that "Case was more successful as a</p><p>contemporary leader than Angle. Case was on the inside</p><p>leading, while Angle was the maverick. He resented</p><p>Calvin Case."</p><p>And what about Case? What kind of man was he?</p><p>One has to read the works of the man to gather a true</p><p>flavor of the man, other than what I have so far written</p><p>of him. For those interested, there is an excellent bi-</p><p>ography of Calvin Suveril Case by Charles R. Baker, 3~</p><p>which appeared in the March 1957 issue of the AMER-</p><p>ICAN JOURNAL OF ORTHODONTICS. In this biography,</p><p>note is given that even his adversary, Martin Dewey,</p><p>had to praise him. Among other things, Dewey states</p><p>"Many times I did not agree with Dr. Case, but his</p><p>wonderful nature was revealed by the fact that even</p><p>though you disagreed with him on a scientific question,</p><p>he always remained your friend and believed that you</p><p>had the right to your opinion that he wished you to</p><p>548 Bernstein Am. J. Orthod. Dentofac. Orthop.</p><p>December 1992</p><p>allow him to have his." Baker says that Dewey was</p><p>also quoted as saying that "Dr. Case told me that one</p><p>of his greatest regrets was that he could not have the</p><p>opportunity of sitting at a conference table with Dr.</p><p>E. H. Angle, for he felt that such a discussion would</p><p>show that their ideas on most orthodontic topics were</p><p>very much alike." Baker ends his article with the fol-</p><p>lowing: "So ends the story of a great man, who was</p><p>sincere in his work, and loyal in his friendships."</p><p>Noyes 3~ also notes that Angle "could never take</p><p>criticism or argument" and told a young man about to</p><p>visit Angle, "Do not ask questions or try to argue; just</p><p>sit and take everything he has to give, then go home</p><p>and think about it." He further points out that "Being</p><p>a genius, he could never defend his own ideas . . . . He</p><p>knew that they were right." Noyes furthers his profile</p><p>by relating how Angle would go to a meeting to present</p><p>his ideas and when verbally attacked by those present,</p><p>"all he could do was call them fools." Further on, Noyes</p><p>relates how Angle would ride a man unmercifully "to</p><p>see if he was man enough to take it" and if he could,</p><p>"he gave him all he could take." At one point, Angle</p><p>went later to visit one of these men and found that he</p><p>had gone to old methods of practice. Not only did Angle</p><p>berate him but upon going home "was sick for 2 weeks."</p><p>In psychologic terms it appears that Angle could only</p><p>justify his sense of being, his absolutist based insecur-</p><p>ity, by finding someone who believed in him absolutely.</p><p>This gave credence and substance to his existence and</p><p>to discover someone who then fell away would appear</p><p>to Angle to be a total repudiation of his own sense of</p><p>self, his insecurities were being confronted and he could</p><p>not take it. Noyes ends his article by saying that "Dr.</p><p>Angle was a great man." I can agree that Dr. Angle</p><p>made many important contributions to orthodontics, but</p><p>a great man would to my mind be capable of intro-</p><p>spection at least to the point of understanding, and</p><p>hopefully overcoming, psychologic barriers. Dr. Angle</p><p>was his own worst enemy, and although the evidence</p><p>supplied by Wuerpel t7 is that he understood that, he</p><p>could not go beyond that in understanding and coming</p><p>to terms with his own psyche. The era of Freud was</p><p>not yet far enough into the general zeitgeist to be of</p><p>any benefit to Angle. I am thus forced to agree with</p><p>N0Yes's earlier statement in this article that "Dr. Angle</p><p>was a most tragic character, for his nature was a</p><p>mixture of the most violently opposite and contending</p><p>qualities."</p><p>Let us look again at Angle's own words in regard</p><p>to his phi!os0PhY of treatment by going to a paper</p><p>delivered bY him8 in the Proceedings of the "Am~erlcan</p><p>Society of Orthodontists in 1902. Try to keep in mind,</p><p>when I come to the sixth edition itself, that this paper</p><p>was published only 2 years after the publication of this</p><p>edition.