ORIGINAL ARTICLE

Relapse in Angle Class II Division 1 malocclusion treated by tandem mechanics without extraction of permanent teeth: A retrospective analysis
Javid Yavari, DMD, MS,a Michael K. Shrout, DMD,b Carl M. Russell, DMD, PhD,c Andrew J. Haas, DDS, MS,d and Edward H. Hamilton, DDSe Augusta, Ga, and Chicago, Ill Ideal orthodontic treatment should achieve long-term stability of the occlusion. The mandibular incisor segment has been described as the segment that is most likely to exhibit relapse after treatment and retention. Therefore, relapse of this is a challenge that clinicians need to address. The purpose of this study is to evaluate the amount of relapse that may occur in Angle Class II Division 1 patients, treated orthodontically with tandem mechanics. All cases in this study were treated without extraction of permanent teeth, and the patients were followed for at least 2 years after the end of the retention phase of treatment. Six predictors were investigated at pretreatment, posttreatment, and postretention periods. A synopsis of this study shows the correction of lower incisor crowding as measured by the irregularity index was stable over 5.2 years of postretention follow-up; but longer followup time revealed increased relapse of incisor irregularity. Intermolar width increased during treatment and remained stable in the follow-up period. Overjet and overbite corrections and changes in the lower incisor to mandibular plane angle were also stable in the follow-up period. In addition, the amounts of overjet correction and loss of expansion of intercanine distance after treatment were associated with increased irregularity index in the follow-up period. It appears the discrepancies between this and previously published works are sufficiently dramatic that the whole question of treatment philosophy and long-term stability may need to be reevaluated. (Am J Orthod Dentofacial Orthop 2000;118:34-42)

major goal of orthodontic treatment is to achieve long-term stability of the occlusion. The mandibular incisor segment has been described by several authors as the segment that is most likely to exhibit relapse after active treatment and retention.1-3 Clinical experience has shown that orthodontic patients perceive the crowding of the anterior teeth as one of the most obvious problems for which they seek treatment. Therefore, relapse of the mandibular anterior teeth after treatment and retention phases is a challenge that clinicians need to address. Several studies have shown that arch lengths and intercanine widths decrease and intermolar distances increase during the development of adolescents arches.4-7 Barrow and White8 evaluated 52 untreated

Department, School of Dentistry, Medical College of Georgia. Oral Diagnosis and Patient Services, School of Dentistry, and Professor, Oral Biology, School of Graduate Studies, Medical College of Georgia. cAssociate Professor, Medical College of Georgia. dAssociate Professor, Department of Orthodontics, University of Illinois; and in private practice, Cuyahoga Falls, Ohio. eProfessor and Interim Chair, Department of Orthodontics, School of Dentistry, Medical College of Georgia. Reprint requests to: Michael K. Shrout, DMD, School of Dentistry, School of Graduate Studies, Medical College of Georgia, Augusta, Georgia 30912-1241. Submitted, 6/99; accepted, 11/99 Copyright 2000 by the American Association of Orthodontists. 0889-5406/2000/$12.00 + 0 8/1/104409 doi.10.1067/mod.2000.104409
bProfessor,

aOrthodontic

individuals and observed that intercanine width decreased after the midteen years. None of the subjects observed had maxillary incisor crowding at age 6, but 24% did by age 14. Fourteen percent of the mandibular anterior teeth experienced crowding by age 6, and 51% by age 14. In a study of 1000 children, Cryer9 reported 62% incisor crowding by age 14; 60% showed an increase in lower incisor alignment compared with age 11. Foster et al10 reported a 70% incidence of mandibular crowding by age 7; this increased to 90% by age 14, and then decreased slightly by age 25. Sinclair and Little11 studied 65 untreated individuals with normal occlusion and found that arch length and intercanine width significantly decreased into early adulthood, whereas incisor irregularity, as defined by Little, 3 significantly increased. When comparing postretention irregularity indexes, the treated cases were higher than the untreated normal group. In addition, the rate of increase in incisor crowding for the treated group was approximately twice that in the untreated normal group.11 Little and Riedel 12 evaluated 30 cases that were 10 years postretention and observed that arch width and arch length decreased with time; 53% demonstrated minimal irregularity indexes, 33% had moderate and 13% had severe postretention irregularity indexes.

