You are on page 1of 14

Searching for predictors of long-term stability

Scott Franklin, DDS, P. Emile Rossouw, BSc, BChD, BChD (Hons-Child Dent),
MChD (Ortho), PhD, FRCD(C), Donald G. Woodside, DDS, MSc, PhD(H), and
Jimmy C. Boley, DDS, MS
The purpose of this investigation was to evaluate a unique sample of
orthodontically treated subjects (N 114; post-retention 11.97 years). All
subjects were treated by one clinician utilizing a consistent diagnostic and
treatment protocol. Subjects were grouped into two distinct groups
according to the lower incisor irregularity: group 1, moderate change
and group 2, minor change. Statistical analyses were performed at a level
of r Z0.6, p o 0.01. Satisfactory long-term stability was achieved in 79% of
the subjects; moreover, no subject exhibited severe incisor irregularity post-
retention. Similar to previous studies, no individual or single predictor for
long-term change could be identied. However, different to most studies,
useful predictors of the post-retention incisor alignment included the
relationship of the lower incisor to the A-Pogonion plane at the end of
treatment (at T
2
), posterior face height (at T
2
), the mandibular plane angle
SN-GoGn (at T
2
), anterior crowding (at T
2
), and starting age (at T
1
). It is clearly
noted that the vertical dimension features in the equation. (Semin Orthod
2013; 19:279292.) Published by Elsevier Inc.
L
ongitudinal investigations to identify treat-
ment and post-treatment variables of clinical
signicance in controlling future mandibular
incisor crowding have been unsuccessful in identi-
fying the individual or exact etiology of post-
treatment and post-retention changes in the lower
incisor alignment.
18
Moreover, longitudinal data
show that changes in arch dimensions as well as
lower incisor crowding occur as a part of the
normal aging process.
911
In addition, the velocity
of this change was found to decrease after 40 years
of age.
12
Thus, late mandibular incisor crowding
may be unrelated to any previous orthodontic
treatment. An evaluation of the National Health
and Nutrition Examination Survey (NHANES)
data provided a compilation of variables that
could assist in the determination of long-term
lower incisor crowding.
13
The post-retention incisor irregularity in
premolar extraction cases increased at a rate
approximately twice that of untreated cases.
1,10
Little et al.
6
and McReynolds and Little
14
also
showed that post-retention incisor irregularity in
orthodontically treated serial extraction cases did
not differ from treated premolar extraction
cases. In a comparison of long-term lower incisor
alignment in serial extraction cases with no
subsequent orthodontic treatment to untreated
matched controls, no signicant differences in
the amount of mandibular incisor irregularity, or
crowding, existed between the two groups or
between males and females.
15
Therefore, since
orthodontically treated premolar extraction cases
(serial and late) showed greater post-retention
changes in incisor alignment than patients who
would have been candidates for premolar
extraction but were not treated, one may con-
clude that the orthodontic mechanotherapy in
the above studies may have contributed to the
long-term changes.
1,6,14
In general, dental parameters tend to return
to their pre-treatment values after treatment.
16
Overcorrection thus appears to favor success.
17
Published by Elsevier Inc.
1073-8746/13/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2013.07.008
Private practice, Austin, TX; Department of Orthodontics,
University of North Carolina School of Dentistry, Chapel Hill, NC;
Department of Orthodontics, University of Toronto, Toronto,
Canada; Private practice, Richardson, TX.
Address correspondence to P. Emile Rossouw, BSc, BChD, BChD
(Hons-Child Dent), MChD (Ortho), PhD, FRCD(C), Department
of Orthodontics, University of North Carolina School of Dentistry, 277
Brauer Hall, Campus Box 7450, Chapel Hill, NC 27599-7450.
E-mail: emile_rossouw@dentistry.unc.edu
279 Seminars in Orthodontics, Vol 19, No 4 (December), 2013: pp 279292
Changes in mandibular growth direction and
rotation during the post-treatment and post-
retention periods (vertical dimension) have
also been implicated in the etiology of late incisor
crowding.
18,19
In addition, the vertical develop-
ment of the mandibular ramus continues until
late adolescence.
20
Crowding of the mandibular
incisors was observed in vertical growers as a
result of chronic airway obstruction.
21,22
In
addition, Fudalej and Artun
23
concluded in their
study on short facial height, long facial height,
and normal facial height at the post-treatment
appliance removal interval (T
2
) that the high- or
low-angled facial patterns were not associated
with post-retention (T
3
) relapse of the man-
dibular incisor alignment; thus providing poor
prediction of this post-retention malalignment.
It appears that the degree of post-treatment
incisor crowding is both unpredictable and vari-
able irrespective of the treatment. In addition, no
pre-treatment variables that were obtained either
before or after treatment from clinical ndings,
dental casts, or cephalometric radiographs have
been found as clinically useful predictors. Fur-
ther investigation is needed in this area.
The purpose of this study was to (1) present the
ndings from a large sample of orthodontically
treated patients who have been without retention
for a minimum of 5 years, (2) identify any stat-
istically signicant differences in cast or cepha-
lometric variables between subjects with minor
(clinically acceptable) and major (clinically
unacceptable) post-retention changes in lower
incisor alignment, and (3) attempt to identify any
descriptive, cast, or cephalometric variables which
might aid the clinician in controlling long-term
changes or predicting future changes.
Materials and methods
Pre-treatment (T
1
), post-treatment (T
2
), and
post-retention (T
3
) patient records including
dental casts, lateral cephalograms, facial photo-
graphs, and treatment records of large sample
(N 114) treated by one clinician using con-
ventional edgewise appliances and Tweed diag-
nostic principles and mechanotherapy were
obtained. No subjects in the sample received any
interproximal re-approximation during the post-
treatment period.
All lateral cephalograms were taken with the
same unit (Weber, model #6B; Reeve Dental
Supply, 1421 Champion Drive #317, Carrollton,
TX 75006). Cephalometric variables were
obtained using the Dentofacial Planner Software
System (Dentofacial Software Inc, 1 First Cana-
dian Place, P.O. Box 300, Toronto, Canada
M5X 1C9).
Cephalometric angular measurements were
included as described in the cephalometric
analyses by Downs,
24
Steiner,
25
and Legan and
Burstone.
