American

Founded

Journal

of ORTHODONTICS

in 1915

Volume
Copyright

85 Number
1984

by The

ORIGINAL

June, 1994

6
C. V. Mosby

Company

ARTICLES

The effects of space closure of the

mandibular Jirst molar area in adults
Barney M. Horn, D.D.S.,* and Patrick K. Turley, D.D.S., M.S.D., M.Ed.**
Los Angeles,
Calif.

Dr. Horn

There is little information regarding the orthodontic closure of remodeled, edentulous spaces in the posterior area
of the mandible. The present study was undertaken to determine the dental and periodontal changes that occur
when mandibular first molar areas are closed in adults. Fourteen adult patients were selected from private
orthodontic practices. Pre- and posttreatment study models were used to measure the mesiodistal length of the
edentulous space and the buccolingual width of the alveolar ridge. The amount of crown and root movement of
the second molar and premolar was measured from lateral cephalometric radiographs. From pre- and
posttreatment panoramic or periapical radiographs, the anatomic changes of the second molar and adjacent
periodontium were also measured. Every case showed significant space closure (x = 6.2 mm) ranging from 2.7 to
11.5 mm. There was crestal bone loss (x = 1.3 mm) mesial to the second molar in all but five cases. These latter
cases showed bone addition. As the molar moved mesially, the alveoiar ridge increased in width an average of
1.2 mm. The adult patient who showed the greatest amount of space closure and the least amount of molar bone
loss had (1) mesiodistal space of 6.0 mm, (2) buccolingual ridge width of 7.0 mm, and (3) mesial molar bone
level 1 .O mm apical to the cementoenamel junction. The results of this study indicate that space closure is not
only possible but may aid the treatment of certain cases. Space closure should be considered as a potential
solution to the absence of mandibular first permanent molars.

Key words: First molar area, mandible, remodeled, spaceclosure, bone loss

common clinical finding in the adult

orthodontic patient is the absence of the mandibular
first molar. When the first molar is lost, the second
molar usually tips mesially , the second premolar drifts
distally, and the alveolar ridge becomes narrower. The
second molar is particularly susceptible to abnormal
stresses and bony breakdown, and pocket formation
may occur mesial to the inclined molar.
Many orthodontists assume that if the buccolingual

From the Section of Orthodontics,

School of Dentistry, University of California Los Angeles.
Based on a thesis submitted by the senior author in partial fulfillment of the
requirements for a certificate in orthodontics,
University
of California Los
Angeles.
The research was pa&ally
funded by the Foundation for Orthodontic
Research.
*Practicing orthodontist in Manhattan Beach, Calif.
**Associate Professor and Acting Chairman, Section of Orthodontics.

width of the alveolar ridge is constricted, the second

molar should not be moved mesially since this will
result in a loss of bone support.* Moreover, there are
problems of gingival dehiscence, root parallelism, and
incomplete space closure. It has been shown, however,
that spaces of 10 mm or more can be closed in the
posterior region of the mandible.3
There is little information regarding the closure of
remodeled edentulous spaces in the posterior area of the
mandible. The purpose of this research is to examine
the dental and periodontal changes that occur when
mandibular first molar areas are closed orthodontically
in adults and to compare the findings with those of a
previous study .3
REVIEW OF THE LITERATURE
Edward H. Angle4 called the first molar the key to
occlusion. Certainly, this tooth is very important in
457

458

Horn

and

Am. J. Orthod.
June 1984

Turley

maintaining the stability of the dentition, as can be seen

by the complications that result when it is prematurely
lost. Vanarsdall and Swartz5 described the common
sequelae to the missing mandibular first molar as (1)
mesially inclined second and/or third molars, (2) distal
drifting of the premolar-s, (3) extrusion of the maxillary
molars, (4) altered gingival form with constriction of
the edentulous ridge, (5) infrabony defect mesial to the
inclined molar, (6) stepped marginal ridges, (7) food
impaction, and (8) posterior bite collapse. The consequences in the maxillary arch are usually not as severe
as those in the mandibular arch. The maxillary second
molar may come forward in a relatively untipped manner with the long axis converging apically . The premolar may or may not drift distally.
There are several alternatives in treating the missing
mandibular first molar. Graber states that space closure of the molar area is seldom possible or desirable
with limited orthodontic therapy. Movement of posterior teeth is often difficult because of the greater root
surface area, the increased tissue resistance, and the
anchorage needs involved. Since there is a consequence
of umwanted tooth movement elsewhere when posterior teeth are moved, partial correction may be the optimal result obtainable. He advocates uprighting the
second molar to its normal position and stabilizing it
with a fixed or removable prosthesis.
Kessle? suggested that if the buccolingual width of
the second molar alveolus is wider than the adjacent
edentulous ridge, the tooth should not be moved mesially since this will result in a loss of bone support.
Moreover, if there is a definite periodontal osseous defect on the mesial aspect of the inclined molar, uprighting the tooth and tipping it distally may widen the defeet , necessitating an autogenous hip marrow graft. The
uprighting of mesially inclined molars is not a panacea.
The possibility exists that uprighting some teeth may
cause bone loss and furcation involvement.
In contrast, Brown6 showed that uprighting of molars produced significant reduction in the depth of existing periodontal defects and highly desirable changes in
the gingival architecture. The gingival margin moved
from a coronal position approaching the marginal ridge
to a more inferior location adjacent to the cementum of
the anatomic root. This increased the length of the clinical crown with a concurrent decrease in the depth of
the periodontal pocket. However, he also found that the
alveolar bone level decreased between 0.5 and 1.O mm,
along with the reduction of total pocket depth. He considered this amount to be therapeutically insignificant.
Ingber showed that forced eruption can correct isolated one- or two-wall infrabony osseous defects. Extrusion of a tooth from its alveolus causes a stretching

