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Edward H. Angle versus Calvin S. Case: Extraction versus nonextraction. Historical revisionism.

Part II
Leonard Bernstein Since Angle had a school for training orthodontists, his philosophy became the predominant one and such was the power accorded him, none dared to say otherwise. Not only did he dominate the philosophy of treatment, but his students and disciples carried it on. This idea is substantiated by Pollock who points out that Many of Angle's followers became teachers in dental schools, and for years the doctrine of the full complement of teeth was widely 31 disseminated. I remember being told that this power carried over to his widow who exerted great influence in seeing that the teachings and principles of her deceased husband remained inviolate. Jackson, as late as 1952, still had to defend his use of extractions for in describing his treatment of a case says, Fortunately, we have as one of our greatest allies the natural unaided readjustment of the tissues themselves which follows that most controversial 32 [emphasis mine] of all subjects, the judicious extraction of teeth. He also probably recognizes the influence of Angle-trained people dominating the universities as evidenced in his lengthy espousal of preceptorship training. This is accompanied by a frontal assault on university-dominated orthodontic training as exemplified by the following statements: The teaching field is naturally besieged by individuals of this type who in many cases are very clever in creating outward impressions of their qualifications as teachers. It is actually very easy to do this by writing papers on any of the highly scientific aspects of the orthodontic problem but which have little practical application. Individuals of this type would welcome nothing better than to win for themselves positions of full -time professorships which would provide sinecures for their financial needs in lieu of their precarious private practices and at the same time establish them in the professional esteems which they so urgently desire. In the first place, it is inconceivable that any man should be all owed to be in charge of any of the orthodontic departments of any of the universities in the country other than a man of long practical experience and recognized personal professional ability and standing in the specialty. Are we orthodontists going to allow this heritage to be lost and taken over by a group of clinical incompetents who are interested primarily in their own personal careers in the teaching field rather than in the broad interests of orthodontics itself? Jackson is less strident in evaluating Angle when he states, As a pioneer, Angle may possibly be forgiven for the fact that his whole concept of orthodontics and his methods of dealing with its basic problems were based on a very obvious but devastatingly fatal fallacy. This fallacy is the absolute impossibility of harnessing infinite variation as found in anything as fantastically complex as orthodontics to a definite set schematic classification and system of mechanical therapy, which in its broad sense is out of harmony with many of the basic biological principles of nature.32 But further, in regard to Angle's personality, he states, In Angle's original groups there naturally happened to be some mature intelligent, free thinkers, some of whom, exercising the prerogatives of free thought and speech, promptly found unceremonious exits through his back door. One would be hard-pressed to find other negative references to Angle in the literature even as late as 1952; such was the nature of the purported power of the man, his disciples, and his widow. The Dental Cosmos, in its section, Proceedings of Societies, published A Memorial Meeting to the Late Edward Hartley Angle, which was held by The Eastern Association of Graduates of the Angle School of Orthodontia, in the Vanderbilt Hotel, New York city, on Jan. 26, 1931.

One of the principal speakers was Professor Edmund H. Wuerpel 17 who delivered a paean to Angle, his friend of 31 years. One should read this paper to get a sense of Angle the person, while keeping in mind that this address was in the nature of a eulogy for an old, good friend. Even in this lengthy paean, it is possible to pick out comments that shed light on the nature of Angle. I quote part of a reconstructed conversation between Angle and Wuerpel as follows: After I got to know him betterand I think it was not over 2 years before I got to know him as well as ever I didI remarked, You have a vision, but you have a mighty obstinate one. What do you mean? The trouble with you is that you want everybody's vision to agree with your own. You will not see that very few people have the brains necessary to have your vision, and because they do not in intelligence come up to your standard, you conclude they do not that they have no vision. They have vision, but it is of lower degree than your own. Later on, Wuerpel says that, I used to plead with him so often, Why don't you look at things in a bigger way? You are a big man, you have big ideas, you understand things so nobly. Why don't you understand humanity better? Don't you realize that you could get along easier if you made people understand you? The trouble with you is that the wind of misunderstanding rises, and you wrap your mantle of pride around you, the more the wind blows the tighter the mantle goes around you. Nobody really sees you, they just see the mantle. Angle's answer to this criticism is informative of the man as he responded, Yes, but there is right and there is wrong. These people have done