</p><p>Nothing could be more succinct than Angle's own</p><p>basis of his philosophy of treatment than that provided</p><p>in this paper. He states that, "I believe we do have a</p><p>rule which artists probably know nothing of (he is re-</p><p>ferring to his friend Wuerpel), and one more unvarying</p><p>and more reliable than even the judgement of the fa-</p><p>vored few (he is referring to Wuerpel's comment that</p><p>"only 1 or 2 in 300" will be able to master the ability</p><p>to judge the "correct proportion of the features in each</p><p>given t y p e " ) - - a rule so invariable and with so few</p><p>exceptions that we may almost consider it a law, and</p><p>if it not be applicable in all cases, the exceptions will</p><p>be so rare that they are hardly worth considering. It is,</p><p>furthermore, a rule so plain and so simple that all can</p><p>understand and apply it in each case. It is that the best</p><p>balance, the best harmony, the best proportions of the</p><p>mouth in its relation to the other features require in all</p><p>cases that there shall be the full complement of teeth,</p><p>and that each tooth shall be made to occupy its normal</p><p>position." He goes on to say, "I know this will surprise</p><p>you who are familiar with the literature of orthodontia,</p><p>in which extraction has been so lavishly advocated [em-</p><p>phasis mine]. How often have we read that in the treat-</p><p>ment of cases of malocclusion extraction was resorted</p><p>to 'to prevent the lips from being too prominent', or,</p><p>that 'the requirements of art necessitated that I remove</p><p>such and such teeth', or that, 'the patient inherited the</p><p>large teeth of one parent and the small jaws of the other,</p><p>making extraction necessary for the art requirements as</p><p>well as those of occlusion." His next sentence could be</p><p>construed as a repudiation of a previously held treatment</p><p>belief system albeit, not in a manner one would expect</p><p>from so forceful and dogmatic a person. He says that</p><p>"Having inherited, as it were, these sayings, I also</p><p>naturally believed them [emphasis mine], but I am now</p><p>positive that they are wrong, without substantiation,</p><p>and that they ought to be abandoned, and that working</p><p>from these dictates must be followed by asymmetry of</p><p>the face, which is perhaps only the least of the evil</p><p>effects." But then, further on, he goes on to say, "Indeed</p><p>I cannot look back over all the long list of my cases</p><p>without feeling that I have made blunders, at least from</p><p>an artistic standpoint, in the cases belonging to this</p><p>class (Class I) in which I have extracted teeth, except</p><p>possibly in one or two, and even these</p><p>are debatable."</p><p>Could it be that Angle underwent some sort of an in-</p><p>tellectual crisis so extreme in its effect on him as to</p><p>result in psychologic denial of previously held posi-</p><p>tions?</p><p>Angle continues this paper by presenting a series</p><p>of cases to illustrate his points, and in conclusion says</p><p>Volume 102 Special article 549</p><p>Number 6</p><p>that "we must work hand in hand with nature and assist</p><p>her to establish the relations of the teeth as the Creator</p><p>intended they should be, and not resort to mutilation."</p><p>Angle does not say how he knows what the Creator</p><p>intended nor does he admit to the possibility that if the</p><p>teeth are not in Angle's assumed correct positions, that</p><p>perhaps malaligned is what the Creator intended or that</p><p>maybe there is no Creator to even offer an opinion.</p><p>At the conclusion of his address, Angle presented</p><p>on the screen pictures of men "most earnest in the</p><p>upbuilding of orthodontia" and asks those assembled</p><p>"to note, as I do with pride, what intelligent, well-</p><p>proportioned faces are represented." Included in this</p><p>group is Calvin Case. If, by this date, Angle was in</p><p>controversy with Case, at least he was honest enough</p><p>to rise above it and recognize Case for what he was.