26
Cephalometric linear measurements were
included as described in the cephalometric analy-
ses by Steiner,
25
Harvold,
27
Bjork/Jarabak (Jarabak
and Fizzell),
28
Ricketts,
29
and McNamara.
30
Mitutoyo electronic digital calipers (Mitutoyo
Corporation, 31-19 Shiba 5-Chome, Manato-Ku,
Tokyo 108, Japan) were used to measure dental
cast variables to the nearest 0.01 mm.
Dental cast measurements included man-
dibular total crowding, mandibular anterior
crowding, overbite, overjet, mandibular arch
length, mandibular arch width, inter-rst molar
width, rst and second inter-premolar width, and
incisor irregularity index as suggested by Little.
31
The entire sample was evaluated as a unit at
each time interval (T
1
, T
2
, and T
3
), as well as
longitudinally (T
1
T
2
, T
2
T
3
, and T
1
T
3
). A nal
subdivision was then made on the basis of post-
retention lower incisor irregularity using Little's
Irregularity Index (Little)
31
of 3.5 mm as a cutoff.
Subjects at T
3
demonstrating moderate (clini-
cally unacceptable) changes in post-retention
lower incisor alignment (irregularity index
43.5 mm) were placed in group 1 (N 24). This
group was then matched and compared to a
similar-sized group (group 2, N 30) demon-
strating only minor (clinically acceptable,
irregularity index o3.5 mm) changes in lower
incisor alignment at post-retention. The follow-
ing matching criteria were used (prioritized) at
T
1
: age, anterior crowding, gender, ANB, and
Angle classication. Characteristics of groups 1
and 2 are presented in Table 1. It should be
pointed out that since groups 1 and 2 were
matched in part on the basis of initial (T
1
) age,
there was a disparity in mean post-retention time
(Table 1). This nal breakdown of the entire
sample on the basis of minor and moderate
incisor irregularity indices was done in an
attempt to better detect statistically signicant
differences among the various descriptive, cast,
and cephalometric parameters included.
Franklin et al 280
Analysis of data
The entire sample (N 114) and individual
subgroups were subjected to descriptive statistics
such as the mean (X) and standard deviation (SD)
at each of the three evaluations (T
1
, T
2
, and T
3
) as
well as longitudinally (T
1
T
2
, T
2
T
3
, and T
1
T
3
).
In addition, between-group and within-group
comparisons were made using independent and
paired Student's t-tests, respectively. A Pearson
Product-Moment correlation coefcient was used
to assess possible associations among variables and
a level of clinical signicance was established at r
0.6. Multiple regression analysis was used in an
attempt to establish predictive indicators for both
the mandibular incisor irregularity index (Little)
31
and anterior crowding.
32
The signicance level
was set at p o0.01. All statistics were performed on
SPSS (version 6.1) statistics software.
Error analysis
Intra-examiner measurement error was deter-
mined by random selection and re-measurement
of 10 dental casts and 10 lateral cephalograms (also
re-digitized) 1 week following the original meas-
urements. Pearson product-moment correlation
coefcients and paired t-tests were used to identify
signicant differences between the measurements.
Results
The results for differences between groups 1 and
2 are portrayed in Table 2.
Dental cast data
Overbite was reduced during treatment (T
1
T
2
)
for the entire sample (X 2:0 mm, p o 0.001).
During the post-treatment period (T
2
T
3
), overbite
increased (X 0:85 mm, p o 0.001); however,
an overall decrease (X 1:15 mm, p o0.001) in
overbite remained post-retention (T
1
T
3
).
Overjet was reduced during treatment (T
1
T
2
)
for the entire sample (X 3:91 mm, p o0.001).
During the post-treatment period (T
2
T
3
),
an increase in overjet occurred (X 0:54 mm,
p o0.001); however, there was an overall decrease
(X 3:37 mm, p o 0.001) at post-retention
(T
1
T
3
) (Fig. 1).
Mandibular arch length was reduced during
treatment (T
1
T
2
) for the entire sample
(X 7:98 mm, p o 0.001). Arch length con-
tinued to decrease (X 2:12 mm, p o 0.001)
during the post-treatment period (T
2
T
3
). Not
surprisingly, subjects in the extraction subgroup
exhibited signicantly shorter mandibular arch
lengths at post-treatment and post-retention than
subjects in the non-extraction subgroup (p o
0.001).
Mandibular intercanine width increased dur-
ing treatment (T
1
T
2
) for the entire sample
(X 0:97 mm, p o 0.001). This dimension
decreased (X 1:45 mm, p o 0.001) during
the post-treatment period (T
2
T
3
), resulting in a
post-retention value that was 0.45 mm less (p o
0.001) than the pre-treatment value. Group 1
(moderate change) experienced a 0.78 mm
greater increase in mandibular intercanine width
than group 2 (minor change) during treatment
(T
1
T
2
). However, group 1 subsequently showed
a 1.26 mm greater decrease in mandibular
intercanine width than group 2 following treat-
ment (p o 0.001).
