EARLY TREATMENT SYMPOSIUM

Stability and relapse: Early

treatment of arch length
deficiency
Robert M. Little, DDS, MSD, PhD
Seattle, Wash

N
early 5 decades dentition to accommodate the future permanent succes-
ago, the faculty sors?
of the Depart-
ment of Orthodontics at WHAT IF NOTHING IS DONE?
the University of Wash- Coenraad Moorrees,2 in his classic 1959 textbook,
ington began collecting reported serial changes in dental arch dimensions of
postretention records for untreated subjects with malocclusion. He showed that
patients treated in their arch length typically decreases with time from the
private practices and at mixed dentition through the transitional dentition and
theUniversity’sorthodon- into early adulthood. He shocked readers by demon-
tic clinic. This collection strating that arch length at age 5 is greater than at age
has grown to over 850 18! With canine eruption, arch width typically reaches
sets of records, the study a maximum in the preteen years, followed by a slow,
of which has molded our diagnostic, treatment-plan- persistent reduction over at least the next decade.
ning, and retention strategies. Others have done parallel Parents (and often dental practitioners) might have a
research, efforts we applaud, and from which we problem with these concepts because the child obvi-
continue to learn. Our clinically based hypotheses have ously grows throughout these years, and one would
been tested, sometimes altered or even abandoned logically assume that the arch would enlarge as well.
because of these data. Unfortunately, the arches tend to constrict in antero-
We have been encouraged and sometimes discour- posterior and transverse dimensions, leading to further
aged by our own findings for cases treated in the full crowding of an already inadequate dental arch. In our
permanent dentition.1 Advocates of earlier intervention studies, we found that this same trend is evident in
have been as enthusiastic as its opponents. However, it untreated normal subjects as well as those with spacing
is incumbent on all to test their opinions with data— pretreatment.3,4
long-term postretention data. Conclusion: Without treatment, a short arch length
will only get worse.
THE PROBLEM
WHAT IF THE DENTAL ARCHES ARE ENLARGED?
What is the treatment of choice for a preadolescent
The father of dental arch enlargement had to be
patient with arch length deficiency? What if nothing is
Edward Angle. His adage that only a complete dental
done? What if the arches are enlarged to accommodate
arch can yield an acceptable occlusion influenced many
the permanent teeth? What if premolars are extracted
orthodontists of that day and later. But some were
early (serial extraction) followed by full treatment plus
skeptical then (Case and others) and later (Tweed and
retention? What if arch length is preserved in the mixed
others). Tweed grew up professionally under the Angle
cloak. Noting significant relapse after his own nonex-
From the Department of Orthodontics, School of Dentistry, University of traction enlargement therapy, he went so far as to
Washington, Seattle.
Presented at the International Symposium on Early Orthodontic Treatment, retreat his patients with premolar extraction after the
February 8-10, 2002; Phoenix, Ariz. significant relapse of his Angle-style nonextraction
Am J Orthod Dentofacial Orthop 2002;121:578-81 treatment. But what if the arches are enlarged earlier?
Copyright © 2002 by the American Association of Orthodontists.
0889-5406/2002/$35.00 ⫹ 0 8/1/124683 To test the value and the efficacy of mixed dentition
doi:10.1067/mod.2002.124683 arch enlargement (arch development), we gathered a
578
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 121, Number 6
sample of long-term postretention records at the Uni-
versity of Washington.5 As noted in the preface of that
article, advocates of enlargement suggest various strat-
egies:
1. Actively move anterior teeth labially with fixed or
removable appliances.
2. Passively move anterior teeth labially by removal of
lip forces.
3. Actively push molars distally by extraoral or in-
traoral means.
4. Widen the arch with fixed or removable devices.
5. Widen the mandibular arch by reciprocal response
to maxillary arch enlargement.
6. Enlarge the dental arch with a combination of
devices and means.
Twenty-six cases with records at least 6 years
postretention (range, 6-23 years) were evaluated. The
degree of relapse was significant and alarming. Al-
though the cases looked clinically acceptable at the end
of active treatment, the degree and severity of relapse
after retention was much worse than with other strate-
gies. In fact, these cases showed the poorest long-term
results of any strategies that we have studied.
Can the arches be enlarged? Absolutely! The prac-
titioner may even look upon this treatment as “conser-
vative” (no permanent teeth removed). Is anterior
alignment stable after removing the retainers? Unfor-
tunately, no.
Conclusion: Without lifetime retention, the strategy
of arch development will yield unacceptable results.
WHAT IF PREMOLARS ARE EXTRACTED EARLY
(SERIAL EXTRACTION) FOLLOWED BY FULL
TREATMENT PLUS RETENTION?
Our studies have shown that premolar extraction in
the full permanent dentition yields variable degrees of
quality, with only about 1 in 3 considered a success at
10 years postretention and even fewer at 20 years.6,7 No
pretreatment variable, such as initial crowding, gave
clues as to what to expect postretention.
Serial extraction, the sequential removal of certain
deciduous teeth followed by premolar extraction, logi-
cally should yield improved results. After all, the
commonly noted self-improvement of anterior crowd-
ing through physiologic drift should set the stage for
improved long-term stability.
A study of 30 first premolar serial extraction cases
that had subsequent orthodontic treatment and retention
showed results nearly identical to those treated with
first premolar extraction in the full permanent denti-
tion.8,9 The early extraction cases became simpler
during the observation stage before active treatment,
Little 579
but to no avail. The same ratio of one-third acceptable
