Fixed partial dentures and operative

dentistry

The mechanism of fixed molar uprighting appliances

F. E. Khouw, D.M.D.,* and 1. A. Norton, D.M.D.**

Department of Orthodontics, College of Dentistry,
University of Kentucky, Lexington, Ky.

U prighting tipped molars can often mean the difference between success and
failure in periodontal and restorative therapy. Removable and fixed orthodontic
appliances have been suggested, I-3 but fixed orthodontic appliances are preferred for
uprighting molars in adults, because they offer continuous force application, superior
control, greater effectiveness, and better patient acceptance.4 The very effectiveness
of these fixed appliances, however, makes it easy to produce undesired tooth move-
ments in addition to the desired molar uprighting. The objective of this article is to
discuss the biomechanical principles of fixed molar uprighting appliances so that
dentists may use them efficiently with a minimum of undesired side effects.
A brief review of some elementary physics terminology is necessary for better
understanding of the anatomy of biomechanics. A “body” is a quantity of inert mat-
ter in which the particles move little or not at all in relation to each other (e.g.,
tooth). A “force” (F) is the action of one body on another body with a given
magnitude, direction, rate of change, and point of application. It can be expressed
in grams, pounds, and the like and is shown as an arrow depicting its magnitude,
direction, and point of application. The term “moment” of force (M) is used when
a force is applied away from the center of mass. In a frictionless system, it is equal
to the force delivered to the body multiplied by the distance from the line of force
to the center of the mass (F x D = M) . This can be expressed numerically in gram-
millimeters (Gm.-mm.) and is depicted by a curved arrow showing its direction.
If we are not dealing with a frictionless system, we may substitute the center of
resistance for the center of mass.
In considering the force systems generated by orthodontic appliances on teeth,
the center of resistance is determined by the number of roots, their size and shape,
and so on. In a single rooted tooth with a parabolic shape, it is at a point approxi-

“Former Assistant Professor of Orthodontics.

**Associate Professor of Orthodontics.

381
382 Khouzu and Norton J Prosthet. Dent.
.4pril, 1974

Fig. 1. (A) In passive form, the hook of the uprighting spring would lie in the muccobuccal
fold. A stabilizing wire is tied into the canine and premolar brackets. This 0.019 x 0.025 wire
should fit passively, and it may need some vertical or horizontal adjustment bends as well as
twisting to accommodate all three brackets without exerting any force on the anchor teeth. (B)
The activated helical uprighting spring in place.

mately 0.4 times the distance from the alveolar crest to the apex.5 In dentistry, the
term “bodily” movement (translation) applies when no change in the axis of orienta-
tion of a tooth takes place during movement. It is also said to have its rotation point
at infinity. “Tipping,” on the other hand, relates to movement (rotation) around an
axis in the mesiodistal or buccolingual plane (mesiodistal tipping). The term “rota-
tion” has been reserved to indicate rotation around the long axis of the tooth. Extru-
sion and intrusion refer to movement along the long axis of the tooth in occlusal
and apical directions respectively. In reality, any combination of these phenomena
can occur clinically.

THE HELICAL UPRIGHTING SPRING

The first appliance for uprighting molar teeth is the helical uprighting spring
as shown in Fig. 1, A and B. The use of this appliance is indicated when a second
molar must be tipped distally to open a partially closed space. In most instances the
third molar, if present, should be removed to make this type of uprighting easier. If
both premolars and canines are present on the ipsilateral side, these three teeth, as
 Fixed molar uprighting appliances 303

Fig. 2. (A) Activation of the spring by lifting the anterior hook occlusally over the stabilizing
segment (broken arrow) will result in a reciprocal depressing force (F) exerted on the
stabilizing wire of the anterior teeth. The opposite action on the molar is a linear extrusive
force (F) and a moment (M’) equal to the product of F’ x D’ [distance from the hook to
the center of resistance (R’) of the molar] . Clinically, the distance between the force (F) and
the center of resistance (R) of the anchor segment is not great enough to produce significant
rotation of the segment in the sagittal plane in the amount of time necessary to upright the
molar. (B) Distal diagrammatic views of the anchor teeth and the molar. The attachments to
the teeth are buccal to the long axis of the tooth, and any force applied to these attachments
results in a linear force plus a moment. Therefore, the depressing force (F) on the premolar
segment has an additional counterclockwise moment M = F x d (distance from F to the center
of resistance of the anterior segment). This moment will have the tendency to rotate the teeth
around their center of resistance (R) and move the apices lingually and the crowns buccally.
On the molar, the extrusive force (F’) exerted on the tube will result in a clockwise moment,
M’ = F’ x d’. This force system will tend to move the root buccally and the crown lingually.
It should be noted that if the teeth are lingually inclined to the extent that the vertical force
has a line of action lingual to the centers of resistance, the opposite action results. R’ = center
of resistance of molars.