Mandibular inter-rst premolar width was not
signicantly altered during treatment (T
1
T
2
) for
the entire sample. Following treatment (T
2
T
3
), a
Table 1. Characteristics of group 1 and group 2
Group 1 (moderate change) Group 2 (minor change)
Number of subjects 24 30
Sex Male: 3 Male: 8
Female: 21 Female: 22
Age (y) T
1
: 13.00 (range 8.2526.50) T
1
: 12.76 (range 11.8314.08)
T
2
: 16.79 (range 13.1729.42) T
2
: 15.30 (range 14.0016.75)
T
3
: 34.92 (range 24.8345.75) T
3
: 29.33 (range 22.8337.92)
Angle classication (rst molar and cuspid) Class I: 4 Class I: 7
Class II division 1: 18 Class II division 1: 22
Class II division 2: 2 Class II division 2: 1
Treatment Extraction: 21 Extraction: 26
Non-extraction: 3 Non-extraction: 4
Post-retention (y) 15.95 (range 8.2524.00) 10.76 (range 5.0019.67)
Searching for Predictors of Long-term Stability 281
Table 2. Comparison of longitudinal changes between groups 1 and 2 (variables are mentioned below) (Group 1, N = 24; Group 2, N = 30)
T
1
T
2
T
2
T
3
T
1
T
3
Variable Grp 1 Grp 2 p Grp 1 Grp 2 p Grp 1 Grp 2 p
Cast
Age (y) 3.79 2.54
b
18.14 14.03
b
21.92 16.57
c
OB (mm) 1.56 1.95 NS 0.90 0.85 NS 0.66 1.10 NS
OJ (mm) 4.24 4.56 NS 0.85 0.63 NS 3.39 3.93 NS
A.L. (mm) 8.57 9.07 NS 1.78 2.29 NS 10.35 11.37 NS
33 (mm) 1.56 0.78 NS 2.09 1.35
b
0.57 0.57 NS
44 (mm) 0.94 0.00 NS 1.37 0.66 NS 0.08 0.65 NS
55 (mm) 1.73 3.18 NS 1.03 0.53 NS 3.06 3.68 NS
66 (mm) 1.53 3.01
a
0.58 0.02
a
2.11 2.99 NS
LII (mm) 5.08 4.62 NS 3.90 1.28
c
1.29 3.34
a
TC (mm) 3.97 2.67 NS 2.42 1.20
c
1.72 1.47 NS
AC (mm) 1.81 2.10 NS 1.76 0.77
c
0.16 1.33
a
Ceph
SNA 1.53 2.20 NS 0.17 0.16 NS 1.35 2.04 NS
SNB 0.07 0.34 NS 0.18 0.39 NS 0.10 0.05 NS
ANB 1.56 1.85 NS 0.35 0.24 NS 1.23 2.09 NS
A-N Vert. 1.55 2.05 NS 0.04 0.03 NS 1.50 2.08 NS
B-N Vert. 0.38 0.74 NS 0.58 0.29 NS 0.96 0.45 NS
Pg-N Vert. 0.96 0.80 NS 0.14 1.01 NS 0.82 1.80 NS
Convexity 4.83 5.66 NS 0.19 1.12 NS 4.63 6.78 NS
Facial angle 0.76 0.61 NS 0.00 0.61 NS 0.76 1.22 NS
Mx length 0.95 0.96 NS 2.19 2.63 NS 3.14 3.59 NS
Md length 5.33 5.84 NS 3.69 5.10
a
9.02 10.93 NS
Unit diff. 4.37 4.89 NS 1.54 2.48 NS 5.91 7.37 NS
UFH 1.90 2.08 NS 1.19 1.74 NS 3.09 3.82 NS
LFH 3.38 3.88 NS 2.49 2.17 NS 5.87 6.06 NS
UFH/LFH 1.01 1.40 NS 1.13 0.03 NS 2.15 1.37 NS
PFH 2.44 3.85 NS 1.54 2.64 NS 3.98 6.50
a
Y-axis 0.38 0.58 NS 0.00 0.57 NS 0.38 0.01 NS
FH-MP 0.61 0.04 NS 0.22 1.42 NS 0.83 1.46 NS
SN-GoGn 0.23 0.24 NS 0.25 1.25 NS 0.48 1.50 NS
SN-OP 1.98 2.55 NS 0.06 1.08 NS 2.03 1.47 NS
U1-PP 4.00 3.36 NS 1.44 1.38 NS 5.44 4.73 NS
U1-NA (mm) 3.06 3.32 NS 0.85 1.06 NS 2.20 2.26 NS
U1-NF (mm) 1.16 0.21 NS 2.00 1.58 NS 3.17 1.80
b
F
r
a
n
k
l
i
n
e
t
a
l
2
8
2
Table 2. (continued)
T
1
T
2
T
2
T
3
T
1
T
3
Variable Grp 1 Grp 2 p Grp 1 Grp 2 p Grp 1 Grp 2 p
U1/L1 4.56 6.79 NS 0.33 2.00 NS 4.89 8.79 NS
IMPA 0.49 2.81 NS 0.88 0.01 NS 0.39 2.82 NS
L1-NB (mm) 0.30 1.19 NS 0.14 0.27 NS 0.44 1.46 NS
L1-A-Pg (mm) 0.02 0.71 NS 0.63 0.46 NS 0.60 1.17 NS
L1-MP (mm) 0.36 0.06 NS 2.06 1.69 NS 1.70 1.63 NS
NLA 3.65 3.79 NS 4.58 4.03 NS 0.92 0.24 NS
UL-E-Line 4.21 4.16 NS 1.17 2.08 NS 5.39 6.25 NS
LL-E-line 2.85 3.43 NS 0.77 1.74 NS 3.62 5.17
a
NS (no signicance, p Z 0.05); Grp 1, group 1 (moderate change); Grp 2, group 2 (minor change).
Dental cast and cephalometric variables
Dental Cast Variables: OB, overbite (mm); OJ, overjet (mm); A.L., mandibular arch length (mm); 33, mandibular intercanine width (mm); 44, mandibular inter-rst premolar width
(mm); 55, mandibular inter-second premolar width (mm); 66, mandibular inter-rst molar width (mm); LII, Littles irregularity index (mm); TC, total mandibular arch crowding
(Careys analysis, mm); AC, anterior mandibular arch crowding (caninecanine, mm).
Cephalometric variables: SNA, SellaNasionA point (degrees); SNB, SellaNasionB point (degrees); ANB, A pointNasionB point (degrees); A-N Vert., A-point to Nasion vertical
(mm); B-N Vert., B point to Nasion vertical (mm); Pg-N Vert., pogonion to Nasion vertical (mm); convexity, facial skeletal convexity (degrees); Facial Angle, facial angle (degrees); Mx
Length, maxillary unit length (mm); Md length, mandibular unit length (mm); Unit Diff., unit length difference (mm); UFH, upper face height (mm); LFH, lower face height (mm);
UFH/LFH, ratio of upper to lower face height (%); PFH, posterior face height (mm); Y-Axis, Y-Axis: SellaNasionGnathion (degrees); FH-MP, Frankfort horizontal to mandibular
plane (degrees); SN-GoGn, SellaNasion to GonionGnathion (degrees); SN-OP, SellaNasion to occlusal plane (degrees); U1-PP, upper central incisor to palatal plane (degrees); U1-
NA, upper central incisor to NasionA point plane (mm); U1-NF, upper central incisor height from nasal oor (mm); U1/L1, interincisal angle (degrees); IMPA, lower central incisor
to mandibular plane (degrees); L1-NB, lower central incisor to NasionB point plane (mm); L1-A-Pg, lower central incisor to A pointpogonion plane (mm); L1-MP, lower central
incisor height from mandibular plane (mm); NLA, nasolabial angle (degrees); UL-E-Line, upper lip to Ricketts E-line (mm); LL-E-Line, lower lip to Rickett's E-line (mm).
a
p o 0.05.
b
p o 0.01.
c
p o 0.001.