</p><p>I have always found, and still do, the power of</p><p>dogma to be incomprehensible. Anyone in the practice</p><p>of orthodontics for any time, even graduate, students,</p><p>recognize that there are case problems that are abso-</p><p>lutely impossible to treat without the removal of teeth.</p><p>How, and even if, these adherents to Angle were able</p><p>to maintain and carry out his concepts in actualpractice</p><p>is unfathomable to me. But then, this is not the only</p><p>example of people being afraid or unable to think and</p><p>decide for themselves, especially when confronted with</p><p>examples to the contrary. Nor is it anymore unusual</p><p>even today to find people who claim they adhere to a</p><p>dogma, while in practice doing the opposite. It does</p><p>say something about human beings; and why large pop-</p><p>ulations are often so easily manipulated.</p><p>The evidence and the examples presented in Angle's</p><p>sixth edition are too numerous to present in total. How-</p><p>ever, to give you the flavor of this edition and why I</p><p>consider this presentation to be historical revisionism,</p><p>some excerpts should be convincing.</p><p>To set the scene, so to speak, one has to keep in</p><p>mind what Angle said in a paper delivered in 1903, 3~</p><p>just 3 years after the 1900 publication of his sixth edi-</p><p>tion; the seventh edition having been published in 1907.</p><p>Angle read that:</p><p>"Extraction is wrong. The full complement of teeth is</p><p>necessary to the best results, and each tooth should be made</p><p>to assume its correct relations with its fellows. I shall try to</p><p>impress you from the orthodontist's standpoint with the full</p><p>value of each individual tooth and with the absolute necessity</p><p>of preserving the full complement of teeth or its equivalent</p><p>in every case. I shall try to bring conclusive evidence that the</p><p>sacrifice of teeth for either the intended prevention or cor-</p><p>rection of malocclusion is not only wrong practice and fal-</p><p>lacious teaching, but most baneful in its results."</p><p>I am struck with his words "or its equivalent." Was</p><p>this an escape clause for Angle who undoubtably, as</p><p>you shall see, was originally a proponent and practi-</p><p>tioner of extractions. Did he mean by this phrase that</p><p>it was permissible to extract if well-coordinated, intact</p><p>arches were the result? It strains my imagination to</p><p>believe that Angle could continue practicing and teach-</p><p>ing with such a rigid position. Yet, that is what has</p><p>come down to us.</p><p>He goes on to say: "I shall further try to show that</p><p>the full complement of teeth is necessary to establish</p><p>the most pleasing harmony of the facial lines." This is</p><p>incomprehensible in view of the opposite argument he</p><p>presented in the sixth edition.</p><p>In his book, Case 28 prints these words of Angle;</p><p>then goes on to give Angle a back-handed compliment</p><p>by writing:</p><p>"No one can say that a radical statement of this kind from</p><p>a man of such eminence, did not do more good in stopping</p><p>the general ruthless extraction of teeth than any half-way</p><p>measures, even though untrue and not according to the rational</p><p>teaching which is practiced by advanced orthodontists today."</p><p>Beyond the fact of what is said by both men, I think</p><p>that one has to be impressed with the way they said it.</p><p>Their use of language appears to be a lost art in most</p><p>scientific presentations today.</p><p>As I stated previously, the raison d'etre of this article</p><p>was to do some historical revisionism of the commonly</p><p>accepted view that Angle was absolutely and incon-</p><p>trovertibly opposed to the extracting of teeth to treat</p><p>orthodontic problems. The first evidence of a contrary</p><p>view in the sixth edition ~2 comes in his sections on</p><p>actual case demonstrations.</p><p>On page 131, there are two cases shown, one in</p><p>Fig. 115, and the other Fig. 116. An argument can be</p><p>made from the drawing of the former that the first pre-</p><p>molars were missing before the onset of treatment.</p><p>Credulousness would be strained by the juxtaposition</p><p>of Fig. 116, which has the one premolar missing in</p><p>what is drawn as a recent extraction site.