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The over-all objective in molar uprighting is ideal positioning of the molar which will eventually become an abutment tooth for a fixed prosthesis. The specific objectives concerning protection against inflammatory periodontal diseases and occlusal traumatism are explained. A multidisciplinary approach to this type of dental therapy is ideal.
The over-all objective in molar uprighting is ideal positioning of the molar which will eventually become an abutment tooth for a fixed prosthesis. The specific objectives concerning protection against inflammatory periodontal diseases and occlusal traumatism are explained. A multidisciplinary approach to this type of dental therapy is ideal.
The over-all objective in molar uprighting is ideal positioning of the molar which will eventually become an abutment tooth for a fixed prosthesis. The specific objectives concerning protection against inflammatory periodontal diseases and occlusal traumatism are explained. A multidisciplinary approach to this type of dental therapy is ideal.
Copyright 1982 by The C. V. Mosby Company ORIGINAL ARTICLES A segmental approach to mandibular molar uprighting Dr. Roberts William W. Roberts, Ill, D.M.D.,* Frederic M. Chacker, D.D.S.,** and Charles J. Burstone, D.D.S., Ph.D.*** Philadelphia, Pa., Lawrenceville, N. J., and Farmington, Conn. Diagnosis and treatment in molar uprighting are discussed. The over-all objective in molar uprighting is ideal positioning of the molar which will eventually become an abutment tooth for a fixed prosthesis. The ideal position will provide an optimal periodontal environment for the molar(s). The specific objectives concerning protection against inflammatory periodontal diseases and occlusal traumatism, which together determine the optimal periodontal environment, are explained. Emphasis is placed on the biomechanics of molar uprighting which will achieve the desired periodontal treatment result. The specific technique recommended for the instances in which the molar is considerably angulated involves a segmental approach which utilizes a modification of the Burstone root spring. Proper application results in the dissociation of the correction of angulation and the extrusion of the molar tooth. It is explained that molar extrusion is, for the most part, an undesirable side effect of molar uprighting. When extrusion of the periodontally involved molar is required, then it should follow the correction of molar angulation. Other advantages of this approach involve the precision and ease of symmetrical preactivation, favorable load/deflection considerations, the low level of patient discomfort, and the reduced tendency of normal function distorting or dislodging the spring. This technique is compared by these parameters to other popular molar-uprighting techniques. It is recognized that a multidisciplinary approach to this type of dental therapy is ideal and that since treatment planning in individual cases varies greatly, each malocclusion and associated periodontal involvement should be evaluated on an individual case basis. Key words: Molar uprighting, periodontal diseases, molar extrusion, segmental biomechanics, prosthodontics This article presents an approach to mandibu- lar molar-uprighting treatment objectives, biomechan- ics, and appliance selection which will be applicable in many clinical situations. Mandibular molar uprighting is a common adult orthodontic procedure, performed in conjunction with periodontal and restorative therapy. *Orthodontist practicing in Philadelphia, Pa., and Lawrenceville, N. J. **Clinical Professor of Periodontology, School of Dentistry, Temple Univer - sity, Philadelphia, Pa. ***Chairman, Department of Orthodontics, University of Connecticut, Farm- ington, Conn. 0002-9416/82/030177+08$00.80/0 1982 The C. V. Mosby Co. Treatment planning involves decision making by clini- cians in addition to the orthodontist, with each adding a point of view reflecting his or her area of expertise. Understanding and appreciation of the treatment objec- tives by all result in improved comprehensive dental treatment for the patient. TREATMENT OBJECTIVES Ideal tooth positioning in molar uprighting is coin- cidental with obtaining an optimal periodontal envi- ronment. This, in turn, provides the following: 177 178 Roberts, Chacker, and Burstone Am. J. Orthod. March 1982
1111011111111w Fig.1. A, The inclined third molar exhibits radiographic signs of occlusal traumatism. B, Correction of molar inclination and stabilization improve the health of the molar periodontium. 1. Protection against inflammatory periodontal disease. A. Elimination of the pathologic periodontal envi- ronment which may exist in the presence of tipped molar(s) and angular osseous crests.' B . Correction of vertical osseous defects, if present, through forced eruption. 2 3
