# Dental care of Anne d'Alègre (1565–1619, Laval, France). Between therapeutic reason and aesthetic evidence, the place of the social and the medical in the care in modern period

Rozenn Colleter, Antoine Galibourg, Jérôme Treguier, Mikaël Guiavarc'H, Éric Mare, Pierre-Jean Rigaud, Florent Destruhaut, Norbert Telmon, Delphine Maret

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Rozenn Colleter, Antoine Galibourg, Jérôme Treguier, Mikaël Guiavarc'H, Éric Mare, et al.. Dental care of Anne d'Alègre (1565–1619, Laval, France). Between therapeutic reason and aesthetic evidence, the place of the social and the medical in the care in modern period. Journal of Archaeological Science: Reports, 2023, 48, pp.103794. 10.1016/j.jasrep.2022.103794. hal-04037713

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# Dental care of Anne d'Alègre (1565–1619, Laval, France). Between therapeutic reason and aesthetic evidence, the place of the social and the medical in the care in modern period

Rozenn Colleter<sup>a,b,c,*†</sup>, Antoine Galibourg<sup>b,d,†</sup>, Jérôme Treguier<sup>e</sup>, Mikaël Guiavarc'h<sup>f</sup>, Éric Mare<sup>a</sup>, Pierre-Jean Rigaud<sup>g</sup>, Florent Destruhaut<sup>d,h</sup>, Norbert Telmon<sup>b,i</sup>, Delphine Maret<sup>b,d,i,*</sup>

## ARTICLE INFO

### Keywords:

Periodontal disease

Dentistry

Seventeenth century

Dental prosthesis

Dental care

Tooth wear

## ABSTRACT

Analysis of the oral cavity of human archaeological remains can provide essential information on the general health status of the person. The objectives of this paper are (i) to highlight an analysis of the oral state of the embalmed body of a 17th century female aristocrat with modern techniques of periodontal diagnosis and (ii) to provide a description of the therapeutic and aesthetic management intended to limit the functional and aesthetic consequences of the loss of teeth related to this periodontal disease. This paper provides the first demonstration of a link between a diagnosis and a therapy on an identified individual using new digital technologies used in modern dentistry. We propose that the objective of the treatment was triple: therapeutic, aesthetic and societal. Beyond the only therapeutic care and far from the only coquetry, this study shows also the importance of the appearance for aristocratic women submitted to strong social constraints (like stress or widowhood), the speech of the disfigured women being could be regarded as depraved.

## 1. Introduction

Reconstructing the anthropological characteristics and the living and health conditions of ancient humans is essential for archaeological and paleoanthropological research. Skeletal remains, notably of the oral cavity, are a significant source of information as oral health is closely related to systemic health and the oral state of human remains can provide an indication for the diagnosis of a specific pathology (Keenleyside et al., 2009; Meller et al., 2009; Benazzi et al., 2009; Cucina et al., 2019).

Tooth loss may be related to a trauma or the presence of oral pathology, notably periodontal disease, which is, perhaps, the most

common oral disease of humans (Papapanou, 1999; Raitapuro-Murray et al., 2014; Caton et al., 2018). It is the result of a chronic gingival inflammatory response due to the accumulation of dental plaque (Papapanou, 1999; Caton et al., 2018). The loss of attachment of the connective tissue and the destruction of the alveolar bone causes a progressive loss of attachment around the teeth concerned, eventually leading to increased mobility (Ericsson et al., 1993). Periodontal health is recognized as an important component of general well-being because of the impact of oral pathologies on general health (Papapanou, 1999; Caton et al., 2018). For decades, archaeologists and anthropologists have been interested in the periodontal status of ancient populations, and several studies have described periodontal disease in ancient

<footnote><sup>a</sup> INRAP (Institut National de Recherches Archéologiques Préventives), 37 rue du Bignon, 35577 Cesson-Sévigné, France</footnote>

<footnote><sup>b</sup> CNRS, CAGT, UMR 5288, Université Paul Sabatier, 37 allées Jules Guesde, 31000 Toulouse, France</footnote>

<footnote><sup>c</sup> Department of Archaeology, Simon Fraser University, Education Building 9635, 8888 University Dr., Burnaby, BC V5A 1S6, Canada</footnote>