34

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Yavari et al 35

Table I. Sample

groups divided by irregularity index (summary statistics)

Irregularity strata Increased Mean SD 3.8 1.7 1.9 5.0 Decreased Mean 11.5 3.3 7.1 3.8 SD 2.4 0.9 1.5 1.3 P value* .1233 .1522 .0517 .0159

Age at the beginning of treatment Periods of observation Treatment Retention Postretention follow-up

14.5 3.9 5.7 7.0

*P value for a significant difference between the increased and the decreased irregularity groups.

Little et al13 concluded that long-term alignment was variable and unpredictable; no descriptive characteristics (such as length of retention), Angle classification, age, gender, or measured variables (such as overbite, overjet, arch width, or arch length) were predictive. Satisfactory mandibular anterior alignment is maintained in less than 30% of the cases with nearly 20% likely to show marked crowding many years after removal of retainers.13 Little et al14 reported that lower anterior crowding continued to increase during 10 to 20 years after retention with only 10% of the cases having clinically acceptable mandibular alignment. McReynolds and Little15 evaluated 46 patients for changes over a minimum of 10 years postretention. Arch length and arch width decreased with time and incisor irregularity increased throughout the postretention period. Shapiro16 studied a nonextraction sample of 22 individuals at 10 years postretention; mandibular arch length and intercanine width decreased during the postretention period regardless of whether arch length had increased or decreased during treatment. The nonextraction group experienced significantly less decrease in intermolar width during postretention than the premolar extraction group. Glenn et al17 evaluated long-term stability in 28 nonextraction patients. Arch length decreased significantly for 96% of the patients during an average of 8 years postretention. Similarly, 95% of the patients with an increase in intercanine width during treatment showed reduction in incisor irregularity during the postretention period. The intermolar width was decreased, whereas overjet and overbite showed no significant changes and incisor irregularity showed only a slight increase postretention. Sadowsky et al18 assessed 22 patients with a minimum of 5 years postretention. Fifteen were treated initially with tandem mechanics; all had light interproximal stripping as the mandibular fixed lingual retainer was removed. Average retention time with a mandibular fixed lingual retainer was 8.4 years. In this study, all variables showed relapse during the postretention stage

except for the maxillary canine and premolar arch width region. The mandibular irregularity index lost 33% of its improvement. Cephalometric studies of postretention changes have evaluated an additional aspect of relapse in orthodontically treated cases. Brodie19 studied nonextraction orthodontic cases and concluded the axial inclination of teeth disturbed by orthodontic treatment tends to return to pretreatment conditions. Cole20 reported a similar observation in orthodontic cases treated with extractions. He noted that mandibular incisors tended to return to their original inclination relative to the mandibular plane. Tweed1 believed placing the teeth upright over basal bone would ensure stability and suggested specific cephalometric angles to achieve stability. Schulaf et al21 reported that the lower incisors anteroposterior positions relative to various cephalometric values had no relationship to postretention crowding of lower incisors. Shields22 assessed long-term postretention changes of 54 orthodontically treated cases using premolar extractions and concluded the long-term response to mandibular anterior alignment was unpredictable and that none of the cephalometric parameters were useful in predicting the relapse potential. However, there was a slight tendency for incisor inclination to return toward the pretreatment value during the postretention period. All cases in this current study were treated with tandem mechanics without extraction of permanent teeth. The patients were followed for at least 2 years or more after the end of the retention phase of orthodontic treatment. Tandem mechanics, where the arch length is preserved by restricting mesial movement of maxillary and mandibular molars during orthodontic treatment, has been previously described.23-26 To summarize, as the dentofacial skeleton grows forward, the maxillary molars are restricted from moving mesially (anteriorly) with headgear. The mandibular molars are restricted from moving mesially (anteriorly) by Class III elastics used in tandem with the headgear. The elas-

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American Journal of Orthodontics and Dentofacial Orthopedics July 2000

Table II. Summary Values observed (mm)

statistics for variables (complete sample)

Mean SD Minimum Maximum

Intercanine distance Before treatment After treatment After retention and follow-up Intermolar distance Before treatment After treatment After retention and follow-up Overjet Before treatment After treatment After retention and follow-up Overbite Before treatment After treatment After retention and follow-up IMPA Before treatment After treatment After retention and follow-up Irregularity index Before treatment After treatment After retention and follow-up *P value for a significant change.