II. Protection against occlusal traumatism. A. Alignment of roots perpendicular to the occlusal plane so that they may optimally withstand the forces of occlusion (Fig. 1). B. Improvement of crown/root ratios of periodon- tally involved molars. C. Provision of the shortest possible edentulous span which also allows the necessary occlusal support of maxillary posterior teeth and an in- terarch cusp-fossa relationship, thus reducing flexing of bridgework in the pontic area and minimizing the related undesirable forces transmitted to the abutment teeth. When both of these treatment objectives are ful - filled, the ensuing restorative dentistry is simplified. Endodontic therapy may be avoided. Paths of bridge- work insertion will parallel the long axes of the roots. Periodontally compromising compensations in size and contour of crowns will not be necessary to provide proper contacts in centric occlusion and excursive movements. Occasionally, the orthodontic result may not justify the means. It is hoped that the orthodontist would avoid treatment in cases where the deleterious effects of tooth movement, such as root resorption and aggravation of periodontal diseases, could result in a weakened peri- odontium. Treatment of the periodontally involved pa- tient who is unable to maintain proper oral hygiene and for whom forced eruption is otherwise indicated may not be desirable, since the relationship of the alveolar bone to the cementoenamel junction may not be main- tained in the presence of the resultant inflammation. 4
Forced eruption without a constant alveolar crest/ cementoenamel junction relationship will result in a lessened attachment apparatus and an increased crown/ root ratio and may create or aggravate furcation prob- lems in multirooted teeth. Inflammatory periodontal disease, considered in the current literature to be a microbiologic phenomenon mitigated by host responses, 5 requires special consid- eration regarding orthodontic treatment, particularly in the adult patient. Preorthodontic periodontal prepara- tion should lead to reduction of inflammation, di - minished pocket depth, and firm, manageable soft tis- sues. During orthodontic treatment, this level of peri- odontal control is also ideal. Recognition of pathologic osseous architecture is critical to proper treatment planning. 6 Though it is not common to encounter deep periodontal pockets and infrabony defects on the distal aspects of mesially inclined molars in the absence of adjacent distal molars, when the latter are present, un- desirable effects of distal uprighting may include the increase of periodontal involvement on the distal as- pects of these teeth. If this type of uprighting is at - tempted, failure to be aware of the presence of inflam- mation and to effect its reduction by repeated scaling, root planing, and curettage may lead to acute exacerba- tions of periodontal disease, such as abscesses or marked edema. Regardless of prior periodontal involvement, the molar that is moved distally during uprighting may be surrounded distally by heavy fibrotic or muscular tissue. In this instance, it may be necessary to perform a surgical procedure to resect or otherwise recontour this area. Occlusal traumatism, one of the noninflammatory forms of periodontal disease, varies greatly in its se- verity. Histologic sections of teeth in marked trauma may show an almost total loss of alveolar bone proper, hemorrhage and/or diminished cellularity within the periodontal ligament, and osteoclastic activity in both the periphery of the alveolus and the root.? Proper orth- odontic movement depends upon osteoblastic activity as well as resorption. It is recommended that orthodon- Volume 81 Segmental approach to mandibular molar uprighting 179 Number 3 tic procedures be instituted after a marked improvement in the clinical and radiographic signs suggestive of occlusal traumatism is observed subsequent to occlusal adjustment and/or Hawley bite plane therapy. During molar uprighting, the inclined, extruded molars (maxil- lary and mandibular) should be adjusted to eliminate occlusal contact and to re-establish a physiologic curve of Spee. When these molars are the only posterior occlusal supports, a Hawley bite plane should help de- termine an appropriate vertical dimension. Biologic limitations may also modify ideal tooth positioning and/or treatment planning. The buccolin- gual width