<footnote><sup>d</sup> Faculté de Chirurgie Dentaire, Université Paul Sabatier, Centre Hospitalier Universitaire, 3 chemin des Maraîchers, 31062 Toulouse, France</footnote>

<footnote><sup>e</sup> Musée des sciences, 21 Rue du Douanier Rousseau, 53000 Laval, France</footnote>

<footnote><sup>f</sup> CNRS, Université de Rennes, UMR6566 CReAAH, Campus de Beaulieu, bâtiment 24/25, 35042 Rennes, France</footnote>

<footnote><sup>g</sup> Laboratoire d'Anatomie Anthropologique et de Paléopathologie de Lyon, Lyon, France</footnote>

<footnote><sup>h</sup> URU EvolSan, Rangueil Hospital Group, Université Paul Sabatier, 3 chemin des Maraîchers, 31062 Toulouse, France</footnote>

<footnote><sup>i</sup> Department of Forensic Medicine, Centre Hospitalier Universitaire de Toulouse, Université de Toulouse, 1 Av. du Professeur Jean Poulhes, 31400 Toulouse, France</footnote>

<footnote>* Corresponding authors at: CNRS, CAGT, UMR 5288, Université Paul Sabatier, 37 allées Jules Guesde, 31000 Toulouse, France. E-mail addresses: rozenn.colleter@inrap.fr (R. Colleter), delphine_maret@yahoo.fr (D. Maret).</footnote>

<footnote n="1">¹ These authors contributed equally to this work.</footnote>
populations (Hildebolt and Molnar, 1991; Gonçalves et al., 2015; Will-
mann et al., 2018; Bertl et al., 2020; Al-Mutairi et al., 2022; Bagis and
Camgoz, 2022).

Because of bone loss, periodontal destruction often leads to tooth
hypermobility. Loose teeth lead to both discomfort and aesthetic
inconvenience for the subject, but also negative functional consequences
such as weakened teeth (Kathariya et al., 2016). Splinting loose teeth
together allows them to distribute the forces of the mobile teeth,
resulting in stronger teeth support. This prolongs the longevity of loose
teeth, provides stability for the periodontium to reattach, and improves
comfort, function and aesthetics (Kathariya et al., 2016; Serio, 1999).
This symptomatic treatment of periodontal destruction by restraint is
known since 2500 BCE in Ancient Egypt (Becker and Turfa, 2017). In
archaeology; examples of prosthesis replacing incisors or canines have
been described (Crubézy et al., 1998; Seguin et al., 2014; Delattre, 2018;
Debouige and Delattre, 2021; Cunha et al., 2017). The question arises
whether these prostheses were made during the individual's lifetime or
after his death. There are cases, where prostheses were found implanted
in the alveolar bone. The evaluation of the degree of osseointegration
allows determining if the act was performed ante or post-mortem
(Seguin et al., 2014).

Studies of past populations rely on the examination of collections of
ancient skulls collections and pose some technical challenges. In
particular, a diagnosis of their periodontal disease depends on the esti-
mation of the loss of attachment from an examination of the hard or
mummified tissues only (skeleton and organic), which is difficult to
reconcile with the application of the standardized case definitions of
disease used in studies today (Caton et al., 2018). Digital technologies
have been developed that can complement, and often replace, direct
anthropometric measurements (Heike et al., 2009; Omari et al., 2021;
Barreau et al., 2022). These indirect methods include methods such as
3D imaging, surface scanning (Omari et al., 2021; Fourie et al., 2011).
With indirect anthropometry, the images are obtained quickly and can
be rotated, enlarged, and archived for later evaluation (Heike et al.,
2009; Omari et al., 2021). In addition, it is non-invasive, which is
particularly useful when the remains are sensitive or fragile because
they can be studied without damage to the original sample (Omari et al.,
2021; Garcia de Leon Valenzuela et al., 2014). Indeed, the preservation
of data and the replicability of analyses are something crucial today in
archaeological ethical issues (Barreau et al., 2022; Colleter and Adèle,
2019). The digital tools of modern dentistry (intra-oral 3D scanning,
digital imaging) can provide a fast, accurate and non-invasive method of
recording dental information (Rajshekar et al., 2017). Scanning, 3D
printing techniques and digital scanners have been used to create virtual
digital models that can be used in dentistry and other related fields.