S
e
a
r
c
h
i
n
g
f
o
r
P
r
e
d
i
c
t
o
r
s
o
f
L
o
n
g
-
t
e
r
m
S
t
a
b
i
l
i
t
y
2
8
3
reduction (X 0:64 mm, p o 0.001) occurred;
however, the overall change (0.26 mm) (T
1
T
3
)
was not signicant.
Mandibular inter-second premolar width was
reduced during treatment (T
1
T
2
) for the entire
sample (X 1:99 mm, p o 0.001) and con-
tinued to decrease (X 0:69 mm, p o 0.001)
following treatment (T
2
T
3
).
Mandibular inter-rst molar width was
reduced during treatment (T
1
T
2
) for the entire
sample (X 2:25 mm, p o 0.001). This
dimension remained stable following treatment,
as evidenced by only a slight and non-signicant
decrease.
Mandibular incisor irregularity
31
(Fig. 2) decrea-
sed during treatment (T
1
T
2
) for the entire sample
(X 4:79 mm, p o 0.001). During the post-
treatment period (T
2
T
3
), mandibular incisor
irregularity increased (X 1:82 mm, p o0.001);
however, an overall decrease (X 3:04 mm) was
still evident (T
1
T
3
). Because groups 1 and 2 were
selected on the basis of their nal mandibular
incisor irregularity, a highly signicant difference
(p o 0.001) existed between these two groups at
post-retention (Fig. 3). It should be pointed out
that the degree of irregularity was not signicantly
different (NS) between these two groups at pre-
treatment (T
1
) or immediately after treatment
(T
2
). Incisor irregularity results as well as the
percentage of subjects in each of three categories
(minor, moderate, and severe) are also presented
in Table 3.
Cephalometric data
Facial convexity decreased during treatment
(T
1
T
2
) for the entire sample, as evidenced by
reductions in Facial Convexity (X 5:41 mm,
p o 0.001) and ANB (X 1:821, p o 0.001)
measurements. Facial convexity continued to
reduce (X 0:88 mm, p o0.01) during the post-
treatment period (T
2
T
3
). An overall reduction of
both facial convexity (X 6:28 mm, p o 0.001)
and ANB (X 1:931, p o0.001) occurred from
O
v
e
r
b
i
t
e

(
m
m
)
0
0.5
1
1.5
2
2.5
3
3.5
T1 T2 T3
***p<0.001
***p<0.001
Mean Overbite :
T1 3.282.06
T2 1.270.54
T3 2.120.95
Figure 1. Changes in overbite for entire sample.
I
r
r
e
g
u
l
a
r
i
t
y

I
n
d
e
x

(
m
m
)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
T1 T2 T3
***p<0.001
***p<0.001
Mean Irregularity Index:
T1 5.253.35
T2 0.450.46
T3 2.271.39
Figure 2. Changes in irregularity index for entire
sample.
I
r
r
e
g
u
l
a
r
i
t
y

I
n
d
e
x

(
m
m
)
0
1
2
3
4
5
6
T1 T2 T3
Group 1
Group 2
NS
NS
***P<0.001
Group 1: Mean Irregularity Index: T1 5.623.18
T2 0.490.65
T3 4.380.62
Group 2: Mean Irregularity Index: T1 5.032.73
T2 0.410.43
T3 1.690.87
Figure 3. Irregularity index: group 1 vs. group 2.
Franklin et al 284
pre-treatment to post-retention (T
1
T
3
) (Table 2).
Males exhibited signicantly less facial convexity
than females at post-treatment (p o 0.01) and
post-retention (p o 0.001).
Mandibular rotation
Statistically signicant changes were found in
mandibular rotation measurements for the entire
sample during treatment (T
1
T
2
). These minimal
changes are depicted by a mean increase of only
0.411 in the Y-axis angle (p o 0.01). Minimal but
statistically signicant, changes also occurred in the
Y-axis angle from post-treatment to post-retention
(T
2
T
3
). The Y-axis angle returned to near its
original value (X 0:471, p o0.001), resulting in
an overall change (T
1
T
3
) that was not signicant.
Males showed higher values for the Y-axis and FH
to MP angles than females at post-retention (p o
0.01). The extraction subgroup showed higher
values for Y-axis, FHto MP, and SNto GoGn angles
at pre-treatment (p o 0.001) and post-treatment
(p o 0.01), but only small and non-signicant
differences at post-retention. No statistically sig-
nicant differences in mandibular rotation were
found between Class I and Class II subgroups or
between groups 1 and 2 at post-treatment and post-
retention.
In order to more closely examine mandibular
rotation and its relationship to mandibular incisor
irregularity, lateral cephalograms for the subjects in
groups 1 and 2 were superimposed at all three time
periods (T
1
, T
2
, and T
3
). An average (mean)
rotation value of the mandible (Gnathion relative
to the SN plane) was determined for each subject
in both groups. Group means were then calculated
and compared to see if the two groups had sig-
nicantly different mandibular growth directions
or rotations across time (T
1
T
3
). Results of this
comparison showed that the mean mandibular
rotation across time was nearly identical for the two
groups, as evidenced by values of 68.661 3.61 and
68.411 3.69 for groups 1 and 2, respectively.
Facial heights
Linear measurements of anterior facial height showed
increases in both upper face height (X 2:49 mm,
p o 0.001) and lower face height (X 3:95 mm,
p o 0.001) for the entire sample during treat-
ment (T
1
T
2
). Increases continued following
treatment (T
2
T
3
) for both upper face height
(X 1:56 mm, p o 0.001) and lower face
height (X 2:35 mm, p o 0.001). The linear
measurement of posterior facial height showed an
increase (X 3:32 mm, p o 0.001) for the
entire sample during treatment (T
1
T
2
), and a
further increase (X 3:04 mm, p o 0.001)
following treatment (T
2
T
3
). Group 2 showed a
slightly larger posterior face height measurement
than group 1 (p o 0.05) at post-retention (T
3
).
