Original Article

Association between arch width changes and long-term stability 20 years

after orthodontic treatment with and without extractions
Vjera Perkovica; Moody Alexanderb; Preston Greerc; Ervin Kamenard; Sandra Anic-Milosevice

ABSTRACT

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Objectives: To investigate long-term stability 20 years after orthodontic treatment and the
association with arch width changes during treatment.
Materials and Methods: This retrospective study investigated 103 patients with Class I and II
malocclusions treated with fixed appliances with and without extractions. The sample was treated
by one experienced orthodontist and collected from a private orthodontic office. Dental casts were
obtained pretreatment (T1), posttreatment (T2), and long-term postretention (T3); they were
scanned and converted to STL files. Measurements were evaluated in for the upper and lower arch:
intercanine width (IC), intermolar (IM) width, Little’s irregularity index (LII).
Results: There were 73 female and 30 male patients. Class I was present in 74 patients and Class
II in 29. Average postretention time was 17.2 (66.5) years after an average active retention time of
3.4 (61.17) years. Extraction was performed in 55 patients while 48 received nonextraction
treatment. Bonferroni Post Hoc test showed that LII in the upper and lower arches at T1 was
significantly higher in the extraction group (P , .001). Upper and lower arch LII at T3 was slightly
higher in extraction cases but remained under 2.05 mm. LII at T3 in the upper and lower arches
showed negative correlation with IM T3 in the upper arch (Pearson, N ¼ 103, P ¼ .047), while IC in
the upper and lower arches at T3 correlated with IM T3 in the upper and lower (N ¼ 103, P , .001).
Conclusions: Clinically relevant long-term stability in both arches was found in extraction and
nonextraction cases. Intermolar width and its change during orthodontic treatment was an
influential factor on long-term stability in extraction cases. (Angle Orthod. 2023;93:261–268.)
KEY WORDS: Stability; Orthodontics; Arch width

INTRODUCTION assumed the teeth will remain stable in the corrected

position for many years after orthodontic treatment.
Orthodontic treatment consists of an active treat-
However, different dental arches show different levels
ment period, in which teeth are moved into a desired
of stability, as demonstrated in previous studies.1–7 It
position, and a retention period, where teeth are
had been claimed that a longer period of posttreatment
retained in the corrected position. After the retention
time (more than 10 years) shows greater instability.2
period, which lasts a certain period of time, it is
According to past research, biological or treatment-
related factors, such as periodontal tissue, muscular
a
Research Assistant, Department of Orthodontics, Faculty of
Dental Medicine, University of Rijeka, Rijeka, Croatia.
imbalance, jaw growth, mandibular rotation, mandibu-
b
Private Practice, Arlington, TX, USA. lar intercanine width, and mandibular incisor position,
c
Private Practice, Waco, TX, USA. can have an impact on long-term stability.4,8–10 Also,
d
Assistant Professor, Faculty of Engineering, Laboratory for retention method and duration can affect treatment
Precision Engineering, University of Rijeka, Rijeka, Croatia.
e
Professor, Department of Orthodontics, School of Dental
stability.11 Yet, some previous studies did not exclude
Medicine, University of Zagreb, Zagreb, Croatia. treatment-related stability factors proven to promote
Corresponding author: Dr Vjera Perkovic, Department of unstable long-term results. These factors should not be
Orthodontics, University of Rijeka, Kresimirova 40, Rijeka overlooked and must be incorporated into studies to
51000, Croatia
(e-mail: [email protected])
fully understand long-term stability results. Perhaps
this is why the literature shows variable results for long-
Accepted: December 2022. Submitted: August 2022.
Published Online: February 06, 2023 term stability. For example, factors such as pro-
Ó 2023 by The EH Angle Education and Research Foundation, nounced proclination of lower incisors, overexpansion
Inc. of intercanine width, or quality of treatment outcome