Beyond the recognition of periodontal symptoms by imagery, the
problem of archaeological contexts that are often poorly documented
(Becker, 1999) is an obstacle to the study of therapeutic treatments over
time. Therefore, the discovery of a lead coffin in a chapel of Laval Castle
(Mayenne, France, GPS: 48.0684, -0.7706) during a preventive
archaeological excavation in 1987 uncovered two well-preserved re-
straint prostheses on the jaw of a perfectly preserved woman by
embalming and identified as Anne d'Alègre (1565-1619) (Colleter et al.,
2011; Moisdon and Rigaud, 1992). This well-documented discovery
(archaeology, anthropobiology, history) allows us to take stock of the
dental prostheses of the modern era, from their manufacturing tech-
nique to their aesthetic and functional character.

The objective of this article is to present an original case of oral
evaluation using the tools of digital technology used in current clinical
practice. Beyond the technical skill of the dentists of the past, between
therapeutic necessity and aesthetic intent, the socio-economic context of
the subject treated also provides information about a practice reserved
for the most privileged from the Modern era.

## 2. Materials

The subject studied here comes from the excavation of the chapel of
the castle of Laval (Mayenne, France; Fig. 1A) (Mare, 1987). It concerns
a woman died after age 60, and was buried in a lead coffin encased in a
wooden plank coffin on which was placed a cardiotaph, a coffin also in
lead in the shape of a heart (Fig. 1B) (Colleter et al., 2011; Moisdon and
Rigaud, 1992). The embalmed body with a combination of aromatic
plants (thyme, oregano, and juniper as main components of the recipe)
(Ruas, 1992) was wrapped and tied up in a linen shroud and was in
perfect anatomical connection. From the urn, a desiccated amalgam
moulded to the wall was extracted without further precision. It was
undoubtedly a human heart, possibly embalmed with odoriferous and
drying materials as the aristocratic tradition required (Corbineau et al.,
2017) even if this was not always the rule (Mokrane et al., 2016).

From a paleopathological view, the skeleton shows numerous
degenerative lesions linked to the advancing age. Therefore, almost all
the joints show osteoarthritis and/or enthesopathy, lesions on the
enthesis which are necessarily due to age. Numerous sequelae of trauma
ante-mortem are visible on the thoracic cage: ossification of the 10th left
rib in the thoracic spine; sequelae of trauma on the sixth and eighth left
ribs and a costovertebral dislocation accompanied by calcified and
ossified hemorrhagic changes on thoracic vertebrae 9 to 12. A congenital
malformation (spina bifida) is visible on the sacrum and on the first
cervical vertebra, and a thoracic scoliosis is also noted. The skull
included the upper and lower jaws, both with most of the teeth. Two
prostheses or ligatures were visible on the maxilla, one of which con-
tained a replacement for a central incisor (Fig. 2).

The proposed identification with Anne d'Alègre was based on the
location of the tomb, the written records, the anthropobiological data
(sex, age at death, dental care) and the funerary practices highlighted
(embalming and burial in a lead coffin), characteristic of aristocratic
burials of the Late Middle Ages and Modern Period (Fig. 1C) (Colleter
et al., 2016).

## 3. Methods: Visual and radiological analyses

The dental study was based on the visual examination of the
mandibular and maxillary pieces.

The type of data collected are presented in Table 1.

Concerning the assessment of periodontal disease, we used the new
classification of periodontal and peri-implant diseases established by the
American Academy of Periodontology (AAP) and the European Feder-
ation of Periodontology (EFP) in 2018 (Caton et al., 2018). The new
classification serves as a diagnostic system and classifies periodontal
disease according to stage and grade (Caton et al., 2018). It considers:
the severity, the complexity of the treatment, the risk of progression and
the expected response to treatment, and comprises 4 stages:

* Stage I: Early stages of attachment loss

* Stage II: Established periodontitis.

* Stage III: Significant damage to the attachment apparatus.

* Stage IV: Significant damage to periodontal support, leading to tooth loss and loss of masticatory function.

All stages of periodontitis are supplemented with information about
the grade of the disease.