of trabecular bone in the edentulous span may be narrowed by the loss of dentition. The resultant thin, primarily cortical bone may preclude mesial root movement. Though tooth movement through cortical bone is possible, the disadvantages of root resorption, dehiscences, and prolonged treatment time generally outweigh the advantages. Commonly, second and third molars are tipped into the first molar extraction space and there exists a Class II relationship between the maxillary first and mandibu- lar second molars (Fig. 2, A). The molars vary in de- gree of inclination, tending to be more upright with early loss of the first molar as a result of mesial drifting of the erupting teeth. If the third molar is close to an acceptable axial inclination, some combination of me- sial root movement and distal crown movement applied to the second molar will fulfill the treatment objectives and create a pontic space approximately the size of a premolar (Fig. 2, B) . When distal crown movement of both second and third molars is indicated and the mo- lars are in good buccolingual position, an appropriate moment applied to the second molar will tend to move the second and third molar crowns distally, rather than move the second molar root mesially, if there is disar- ticulation of both molars. (The opening of the inter- dental embrasure between second and third molars which results from distal uprighting facilitates the en- suing restorative dentistry and periodontal mainte- nance.) TREATMENT BIOMECHANICS A list of definitions helps clarify the terminology which follows': ActivationThat force system that must be applied to a spring or wire which is equal and opposite to the force system desired (deactivation). Alpha positionThe anterior component of a spring or an- terior point of attachment of a spring. Beta positionThe posterior components of a spring or the posterior point of attachment of a spring. Center of resistanceIn a constraining system, such as a tooth in its alveolus, the center of resistance is defined as that A Fig. 2. Creation of a pontic space the size of a premolar may adequately fulfill molar-uprighting treatment objectives. point where a force would result in translation of the tooth; there would be no rotational effect. DeactivationThe force system acting on the tooth from an orthodontic appliance. Moment of a forceThe external effect of a moment of a force is that it produces or tends to produce a turning or rotation of the body on which the force acts. The magnitude of the moment is equal to the product of the force times the per- pendicular distance from the line of action of that force to the point or line about which rotation is being considered. Thus, M = F x D, where M = moment, F = magnitude of force and D the perpendicular distance from the line of action of the force to the point being considered. A moment can be expressed numerically in gram-millimeters (Gm.-mm.) and is depicted by a curved arrow showing its direction. Preactivation bendThe final bend placed into a wire or spring, which, when activated, will produce the desired force system. Pure rotationAll points on a tooth or body move around the center of resistance. TranslationAll points on a tooth or body move in a parallel straight line; the center of rotation is at infinity. Since the forces of occlusion to the molar(s) are eliminated by occlusal reduction prior to tooth move- ment and facial growth is not a consideration in the adult, molar uprighting provides a good clinical dem- onstration of the results of moment and force applica- tion. The center of resistance (CR) of a single-rooted tooth with a parabolic shape is 0.33 of the distance from the alveolar crest to the apex. 9 The CR varies with the number of roots, their sizes and shapes, and the nature of the attachment apparatus and gingival unit. As the attachment apparatus is reduced by periodontal disease, the CR approaches the apex. Conversely, thick, fibrotic gingiva tends to move the CR coronally. Application of force to a tooth directly through its CR produces translation (Fig. 3). Clinically, orthodon- tic forces are applied to teeth at crown level and rarely pass directly through the CR. A force not passing through the CR creates, in addition to translation, a moment (equal in magnitude to the product of the force times the perpendicular distance to the CR) which tends to rotate the tooth about it s CR (Fi g. 4). Molar- uprighting techniques depend upon this moment to pro-
180 Roberts, Chacker, and Burstone Am. J. Orthod. March 1982
if( 1 I / ) " N. 1
Crk , czL N.1 . 1