DOI: 10.2319/080822-557.1 261 Angle Orthodontist, Vol 93, No 3, 2023

262 PERKOVIC, ALEXANDER, GREER, KAMENAR, ANIC-MILOSEVIC

can also affect treatment stability.12–14 Studies that posttreatment (T2), and long-term postretention of at
reported greater posttreatment irregularity often includ- least 5 years (T3). All dental casts were scanned with
ed patients treated at university training programs.1,15,16 an Ortho Insight 3D scanner (Motion View LLC, Hixon,
In addition, excessive proclination of lower incisors Tenn, USA) and converted to digital 3D dental casts
during treatment seems to be related to posttreatment (STL files). Linear measurements were evaluated in
retroclination.17 customized MATLAB software, programmed for this
A larger number of studies investigated the mandib- research, at all three timepoints:
ular arch since it seems that irregularity is greater in the
mandibular arch.2,3,7,15,18 Bjering et al. concluded that 1. Intercanine width (IC): measured as the distance
extraction of premolars significantly improved long-term between cusp tips of the left and right canines (mm)
in the upper and lower arch.

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stability of mandibular incisor alignment, while Swidi et
al. concluded that irregularity increases were slightly 2. Upper intermolar width (IM): measured as the
greater in patients treated with mandibular premolar distance between intersections of the transverse
extractions.2,7 Fewer studies compared extraction and and buccal fissures of the left and right permanent
nonextraction treatment long-term stability. A recent first molars.
study by Cotrin et al. showed there was no difference in 3. Lower intermolar width (IM): distance between
the long-term change in anterior alignment and trans- mesiobuccally cusp tips of the left and right
verse arch dimensions between patients treated with permanent first molars.
and without extractions; however, there was clinically 4. Little’s irregularity index (LII): the sum of five linear
unsatisfactory Little’s irregularity index measures in the displacements of anatomic contact points of the six
long-term period in both arches (.3.5 mm).6 anterior teeth, measured in the upper and lower arch.
In the current literature, no predictors of long-term Measurements were performed by one experienced
stability after orthodontic treatment have been identi- and calibrated examiner (VP). Thirty days after initial
fied. This study aimed to investigate the effect of arch measurements, 40 dental casts were randomly
widths and their changes during treatment on the long- selected to check for intraexaminer reliability. There
term stability of dental arches. were no statistically significant systematic errors
between repeated measurements. Random errors
MATERIALS AND METHODS were calculated according to Dahlberg’s formula and
ranged between 0.05 to 0.21 mm. Statistical analyses
This retrospective study was approved by the Ethics
was performed in STATISTICA 64, version 10 for
Committee of the School of Dental Medicine, University
Windows.
of Zagreb (Protocol No. 05-PA-30-XV-3/2020). The
study included dental casts from 103 patients. The
RESULTS
sample was collected from a patient database of a
private orthodontic office in Arlington, Texas, USA, and There were 73 (70.9%) female and 30 (29.1%) male
patients were treated by one experienced orthodontist patients; 71.8% of cases were Class I and 28.2% were
(RWA) during the 1970s and 1980s. Inclusion criteria Class II at T1. The average post retention time was
were: patients with initial Class I or Class II malocclu- 17.2 6 6.5 years after an average active retention time
sion treated with comprehensive orthodontic treatment of 3.4 6 1.17 years. Overall, T3 was 20.5 6 6.51 years
with bonded fixed appliances in both arches with and after orthodontic treatment was finished. Extraction
without extraction of permanent premolars, full records was performed in 55 (53.4%) patients, and 48 patients
before treatment, after treatment, and with a post- (46.6%) were treated nonextraction. The average age
retention period of at least 5 years. Exclusion criteria at T1 was 12.8 6 1.78 years, at T2 was 15.2 6 1.78
were: missing permanent teeth (except third molars), years, and at T3 was 35.8 6 6.53 years.
Class III patients and craniofacial anomalies, missing There was no significant difference in LII associated
full records, and circumferential supracrestal fiber- with sex or classification. However, there were
otomy (CSF) performed. The active retention protocol significant differences in LII between extraction and
lasted for 3 years with the following appliances: nonextraction cases. LII according to treatment method
wraparound retainer in the upper arch and fixed and timepoint is shown in Table 1. At T1, the sample
retainer from canine to canine in the lower arch. was divided into extraction or nonextraction groups
Retention appliances were removed after 3 years and according to their initial treatment plan even though
interproximal reduction (IPR) was performed in the extractions were not done in the T1 time period. LII in
lower intercanine segment in patients for whom this the upper arch showed a statistically significant
was not done during treatment. Dental casts were difference between treatment modalities and among
obtained at three time points: pretreatment (T1), time periods as well as their interactions (analysis of

