Comparison of Roth appliance and standard edgewise

appliance treatment results

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. (AMJ ORTHODDENTOFACORTHOP
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 commonality
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 Diego, 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 completed to critically eval-
uate the SWA. Anecdotal assessments conclude there
is a reduction in both treatment time and chair time
with the SWA, 35 and that results are better and more
consistentY 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 aaicle 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
24
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 patient's
teeth may vary from the average, but when that occurs,
it will do so in an orderly manner throughout the arch.
9The 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 sample, and for this reason lacked the critical
measures necessary for an evaluation of treatment re-
9 In 1989 Haegeta~ modified the methods intro-
duced by Hellman 26 for evaluating occlusal relation-
ships. A static occlusal analysis, the ideal tooth rela-
tionshipindex (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
Volunle 103 Roth appliance treatnlent results 25
Number I

Table I. S a m p l e description
Practitioner no. 1 Practitioner no. 2

SEA [ RA SEA [ RA

Number 30 30 30 30
Angle molar 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.

MATERIALS AND METHODS
The sample for this study (Table I) consisted of records
collected from two private practices in which the clinicians
have used both the standard edgewise 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-inch slot) straight
wire brackets. Partial or limited treatment cases, cases pre-
senting with significant skeletal asymmetry, or cases with
congenitally missing teeth were not included. In addition,
those cases with fixed or removable prosthetic restorations,
periodontal complications, models with chipped or broken
teetfi, or questionable articulation of upper and Iov,'er casts
were excluded. 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 encountered during
treatment.
This study consisted of two parts. Part I evaluated treat-
ment results with the ITRI, whereas Part I1 evaluated results
with Andrews' six keys?
Ideal tooth relationship index
Visual inspection of dental casts trimmed 1o centric oc-
clusion was completed as des~zribcd by Haeger. :3 The ITRI is
expressed as a percentage ofpossible intraarch (intcrproximal)
and interarch relationships with the total number of potential
contacts varying with the clinical situation. Permanent second
molars and all deciduous teeth were excluded. Since it was
not possible to determine if 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 proximal relationships. A range of approximately
mm was permitted for a contact to deviate from its
ideal position. This determination was subjective.
Ideal relationships were evaluated as follows:
I. Overall scores
2. Anterior 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 wire sizes were recorded for each of the RA
cases used in the sample.
Six keys analysis
The. method used for cvaluation of Andrews' six keys'
was a modification of that used by Uhde. '~ An acrylic plate
for determining the occlusal plane orientation and a modified
protractor were constructed as described by Andrews :7 and
26 Kattner o/zd Schneider Am. J. Orthod, Dentofac. Orthop.
Janua,o' 1993

T a b l e II. I T R I r e p r o d u c i b i l i t y

Trial 1 Trial2 Difference

Variable N Mean % SD Mean % SD Mean % I SD P value

Overall 20 26.6 15,7 27.1 16.0 0.5 1.4 0.149

Anterior intraarch 20 14.8 18.9 14.8 18.9 0.0 2.7 1.000
Posterior intraarch 20 31.3 29.0 31.4 29.4 0.1 1.5 - 0.772
Anterior interarch 20 32.4 29.0 32.4 29.4 0.0 3.2 1.000
Posterior interarch 20 23.0 25.6 23.6 25.2 0.6 2.8 0.330
Posterior interarch 20 34.4 30.8 34.8 30.6 0.4 1.6 0.330
buccal
Posterior interarch 20 28.3 30.1 28.8 30.9 0.5 2.2 0,330
lingual

ot = 0.05.

Table III. S i x k e y s r e p r o d u c i b i l i t y
Trial I Trial 2 Difference
I
Variable N Mean % I SD Mean % I SD Mean % SD P value

Angulation maxillary 20 ~. 75.8 19.8 76.7 17.4 0.8 6.6 0.579

antenor
Angulation maxillary 20 53.8 27.6 52.5 28.4 1.3 5.6 0.330
posterior
Angulation mandibular 20 62.5 20.1 61.3 19.5 1.3 7.8 0.480
antenor
Angulation mandibular 20 74.6 15.6 75.4 14.7 0.8 3.7 0.330
posterior
Inclination maxillary 20 86.7 ! 3.9 85,0 13.1 !,7 7.5 0.330
anterior
Inclination maxillary 20 90.8 15.7 91.7 14.8 0.8 3.7 0.330
posterior
Inclination mandibular 20 36.7 25. ! 38.3 24.8 1.7 5.1 0. ! 63
anterior
Inclination mandibular 20 100.0 0.0 100.0 0.0 0.0 0.0 1.000
posterior
Rotations 20 93.4 4.3 93.5 4.3 0.2 0.9 0.368
Contacts 20 93.0 6.8 93. ! 6.3 0. I 1.8 0.755

et = 0.05.