T0 T1 T2 T0 T1 T2 T0 T1 T2 T0 T1 T2 T0 T1 T2 T0 T1 T2

26.2 27.3 26.4 43.1 46.4 46.5 7.8 0.9 1.0 4.7 1.9 2.6 97.6 95.7 96.1 4.5 1.0 1.0

2.1 1.5 1.6 2.5 3.1 3.1 2.0 0.8 0.7 1.9 0.8 1.0 7.0 7.0 6.2 1.7 0.9 1.0

20.3 24.7 22.8 38.6 37.7 41.0 3.6 0.0 0.0 1.3 0.0 1.0 82.0 81.0 84.0 1.2 0.0 0.0

30.7 30.4 29.6 47.8 52.4 52.0 11.8 2.6 2.5 9.3 3.5 4.8 110.0 109.0 111.0 7.6 4.6 4.1

tics used with the headgear in tandem help preserve, and possibly create, arch length. The specific predictors investigated in this study included: intercanine width, intermolar width, overjet, overbite, irregularity index, and lower incisor to mandibular plane angle. All these parameters were examined at pretreatment, posttreatment, and postretention periods. Azizi et al27 have previously described a retrospective study of Angle Class I malocclusions treated orthodontically without extractions using tandem mechanics and 2 palatal expansion methods. The purpose of this study is to evaluate the amount of relapse that may occur in Angle Class II Division 1 patients, who were treated nonextraction orthodontically with tandem mechanics. The intent is to search for clinically significant predictors or associations with values measured from the dental casts with particular emphasis on mandibular anterior alignment.
MATERIAL AND METHODS

Patient records for 55 patients were obtained from Dr Andrew J. Haas of Cuyahoga Falls, Ohio. An assistant in Dr Haas office selected the cases on the basis of their original classification as Angle Class II malocclusion and the existence of some postretention follow-up records. According to Dr Haas, neither treatment outcome nor patient satisfaction was an explicit criterion for selection.

Case records were sent to the Medical College of Georgia, Department of Orthodontics. These case records consisted of dental models and lateral cephalometric radiographs collected before treatment, after treatment, and at least 2 years after cessation of retainer wear. Progress notes were included that contained date of birth, gender, and dates of treatment and follow-up event visits. All subjects were treated by a single clinician. The retention strategy used was first premolar to first premolar mandibular fixed lingual retention with maxillary Hawley retainer. In addition, 6 criteria were used to select a study sample of 31 from the 55 cases: 1. Angle Class II Division 1 malocclusion 2. No missing permanent teeth at pretreatment 3. Treatment without the extraction of permanent teeth 4. Good quality dental models and lateral cephalometric radiographs at each time point 5. Minimal 2 years of follow-up after cessation of retention 6. Treatment involved the use of tandem mechanics To ensure consistency with the requirement of Angle Class II Division 1 malocclusion, an overjet of at least 3.0 mm was required. The overbite was required to be positive in order to eliminate openbite cases. Gender, age at the time treatment began, treatment time, retention time, and time of follow-up after

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Yavari et al 37

Changes observed (mm)

Mean

SD

Minimum

Maximum

P value*

During treatment During retention and follow-up During treatment, retention, and follow-up During treatment During retention and follow-up During treatment, retention, and follow-up During treatment During retention and follow-up During treatment, retention, and follow-up During treatment During retention and follow-up During treatment, retention, and follow-up During treatment During retention and follow-up During treatment, retention, and follow-up During treatment During retention and follow-up During treatment, retention, and follow-up