of the gingival and periodontal ligament fibers. This

results in a coronal shift of the bone at the base of the
defect as the tooth moves occlusally . These vertical
osseous defects frequently occur along with an inclined
alveolar crest on the mesial side of the second molar.
Roberts and associate9 noted that if the relationship
between the alveolar crest and the cementoenamel
junction is constant during molar uprighting, the angular osseous crest mesial to the tipped molar is not only
eliminated but also somewhat reversed in inclination,
corresponding to the amount of extrusion which occurs.
Moreover, if extrusive forces are used to correct vertical osseous defects, they should follow the correction
of molar inclination in order to have better control of
the rapid molar extrusion and the periodontal inflammation.
Although most clinicians caution against closing
edentulous first molar spaces, this procedure has been
attempted in certain situations. Stepovich3 studied the
changes in the edentulous ridge and adjacent teeth before and after closure of first molar spaces in the mandible. The first molar areas had no evidence of the
residual socket. The sample consisted of eight teenagers and eight adults who had completed orthodontic
treatment. He found that the buccolingual width of the
alveolar ridge can be changed by orthodontic treatment.
In teen-agers the alveolar bone readily followed the
tooth as it was moved into an edentulous space that was
narrower than the tooth. In contrast, half of the adult
patients resisted the formation of any new bone during
space closure; the other half developed only minimal
amounts of new bone. Crestal bone loss mesial to the
second molar was evident in both groups, but the adult
group showed twice as much loss. Root resorption was
not seen in the teen-age group; in the adult group, resorption occurred in only two of eight patients.
Stepovich concluded that spaces of 10 mm or more can
be closed without tipping in both the teen-age and the
adult patient. However, closed spaces were difficult to
maintain in the adult patient.
MATERIALS

AND METHODS

Fourteen adult patients ranging in age from 20 to 39

years were selected from private orthodontic practices.
From these patients nineteen quadrants with edentulous
mandibular first molar spaces were used in the study.
(five patients had bilateral absence of first molars.) All
patients had been fully treated with edgewise orthodontic appliances. The first molar areas lacked radiographic evidence of a residual socket. The patients had
complete pre- and posttreatment records that included
plaster casts, lateral cephalometric radiographs, and
panoramic or periapical radiographs.

Volume 85
Number 6

From the pre- and posttreatment study models, the

mesiodistal length of the edentulous space and the buccolingual width of the alveolar ridge were measured
with dial calipers. The mesiodistal length was measured from contact point to contact point of the teeth
adjacent to the edentulous space. The buccolingual
width of the alveolar ridge before treatment was measured in a manner described by Stepovich .3 A point was
located at the middle of the ridge mesiodistally. The
calipers were placed 4 mm apical to this point on the
buccal and lingual aspects, and the width of the ridge
was recorded. The posttreatment width of the ridge was
measured similarly if there was incomplete space closure. If there was complete space closure, a point on
the ridge beneath the contact point of the second premolar and the second molar crown was used. Again the
calipers were placed 4 mm apical to this point to measure the width.
The amount of crown and root movement of the
second molar and second premolar was measured from
the pre- and posttreatment lateral cephalometric tracings. First, a Ricketts eleven-factor summary analysis
was performed. I7 The corpus axes of the two tracings
were then superimposed at PM point (protruberance
menti). The occlusal plane of the pretreatment tracing
was traced onto the posttreatment cephalometric tracing. Perpendicular lines to the occlusal plane were
drawn from the following points (Fig. 1, A): (A) the
most mesial point of the second molar crown, (B) the
most inferior point on the mesial root of the second
molar, (D) the most distal point of the second premolar
crown, and(E) the most inferior point on the root of the
second premolar.
By measuring the change in these points from T, to
T,, the following information was obtained:
A-The
distance that the second molar crown
moved mesiodistally (M-D).
B-The
distance that the second molar root
moved M-D.
C-The
distance that the second molar crown
moved vertically.
D-The
distance that the second premolar crown
moved M-D.
E-The
distance that the second premolar root
moved M-D.
The anatomic changes in the second molar and adjacent periodontium were measured from the pre- and
posttreatment panoramic or periapical tracings (Fig. 1,
B). First, the second molar, second premolar, and the
interproximal alveolar bone were traced. An occlusal
plane of the second molar was then drawn; this plane
was determined from the best fit of the pre- and
posttreatment molar. Lines parallel to the molar