Grading is based on direct and indirect evidence of risk factors:

* Grade A: rate of periodontal disease progression is low.

* Grade B: called the expected progression with a moderate rate of progression.

* Grade C: high risk of periodontal disease progression.

The dental observation and the ligature were first studied with an
Unitron EXAMET-4 Metallurgical Microscope Series 14,250 / 14,251 to
<figure><img src="image_4.png" /><figcaption>**Fig. 1.** A: Topographical location of Laval (France); B: View of the lead coffin when discovered; C: Oil on canvas representing the portrait of Anne d'Alègre after 1583.</figcaption></figure>

<figure><img src="image_5.png" /><figcaption>**Fig. 2.** Vestibular view of the maxilla and mandible. A: Photograph and B: Cone Beam Computed Tomography (CBCT).</figcaption></figure>

determine the wear of the unit and the material used. Precise 2D views were realized and are shown in the results.

Additionally, X-ray examinations were performed using a Kodak 9600 Cone Beam Computed Tomography (CBCT) X-ray apparatus. Periodontal bone loss, osteolytic infectious lesions of endodontic origin, such as periapical granulomas or cysts, bone deformation due to residual periodontal cysts and intra bony cavities were analysed with CBCT. Dental abscesses were scored as present when maxillary or mandibular bone was destroyed by an infectious process, creating a rounded cavity in the spongy bone and a radiolucent lesion.

Ligatures were also described, both visually and with a surface analysis using an intraoral scanner (Planscan; Planmeca, Inc).

<table><caption>**Table 1**
Type of data and method or qualifying characteristics.</caption><thead><tr><td>Type of Data</td><td>Method or qualifying characteristics</td></tr></thead><tbody><tr><td>Teeth present</td><td>FDI World Dental Federation numbering system</td></tr><tr><td>Teeth lost ante / post-mortem (Seguin et al., 2014)</td><td>Visual and radiological appearance of the alveolar bone opposite the affected tooth</td></tr><tr><td>Dehiscences, fenestrations and developmental bony defects</td><td>Alveolar bone destroyed by infectious process, marked by rounded cavity in spongey bone and radiolucent lesion</td></tr><tr><td>Dental caries (Nyvad, 2004)</td><td>Evaluation by physical criteria of size, depth, and presence of cavitation.</td></tr><tr><td>Tooth wear (Chattah and Smith, 2006)</td><td>Located on the occlusal surfaces primarily, it is the result of various phenomena: abrasion, attrition, and erosion.</td></tr><tr><td>Estimated horizontal bone loss</td><td>Evaluation of the loss of bone height in relation to the amelo-dentinal junction</td></tr><tr><td>Dental calculus</td><td>Calcified dental plaque</td></tr></tbody></table>

# 4. Results

## 4.1. Macroscopic and imaging analyses

The dental notation data according to the FDI classification recorded are shown in **Fig. 3A**. The CBCT panoramic view of the oral cavity allows the visualization of dental anomalies, including periodontal bone defects and tooth losses (**Fig. 3B**). Concerning the coronal anatomy, the presence of wear veneers was visible on all occlusal surfaces of the posterior teeth and on the free edge of the anterior teeth (**Fig. 4**). There was a post-mortem fracture of tooth 31, with a root remnant still present in the alveolus (**Figs. 2, 4B**). Dentin staining in the form of sclerotic dentin was present on all teeth. Fissures and tissue loss due to the process of post-mortem dehydration were noted (**Fig. 5A**). Coronal fissures were present.

At the edentulous sites, analysis of CBCT 3D imagery showed the following results:

* **16:** old edentulous with version/regression of 18;

* **21:** cortical bone present / bone volume present, suggesting loss of tooth ante-mortem due to traumatic or endoparodontal lesion (**Fig. 6A**). If a link between the loss of the central incisor and the sequelae of trauma observed on the subject's chest (multiple rib fractures) can be postulated, the attrition of the maxillary bone must
<figure><img src="image_6.png" /><figcaption>**Fig. 3.** A: Odontogram with FDI World Dental Federation numbering system; B: Periodontal charting representing the height of jawbone within millimeter in relation to the amelo-dentinal junction.</figcaption></figure>

still be noted. Indeed, the periodontal damage is generalized. The alveolar bone has a cortical bone and the spongiosa is homogeneous at the site of this incisor (tooth 21), indicating an ante-mortem loss of more than 6 months. Traumatic etiology is possible with an expulsion without a bone fracture opposite. This seems to us to be the most likely scenario to explain the loss of this tooth, especially since other teeth are also missing and are part of a periodontal process;