Uhde.:8 Both the maxillary and the mandibular dentitions were

considered, and each key was evaluated as being present or
absent, Reported values for the angulation, inclination, ro-
tation, and contacts variables are the percentage of teeth dem-
onstrating the correct relationship. The AP molar and curve
of S p e e variables are reported as the percentage of dental
casts meeting Andrews' specifications.l. Angulation is defined
as the mesiodistal tip of the crown; inclination is the buc-
colingual tip of the crown. Many of the prctreatment casts'
included deciduous teeth, making it difficult to apply the six
keys analysis. For this reason, only posttreatment casts were
studied. Andrews 27 used the second molars as the posterior
limit of the occlusal plane. Since these teeth were occasionally
unerupted in this sample, only first molars were used. The
interested reader is referred to K a t t n e r"~ for a complete de-
scription of the six keys analysis.
Statistical analysis
To investigate reproducibility o f the 1TRI and six keys
analyses, dual measurements w e r e made on a sample of 20
dental casts, allowing 14 days between trials (Tables II and
III). No significant differences were found when the trials
were compared using matched pair t tests (or = 0.05).
The nature of the ITRI suggested that scores for each of
the variables should be correlated. This was examined by
computing Peai'son correlation coefficients. A correlation of
at least 0.5 was found for one-third of the variable combi-
nations. Multivariate analysis of variance (MANOVA) tests
with Hotelling's T 2 (t~ = 0.05) were completed to seek sig-
nificant differences between appliances or between practitio-
ners (Table IV). A MANOVA considers e a c h of the arch
segments is a way that takes into account the correlation
between them. Since the MANOVA indicated significant dif-
 Volume 103 Roth appliance treattnent restdts 27,
Number I

T a b l e IV. ITRI, multivariate analysis o f variance results

Stage [ Variable [ T: I P value
Pretreatment Practitioner differences 1.47 0.195
Appliance differences 0.82 0.558
Interaction (PR*APL) 1.16 0.332
Posttreatment Practitioner differences 10.52 0.0001
Appliance differences 3.49 0.003
Interaction (PR*APL) 4.44 0.0001

c~ = 0.05.

Table V. ITRI, ANOVA pretreatment results

I Overall
Anterior
intraarch
Anterior
interarch
Posterior
intraarch
I PosteriorI
interarch
Posterior
buccal
Posterior
lingual

Practitioner no. 1 25.4 11.8 18.3 .4- 17.6 13.6 17.3 15.0 16.0 38.2 23.3 38.0 23.2 34.3 - 21.7
Practitioner no. 2 23.7 i1.1 18.8 19.3 11.2 19.7 15.2 17.7 29.7 _ 14.3 34.7 19.8 24.5 15.3
F ratio 0.63 0.02 0.49 0.01 5.84 0.71 8.13
P value 0.430 0.882 0.487 0.926 0.017 0.402 0.050
Standard edge- 25.7 --+ 10.3 19.3 20.2 10.7 13.5 16.0 17.0 35.3 17.7 37.6 -4- 22.2 31.7 - 17.3
wise appliance
Roth appliance 23.4 ___ 12.5 17.8 --- 16.7 14.2 22.4 14.2 -'- 16.7 32.6 .4- 21.7 35.1 _ 20.9 27.2 21.6
F ratio 1.18 0. 19. 1A08 0.33 0.56 0.39 1.75
P value 0.279 0.665 0.301 0.566 0.456 0.532 0.188
Interaction
F ratio 0.34 0.003 0.004 3.80 1.30 0.26 0.21
P value 0.560 0.956 0.947 0.054 0.256 0.609 0.651

-c~ = 0.008 (using bonferroni correction).