</p><p>Page 144 shows the continuation of treatment in</p><p>Fig. 129 in which "the cuspid is retracted into the space</p><p>made vacant by the loss of the first bicuspid." I note</p><p>that the word "loss" rather than extraction is used, but</p><p>in this case one would like to assume that even Angle</p><p>would extract, being he was so interested in occlusion,</p><p>rather than produce a much larger overjet.</p><p>For those now given to some skepticism, I offer the</p><p>following quotation found on page 195, which should</p><p>be prima facie evidence. Here, Angle writes "We should</p><p>aim, as far as may be consistent with conditions found</p><p>to exist in each given case, to place the teeth in normal</p><p>occlusion. This, however, is not always possible or</p><p>advisable, for to do so the full complement of teeth</p><p>550 Bernstein Am. J. Orthod. Dentofac. Orthop.</p><p>December 1992</p><p>must be retained, which in rare instances would result</p><p>in giving too great a prominence to the teeth and lips,</p><p>thereby creating a condition probably quite as unpleas-</p><p>ing as the original. In some instances, with the full</p><p>complement of teeth it may be impracticable to establish</p><p>harmony in the occlusal inclines, as for example in the</p><p>subdivisions of all the classes. Therefore it becomes</p><p>necessary in some cases to sacrifice some of the teeth</p><p>in order that we may have the best attainable degree of</p><p>occlusal and facial harmony, in which case the result</p><p>may be defined as improved occlusion, as distinguished</p><p>from normal occlusion."</p><p>Well, there it is for all the world to see (at least the</p><p>orthodontic world). After all the words spoken, all the</p><p>words written on this issue, after all the arguments and</p><p>controversies, after all the treatment decisions made on</p><p>accepted dogma, after all the training programs estab-</p><p>lished on a strict nonextraction dictum, after how many</p><p>untold thousands of patients were maltreated as a result,</p><p>it boggles the mind to see these words before one's</p><p>eyes. What is it in the nature of us as human beings,</p><p>supposedly endowed with the ability to reason and to</p><p>think, that drives us to throw reason to the wind and</p><p>to follow whatever pied piper we think is playing the</p><p>right tune? And this is just in orthodontics! Look at</p><p>what happens on the world stage when political or re-</p><p>ligious dogmas actually propel people to hate and even</p><p>to kill one another.</p><p>If you are still not convinced about Angle's phi-</p><p>losophy, let us turn to his words starting on page 198.</p><p>He writes, "The establishment of normal occlusion may</p><p>and should be the result in by far the largest percentage</p><p>of cases belonging to this class (Class I), but this is</p><p>only possible with the full complement of teeth. There</p><p>are cases, however (though the author believes they are</p><p>very few), in which extraction is n e c e s s a r y . . , the</p><p>author can conceive of but</p><p>two reasons for extraction</p><p>in this class.</p><p>First, where the jaws are so small, either naturally</p><p>or because of arrested development, that the angles of</p><p>inclination would be too great if all the teeth were placed</p><p>in line . . . .</p><p>Second, where extraction is necessary from the re-</p><p>quirements of the facial lines, for the development of</p><p>the arches may be such as to afford an abundance of</p><p>room for the malposed teeth, and the placing of them</p><p>in the line of occlusion may result in marked dental or</p><p>labial prominence, and the facial result be more un-</p><p>pleasing than if the teeth had been allowed to remain</p><p>in malpositions . . . .</p><p>It is difficult to lay down any precise rule regarding</p><p>extraction, but it is a matter which involves the broadest</p><p>consideration and closest study of each case, often tax-</p><p>ing the judgement as much as does any problem in</p><p>orthodontia. A rule that the attthor has followed for</p><p>some thne [emphasis mine], when at all in doubt, is to</p><p>pursue treatment according to the conservative method,</p><p>studying the relations of the dental arches and features</p><p>carefully, until a certainty in the matter shall become</p><p>apparent."