* **24:** absence of cortical bone with vestibular concavity (Fig. 6B and D); and **27:** old edentulous;

* **31:** presence of the apex in the alveolus, showing a postmortem fracture (Fig. 6C); and **48:** old edentulous.

The use of the intra-oral scanner, a digital tool used in clinical practice, allows for a more detailed clinical examination in this

archaeological context (Fig. 7). After image registration, scanned surfaces revealed areas of wear such as retention wire and wear facets (Fig. 4C, 4D, 7A and 7B). Using the volume CBCT acquisition, the segmentation of the dental prosthesis allowed to model the 3D surface and to identify the retention and stabilization characteristics of this prosthesis (Fig. 6 and SI1).

According to the new classification, the diagnosis of periodontal disease is classified as stage 5, grade C, generalized and unstable with potential risk factors (Immune system, possible diabetes, vitamin D, Scurvy). No nutritional deficiencies (*Cribra Orbitalia*, Linear Enamel Hypoplasia, rickets) or stress indicators are observed on the body to correlate to this diagnosis.
<figure><img src="image_7.png" /><figcaption>**Fig. 4.** Occlusal view of the maxilla (A, C) and mandible (B, D). A, B: Photograph and C, D: Cone Beam Computed Tomography (CBCT). The surfaces in red represent the occlusal contacts. The absence of a homogeneous distribution of contacts indicates a possible periodontal degradation posterior to the occlusal wear of the teeth. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)</figcaption></figure>

<figure><img src="image_8.png" /><figcaption>**Fig. 5.** A: Macro-view of the right maxilla in detail; B: Vestibular macroscopic view of the three lower left molars.</figcaption></figure>

## 4.2. Oral pathologies

Concerning oral pathologies, interdental and root cavities were located on the mesial of the second (distal side) and third (mesial side) lower molars (Fig. 5B). The carious lesions extended into the vestibular area. With regard to the periodontal condition, generalized bone lysis showed at least 2/3 of the tooth roots on the arches and the visualization of 2/3 of the roots of all teeth present on both arches revealed generalized bone lysis. All teeth that were pluriradiculate (molars) showed furcatory involvement. Calculus was present on all the roots (Fig. 5B).

Only tooth wear was present on the occlusal surfaces except for the upper left third molar (tooth 28) which was intact (Fig. 2B, 4). No chipping, notching or interproximal grooves were observed. Except from the upper left third molar, untouched and can thus serve as a witness, on each molar, premolar and incisor, tissue loss or tooth wear, occurs,

especially on the outer enamel layer. Enamel does not remodel over time, and macroscopic wear can be seen on many occlusal surfaces or free margins of maxillary and mandibular teeth (Lagan and Ehrlich, 2021). Occlusal examination of the triturating surfaces suggests three types of wear:

i. Abrasion, especially on the molar and premolar areas, which may be related to the nature of the food consolidated at the time (Esclassan et al., 2009) and to the fact of the presence of silica particles and/or phytoliths (Romero et al., 2012; Reinhard and Danielson, 2005; Guan et al., 2022; Grine et al., 2012) or bruxism (Carlsson et al., 2003; Khan et al., 1998; Foley, 2020). This last hypothesis could be favored by the absence of wear of the right maxillary third molar, which has no antagonist or wear.
<figure><img src="image_9.png" /><figcaption>**Fig. 6.** 3D CBCT imaging analysis. A. Left upper central incisor (tooth 21); B and D: Left upper first premolar (tooth 24), absence of cortical bone; C: Left lower central incisor (tooth 31) apex in the alveolus, showing a post-mortem fracture.</figcaption></figure>

<figure><img src="image_10.png" /><figcaption>**Fig. 7.** Screenshots of the visualization of the maxillary and mandibular arch. A and C: Occlusal wear facets of the posterior teeth and the free edges and buccal surfaces wear facets of the anterior teeth. B: Loss of attachment of the molars, regression, and version of molar 18 and the retention bracket. D: Root caries of molars 37 and 38.</figcaption></figure>
ii. Attrition, especially on the anterior sectors, linked to a probable mandibular sagittal shift due to the loss of posterior teeth in connection with periodontapathy.

iii. Secondary erosion with the presence of dentinal cups.

