Comparison of Roth appliance

appliance treatment results

and standard edgewise
Paul F. Kattner, DDS, MS, and Bernard J. Schneider, DDS, MS*
Chicago. !11.
A retrospective comparison of Roth appliance and standard edgewise appliance treatment results
was made using two indices. The first, the ideal tooth relationship index (ITRI), scored dental casts
for the presence of ideal tooth contacts. The second judged posttreatment dental casts on the basis
of criteria established by Andrews' in his "Six Keys to Normal Occlusion." The sample consisted of
120 orthodontically treated cases completed by two practitioners who have used both the Roth and
standard edgewise appliances. Thirty cases of each appliance type were collected from each
practitioner. The overall posttreatment ITRI percentage scores showed no significant differences
between the appliances. Practitioner differences existed for the anterior intraarch, anterior interarch,
and posterior buccal interarch relationships. These differences were related to both treatment time
and finishing arch wire size. The results of the Six Keys Analysis showed that the angulation and
inclination of the maxillary posterior teeth were better with the Roth appliance. However, success in
achieving some components of the six keys did not translate into an increased percentage of ideal
tooth contacts as measured by the ITRI. Despite using the Roth appliance, experienced clinicians
still found it difficult to achieve all six keys to normal occlusion. (AM J ORTHOD DENTOFAC ORTHOP
1993;103:24-32.)
I n 1972 Andrews t reported on 120 casts of
nontreated subjects with dentitions he considered to be
optimal. His purpose was to seek data that uniquely
characterized these dentitions and to establish basic
standards against which deviations could be recognized
and measured. Andrews referred to these standards as
the "Six Keys to Normal Occlusion. ' ' t The commonal i t y
of objectives for most persons meant to Andrews' - that
it should be possible to develop an efficient appliance,
economical in both time and energy requirements, for
achieving these goals. The result was the Straight-Wire
Appliance ( "A" Company, San Di ego, Calif.).
The Straight-Wire Appliance (SWA) has had an im-
portant impact on appliance design and selection. Sur-
prisingly, a review of the scientific literature reveals
that few studies have been compl et ed to critically eval-
uate the SWA. Anecdotal assessments conclude there
is a reduction in both treatment time and chair time
wi t h the SWA, 35 and that results are better and more
cons i s t ent Y One cgmponent of the SWA design, the
assumption of tooth facial surface contour consistency,
has been investigated, 8"tt and Ross et al."- have docu-
"mented the effects of skeletal growth Variation on treat-
From the Department of orthodontics. University of Illinois at Chicago, College
of Dentistry.
This aai cl e is based on research submitted by Dr. Kattner in partial fulfillment
of the requirements for the degree of Master of Science in Orthodontics,
University of Illinois at Chicago.
*Professor, Department of Orthodontics.
0889-5406193151.00 + 0. 10 811133301
ment with preadjusted appliances. Some have con-
cluded that this biologic variability precludes the
application of a single appliance prescription in
the treatment of individualized malocclusions, s't'-
Andrews t3 has stressed that the inclination of a pat i ent ' s
teeth may vary from the average, but when that occurs,
it will do so in an orderly manner throughout the arch.
9 The SWA is available in 11 prescriptions. The se-
lection of the appropriate appliance is made based on
maxillary and mandibular treatment plans. The Roth
appliance ("A" Company, San Diego, Calif.) is one of
the available SWA bracket prescriptions. The purpose
of this study was to compare the treatment results of
Roth appliance (RA) cases with those treated with a
standard edgewise appliance (SEA).
The selection of an appropriate tool to measure
treatment results was important for this research. Epi-
demiologic and treatment priority interests have led to
the development of a variety of occlusal analyses, t4-24
The goal of many of these was to assess malocclusion
in a large sampl e, and for this reason lacked the critical
measures necessary for an evaluation of treatment re-
9 In 1989 Haeget a~ modified the methods intro-
duced by Hellman 26 for evaluating occlusal relation-
ships. A static occlusal analysis, the ideal tooth rela-
t i onshi pi ndex (ITRI), was formulated based on ideal
interarch and intraarch relationships. In addition, An-
drews has described the six keys to normal occlusion
as a means of evaluating both static occlusion 27 and
treatment results, t
24
Volunle 103
R o t h a p p l i a n c e t r e a t n l e n t r e s u l t s 25
Number I
Tabl e I. Sa mp l e de s c r i pt i on
Pract i t i oner no. 1
SEA [ RA
Pract i t i oner no. 2
SEA [ RA
Numbe r 30 30 30 30
Angl e mol ar classification
Class I 18 18 16 19
Class II, Divison 1 11 12 14 11
Class II, Divsion 2 1 0 0 0
Stage
Mixed 11 12 16 15
Permanent 19 18 14 15
T~pe
Nonextraction 17 19 22 24
2 premolar 3 3 I 0
4 premolar 10 8 7 6
Sex
Male 12 14 14 17
Female 18 16 16 13
Age at otzsel
Average 14/0" 12/11 12/5 13/4
Minimum-maximum o/ 7-30/ 0 10/0-19/3 9/9-22/7 9/ 7-28/ 8
Age at deband
Average 16/I 14/7 14/11 15/9
Minimum-maximum 12/1-32/2 I I/5-20/11 10/9-24/1 ! 12/6-30/6
Duration
Average 2/1 I/ 8 2/ 6 2/ 4
Minimum-maximum 1/4-3/0 0/ I I-2/8 1/0-6/7 ! 14-411
*X/Y represents years/months.