Angle Orthodontist, Vol 93, No 3, 2023

LONG-TERM STABILITY AFTER ORTHODONTIC TREATMENT 263

Table 1. Little’s Irregularity Index (LII) According to Treatment Method at Different Timepoints
Little Irregularity Index Period Treatment Method Na x̄ b sc Mind Maxe
Upper arch T1 Extraction 44 6.96 2.93 1.31 14.49
Nonextraction 45 5.60 2.05 2.16 11.45
Total 89 6.27 2.60 1.31 14.49
T2 Extraction 55 0.54 0.63 0.00 2.48
Nonextraction 48 0.27 0.42 0.00 2.26
Total 103 0.41 0.56 0.00 2.48
T3 Extraction 55 1.69 1.27 0.00 5.54
Nonextraction 48 1.10 0.79 0.00 3.22
Total 103 1.42 1.11 0.00 5.54
Lower arch T1 Extraction 49 6.69 3.55 1.13 14.44

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Nonextraction 48 4.53 2.68 0.37 12.27
Total 97 5.62 3.31 0.37 14.44
T2 Extraction 55 0.54 0.67 0.00 3.76
Nonextraction 48 0.41 0.39 0.00 1.35
Total 103 0.48 0.56 0.00 3.76
T3 Extraction 55 2.05 1.64 0.00 7.27
Nonextraction 48 1.52 1.27 0.09 6.53
Total 103 1.80 1.49 0.00 7.27
a
number of participants; b mean; c standard deviation; d minimal value; e maximal value.

variance, F ¼ 3.05, df ¼ 2, P , .005). Figure 1 and males at T2 was significantly greater than intercanine
Figure 2 show average LII values for extraction and width in females at T1. In females, intercanine width did
nonextraction cases in the upper and lower arch, not change significantly at different timepoints in
respectively. The Bonferroni post hoc test showed that nonextraction cases.
average LII at T1 in the upper and lower arch was Intermolar widths in extraction cases are shown in
significantly higher in extraction cases (P , .001). At Table 3. Intermolar width in females at T3 was
T2 and T3, these differences were not statistically significantly lower than in males. Figures 5 and 6 show
significant. In both groups, there was a significant average values of intermolar width in the upper and
decline of LII at T2, which slightly increased at T3, but lower arch, respectively, for male and female extraction
not significantly. and nonextraction cases. Extraction significantly de-
Intercanine width was greater in both arches in creased intermolar width at T2 in both arches and
males at all three timepoints (Table 2). In females, maintained its value at T3. Changes in nonextraction
upper arches treated with extraction showed de- treatment were opposite to those in extraction cases,
creased intercanine width at T3 and, in males, but similar in the upper and lower arches. Intermolar
extractions caused an increase of intercanine width width increased and maintained its value in both arches.
at T2 and T3. Similar results were seen in the lower Before orthodontic treatment (T1), Pearson’s corre-
arch (Figures 3 and 4). Lower arch intercanine width in lation showed that LII in the upper arch was not

Figure 1. Average values of irregularity index in the upper arch at Figure 2. Average values of irregularity index in the lower arch at
three timepoints in extraction and nonextraction cases. three timepoints in extraction and nonextraction cases.

Angle Orthodontist, Vol 93, No 3, 2023

264 PERKOVIC, ALEXANDER, GREER, KAMENAR, ANIC-MILOSEVIC

Table 2. Intercanine Width According to Treatment Method at Different Timepoints.