### 4.3. Therapeutic elements

Concerning the therapeutic elements, the presence of a restraint ligature was observed in the form of a ladder ligature with a wire strand between 14 and 15 and mesial of 14 (Fig. 8A, C). This type of element is a ligature of the teeth with a 0.40 mm diameter gold wire. A first wire, the two ends of which are clamped by pliers and pushed back into the interdental space, surrounds the two teeth while a second wire tightens the whole between the teeth. Tooth 21 had been replaced by a prosthetic element made of ivory (Fig. 9). This element was held in place with a doubled wire passing through two tunnels (Fig. 10). The proximal surfaces were concave. These elements contributed to the stability of the prosthetic part (Figs. 8C, 10). The artificial tooth, rectangular, replaced the central right incisor, lost previously. Its macroscopic striated structure evokes the ivory used in modern dentistry, designated by the term Rohart by the famous king's physician Ambroise Paré, contemporary of our case (Paré, 1652.), even if hippopotamus dentin replaced it at the end of the 17th century until the discovery of vulcanite in the 1860s (Philippe, 2013) (Fig. 9). This mobile tooth was pierced by two holes through which gold wires, finer (0.20 mm diameter) than for the retention prosthesis, were passed. The first wire passed through the tooth from one side to the other, and the other passed through a bucket handle tunnel on the posterior surface. The artificial tooth was thus held in place by the other incisors (Fig. 8A, C). A surface reconstruction of the prosthesis obtained by segmentation is available in STL format for download (Fig. SI).

We also note the presence of a ladder ligature with a wire twisted between 14 and 15 and mesial to 14. The gold wire has the same characteristics as the one holding the prosthesis (0.4 mm diameter) (Figs. 2B, 4A, 8B). Symmetrically, traces of wear are visible on the cervical view of 25. They could come from another retention for the central bridge (another retention wire) or another missing prosthesis (Fig. 8D). These restraints were present for both left and right premolars as there are traces of wear on the neck of 25 on the CBCT. These traces of wear indicate the ante-mortem realization and are a sign of long-term use with the possibility of maintenance of these ligatures, such as tightening.

## 5. Discussion

Studies of periodontitis in past populations rely on the examination of collections of dried skulls and pose some technical challenges. A diagnosis of periodontal disease depends on the estimation of attachment levels achieved by examining the hard tissues only, a technique that is not really suitable for the application of standardized case definitions of disease used in current studies.

### 5.1. Analysis of the diagnosis of periodontal disease

To our knowledge, the new classification of periodontal and peri-implant diseases (Caton et al., 2018) has never used in an archaeological context. It brings a new fundamental evaluation for the analysis of the oral condition of ancient populations: the notion of progression of periodontal disease. The interest of the new classification and particularly of its grading system is that it provides information on the progression of periodontitis and the potential impact on systemic health (Caton et al., 2018). This evaluation is made possible by associating

<figure><img src="image_11.png" /><figcaption>**Fig. 8.** Macroscopic view of the prosthetic element. A, B and D: Vestibular view; C: Occlusal view. B: Vestibular macroscopic view of the ligature between 14 and 15. Note the presence of glue used for the consolidation of the ligature after its discovery. D: Cervical wear of 25 indicating the presence of a ligature or a restraint similar to 14/15.</figcaption></figure>
<figure><img src="image_12.png" /><figcaption>**Fig. 9.** Microscopic view with Metallurgical Microscope of the prosthetic element (occlusal [A] and apical [B] views) and comparison with hippopotamus dentin (C) and elephant ivory (D).</figcaption></figure>

<figure><img src="image_13.png" /><figcaption>**Fig. 10.** Orthogonal views of the denture replacing the upper central incisor (tooth 21). The proximal surfaces are concave, which allowed for stabilization. Retention was ensured by a hole dug in the width to insert the retention wire.</figcaption></figure>

visual and radiological examination.