Effects

of space

closure

of mandibular

first

molar

area

459

Fig. 1. A, The pre and posttreatment tracings were superimposed along the corpus axis at PM to determine the
amount of crown and root movement of the second molar and
premolar.
A, Second molar crown movement M-D; 8, second
molar root movement M-D; C, second molar crown movement
vertically: D, second premolar crown movement M-D; E, second
premolar root movement M-D. B, The anatomic changes of the
second molar and adjacent periodontium were measured from
the pre- and posttreatment panoramic or periapical tracings. f,
Crestal bone change; G, molar root resorption; /-/, vertical alveolar ridge change; I, cementoenamel junction change (indicating
x-ray distortion).

occlusal plane were drawn from the following points:

(1) crestal bone mesial to the molar, (2) cementoenamel
junction (CEJ) mesial to the molar, (3) the most inferior
point on the mesial root of the molar, and (4) the interproximal bone halfway between the molar and the premolar.
By measuring the change in these lines from T, to
TZ the following information was obtained:
F-Amount
of crestal bone change.
G-Amount
of molar root resorption.
H-Amount
of vertical alveolar ridge change.
I-Change
in cementoenamel junction position.
Of the nineteen edentulous spaces studied, periapical radiographs were taken of eleven and panoramic
radiographs were taken of eight. To minimize measurement errors, the elongation or foreshortening factor
in the radiographs was calculated by measuring the
change in the position of the cementoenamel junction

466

Horn

Table

and

Am. J. Orthod.
June 1984

Turley

IA. Dental changes with space closure (mm)

Space
Mesiodistal

Range

Mean
T test significance
Standard deviation

closure

space

Tl

T2

Net
space
closure

3.5
to
12.6
6.9
NA
2.3

0.0
to
1.1
0.7
NA
0.6

2.7
to
11.5
6.2
0.01
2.5

Positive values indicate mesial movement

of molars
NA = Test for statistical
significance
not applicable.

Table

Mesiodistal

and distal

movement

Crown

tooth

movement

movement

Molar

Root movement

Premolar

-1.1
to
8.9
4.1
0.01
2.6

-0.4
to
5.9
2.0
0.01
1.9

Molar

Premolar

I.0
to
15.7
1.1
0.01
3.6

-3.1
to
5.3
2.0
0.01
2.0

of premolars.

18. Periodontal changes with space closure (mm)

Vertical

bone change

Bone height

Range

Mean
T test significance
Standard deviation
Positive
NA-Test

T,

7-2

Net
change

5.5
to
10.6
8.0
NA
2.8

6.5
to
14.4
9.3
NA
3.0

-4.2
to
1.8
-1.3
0.01
1.7

values indicate mesial movement

of molars
for statistical
significance
not applicable

and distal

movement

(I in Fig. l), which should change much like the other

anatomic landmarks.
The facial pattern of the patient was determined
from the measurements of five cephalometric angles:
facial axis, mandibular arc, mandibular plane, facial
plane, and lower face height. A composite number was
derived by determining the clinical deviations from the
norm of these angles. A positive number indicated a
more brachyfacial pattern, while a negative value indicated a doliocofacial pattern.
A computerized statistical analysis was performed
on the collected data: (1) the range, mean, and standard
deviation of all variables, (2) t tests for significant
changes from pretreatment to posttreatment, (3) correlation coefficients of all variables matched against each
other, and (4) multiple regression analysis for prediction of space closure and molar bone loss.
RESULTS

Space closure was accomplished in all patients with

closing loops on rectangular wires. The treatment time
ranged from 23 months to 52 months.

Buccolingaal

alveolar

change

- 1.6 to 4.8
+1.2
0.01
1.1

Root resorption

-3.3

to 1.3

-1.3
0.01
1.2

of premolars.

