Escolar Documentos
Profissional Documentos
Cultura Documentos
INTRODUCTION
727
728
genioplasty) are necessary and will improve the
monitoring of treatment progress and communication between the orthodontist and the maxillofacial
surgeon.9,10
The position of the mandibular incisors in relation
to the jaw bone is determined using cephalometric analysis. The incisor-mandibular plane angle
has been used as a diagnostic measurement and
a treatment goal for many decades.1113 A marked
change in incisor angulation is clinically significant, as
it influences the health of the supporting soft tissues,
esthetic profile of the patient, and long-term treatment
stability.1115
The aim of this study was to examine the relationship between the degree of change in mandibular
incisor proclination and protrusion as a result of
crowding alleviation during orthodontic treatment and
to examine other variables that might influence the
resultant change.
MATERIALS AND METHODS
The Institutional Review Board of the Hadassah
University Medical Centre approved the study protocol.
A total of 111 patient clinical records were randomly
selected from the private practice of one of the authors.
Inclusion criteria: (1) nonextraction orthodontic treatment and no interproximal reduction of the mandibular
dental arch, (2) fully erupted permanent mandibular
dentition (not including second and third molars) before
treatment, (3) good-quality lateral cephalograms and
plaster models before and after treatment and (4) no
missing or morphologically aberrant mandibular teeth.
Treatment protocol included full orthodontic fixed
appliances (Roth prescription, 0.022-inch slot, rectangular arch form wires). Both self-ligating brackets
(InOvation R or InOvation C, GAC, Islandia, NY) and
conventional brackets (Ovation, GAC) were used. Age,
gender, type of appliance, and use of Class II elastics
were recorded for all patients.
Lateral cephalograms were hand traced on tracing
paper (3M Unitek, Monrovia, Calif) in a darkened
room on a view box. The following cephalometric
landmarks were marked with a fine pencil dot:
(1) A-point, subspinale; (2) B-point, supramentale;
(3) menton, the lowest point on the symphyseal shadow
of the mandible; (4) Li, mandibular incisor tip; (5) La,
mandibular incisor root apex; (6) L1, the most anteriorly
placed point of the mandibular incisor crown; and
(7) pogonion, the most anterior point of the chin. The
following cephalometric measurements were made
with a protractor (Ormco, Orange, Calif): (1) incisormandibular plane angle (IMPA), which is the angle
between a plane tangent to the mandibular border of
Angle Orthodontist, Vol 86, No 5, 2016
Figure 1. Arch depth from molars (depth 6-6) was measured as the
distance A-C. Arch depth from canines (depth 3-3) was measured as
the distance B-C.
729
L1 to A-Pog
(mm)
TSALD (mm)
Curve of Spee
(mm)
Width Canine
(mm)
Width Premolar
(mm)
Width Molar
(mm)
Depth 6-6
(mm)
Depth 3-3
(mm)
a
Before
After
DIMPAa
Before
After
DL1 to A-Pogb
Before
After
DTSALDc
Before
After
DCOS
Before
After
Before
After
DWidth canine
0.3
DWidth premolar
DWidth molar
Before
After
Before
After
DDepth 6-6
Before
After
DDepth 3-3
93.9
96.7
2.7
2.9
4.2
1.3
1.2
0.2
21.0
2.2
0.3
21.9
26.3
26.6
6.6
6.1
4.5
1.6
1.6
1.2
3.2
0.9
3.1
1.1
0.5
1.1
1.8
1.4
1.6
33.6 2.3
36.0 1.8
2.4 2.4
43.3
44.7
1.4
23.4
23.7
0.3
9.5
9.8
0.3
2.5
1.6
2.0
2.3
1.6
2.2
1.4
1.8
2.1
74.0
73.0
28.0
21.0
1.0
21.5
210.9
21.6
28.1
0.0
0.0
25.5
21.4
22.4
24.1
28.7
26.4
26.5
110.0
112.0
13.0
7.5
8.0
3.5
9.1
1.8
12.7
5.5
2.0
0.0
30.0
30.1
3.9
39.2
39.3
8.1
37.6
41.8
25.9
9.2
19.9
26.6
6.0
7.6
23.1
50.2
49.1
5.3
27.1
27.1
13.4
12.4
24.3
14.5
730
Table 2. Results of First and Last Steps of Stepwise Process for DL1 to A-Pog Multilinear Regression
Unstandardized Coefficients
Model DL1APOG
1*
4**
(Constant)
DCrowding
DWidth premolar
DWidth molar
DDepth 3-3
DDepth 6-6
(Constant)
DCrowding
DDepth 6-6
Beta
Std Error
0.987
20.117
0.057
0.005
20.098
0.217
1.083
20.155
0.126
0.161
0.051
0.063
0.069
0.118
0.122
0.117
0.040
0.057
Standardized
Coefficients
Beta
20.0297
0.110
0.008
20.163
0.0384
20.0393
0.223
t-test
Level of
Significance
Mandibular Bound
Maxillary Bound
6.143
22.307
0.906
0.067
20.832
1.782
9.283
23.901
2.207
,.001
.023
.367
.946
.408
.078
,.001
,.001
.030
0.668
20.218
20.068
20.132
20.332
20.025
0.851
20.234
0.013
1.307
20.016
0.183
0.142
0.136
0.460
1.315
20.076
0.239
* Adjusted R2 5 0.259.