Fig. 3. Force application through the center of resistance of a tooth produces translation. Fig. 4. Force application which does not pass through the cen- ter of resistance produces a combination of rotation and trans- lation. duce the rotational tooth movement which corrects molar inclination. (An additional moment is produced by the straight wire in the molar tube.) In Fig. 5, the hypothetical pure rotation anticipated from the application of a moment (without an associ- ated force) to a mesially tipped molar is diagrammed. As the inclined, extruded molar is uprighted, it seems to erupt. The "false" eruption during uprighting is ac- tually a demonstration of the eruption, or extrusion, which occurred during the period of time the molar tipped into the extraction space. During molar upright - ing by pure rotation, the CR does not move occlusally (which means that the tooth is not erupting), yet much of the molar crown rises above the occlusal plane. The elevation resulting from this tipping effect is particularly dramatic in the area of the mesial alveolar crest. If a constant alveolar crest/cementoenamel junc- tion relationship is maintained during correction of in- clination, the angular osseous crest associated with the tipped molar is not only eliminated but is somewhat reversed in inclination, corresponding to the amount of extrusion which occurred as a result of tooth loss."' Some of the commonly used devices, such as tip-back springs, produce, in addition to moments, extrusive forces to molars during correction of inclination. In most situations, molar extrusion is not indicated. As will be discussed later, when extrusive forces are indi- cated, they should follow correction of inclination. In Fig. 6, a resisting force (ligature tie) added at the level of the crown inhibits distal crown movement. Uprighting by mesial root movement also results in "false" eruption. The tipping effects of a moment,
Fig. 5. Elevation results from correction of molar inclination by pure rotation. regardless of whether or not the crown is permitted to move distally, provide the elevation necessary to more than level the angular crests associated with the mo- lar(s) and to improve crown/root ratios of periodontally involved molars. Frequently there exists, in addition to the angular crest relationship, a vertical osseous defect. When forced eruption is included in the treatment plan, a light (maximum of 30 Gm. to the molar with little loss of attachment apparatus") net vertical force should be applied to the molar following the correction of in- clination and re-evaluation. Control of periodontal inflammation, by both patient and dentist, is facilitated during eruption of the vertically upright molar, as com- pared to the inclined molar. In addition, forced eruption of the periodontally involved molar results in rapid ex- trusion (approximately 5 mm. per month) which cannot be well controlled during correction of inclination, which generally requires 3 to 6 months. Proper forced eruption maintains a constant cemen- toenamel junction/alveolar crest relationship, not only in the area of the vertical defect but also circumferen- tially. Elimination of a vertical defect on one aspect of a tooth creates an angular crest relationship with the adjacent tooth on the opposite aspect. In Fig. 7, up- righting followed by eruption of the second molar elim- inates the mesial vertical defect associated with the second molar and yet creates or increases the inclina- tion of the angular crest relationship between the sec- ond and third molars. Although the angular osseous crest, as described by Ritchey and Orban' in 1953, is physiologic periodontal architecture, it may encourage a pathologic periodontal environment (particularly in the periodontally susceptible patient) in a location in which it is difficult for the patient to maintain adequate oral hygiene. In this instance, osseous recontouring is suggested. Forced eruption is ideally a multistep process. Orthodontic correction should be followed by a waiting period sufficient to allow maturation of the osteoid ma- Volume 81 Number 3 Segmental approach to mandibular molar uprighting 181