Anteroposterior incisor positions
Treatment produced a retroclination of the
maxillary incisors for the entire sample, as evi-
denced by changes in the U1 to PP value
(X 2:061, p o 0.05). The maxillary incisors
continued to retrocline relative to the palatal
plane following treatment (X 1:311, p o0.01).
Vertical incisor positions
Maxillary incisor heights were not altered signi-
cantly during treatment for the entire sample.
Following treatment, however, an increase
occurred, as shown by an increase in the U1 to
NF value (X 1:68 mm, p o 0.001).
Mandibular incisor heights remained relatively
unchanged during treatment for the entire sample.
Following treatment, however, an increase in
Table 3. Mandibular incisor irregularity for entire sample and individual subgroups
Group Irregularity index (mm) Percentage distribution at T
3
T
1
T
2
T
3
Minor
(o3.5 mm) (%)
Moderate
(3.56.5 mm ) (%)
Severe
(46.5 mm) (%)
Entire sample 5.25 0.45 2.27 78.9 21.1 0
Males 5.58 0.36 1.75 90.9 9.1 0
Females 5.14 0.48 2.48 74.1 25.9 0
Extraction 5.84 0.41 2.28 77.7 22.3 0
Non-extraction 2.77 0.60 2.24 85.0 15.0 0
Class I 7.15 0.39 2.03 88.2 11.8 0
Class II 4.41 0.47 2.37 75.0 25.0 0
Searching for Predictors of Long-term Stability 285
mandibular incisor height occurred, as shown
by an increase in the L1 to MP value
(X 1:89 mm, p o 0.001).
Soft tissue changes
The distance from both upper lip to E-Line
(X 4:35 m, p o0.001) and lower lip to E-Line
(X 3:28 mm, p o 0.001) reduced during
treatment for the entire sample. Reductions
continued to occur during the post-treatment
period in both variables (p o 0.001).
Interparameter correlations (Pearson product-
moment correlation coefcients). None of the
dental cast or cephalometric variables correlated
signicantly (r 4 0.6) with the post-retention
measures of mandibular incisor irregularity or
crowding. However, some of the cast and
cephalometric variables were correlated with
each other at different time periods (T
1
, T
2
,
and T
3
) making regression analysis for prediction
possible.
Prediction of post-retention mandibular incisor
irregularity (multiple regression analysis). An
attempt was made to identify any pre- or post-
treatment dental cast variables, combinations of
variables, or changes in variables across time (T
1

T
2
and T
2
T
3
) that might serve as clinically useful
predictors of the post-retention mandibular
incisor alignment or changes in alignment from
T
2
T
3
. Therefore, irregularity index
31
and anterior
crowding at post-retention as well as the changes in
these variables from post-treatment to post-
retention were used as dependent variables in
the regression model. The signicance of the t-
value of the coefcient assigned to the particular
variable had to be p o 0.05 for inclusion in the
regression model.
The general formula for the regression equa-
tion is as follows:
Y b
0
b
1
x
1
b
2
x
2
b
n
x
n
where : Y dependent variable, b Y-intercept,
b
1
b
n
coefcients of the independent
variables, and x
1
x
n
independent variables
Those subjects from the entire sample who
demonstrated clinically unacceptable incisor
alignment (43.5 mm) at post-retention (group
1, N 24) were further analyzed in an attempt to
identify specic factors that might help the
orthodontist predict future incisor instability.
Multiple regression analysis showed the following
three independent variables combined to
explain 65.8% of the variation in incisor irreg-
ularity at post-retention: L1 to A-Pg (T
2
), U/L face
height ratio (T
1
), and Mx/Md unit difference (T
1
). Of
the three variables, L1 to A-Pg (T
2
) accounted for
the majority of the variation.
Those subjects from the entire sample who
demonstrated good stability of lower incisor
alignment (o3.5 mm) at post-retention (group
2, N 30) were also analyzed in an attempt to
identify predictors of long-termincisor alignment.
Interestingly, the following three independent
variables combined to explain 49.3% of the
variation in incisor irregularity at post-retention:
Posterior Face Height (T
2
), Arch Length (T
2
), and
Upper to Lower Face Height Ratio (T
1
). Furthermore,
the following three variables combined to explain
51.3% of the variation in the change in incisor
irregularity from T
2
T
3
: SN to GoGn (T
2
), Age (T
1
),
and A point to Nasion Vertical (T
2
).
Error analysis
Paired t-tests failed to show any statistically sig-
nicant (p o0.05) differences between rst and
second measurements during intra-examiner
error determination; therefore, no systematic
errors in measurement occurred.
Discussion and clinical implications
The study is unique as three difcult aspects of an
orthodontic clinical study is satised; that is, a
sufciently large sample of subjects studied, a
post-retention time that can truly be considered
long-term(mean of 11.97 years), and treatment
performed by one clinician following one specic
philosophy of treatment.
Overbite and overjet demonstrated reason-
able stability following treatment. Changes less
than 1mm were observed. Overcorrection in
most cases required a slight rebound following
active treatment in order to establish normal
overbite and coupling of the incisors. Similar
ndings were reported by Glenn et al.
33
and
Paquette et al.
8
Class II subjects exhibited a
greater degree of overbite at post-retention than
the Class I subjects (p o 0.01).
Not surprisingly, the present study agrees with
previous ndings from studies of both treated and
Franklin et al 286
untreated occlusions that mandibular intercanine
width typically decreases with time.
2,12,33,34
The
post-treatment changes observed in intercanine
width were most likely a reection of maturational
changes in the dentition rather than the inuences
of orthodontic treatment. One particularly note-
worthy nding was that the mandibular inter-
canine width in group 1 (moderate change) was
increased twice as much during treatment (T
1
T
2
)
compared to group 2 (minor change). Following
treatment (T
2
T
3
), group 1 showed a signicantly
greater reduction in this dimension than group 2
(p o 0.01). Moreover, these differences in inter-
canine width changes between groups 1 and 2 may
also partly explain the dichotomy in post-retention
incisor alignment.
Inter-rst molar width demonstrated the best
stability of any of the arch dimension parameters
investigated in this study. A statistically signicant
reduction in inter-rst molar width occurred
during treatment (p o 0.001) for the entire
sample. The ndings on inter-rst molar width in
the present study coincide with those from
studies on both untreated occlusions
912
and
orthodontically treated occlusions.
