European Journal of Orthodontics 14 (1992) 449-455 ) 1992 European Orthodontic Society

Periodontal conditions around tipped and upright molars in

adults
An intra-individual retrospective study
Dan Lundgren,* Juri Kurol,** Bjorn Thorstensson,*** and Anders Hugoson*
Departments of "Periodontology, "Orthodontics, and ""Prosthodontics, The Institute for Postgraduate
Dental Education, Jonkoping, Sweden

SUMMARY In 69 individuals from a randomized epidemiological material comprising 450 adults,

an intra-individual comparison of the periodontal condition of 73 mesially tipped molars (30
degrees or more to a line perpendicular to the occlusal plane) and contralateral upright molars
was made. The alveolar bone level mesially and distally of each tooth was registered in periapical
radiographs. The occurrence of plaque, gingivitis and probeable pocket depths of 4 mm or more
mesially and distally of each tooth was registered.
No significant differences between tipped and upright molars could be found, regardless of
the variable tested. The clinical implications of the findings are discussed from an orthodontic

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as well as a periodontal and prosthetic point of view.

Introduction most opinions concerning the negative influence

The problem of mesially tipped permanent
molars has been the subject of a great number
of anecdotal reports over the last 25 years. The
tipping has traditionally been considered to be
hazardous to the tipped molar itself as well as
to the long-term function of the dentition. Thus,
several authors have reported dysfunctional
consequences in connection with tipped molars,
such as elongations of opposing teeth, often
causing balance interferences and symptoms
from the temporomandibular joints and muscles
(Mohlin and Kopp, 1978; Stern et al., 1981;
Mohlin, 1983). Prosthetic disadvantages in the
form of paralleling problems have also been
mentioned (Diedrich, 1980; Lubow et al., 1982).
Not least, tipped molars have been considered
a causative or at least an aggravating factor for
periodontal breakdown in the future (Fig. 1).
Thus, it has been stated that more or less severe
soft tissue as well as infrabony lesions are more
common mesial to mesially tipped molars than
mesial to non tipped molars (Brown, 1973;
Norton, 1981; Stern et al., 1981; Becker et al.,
1982; Lubow et al., 1982; Simon, 1984).
Orthodontic uprighting of tipped molars has
consequently been considered desirable in a
majority of the presented papers. However,
upon the periodontal health have been put
forward without scientific support and, thus,
have the character of general subjective state-
ments. Only a few clinical experimental studies
have been presented. Brown (1973) reported a
study in five individuals with severe periodontal
disease. An average mesial pocket depth reduc-
tion of 3.5 mm was found after orthodontic
uprighting of the mesially tipped molars. Con-
comitantly, however, the uprighting procedure
resulted in a mesial marginal bone loss of
0.5-1 mm as measured in periapical radio-
graphs. One orthodontically untreated control
tooth was included in the study.
In an epidemiological study, Geiger and
Wasserman (1980) found only minor differences
in periodontal health between tipped and non-
tipped molars. They put forward the opinion
that the generally mentioned mesial infrabony
pocket at mesially tipped molars is illusive and
solely a consequence of the inclination of the
molar relative to the alveolar bone. They also
stated that tipping occurs relatively soon after
loss of the mesial neighbouring tooth and is
thereafter not further increased. Kraal et al.
(1980) presented a study of 22 individuals who
were examined 3.5 years after orthodontic
uprighting of mesially tipped molars. They
450
Figure 1 Bitewing radiographs from a 12i-year-old girl
with protruding maxillary incisors and some space loss and
crowding in the lower jaw (A). When the reamer broke
during endodontic treatment of the left lower first molar,
it was decided to extract allfirstmolars instead of premolars.
Unfortunately, orthodonticfixedappliance treatment could
not be completed due to lack of co-operation (B-C). The
development after extraction from 16 to 22 years of age,
(C—F) with an increasing degree of mesial tipping of the
second molars. What will happen to the periodontium
during the next 10-year period if we leave it like this?
D. LUNDGREN ET AL
found no difference in bone level or gingival
inflammation before and after treatment of the
test teeth, but, on the other hand, shallower
pockets at these teeth when compared with 15
intra-individual control teeth. In a study of 58
individuals, Ehrlich and Jaffe (1983) could not
find 'more periodontal disease' around tipped
molars.
In none of the studies referred to, with the
exception of the one presented by Geiger and
Wasserman (1980) (who classified the tipping as
normal, moderate, or severe), is a definition of
a tipped tooth given. An objective comparison
between these studies is, therefore, difficult to
make.
It seems desirable to assess the need for
orthodontic uprighting of tipped molars by
studying the periodontal status of tipped molars
in relation to the degree of tipping.
Aim
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The aim of the investigation was to compare
intra-individually the periodontal status of uni-
laterally tipped molars with contralateral, norm-
ally positioned, molars in a randomly selected
patient material.
Subjects and methods
From the material of an epidemiological dental
health survey representing an urban population
in Sweden (Hugoson et al., 1974), were chosen
all those individuals of the age-groups 30, 40,
50, 60, and 70 years who fulfilled the following
criteria:
1. One or more molars mesially tipped 30° or
more relative to the perpendicular to the
occlusal plane with or without mesial contact
with the neighbouring tooth.
2. Concomitant presence of an upright con-
tralateral molar in the normal vertical posi-
tion, i.e. tipped no more than 10°.
3. Extraction of the tooth mesial to the tipped
molar more than 10 years ago.
4. No history of orthodontic treatment and/or
fixed or removable prosthetic constructions
involving either test or control teeth.
The total material consisted of 69 individuals
with 73 comparable pairs of molars (Table 1).
Sixty-five of these were mandibular and eight
maxillary molar pairs (Table 2).
TIPPED MOLARS 451