wrong. Wuerpel spoke of the humble background that Angle came from and noted that He came from an ancestry, which was rather bigoted. According to Wuerpel, he harbored a great dislike for Germans. He goes on to say that And although he rose above his narrow upbringing, he had all of the prejudices of that narrowness, and he never rid himself of them. This freedom, which we call modernism, he couldn't tolerate. He couldn't understand it. No matter how I argued, no matter what I said, he said, It is wrong. Wuerpel goes on to admonish Angle and asking him to be more tolerant of other people's ways of looking at things; this Angle coul d not do and thus, He made enemies because he made remarks about it. People couldn't understand. They couldn't understand because they weren't with him; they thought he was narrow, prejudiced, a cantankerous old fool. And he was, in certain ways. I will grant it. He stood in his own light in some instances, but if people had only understood, they would have had tolerance. Throughout his eulogy, Wuerpel17 alludes again and again to the high ideals and standards that Angle set for himself and his impatience with those who did not live up to what Angle set as the standard. It is summed up by Wuerpel when he rhetorically asks, Why was it that people in the majority of cases went against him instead of with him? He answers himself by saying, It was because of this idealism, because of this insatiable desire to live on the heights, and because he required this of himself, he required it of all mankind. If this portrait of Angle is correct, and one has to read the whole eulogy to get the flavor of the man Wuerpel is describing, then the more enigmatic the mystery of the sixth edition becomes. Why did Angle never make reference to this book? Why did he supposedly have it withdrawn from publication? Why did he not, in regard to his putative high ideals, repudiate it? I regret that I have no definitive answers for you. In terms of Freudian psychology today, we can analyze Angle in ways that were not as readily facile then as today. If Professor Wuerpel's degree had been in psychology rather than art, and were he to give an evaluation of his friend today, there might be some different conclusions as the nature of the man. In a profile of Angle, Noyes starts off by saying that Dr. Angle was a genius, essentially a 33 mechanical [emphasis mine] genius. After reading things that Angle himself wrote and reading what others wrote about him, the flavor of the man that starts to emerge is that indeed he was a genius but was not so in many areas. Wuerpel,17 Noyes,33 and Dewel23 all point out the range of Angle's talents and far-ranging interests from inventing appliances to woodworking and carpentry to collecting Southwest Indian beadwork and blankets. Even with all this, when compared to Case, Case emerges as more of a true scientist and more of a Renaissance man, seemingly knowledgeable in many

areas. Indeed, Angle himself may have consciously or subconsciously recognized his own shortcomings in comparison with Case. Another flavor of Angle that appears to me is that of a basically insecure man who is working overly hard to cover his insecurities by hiding behind the dogmatic, absolutist positions he takes. This insecurity puts him in conflict with most people, as documented by Wuerpel,17 and puts him into the position of having to be always right and incapable of accepting criticism. In a letter to me dated Apr. 4, 1991, Graber points out that Case was more successful as a contemporary leader than Angle. Case was on the inside leading, while Angle was the maverick. He resented Calvin Case. And what about Case? What kind of man was he? One has to read the works of the man to gather a true flavor of the man, other than what I have so far written of him. For those interested, there is an excellent biography of Calvin Suveril Case by Charles R. Baker,34 which appeared in the March 1957 issue of the AMERICAN JOURNAL OF ORTHODONTICS. In this biography, note is given that even his adversary, Martin Dewey, had to praise him. Among other things, Dewey states Many times I did not agree with Dr. Case, but his wonderful nature was revealed by the fact that even though you disagreed with him on a scientific question, he always remained your friend and believed that you had the right to your opinion that he wished you to allow him to have his. Baker says that Dewey was also quoted as saying that Dr. Case told me that one of his greatest regrets was that he could not have the opportunity of sitting at a conference table with Dr. E. H. Angle, for he felt that such a discussion would show that their ideas on most orthodontic topics were very much alike. Baker ends his article with the following: So ends the story of a great man, who was sincere in his work, and loyal in his friendships. Noyes also notes that Angle could never take criticism or argument and told a young man about to visit Angle, Do not ask questions or try to argue; just sit and take everything he has to give, then go home and think about it. He further points out that Being a genius, he could never defend his own ideas . . .. He knew that they were right. Noyes furthers his profile by relating how Angle would go to a meeting to present his ideas and when verbally attacked by those present, all he could do was call them fools. Further on, Noyes relates how Angle would ride a man unmercifully to see if he was man enough to take it and if he could, he gave him all he could take. At one point, Angle went later to visit one of these men and found that he had gone to old methods of practice. Not