T1-T0 T2-T1 T2-T0 T1-T0 T2-T1 T2-T0 T1-T0 T2-T1 T2-T0 T1-T0 T2-T1 T2-T0 T1-T0 T2-T1 T2-T0 T1-T0 T2-T1 T2-T0

1.1 0.9 0.2 3.3 0.1 3.4 6.9 0.2 6.8 2.9 0.8 2.0 2.3 0.5 2.2 3.5 0.0 3.5

2.1 1.0 2.0 2.6 1.3 3.0 2.4 0.7 2.2 1.8 0.8 1.8 7.3 5.6 6.0 2.0 1.1 2.1

3.6 2.8 3.9 1.9 2.6 1.5 11.5 1.5 11.1 7.2 1.1 5.8 19.0 0.0 -13.0 6.8 4.1 6.7

4.7 1.6 4.2 10.2 3.2 11.5 1.5 1.6 1.6 0.3 2.7 1.1 10.0 12.0 10.0 1.2 2.5 0.2

.0039 .0001 .5972 .0001 .8140 .0001 .0001 .2057 .0001 .0001 .0001 .0001 .0995 .6160 .0599 .0001 .8499 .0001

retention were recorded for each subject. The names of patients were not used for identification as the data were collected. The Human Assurance Committee of the Medical College of Georgia approved this study. The study variables were: Intercanine distance: the distance (mm) between the cusp tips of the mandibular canines or estimated cusp tips in cases of wear facets.13 Intermolar distance: the distance (mm) between the mesiobuccal cusp tips of the mandibular first permanent molars or estimated cusp tips in cases of wear facets.13 Overjet: the horizontal distance (mm) parallel to the occlusal plane from the lingual surface of the most labial maxillary incisor to the labial surface of the most lingual mandibular incisor.28 Overbite: the mean vertical overlap (mm) of upper and lower central incisors.29 IMPA (lower incisor to mandibular plane angle): angle formed by the intersection of the long axis of the lower central incisors with the mandibular plane as measured on the lateral cephalometric radiograph.1 Total irregularity index: the irregularity index (IR) is the summed displacement of the anatomic contact points of the lower anterior teeth.3

To ensure recording horizontal displacement, the caliper was consistently parallel to the occlusal plane while obtaining each measurement. The mesiodistal spacing was disregarded if teeth were in proper arch form. However, if displacement of the teeth in conjunction with spacing occurred, then only the labiolingual displacement from proper arch form was recorded. For accurate measurements of mandibular incisors, the dial caliper used in this study was precise to one-hundredth of a millimeter.29 Among the 31 subjects in the complete study sample, 17 subjects showed a decrease or no change in irregularity index during the retention and postretention follow-up periods. The remaining 14 subjects showed a mild increase in irregularity index during this same period of observation. In order to determine associations between the relapse of mandibular anterior crowding with other study variables, the sample was divided into these 2 groups. Statistical analysis of changes in study variables over time was performed using the paired t test. Differences in groups with increased and decreased irregularity were analyzed using the 2-sample t test. Significant results of statistical tests were reported when the P value was less than or equal to .0500. Reliability of study measurements was assessed. A second evaluator measured 30 models and radiographs selected at random. Interevaluator reliability was measured with intraclass correlation coefficient (ICC),

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American Journal of Orthodontics and Dentofacial Orthopedics July 2000

paired t test, and the variance component of the Bradley-Blackwood test (BBT).30,31
RESULTS

To determine associations between the relapse of mandibular anterior crowding with other study variables, the sample was divided into 2 groups (Table I). They are designated in the text as group D (decreased irregularity, N = 17) and group I (increased irregularity, N = 14). The mean postretention follow-up time in group D was 3.8 years and in group I was 7.0 years. This difference of 3.2 years was significant (P value = .0159). Of the 31 subjects meeting the studys selection criteria, 22 were females and 9 were males. There is some evidence that sexual dimorphism could be a long-term consideration because of greater incisor irregularity in males as a result of final mandibular growth increments, unmatched by maxillary changes. The mean age at the beginning of treatment was 11.0 years; the mean treatment time was 3.5 years; the mean retention time was 6.4 years; and the mean postretention follow-up time was 5.2 years. Summary statistics for each variable are provided in Table II.
Intercanine Distance (Table II)