well as the tipped molar, should be banded. Edgewise brackets, 0.022 x 0.028 (single
with rotation wings or eyelets or double, but not single brackets by themselves), are
welded to the bands of the canine and premolars, and an 0.022 x 0.028 edgewise
tube is welded to the molar band. If the second premolar is missing, the canine tooth
on the contralateral side should be banded, and a fixed canine band-tosanine band,
soldered lingual arch should be employed to provide additional anchorage. The
reason for this will be clear when the mechanics of this appliance are discussed. Fig.
2, A and B, is a diagrammatic representation of the force system of the helical spring
uprighting segment.
The helical spring should be made of 0.019 x 0.025 stainless steel wire to be most
effective. With such a spring, the buccolingual side effects are significant. For exam-
ple, a typical moment may amount to approximately 1,800 Gm.-mm. on the molar
if, for example F’ equals 300 Gm. and the distance (d’) equals 6 mm. (Fig. 2, B) .
As for the anchor teeth, it can amount to 300 x 4 = 1,200 Gm.-mm. if the dis-
384 Khouw and Norton J. F’rosthet. Dent.
April, 1972

Fig. 3. Occlusal diagrammatic Cew. By contouring the anterior leg of the uprighting spring,
a lingual force can be exerted on the anterior segment and a buccal force on the molar.
Fig. 4. Distal diagrammatic view of the anterior stabilized segment and the molar. A lingual
force (X) at the brackets will exert linear force and a clockwise moment (product of X and
Y) on the anterior segment. A buccal force (X’) at the molar bracket will exert a counter-
clockwise moment on the molar in addition to the linear force. The force diagram resulting
from torque (twist) in the wire is not illustrated here.

tance (d) equals 4 mm. and the force exerted on the stabilizing wire equals 300 Gm.
(Fig. 2, B) . Such a force system is sufficient to produce tooth movement. Clinically,
this means that the crowns of the anchor teeth (canines and premolars) will be
tipped buccally and the apices tipped lingually, unless some provision is made to
prevent this undesirable side effect.
The side effects can be minimized by building a counteracting lingual force (X)
into the anterior segment. This produces a counter movement to neutralize the
moments, m and M’ (Figs. 2, B, 3, and 4) . Given the same circumstances (m =
1,800 Gm.-mm.) and a vertical distance of 12 mm. (y) between attachment and
center of resistance (R) , the lingual force on the anchor segment should be approxi-
mately 1,800 Gm.-mm. divided by the distance of 12 mm. which is 150 Gm.
Therefore, the anterior leg of the uprighting spring should exert a force on the
stabilizing segment in a lingual direction of approximately 50 Gm. under the above
mentioned circumstances. In turn, the molar will be rotated mesiobuccally which
will correct the often-encountered mesiolingual rotation. The lingual tipping of the
molar crown will also be minimized due to the counterclockwise moment produced
by the buccally directed force (Fig. 4).
If the hook that engages the anterior stabilizing segment ends up far to the
lingual side relative to the molar tube, the uprighting spring will tend to twist when
the hook is lifted and, thus, exert a buccal tipping force on the molar crown due to
torque (Fig. 3). This would be useful but usually is of insignificant magnitude for
effective tooth movement. The required amount of force is extremely difficult to
determine since the location of the center of resistance can only be approached as a
result of the multiple roots in this anterior segment. Therefore, anchorage should be
enforced by the canine-to-canine lingual arch, if only one premolar is present.
EK ‘4 Fixed molar uprighting appliances 385

Fig. 5. The coil spring appliance. Note the Lewis brackets with antirotation wings. Double
brackets will also function well in this instance. The diameter of the coil should not be much
greater than the diameter of the wire. If it is, it will buckle and loose efficiency through
friction.