only did Angle berate him but upon going home was sick for 2 weeks. In psychologic terms it appears that Angle could only justify his sense of being, his absolutist based insecurity, by finding someone who believed in him absolutely. This gave credence and substance to his existence and to discover someone who then fell away would appear to Angle to be a total repudiation of his own sense of self, his insecurities were being confronted and he could not take it. Noyes ends his article by saying that Dr. Angle was a great man. I can agree that Dr. Angle made many important contributions to orthodontics, but a great man would to my mind be capable of introspection at least to the point of understanding, and hopefully overcoming, psychologic barriers. Dr. Angle was his own worst enemy, and although the evidence supplied by Wuerpel17 is that he understood that, he could not go beyond that in understanding and coming to terms with his own psyche. The era of Freud was not yet far enough into the general zeitgeist to be of any benefit to Angle. I am thus forced to agree with Noyes's earlier statement in this article that Dr. Angle was a most tragic character, for his nature was a mixture of the most violently opposite and contending qualities. Let us look again at Angle's own words in regard to his philosophy of treatment by going to a paper delivered by him8 in the Proceedings of the American Society of Orthodontists in 1902. Try to keep in mind, when I come to the sixth edition itself, that this paper was published only 2 years after the publication of this edition. Nothing could be more succinct than Angle's own basis of his philosophy of treatment than that provided in this paper. He states that, I believe we do have a rule which artists probably know nothing of (he is referring to his friend Wuerpel), and one more unvarying and more reliable than even the judgement of the favored few (he is referring to Wuerpel's comment that only 1 or 2 in 300 will be able to master the ability to judge the correct proportion of the features in each given type)a rule so invariable and with so few exceptions that we may almost consider it a law, and if it not be applicable in all cases, the exceptions will be so rare that they are hardly worth considering. It is, furthermore, a rule so plain and so simple that all can understand and
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apply it in each case. It is that the best balance, the best harmony, the best proportions of the mouth in its relation to the other features require in all cases that there shall be the full complement of teeth, and that each tooth shall be made to occupy its normal position. He goes on to say, I know this will surprise you who are familiar with the literature of orthodontia, in which extraction has been so lavishly advocated [emphasis mine]. How often have we read that in the treatment of cases of malocclusion extraction was resorted to to prevent the lips from being too prominent, or, that the requirements of art necessitated that I remove such and such teeth, or that, the patient inherited the large teeth of one parent and the small jaws of the other, making extraction necessary for the art requirements as well as those of occlusion. His next sentence could be construed as a repudiation of a previously held treatment belief system albeit, not in a manner one would expect from so forceful and dogmatic a person. He says that Having inherited, as it were, these sayings, I also naturally believed them [emphasis mine], but I am now positive that they are wrong, without substantiation, and that they ought to be abandoned, and that working from these dictates must be followed by asymmetry of the face, which is perhaps only the least of the evil effects. But then, further on, he goes on to say, Indeed I cannot look back over all the long list of my cases without feeling that I have made blunders, at least from an artistic standpoint, in the cases belonging to this class (Class I) in which I have extracted teeth, except possibly in one or two, and even these are debatable. Could it be that Angle underwent some sort of an intellectual crisis so extreme in its effect on him as to result in psychologic denial of previously held positions? Angle continues this paper by presenting a series of cases to illustrate his points, and in conclusion says that we must work hand in hand with nature and assist her to establish the relations of the teeth as the Creator intended they should be, and not resort to mutilation. Angle does not say how he knows what the Creator intended nor does he admit to the possibility that if the teeth are not in Angle's assumed correct positions, that perhaps malaligned is what the Creator intended or that maybe there is no Creator to even offer an opinion. At the conclusion of his address, Angle presented on the screen pictures of men most earnest in the upbuilding of orthodontia and asks those assembled to note, as I do with pride, what intelligent, well-proportioned faces are represented. Included in this group is Calvin Case. If, by this date, Angle was in controversy with Case, at least he was honest enough to rise above it and recognize Case for what he was. I have always found, and still do, the power of dogma to be incomprehensible. Anyone in the practice of orthodontics for any time, even graduate students, recognize that there are case problems that are absolutely impossible to treat without the removal of teeth. How, and even if, these adherents to Angle were able to maintain and carry out his concepts in actual practice is unfathomable to me. But then, this is not the only