Table 1 Distribution of individuals and comparable following variables were registered and intra-
molar pairs according to age group. individually compared:
Relative number (per cent) of sites (mesial
Age group Number of Number of and distal surfaces respectively) with:
(Years) individuals molar pairs
(1) presence of plaque corresponding to the
30 25 26 criteria of the Plaque Index system (Silness
40 19 26 and Loe, 1964) scores 2 and 3;
50 14 16
60 8 8 (2) presence of gingival inflammation corres-
70 . 1 5 ponding to the criteria of the Gingival Index
system (Loe and Silness, 1963) scores 2 and
Total 69 73
3;
(3) probing pocket depths equal to or exceeding
Table 2 Number offirst,second, and third maxillary 4 mm.
and mandibular comparable molar pairs.
On inquiry, the subjects declared that the test
First Second Third molars had in all cases spontaneously tipped
molar molar molar Total into the space created by extraction of mesially
positioned neighbouring teeth. The extractions
Maxilla 3 3 had, in general, been performed as part of
Mandible 50 10 65 comprehensive school dental treatment. The
Total 53 13 73
time since extraction varied between 10 and 60
years, and mostly exceeded 20 years, according

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The angle between the long axis of the tooth
and a line perpendicular to the occlusal plane
was used for measuring the degree of tipping,
which was registered to the nearest 10 degrees
in periapical radiographs (Fig. 2). The alveolar
bone level was registered according to the tech-
nique described by Bjorn et al. (1969), i.e. the
proximal bone height mesially and distally to
the tooth was measured, and presented as a
percentage of the total length of the tooth.
In addition to the radiographic analysis, the
to the information given by each subject.
Table 3 shows the distribution of the tipped
molars according to the degree of tipping. It
should be observed that a majority of the teeth
were tipped 40 degrees or more in relation to
the perpendicular to the occlusal plane (Fig. 2).
Statistical analyses
Statistical analysis of differences in frequency
between plaque, gingivitis, and probing pocket
depth, respectively, on the different surfaces was
carried out using McNemar's test. Statistical
analysis of differences between bone level values
was performed using Student's /-test for paired
data. Differences with probabilities of less than
5 per cent (/ > <0.05) were considered to be
statistically significant.

Results
Table 4 gives the relative number of sites
(proximal surfaces) with plaque, gingivitis and

Table 3 Distribution of the 73 tipped molars accord-

ing to the degree of tipping in relation to the perpen-
dicular to the occlusal plane assessed to the nearest
10 degrees.
Figure 2 Periapical radiographs of two cases, one in the Tipping
maxilla and one in the mandible. Arrows denote registered 30° 40° 50° 60° 70° 80°
bone levels. Bars through the long axis of the teeth and
perpendicular to the occlusal plane respectively show the Number 34 27 10
reference lines used for measuring the degree of tipping.
452 D. LUNDGREN ET AL

Table 4 Relative number of sites with plaque, faces there was a higher frequency of plaque,
gingivitis and probing pocket depth equal to or gingivitis, and probing depth equal to or
exceeding 4 mm. exceeding 4 mm at the mesial surfaces. These
differences were all statistically significant.
Mesial Distal Regarding plaque, gingivitis, and pockets, a
Tipped Upright Tipped Upright high degree of intra-individual symmetry for all
variables was found.
Figure 3 shows the distribution of alveolar
I
Plaque 72 56 59 bone loss in per cent of the total tooth length
67
mesial and distal to tipped and upright molars.
No bone loss was registered for nearly 50 per
I cent of the mesial surfaces irrespective of
Gingivitis 55 59 41 45 whether the molar was tipped or not. The
-NS- •NS-
Probing corresponding values for the distal surfaces
ranged between 30 and 42 per cent. Very few
Depth I individuals showed moderate or advanced (30
>4 mm 29 25 12 per cent or more) bone loss. No statistically
•NS- "-NS- significant differences (Table 5) were found
between any of the four groups (Fig. 3).