THE OPEN COIL SPRING

The helical uprighting spring is often followed by the compressed coil spring.
This device allows the prosthodontist to achieve the fine root parallelism and bucco-
lingual positioning for construction of an excellent fixed partial denture.
The open coil spring (Fig. 5) is used when there is a minimal tipping of the
teeth or for final uprighting after use of the helical spring or box loop mechanisms.
It also may be used for final placement and rotation of teeth in preparation for band
removal. A straight wire, round or edgewise, is passed through the molar tube, pre-
molar, and canine brackets; then an open coil spring (with a coil diameter not much
larger than the greatest diameter of the archwire) is compressed between the molar
tube and the most distal premolar and the arch wire is tied in. Thus, it will exert
a distally directed force on the molar crown and a reciprocal mesially directed force
on the premolars and canine, resulting in tipping movements of the teeth. (Forces do
not go through the center of resistance.) There are no undesired side effects in the
sagittal plane if there is suficient anchorage of the anterior segment, but there are
additional things to control in the horizontal plane. Since the attachments are buccal
to the long axes of the teeth, moments of force result in addition to the linear force.
If a single bracket is used, this can readily rotate the most distal premolar which
often is enhanced if an insufficiently rigid wire is used between the teeth (Fig. 6).

THE BOX LOOP

This appliance is indicated where a molar has tipped into an extraction space
which has a molar distal to it that must be maintained.‘Both remaining molars, as
well as the premolars and canines, are banded. The terminal molar carries a 0.022
x 0.028 edgewise tube, the second molar a wide Siamese-twin bracket (0.022 x
0.028)) and the premolars and canine either single or curved twin brackets of the
same slot size (Figs. 7 and 11) . In order to understand the biomechanics of this
appliance, consider Fig. 8, a schematic drawing of an incorrectly constructed box
loop. This loop is designed so that, in the passive stage, the section between bends 4
and 5 crosses the bracket of the molar that is to be uprighted. The distal end goes
386 Khouw and Norton ,I. Prosthet. Dedt.
April, 1972

Fig. 6. Occlusal view. Since the attachments are buccal to the long axes of the teeth, a linear
force, as well as a moment, is exerted on the teeth in the horizontal plane. Particularly if
single brackets are used, this side effect can easily rotate these teeth which often is enhanced
if an insufficiently rigid wire is used. The coil spring will have a tendency to bow the archwire
out and thus increase the undesirable effect. If this rotational movement is desired, this side
effect can be taken advantage of. R = center of resistance of premolar; R = center of resistance
of molar.

Fig. 7. The box loop appliance in place. Care should be taken to contour the segment to insure
proper arch form. Occlusal interferences should be removed at regular intervals.