Fig. 6. Molar elevation occurs regardless of the distance the molar crown is moved distally. trix (approximately 2 months 12 ). After calcification, os- seous periodontal surgery is performed in order to level the osseous architecture. Upon healing, the orthodontic appliances should be removed, the crowns prepared, and temporary or provisional bridgework placed. (Su- pragingival provisional stabilization may also be placed immediately following uprighting.) Endodontic therapy also may be indicated at this time. It is important to maintain the edentulous span after removal of orth- odontic appliances in all molar-uprighting cases. After debanding and/or debonding, significant relapse of the molar(s) may occur within hours, so appliance removal and provisional bridgework insertion should be well synchronized. APPLIANCE SELECTION When treatment biomechanics indicate mild distal crown tipping of the molar(s) and premolar spacing is also present, an open coil spring approach is suggested. This is also recommended in the case in which, because of alveolar bone loss, the CR of the molar is located near the apex. In this instance, the perpendicular dis- tance from the point of force application to the CR of the tooth is elongated, generating a larger moment from a given distal force. The factors generally limiting open coil spring uprighting do not result from the moment but, rather, from the mesial and distal forces generated by the spring. These limitations are (1) the anchorage potential of the anterior stabilizing segment and (2) the amount of molar translation which is acceptable as the molar inclination is corrected. For the markedly inclined molar(s) requiring distal
Fig. 7. Elimination of a vertical defect on the mesial aspect of the second molar creates an angular crest relationship between second and third molars. crown tipping, or when some component of mesial root movement and/or forced eruption is indicated, a mod- ification of the root spring described by Burstone" al- lows the flexibility to provide the desired combinations of moments and forces (Fig. 8). The anterior stabilizing segment consists of the following: (1) A lingual arch wire (approximately 0.032 inch) bonded, or soldered to bands, from canine to canine. Bonding the mandibular incisors to the lingual arch wire adds stability to these periodontally involved teeth. This is also recommended when the mandibular second premolar is missing from the quadrant containing the inclined molar, when sec- ond and third molars are being uprighted or when the second molar is considerably tipped, and when there is concern about the possibility of well-aligned incisors shifting in relation to each other. (2) Buccal edgewise brackets (0.018 or 0.022 inch slots) banded or bonded to the canine and premolars in the involved quadrant(s). The canine bracket contains two horizontal slots.* (3) A full-size rectangular stabilizing wire passing from canine to premolar(s), stopped at both ends in order to *Bowles Multiphase, Unitek Corporation, Monrovia, Calif. 182 Roberts, Chacker, and Burstone Am. J. Orthod. March 1982 ALPHA t 4 - 3-4mm. BETA 2. LINGUAL BUCCAL 3. r - - 0 PASSIVE
4. r / 0 c J PREACTIVATION
5. COMPENSATION Fig. 9. Stages of fabrication of the uprighting spring. prevent spacing and inserted into the occlusal slot of the canine bracket. There are several alternatives to stabilizing the an- terior segment as suggested in the previous paragraph: (1) The lingual arch wire may be replaced by bracket- ing of the incisors labially and continuing the labial stabilizing wire from the premolar area on the side of the uprighting to the canine or beyond on the opposite side. In this manner, segmental molar uprighting may also be incorporated into concomitant comprehensive orthodontic treatment. (2) The lingual arch may extend to the premolars and molars, if desired, and lingually bonded to each tooth in the anchorage segment. The alpha (anterior) portion of the uprighting spring inserts into the gingival slot of the canine bracket. The beta (posterior) attachment, into which inserts the beta portion of the uprighting spring, is ideally a rectangular buccal tube, bonded so that gingival irritation is mini-
Degree of Preactivation 70 Cr; Force of Deactivation ALPHA BETA ALPHA BETA +45 o +45 o
III r i l l I I I o -20 0 0
Fig. 10. The deactivation forces which result from typical de- grees of preactivation. mized and placed far gingivally in order to facilitate occlusal adjustment of the molar. Prior to correction of inclination of the molar, the canine and premolar(s) should be consolidated and aligned. Ideally, molar ro- tations and cross-bite should also be corrected with a light continuous wire, offset to the angulation of the inclined molar. Fabrication, preactivation, and compensation com- pose the three steps which prepare the uprighting spring for insertion (Fig. 9). The spring is composed of ap- proximately 0.018 by 0.025 inch wire for insertion into a 0.022 by 0.028 inch bracket. A 0.018 by 0.025 inch bracket would require a corresponding wire size. The uprighting spring is constructed to fit passively (in all three planes of space) into alpha and beta positions.