versus two-thirds unacceptable seemed to prevail. Sec-
ond premolar serial extraction fared no better.10
We cannot predict which premolar extraction cases
will succeed and which will fail. Whether extracted
early or late, the net result is the same.
Conclusion: Serial extraction of deciduous teeth to
temper a developing arch length problem followed by
premolar extraction and routine treatment yields no
long-term improvement over premolar extraction in the
full dentition and routine treatment. Long-term reten-
tion must be part of a premolar extraction strategy
whether the teeth are extracted in the mixed dentition or
in the full permanent dentition.
WHAT IF ARCH LENGTH IS PRESERVED IN THE
MIXED DENTITION TO ACCOMMODATE THE
FUTURE PERMANENT SUCCESSORS?
In 1947, Hays Nance11 taught us that there is a
difference between the space occupied by the decidu-
ous canines and molars in both arches and that needed
by the succedaneous permanent canines and premolars.
From G. V. Black’s material from 1902, Nance learned
that the mandibular arch average excess amount was
3.4 mm. He labeled this beneficial size differential
“leeway space.” The maximum leeway space that he
measured from cases in his practice was 8 mm and the
least was 0 mm. Enlarging the arch beyond this leeway
he considered futile.12 The issue is whether we can use
leeway space to offset crowded anterior teeth. Misin-
terpreting Nance, many thought that 3.4 mm of “leeway
space” had to be lost, but that was not what Nance was
recommending. He encouraged exact measuring of the
available and required arch lengths to determine the
leeway for each patient. He recommended a passive
lingual arch when the leeway space was equal to or
greater than the degree of anterior crowding. Review of
his own postretention records was promising with this
strategy, but are cases treated in this way stable in the
long term?
We had to wait 48 more years to learn the answer.
Thanks to Steve Dugoni et al,13 looking at Art Dugoni’s
records, we learned that leeway space could be success-
fully held to offset anterior crowding with excellent
long-term results. They reviewed the records of 25
patients treated with a mandibular lingual arch designed
to maintain but not advance all 4 mandibular incisors a
minimum of 5 years postretention. All had maxillary
arch 2 ⫻ 4 appliances, some combined with headgear,
as needed. The mandibular deciduous molars were
extracted, as needed, to facilitate eruption of the pre-
molars. About half had circumferential supracrestal
580 Little
Fig. Nonextraction treatment without arch development. A, Pretreatment (age 8 years 2 months); B,
end of phase 1 nonextraction treatment (age 12 years 0 months); C, end of phase 2 comprehensive
treatment (age 13 years 6 months); D, 16 years postretention (age 33 years 8 months).
fibrotomies, and a similar number had interproximal
enamel reduction.
These cases fared much better in the long term than
did our premolar extraction and arch development
cases. Steve Dugoni prodded us to search for records
from our collection, and we found a few, all with
equally great results (Fig). Apparently, Nance had been
correct; we can use the full leeway space to our
advantage.
Conclusion: For mixed dentition cases in which
leeway space is favorable compared with anterior
crowding, use a passive lingual arch. The results appear
to be quite stable.
AFTERTHOUGHT
Dick Riedel, former orthodontic chairman at the
University of Washington, enjoyed describing a chance
meeting at an orthodontic conference many years ago.
An elderly gentleman leaned over and whispered a
question to Riedel as the speaker was going on and on
about Nance and his many insights. “What do you think
of this Nance material?” Riedel leaned over and re-
plied, “Nance is my hero. He had it dead right!” The old
American Journal of Orthodontics and Dentofacial Orthopedics
June 2002
gentleman quietly said, “That’s a relief. Let me intro-
duce myself. I’m Hays Nance.”
I think I’ll go back and read Hays Nance once more.
REFERENCES
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University of Washington studies. Sem Orthod 1999;5:191-204.
2. Moorrees C. The dentition of the growing child. A longitudinal
study of dental development between 3 and 18 years of age.
Cambridge: Harvard University Press; 1959.
3. Sinclair P, Little R. Maturation of untreated normal occlusions.
Am J Orthod 1983;83:114-23.
4. Little R, Riedel R. Postretention evaluation of stability and
relapse: mandibular arches with generalized spacing. Am J
Orthod Dentofacial Orthop 1989;95:37-41.
5. Little R, Riedel R, Stein A. Mandibular arch length increase
during the mixed dentition: postretention evaluation of stabil-
ity and relapse. Am J Orthod Dentofacial Orthop 1990;97:
393-404.
6. Little R, Wallen T, Riedel R. Stability and relapse of mandibular
anterior alignment: first premolar extraction cases treated by
traditional edgewise orthodontics. Am J Orthod 1981;80:349-65.
7. Little R, Riedel R, Artun J. An evaluation of changes in
mandibular anterior alignment from 10 to 20 years postretention.
Am J Orthod Dentofacial Orthop 1988;93:423-8.
8. Little R, Riedel R, Engst E. Serial extraction of first premolars—
American Journal of Orthodontics and Dentofacial Orthopedics
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postretention evaluation of stability and relapse. Angle Orthod
1990;60:255-62.
9. Little R. The effects of eruption guidance and serial extraction on
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10. McReynolds D, Little R. Mandibular second premolar extrac-
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Orthod 1991;61:133-44.
11. Nance H. The limitations of orthodontic treatment. I. Mixed
Little 581
dentition diagnosis and treatment. Am J Orthod Oral Surg
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12. Nance H. The limitations of orthodontic treatment. II. Diagnosis
and treatment in the permanent dentition. Am J Orthod Oral Surg
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13. Dugoni S, Lee J, Varela J, Dugoni A. Early mixed dentition
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