During the retention and postretention follow-up periods, the mean overjet was maintained: 0.9 mm to 1.0 mm. This small difference of 0.2 mm (due to rounding) was not significantly greater than zero (P = .2057). Thus, the reduction in overjet measured across the treatment, retention, and postretention periods was 6.8 mm. This was a significant overall change (P = .0001).
Overbite (Table II)

Overbite was reduced from a mean of 4.7 mm to a mean of 1.9 mm during treatment. This reduction of 2.9 mm was significantly greater than zero (P = .0001). During the retention and postretention follow-up periods, the mean overbite increased from 1.9 mm to 2.6 mm. This small relapse of 0.8 mm was significantly greater than zero (P = .0001). The reduction in overbite measured across the treatment, retention, and postretention periods was 2.0 mm. This was a significant overall change (P = .0001).
IMPA (lower incisor to mandibular plane angle) (Table II)

Intercanine distance changed from a mean of 26.2 mm to a mean of 27.3 mm during treatment. This change of 1.1 mm was significantly greater than zero (P = .0039). During the retention and postretention follow-up periods, the mean intercanine distance relapsed from 27.3 mm to 26.4 mm. This relapse of 0.9 mm was significantly greater than zero (P = .0001). The residual change measured across the treatment, retention, and postretention periods was 0.2 mm. This was not a statistically significant overall change (P = .5972).
Intermolar Distance (Table II)

IMPA was reduced from a mean of 97.6 to a mean of 95.7 during treatment. This reduction of 2.3 was not significantly different from zero (P = .0995). During the retention and postretention follow-up periods, the mean IMPA changed by only 0.5. This change was not significant (P = .6160). Thus, the reduction in IMPA measured across the treatment, retention, and postretention periods was 2.2. This reduction did not achieve the customary 0.05 alpha level and is therefore considered a nonsignificant change (P = .0599).
Irregularity Index (Table II)

Intermolar distance changed from a mean of 43.1 mm to a mean of 46.4 mm during treatment. This change of 3.3 mm was significantly greater than zero (P = .0001). During the retention and postretention follow-up periods, the mean intermolar distance remained expanded: 46.4 to 46.5 mm. This small difference of 0.1 mm was not significantly greater than zero (P = .8140). Thus, the change measured across the treatment, retention, and postretention periods was 3.4 mm. This was a significant overall intermolar expansion of 3.4 mm (P = .0001).
Overjet (Table II)

The irregularity index was reduced from a mean of 4.5 mm to a mean of 1.0 mm during treatment. This reduction of 3.5 mm was significantly greater than zero (P = .0001). During the retention and postretention follow-up periods, the mean irregularity index remained constant at 1.0 mm. Thus, the reduction in irregularity index measured across the treatment, retention, and postretention periods was 3.5 mm. This was a significant overall change (P = .0001).
Associations With Irregularity Index (divided sample)

Overjet was decreased from a mean of 7.8 mm to a mean of 0.9 mm during treatment. This reduction of 6.9 mm was significantly greater than zero (P = .0001).

The following results involve the divided sample (Table I), designated as group D (decreased irregularity, N = 17) and group I (increased irregularity, N = 14). The summary statistics for these groups are listed in Table III. The mean age at the beginning of treatment for group I was 14.5 years, and the mean for group D was 11.5 years. The difference in age was not significant (P = .1233). The mean treatment time was

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Table III. Summary

statistics of divided sample variables

Irregularity strata Increased Mean SD Decreased Mean SD P value*

Intercanine distance (divided sample) Values observed (mm) Before treatment After treatment After retention and follow-up Changes observed (mm) During treatment During retention and follow-up During treatment, retention, and follow-up Intermolar Distance (divided sample) Values observed Before treatment After treatment After retention and follow-up Changes observed (mm) During treatment During retention and follow-up During treatment, retention, and follow-up Overjet (divided sample) Values observed Before treatment After treatment After retention and follow-up Changes observed (mm) During treatment During retention and follow-up During treatment, retention, and follow-up Overbite (divided sample) Values observed (mm) Before treatment After treatment After retention and follow-up Changes observed (mm) During treatment During retention and follow-up During treatment, retention, and follow-up IMPA (divided sample) Values observed (mm) Before treatment After treatment After retention and follow-up Changes observed (mm) During treatment During retention and follow-up During treatment, retention, and follow-up