Space

closure

The size of the edentulous space prior to treatment

ranged from 3.5 mm to 12.6 mm, with a mean of 6.9
mm (Table I). Thirteen quadrants had openings of 6
mm or more (Table II). In every case there was significant space closure with a mean of 6.2 mm. However, in only 5 of 19 quadrants were spaces completely
closed on the posttreatment models. Twelve cases
showed mesiodistal openings of less than 1 mm after
treatment, with an average opening of 0.7 mm (Figs. 2,
D, 9, 10). In one case that started with 12.6 mm of
space, only 1.1 mm of space remained after treatment.
Mesiodistal

tooth

movement

The amount of mesiodistal movement of both the

crown and root of the second molar and premolar was
determined by measuring the changes in these landmarks from the T1 and T2 cephalometric tracings. The
molar crown moved mesially an average of 4.1 mm,
with the greatest movement being 8.9 mm (Table I).
On the average the molar moved mesially twice as
much as the premolar moved distally-4.1
mm versus

Volume 85
Number 6

Effects

of space

closure

of mandibularjrst

molar

area

461

Table II. Space closure and tooth movement (mm)

Space closure
Mesiodistal

Patient
J.
M.
D.
G.
L.
J.
L.
c.
D.

D.
R.
K.
H.
B.
T.
s.
L.
S.

E. H.
A. D. R.
E. D.
M. H.
S. D.
*Positive

values

Mesiodistal
Crown

space

Side

Tl

7-2

Net
space
closure

L
R
L
R
L
L
R
L
L
R
L
R
L
R
L
R
L
R
L

6.2
7.3
6.5
5.1
7.7
8.3
9.8
3.1
8.1
3.5
5.0
9.2
1.1
12.6
6.9
5.6
6.4
1.5
3.5

1.2
0
1.7
0
0.6
1.6
1.5
0.6
0.6
0.8
0.8
0
1.4
1.1
0.8
0
0
1.0
0.6

5.0
7.3
4.8
5.1
7.1
6.1
8.3
3.1
1.5
2.1
4.2
9.2
6.3
11.5
6.1
5.6
6.4
6.5
2.9

indicate

mesial

movement

of molars

and distal movement

2.0 mm (Fig. 2, B). Five quadrants showed more distal

movement of the premolar than mesial movement of
the molar (Table II). Only one case showed distal
movement of the second molar.
The roots of the second molar moved mesially almost twice as much as the crown (7.1 mm versus 4.1
mm), indicating significant uprighting. Only three
cases showed more crown movement than root movement (that is, tipping). Six cases had molar root movement of 9.5 mm or more, with the greatest amount
being 15.7 mm. Figs. 8, 9, and 10 illustrate a case in
which the roots moved mesially 12.2 mm. Prior to
treatment all second molars were tipped mesially. As
the molars were uprighted and moved mesially during
treatment, they erupted an average of 1.5 mm.
Vertical bone change
Examination of vertical bone changes with treatment revealed crestal bone loss mesial to the second
molar in all but five cases (Table III). In those latter
cases there appeared to be an increase in bone as the
molar moved mesially (Figs. 3 to 7). On the average,
however, there was - 1.3 mm of vertical bone loss,
with a range of 1.8 mm (bone addition) to -4.2 mm
(bone loss) (Table I). Fig. 8 illustrates a case with - 2.5
mm of vertical bone loss.

tooth movement*

movement

Molar
crown

Premolar
movement

4.4
-1.1
3.2
0.5
7.5
5.9
1.5
1.4
4.1
1.7
4.5
3.9
4.6
8.9
5.7
4.9
6.3
0.1
2.8

1.5
5.8
1.1
3.5
-0.4
0.3
0.4
2.1
2.8
1.6
0.7
4.1
1.7
3.4
1.3
1.0
0
5.9
1.5

Root movement
Molar
root
2.6
1.0
5.0
7.5
8.7
5.8
12.2
5.8
10.3
5.5
3.6
1.4
5.5
15.7
10.1
9.5
9.5
3.0
5.7

Premolar
movement
1.8
1.5
1.1
2.6
0
5.3
1.8
1.9
1.9
-3.1
1.0
2.1
-0.6
4.5
3.4
3.0
2.8
5.3
0.2

of premolars.

Buccolingual

alveolar width change

Examination of the change in buccolingual width of

the alveolar ridge revealed that the ridge increased in
width an average of 1.2 mm as the molar moved mesially (Table I, Figs. 4 and 6). The values ranged from
- 1.6 mm (decrease) to 4.8 mm (increase). Seven cases
had a narrower ridge (j7 = 0.8 mm) in the posttreatment
models, indicating slight bone loss with treatment (Fig.
9). There was no correlation between ridge width and
change in vertical bone height.
Root resorption
Root resorption of the second molar was minimal.
There was an average of only 1.3 mm of resorption,
with the greatest resorption being 3.3 mm (Table I,
Figs. 3,5, and 8). Only four cases had more than 2 mm
of resorption. Four cases showed a root-length increase of up to 1.3 mm (Table III). This apparent root
lengthening was due to elongation in the radiographs, a
problem that will be discussed later.
Correlation coefficients
Correlation coefficients between forty-one variables
were used to test for significant linear relationships.
There were several notable findings:
1. The higher the bone level on the mesial aspect of

462

Am. J. Orthod.
June 1984

Horn and Turley

Fig. 2 (Contd). C, Pretreatment

study

Fig.