probing depth equal to or exceeding 4 mm. The

presence of plaque varied between 56 and 72 Table 5 Bone height as a percentage of tooth length

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per cent. The corresponding frequency of gingiv- mesial and distal to the tipped and upright molars.
itis varied between 41 and 59 per cent. Probing Mean values and standard deviations.
depth reaching 4 mm or more varied from 8 per
cent (about 1 surface out of 12) to 29 per cent Mesial surface Distal surface
(about 1 surface out of 4). No clear-cut differ- Tipped Upright Tipped Upright
ences were found between upright and tipped
molars for any of the variables. However, when 62.5 + 3.6 62.8+4.2 63.2 + 4.1 64.1+4.2
mesial surfaces were compared with distal sur-

100 TIPPED 00 UPRIGHT

00 U a i l a l surfaca 00 Maslal surfaca

BO 80'
70 70
SO SO
SO SO
40 40
30 30-
20 20
10 10
0
0
ll
10 20 30 40 50 60 70 90 90 W O Bon* lost <%)
l.a
0 10 20 30 40 50 60 70 80 90 100 Bon* loas <%)

Molart<X>

100 TIPPED 100 UPRIGHT

90 Dials! turrscs 00 Distal surtaca
SO so
70- 70
SO 60'
SO SO
40 40
30
20 •

iL
0 102030405080 70 8090 100 Bon* lo.i (I)
10
1l.
0 10 20 30 40 SO SO 70 80 90 100 Bon. loss I I I