T0 T1 T2 T1-T0 T2-T1 T2-T0

26.2 26.8 25.5 0.6 1.3 0.6

1.7 1.4 1.1 1.9 1.0 2.0

26.2 27.8 27.1 1.5 0.6 0.9

2.4 1.4 1.5 1.6 0.9 1.7

.9930 .1033 .0037 .2290 .0575 .0288

T0 T1 T2 T1-T0 T2-T1 T2-T0

42.6 46.0 45.6 3.4 0.3 3.1

2.1 2.3 2.9 3.2 1.3 3.8

43.5 46.8 47.1 3.3 0.4 3.7

2.8 3.7 3.2 2.1 1.3 2.2

.3435 .4827 .1898 .9432 .1436 .5803

T0 T1 T2 T1-T0 T2-T1 T2-T0

8.9 0.6 0.9 8.3 0.4 7.9

1.8 0.7 0.6 2.2 0.9 1.9

7.0 1.1 1.1 5.9 0.0 5.8

1.8 0.8 0.8 2.1 0.7 2.1

.0067 .0409 .4001 .0031 .1375 .0059

T0 T1 T2 T1-T0 T2-T1 T2-T0

5.0 2.0 2.8 2.9 0.9 2.1

2.1 0.8 1.3 2.1 1.0 1.9

4.5 1.9 2.6 2.7 0.7 1.9

1.7 0.8 0.7 1.6 0.6 1.7

.5389 .5222 .5161 .7259 .8479 .7816

T0 T1 T2 T1-T0 T2-T1 T2-T0

96.1 94.3 95.9 2.4 1.5 1.4

8.0 5.4 6.6 6.3 4.0 4.9

98.9 96.7 96.3 2.2 0.2 2.8

6.2 8.0 6.2 8.2 6.6 6.7

.2885 .3622 .8920 .9399 .4394 .5501

*P value for a significant difference between the increased irregularity group (N = 14) and the decreased irregularity group (N = 17).

3.9 years in group I and 3.3 years in group D. This difference in treatment time was not significant (P = .1522). The mean retention time was 5.7 years in group I and 7.1 years in group D. The difference of 1.4 years was not significant (P = .0517). The mean postretention follow-up time was 7.0 years in group I and 3.8 years

in group D. This difference in postretention follow-up time was significant (P = .0159).

Intercanine Distance (divided sample) (Table III)

The mean intercanine distance before treatment was the same in groups I and D, 26.2 mm. Group I

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Table IV. Summary

of interevaluator reliability indicators

Evaluator 1 Evaluator 2 Mean 27.0 45.6 3.3 3.2 1.9 94.1 SD 1.8 3.6 3.4 1.5 1.7 7.3 ICC 0.94 0.99 0.99 0.98 0.92 0.95 Paired t test .003 .078 .916 .524 .220 .357 P values Variance test (BBT) .049 .669 .709 .841 .359 .253 2-df BBT .002 .198 .926 .803 .311 .339

Variables Intercanine distance Intermolar distance Overjet Overbite Irregularity index IMPA

Mean 26.6 45.5 3.3 3.1 1.7 94.5

SD 2.0 3.6 3.4 1.5 1.8 7.8

experienced slightly less expansion during treatment (0.6 mm) than group D (1.5 mm), but this difference was not significant (P = .2290). During retention and postretention follow-up, group I experienced 1.3 mm of loss of expansion; group D experienced 0.6 mm of loss of expansion. This difference was not quite significant (P = .0575). However, considering the overall change throughout the treatment, retention, and postretention follow-up periods, group I experienced a net decrease in intercanine distance (0.6 mm) in contrast to a net increase in intercanine distance (0.9 mm) in group D. This difference of 1.5 mm was significant (P = .0288).
Intermolar Distance (divided sample) (Table III)