MATERI ALS AND METHODS
The sample for this study (Table I) consisted of records
col l ect ed from two private practices in which the clinicians
have used both the standard edgewi se and the Roth appliances.
The total sample of 120 subjects included 30 cases of each
appliance type from each of the clinicians. Both practitioners
used the Roth prescription (0. 018 0. 025-i nch slot) straight
wire brackets. Partial or limited treatment cases, cases pre-
senting with significant skeletal asymmet ry, or cases with
congeni t al l y missing teeth were not included. In addition,
those cases with fixed or r emovabl e prosthetic restorations,
periodontal compl i cat i ons, models with chipped or broken
teetfi, or quest i onabl e articulation of upper and Iov,'er casts
were excl uded. Pretreatment models were taken as part of the
diagnostic records, and posttr.eatment models were taken the
day of debanding. The sample was selected without regard
for the quality of treatment or difficulties encount ered during
treatment.
This study consisted of t wo parts. Part I evaluated treat-
ment results with the ITRI, whereas Part I1 evaluated results
with Andr ews' six keys ?
Ideal tooth relationship index
Visual inspection of dental casts t ri mmed 1o centric oc-
clusion was compl et ed as des~zribcd by Haeger. :3 The ITRI is
expressed as a percent age of possi bl e intraarch (intcrproximal)
and interarch relationships with the total number of potential
contacts varyi ng with the clinical situation. Permanent second
molars and all deci duous teeth were excl uded. Si nce it was
not possible to det ermi ne i f proximal spacings in areas of
recent band removal were due solely to the band thickness
or were actual dental spacings, all open contacts were treated
as absent proxi mal relationships. A range of approxi mat el y
mm was permitted for a contact to deviate from its
ideal position. Thi s det ermi nat i on was subj ect i ve.
Ideal relationships were evaluated as follows:
I. Overal l scores
2. Ant er i or segment scores
a. Intraarch relati0nships
b. lnterar h relationships
3. Posterior segment scores
a. Intraarch relationships
b. Interarch rela!ionships (including an analysis of
buccal and lingual relations).
Finishing arch wi re sizes were recorded for each of the RA
cases used in the sample.
Six keys anal ysi s
The. method used for cvaluation of Andrews' six keys'
was a modi fi cat i on of that used by Uhde. '~ An acrylic plate
for det ermi ni ng the occlusal plane orientation and a modified
protractor were constructed as described by Andrews :7 and
2 6 Kat t ner o/zd Schneider Am. J. Orthod, Dentofac. Orthop.
Janua,o' 1993
T a b l e II. I TRI r e p r o d u c i b i l i t y
Trial 1
Variable N Mean % SD
Overall 20
Anterior intraarch 20
Posterior intraarch 20
Anterior interarch 20
Posterior interarch 20
Posterior interarch 20
buccal
Posterior interarch 20
lingual
26.6 15,7
14.8 18.9
31.3 29.0
32.4 29.0
23.0 25.6
34.4 30.8
Trial2
Mean % SD
Difference
Mean % I SD P value
27.1 16.0 0.5 1.4 0.149
14.8 18.9 0.0 2.7 1.000
31.4 29.4 0.1 1.5 - 0.772
32.4 29.4 0.0 3.2 1.000
23.6 25.2 0.6 2.8 0.330
34.8 30.6 0.4 1.6 0.330
28.3 30.1 28.8 30.9 0.5 2.2 0,330
ot = 0.05.
Table I I I . Si x k e y s r e p r o d u c i b i l i t y
Variable
Angulation maxillary
antenor
Angulation maxillary
posterior
Angulation mandibular
antenor
Angulation mandibular
posterior
Inclination maxillary
anterior
Inclination maxillary
posterior
Inclination mandibular
anterior
Inclination mandibular
posterior
Rotations
Contacts
Trial I
I
N Mean % I SD
20 ~. 75.8 19.8
20 53.8 27.6
20 62.5 20.1
20 74.6 15.6
20 86.7 ! 3.9
20 90.8 15.7
20 36.7 25. !
20 100.0 0 . 0
20 93.4 4.3
20 93.0 6.8
Trial 2 Difference
Mean % I SD Mean % SD P value
76.7 17.4 0.8 6.6 0.579
52.5 28.4 1.3 5.6 0.330
61.3 19.5 1.3 7.8 0.480
75.4 14.7 0.8 3.7 0.330
85,0 13.1 !,7 7.5 0.330
91.7 14.8 0.8 3.7 0.330
38.3 24.8 1.7 5.1 0. ! 63
100. 0 0.0 0.0 0.0 1 . 0 0 0
93.5 4.3 0.2 0.9 0. 368
93. ! 6.3 0. I 1.8 0.755
et = 0.05.