Intercanine Width Period Treatment Method Na x̄ b sc Mind Maxe
Upper arch T1 Extraction 43 33.46 2.22 29.26 38.35
Nonextraction 47 33.96 2.46 28.77 40.60
Total 90 33.72 2.35 28.77 40.60
T2 Extraction 55 34.13 1.95 29.27 39.29
Nonextraction 48 33.86 1.45 30.75 36.81
Total 103 34.01 1.73 29.27 39.29
T3 Extraction 55 33.50 2.09 29.15 38.46
Nonextraction 48 33.88 1.79 29.24 37.14
Total 103 33.68 1.95 29.15 38.46
Lower arch T1 Extraction 49 25.23 1.93 22.47 30.19

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Nonextraction 48 25.45 1.87 20.59 30.23
Total 97 25.34 1.90 20.59 30.23
T2 Extraction 55 26.13 1.39 22.21 30.18
Nonextraction 48 25.59 1.25 22.82 28.00
Total 103 25.88 1.35 22.21 30.18
T3 Extraction 55 24.87 1.47 22.53 28.11
Nonextraction 48 25.36 1.38 22.77 29.05
Total 103 25.10 1.45 22.53 29.05
a
number of participants; b mean; c standard deviation; d minimal value; e maximal value.

significantly correlated to any arch width measure- orthodontic treatment was 17 6 6.5 years in post-
ments. However, LII in the lower arch was significantly retention. The present study showed minimal misalign-
negatively correlated to all of the width measurements ment in the postretention period with satisfactory
except the upper intercanine width. Therefore, higher alignment (LII under 3 mm) in 95 (92.2%) cases in
LII in the lower arch was accompanied by narrower the upper arch, and 85 (82.5%) cases in the lower
lower intercanine width and narrower intermolar width arch. Overall, these results demonstrated excellent
in both arches. At the T3 timepoint, in patients treated stability for such a long postretention period. Although
with extractions, there was a significant negative only a few studies investigated long-term changes over
correlation between intermolar width treatment change 10 years posttreatment, the findings were in agreement
in the upper arch (T2  T1) and LII in the upper and with two other studies with similar postretention time
lower arches (N ¼ 55, P ¼ .010; N ¼ 55, P , .001) periods, but only with extraction cases. Vaden et al.
(Tables 4 and 5). studied extraction cases 15 years postretention and
found minimal irregularity in both arches.19 Dyer et al.
DISCUSSION investigated long-term stability 24 years postretention
in extraction cases. Maxillary LII was stable long term,
This was a retrospective study in which the average while mandibular LII at T3 was less than 3.5 mm in
evaluation time of long-term changes in stability after 77% of patients.20 In both studies, patients were treated

Figure 3. Average values of intercanine width in the upper arch at Figure 4. Average values of intercanine width in the lower arch at
three timepoints in extraction and nonextraction cases for males and three timepoints in extraction and nonextraction cases for males and
females. females.

Angle Orthodontist, Vol 93, No 3, 2023

LONG-TERM STABILITY AFTER ORTHODONTIC TREATMENT 265

Table 3. Intermolar Width According to Treatment Method at Different Timepoints

Intermolar Width Period Treatment Method Na x̄ b sc Mind Maxe
Upper arch T1 Extraction 55 43.46 2.79 38.57 53.01
Nonextraction 48 45.69 2.89 38.75 51.78
Total 103 44.50 3.03 38.57 53.01
T2 Extraction 55 42.45 2.10 38.26 47.85
Nonextraction 48 46.99 2.68 41.91 53.59
Total 103 44.56 3.29 38.26 53.59
T3 Extraction 55 42.05 2.40 36.45 48.16
Nonextraction 48 46.98 2.81 41.77 53.19
Total 103 44.35 3.58 36.45 53.19
Lower arch T1 Extraction 55 44.34 3.14 39.10 52.14

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Nonextraction 48 45.90 2.66 40.14 51.19
Total 103 45.07 3.01 39.10 52.14
T2 Extraction 55 42.41 2.12 39.23 46.93
Nonextraction 48 46.84 2.42 42.79 52.69
Total 103 44.48 3.16 39.23 52.69
T3 Extraction 55 42.08 2.51 37.24 47.37
Nonextraction 48 46.93 2.49 42.22 53.42
Total 103 44.34 3.48 37.24 53.42
a
number of participants; b mean; c standard deviation; d minimal value; e maximal value.