Overbite (divided sample) (Table III)

The mean value for overbite before treatment was 5.0 in group I and 4.5 in group D. Overbite was reduced during treatment and approximately maintained after treatment in each group. Treatment reduction was 2.9 mm in group I and 2.7 mm in group D. Overall net reduction was 2.1 mm in group I and 1.9 mm in group D. There were no significant differences between groups I and D in overbite across any of the periods of observation.
IMPA (divided sample) (Table III)

The mean intermolar distance before treatment was 42.6 for group I, and the mean intermolar distance was 43.5 for group D. Intermolar distance was expanded during treatment and maintained after treatment in each group. Treatment expansion was 3.4 mm in group I and 3.3 mm in group D. Overall net expansion was 3.1 mm in group I and 3.7 mm in group D. There were no significant differences between groups I and D in intermolar distance across any of the periods of observation.
Overjet (divided sample) (Table III)

The mean value for overjet before treatment was 8.9 mm in group I and 7.0 mm in group D. This difference was significant (P = .0067). The mean value for overjet after treatment was 0.6 mm in group I and 1.1 mm in group D. This difference was significant (P = .0409). Group I started with more overjet before treatment and ended with less overjet after treatment than group D. The treatment reduction in overjet for group I was a mean of 8.3 mm and for group D, a mean of 5.9 mm. This treatment reduction difference was significant (P = .0031). The change in overjet during the retention and postretention follow-up periods was not significant in either group. Therefore, the overall reduction in overjet in group I was 7.9 mm and in group D was 5.8 mm. This difference was significant (P = .0059).

The mean value for IMPA before treatment was 96.1 in group I and 98.9 in group D. IMPA was reduced during treatment and approximately maintained after treatment in each group. Treatment reduction mean value was 2.4 in group I and 2.2 in group D. Overall net mean reduction was 1.4 in group I and 2.8 in group D. There were no significant differences between groups I and D in IMPA across any of the periods of observation. The reliability indicators (Table IV) were applied and interpreted as recommended by physical anthropology studies.32 The intraclass correlation coefficients (ICCs) for the variables in this study were between 0.92 and 0.99. Excellent reliability is considered at the level of ICC greater than or equal to 0.85. For intercanine distance there were minor differences between evaluators. This difference was 0.4 mm in the mean and 0.2 mm in the SD. Though statistically significant in the paired t test and BBT components, the ICC was 0.94. This indicated that the differences were small compared with the scale and range of measurements, and no corrective action was indicated.
DISCUSSION

The 3.2 year difference in the mean postretention follow-up time between group D and group I was significant (P value = .0159). These results support previous work by Katz32 who reported that potential for relapse increased with more years out of retention. How-

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Yavari et al 41

ever, there was no relationship between the number of years in retention and the other variables that he studied. Intercanine distance increased as a result of treatment; however, it relapsed to near pretreatment level in the main sample. Intercanine distance relapsed approximately 80%, maintaining 0.2 mm of expansion in the lower anterior segment. This observation was also reported by others.14,33,34 The data from the present study for the 2 groups suggested that there was postretention relapse of intercanine distance that was associated with an increase in the irregularity index. In fact, the mean value of intercanine distance for group I at postretention was 0.7 mm less than the pretreatment value. This finding is in contrast with the findings of Little et al,14 who reported that the maintenance of initial canine distance during treatment had little apparent influence on the postretention crowding. Our results were in agreement with rtun et al35 who found an association between postretention reduction of intercanine distance and relapse of incisor alignment in Angle Class II Division 1 patients. Intermolar distance was also increased as a result of treatment. In contrast to intercanine distance, expansion of intermolar distance remained stable throughout the postretention period. These findings support previous studies, which reported long-term stability of intermolar distance.17,19 This study focused on Angle Class II Division 1 malocclusion characterized by a large overjet. The overall overjet changes from pretreatment to the end of the observation period were significantly stable, maintaining 89% of correction throughout the entire observation period. These findings are in agreement with the results of previous studies17,19,36 that suggested that overjet displayed long-term stability. Analyzing the results for the 2 groups in the present study revealed that a large overjet at pretreatment was associated with an increased irregularity index. In addition, samples with large overjet corrections were also associated with increased irregularity indexes during postretention. Therefore, we concluded that the magnitude of overjet correction may be associated with the relapse of lower incisor alignment in Angle Class II Division 1 malocclusions. The amount of overbite was decreased by the orthodontic treatment, and it showed a slight relapse by the end of the postretention period. However, this difference was not statistically significant. These findings are in agreement with previous studies.17,19,36 The irregularity index decreased significantly during treatment. This may be one of the most distinguishing features of the study. The mean value for irregularity index was reduced from 4.5 mm at pretreatment to a mean value of 1.0 mm at the end of treatment. This reduction in irregularity remained sta-