Uhde. : 8 Bot h t he maxi l l ar y and t he mandi bul ar dent i t i ons wer e
consi der ed, and each key was eval uat ed as bei ng pr esent or
absent , Repor t ed val ues for t he angul at i on, i ncl i nat i on, ro-
t at i on, and cont act s var i abl es are t he per cent age of t eet h dem-
onst r at i ng t he cor r ect rel at i onshi p. The AP mol ar and cur ve
of Sp e e var i abl es are report ed as t he per cent age of dent al
cast s meet i ng Andr ews ' specifications. l. Angul at i on is defi ned
as t he mesi odi st al t i p of t he cr own; i ncl i nat i on is t he buc-
col i ngual t i p of t he cr own. Many of t he pr ct r eat ment cast s'
i ncl uded deci duous t eet h, maki ng it di ffi cul t to appl y t he six
keys anal ysi s. For t hi s r eason, onl y post t r eat ment cast s wer e
st udi ed. Andr ews 27 used t he second mol ar s as t he post er i or
l i mi t of t he occl usal pl ane. Si nce t hese t eet h wer e occasi onal l y
uner upt ed i n t hi s sampl e, onl y first mol ar s wer e used. The
i nt er est ed r eader is referred to Ka t t n e r "~ f or a compl et e de-
scr i pt i on of t he si x keys anal ysi s.
Statistical analysis
To i nvest i gat e r epr oduci bi l i t y o f t he 1TRI and si x keys
anal yses, dual measur ement s we r e made on a sampl e of 20
dent al cast s, al l owi ng 14 days bet ween t ri al s (Tabl es II and
III). No si gni fi cant di f f er ences wer e f ound when t he t ri al s
wer e compar ed usi ng mat ched pai r t t est s (or = 0. 05) .
The nat ure of t he ITRI suggest ed t hat scores for each of
t he var i abl es shoul d be correl at ed. Thi s was exami ned by
comput i ng Peai ' son cor r el at i on coeffi ci ent s. A cor r el at i on of
at l east 0. 5 was f ound for one- t hi r d of t he var i abl e combi -
nat i ons. Mul t i var i at e anal ysi s of var i ance (MANOVA) t est s
wi t h Hot el l i ng' s T 2 (t~ = 0. 05) wer e compl et ed t o seek si g-
ni fi cant di f f er ences bet ween appl i ances or bet ween pract i t i o-
ner s ( Tabl e IV). A MANOVA consi der s e a c h of t he arch
s egment s is a way t hat t akes i nt o account t he cor r el at i on
bet ween t hem. Si nce t he MANOVA i ndi cat ed si gni fi cant di f-
Volume 103 Rot h appl i ance t reat t nent rest dt s 2 7 ,
Number I
Ta b l e IV. I TRI , mul t i va r i a t e anal ys i s o f va r i a nc e r es ul t s
Stage [ Variable [
Pretreatment
Posttreatment
T: I P value
Practitioner differences 1.47 0.195
Appliance differences 0.82 0.558
Interaction (PR*APL) 1.16 0.332
Practitioner differences 10.52 0.0001
Appliance differences 3.49 0.003
Interaction (PR*APL) 4.44 0.0001
c~ = 0.05.
Tabl e V. I TRI , ANOVA pr e t r e a t me nt r es ul t s
I Anterior Anterior
Overall i n t r a a r c h interarch
Practitioner no. 1 25.4 11.8 18.3 .4- 17.6 13.6 17.3
Practitioner no. 2 23.7 i1.1 18.8 19.3 11.2 19.7
F ratio 0.63 0.02 0.49
P value 0.430 0.882 0.487
Standard edge- 25.7 --+ 10.3 19.3 20.2 10.7 13.5
wise appliance
Roth appliance 23.4 ___ 12.5 17.8 --- 16.7 14.2 22.4
0. F ratio 1.18 19. 1 A08
P value 0.279 0.665 0.301
Interaction
F ratio 0.34 0.003 0.004
P value 0.560 0.956 0.947
Posterior I P osterior I Posterior Posterior
i n t r a a r c h interarch buccal lingual
15.0 16.0 38.2 23.3 38.0 23.2 34.3 - 21.7
15.2 17.7 29.7 _ 14.3 34.7 19.8 24.5 15.3
0.01 5.84 0.71 8.13
0.926 0.017 0.402 0.050
16.0 17.0 35.3 17.7 37.6 -4- 22.2 31.7 - 17.3
14.2 -'- 16.7 32.6 .4- 21. 7 35.1 _ 20.9 27.2 21.6
0.33 0.56 0.39 1.75
0.566 0.456 0.532 0.188
3.80 1.30 0.26 0.21
0.054 0.256 0.609 0.651
-c~ = 0.008 (using bonferroni correction).
ferences existed, univariate tests (two-way ANOVAS anal yz-
ing practitioner differences and appliance differences) were
completed to i dent i fy the arch segment(s) responsible. For
these univariate tests, a Bonferroni correction was applied,
which yielded a significance level of et = 0. 008 ( a =
0. 05/ 6 variables). The Bonferroni correction mai nt ai ns a at
the 0. 05 level for the entire set of comparisons, thus con-
trolling the probability of type I error.
When the six keys analysis variables were exami ned for
significant correlations by comput i ng Pearson correlation co-
efficients, none of the variable combi nat i ons scored greater
than 0. 5. For this reason, onl y univariate tests (two-way
ANOVAS, a = 0. 05) were completed for the angul at i on and
i ncl i nat i on variables of the six keys analysis. A Bonferroni
correction was not used in this analysis because the variables
were not subst ant i al l y correlated. Two-way ANOVA tests
were also performed on the rotation and contacts variables.