by one orthodontist whose treatment philosophy was to and nonextraction cases; however, both groups
keep the roots in the basal bone. Other studies showed showed moderate Little’s irregularity index (.3.5 mm)
poor stability in the long term (more than 10 years).1,6,21 in both arches in the long term.6,21 Eventhough long-
Little et al. conducted one of the first comprehensive term changes were investigated in previous literature,
long-term stability studies that showed poor stability no predictors for long-term stability were established,
results. In the study, satisfactory mandibular anterior though some clinical treatment guidelines for better
alignment (under 3.5 mm) was found in less than 30% stability were given.
of cases in a 10-year postretention period, while only The explanation for good stability of anterior align-
10% of cases showed satisfactory alignment 10 to 20 ment in extraction and nonextraction cases in this
years postretention. The sample consisted of extrac- study perhaps lies in the fact that good diagnostics and
tion cases and the quality of treatment was not treatment decisions were made in the beginning. Many
evaluated. The study concluded that there was no studies did not address this problem, which resulted in
perfect stability in the long term and retention should be inconsistent conclusions. We may assert now that,
permanent.1 A more recent study compared long-term when stability guidelines are not respected, instability
dental arch changes in a postretention period of 37 is inevitable.
years. There were no differences between extraction The orthodontist who treated the patients in this
study previously developed a technique, having long-

Figure 5. Average values of intermolar width in the upper arch at Figure 6. Average values of intermolar width in the lower arch at
three timepoints in extraction and nonextraction cases for males and three timepoints in extraction and nonextraction cases for males and
females. females.

Angle Orthodontist, Vol 93, No 3, 2023

266 PERKOVIC, ALEXANDER, GREER, KAMENAR, ANIC-MILOSEVIC

Table 4. Correlation Between Little’s Irregularity Index and Table 5. Correlation Between Little’s Irregularity Index and
Intercanine and Intermolar Width Changes in Patients Treated With Intercanine and Intermolar Width Changes in Patients Treated
Extractions Nonextraction
Variable LII_U_T3 LII_U_T32 LII_L_T3 LII_L_T32 Variable LII_U_T3 LII_U_T32 LII_L_T3 LII_L_T32
IC_U_T21 0.1341 0.1228 0.2838 0.2179 IC_U_T21 0.0304 0.0367 0.0062 0.0835
N ¼ 43 N ¼ 43 N ¼ 43 N ¼ 43 N ¼ 47 N ¼ 47 N ¼ 47 N ¼ 47
P ¼ .391 P ¼ .433 P ¼ .065 P ¼ .160 P ¼ .839 P ¼ .807 P ¼ .967 P ¼ .577
IC_L_T21 0.1315 0.1467 0.0690 0.0360 IC_L_T21 0.0685 0.0673 0.1923 0.2139
N ¼ 49 N ¼ 49 N ¼ 49 N ¼ 49 N ¼ 48 N ¼ 48 N ¼ 48 N ¼ 48
P ¼.368 P ¼ .314 P ¼ .638 P ¼ .806 P ¼ .644 P ¼ .650 P ¼ .190 P ¼ .144
IM_U_T21 0.3430 0.1681 0.1235 0.0510 IM_U_T21 0.0405 0.0307 0.0080 0.0038
N ¼ 55 N ¼ 55 N ¼ 55 N ¼ 55 N ¼ 48 N ¼ 48 N ¼ 48 N ¼ 48