ble to the end of the observation period, which supports the findings of another recent study use27; both are in contrast to results of Little et al12-15 that reported 89% of orthodontically treated cases without extractions exhibited unacceptable lower anterior alignment. As a minimum, this suggests it may be possible to achieve long-term stability, which is better than has been reported. These particular differences may be related to the practitioner or the protocol. With tandem treatment mechanics, forces are directed toward distalizing or preventing maxillary and mandibular first molars from moving mesially while the maxillary and mandibular complex is growing anteriorly. Hopefully, arch length is preserved or gained especially in crowded malocclusions without moving incisors anteriorly into unstable positions. For best results, our practitioner believes cases should be started in the late mixed dentition stage before the loss of primary second molars and leeway spaces. To use this technique, the clinician must be a believer in headgear therapy, growth and development concepts, and possess the ability to convince patients that tandem treatment will be beneficial before long-term stability can be achieved. This practitioner selected his protocol based on his diagnosis and treatment experience; one must be cautious in applying these results to patients with more crowding or more protrusion. IMPA was reduced by orthodontic treatment in this study. The results indicated that there was no significant correlation between the changes in IMPA and the irregularity index. Our results are in agreement with the results of previous studies14,22,23 that indicated no significant correlation between the long-term stability of the mandibular anterior teeth and any of the cephalometric measurements. This study examined patients with one type of malocclusion, Angle Class II Division 1, thus, maintaining this variable constant. The majority of published studies include a variety of different types of malocclusions. Furthermore, the present study included only subjects treated with tandem mechanics without previous extractions of permanent teeth. Treatment mechanics may have an impact on the stability of the orthodontic results and is not addressed in many studies. For example, a unique feature of tandem mechanics is thought to be the class III elastics in tandem with the headgear that preserves the arch length needed to decrease the amount of crowding in the mandibular anterior region. This factor may be a reason for stability of lower incisor alignment in this study. Another possible consideration is removal of third molars, which increases arch length in the alveolar trough. This was not recorded in this study.

42 Yavari et al

American Journal of Orthodontics and Dentofacial Orthopedics July 2000

Finally, all subjects in this study were treated by a single clinician. This eliminates the variability of multiple clinicians but may reduce generalization of results. Furthermore, this study was retrospective. Elimination of case selection bias in this kind of study is impossible because of the self-selection of patients as they are recalled. All cases were selected based on the availability of complete records and not on treatment outcome. However, future study models should include prospective randomized trials.
CONCLUSIONS

13.

14.

15.

16. 17.

A synopsis of this study shows that the correction of lower incisor crowding as measured by the irregularity index was stable over 5.2 years of postretention follow-up; but longer follow-up time revealed increased relapse of incisor irregularity. Intermolar width increased during treatment and remained stable in the follow-up period. Overjet and overbite corrections and IMPA changes were also stable in the followup period. In addition, the amounts of overjet correction and loss of expansion of intercanine distance after treatment were associated with an increased irregularity index in the follow-up period. This and a previous study27 have demonstrated that it is possible to combine case diagnoses with treatment protocols to achieve outcomes superior to what has been reported. It appears the discrepancies between these reports are sufficiently dramatic that the question of current treatment philosophies and long-term stability of mandibular incisors may need to be reevaluated.
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