2.

A,

Pre- and posttreatment

cephalometric
tracings
of
Patient A.D.R. showing
distal premolar
movement
greater
than
mesial molar movement
(4.7 mm distal versus
3.9 mm mesial),
right side. B, Mesial
molar movement
greater
than twice the
distal premolar
movement
(4.6 mm mesial versus
1.7 mm distal), left side

the second molar at Tr, the greater the amount of bone

loss at T2 (r = 0.546).
2. The older the patient, the greater the amount of
molar eruption (r = 0.7 16).
3. The higher the molar bone level at Ti, the
greater the amount of mesiodistal space at T2 (r =
0.492).
4. The wider the alveolar ridge at T1 , the greater
the amount of mesiodistal space at T, (r = 0.478).
5. The facial pattern of the patient did not correlate
significantly with any of the other variables in the
study.

casts

showing

study casts. D, Posttreatment

1.4 mm space opening
on left side.

Prediction of space closure

In order to predict the amount of mesiodistal space
after treatment, a multiple regression analysis was performed. Nine variables were analyzed as potential predictors. It was found that three of the variables
(mesiodistal space, width of alveolar ridge, and mesial
molar bone height, all at T,) were significantly
(P < 0.01) related to the amount of mesiodistal space at
TZ. An equation was derived to predict the amount of
mesiodistal space after treatment:
M-D space at T2 = 1.15 mm + 0.07 mm (M-D space at
Tl + 0.18 mm) width of ridge at
T, _ 1.95 mm (bone height on mesial side of molar at T1)*
(CEJ height on mesial side of molar at Tl)

The multiple correlation coefficient is 0.73, and the

standard error of a predicted value is 0.43 mm.
*The bone and CEJ height of the molar were measured from the molar occlusal
table.

Volume 85
Number 6

Effects

of space

closure

of mandibular

jirst

molar

area

463

Table III. Alveolar bone changes and root resorption (mm)

Vertical

bone change

Vertical
bone height
Patient
J.
M.
D.
G.
L.
J.
L.
c.
D.

D.
R.
K.
H.
B.
T.
s.
L.
S.

E. H.
A. D. R.
E. D.
M. H.
S. D.

Side

T,

T*

L
R
L
R
L
L
R
L
L
R
L
R
L
R
L
R
L
R
L

8.0
9.5
10.2
1.3
7.1
7.6
5.5
8.4
7.1
5.8
8.1
8.0
6.6
1.9
8.0
9.3
7.1
10.6
10.1

11.6
9.1
14.4
8.5
7.6
11.6
8.0
8.0
10.4
7.9
7.5
7.5
8.4
9.5
8.9
7.5
6.5
11.8
11.5

Prediction of vertical bone change

A multiple regression analysis was also performed,
with the same nine variables as predictors of molar
bone loss. It was found that only the bone height on the
mesial aspect of the molar at T1 was significantly
(p < 0 .Ol) related to the amount of molar bone loss. An
equation was derived to predict the amount of molar
bone loss on the mesial part of the tooth after space
closure: Molar bone loss = 1.48 mm (CEJ height on
mesial aspect of molar at T,) - 1.17 mm (bone height
on mesial aspect of molar at Tz).* The multiple correlation coefficient is 0.55, and the standard error of a
predicted value is 1.5 mm.
DISCUSSION
The findings in the study indicate that orthodontic
space closure can be achieved with edentulous, remodeled mandibular first molar spaces. All nineteen
quadrants showed significant space closure, with a
mean of 6.2 mm (Table I). In sixteen quadrants there
was bodily movement of second molars, with the roots
coming forward almost twice as much as the crowns
(7.1 mm versus 4.1 mm, Table I). Six cases showed
molar root movement of 9.5 mm or more, with the
*Assume

no radiographic

magnification

at TZ.

Net

Net
vertical
bone change
-3.6
-0.2
-4.2
-1.2
-0.5
-4.0
-2.5
0.4
-2.1
-2.1
0.6
0.5
- 1.8
- 1.6
-0.9
1.8
1.2
-1.2
- 1.4

Buccolingwl
alveolar
width change
0.5
4.8
-0.2
0.8
1.5
-1.6
-1.0
1.2
3.5
-0.4
1.5
2.8
-0.9
2.4
3.1
3.2
2.2
-0.6
-1.2