example of people being afraid or unable to think and decide for themselves, especially when confronted with examples to the contrary. Nor is it anymore unusual even today to find people who claim they adhere to a dogma, while in practice doing the opposite. It does say something about human beings; and why large populations are often so easily manipulated. The evidence and the examples presented in Angle's sixth edition are too numerous to present in total. However, to give you the flavor of this edition and why I consider this presentation to be historical revisionism, some excerpts should be convincing. To set the scene, so to speak, one has to keep in mind what Angle said in a paper delivered in 1903,30 just 3 years after the 1900 publication of his sixth edition; the seventh edition having been published in 1907. Angle read that: Extraction is wrong. The full complement of teeth is necessary to the best results, and each tooth should be made to assume its correct relations with its fellows. I shall try to impress you from the orthodontist's standpoint with the full value of each individual tooth and with the absolute necessity of preserving the full complement of teeth or its equivalent in every case. I shall try to bring conclusive evidence that the sacrifice of teeth for either the intended prevention or correction of malocclusion is not only wrong practice and fallacious teaching, but most baneful in its results.

I am struck with his words or its equivalent. Was this an escape clause for Angle who undoubtedly, as you shall see, was originally a proponent and practitioner of extractions. Did he mean by this phrase that it was permissible to extract if well-coordinated, intact arches were the result? It strains my imagination to believe that Angle could continue practicing and teaching with such a rigid position. Yet, that is what has come down to us. He goes on to say: I shall further try to show that the full complement of teeth is necessary to establish the most pleasing harmony of the facial lines. This is incomprehensible in view of the opposite argument he presented in the sixth edition. In his book, Case28 prints these words of Angle; then goes on to give Angle a back-handed compliment by writing: No one can say that a radical statement of thi s kind from a man of such eminence, did not do more good in stopping the general ruthless extraction of teeth than any half-way measures, even though untrue and not according to the rational teaching which is practiced by advanced orthodontists today. Beyond the fact of what is said by both men, I think that one has to be impressed with the way they said it. Their use of language appears to be a lost art in most scientific presentations today. As I stated previously, the raison d'etre of this article was to do some historical revisionism of the commonly accepted view that Angle was absolutely and incontrovertibly opposed to the extracting of teeth to treat orthodontic problems. The first evidence of a contrary view in the sixth edition12 comes in his sections on actual case demonstrations. On page 131, there are two cases shown, one in Fig. 115, and the other Fig. 116. An argument can be made from the drawing of the former that the first premolars were missing before the onset of treatment. Credulousness would be strained by the juxtaposition of Fig. 116, which has the one premolar missing in what is drawn as a recent extraction site. Page 144 shows the continuation of treatment in Fig. 129 in which the cuspid is retracted into the space made vacant by the loss of the first bicuspid. I note that the word loss rather than extraction is used, but in this case one would like to assume that even Angle would extract, being he was so interested in occlusion, rather than produce a much larger overjet. For those now given to some skepticism, I offer the following quotation found on page 195, which should be prima facie evidence. Here, Angle writes We should aim, as far as may be consistent with conditions found to exist in each given case, to place the teeth in normal occlusion. This, however, is not always possible or advisable, for to do so the full complement of teeth must be retained, which in rare instances would result in giving too great a prominence to the teeth and lips, thereby creating a condition probably quite as unpleasing as the original. In some instances, with the full complement of teeth it may be impracticable to establish harmony in the occlusal inclines, as for example in the subdivisions of all the classes. Therefore it becomes necessary in some cases to sacrifice some of the teeth in order that we may have the best attainable degree of occlusal and facial harmony, in which case the result may be defined as improved occlusion, as distinguished from normal occlusion. Well, there it is for all the world to see (at least the orthodontic world). After all the words spoken, all the words written on this issue, after all the arguments and controversies, after all the treatment decisions made on accepted dogma, after all the training programs established on a strict nonextraction dictum, after how many untold thousands of patients were maltreated as a result, it boggles the mind to see these words before one's eyes. What is it in the nature of us as human beings, supposedly endowed with the ability to reason and to think, that drives us to throw reason to the wind and to follow whatever pied piper we think is playing the right tune? And this is just in orthodontics! Look at what happens on the world stage when political or religious dogmas actually propel people to hate and even to kill one another.

