Changes in Ability of Patients to Differentiate Intensity

of Forces Applied to Maxillary Central Incisors

During Orthodontic Treatment

JESSE E. SOLTIS,* PATRICK R. NAKFOOR, and DOUGLAS C. BOWMAN

Department of Orthodontics and Physiology, Loyola University Dental School,
Maywood, Illinois 60153, USA

Changes in the subjective ability of patients maxillary central incisor before and during
undergoing orthodontic treatment to dis- prolonged orthodontic treatment.
tinguish differences in intensity of forces ap- Weber' performed a study dealing with
plied to maxillary central incisors were the perception of small differences among
evaluated. A decided reduction of this dis- weights, the lengths of lines, and the pitch
criminatory ability was recorded four days of tones for a particular sensory modality.
after the insertion of orthodontic appliances. He found that for a subject to notice a
A significant reduction in pain threshold to change in intensity of the stimulus, or the
these forces also was noted. Subsequent "just noticeable difference", the change must
measurements showed a definite trend constitute a certain percentage of the stimu-
toward the initial pretreatment values. lus or a constant. Weber' maintained that
in comparing sensations and evaluating the
For many years dentists have been aware distinction between them, it is not the dif-
of the significance of the measure of pro- ference between the sensations that is per-
prioceptive end organs in the periodontal ceived, but the ratio of this difference to
ligament of human teeth. They also have the magnitude of the sensations compared.
been aware of the discomfort that patients This may be expressed mathematically as C
- dlII, where I represents the intensity of
undergo on the onset and during various
stages of orthodontic treatment. The dis- the stimulus, dI the "just noticeable differ-
comfort these patients experience is at- ence, and C the Weber ratio. Hecht2 thought
tributed to a lowering of the pain threshold that the Weber ratio was constant only
and to a disruption of the level of proprio- within the moderate ranges and not through-
ception of the end organs located in the out the extremes in the intensity scale. As
periodontal ligament. The study of these a continuous physiologic phenomenon, the
periodontal receptors has been accom- discrimination ratio decreases steadily as the
plished, for the most part, by stimulating intensity increases.
the teeth of mammalian laboratory animals Woolworth and Schlosberg,3 in summariz-
and monitoring the sensory response some- ing the results of many investigators, stated
where along the neural pathways. Research that Weber's constant is a rough empirical
in this area has been confined to laboratory generalization in the midranges of most
animals because of the difficulty in attempt- senses both for intensity and for quality, and
ing to study quantitatively changes in the these midranges can be considered the op-
level of proprioception and pain threshold timal working area of the senses. Treisman4
in humans. maintains that Weber's law is approximately
The purpose of this investigation was to true for the midranges of many stimulus
study the dental patient's conscious proprio- modalities, but for low intensities and often
ceptive evaluation of forces applied to the for high values the Weber ratio tends to
increase.
Received for publication June 10, 1970. Bowman and Nakfoor5 studied the ability
* Present address: 8748 N Wisner, Niles, Ill, USA. of humans to distinguish differences in in-
590
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Vol 50 No. 3 PATIENT SENSITIVITY DURING TREATMENT 591