Root
resorption
1.3
-1.6
0.5
-0.4
-1.5
-0.4
-1.7
-1.5
0.7
-2.2
-2.1
-1.3
- 1.4
-1.6
1.3
-2.8
-3.3
-1.9
-1.6

greatest amount being 15.7 mm (Table II). Similarly,

Stepovich3 also showed that second molars can be
moved forward through edentulous areas without tipping. This is in contrast with the viewpoint of Graber,
who states that space closure of the mandibular first
molar area is seldom possible because of the greater
molar root surface area and increased tissue resistance.
The results of the study indicate that space closure not
only is possible but also may aid in the treatment of
certain cases, such as those with anterior crowding.
Cases that might normally require extraction of premolars to alleviate crowding were treated without extractions by using the space provided by the missing
first permanent molars. In these cases space closure
occurred reciprocally with mesial molar movement and
distal premolar movement (Figs. 2, C, D, and 10, A
and B) .
In fourteen out of nineteen quadrants, some space
existed between the second molar and the second premolar on the posttreatment models. In most cases it was
not known whether the space had opened after treatment or whether the space was never entirely closed. In
attempting to maintain space closure, Hatasakag observed that the best postretention results were in cases
in which roots and crowns were positioned in normal,
upright parallel positions. EdwardslO suggested that ex-

464 Horn and Tut&y

Fig. 3. Periapical
radiograph
of right first permanent
of Patient M.H., showing
bone level prior to space
Radiograph
showing
1.8 mm vertical
bone addition
closure.
2.8 mm of root resorption
occurred
on
molar.

Am. J. Orthod.
June 1984

molar area
closure.
8,
after space
the second

cess gingival tissue could be a factor associated with

residual spaces and advocated the surgical removal of
any tissue that accumulates interproximally during
treatment. In this study the mesiodistal space and the
buccolingual width of the alveolar ridge prior to treatment were significantly (P < 0.01) related to the
amount of space left after treatment. Those quadrants
with less than 1 mm of residual space started with edentulous spaces that averaged 6.0 mm and a ridge width
of 6.8 mm. Cases that began with a wider ridge actually
showed more space after treatment. Although the distribution pattern showed some individual variation, an
adult patient with an edentulous space of this approximate size would have a favorable probability of maintaining good space closure after treatment.
KesslerZ suggested that moving a molar into a remodeled, constricted mandibular ridge could result in
loss of periodontal support. In studying recent first
premolar extraction sites that were closed orthodontically, Baxter observed that the mesial aspect of the
mandibular second premolars had 0.10 mm of bone

Fig. 3 (Contd).
C and D, Tracings
of right first permanent
shown
in A and B, before and after space closure.

molar

loss after treatment. With a similar extraction sequence, Zachrisson and Alnaes12 found that the second
premolars had 0.22 mm of bone loss when compared to
homologous, untreated teeth. Although the figures
from these studies may be statistically significant, the
clinical significance of these values may be minimal. In
examining remodeled extraction sites of the mandibular
first molar area, Stepovich3 found that the mesial aspect
of the second molar lost 2.0 mm of bone as it was
uprighted and moved forward. The results in this study
were similar to those of Stepovich in that there was a
tendency for the mesial bone height to decrease with
treatment. The nineteen quadrants averaged 1.3 mm of
crestal bone loss mesial to the second molar with treatment. The range varied from + 1.8 mm (bone addition)
to -4.2 mm (bone loss). Although bone loss is to be
avoided if at all possible, the consequence of moderate
molar bone loss is not necessarily a contraindication to
closure of the edentulous space. If hygiene can be
maintained by the patient or the dentist, space closure
may be a reasonable alternative to a fixed prosthesis.
Fixed prostheses are often considered the best solution
for replacement of missing teeth. However, they also

Volume 85
Number 6

Fig. 4. Pre- and posttreatment

study casts showing
3.2
increase
in buccolingual
alveolar
ridge width after space
sure (right side, Patient M.H.).

Effects

mm
clo-

have their shortcomings: (1) initial expense, (2) replacement due to caries, (3) reduction of two teeth in
crown preparation for abutments, and (4) limited orthodontics may still be needed to upright the tipped second
molar. Hence, both space closure and a fixed prosthesis
should be considered as potential solutions to missing
teeth.
In examining etiologic factors associated with periodontal bone loss, Skillen13 and Stuteville* showed
that the presence of gingival inflammation during orthodontic tooth movement may augment alveolar crest resorption. Similarly, Suomi and associates15 observed
that the maintenance of optimal oral hygiene in adults
retards the rate of alveolar bone loss. In this study the
nature of the patients oral hygiene and the presence or
absence of gingival inflammation during orthodontic
therapy could not be determined. Only radiographs and
plaster casts were available for study. In attempting to
identify factors which might be related to bone loss
with treatment, the mesial bone height of the molar
prior to treatment was the only statistically significant
(P < 0.01) variable. Cases with a higher mesial bone
level at the start of treatment actually showed the

of space

closure

of mandibular

jirst

molar

area

465

Fig. 5. A, Periapical
radiograph
of left first permanent
molar
area of Patient M.H., showing
bone level prior to space closure.
B, Radiograph
showing
1.2 mm vertical
bone addition
after
space closure;
3.3 mm of root resorption
occurred
on the second molar.