The presence of little tartar on the upper part of the roots and the presence of tartar on the apical part indicate the possibility of the tooth and root surfaces having been brushed or cleaned. In fact, instruments for scaling already existed at that time. Even if the first mentions of dental hygiene were found in inscriptions from Mesopotamian clay tablets (Gurudath et al., 2012), the first toothbrushes would be Chinese and date from the late 15th century (Fischman, 1997). In Europe; the first mentions of brushes date from the early 18th century when the king's physician, Dionis, recommended "rubbing your teeth with a small sponge every morning" (Philippe, 2016; Dionis, 2012). Before, the scaling technique is already explained by Abul Al-Qasim in the 11th

century and mentioned in the medieval and early modern medical treatises such as Ambroise Paré, contemporary of Anne of Alegre (Paré, 1652.; Philippe, 2014).

Given the loss of height of the jawbone of the maxilla and the mandibular, mobility of the teeth was very likely. Anne d'Alègre must have had difficulty eating hard food. Moreover, the presence of excessive wear of veneers indicates bruxism, pathology commonly associated with severe or chronic psychosocial stress (Foley, 2020; Rai, 2013). In this case, the occlusal instability and bruxism were prior to the periodontitis. Bruxism may even have aggravated the severity of the periodontitis or even possibly caused it. Then again, chronic stress and depression can lead to a general dysregulation of the immune system, both cellular and humoral pathways, which can contribute to pathogenic infection and concomitant destruction of periodontal tissue (Warren et al., 2014).

## 5.2. Restraint Analyses: medical, aesthetic and social implications

Tooth loss, whether accidental, broken or due to decay, leaves an empty space that must be filled to prevent oral imbalances and loosening of the peripheral teeth. However, generally, tooth loss, especially of premolars and molars, is considered a normal part of aging (Peterson, 2003), and the concern for their replacement is still limited to the
wealthiest people in the world's most industrialized countries. Indeed, the loss of teeth concerns globally more the poorest populations, who still benefit today from more rudimentary therapeutic treatments such as the extraction of the tooth because of a cavity (Costa et al., 2012). Also, given the technical complexity of the implementation of a restraint, it is a therapeutic means still largely reserved for the privileged socio-economic classes (Gilbert et al., 2003). Thus, the ability of our ancestors to make such prostheses still amazes us by their technicality and antiquity (Becker, 1999). In archaeology, the few known examples of osseointegrated prostheses and implants concern mostly monoradical teeth (incisor and canine) (Teschler-Nicola et al., 1998; Becker, 1999; Cunha et al., 2017), undoubtedly testifying to aesthetic rather than functional considerations (Crubézy et al., 1998). To our knowledge, no case of prosthesis worn on men has been found in archaeology, even if this remark must be temporized since these finds (mostly from Egypt or Etruscan collections) are often ancient or lost since their discovery (Becker and Turfa, 2017; Becker et al., 2003). This lack of documentation impedes an anthropobiological approach to these remains, putting the subject back at the center of the analysis. The case of the two young women from the Neolithic site of Nabla Playa in Egypt (Irish et al., 2003) or the Gallic one from "Le Chêne" in France (Seguin et al., 2014) reinforces this aesthetic prosthesis paradigm. Although the addition of these devices has been known since the Neolithic period (Irish et al., 2003; Irish, 2004; Granat, 1990; Vallois, 1954), their rarity implies an important selection of subjects fitted with them in elite populations. Some of these pieces may have been added after the death of the subject to perpetuate a physical integrity of the corpse (Seguin et al., 2014; Irish et al., 2003; Vallois, 1954; Bocquentin and Aoudia-Chouakri, 2009) or serve only as votive amulets (Becker, 1999). The discovery of compensatory devices also indicates the social status of the subjects, especially when they are purely aesthetic objects. The extent of peripheral wear to the restraints suggests the removal of several restraint threads over time. It implies a dental care budget for the medical follow-up of the patient. The position of the intrasulcular wire is probably the consequence of an aesthetic gesture. These ligatures aggravated the patient's periodontal disease. Indeed, this type of ligature which has the disadvantage of reintroducing dental plaque causes gingival inflammation. This is the experimental device for triggering periodontitis in animals (Bienengräber et al., 1973).