Fig. 8. Buccal and occlusal views (photographed at different stages of treatment) of the molar- uprighting appliance. The spring is offset lingually in the edentulous area for added patient comfort. Volume 8I Number 3 Segmental approach to mandibular molar uprighting 183
Fig. 11. A, Molar uprighting requiring mesial root movement. B, Pretreatment radiograph of the molar shown in A. C, Mesial root movement is evidenced by the radiographic shadow of the original tooth position (8 weeks' active treatment). After the spring has been contoured buccolingually, one leg is engaged into its respective bracket and ad- justed so that the opposite leg lies passively (occluso- gingivally and buccolingually) at the level of the oppo- site bracket, without engaging the bracket. The reverse procedure is then followed, making the spring com- pletely passive if inserted into the alpha and beta at- tachments. The alpha and beta helices are then pre- activated the designated degrees, depending upon the desired forces and moments (Fig. 10). It is important to measure the degree of preactivation from the inclina- tion of the bracket and not from the level of the occlusal plane. Preactivation bends should be tested during fab- rication, at insertion, and during treatment, since tooth movement alters the force system. Typical activations (in the case where there is no loss of attachment appara- tus) for equal and opposite moments are 45 degrees to the attachments in the alpha and beta positions. It is recommended that the moment generated not exceed 3,000 Gm. mm. to a molar which demonstrates no radiographic evidence of loss of attachment appara- tus. The degree of uprighting spring preactivation will vary greatly, depending not only upon the magnitude of the desired moment but also upon the size and chemical composition of the wire used for uprighting and the interattachment distance. Symmetric alpha and beta activations are indicated for correction of inclination, so that there are no net vertical forces which result in eruption of the molar or anterior segment. If eruption is also indicated, either to attempt correction of a vertical defect or to level the osseous crests and marginal ridges between second and third molars, the spring can be preactivated to produce pure molar eruption (Fig. 10). Compensation for bending in the span of wire be- tween alpha and beta loops, which occurs upon trial activation and alters the desired force level, is made by bending in a mild reverse curve, equal and opposite to the curve observed upon trial activation. After final placement of the uprighting spring, the span of wire between alpha and beta helices should then be straight. If some component of mesial root movement is planned, the alpha leg should be stopped at the mesial aspect of the canine bracket and the beta leg stopped at the distal aspect of the molar bracket. In this instance, the molar attachment must be a bracket instead of a tube. The soft tissues of the cheek and tongue habitu- 184 Roberts, Chacker, and Burstone Am. J. Orthod. March 1982 ally rest in this long edentulous span, and it is important to minimize the patient's discomfort by lingually off- setting the uprighting spring so that it lies over the edentulous ridge (Fig. 11). Stopping the wire in this manner does alter the force levels at alpha and beta positions, but for clinical purposes it is fairly effective in producing mesial root movement of the molar. In the instance where there is a short edentulous span, tightly common-tying from canine to molar brackets will in- hibit distal molar crown movement. In the long edentu- lous span, however, this kind of ligature tie will loosen during normal function. Buccolingual compensation for rotation of the molar should also be incorporated in the wire design when mesial root movement is at - tempted. DISCUSSION Molar uprighting and the associated periodontal considerations have been frequently addressed in the recent dental literature. Some uprighting springs de- scribed generally delivery net extrusive forces to the molars. 