greatest amount of bone loss with treatment. This

finding is difficult to explain since cases with prior
periodontal bone loss might be more prone to bone loss
with treatment. In contrast, however, a tooth being
moved through a lesser volume of bone support might
move more easily, thus resulting in less overall bone
loss. With regard to our findings, however, even
though cases with higher pretreatment bone levels experienced the most bone loss, the changes did not
compromise the periodontal support of these teeth and
hence a successful result with space closure was
achieved. However, other factors appear to be relevant
when the characteristics of those that showed less than
1 mm of bone loss (Group 1) are compared to those that
showed more than 2 mm of bone loss (Group 2). In
comparison, Group 1 had (1) a shorter mesiodistal
space prior to treatment (6.5 mm versus 7.1 mm), (2) a
narrower alveolar ridge width (6.7 mm versus 7.7
mm), and (3) a molar bone level that was more apical to
the cementoenamel junction (1.2 mm versus 0.3 mm).
There was considerable individual variation in both

466

Horn

and

Am. J. Orthod.
June 1984

Turley

Fig. 5 (Contd).
C and D, Tracings
of left first permanent
shown in A and 9, before and after space closure.

molar

groups. It is noteworthy that the figures for mesiodistal

space and width of ridge in Group 1 are very similar to
those in the group with less than 1 mm of residual
space. Therefore, the adult patient who showed the
least amount of molar bone loss and the greatest
amount of space closure met the following criteria: (1)
mesiodistal space of approximately 6 mm or less, (2)
buccolingual ridge width of approximately 7 mm, and
(3) mesial molar bone level of approximately 1 mm
apical to the cementoenamel junction.
As space closure occurs, there is not only vertical
bone change mesial to the second molar but also buccolingual change to the alveolar ridge. Examination of
the change in the width of the alveolar ridge shows that
the width increased an average of 1.1 mm after treatment. The values ranged from - 1.6 mm (width decrease) to 4.8 mm (width increase). Stepovich3 found
that four out of eight adult patients resisted formation of
any new bone. The other half developed only a small
amount of new bone. In this study seven quadrants had

Fig. 6. Pre- and posttreatment

study casts showing
2.2
increase
in buccolingual
alveolar
ridge width after space
sure (left side, Patient M.H.).

mm
clo-

a narrower ridge after treatment, with a mean decrease

of 0.8 mm. However, these cases prior to treatment had
a much wider ridge than the average (8.6 mm versus
7.2 mm) and, even after treatment, there appeared to be
a sufficient amount of bone interproximally (7.8 mm).
Root resorption is always a major concern in tooth
movement. In this study root resorption of the second
molar was minimal. There was an average of 1.3 mm
of resorption, with the greatest amount being 3 $3 mm.
Only four cases had more than 2 mm of root resorption.
In those six cases in which the roots traveled 9.5 mm or
more, only 1.7 mm of root length was lost. Similarly,
Stepovich3 found minimal change in root length in six
out of eight patients, with the average amount of resorption being 0.4 mm. Phillips16 observed, in his
study of apical root resorption under orthodontic therapy, that 96% of mandibular second molars showed no
resorption at all. The remaining 4% exhibited minimal
blunting of the root apices. Moreover, there was no
correlation between the amount of apical root loss and
the amount of tooth movement through bone.
In this study three cases showed a root length in-

Volume 85
Number 6

Fig. 7. Pre- and posttreatment study casts of mandibular arch in

Patient M.H.

crease as great as 1.3 mm, which is attributed to radiographic distortion. Despite making corrections for
magnification, there are still slight errors in the radiographic values. Periapical radiographs were available
in eleven cases and panoramic radiographs were available in eight. Ideally, it would have been better to use
only one type of radiograph, but this was not possible.
The overall periodontal health of the mandibular
second molar after space closume is certainly pertinent
to the success of the case. An examination of the patients before and after treatment to determine pocket
depths, amount of attached gingiva, tooth mobility, and
gingival recession would provide valuable information
to the clinician. However, this step was beyond the
scope of this project. A future study should include
monitoring the patients gingival health along with
using a standardized, reproducible radiographic technique to document the periodontal changes accompanying space closure.
CONCLUSIONS

1. Mandibular second molars can be moved forward through remodeled, edentulous first molar areas

Effects

of space

closure

of mandibular

jirst

molar

area

467

Fig. 8. A, Periapical radiograph of first permanent molar area of

Patient L.S., showing bone level prior to space closure. 8, Radiograph showing 2.5 mm of bone loss after space closure; 1.7
mm of root resorption was measured on the first permanent
molar.