33,35
Statistically signicant increases in mandibular
incisor irregularity
31
(Fig. 3) and anterior
crowding (Fig. 4) occurred from post-
treatment to post-retention (T
2
T
3
) for the
entire sample. However, the mean incisor
irregularity for the entire sample at post-
retention (T
3
) was only 2.27 1.39 mm, which
is still considered to be clinically acceptable.
1
Ninety cases (79%) demonstrated acceptable
mandibular incisor alignment at post-retention,
whereas only 24 (21%) cases showed an
irregularity value that was above a clinically
acceptable level of 3.5 mm. Furthermore, no
cases demonstrated severe mandibular incisor
irregularity (46.5 mm). These results are also
presented in Table 3. Figure 5 shows a lower arch
study model from a representative subject in
group 1 (moderate change). Figure 6 shows a
lower arch study model from a representative
subject in group 2 (minor change).
Few studies reported in the orthodontic lit-
erature have been able to document long-term
mandibular incisor stability of this nature.
17,33,36
The majority of studies on stability of both
extraction and non-extraction treatments have
reported unpredictable and disappointing
results with regard to the long-term alignment of
mandibular incisors.
1,2,14
Sinclair and Little
10
compared a sample of untreated normal
occlusions to a sample of premolar extraction
cases
1
and found the rate of mandibular incisor
irregularity increase in the treated sample to be
approximately twice as fast as in the untreated
sample. Their ndings suggest that the
orthodontic treatment may have accelerated
post-treatment changes in the dentition, partic-
ularly lower incisor crowding. In contrast to the
above studies, the sample used in the present
study demonstrated good overall stability, sug-
gesting that satisfactory long-term lower incisor
stability can be achieved for the majority of
patients undergoing orthodontic treatment.
The remarkable long-term stability of incisor
alignment observed in the majority of subjects in
this study may be because the mandibular arch
form was not altered signicantly during treat-
ment in the majority of cases. Even in the non-
extraction subgroup, mandibular intercanine
width and arch length were held relatively con-
stant during treatment. Since it has been well
documented that mandibular arch length and
intercanine width decrease over time in both
untreated normal occlusions and in orthodon-
tically treated occlusions, it seems only prudent
to respect these dimensions during treatment.
Comparison of the extremes (Groups 1 and 2)
yielded two variables that could have resulted in the
difference in post-retention incisor alignment
between the two groups. First, as previously
A
n
t
e
r
i
o
r

C
r
o
w
d
i
n
g

(
m
m
)
-2
-1.5
-1
-0.5
0
0.5
T1 T2 T3
***p<0.001 ***p<0.001
Mean Anterior Crowding:
T1 -1.811.93
T2 0.050.40
T3 -0.930.80
Figure 4. Changes in anterior crowding for entire
sample.
Searching for Predictors of Long-term Stability 287
mentioned, mandibular intercanine width in group
1 (moderate change) was increased twice as much
during treatment as that in group 2 (minor
change). Interestingly, group 1 subsequently show-
ed a decrease in this dimension after treatment that
was almost twice that observed in group 2. Although
no cause-and-effect relationship has been docu-
mented, it seems reasonable to assume that man-
dibular incisors must eventually crowd in response
to an arch that is slowly shrinking in width in the
canine region. Perhaps Strangs
37
advice regarding
the inviolation of mandibular intercanine width
during treatment should be re-emphasized in con-
temporary orthodontic treatment. Second, the
mean age for group 1 at the time of post-retention
records was 5.59 years greater than that of group 2.
Furthermore, the mean post-retention time was
15.95 years for group 1 and 10.76 years for group2, a
Figure 5. Lower arch study model from a representative subject in group 1 (moderate change).
Franklin et al 288
difference of 5.19 years. These differences in nal
age and post-retention time are important since it
has been shown that developmental crowding
occurs as a part of the natural aging process.
10,12
Sinclair and Little
10
calculated a mean annual
increase in incisor irregularity of 0.21 mm up to
the age of 20 years in a sample of treated individuals.
If one uses this estimation (0.21 mm/y), it can be
assumed that group 2 would have experienced an
additional 1 mmof lower incisor irregularity over an
additional 5 years of aging. Hence, a nal
irregularity index of 2.69 mm (1.69 1.0) can be
projected for group 2, which is still below the nal
irregularity value of 4.38 mm found in group 1, and
well within the range of clinical acceptability
31
and
physiological stability.
38
It should be noted that the
mean annual rate of increase from Sinclair and
Littles study
10
was derived from a sample of
Figure 6. Lower arch study model from a representative subject in group 2 (minor change).
Searching for Predictors of Long-term Stability 289
untreated subjects who showed more post-retention
irregularity than group 2 (X 3:54:8 mm vs.
1.69 mm). Therefore, the calculated value of
2.69 mm probably represents an over-estimation of
what might have actually occurred in group 2,
further illustrating the remarkable stability of the
subjects in this group.
One of the most noteworthy ndings was the
control of vertical skeletal proportions during
treatment. Undesirable backward rotation of the
mandible was minimized during the treatment
period. In addition, anterior vertical facial pro-
portions remained constant both during and
after treatment, while posterior face height
continued to increase from pre-treatment to
post-retention. These changes represent normal
patterns of mandibular growth
11,18,19
and further
illustrate that treatment favored normal growth.
The reduction of facial convexity is a frequent
objective of orthodontic treatment, especially in
patients with Class II malocclusions. In this
sample, facial convexity was reduced during
treatment, as illustrated by the normalization of
the ANB and Convexity angles from T
1
T
2
.
Following active treatment, A point (SNA angle)
remained relatively constant, while the mandible
(SNB angle) continued to grow in an anterior
direction. This post-treatment mandibular
growth could play a role in the noted dental
changes.
Maxillary and mandibular incisors were
antero-posteriorly positioned in conformity with
Tweed philosophy cephalometric and facial
standards. Thus, mandibular incisors were ret-
roclined or maintained in their original ante-
roposterior position, with no active advancement
or proclination performed. In some cases,
mandibular incisors were slightly over-corrected,
leading to a slight rebound in an anterior
direction following active treatment. Although
the IMPA showed a stable position from T
2
T
3
,
the slight forward rebound may have assisted in
the creation of additional space to accommodate
the lower incisors as intercanine width and arch
length decreased. Sandusky
17
experienced a
similar nding in his study of long-term incisor
stability.