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P ¼ .010 P ¼ .220 P ¼ .369 P ¼ .711 P ¼ .784 P ¼ .836 P ¼ .957 P ¼ .980
IM_L_T21 0.5054 0.3751 0.0130 0.1392 IM_L_T21 0.1608 0.0526 0.1071 0.1006
N ¼ 55 N ¼ 55 N ¼ 55 N ¼ 55 N ¼ 48 N ¼ 48 N ¼ 48 N ¼ 48
P¼0 P ¼ .005 P ¼ .925 P ¼ .311 P ¼ .275 P ¼ .723 P ¼ .469 P ¼ .496
a
This Note is for Tables 4 and 5. Note: IC_U_T21 indicates
upper intercanine width change from T1 to T2 period; IC_L_T21,
term stability as a treatment goal, and incorporated lower intercanine width change from T1 to T2 period; IM_U_T21,
principles into a treatment technique promoting stabil- upper intermolar width change form T1 to T2 period; IM_L_T21, lower
intermolar width change from T1 to T2 period; LII_U_T3, upper Little
ity, such as keeping the teeth inside the basal bone, Irregularity Index at T3 period; LII_U_T32, upper Little Irregularity
limiting proclination of lower incisors to 38, and limiting Index change from T2 to T3 period; LII_L_T3, lower Little Irregularity
expansion of intercanine width to a maximum of 1 mm.8 Index at T3 period; LII_L_T32, lower Little Irregularity Index change
from T2 to T3 period.
According to his philosophy, if teeth were placed in the
appropriate positions during active treatment, inter-
proximal reduction was properly performed, and third intercanine width reduced from T2 to T3, while it
molars were resolved, then the chance of the result increased in males. Perhaps this difference could be
remaining stable after retainer removal was excellent. attributed to the fact that narrower arches (such as
Since several studies have concluded that third molars those in which extraction was performed or female
do not influence crowding, that issue was not arches in contrast to male arches) in general tend to
addressed in the current study.22 have greater posttreatment changes.27
Another aspect that might have contributed to stability Though intermolar width was a variable that showed
in this study was interproximal reduction (IPR), which very little change in extraction and nonextraction cases
was performed at the end of the retention period in the in both arches and had presented with good stability
lower canine-to-canine segment. IPR was done only in long term, intermolar width was associated with
cases where it was not done during the treatment, stability in this research. Treatment changes of
whether the treatment method was extraction or intermolar width in upper arch in extraction cases
nonextraction. Contact points were modified into contact significantly negatively correlated with Little’s irregular-
surfaces, which were used as a stabilizing procedure. ity index in the upper arch in the postretention period.
The amount of IPR was not indicated. However, other Thus, greater change in intermolar width in extraction
authors have observed and promoted this method.3, 23–26 cases in the upper arch influenced stability in the
Intercanine width changed as expected and as has postretention period. It may be concluded that, in these
been reported in previous research.7,18 In nonextraction cases, extraction was a good decision, since an
cases, changes between each timepoint were minimal: extraction created a narrower arch that contributed to
less than 0.5 mm in both arches. In extraction cases, better stability. In contrast, if patients were treated with
changes were greater but still less than 1 mm with nonextraction, overexpansion would be performed and
slightly larger change in long-term postretention in the stability may have been worse. Also, male patients
lower arch. Greater changes are attributed to the presented with greater intermolar width at all timepoints
movements of canines into extraction spaces. It was in extraction and nonextraction cases.
not the study’s aim to compare changes between Since good stability of the dental arches was
males and females, but there was a notable difference reported 17 years out of retention, the findings did
in intercanine width between genders. Males showed not support research suggesting long-term use of fixed
wider arches than females at all timepoints. In or removable retainers to maintain satisfactory align-
extraction cases, changes of intercanine width were ment. In this study, the active retention protocol lasted
similar in both arches between females and males: it for 3 years. This was considered important since
reduced from end of treatment to the postretention patients were treated and retained throughout the
period. Interestingly, in nonextraction female cases, critical growth ages when greatest irregularity changes

Angle Orthodontist, Vol 93, No 3, 2023

LONG-TERM STABILITY AFTER ORTHODONTIC TREATMENT 267

are expected to occur.2 One recent study investigated  Long-term stability in extraction cases and nonex-
relapse with removable retainers and the associations traction cases is achievable.
of short- and long-term wear with stability.28 Mandibular  Upper intermolar width and its change during
irregularity was significantly greater with a shorter wear orthodontic treatment may be an influential factor
time than with a longer wear time at the end of the 12- on long-term stability in extraction cases while, in the
month follow-up period. The amount of mandibular LII lower arch of extraction and nonextraction cases,
after a 1-year retention period was almost the same as factors associated with stability are yet to be
LII at 17 years out of retention reported in this study. established.
When discussing long-term alignment, physiological
changes should also be considered. There is a trend
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