Figure 3 Frequency distribution of alveolar bone loss (percentage) mesial and distal to tipped and upright molars.
TIPPED MOLARS
The intra-individual frequency distribution of
the difference in alveolar bone support between
the test and the control teeth at mesial and
distal surfaces is shown in Fig. 4. It will be seen
that the majority of the cases showed no intra-
individual differences at the mesial surfaces.
However, about 30 per cent of the tipped
molars exhibited a more advanced mesial bone
loss compared to their upright contralaterals,
while the latter showed more advanced mesial
bone loss in 25 per cent of the cases. About the
same pattern was noted for the distal surfaces,
but with slightly larger intra-individual vari-
ations.
Discussion
The individuals included in this study all had
at least one molar mesially tipped 30 degrees
or more relative to the perpendicular to the
occlusal plane and the corresponding contralat-
eral upright molar was used as a control tooth.
This intra-individual approach should be prefer-
able to an inter-individually designed study in
order to reduce differences in those environ-
mental factors that might influence the condi-
tions for the studied teeth.
Molars %
100
90
80
70
60
50
A •!
40
30
20
10
0 around such teeth. Thus, no firm conclusions
Mesial surface Distal surface
Figure 4 Frequency distribution (percentage) of intra-
individual difference of degree of alveolar bone loss between
tipped and upright molars mesially and distally. Bars signed
zero denote no difference between the tipped and upright
molar, bars with positive signs denote more bone loss for
tipped teeth and bars with negative signs denote less bone
loss for tipped teeth.
453
It seemed reasonable to consider a molar
inclined less than 10 degrees in relation to the
perpendicular to the occlusal plane to be a
normal upright tooth with regard to normal
variations in the curve of Spee, etc. The
inclusion criterion for the test teeth to be
regarded as mesially tipped was set to 30
degrees to make it quite clear that they really
were tilted. The majority of the teeth were in
fact found to be tilted 40 degrees or more. In
addition, they were required to have been
located in this tilted position for at least 10
years. It is very likely that most of the tipped
molars had been in that position for 20-30
years as the tooth anterior to the test tooth
had usually been extracted in school dentistry
and it is well known that the tooth posterior
to such an extraction site tilts quite rapidly
into it, especially at that young age (Geiger
and Wasserman, 1980). This is illustrated in
the case presented in Fig. 1.
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All individuals were drawn from a randomly
selected group of adults aged between 30 and
70 years, and representing the 1973 year's cohort
of the inhabitants of a medium-sized town,
Jonkoping, Sweden. This material has been
demonstrated to consist mostly of individuals
who have no or only slight periodontal break-
down as evaluated on radiographs and/or by
periodontal probing (Hugoson et ah, 1974).
This periodontal disease profile is in agreement
with epidemiological data presented from other
European populations (Pilot and Miyazaki,
1991). The low frequency of severe periodontal
destruction is also verified by the data pre-
sented in Fig. 2, showing very few sites with
moderate or advanced bone loss. This investi-
gation, therefore, tests whether a healthy or
slightly diseased (gingivitis or incipient
periodontitis) mesially tipped molar is more
susceptible to destructive periodontal disease
than an upright molar, rather than testing the
risk of increased aggravation of an already
established, advanced periodontal destruction
concerning the potential risk for aggravation
of an already established, advanced period-
ontal disease at the mesial surface of tipped
molars can be drawn from this study.
However, the data obtained unequivocally
demonstrate that in randomly selected material
markedly tipped molars do not constitute an
454
increased risk for initiation of destructive
periodontitis or transition of gingivitis or slight
periodontitis into more advanced forms of
periodontitis. The fact that most of the molars
had been tipped for 20-30 years makes this con-
clusion highly reliable. The findings from this
study thus do not support orthodontic
uprighting of tipped molars based solely on peri-
odontal indications or fear of more periodontal
disease around tipped molars.
At the time of examination, about 70 percent
of the molars, whether tipped or not, showed
plaque on their mesial surfaces. The correspond-
ing value for gingivitis (bleeding on probing)
was about 50 per cent. This strongly suggests
that the main requirement for initiation and
establishment of destructive periodontitis has
been present for a very long time at most of
these surfaces, yet only minor if any loss of
periodontal support was observed at these
sites in the majority of the subjects. This
supports the opinion that most individuals
host defence can resist the plaque attacks quite
successfully.
As shown in Table 4, there is a clearly higher
frequency of plaque, gingivitis, and increased
probing depth of 4 mm or more at the mesial
surfaces of both tipped and upright molars com-
pared to distal surfaces. These findings may be
related to topographical differences causing
increased plaque retention with gingivitis and
pseudopockets. However, this evidently does
not result in an accelerated periodontal break-
down of supporting periodontal tissue as evalu-
ated from the radiographic findings in the
present investigation. This is in agreement with
the observations recently made of the complex
relationships between plaque, gingivitis, and
periodontal breakdown (Magnusson et al.
1991).
However, comparing the mesial or distal sur-
faces of tipped and upright molars, no such
differences were found. The data of the present
investigation thus do not lend support to the
generally held opinion that a markedly mesially
inclined tooth should be more prone than an
upright tooth to lose periodontal support at its
mesial surface.
In a thorough study Lang (1977) demon-
strated a reduction, mean 0.6 mm, in pocket
depth by orthodontic uprighting of 30 mesially
tipped molars and also a gain of periodontal
D. LUNDGREN ET AL
attachment mean 0.4 mm. After the initial
hygienic phase a more significant pocket reduc-
tion, mean 1.0 mm, was registered. On the other
hand, Brown (1973) reported a mesial marginal
bone loss of 0.5-1 mm as a result of molar
uprighting. Also Kessler (1976) pointed out the
risks of uprighting mesially tipped second
molars. Bone loss and furcation involvement
may be caused by the uprighting as a period-
ontal osseous lesion is widened when the tooth
is uprighted.
Therefore, as risks may be involved in ortho-
dontic uprighting in cases with periodontal
osseous lesions along the mesial surface or
bifurcation involvement, the indications for
uprighting the molar must be clear.
It should be observed that the lack of correla-
tion between the tipped position of a molar and
its periodontal status does not mean that a
tipped molar (or other tooth) should never be
uprighted. There may be other indications for
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orthodontic uprighting of a tipped tooth such
as functionally disturbing interferences (Mohlin
and Kopp, 1978; Mohlin, 1983) or paralleling
and space problems in conjunction with pros-
thetic rehabilitation (Lang, 1977; Diedrich,
1980; Lubowe/a/., 1982; Tulloch, 1982; Wagen-
berg et al. 1986) Traumatic occlusion may be
another reason for wanting an uprighting.
Although the quality of occlusion was not
specifically studied in this investigation, the
questionnaire that had to befilledin by all parti-
cipants contained questions related to subjective
evaluations of the occlusal comfort. No over-
representation of claims of occlusal discomfort
or subjective dysfunctional symptoms were
observed among individuals with tipped molars
(Hugoson et al. 1974).
In conclusion, this study does not support the
widely held view that a mesially markedly tipped
molar should constitute a greater risk than an
upright molar for initiation or aggravation of
moderate periodontal breakdown at its mesial
surface. Tipped molars, thus, do not constitute
an indication for orthodontic up-
righting to prevent acceleration of destructive
periodontal disease.
This finding should be taken into considera-
tion when clinical decisions are made aiming at
orthodontic uprighting of teeth solely for
improvement of the periodontal prognosis of
the tipped molar.
TIPPED MOLARS
Address for correspondence
Dr Jiiri Kurol
Department of Orthodontics
The Institute for Postgraduate Dental Education
Jarnvagsgatan 9
S-553 15 Jonkoping
Sweden
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