In the vertical direction, neither maxillary nor
mandibular incisors were altered signicantly
during treatment. Schudy
39
suggested that the
occlusal plane was more stable when the lower
incisors were not intruded during leveling.
Statistically signicant increases in maxillary
and mandibular incisor heights were observed
from post-treatment to post-retention, which
probably reect continued vertical growth of the
alveolar processes. In addition, overbite was
slightly over-corrected in most cases, which may
have resulted in a rebound in order to establish
normal overbite and coupling of the incisors.
Group 1 (moderate change) experienced a
signicantly greater increase in maxillary incisor
height from pre-treatment to post-retention than
group 2 (minor change), which could have
contributed to the greater degree of mandibular
incisor irregularity in group 1.
Soft tissue changes during and following active
treatment were also observed. Both upper and
lower lips became more retrusive relative to
Ricketts E-line
29
during these time periods. It
should be mentioned that these measurements
are functions of not only the position of the lips
but also the positions of the anterior-most aspects
of the nose and chin. Therefore, one would
expect to see reductions in lip protrusion relative
to the nose and chin, especially after treatment,
since it has been documented that the nose and
soft tissue chin become more prominent with
age.
11
One particularly important nding was the
similarity in upper and lower lip positions
between extraction and non-extraction sub-
groups at post-retention. This nding contradicts
the popular opinion that extraction treatment
attens the prole.
Prediction of long-term incisor irregularity
Multiple regression analysis of the entire sample
data failed to yield any clinically useful pre-
dictors of the post-retention mandibular incisor
irregularity or crowding. However, regression
analysis of the group 1 (moderate change)
data yielded independent variables that com-
bined to explain the variation in incisor irreg-
ularity at post-retention. Interestingly, the
anteriorposterior post-treatment lower incisor
position considered in the regression equation
by itself accounted for 41.5% of the variation in
incisor irregularity at post-retention. Thus, for
every millimeter increase L1 to A-Pg at T
2
,
incisor irregularity at T
3
increased by 0.16 mm,
when all other variables were held constant.
Furthermore, the vertical dimension played a
role in the regression analysis. It is noteworthy
Franklin et al 290
that when the changes in inter-rst molar width
and maxillary length from T
2
T
3
were added to
the equation with L1 to A-Pg (T
2
T
3
), 67% of the
variation in the change in anterior crowding
from T
2
T
3
was explained.
Multiple regression analysis of the group 2
(minor change) data also revealed several
signicant ndings. Forty-nine percent of the
variation in incisor irregularity at post-retention
was explained by a combination of the following
three independent variables: Posterior Face Height
(T
2
), Arch Length (T
2
), and Upper to Lower Face
Height Ratio (T
1
). For every millimeter increase in
posterior face height at T
2
, a decrease in incisor
irregularity of 0.10 mm at T
3
is produced. The
following three independent variables combined
to explain 51.3% of the variation in the change in
incisor irregularity from T
2
T
3
: SN to GoGn (T
2
),
Age (T
1
), and A-point to Nasion Vertical (T
2
). In this
model, each degree increase in SN to GoGn at T
2
elicited an increase in incisor irregularity of
0.11 mm from T
2
T
3
, while each year increase in
age at T
1
elicited an increase in incisor irregu-
larity of 0.55 mm from T
2
T
3
. It is apparent that
the vertical dimension features also in this group.
Clinical implications
In contrast to many of the published ndings on
the stability of orthodontic treatment, this study
offers a degree of optimism. First, it is extremely
important for the orthodontist to know that
satisfactory long-term stability can be achieved in
the majority of patients if sound treatment
principles are followed. These principles
included the maintenance of mandibular arch
form during treatment, in particular intercanine
width, as well as treating to near-ideal cephalo-
metric and clinical standards.
Second, it appears that there are several varia-
bles that may aid in predicting the outcome of the
lower incisors following treatment. In particular,
lower incisor to the A-Pg plane at T
2
appears to be
one variable with considerable predictive value of
the nal incisor alignment. In addition, post-
treatment vertical skeletal dimensions, such as
posterior face height and SN to GoGn, may have
some value for predicting the post-retention incisor
alignment. Furthermore, the patients age may be
an important variable that should be considered
when planning a retention protocol.
Finally, we cannot escape the developmental
changes that occur with aging. Hence, we should
expect some degree of changes in the dentition,
especially lower incisor crowding, with time.
38,40,41
Patients should always be well-informed before the
commencement of orthodontic treatment that
some changes will occur, and that at present, the
only means of preventing these changes is with
retention after treatment. Developmental changes
in the dentition must not be interpreted as
relapse associated with orthodontic treatment,
unless improper treatment has been performed.
Conclusions
1. Satisfactory long-term stability of the dentition
was achieved in this sample.
2. Overbite and overjet showed clinically good
stability. It is recommended to overcorrect
these variables, example to an almost end-to-
end relationship, and should some change
occur post-treatment, the tendency of the
change will be in a direction towards the
original, thus establishing the norm.
3. Mandibular intercanine width generally
decreased in the long-term, even when min-
imal expansion occurred during treatment. It
appeared that the greater the increase in this
dimension during treatment, the greater the
decrease after treatment. Minimal expansion,
if at all, should be the treatment goal.
4. Useful clinical predictors of the long-term meas-
ures of incisor irregularity required a combina-
tion of variables in a regression equation.
5. The results from the regression analysis
suggest that vertical management of treatment
could play a role in stability. Vertical control is
the corner stone of all excellent orthodontic
treatment and thus it is no surprise to see
these variables feature as indicated.