The AP molar and curve of Spee variables were graded as
present or absent and therefore were analyzed with the Chi-
square analysis (or = 0.05).
RESULTS
Pr e t r e a t me nt a nd pos t t r e a t me nt val ues for t he over -
al l I TRI pe r c e nt a ge scor es are pr ovi ded i n Ta bl e s V
a nd VI . No s i gni f i cant di f f er ences exi s t ed b e t we e n
gr oupi ngs pr e t r e a t me nt . Po~t t r eat ment di f f er ences ex-
i st ed for t he pr a c t i t i one r ef f ect wi t h dent al cast s o f t he
pr act i t i oner no. 2 s c or i ng s i gni f i c a nt l y hi gher . The r e
wer e no s i gni f i c a nt di f f er ences be t we e n t he SEA a nd
RA pos t t r e a t me nt scor es.
Tabl es V a nd VI al so pr e s e nt t he I TRI s cor i ngs f or
t he i ndi vi dua l ar ch s e gme nt s . Pos t t r e a t me nt a ppl i a nc e
di f f er ences exi s t ed f or t he pos t er i or l i ngua l r el at i on-
shi ps wi t h t he S EA s h o wi n g a hi ghe r s cor ed pe r c e nt a ge .
Pr act i t i oner di f f er ences exi s t ed f or t he a nt e r i or i n-
t r aar ch, a nt e r i or i nt er ar ch, a nd pos t er i or buc c a l i nt er -
ar ch r e l a t i ons hi ps . Pr a c t i t i one r no. 2 s cor ed s i gni f i -
c a nt l y hi ghe r t ha n pr a c t i t i one r no. 1 f or each o f t hes e
ar ch s e gme nt s . A s i gni f i cant pos t t r e a t me nt i nt er act i on
exi s t ed f or t he pos t er i or i nt r aar ch scor e. For t hi s re-
s ear ch, i nt e r a c t i on me a n s t hat t he s ucces s o f ' a g i v e n
a ppl i a nc e is c o n t i n g e n t on whi c h pr a c t i t i one r is u s i n g
it ( f or e x a mp l e , Fi g. 1). Wh e n e v e r a s i gni f i cant i nt er -
' act ! on o c c u r s , t he i nt er pr et at i on of t he ma i n ef f ect s
( pr a c t i t i one r a nd a ppl i a nc e ) mus t be qual i f i ed.
Tr e a t me nt dur a t i on was r ecor ded f or each o f t he
cas es i nc l ude d i n t he s a mpl e ( Tabl e I). The t r e a t me nt
t i me for pr a c t i t i one r no. 2 aver aged 2 year s a nd 5
mont hs ; t he a ve r a ge t r e a t me nt per i od for pr a c t i t i one r
no. 1 was 6 mo n t h s l ess. The di s t r i but i on o f f i ni s hi ng
ar ch wi r e si zes f or each of t he pr act i t i oner s was al so
9 8 Ka t t n e r a n d S c l me i d e r
Tabl e VI. ITRI, ANOVA post t reat ment resul ts
Am. J. Orthod. Dentofac. Orthop.
9 Januqo" 1993
I A nterior I Ant eri or
Overal l intraarch interarch
Post eri or
intraarch
Post eri or
interarch
I Post eri or Post eri or
buccal lingual
Practitioner no. 1 48.9 12,8 61.7 23.4 49.5 63.5 27.3 38.8 _-. 21.1 39.4 _ 19.7 33.7 _ 18.6
Practitioner no. 2 60.0 10.2 87.2 17.2 61.7 19.7 63.7 18.6 45.9 16.5 52.1 19.8 40.2 22.4
F ratio 27.09 46.62 8.44 0.002 4.34 12.18 3.13
P value 0.0001 0.0001 0.004 0.961 0.039 0.001 " 0.079
Standard edge- 55.2 11.5 71.3 21.3 56.4 20.6 66.4 19.5 42.7 19.2 45.9 20.5 41.8 18.7
wise appliance
Roth appliance 53.7 +-- 14.0 77.5 26.5 54.8 26.1 60.9 26.3 42.1 19.4 45.7 _ 21.1 32.1 21.7
F ratio 0.51 2.73 0.15 1.83 0.03 0,002 7.00
P value 0.479 0.101 0.699 0.178 0.872 0.965 0.009
Interaction
F ratio 0.19 0.10 0.43 14.24 4.66 0.30 1.76
P value 0.662 0.754 0.514 0.0001 0.033 0.588 0.187
ct = 0.008 (using bonferroni correction)
Tabl e VII. Si x ke y s anal ys i s , ANOVA post t reat ment results
Pract i t i oner Appl i ance
Angulation
Maxilla
Anterior
Posterior
Combined
Mandible
Anterior
Posterior
Combined
Combined
Inclination
Maxilla
Anterior
Posterior
Combined
Mandible
Anterior
Posterior
Combined
Combined
Rotations
Cont act s
AP mol ar
Curve of Spee
F-ratio P-val ue SEA RA
78.6 18.7 79.2 21.2 0.03 0.871