14-16 In the instance in which extrusion is indi- cated, generally for correction of infrabony defects, extrusion during the correction of inclination is unde- sirable because it occurs too rapidly compared with the change in molar inclination. Excessive occlusal ad- justment is then required to keep interferences from slowing the correction of inclination and also damaging the periodontal support. Many clinicians advocate the use of an uprighting spring with the stabilizing arch wire passing through the molar tube and exerting an intrusive force to the molar, equal and opposite to the force of activation of the uprighting spring. ' 7 18 This design is biomechani- cally similar to that which is described in this article and may be properly adjusted to produce the same type of movement that we recommend. The advantages of the uprighting spring recom- mended in this article are as follows: 1. Symmetrical preactivation is an extraoral proce- dure. Force levels are easy to determine and to check periodically . 2. Few adjustments are necessary during treatment because of load/deflection considerations in spring design. 3. In the edentulous span, the wire is not disturbed by normal function because it is positioned at the level of the gingiva. 4. Patient discomfort is minimized by offsetting the spring over the edentulous ridge. CONCLUSION It is important, particularly after a discussion of orthodontic appliance selection, to reaffirm the biologic nature of molar uprighting. 'The concepts and quantita- tive measurements hypothesized result mainly from clinical impressions. Individual cases must be consid- ered on an individual basis. Treatment varies greatly from case to case, depending particularly upon the mit- igations of periodontal disease. Although the hypothe- ses presented should be clinically useful, there is a need to examine scientifically the extent of the differing re- sponse of teeth that are periodontally involved, as com- pared with those of a physiologic periodontium. An interchange of information among clinicians and investigators of the various disciplines is neces- sary. Orthodontic movement must serve to establish an environment which provides for physiologic function as well as the re-establishment of what is considered "proper tooth position. " REFERENCES 1. Ritchey, B., and Orban, B.: The crests of the interdental septa, J. Periodontol. 24:75, 1953. 2. Brown, 1. S.: The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings, J. Periodontol. 44:742, 1973. 3. Ingber, J.: Forced eruption. Part I. A method of treating isolated one and two wall infrabony osseous defects-Rationale and case report, J. Periodontol. 45:199, 1974. 4. Kennedy, J. E.: Effect of inflammation on collateral circulation of the gingiva, J. Periodont. Res. 6:147-152, 1974. 5. Socransky, S. S.: Relationship of bacteria to the etiology of periodontal disease, J. Dent. Res. 49:Supp. 1, 209-221, 1970. 6. Goldman, H. M., and Cohen, D. W.: The infrabony pocket: classification and treatment, J. Periodontol. 29:272, 1958. 7. Lindhe, J., and Ericsson, I.: The influence of trauma from oc- clusion by healthy periodontal tissues in dogs, J. Chit Peri- odontol. 3:110-122, 1976. 8. Burstone, C. J.: Segmented arch mechanics technique manual, Farmington, 1975, University of Connecticut. 9. Burstone, C. J., and Pryputniewicz, R. J.: Holographic determi- nation of centers of rotation produced by orthodontic forces, Am. J. ORTHOD. 77:396-409, 1980. 10. Weinmann. J.: Bone changes related to eruption of the teeth, Angle Orthod. 11:831, 1941. 11. Reitan, K.: Some factors determining the evaluation of forces in orthodontics, AM. J. ORTHOD. 43:32-45, 1957. 12. Melcher, A. H.: Biology of the Periodontium, New York. 1969, Academic Press, Inc. 13. Burstone, C. J.: Mechanics of the segmented arch technique. Angle Orthod. 36:99-120, 1966. 14. Norton, L. A., and Proffit, W. R.: Molar uprighting as an ad- junct to fixed prostheses, J. Am. Dent. Assoc. 76:312-315, 1968. 15. Goldman, H. M., and Cohen, D. W.: Periodontal therapy, ed. 6, St. Louis, 1980, The C.V. Mosby Company, pp. 564-627. 16. Toncay, 0. C., et al.: Molar uprighting with T-loop springs, J. Am. Dent. Assoc. 100:863-866, 1980. 17. Vanarsdall, R. L., and Swartz, M. L.: Molar uprighting, Ormco Catalog No. 740-0014, Ormco Corporation, Glendora, Calif., 1980. 18. Broussard, G.: Personal communication, Sept ember, 1981.