References
1. Little RM, Wallen TR, Riedel RA: Stability and relapse of
mandibular anterior alignment-rst premolar extraction
cases treated by traditional edgewise orthodontics. Am J
Orthod 80:349-365, 1981
2. Little RM, Riedel RA, Artun J: An evaluation of changes in
mandibular anterior alignment from 10 to 20 years post-
retention. Am J Orthod Dentofac Orthop 93:423-428, 1988
3. Little RM, Riedel RA: Post-retention evaluation of stability
and relapseMandibular arches with generalized spac-
ing. Am J Orthod Dentofac Orthop 95:37-41, 1989
Searching for Predictors of Long-term Stability 291
4. Ades AG, Joondeph DR, Little RM, Chapko MK: A long-
term study of the relationship of third molars to changes
in the mandibular dental arch. Am J Orthod Dentofac
Orthop 97:323-335, 1990
5. Little RM: Stability and relapse of dental arch alignment.
Br J Orthod 17:235-241, 1990
6. Little RM, Riedel RA, Engst ED: Serial extraction of rst
premolars-post-retention evaluation of stability and
relapse. Angle Orthod 60:255-262, 1990
7. Little RM, Riedel RA, Stein A: Mandibular arch length
increase during the mixed dentition: post-retention
evaluation of stability and relapse. Am J Orthod Dentofac
Orthop 97:393-404, 1990
8. Paquette DE, Beattie JR, Johnston LE: A long-term
comparison of non-extraction and premolar extraction
edgewise therapy in borderline Class II patients. Am J
Orthod Dentofac Orthop 102:1-14, 1992
9. Moorrees CFA: The Dentition of the Growing Child.
Cambridge, MA Harvard University Press; , 1959
10. Sinclair PM, Little RM: Maturation of untreated normal
occlusions. Am J Orthod 83:114-123, 1983
11. Behrents RG: Growth in the Aging Craniofacial Skeleton.
Monograph 17 Craniofacial Growth Series Ann Arbor,
Michigan, Centre for Human Growth and Development,
University of Michigan, 1985
12. Eslambolchi S, Woodside DG, Rossouw PE: A descriptive
study of mandibular incisor alignment in untreated
subjects. Am J Orthod Dentofac Orthop 133:343-353, 2008
13. Buschang PH, Shulman JD: IncisorcCrowding in
untreated persons 1520 years of age: United States,
19881994. Angle Orthod 73:502-508, 2003
14. McReynolds DC, Little RM: Mandibular second premolar
extraction-post-retention evaluation of stability and
relapse. Angle Orthod 61:133-144, 1991
15. Shearer DH: Evaluation of Post-Retention Mandibular
Incisor Stability in Premolar Extraction Cases Treated by
Serial Extraction Without Subsequent Fixed Orthodontic
Mechanotherapy Diploma Thesis, University of Toronto,
Toronto, Canada, 1994
16. Uhde MD, Sadowsky C, Begole EA: Long-term stability of
dental relationships after orthodontic treatment. Angle
Orthod 53:240-252, 1983
17. Sandusky WC: A Long-Term Postretention Study of
Tweed Extraction Treatment Masters Thesis, University
of Tennessee, Memphis, Tennessee, 1983
18. Bjrk A: Prediction of mandibular growth rotation. Am J
Orthod 55:585-599, 1969
19. Bjrk A, Skieller V: Facial development and tooth
eruption: an implant study at the age of puberty. Am J
Orthod 62:339-383, 1972
20. Buschang PH, Baume RM, Nass GG: A craniofacial growth
maturity gradient for males and females between 4 and 16
years of age. Am J Phys Anthrop 61:373-381, 1983
21. Woodside DG, Linder-Aronson S, Stubbs DO: Relation-
ship between mandibular incisor crowding and nasal
mucosal swelling. Proc Finn Dent Soc 87:127-138, 1991
22. Linder-Aronson S, Woodside DG, Hellsing E, Emerson
W: Normalization of incisor position after adenoidec-
tomy. Am J Orthod Dentof Orthop 103:412-427, 1993
23. Fundalej P, Artun J: Mandibular growth rotation effects
on postretention stability of mandibular incisor align-
ment. Angle Orthod 77:199-205, 2007
24. Downs WB: Variations in facial relationships; their
signicance in treatment planning and progress. Am J
Orthod 34:812-840, 1948
25. Steiner CC: The use of cephalometrics as an aid to
planning and assessing orthodontic treatment. Am J
Orthod 46:721-735, 1960
26. Legan H, Burstone CJ: Soft tissue cephalometric analysis
for orthognathic surgery. J Oral Surg 38:744-751, 1980
27. Harvold EP: The Activator in Interceptive Orthodontics
St.Louis, CV Mosby Company, 1974
28. Jarabak JR, Fizzell JA: 2nd ed. Technique and Treatment
With Light-Wire Appliances 1. St. Louis, CV Mosby
Company, 1972
29. Ricketts RM: Perspectives in the clinical application of
cephalometrics. Angle Orthod 51:115-150, 1981
30. McNamara JA: A method of cephalometric evaluation.
Am J Orthod 86:449-469, 1984
31. Little RM: The irregularity index: a quantitative score of
mandibular anterior alignment. Am J Orthod 68:554-563,
1975
32. Carey CW: Linear arch dimensions and tooth size An
evaluation of the bone and dental structures in cases
involving the possible reduction of dental units in
treatment. Am J Orthod 35:762-775, 1949
33. Glenn G, Sinclair PM, Alexander RG: Non-extraction
orthodontic therapy: post-treatment dental and skeletal
stability. Am J Orthod Dentofac Orthop 92:321-328,
1987
34. Sillman JH: Dimensional changes of the dental arches:
longitudinal study from birth to 25 years. Am J Orthod
50:824-841, 1964
35. Freeman BV: A Comparison of Post-Retention Mandib-
ular Incisor Irregularity in Treated Class II Division 1
Malocclusions Versus Untreated Class I Normals Diploma
Thesis, University of Toronto, Toronto, Canada, 1993
36. Rossouw PE, Preston CB, Lombard CJ, Truter JW: A
longitudinal evaluation of the anterior border of the
dentition. Am J Orthod Dentof Orthop 104:146-152, 1993
37. Strang R: The fallacy of denture expansion as a treatment
procedure. Angle Orthod 19:12-22, 1949
38. Rossouw PE: Terminology: semantics of postorthodontic
treatment changes in the dentition. Sem Orthod 5:138-
141, 1999
39. Schudy FF: Concepts to live by. J Clin Orthod 27:121-122,
1993
40. Little RM: Clinical implications of the University of
Washington post-retention studies. J Clin Orthod 43:645-
651, 2009
41. Little RM, Robert M: Little on the University of
Washington post-retention Studies. J Clin Orthod
43:723-727, 2009
Franklin et al 292

You might also like