71.7 27.3 76.9 --- 20.1 1.51 0.222
75.1 16.2 78.1 14.9 1.13 0.289
68.1 22,2 66.9 21. 4 0.08 0.779
76.9 -4- 18,6 78.7 -- 21.6 0.24 0.627
72.5 15.6 72.8 16.6 0.01 0.906
73.8 12.5 75.4 11.4 0.59 0.442
F-ratlo
74.7 21.6 83.0 --, 17.2
69.6 28.4 79.0 +-- 17.7
72.2 ~ 17,4 81.0 12.1
hzterar
P-val ue F-rat i o value
5.85 0.017 10.42 0,0002
4.83 0.030 1.67 0.199
10.53 0.002 !.03 0.312
65.0 23.1 70.0 --- 20.1 1.59 0.209 1.26 0.264
76.8 17.8 78.9 22.2 0.32 0.574 0.24 0.627
70.9 15.9 74.4 16.1 !.45 0.230 0.20 0.654
71.5 12.7 77.7 10.3 8.63 0.004 0.94 0.334
83.3 18.4 84.7 -+ 22.0 0.14 0.705 85.0 19.8 83.1 20.7 0.28 0.596 4.85 0.029
89.3 21.3 91.0 19.8 0.20 0.654 86.0 - 25.4 94.3 13.0 5.06 0.026 0.14 0.708
86.3 --- 13.4 87.8 13.6 1.20 0.274 85.5 15.2 88.7 --- 11.3 1.71. 0.194 !.87 0.176
51.4 _ 33.9 64.2 ~ 32.7 4.34 0.039 56.9 33.4 58.6 34.5 0.07 0.786 0.3"0 0.586
98.5 6.0 99. 4-' - 3.0 1.22 0.271 99.0 4.4 98.9 5.2 0.02 0.875 0.02 0.875
74.9 18.2 81.8 16.7 4.57 0.034 78.0 17.3 78.7 18.3 0.06 0.813 0.25 0.619
80.6 I1.1 84.8 10.4 4.54 0.035 81.7 12.0 83.7 9.8 i.01 0.317 0.19 0.662
93.2 4.8 92.7 5.5 0.32 0.576 92.1 5.4 93.7 4.8 2.97 0.087 2.55 0.113
92.0 8.6 94.0 -'- 6.7 2.03 0.157 91.6 8.7 94.4 6.4 4.42 0.038 4.24 0.042
.14.8 11.9 X 2 = 0.213 0.644 14.3 12.3 = 0.100 0.753
100.0 100.0 100.0 100.0
et = 0.05.
recorded. Practi ti oner no. 2 us ual l y fi ni shed on an
0 . 0 1 7 0 . 0 2 5 - i nc h arch wi re ( 25 o f 30 cas es ) ; prac-
ti ti oner no. 1 wa s more l i kel y t o fi ni sh on an
0 . 0 1 6 0 . 0 2 2 - i nc h arch wi re (23 o f 30 c as e s ) .
The resul ts o f t he si x ke y s anal ys i s are s h o wn in
Tabl e VII. St at i st i cal l y si gni fi cant di f f erences be t we e n
practi ti oner no. 1 and practi ti oner no. 2 we r e f ound f or
t he f o l l o wi ng variables:
Volume 103 Roth appliance treatment results 2 9
Number 1
Table VIII. Percentage of casts with
keys present
Variable I Andrews* I Kattnert
Key I, AP molar 20% 13%
Key It, angulation 9% < 1 %
Key Ill, inclination 22% 10%
Key IV rotations 33% 19%
Key V, contacts 57% 31%
Key VI, curve of 44% 100%
Spee
*Posterior limit of the occlusal plane = second molars.
";Posterior limit of the occlusal plane = first molars.
1. Inclination of mandibular anterior teeth
2. Inclination of combined mandibular anterior and
posterior teeth
3. Inclination of combined maxillary and mandib-
ular teeth
Practitioner no. 2 scored significantly higher than prac-
titioner no. 1 for each of these variables.
Statistically significant differences] between the
SEA and the RA were found for the following variables:
I. Angulation of maxillary posterior teeth
2. Angulation of combined maxillary anterior and
posterior teeth
3. Angulation of combined maxillary and mandib-
ular teeth
4. Inclination of maxillary posterior teeth
The RA scored higher for each of these.
Interaction effects were found for the following
variables:
1. Angulation of maxillary anterior teeth
. 2. Inclination of maxillary anterior teeth
3. Contacts
For each of these, practitioner no. 1 scored higher when
using the SEA and practitioner no..2 scored higher with
the RA.
When the variables used in the six keys analysis
were combined, a calculation of the percentage of casts
achieving each of Andrews' six keys' was possible
(Table VIII). No single case achieved all six keys.
DISCUSSION
Ideal tooth relationship index
Analysis of overall scores. Given human nature and
differences in perception significant differences be-
tween the treatment results of the two practitioners is
not surprising. The ITRI overall posttreatment score for
practitioner no. I was 48. 9%, whereas practitioner no.