in adults. Although every case showed significant space

closure, only five cases had complete space closure.
2. In the majority of cases space closure occurred
by bodily movement of the molars, with the roots moving mesially almost twice as much as the crowns.
3. On the average, the width of the alveolar ridge
increased buccolingually 1.1 mm as the second molar
moved forward. However, seven cases had narrower
alveolar ridges after treatment.
4. With treatment there was crestal bone loss mesial to the second molars in all but five cases.
5. Root resorption of the molars was minimal.
6. The adult patient who showed the greatest
amount of space closure and the least amount of molar
bone loss met the following criteria: (1) mesiodistal
space of approximately 6 mm or less, (2) buccolingual
width of the ridge of approximately 7 mm, and (3)
mesial molar bone level of approximately 1 mm apical
to the cementoenamel junction.
7. Space closure is not only possible but may aid

468 Horn and Turley

Fig. 8 (Contd).
A and 6, before

C and D, Tracings
of first
and after space closure.

Am. J. Orthod.
June 1984

molar

area

shown

in
Fig. 10. Pre- and posttreatment
in Patient L.S.

study

casts

of mandibular

arch

the treatment of certain cases. Space closure should be

considered a potential solution to the absence of mandibular first permanent molars.
The formulas and recommendations for space closure and molar bone loss are only guidelines to help the
clinician decide if space closure of this type is feasible.
The equations were derived from a select group of nineteen quadrants, and there remains some error in the size
of a predicted value. Therefore, the clinician must still
exercise sound clinical judgment before initiating orthodontic therapy,
The authors would like to acknowledge the special assistance of Dr. Kunihiko Miyashita of Tokyo, Japan, Mr. Gary
Engel of The Foundation for Orthodontic Research in the
collection of the data and preparation of the manuscript, and
the Word Processing Center of the UCLA School of Dentistry
for the typing of the manuscript.
REFERENCES

Fig. 9. Pre- and posttreatment

study casts
showing
1.0 mm
decrease
in buccolingual
alveolar
ridge width after space closure (Patient
L.S.).

1. Graber TM: Orthodontics: principles and practice, ed. 3,

Philadelphia, 1972, W.B. Saunders Company.
2. Kessler M: Interrelationships between orthodontics and periodontics. AM J ORTHOD 70: 154-172, 1976.
3. Stepovich ML: A clinical study on closing edentulous spaces in
the mandible. Angle Orthod 49: 227-233, 1979.

Volume 85
Number

8.
9.
10.
11.

12.

Effects

of space

closure

of mandibular

first

molar

area

469

Angle EH: New system of regulation and retention.

Dent Register 41: 497-603,
1887.
Vanarsdall
RL, Swartz ML: Molar uprighting,
Ormco catalog
No. 740-0014,
Glendora,
Calif., 1980, Ormo Corporation.
Brown IS: The effect of orthodontic
therapy on certain types of
periodontal
defects. .I Periodontol44:
742-756,
1973.
Ingber JS: Forced eruption. Part 1. A method of treating isolated
one and two wall infrabony
osseous defects-rationale
and case
report. J Periodontol45:
199-206,
1974.
Roberts W, Chacker F, Burstone
C: A segmental
approach to
mandibular
molar uprighting.
AM J 0~~~0~81:
177-184, 1982.
Hatasaka HH: A radiographic
study of roots in extraction
sites.
Angle Orthod 46: 64-68, 1976.
Edwards JG: The prevention
of relapse in extraction
cases. AM J
ORTHOD 60: 128-141,
1971.
Baxter DH: The effect of orthodontic
treatment on alveolar bone
adjacent to the cementoenamel
junction.
Angle Orthod
37:
34-49, 1967.
Zachrisson
BU, Alnaes L: Periodontal
condition
in orthodon-

13.
14.

15.

16.

tically treated and untreated individuals.

II. Alveolar bone loss:
radiographic
findings.
Angle Orthod 44: 48-55, 1974.
Skillen WG: Tissue changes the result of artificial
stimuli and
injury. J Am Dent Assoc 27: 1554-1563,
1940.
Stuteville
OH: Injuries to the teeth and supporting
structures
caused by various orthodontic
appliances,
and methods of preventing these injuries. J Am Dent Assoc 24: 1494-1507,
1937.
Suomi JD, West TD, Chang JJ, McClendon
BJ: The effect of
controlled
oral hygiene procedures
on the progression
of periodontal disease in adults: radiographic
findings.
J Periodontol
42: 562-564,
1971.
Phillips JR: Apical root resorption
under orthodontic
therapy.
Angle Orthod 25: 1-21, 1955

Reprint requests to:

Dr. Patrick Turley
Center for Health Sciences
University
of California
School
10833 Le Conte
Los Angeles, CA 90024

of Dentistry