** Adjusted R2 5 0.271.
Table 3. Results of First and Last Steps of Stepwise Process for DIMPA Multilinear Regression
Unstandardized Coefficients
Model DIMPA
*
5**
(Constant)
DCrowding
DWidth premolar
DWidth molar
DDepth 3-3
DDepth 6-6
DWidth canine
(Constant)
DCrowding
DDepth 6-6
Beta
Std Error
1.459
20.274
0.374
20.053
20.092
0.504
20.033
2.136
20.407
0.413
0.631
0.197
0.255
0.267
0.489
0.494
0.356
0.449
0.153
0.220
* Adjusted R2 5 0.149.
** Adjusted R2 5 0.161.
Angle Orthodontist, Vol 86, No 5, 2016
Standardized
Coefficients
Beta
20.194
0.199
20.024
20.043
0.248
20.012
20.288
0.203
t-test
Level of
Significance
Mandibular Bound
Maxillary Bound
2.311
21.388
1.469
20.200
20.189
1.022
20.094
4.756
22.667
1.880
.023
.169
.145
.842
.851
.310
.926
,.001
.009
.063
0.204
20.667
20.132
20.583
21.065
20.477
20.742
1.244
20.711
20.023
2.713
0.118
0.880
0.477
0.880
1.486
0.675
3.028
20.104
0.849
731
Figure 2. Scatter plot of the change in incisor protrusion (y-axisDL1 to A-Pog) as a result of crowding alleviation (x-axisDTSALD). For every
millimeter of DTSALD, DL1 to A-Pog will increase by 0.19 mm.
Figure 3. Scatter plot of the change in incisor angulation (y-axisDIMPA) as a result of x-axisDTSALD. For every millimeter of DTSALD, DIMPA
will increase by 0.52u.
Angle Orthodontist, Vol 86, No 5, 2016
732
upgrading adjusted R2 to 0.16 and 0.27, respectively.
This result is logical, since the change in proclination and
protrusion is equivalent to a forward movement of the
mandibular incisors, which increases mandibular arch
depth. Class II elastics were also found to be significant
in the protrusion relationship (with a moderate contribution to the adjusted R2).
The results are based on the main effects identified
during stepwise analysis. When the possible interactions between independent variables are considered,
we improve adjusted R2 to 0.31 and 0.47, respectively.
Some of these interactions are interesting, for example, that between arch depth and intercanine width and
between intercanine width and Class II elastics should
be investigated further.
Abdulaziz et al. examined the change of mandibular
incisor proclination as a result of different types of
mechanics. The research included 28 patients, divided
into two groups by the mechanics used for COS leveling
(rectangular vs round archwires).19 They concluded that
a comparable amount of proclination is expected using
both types of mechanics for leveling the COS. They
also examined the influence of different variables (arch
depth, intercanine width, etc) on the amount of incisor
proclination (by using a multiple regression analysis)
and came to a conclusion very similar to ours, that only
about a third of the variance in incisor proclination can be
explained by changes in width and crowding. Compared
with the present study, their sample was smaller and
included only patients with mild or no crowding,19 yet
we wrongly expected to find a stronger correlation in our
research. Pandis et al. studied the relationship between
several arch variables and the change in COS and
concluded that for every 1 mm of COS leveling, a 4u
incisal proclination is expected in the mandibular arch.20
The regression equation and the amount of variability
were not presented, but the backward regression analysis
also highlighted the problems of predicting changes in
the COS from other arch dimensions. We can therefore
conclude that attempting to associate any two parameters
of arch dimension is simplistic and must be treated
suspiciously, having only limited clinical application.
The phenomena of incisor angulation change and
arch leveling are complicated, so all arch dimensions,
growth changes, soft tissue influences, and treatment
mechanics must be considered. More research is
needed to offer an applicable and practical formula
to clinicians with a fair R2, both for protrusion and
proclination based on a multidimensional model.
Mathematical models might help explain some of
clinical observations.2123 For example, Germane et al.
found that incisor expansion (which may represent
incisor protrusion) contributes more to arch perimeter
than intermolar or intercanine width change.21 We found
that incisor protrusion is better predicted by crowding
Angle Orthodontist, Vol 86, No 5, 2016
733