2 achieved 60. 0% of ideal contacts. The standard de-
viation for practitioner no. I was also greater than that
M 75
E
A
N 70
P
E 65
R
C
E 60
N
T
A 55
G
E
50
S E A
R A
A
R A
1
P R A C T I T I O N E R
Fig. 1. Plot describing posterior intraarch interaction.
for practitioner no. 2. For this sample, then, practitioner
no. 2 achieved better and more consistent results than
practitioner no. 1.
The overall posttreatment percentage scores for the
SEA and the RA show no significant differences. Given
the reported benefits 47 of a preadjusted appliance, this
result is surprising. Several questions must therefore be
addressed. First, is the ITRI a valid method of assessing
treatment? Any attempt at measuring treatment results
is difficult. However, since the "Six Keys to Normal
Occlusion"' were derived from a study of optimal oc-
clusions and led to the design of the SWA, it was be -
lieved that an index that looks for ideal tooth relation-
ships was appropriate. Haeger :5 reported that ITRI scor-
ings of treatment and posttreatment changes are
consistent with the results of others. 3~ The second
question is whether the examiner used the ITRI cor-
rectly. Haeger 25 reported pretreatment and posttreat-
ment overall scores o f 26.8% _ 1i . 8% and
52. 1% _-+ I0. 7%, respectively. The sample size for
Haeger' s study was 92 cases. In this analysis of 120
treated malocclusions, the pretreatment average was
24. 7% __-11.8%. The posttreatment average was
54. 5% _ 11.7%. The results are remarkably similar.
The ne:~t question to be addressed is whether each of
the practitioners used the RA correctly. In a retrospec-
tive clinical study it is not possible to control all con-
ceivable variables, therefore deviation from the text
book description of the RA bracket placement by the
practitioners is possible. However, each practitioner has
30 Kattner and Schneider
instructed orthodontic graduate students in the place-
ment of and observed subsequent treatment with the
RA. It is presumed these persons use the RA at least
as well as the average clinician.
Analysis of individual arch segments. An evaluation
of individual arch segments revealed that intraarch re-
lationships (interdental proximal contacts) were han-
dled better than any of the interarch relationships. The
anterior intraarch segment scored higher than the pos-
terior intraarch segment. The anterior interarch segment
also shows better treatment results than the posterior
interarch segment . Within the posterior segment , scores
for buccal contacts are generally higher than those for
lingual relationships. It appears, then, that practitioners
do a better j ob correcting discrepancies that are highly
visible. Haeget a5 found similar results.
The onl y variable to show an appliance difference
was the posterior lingual relationship. The SEA scored
significantly higher than the RA. It was noted previ-
ously that the lingual dental relationships are not treated
to as excellent an occlusion as.the buccal relationships.
It is also generally thought th'at lingual cusps are not
handled as well as buccal cusps clinically, that the max-
illary lingual cusps are often left vertically out of contact
with the l ower teeth after orthodontic therapy. It might
have been anticipated that the inclination built into the
RA would have predictably positioned the lingual cusps
of the upper posterior teeth in the proper contact rela-
tionship. Thi s was not the case. A more detailed review
of this arch segment will be included in the discussion
of the six keys analysis findings.
Posttreatment practitioner differences did exist for
anterior intraarch, anterior interarch, and posterior buc-
cal arch segment s. Practitioner no. 2 scored signifi-
Cantly higher than practitioner no. 1 for each of these
variables. These same arch segments were also gen-
erally treated better than any other arch segments in-
dependent of the operator. Recall that the treatment t i me
for practitioner no. 2 averaged 2 years and 5 months,
and the treatment period for practitioner no. l was 6
months less (Table I). Improvement s (finishing details)
in these highly visible areas may have been the focus
of concern during the extended period of treatment for
practitioner no. 2."The cost to benefit ratio of continuing
treatment to achieve a more i deal ' st at i c occlusion has
not been adequately studied in the literature. The ITRI
analysis of dental casts taken after an extended post-
treatment period might help resolve this issue. Practi-
tioner no. 2 was also more likely to finish cases on a
full-sized arch wire. Thi s difference may be important:
Meyer and Nelson 3~ emphasized the importance of us-
ing full-sized arch wires with the SWA, without which
the compl et e expression of built in adjustments would
Am. J. Orlhod. Dentofac. Orthop.
January 1993
not occur. Interestingly, Andrews 7 has pointed out that
he does not finish any of his cases on full-sized arch
wires.
Andrews, 3 Roth, 4 and Magness 6 have observed that
the use of the SWA has reduced treatment time. In this
study, treatment t i me for practitioner no. 1 was 5
months less with the RA than with the SEA. For prac-
titioner no. 2, the RA treatment t i me was 2 months
less. Each of these clinicians used the SEA earlier in
their clinical experience and then changed to the RA.
Thi s decrease in overall treatment t i me may be due to
the gain in experience by a practitioner over time, the
introduction of the newer arch wires (e. g. , nickel-ti-
tanium), change in the criteria used by the practitioner
to discontinue treatment, or to the appliance itself. This
difference in treatment t i me has not been adequately
studied here to draw any definitive conclusions.