If you are still not convinced about Angle's philosophy, let us turn to his words starting on page 198. He writes, The establishment of normal occlusion may and should be the result in by far the largest percentage of cases belonging to this class (Class I), but this is only possible with the full complement of teeth. There are cases, however (though the author believes they are very few), in which extraction is necessary. . . the author can conceive of but two reasons for extraction in this class. First, where the jaws are so small, either naturally or because of arrested development, that the angles of inclination would be too great if all the teeth were placed in line . . .. Second, where extraction is necessary from the requirements of the facial lines, for the development of the arches may be such as to afford an abundance of room for the malposed teeth, and the placing of them in the line of occlusion may result in marked dental or labial prominence, and the facial result be more unpleasing than if the teeth had been allowed to remain in malpositions . . .. It is difficult to lay down any precise rule regarding extraction, but it is a matter which involves the broadest consideration and closest study of each case, often taxing the judgement as much as does any problem in orthodontia. A rule that the author has followed for some time [emphasis mine], when at all in doubt, is to pursue treatment according to the conservative method, studying the relations of the dental arches and features carefully, until a certainty in the matter shall become apparent. Angle proceeds on to a rather lengthy discussion of the teeth, or tooth, of choice if extraction is deemed advisable. He remonstrates against the removal of first molars for its loss not only could not benefit the crowded condition of the incisors, but would probably be followed by other forms of malocclusion even more serious. As to the removal of canines or lateral incisors, he states that unless the root be malformed in such a manner as to make adjustment impractical, the author believes [this] to be no longer excusable even in a country physician. He has an involved discussion on premolar extractions that includes the statement As between the first and second bicuspids, their resemblance in form is so close as to make the choice for sacrifice a matter of indifference were it not that the loss of the second bicuspid greatly increases the difficulty of treatment. Later on in his text, we come to Chapter 18 that deals with treatment of Class II, Division 1 cases, Chapter 19 that presents Class II, Division 2 cases, and Chapter 20 that discusses Class III treatment problems. In each of these chapters there are several examples of cases where it was necessary for Angle to resort to the extraction of teeth to treat his patients. Finally, in the last chapter in Part I, Chapter 22, (Part II is Fractures of the Maxillae) entitled General Suggestions, we come to suggestion no. 9. In this he writes that The author hopes to impress two points upon those who study this book. First, the importance of occlusion, in which he would arouse a keener interest. Second, the relation that each tooth bears to all others in both arches, that there may always be careful deliberation before sacrificing a tooth. The consequences of extraction of even a single tooth are often far-reaching, and sometimes make impossible the attainment of results which otherwise might closely approach the ideal. All dentists should cultivate the habit of observing the results following the extraction in the cases of patients in their regular practice. We have taken a rather quick journey through this sixth edition of Angle's book, but enough of one to have forever dispelled the up-to-now held belief that Angle was unalterably opposed to extractions. I have quoted at length from parts of the text because it appears that my copy of this text is the only extant one, and therefore it may not be possible for others to refer to it. I have tried to develop the lines of thinking in this enigmatic controversy and to place it all into the zeitgeist of the times. But even with all this, the central enigma remains that I cannot answer for you. And that is why was this sixth edition withdrawn from publication? Other questions are why there seems to be no other copies available, why Angle himself did not own up to his previous positions, why others who he most likely had made privy to them by word, training

session, or case demonstration did not challenge him directly or write about it, and why it took him 7 years to produce the expurgated seventh edition? Not all the questions in life get answered, and we have to accept that as part of life. Perchance someday someone else will come across material that might shed further light on this. Until then, on this question, I leave you with a quotation from Gertrude Stein who said, There ain't any answer, there ain't going to be any answer, there never has been an answer, that's the answer.