ferences existed, univariate tests (two-way ANOVAS analyz-
ing practitioner differences and appliance differences) were
completed to identify 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 maintains 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 examined for
significant correlations by computing Pearson correlation co-
efficients, none of the variable combinations scored greater
than 0.5. For this reason, only univariate tests (two-way
ANOVAS, a = 0.05) were completed for the angulation and
inclination variables of the six keys analysis. A Bonferroni
correction was not used in this analysis because the variables
were not substantially 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-
'act!on o c c u r s , the interpretation of the m a i n effects
square analysis (or = 0.05).
(practitioner and appliance) must be qualified.
RESULTS
Pretreatment and posttreatment values for the over-
all ITRI percentage scores are provided in Tables V
and VI. N o significant differences existed b e t w e e n
groupings pretreatment. Po~ttreatment differences ex-
isted for the practitioner effect with dental casts o f the
practitioner no. 2 scoring significantly higher. There
were no significant differences between the S E A and
R A posttreatment scores.
Tables V and VI also present the ITRI scorings for
the individual arch segments. Posttreatment appliance
differences existed for the posterior lingual relation-
ships with the S E A s h o w i n g a higher scored percentage.
Practitioner differences existed for the anterior in-
traarch, anterior interarch, and posterior buccal inter-
arch relationships. Practitioner no. 2 scored signifi-
cantly higher than practitioner no. 1 for each o f these
arch segments. A significant posttreatment interaction
existed for the posterior intraarch score. For this re-
search, interaction m e a n s that the success o f ' a given
appliance is c o n t i n g e n t on which practitioner is using
it (for e x a m p l e , Fig. 1). W h e n e v e r a significant inter-
Treatment duration was recorded for each o f the
cases included in the sample (Table I). The treatment
time for practitioner no. 2 averaged 2 years and 5
months; the average treatment period for practitioner
no. 1 was 6 m o n t h s less. The distribution o f finishing
arch wire sizes for each of the practitioners was also
 Am. J. Orthod. Dentofac. Orthop.
98 Kattner and Sclmeider
9 Januqo" 1993

Table VI. ITRI, ANOVA posttreatment results

I Overall
AnteriorI
intraarch
Anterior
interarch
Posterior
intraarch
Posterior
interarch
I Posterior
buccal
Posterior
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)

Table VII. Six keys analysis, ANOVA posttreatment results

Practitioner Appliance hzterar

F-ratio P-value SEA RA F-ratlo P-value F-ratio value

Angulation
Maxilla
Anterior 78.6 18.7 79.2 21.2 0.03 0.871 74.7 21.6 83.0 --, 17.2 5.85 0.017 10.42 0,0002
Posterior 71.7 27.3 76.9 --- 20.1 1.51 0.222 69.6 28.4 79.0 +-- 17.7 4.83 0.030 1.67 0.199
Combined 75.1 16.2 78.1 14.9 1.13 0.289 72.2 ~ 17,4 81.0 12.1 10.53 0.002 !.03 0.312
Mandible
Anterior 68.1 22,2 66.9 2 1 . 4 0.08 0.779 65.0 23.1 70.0 --- 20.1 1.59 0.209 1.26 0.264
Posterior 76.9 -4- 18,6 78.7 -- 21.6 0.24 0.627 76.8 17.8 78.9 22.2 0.32 0.574 0.24 0.627
Combined 72.5 15.6 72.8 16.6 0.01 0.906 70.9 15.9 74.4 16.1 !.45 0.230 0.20 0.654
Combined 73.8 12.5 75.4 11.4 0.59 0.442 71.5 12.7 77.7 10.3 8.63 0.004 0.94 0.334
Inclination
Maxilla
Anterior 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
Posterior 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
Combined 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
Mandible
Anterior 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
Posterior 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
Combined 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
Combined 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
Rotations 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
Contacts 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
AP molar .14.8 11.9 X2 = 0.213 0.644 14.3 12.3 = 0.100 0.753
Curve of Spee 100.0 100.0 100.0 100.0

et = 0.05.

recorded. Practitioner no. 2 usually finished on an The results of the six keys analysis are shown in
0.017 0.025-inch arch wire (25 of 30 cases); prac- Table VII. Statistically significant differences between
titioner no. 1 was more likely to finish on an practitioner no. 1 and practitioner no. 2 were found for
0.016 0.022-inch arch wire (23 of 30 cases). the following variables:
Volume 103 Roth appliance treatment results 29
Number 1

Table VIII. Percentage of casts with

keys present
Variable I Andrews* I Kattnert M 75 SEA
E
Key I, AP molar 20% 13% A
N 70 RA
Key It, angulation 9% <1%
Key Ill, inclination 22% 10% P
Key IV rotations 33% 19% E 65
Key V, contacts 57% 31% R
Key VI, curve of 44% 100% C
E 60
Spee
N A
T
*Posterior limit of the occlusal plane = second molars. A 55
";Posterior limit of the occlusal plane = first molars. G
E RA
50
1. Inclination of mandibular anterior teeth
2. Inclination of combined mandibular anterior and
posterior teeth 1