One of the principal objectives of orthodontic treat-
me n t i s the establishment of proper or ideal occlusal
relationships. The I TRI is a useful index in that it mea-
sures the incidence of these specific dental relation-
ships. In this way, the ITRI is a measure of the success
of orthodontic treatment. At the same time, the ITRI
is limited by the rigid criteria to be met when ideal
occlusal relationships are evaluated. Marked i mprove-
ment in dental relationships, which are perceived to be
clinically correct, may fall short of inclusion when the
dental casts are scrutinized closely. From a clinical per-
spect i ve, what appears to be excellent treatment may
not score ext remel y well with the ITRI. In addition,
the I TRI does not consider treatment objectives as part
of the analysis. For exampl e, overcorrections, although
they may be considered excellent treatment, could result
in an absent relationship. The ITRI, as implemented
here, made no allowance for this aspect of treatment
in those instances where the overcorrection exceeded
approxi mat el y 0.5 mm.
Six keys analysis
Analysis of overall results. The SWA was intro-
duced to aid in achieving the six keys to normal occlu-
sion. Part II of this study scored posttreatment dental
casts for these parameters. In a 1990 interview, ~ An-
drews reported on his analysis of 314 dental casts sub-
mitted to the Ameri can Board of Orthodontics for can-
didate board certification. Onl y 3 of the 314 casts
achieved all six keys. Table VI I I compares Andrew' s
findings with those of this study. No single case from
this current research achieved all six keys. Overall, the
percentage of cases meeting the requirements of each
individual key was less than found by Andrews. How-
ever, the cases considered by Andrews had been sub-
mitted for Board certification and presumabl y repre-
Volume 103 Roth appliance treatment results 31
N u m b e r I
s ent ed t he bes t e f f o r t o f a g i v e n pr act i t i oner . Th e dent al
c a s t s us e d in t hi s s t udy we r e s el ect ed on t he bas i s o f
r e c or d a va i l a bi l i t y.
Analysis of h~dividua/ variables. Th e p o s t t r e a t me n t
i ncl i nat i on o f ma n d i b u l a r ant er i or t eet h wa s f ound t o
be be t t e r f o r p r a c t i t i o n e r no. 2 t han f o r pr a c t i t i one r no.
1. Thi s d i f f e r e n c e wa s gr e a t e nough t hat wh e n e v e r t he
ma n d i b u l a r a nt e r i or s e g me n t wa s c o mb i n e d wi t h o t h e r
a r c h s e g me n t i ncl i nat i on s c or e s , t he c o mb i n e d va r i a bl e
a l s o t es t ed t o be si gni f i cant . Th i s s t r ong di f f e r e nc e ma y
be due t o t he r out i ne us e o f f ul l - s i zed a r c h wi r e s b y
pr a c t i t i one r no. 2.
Wh e n ma x i l l a r y a nd ma n d i b u l a r t oot h a ngul a t i on
wa s e x a mi n e d as a c o mb i n e d va r i a bl e , t he RA wa s
be t t e r a bl e t o a c hi e ve t hi s key. I f u p p e r and l o we r an-
gul a t i ons we r e s t udi e d s e pa r a t e l y, o n l y t he ma x i l l a r y
t e e t h c ont i nue d t o s h o w a ppl i a nc e di f f e r e nc e s . Wh e n
ma x i l l a r y t oot h a ngul a t i on wa s br oke n d o wn i nt o an-
t e r i or a nd p o s t e r i o r s e g me n t s , onl y t he pos t e r i or s e g-
me n t s h o we d s i gni f i cant di f f e r e nc e s , a ga i n, wi t h t he
RA s c or i ng hi gher . He r e , a ga i n, a s t r ongl y s i gni f i cant
d i f f e r e n c e in o n e a r c h s e g me n t has i nf l uenced t he fi nd-
i ngs f or c o mb i n e d va r i a bl e s i f t hey i ncl ude t hat pa r t i c -
ul a r a r c h s e g me n t .
Ap p l i a n c e d i f f e r e n c e s we r e al so s i gni f i cant f or t he
i ncl i nat i on o f t he ma x i l l a r y pos t e r i or t eet h. On c e a ga i n,
t he RA wa s mo r e l i kel y t o pos i t i on t he t eet h at t he i r
p r o p e r i ncl i nat i ons as de f i ne d b y t he " Si x Ke y s t o No r -
ma l Oc c l u s i o n . " Thi s f i ndi ng is i nt er est i ng in l i ght o f
t he I TRI r es ul t s f or l i ngual i nt er dent al r e l a t i ons hi ps .