The state of corticalisation of an edentulous site informs us about the age of the edentulism. In contrast to the central incisor (tooth 21), whose bone is corticalized, the canine (tooth 24) is concave and irregular. This informs us that the incisor (tooth 21) had been missing for longer than the canine, and that 24 was lost less than a year before Anne d'Alègre's death. Moreover, the traces of wear left by the gold wires of the incisor prosthesis are similar to those observed on the maxillary premolars. This indicates that the prosthesis and the restraints were worn ante-mortem and for a long time.

The posterior restraints had to have a dual aesthetic and functional indication. In fact, the two contentions were intended to contain the first premolars. In 1557, Francisco Martinez, the dentist of Philip II's Spanish court, warned his readers who wanted to put on false teeth for aesthetic reasons. Therefore, he notes:

> "To place a tooth, it must be attached to two others, and with the same force that is used to tighten it, and with the act of attaching and detaching it, either to clean it, or because the wire breaks, or because it moves, or because it is not well put in, inevitably the two to which it is attached will move and for the same reason will fall out; who has put on one, will want to put on three and if one has made two fall, three make more fall and so on. In this way, because she wanted to spend a year with a false tooth, she finds herself for life without her real teeth and with a thousand other sufferings that follow" (Martínez de Castrillo, 2010).

Despite these recommendations, placing a false tooth was probably not only for therapeutic or aesthetic purposes. We have noted that the

bruxism observed on Anne d'Alègre could be the sign of important stress states. Although the chronicles of the time presented her as being on the lookout for new and luxurious fashions, and "riding in carriages" to go to preach on Sundays. (Colleter et al., 2011). Her artificial teeth were probably not just a coquetry on her part. The various widowhood she experienced undoubtedly contributed to her anxiety, and few women in modern times choose the freedom that widowhood gives them (Colleter et al., 2021). She was married to Paul de Coligny from 1583 to 1586 and then to Guillaume IV d'Hautemer from 1599 to 1613. At the age of 48, when she was widowed a second time, she also lost her child, Guy XX de Laval, killed in a battle in Hungary.

Her periods of widowhood were undoubtedly complicated in a 17th century society where stereotypes and patriarchy were prevalent (Roy and Women, 2015). Furthermore; it is important to remember that at that time, physical appearance was still considered to be related to a person's intrinsic qualities (Weeda, 2021). Therefore; in accordance with the Hippocratic theory of humors in vogue in post-renaissance medical circles, any imbalance threatens the health of the subject, which is itself linked to one's own sins (Wallis, 2010). The appearance of the person; moreover noble, is an essential social element. Ambroise Paré notes that if the patient remains toothless and disfigured, his speech also becomes depraved (Paré, 1652.). Beyond the only aesthetic aspects, the installation of a dental prosthesis, and despite the possible odontological complications and known at that time, perhaps allowed Anne d'Alègre to maintain a certain social rank in front of her detractors.

## 6. Conclusion

The tools of current clinical practice allow for further analysis of oral examinations of past populations. Here, with the new classification of periodontal and peri-implant diseases associated with digital tools (CBCT examination, intraoral CT scan), an innovative approach to oral assessment is presented. It also allows us to characterize privileged subjects who benefit from dental care. Putting the subject at the center of the paleopathological analysis, the study of Anne d'Alègre's dental care allows a better understanding of the modern society that surrounds her, her choices, beyond the only therapeutic or aesthetic considerations.

## Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

## Data availability

Data will be made available on request.

## Acknowledgments

The skeleton of Anne d'Alègre (ML-OST-A-0433 to ML-OST-A-0632) is preserved at the Museum of Sciences of Laval that we thank for its availability. This work was supported by the Fossil team (Forensic Sciences and the Study of Image Libraries) of the Centre for Anthropobiology and Genomics of Toulouse - UMR 5288 (CNRS/UT3) and the Marie Sklodowska-Curie individual fellowship, AIDE project for Rozenn Colleter (grant 897565). We also thank the anonymous reviewers who improved the quality of this paper with their constructive comments.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jasrep.2022.103794.
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