Acknowledgements I acknowledge and thank Celia E. Giltinan, the librarian of the American Association of Orthodontists, for her help in looking for and providing, many of the papers I used in the preparation of this article. References 1. 1905 Volume. Ottolengui R, ed. Items of Interest. 29:1907:56 2. Symposium on extraction. Second Distr Dent Soc NY. Feb.13,1905; 3. Dewey M. How much orthodontia should the general practitioner do?. Texas Dent J. 1906;24:21-26 4. Case CS. Correcting facial deformities in young subjects. Catching's Compendium Pract Dent. 1896;133-139 5. Case CS. Exhibit of models showing the injudicious extraction of the permanent teeth. Dent Rev. 1903;17:58-60 6. Cryer MH. Something definite. Dent Cosmos. 1905;203-205 7. Exchanges between Dr. Ketcham of the new school and T. E. Constant, MRCS, LRCP, LDS, of Scarboro, England, Extraction versus retention of full complement of teeth. [Special issue]. Dental Cosmos. 1911;53(773-783):1409 8. Angle EH. Art in relation to orthodontia. Proc Am Soc Orthod. 1902; 9. Angle EH. New system of regulation and retention. Dent Register. 1887;41:597-603 10. Angle EH. The Angle system of regulation and retention of the teeth. (1st ed) Philadelphia: SS White Manufacturing 1887 11. Angle EH. The Angle system of regulation and retention of the teeth and treatment of fractures of the maxillae. (5th ed) Philadelphia: SS White Manufacturing 1897 12. Angle EH. Treatment of malocclusion of the teeth and fractures of the maxillae. (6th ed) Philadelphia: SS White Manufacturing 1900 13. Angle EH. Malocclusion of the teeth. (7th ed) Philadelphia: SS White Manufacturing 1907 14. Exchanges between Calvin Case, and Martin Dewey on The Question of Extraction in Orthodontia. National Dental Association, Cleveland, Ohio, July 15, 1911 [Special issue]. Dent Cosmos. 1912 and 1913;

15. The Extraction Debate of 1911. AM J ORTHOD. 1964;50:656-691751-68,843-51,900-12 16. Case CS. The advisability of extracting teeth in the correction of irregularities. Dent Cosmos. 1905;67 17. Wuerpel EH. My friend, Edward Hartley Angle. Dent Cosmos. 1931;73:908-921 18. Bates JD. The extraction debate of 1911. New Dentist. 1980;37 19. Tweed CH. Why I extract teeth in the treatment of certain types of malocclusion. Alpha Omegan. 1952;46:93-104 20. Tweed CH. The application of the principles of the edgewise arch in the treatment of malocclusion, I, II. Angle Orthod. 1941;11:512 21. Tweed CH. Indications for the extraction of teeth in orthodontic procedure. AM J ORTHOD ORAL SURG. 1944;30:405 22. Tweed CH. A philosophy of orthodontic treatment. AM J ORTHOD ORAL SURG. 1945;31:74-103 23. Dewel BF. The Case-Dewey-Cryer extraction debate: a commentary. AM J ORTHOD. 1964;50:862-865 CrossRef 24. Asbell M. A brief history of orthodontics. AM J ORTHOD DENTOFAC ORTHOP. 1990;98:206-213 25. Graber TM. Orthodontics, principles and practice. (3rd ed) Philadelphia: WB Saunders 1972 26. Greenstein AV. The Tweed philosophy. AM J ORTHOD ORAL SURG. 1944; 27. Margolis HI. The axial inclination of the mandibular incisors. AM J ORTHOD ORAL SURG. 1943;29:571-594 28. Case CS. A practical treatise on the technics and principles of dental orthopedia and prosthetic correction of cleft palate. (2nd ed) 1921 29. Case CS. Origin, use and misuse of the intermaxillary force, and its relations to occipital and other anchorage forces in orthdontia. Dent Cosmos. 1904;66:345-351 30. Angle EH. The importance of the first molars in their relation to orthodontia. Dent Cosmos. 1903; 31. Pollock HC. Introduction, the extraction debate of 1911 by Case, Dewey, and Cryer. AM J ORTHOD. 1964;50:656-657 32. Jackson AF. Orthodontic growing pains. AM J ORTHOD. 1952;38:485-505 CrossRef 33. Noyes FB. Orthodontic profile, Edward H. Angle. AM J ORTHOD. 1957;43:132-134 CrossRef 34. Baker CR. Calvin Suveril Case. AM J ORTHOD. 1957;43:210-218 CrossRef

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