into the terminal molar tube, and the m&al end into the brackets of the premolar(s)
and canine. By forcing the section, 4 and 5, into the bracket of the tipped molar, the
spring in the wire will upright the tooth in time. This is true, but let us consider what
side effects occur on the anchor teeth if a wire of this design is inserted (Figs. 9 and
10).
The box loop is fabricated of 0.019 x 0.025 wire, primarily to have sufficient
bracket engagement to control (buccolingual) movement. Here the forces exerted
on the teeth are harder to determine. This appliance delivers an extrusive force of
100 Gm. or more on the terminal molar, which can move the molar well above the
plane of occlusion if no antagonist is present. To use this loop, we can minimize these
side effects by building in additional activations and by relying on the clinical obser-
vation that extrusive forces are very effective, while intrusive forces, at least of large
magnitude, are not. Since the undesirable side effect on the terminal molar is pri-
marily of an extrusive nature, we must construct the wire so that the distal end of
 Fixed molar uprighting appliances 307

~~~]/-=~;fy=+Jfy
8 6 7
6 7

DISTAL
DISTAL C-J t ’
-------; ,
--- _----
:

Fig. 8. Schematic representation of the “unmodified” box loop. Section 4-5 crosses the bracket
of the molar to be uprighted. The bends have been numbered, 1 through 8, starting from the
distal.
Fig. 9. The box loop is activated by forcing the section between bends 4 and 5 into the molar
bracket, which is done by forcing the mesial bend (4) down and the distal bend (5) up. This
will result in a series of changes, which will ultimately push bend 1 forward and up. The re-
sult is the extrusion and distal tipping of the terminal molar. This latter movement is due to
a counterclockwise moment on the terminal molar resulting from the wire lifting the mesial
end of the edgewise tube (Fig. 11). Similarly, bend 8 will cause a tendency to intrude the pre-
molars and canine mesially depending on the severity of tipping of the molar.
Fig. 10. A counterclockwise moment results from the wire pressing down on the distal end of
the bracket of the most distally located premolar, thereby lifting the most forward end of
the wire. This would tip the premolars and canine back into the extraction space. Another
effect is extrusion of the terminal molar. The distal end of the box loop is lifted which exerts
an extrusive linear force, as well as a counterclockwise moment on the terminal molar.
Fig. 11. A schematic modification of the box loop for the prevention of undesired side effects.
The broken line represents the height of the brackets of the molar distal to and the premolars
mesial to the molar to be uprighted. Construct the box loop in such fashion that, upon activa-
tion, the distal end will be at the height of the terminal molar tube. Additional gable bends
complete the modification.

the box loop lies at the level of the terminal molar tube after activation. This will
greatly decrease this extrusive force component. As the tipped molar uprights, how-
ever, the intrusive action of this spring on the terminal molar will tip the molar
mesially. To eliminate this side effect, an angular bend (gable bend) must be added
to this distal portion of the wire (Fig. 11) . Clinically, bodily intrusion of the termi-
nal molar will usually occur under these conditions; therefore this potential side ef-
fect can be neglected.
In the anterior segment, there is a strong intrusive force on the premolars and
canine. Again, this intrusive action will have minimal clinical effect. After molar
uprighting is completed, a secondary distal tipping side effect occurs. This appears
as a clockwise moment which rotates the anterior segment distally (Fig. 10). To
counteract this, a slight gable bend must be added to exert a clockwise moment. If
only one premolar on the ipsilateral side is present, it is necessary to support anchor-
age by adding a soldered lingual arch from canine band to canine band in order to
minimize movement of anchor teeth, particularly since exact force quantification is
extremely difficult.
388 Khouw and Norton J. Prosthet. Dent.
April, 1972

The reader experienced with biomechanics employing rectangular wire may have
observed that something else should be discussed, namely torque (twist). It is easy to
see that active torque exerted on a tooth exerts a moment (couple). To simplify the
force system in the box loop, we suggest that the wire be completely passive in torque
(third-order movement).
Finally, it should be remembered that from an occlusal view, the arch segment
must conform with the existing arch form (molar offsets and the like).

CONCLUSIONS
The mechanical prin(;iples of three-banded segmental appliances suggested for
the correction of tipped posterior teeth were discussed. This presentation was a
simplified version of the theoretical principles involved in the use of these appliances.
In clinical situations, there are an infinite variety of mechanical problems. The basic
biomechanical principles were outlined to reduce the incidence of adverse side effects
and give suggestions about the probable causes of an unanticipated result.

SUMMARY
The following measures are suggested with the use of segmented molar upright-
ing appliances to minimize undesired side effects:
1. The helical uprighting spring
a. Bend the stabilizing segment so that it fits completely passive in the brackets
of premolars and cuspid. Check for arch form.
b. The helical spring should push lingually on the stabilizing segment when in-
serted in the molar tube. The exact amount of force depends on dimensions
and other clinical data.
2. The compressed coil spring
a. Use sufficiently rigid wire to prevent bowing of the wire.
b. Make sure the most distal premolar cannot rotate by using double brackets or
Lewis brackets with antirotation wings. If single brackets are used, an eyelet
can be used to tie the mesial to the archwire.
3. The box loop
a. The anterior leg of the loop should have a gable bend to prevent distal tipping
of the anchor segment.
b. The distal leg of the loop should be shorter (more apical) so that it will be at
the height of the terminal molar upon activation of the box loop.
C. The distal leg should also have a gable bend to get or maintain the terminal
molar in an upright position.
d. Contour the box loop for proper arch form.
4. Anchorage can be supported by a canine-to-canine lingual arch in all three sug-
gested appliances.
5. In order to prevent undesired side effects, torque (twist) should not be present in
active form. It is not necessary for these purposes.

References
1. Herrick, P. R.: A Method for Repositioning Abutment Teeth, Fornightly Review, Chicago
Dental Society 25: 13-15, May, 1953.
 Fixed molar uprighting appliances 389

2. Proffit, W. R., and Norton, L. A.: Orthodontics for the General Practice, in Morris, A. L.,
and Bohannan, H. M., editors: The Dental Specialties in General Practice, Philadelphia,
1969, W. B. Saunders Company, pp. 197-256.
3. Norton, L. A., and Parker, W. T.: Management of Repositioned Teeth in Preparation for
Fixed Partial Dentures, J. Am. Dent. Assoc. 81: 916-922, 1970.
4. Norton, L. A., and Proffit, W. R.: Molar Uprighting as an Adjunct to Fixed Prostheses,
J. Am. Dent. Assoc. 76: 312-316, 1968.
5. Burstone, C. J.: The Biomechanics of Tooth Movement, in Kraus, B. C., and Riedel, R. A.,
editors: Vistas in Orthodontics, Philadelphia, 1962, Lea & Eebiger, Publishers, pp. 197-
213.

DR. KHOLJW
5 CENTRAL SQUARE
KEENE, N. H.

DR. NORTON
DEPARTMENT OF ORTHODONTICS
COLLEGE OF DENTISTRY
UNIVERSITY OF KENTUCKY
LEXINGTON, KY. 40506