tensity of forces applied to the maxillary were applied to the teeth were developed by
incisors. The Weber ratios for their study the torque wrench instrumentation. They
were found to range between 0.10 and 0.5 were intermittent forces that were used to
of the standard force values used. They re- establish Weber ratios at the different test-
ported that the optimal functioning range ing periods.
for making these discriminations fell be- The experimental forces were developed
tween 50 and 500 gm force applied to the through four torque wrenches, each cali-
crowns of the teeth. brated in grams and graduated in varying
increments. This allowed optimal spacing
Materials and Methods of the increments on the various scales as
The 50 subjects used in this study were well as a high degree of accuracy. All torque
selected from patients about to receive orth- wrenches had calibrations that were certified
odontic treatment in the department of as true with a maximal allowable error that
orthodontics of Loyola University Dental did not exceed 2 % of the full scale read-
School. They were from 11 to 17 years old. ings. The four torque wrenches were cali-
The patients were separated into two groups. brated as follows: (1) 0 to 16 gm calibrated
One group consisted of 19 patients whose in 0.5 gm increments; (2) 0 to 70 gm cali-
treatment plan did not require the removal brated in 2 gm increments; (3) 0 to 350 gm
of teeth. The remaining group of 31 patients calibrated in 5 gm increments; and (4) 0 to
required the removal of premolars to facili- 1,500 gm calibrated in 50 gm increments.
tate treatment of malocclusions. All data The differential threshold, or the just
were recorded from maxillary incisors. noticeable difference between forces, was
The patients were tested at four prin- determined for each patient at each of the
ciple testing periods. The first testing period standard forces centered around 10, 50,
was before any treatment, The second test- 100, 200, 500, and 1,000 gm. These forces
ing period was four days after the ortho- were applied to the incisal surface and di-
dontic appliances were placed. The patients rected along the long axis of the crown,
had been wearing activated appliances for and to the labial surface and directed 900
to the long axis of the crown. A compara-
approximately five to six months when the tive force differing by + 10% from the
third set of experimental data was gathered, standard force was applied to the tooth and
ie, after the initial stages of treatment were this was then followed by the application
completed. The fourth and final measure- of the standard force. The patient then
ments were taken when all of the patients judged which of the two forces was heavier
were approximately 12 months into treat- and the comparative forces were then in-
ment. At this time the patients were in vari- creased or decreased as necessary to estab-
ous stages of treatment, but none were wear- lish the minimal differential threshold. The
ing appliances that were delivering forces validity of the resolved differential threshold
directly to the maxillary anterior teeth. was established by the patient's ability to
The force producing instrumentation was identify correctly the heavier force at least
a specially designed and modified torque seven out of ten times. Forces were admin-
wrench*; a complete description of this in- istered in random order.
strumentation has been reported pre- The differential threshold was determined
vioUsly.5'6 above and below the standard force. This
The patients were subjected only to light was done to insure a true differential
differential orthodontic forces. These forces threshold because the values above and be-
were applied continually to the teeth during low the standard force values were not
the four day period preceding the second always identical. In instances where the
measurement period. They ranged from 40 threshold values were not identical, the two
to 150 gm. Magnitudes varied and were values were averaged.
dependent on the intrinsic and extrinsic If the patients were unable to judge the
forces used. The experimental forces that heavier of the two forces at least seven out
* Designed and constructed by P.A. Sturtevant Co.,
of ten times, the differential threshold was
Addison, III. considered too low. The force differential

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592 SOLTIS, NAKFOOR, AND BOWMAN J Dent Res May-June 1971
then was increased gradually, in relation to the patients experienced pain with force ap-
the standard force, until the patient could plications above this value.
identify correctly the heavier of the two The mean Weber ratios are plotted
forces at least 70% of the time. This was against the first, second, third, and fourth
considered the true differential threshold. measurement periods for each standard
The differential threshold was considered force stimulus in Figures 1 through 6.
too high if the patient could identify cor- These are graphic representations of the
rectly the heavier force 100% of the time. changes in the Weber ratio between the
The force differential then was decreased measurement periods for each particular
gradually, in relation to the standard force, standard force used.
until the patient could identify the heavier The plots of the Weber ratios for the 10
force correctly seven, eight, or nine times gm force standard are presented in Figure
of ten. 1. The values begin high (indicating poor
subject discrimination of force magnitude
Results differences) and are similar over the first
The mean Weber ratios determined for two measurement periods. The ratios vary
varying forces applied to the incisal surface somewhat at the third measurement period:
and directed along the long axis of the maxil- the ratio for forces applied 90° to the long
lary central incisor in the 50 patients tested axis continues to rise, whereas the ratios
at the four measurement periods are pre- for forces directed along the long axis
sented in Table l. Table 2 shows the mean clearly decline. The fourth measurement
Weber ratios determined for varying forces ratios approximate each other and are
applied to the labial surface and directed somewhat lower than those of the first mea-
90° to the long axis of the maxillary cen- surement period. Overall, the patients' abil-
tral incisor for the four measurement pe- ities to distinguish consciously differences
riods. For the second measurement period in intensity of force application is poor at
mean Weber ratios are not reported for this force range for all of the measurement
forces above 200 gm because a majority of periods.
TABLE 1
MEAN WEBER RATIOS FOR FORCES APPLIED TO THE INCISAL SURFACE AND DIRECTED ALONG
THE LONG AXIS OF THE MAXILLARY CENTRAL INCISOR
Standard
Force 4 Days After 6 Months After 1 Year After
Value Before Insertion of Initiation of Initiation of
(gm) Treatment Appliances Treatment Treatment
10 0.467 + 0.053* 0.549 ± 0.101 0.509 + 0.124 0.365 ± 0.116
50 0.132 + 0.036 0.311 + 0.059 0.199 ± 0.042 0.134 ± 0.038
100 0.147 ± 0.041 0.400 + 0.074 0.206 ± 0.063 0.122 + 0.031
200 0.124 ± 0.030 0.328 ± 0.081 0.122 + 0.035 0.077 ± 0.019
500 0.108 ± 0.031 ... 0.124 ± 0.038 0.105 ± 0.027
1,000 0.179 ± 0.043 0.091 ± 0.051 0.072 ± 0.021
Fifty patientsand four different measurement periods.
* Mean + one standard deviation.