3. Inclination of combined maxillary and mandib- PRACTITIONER

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
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 benefits47 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. Haeger25 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 Kattnerand 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 job correcting discrepancies that are highly
visible. Haegeta5 found similar results.
The only 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 lower 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. This 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 segments. 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 time
for practitioner no. 2 averaged 2 years and 5 months,
and the treatment period for practitioner no. l was 6
months less (Table I). Improvements (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 ideal'static 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. This difference may be important:
Meyer and Nelson 3~ emphasized the importance of us-
ing full-sized arch wires with the SWA, without which
the complete 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 time for practitioner no. 1 was 5
months less with the RA than with the SEA. For prac-
titioner no. 2, the RA treatment time was 2 months
less. Each of these clinicians used the SEA earlier in
their clinical experience and then changed to the RA.
This decrease in overall treatment time 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 time has not been adequately
studied here to draw any definitive conclusions.
One of the principal objectives of orthodontic treat-
m e n t i s the establishment of proper or ideal occlusal
relationships. The ITRI 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 improve-
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-
spective, what appears to be excellent treatment may
not score extremely well with the ITRI. In addition,
the ITRI does not consider treatment objectives as part
of the analysis. For example, 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
approximately 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 American Board of Orthodontics for can-
didate board certification. Only 3 of the 314 casts
achieved all six keys. Table VIII 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 presumably repre-
Volume103
Number I
sented the best effort of a given practitioner. The dental
casts used in this study were selected on the basis of
record availability.
Analysis of h~dividua/ variables. The posttreatment
inclination of mandibular anterior teeth was found to
be better for practitioner no. 2 than for practitioner no.
1. This difference was great enough that whenever the
mandibular anterior segment was combined with other
arch segment inclination scores, the combined variable
also tested to be significant. This strong difference may
be due to the routine use of full-sized arch wires by
practitioner no. 2.
When maxillary and mandibular tooth angulation
was examined as a combined variable, the RA was
better able to achieve this key. If upper and lower an-
gulations were studied separately, only the maxillary
teeth continued to show appliance differences. When
maxillary tooth angulation was broken down into an-
terior and posterior segments, only the posterior seg-
ment showed significant differences, again, with the
RA scoring higher. Here, again, a strongly significant
difference in one arch segment has influenced the find-
ings for combined variables if they include that partic-
ular arch segment.
Appliance differences were also significant for the
inclination of the maxillary posterior teeth. Once again,
the RA was more likely to position the teeth at their
proper inclinations as defined by the "Six Keys to Nor-
mal Occlusion." This finding is interesting in light of
the ITRI results for lingual interdental relationships.
The ITRI scored the SEA higher for this variable. Sev-
eral explanations are possible. The negative maxillary
posterior segment inclination created by the RA may
contribute to the absence of proper lingual interdigi-
tation. By positioning the gingival portion of the facial
crown surface buccal to the occlusal portion there is a
relative raising of the maxillary lingual cusps. In ad-
dition, the previously noted failure of proper lingual
interdigitation in RA cases may be due to excessive
posterior inclination in the lower arch. The inclination
built into the mandibular posterior brackets is greater
than that used for any other arch segment. However,
for the built-in inclination to be expressed in the proper
manner, the bracket must be placed at the occlusogin-
gival center of the clinical crown. If the-lower molar
p
bracket is placed too far gingivally (possibly to keep
the bracket out of occlusion), excessive lingual tipping
of these teeth would result. In the six keys analysis,
the inclination of the mandibular posterior segment was
not significantly different for appliance or practitioner.
However, the extremely high mean scores for this vari-
able ( > 9 8 % ) may mean that the assessment for this
segment lacked the discriminatory ability to find a dif-
Roth appliance treatment results 31
ference if one did exist. Excessive inclination was not
used as a criterion for rejection of this variable.
Andrews 27 describes the six keys as a means of visually
inspecting the static occlusion. Actual measurements
- would be needed to determine if a real difference does
exist between the SEA and RA.
Despite the ability of the RA to achieve some of
the six keys to normal occlusion, this did not translate
into an increase in the number of ideal tooth relation-
ships. It might have been expected that casts scoring
well based on an analysis of the six keys would also
score well with the ITRI; this was not the case. The
six keys may lack the discriminatory ability to define
an idealized occlusal scheme because they are primarily
qualitative' i n nature. However, no single dental cast
from this study achieved all six keys; it would be in-
teresting tO score a sample of such models for ideal
tooth relationships.
CONCLUSIONS
1. The overall posttreatment ITRI percentage
scores for the SEA and the RA are not significantly
different.
2. Posttreatment ITRI scores revealed practitioner
differences for the anterior intraarch, anterior interarch,
and posterior buccal interarch relationships. These dif-
ferences may be related to both treatment time and
finishing arch wire size.
3. The following conclusions can be made about
the RA and the six keys to normal occlusion: (1) Despite
using the RA, experienced clinicians still found it dif-
ficult to achieve all of the six keys to normal occlusion,
a n d the RA scored significantly higher than the SEA
for the angulation and inclination of the maxillary pos-
terior teeth.
4. Success in achieving some.components of the
six keys to normal occlusion did not translate into an
increased percentage of ideal tooth contacts as measured
by the ITRI.
We acknowledge E. BeGole 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