</p><p>Angle proceeds on to a rather lengthy discussion of</p><p>the teeth, or tooth, of choice if extraction is deemed</p><p>advisable. He remonstrates against the removal of first</p><p>molars "for its loss not only could not benefit the</p><p>crowded condition of the incisors, but would probably</p><p>be followed by other forms of malocclusion even more</p><p>serious." As to the removal of canines or lateral inci-</p><p>sors, he states that "unless the root be malformed in</p><p>such a manner as to make adjustment impractical, the</p><p>author believes [this] to be no longer excusable even in</p><p>a country physician." He has an involved discussion</p><p>on premolar extractions that includes the statement "As</p><p>between the first and second bicuspids, their resem-</p><p>blance in form is so close as to make the choice for</p><p>sacrifice a matter of indifference were it not that the</p><p>loss of the second bicuspid greatly increases the diffi-</p><p>culty of treatment."</p><p>Later on in his text, we come to Chapter 18 that</p><p>deals with treatment of Class II, Division 1 cases, Chap-</p><p>ter 19 that presents Class II, Division 2 cases, and</p><p>Chapter 20 that discusses Class III treatment problems.</p><p>In each of these chapters there are several examples of</p><p>cases where it was necessary for Angle to resort to'the</p><p>extraction of teeth to treat his patients.</p><p>Finally, in the last chapter in Part I, Chapter 22,</p><p>(Part II is "Fractures of the Maxillae") entitled "General</p><p>Suggestions", we come to suggestion no. 9. In this he</p><p>writes that "The author hopes to impress two points</p><p>upon those who study this book. First, the importance</p><p>of occlusion, in which he would arouse a keener in-</p><p>terest. Second, the relation that each tooth bears to all</p><p>others in both arches, that there may always be careful</p><p>deliberation before sacrificing a tooth. The conse-</p><p>quences of extraction of even a single tooth are often</p><p>far-reaching, and sometimes make impossible the at-</p><p>tainment of results which otherwise might closely ap-</p><p>proach the ideal. All dentists should cultivate the habit</p><p>of observing the results following the extraction in the</p><p>cases of patients in their regular practice."</p><p>We have taken a rather quick journey through this</p><p>sixth edition of Angle's book, but enough of one to</p><p>have forever dispelled the up-to-now held belief that</p><p>Angle was unalterably opposed to extractions. I have</p><p>quoted at length from parts of the text because it appears</p><p>that my copy of this text is the only extant one, and</p><p>therefore it may not be possible for others to refer to</p><p>it.</p><p>I have tried to develop the lines of thinking in this</p><p>Volume 102 Special article 551</p><p>Number 6</p><p>enigmatic controversy and to place it all into the zeit-</p><p>geist of the times. But even with all this, the central</p><p>enigma remains that I cannot answer for you. And that</p><p>is why was this sixth edition withdrawn from publi-</p><p>cation? Other questions are why there seems to be no</p><p>other copies available, why Angle himself did not own</p><p>up to his previous positions, why others who he most</p><p>likely had made privy to them by word, training session,</p><p>or case demonstration did not challenge him directly or</p><p>write about it, and why it took him 7 years to produce</p><p>the expurgated seventh edition?</p><p>Not all the questions in life get answered, and we</p><p>have to accept that as part of life. Perchance someday</p><p>someone else will come across material that might shed</p><p>further light on this. Until then, on this question, I leave</p><p>you with a quotation from Gertrude Stein who said,</p><p>"There ain't any answer, there ain't going to be any</p><p>answer, there never has been an answer, that's the</p><p>answer."</p><p>I acknowledge and thank Celia E. Giltinan, the li-</p><p>brarian of the American Association of Orthodontists,</p><p>for her help in looking for and providing, many of the</p><p>papers I used in the preparation of this article.