TABLE 2
MEAN WEBER RATIOS FOR FORCES APPLIED TO THE LABIAL SURFACE AND DIRECTED 900 TO
THE LONG AXIS OF THE MAXILLARY CENTRAL INCISOR
Standard
Force 4 Days After 6 Months After 1 Year After
Value Before Insertion of Initiation of Initiation of
(gm) Treatment Appliances Treatment Treatment
10 0.453 0.168* 0.536 0.116 0.565 + 0.119 0.382 ± 0.133
50 0.133 ± 0.032 0.304 ± 0.061 0.213 ± 0.037 0.139 ± 0.040
100 0.135 ± 0.037 0.406 ± 0.076 0.223 ± 0.071 0.131 ± 0.032
200 0.126 ± 0.031 0.336 ± 0.066 0.133 ± 0.036 0.083 ± 0.058
500 0.105 0.032 . . 0.136 0.046 0.110 ± 0.039
1,000 0.195 ± 0.035 ... 0.097 ± 0.044 0.074 + 0.023
Fifty patients and four different measurement periods.
* Mean -+- one standard deviation.

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Vol 50 No. 3 PATIENT SENSITIVITY DURING TREATMENT 593
.50o

I
11 \\"
"I . .4 0_
/, \
I
I

I- \ ,. .. \
*.\
0O { *.
- .30_
I..\ I%
/ *--.\.
, *. \
r *. \

,; *-.'\
./ *S
WW .2 0_

*- .sE-
3.
.10_

0o^----- S _ _1_________1__________ 1_
1st 2nd 3 rd 4t h,
Measurement Period
1st 2nd 3 rd 4t h
FIG 3.-Mean Weber ratios plotted against
Measu r ement Period
measurement periods for 100 gm force stan-
FIG 1.-Mean Weber ratios plotted against dard. Dotted line, forces applied along long
measurement periods for 10 gm force stan- axis; broken line, forces applied 900 to long
dard. Dotted line, forces applied along long axis.
axis; broken line, forces applied 90° to long
axis.

The plots in Figures 2, 3, and 4 resemble .4 0_

each other closely in that the plots for the
second measurement period are higher than
the first and in each instance this is followed ._ .30_ ,!4\
by a more or less linear return of the Weber
ratio to the fourth measurement period. ,=s .20
I

This is most evident in Figure 2. The high- 4)

4~~~~~~~~~~~~~~~~~~~i
est mean Weber ratios recorded for these A\~~~~~~~~~~~~~~~~~~; -,0

forces at the second measurement period 3:.10 . '.

were for the 100 gm force application,

whereas the 200 gm ratios were slightly o, I I I I
higher than those for the 50 gm force ap- 1st 2nd 3rd 4th
Measurement t Per iod

FIG 4.-Mean Weber ratios plotted against

measurement periods for 200 gm force stan-
dard. Dotted line, forces applied along long
axis; broken line, forces applied 900 to long
axis.

..I'd.,
plication.
1~I00
The Weber ratios for the 50 and
forces at the third measurement
gm
4.0 I
period approximate each other, and at the
/11 fourth measurement period they are nearly
3. I/
identical to each other as well as to the
ratios obtained at the first measurement
period.
^J 2 nd 3rd 4th
J 1 _ plots were not possible for
Complete
Figures 5 and 6 because the 500 and 1,000
Measurement Period
gm values could not be obtained at the
FIG 2.-Mean Weber ratios plotted against second measurement period. The segmented
measurement perin ods for 50 gm force standard. curves for the two force directions of the
Dotted line, forc es applied along long axis; 500 gm plots appear nearly identical and
broken line, force s applied 900 to long axis. the ratios for the first and fourth measure-

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594 SOLTIS, NAKFOOR, AND BOWMAN J Dent Res May-June 1971
1,000 gm force are lower at the third and
fourth measurement period than those re-
corded at the first measurement period.
z
Discussion
..
The Weber ratios reported in this study
are quantitative assessments of the patient's
ability to consciously distinguish differences
in intensity between forces applied to the
maxillary central incisors. These stimuli
.......... were conducted through the sensory recep-
-

tors located in the periodontal ligament.