T h e I TRI s c o r e d t he SEA hi ghe r f or t hi s va r i a bl e . Se v-
er al e x p l a n a t i o n s ar e pos s i bl e . The ne ga t i ve ma x i l l a r y
p o s t e r i o r s e g me n t i ncl i nat i on c r e a t e d b y t he RA ma y
c ont r i but e t o t he a b s e n c e o f p r o p e r l i ngual i nt er di gi -
t a t i on. By pos i t i oni ng t he gi ngi va l por t i on o f t he f aci al
c r o wn s u r f a c e b u c c a l t o t he occl us al por t i on t her e is a
r e l a t i ve r a i s i ng o f t he ma x i l l a r y l i ngual c us ps . In a d-
di t i on, t he p r e v i o u s l y not e d f ai l ur e o f p r o p e r l i ngual
i nt er di gi t at i on in RA c a s e s ma y be due t o e x c e s s i v e
p o s t e r i o r i nc l i na t i on in t he l o we r ar ch. Th e i ncl i nat i on
bui l t i nt o t he ma n d i b u l a r pos t e r i or br a c ke t s i s gr e a t e r
t han t hat us ed f o r a ny o t h e r a r c h s e g me n t . Ho we v e r ,
f or t he bui l t - i n i nc l i na t i on t o be e xpr e s s e d in t he p r o p e r
ma nne r , t he b r a c k e t mus t be pl a c e d at t he oc c l us ogi n-
gi va l c e n t e r o f t he cl i ni cal c r o wn . I f t h e - l o we r mo l a r
b r a c k e t i s p l a c e d t oo f a r gi ngi va l l y ( pos s i bl y t o k e e p
t he b r a c k e t out o f oc c l us i on) , e x c e s s i v e l i ngual t i ppi ng
o f t he s e t eet h wo u l d r es ul t . I n t he si x ke ys a na l ys i s ,
t he i ncl i nat i on o f t he ma n d i b u l a r pos t e r i or s e g me n t wa s
not s i gni f i c a nt l y di f f e r e nt f or a ppl i a nc e or pr act i t i oner .
Ho we v e r , t he e x t r e me l y hi gh me a n s c or e s f or t hi s va r i -
a bl e ( > 9 8 %) ma y me a n t hat t he a s s e s s me n t f or t hi s
s e g me n t l a c ke d t he di s c r i mi na t or y abi l i t y t o fi nd a di f -
f e r e nc e i f o n e di d exi s t . Ex c e s s i v e i ncl i nat i on wa s not
us ed as a c r i t e r i on f or r e j e c t i on o f t hi s va r i a bl e .
An d r e ws 27 d e s c r i b e s t he s i x ke ys as a me a n s o f vi s ua l l y
i ns pe c t i ng t he st at i c oc c l us i on. Ac t ua l me a s u r e me n t s
- woul d b e n e e d e d t o d e t e r mi n e i f a r eal d i f f e r e n c e doe s
exi st b e t we e n t he SEA a nd RA.
De s p i t e t he a bi l i t y o f t he RA t o a c hi e ve s o me o f
t he s i x k e y s t o n o r ma l o c c l u s i o n , t hi s di d not t r ans l at e
i nt o an i nc r e a s e in t he n u mb e r o f i deal t oot h r el at i on-
shi ps. It mi g h t h a v e be e n e x p e c t e d t hat cas t s s c or i ng
wel l b a s e d o n an a na l ys i s o f t he si x k e y s wo u l d al s o
s c or e we l l wi t h t he I TRI ; t hi s wa s not t he c a s e . Th e
si x k e y s ma y l ack t he d i s c r i mi n a t o r y a bi l i t y t o def i ne
an i de a l i z e d o c c l u s a l s c h e me b e c a u s e t he y a r e p r i ma r i l y
q u a l i t a t i v e ' i n na t ur e . Ho we v e r , no s i ngl e dent al cas t
f r o m t hi s s t u d y a c hi e ve d al l si x k e y s ; it woul d be i n-
t e r e s t i ng tO s c or e a s a mp l e o f s uc h mo d e l s f or i deal
t oot h r e l a t i ons hi ps .
CONCLUSIONS
1. Th e overall p o s t t r e a t me n t I TRI p e r c e n t a g e
s c or e s f o r t he S EA and t he RA a r e not s i gni f i c a nt l y
di f f e r e nt .
2. Po s t t r e a t me n t I TRI s c or e s r e ve a l e d pr a c t i t i one r
di f f e r e nc e s f o r t he a nt e r i or i nt r aar ch, a nt e r i or i nt er ar ch,
and p o s t e r i o r b u c c a l i nt e r a r c h r e l a t i ons hi ps . Th e s e di f -
f e r e nc e s ma y be r e l a t e d t o bot h t r e a t me n t t i me and
f i ni shi ng a r c h wi r e s i ze.
3. Th e f o l l o wi n g c o n c l u s i o n s c a n b e ma d e a bout
t he RA a nd t he si x k e y s t o n o r ma l oc c l us i on: (1) De s pi t e
us i ng t he RA, e x p e r i e n c e d cl i ni ci ans still f ound it di f -
fi cul t t o a c h i e v e all o f t he s i x k e y s t o n o r ma l oc c l us i on,
a n d t he RA s c o r e d s i gni f i c a nt l y hi ghe r t ha n t he SEA
f or t he a n g u l a t i o n a nd i ncl i nat i on o f t he ma x i l l a r y pos -
t er i or t eet h.
4. Su c c e s s in a c hi e vi ng s o me . c o mp o n e n t s o f t he
si x k e y s t o n o r ma l oc c l us i on di d not t r ans l at e i nt o an
i nc r e a s e d p e r c e n t a g e o f i deal t oot h c o n t a c t s as me a s u r e d
b y t he I TRI .
We acknowl edge E. BeGol e and V. Ramakrishnan for
their assistance in the completion of portions of the statistical
analysis. Also, the private practitioners who generously al-
lowed uninhibited access to their orthodontic records.
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Reprint requests to:
Dr. Bernard J. Schneider
University of Illinois at Chicago
College of Dentistry
Department of Orthodontics
801 South Paulina
Box 6998
Chicago, IL 60680