</p><p>REFt::FIENCI::S</p><p>1. Ottolengui R, ed, 1905 Volume. Items of Interest 1907;29:56.</p><p>2. Symposium on extraction. Second Distr Dent Soc NY, Feb. 13,</p><p>1905.</p><p>3. Dewey M. How much orthodontia should the general practitioner</p><p>do? Texas Dent J 1906;24:21-26.</p><p>4. Case CS. Correcting facial deformities in young subjects. Catch-</p><p>ing's Compendium Pract Dent, 1896:133-9.</p><p>5. Case CS. Exhibit of models showing the injudicious extraction</p><p>of the permanent teeth. Dent Rev 1903; ! 7:58-60.</p><p>6. Cryer MH. Something definite. Dent Cosmos 1905:203-5.</p><p>7. Exchanges between Dr. Ketcham of the "new school" and T. E.</p><p>Constant, MRCS, LRCP, LDS, of Scarboro, England, "Extrac-</p><p>tion versus retention of full complement of teeth." Dental Cos-</p><p>mos 1911;53:773-783;1409.</p><p>8. Angle EH. Art in relation to orthodontia. Proc Am Soc Orthod,</p><p>1902.</p><p>9. Angle EH. New system of regulation and retention. Dent Reg-</p><p>ister 1887;41:597-603.</p><p>10. Angle EH. The Angle system of regulation and retention of the</p><p>teeth. 1st ed. Philadelphia: SS White Manufacturing, 1887.</p><p>1 i. Angle Eli. The Angle system of regulation and retention of the</p><p>teeth and treatment of fractures of the maxillae. 5th ed. Phila-</p><p>delphia: SS White Manufacturing, 1897.</p><p>12. Angle EH. Treatment of malocclusion of the teeth and fractures</p><p>of the maxillae. 6th ed. Philadelphia: SS White Manufacturing,</p><p>1900.</p><p>13. Angle EH. Malocclusion of the teeth. 7th ed. Philadelphia: SS</p><p>White Manufacturing, 1907.</p><p>14. Exchanges between Calvin Case, and Martin Dewey on "The</p><p>Question of Extraction in Orthodontia." National Dental Asso-</p><p>ciation, Cleveland, Ohio, July 15, 1911. Dent Cosmos, 1912</p><p>and 1913.</p><p>15. The Extraction Debate of 1911. AM J OR'rlloo 1964;50:656-91,</p><p>751-68,843 -51,900-12.</p><p>16. Case CS. The advisability of extracting teeth in the correction</p><p>of irregularities. Dent Cosmos 1905:67.</p><p>17. Wuerpel EH. My friend, Edward Hartley Angle. Dent Cosmos</p><p>1931;73:908-21.</p><p>18. Bates JD. The extraction debate of 1911. New Dentist 1980:37.</p><p>19. Tweed Ctt. Why I extract teeth in the treatment of certain types</p><p>of malocclusion. Alpha Omegan 1952;46:93-104.</p><p>20. Tweed CH. The application of the principles of the edgewise</p><p>arch in the treatment of malocclusion, I, 11. Angle Orthod</p><p>1941;! 1:5,12.</p><p>Tweed CH. Indications for the extraction of teeth in orthodontic</p><p>procedure. AM J OR'roOD ORAL SURO 1944;30:405.</p><p>Tweed CH. A philosophy of orthodontic treatment. AM J ORTItOD</p><p>ORAL Suao 1945;31:74-103.</p><p>Dewel BF. The Case-Dcwey-Cryer extraction debate: a com-</p><p>mentary. AM J OR'ntOD 1964;50:862-5.</p><p>Asbell M. A brief history of orthodontics. AM J OR'IqtOD DEN-</p><p>TOFAC OR'mOP 1990;98:206-13.</p><p>Graber TM. Orthodontics, principles and practice. 3rd ed. Phil-</p><p>adelphia: WB Saunders, 1972.</p><p>Greenstein AV. The Tweed philosophy. AM J ORrrIOD ORAL SURO</p><p>1944.</p><p>Margolis HI. The axial inclination of the mandibular incisors.</p><p>AM J ORTHOD ORAL Stmo 1943;29:571-94.</p><p>Case CS. A practical treatise on the technics and principles of</p><p>dental orthopedia and prosthetic correction of cleft palate. 2nd</p><p>ed. 1921.</p><p>29. Case</p><p>CS. Origin, use and misuse of the intermaxillary force,</p><p>and its relations to occipital and other anchorage forces in orth-</p><p>dontia. Dent Cosmos 1904;66:345-51.</p><p>30. Angle EH. The importance of the first molars in their relation</p><p>to orthodontia. Dent Cosmos 1903.</p><p>31. Pollock HC. Introduction, the extraction debate of 1911 by Case,</p><p>Dewey, and Cryer. AM J OR'roOD 1964;50:656-7.</p><p>32. Jackson AF. Orthodontic "growing pains". AM J ORTItOD</p><p>1952;38:485-505.</p><p>33. Noyes FB. Orthodontic profile, Edward H. Angle. AM J OR'mOO</p><p>1957;43:132-4.</p><p>34. Baker CR. Calvin Suveril Case. AM J Oa'ntoD 1957;43:210-8.</p><p>Reprint requests to:</p><p>Dr. Leonard Bemstein</p><p>Boston University</p><p>School of Graduate Dentistry</p><p>1247A Beacon St.</p><p>Brookline, MA 02146</p><p>21.</p><p>22.</p><p>23.</p><p>24.</p><p>25.</p><p>26.</p><p>27.</p><p>28.</p>