The comparison of Weber ratios for the
1st 2nd 3rd 4th four measurement periods reveals that the
Measurement Period highest values recorded were for the second
FIG 5.-Adean Weber ratios plotted against measurement period (four days after the
measuremen periods for 500 gm force stan- insertion of orthodontic appliances), whereas
dard. Dottedd line, forces applied along long the fourth readings (one year after initia-
axis; brokeni line, forces applied 900 to long tion of treatment) could be compared
axis. grossly to the pretreatment values.
The high values at the second measure-
ment period indicate that there was a sig-
nificant and measurable loss of propriocep-
tive discrimination four days after the onset
of active orthodontic treatment. Signifi-
cantly, there was also a definite lowering
a.3
of the pain threshold at this time, with ap-
m proximately 80% of the patients experienc-
ing pain on application of standard force
stimuli at the first measurement period.
Measurements made after approximately
V .- 1 .year of orthodontic treatment demon-
-..
one
strated that this subjective discriminatory
L ---capacity was returning and, in general, could
1st 2nd 3rd 4th be compared to the discriminatory ability
Measurement Period possessed before any treatment had taken
FIG 6.-A/lean Weber ratios plotted against place. Further, the pain threshold had ap-
measuremen t periods for 1,000 gm force stan- parently risen to near its original level:
dard. Dottedd line, forces applied along long none of the patients experienced pain with
axis; broken line, forces applied 900 to long the application of the 500 or 1,000 gm
axis. forces.
The initial orthodontic appliances create
ment periodds appear equal. The two seg- forces that are applied to the teeth and af-
mented ploi ts in Figure 6 also appear to be fect the periodontal ligament and distort
similar, but the values obtained at the third the sensory receptors. This continual stimu-
and fourth measurement periods are below nation of the periodontal proprioceptive
those obtaiined at the first measurement mechanism decreases the patient's ability to
period. discriminate between forces. It is most likely
Comparirng the 200 gm force ratios with that the fourth readings compared favorably
those of the 500 and 1,000 gm ratios shows with the starting values because of adapta-
that the plc Ats of the 200 and 500 gm force tion of the sensory receptors within the
values are rnearly identical at the third mea- periodontal ligament. Even though there
surement pe.riod, whereas the 200 and 1,000 was a sustained force on these teeth, straight,
gm values aire nearly identical at the fourth long range neural adaptation was to be ex-
measuremernt period and are lower than the pected. The continuous stimulus input from
500 gm vablues. The Weber ratios for the the maxillary central incisor is altered within

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Vol 50 No. 3 PATIENT SENSITIVITY DURING TREATMENT 595
the central nervous system as central ac- nificant difference was found between the
commodation, ie, the ability for the central two groups in their ability to discriminate
nervous system to learn the altered levels between forces applied at the various mea-
of adaptation as the orthodontic treatment surement periods. The two maxillary first
continued. premolars were extracted in all patients re-
Another consideration is that as treat- quiring the removal of teeth. It can be spec-
ment time continues and the major tooth ulated that there was no difference between
movements have been accomplished, the the two groups because the maxillary cen-
actual force delivered to the teeth by the tral incisor is too far removed in the dental
arch wire is diminished. This allows the dis- arch from the first premolar to seriously
torted sensory receptors in the periodontal affect its proprioception.
ligament to attain a more normal and thus The accumulated data show a definite
more functional configuration. When teeth trend indicating that a return to normal dis-
are moved through alveolar bone to a crimination is to be expected on the com-
more desirable position, bone resorption pletion of orthodontic treatment. It is ex-
occurs on the pressure side of the alveolus. pected that the Weber ratios for the 1,000
This biologic process permits the sensory gm force level will rise to normal after the
receptors to return to a more normal, phys- removal of appliances and complete re-
iologic configuration by reestablishing a adaptation. The periodontal proprioceptors
normal biologic relationship among the root should return to their normal physiologic
of the tooth, the periodontal ligament, and configuration on final attainment of a nor-
the alveolus. mal biologic relationship among the roots
The data from this study indicate that of the teeth, the periodontal ligament, and
the optimal working range for the proprio- the surrounding alveolus.
ceptors of the human periodontal ligament
of the maxillary incisor in terms of forces Conclusions
applied to the crown begins at approximately A clinical method for testing dental pro-
50 gm and extends to an upper limit some- prioceptive discrimination involving the hu-
where between 500 and 1,000 gm. The man periodontal ligament was described.
Weber ratios for the 1,000 gm level at the This method was used to determine the ef-
fourth measuremnet period were 0.074 for fects of prolonged orthodontic treatment
the 900 axis and 0.072 for the long axis as on periodontal proprioceptors. This quan-
compared to the first measurement period titative study of variations in discriminatory
when they were 0.195 for the 9(0 axis and proprioceptive thresholds under different
0.179 for the long axis. These values tend phases of orthodontic treatment led to in-
to indicate that the patients could discrim- formation concerning the sensitivity of the
inate better between forces at the fourth teeth to light orthodontic forces. Variations
measurement period than they could before can be put in quantitative form.
treatment. The evaluation of proprioceptive Proprioceptive discriminations dependent
comparisons at this time period showed on the periodontal ligament are altered sig-
improvement of the values recorded at the nificantly with the application of light or-
third measurement period in the other five thodontic forces. Four days after these light
standard forces used, so improvement at orthodontic forces were applied to the max-
the 1,000 gm force is to be expected at the illary central incisor, the ability of the pa-
fourth period. The fact that the Weber ra- tients to differentiate between forces of
tios were lower at this period than at the proportional magnitudes was decreased sig-
beginning of treatment might be related at nificantly. The patients were separated into
the second measurement period. Apprehen- two groups before the experimentation
sion of pain at this force level could have started. One group needed the extraction
made the patients more critical in their dis- of first premolars in treatment of malocclu-
sion. The second group did not require ex-
criminatory efforts in subsequent measuring traction of teeth in their treatment plan.
periods. No significant difference was found between
Patients requiring the removal of teeth, the two groups in their ability to discrimi-
as well as patients not requiring the removal nate between forces at any of the four
of teeth, were used in this study. No sig- measuring periods.

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596 SOLTIS, NAKFOOR, AND BOWMAN J Dent Res May-June 1971
No greater discriminatory sensitivity was References
found for forces applied to the incisal sur- 1. WEBER, E.H.: De Pulsu Resorptione et
face and directed along the long axis of the Tactu Annotation Anatomical et Physiolo-
crown than for forces applied to the labial gische, Arch Anat Physiol 152, 1834.
surface and directed 900 to the long axis of 2. HECHT, S.: The Visual Discrimination of
the crown, as has been reported for some Intensity and the Weber-Fechner Law, J
experimental animals.6,7 It may be con- Gen Physiol 7:235-267, 1924.
cluded from this that the proprioceptors of 3. WOOLWORTH, R.S., and SCHLOSBERG, H.:
Experimental Psychology, New York: Hen-
the periodontal ligament of the human pre- ry Holt and Co., 1958.
sent a different configuration or arrange- 4. TREISMAN, M.: Noise and Weber's Law:
ment than that reported for experimental The Discrimination of Brightness and Other
animals. Dimensions, Psychol Rev 71:314-330, 1964.
Insertion of orthodontic appliances mea- 5. BOWMAN, D.C., and NAKFOOR, P.R.: Evalu-
surably reduced the pain threshold to force ation of the Human Subject's Ability to
application. There was a reduction in the Differentiate Intensity of Forces Applied to
pain threshold to force application that the Maxillary Central Incisors, J Dent Res
could be measured in 84% of the patients 47:252-259, 1968.
four days after insertion of orthodontic ap- 6. KIziOR, J.E.; Cuozzo, J.W.; and BOWMAN,
pliances. After prolonged orthodontic treat- D.C.: Functional and Histologic Assess-
ment of the Sensory Innervation of the
ment, the pain theshold rose to near its Periodontal Ligament of the Cat, J Dent
original level. Res 47:59-64, 1968.
The overall trend to normal propriocep- 7. PFAFFMAN, C.: Afferent Impulses from the
tive discrimination is expected on the com- Teeth Due to Pressure and Noxious Stimu-
pletion of orthodontic treatment. lation, J Physiol 97:207-219, 1939.

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