ORIGINAL ARTICLE

Effectiveness and duration of orthodontic treatment in adults

and adolescents

Stuart I. Robb, DDS, MS,a Cyril Sadowsky, BDS, MS,b Bernard J. Schneider, DDS, MS,b and Ellen A.
BeGole, PhDc
Chicago, Ill

The purpose of this investigation was to compare the effectiveness and duration of orthodontic treatment in
adults and adolescents with a valid and reliable occlusal index. Another aim was to evaluate variables that
may influence the effectiveness and duration of orthodontic treatment in general. Pretreatment and
posttreatment study models were scored using the Peer Assessment Rating Index. The difference in scores
between pretreatment and posttreatment stages reflects the degree of improvement and therefore the
effectiveness of treatment. Variables that reflect patient compliance were recorded from written treatment
records from three private orthodontic practices. The sample consisted of 32 adults (mean age, 31.3 years)
and 40 adolescents (mean age, 12.9 years), all of whom had four premolars extracted as part of the
treatment strategy. The results indicated that there were no statistically significant differences (P > .05)
between adults and adolescents regarding treatment effectiveness (occlusal improvement) and treatment
duration. Multiple regression techniques revealed that the number of broken appointments and appliance
repairs explained 46% of the variability in orthodontic treatment duration and 24% of the variability in
treatment effectiveness. Furthermore, orthodontic treatment of the buccal occlusion and overjet explained
46% of the variability in treatment duration. (Am J Orthod Dentofacial Orthop 1998;113:383-6)

Adults make up approximately 20% of the
average orthodontists patient load.1 Conventional wis-
dom maintains that adult treatment when compared
with traditional adolescent treatment is more difficult
and takes longer to complete. The literature perpetuat-
ing this myth is usually based on the clinical impres-
sions of practitioners without objective data.2-5 Further-
more, traditional thinking purports that compromised
results may be necessary leading to less ideal treatment
in adults than in their adolescent counterparts.5
Recently, the Peer Assessment Rating (PAR) Index
was developed to provide a numeric summary for the
occlusal relationships found in a dentition.6 The score
provides an estimate for the severity and treatment dif-
ficulty of a particular malocclusion.7 The difference in
scores between pretreatment and posttreatment stages
reflects the degree of improvement and therefore the
effectiveness of treatment.
From the Department of Orthodontics, University of Illinois at Chicago, College
of Dentistry.
aThis article is based on research submitted by Dr Robb as partial fulfillment of
the requirements for the Degree of Master of Science in Oral Sciences in the
Graduate College of the University of Illinois at Chicago, 1996.
bProfessor, Department of Orthodontics, University of Illinois at Chicago.
cAssociate Professor of Biostatistics, University of Illinois at Chicago.
Reprint requests to: Cyril Sadowsky, BDS, MS, University of Illinois at Chica-
go, 801 S Paulina, Chicago, IL 60612
Copyright 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 + 0 8/1/87105
The purpose of this study was to compare ortho-
dontic treatment effectiveness and duration between
adults and adolescents. Another aim was to assess vari-
ables that may influence the effectiveness and duration
of treatment.
REVIEW OF THE LITERATURE
The PAR index is an occlusal index that has been
shown to be valid and reliable.6,7 The index scores the
maxillary anterior alignment, buccal occlusion, overjet,
overbite, and midline discrepancies. Each of these indi-
vidual components are then weighted and summed; the
total score reflects the severity and treatment difficulty
for the particular malocclusion. This index can be used
as an outcome measure for the degree of improvement
by assessing the difference in scores between pretreat-
ment and posttreatment study models.6,7
The histologic differences in the periodontal struc-
tures of adults and adolescents have been compared
both before and after tooth movement.8 In the adoles-
cent, the supporting tissues of the teeth appear to be in
a state of proliferation; there are large numbers of
connective tissue cells and an extensive blood supply
even before orthodontic tooth movement. Adults, on
the other hand, appear to be in a state of rest, the
alveolar bone is more dense, cell populations are
reduced, and there is less vascularity. After the initia-
tion of tooth movement, it takes about 2 weeks for
383
384 Robb et al American Journal of Orthodontics and Dentofacial Orthopedics
October 1998

Table I. Sample description The effectiveness and duration of orthodontic

Table II.
Variable Adults Adolescents
treatment in adults and adolescents
Adults Adolescents
Sample size 32 40
Age at start (years) 31.3 (SD = 7.7) 12.9 (SD = 1.3) Variables Mean SD Mean SD p
Gender 12 M 15 M
20 F 25 F PAR score
Malocclusion Class I = 30 Class I = 38 Pretreatment 25.4 11.2 25.5 8.8 0.95
Class II = 2 Class II = 2 Posttreatment 3.7 3.3 3.1 4.3 0.57
Sample size from Treatment duration 30.6 8.0 29.4 8.8 0.56
Practice I 10 10 (months)
Practice II 12 15 PAR reduction 21.7 10.3 22.9 9.2 0.62
Practice III 10 15 % PAR reduction 84.5 16.5 88.1 18.7 0.38
% PAR reduction rate 3.0 1.1 3.2 1.1 0.35
SD, Standard deviation.
SD, Standard deviation.

adults to reach the same state of proliferation as the

adolescent and furthermore it takes about 4 days longer
to see evidence of bone apposition in the adult as com-
pared with the adolescent.8 In comparing the effective-
ness and duration of tooth movement between these
two groups, this short delay may not be of clinical sig-
nificance over the duration of treatment.
The dentoskeletal changes have been used to com-
pare and contrast adults and adolescents with Class II
Division 1 malocclusions.9,10 The findings revealed
that differential mandibular growth in the adolescents
contributed to 70% of the total molar correction; ortho-
dontic tooth movement accounted for the remaining
30%. In adults, however, tooth movement alone
accounted for the total molar correction. It was also
noted that adult treatment does not necessarily take
longer, the average treatment times in both groups were
comparable at 2.5 years. A shortcoming of these stud-
ies was that neither the severity of the initial malocclu-
sion nor the final treatment result were assessed.
Successful orthodontic treatment depends on a vari-
ety of factors. Although the knowledge and skills of the
clinician remain significant, the cooperation of the
patient plays a major role in achieving the desired
results.11,12 The effectiveness and duration of ortho-
dontic treatment is considered to depend largely on
patient cooperation.13-15
METHODS
A determination of the appropriate sample size was
made for this investigation with data from previous
studies.16-18 To achieve a power of 0.80 at an alpha
level of 0.05, the required sample size was calculated to
be 21 patients in each group.
Data were obtained from a sample collected from
three experienced practitioners in private practice.
Consecutively completed cases within the previous 5
years that fulfilled the criteria were used. The eligibili-
ty criteria included patients that completed comprehen-
sive orthodontic treatment involving the extraction of
four premolars. The age at the start of treatment for
adolescents to be included was 11 to 14 years and for
adults was 21 years and older. These criteria were used
to establish two discrete groups and to compare with
ages from other studies.9,10 Only those cases with pre-
treatment and posttreatment records comprising study
models and complete written treatment records were
included. Table I summarizes the sample based on size,
age, gender, malocclusion, and sample size from each
practice.
The following information was recorded from the
patients written treatment records: age at start; gender;
duration of treatment; number of broken appointments;
number of appliance repairs; number of written refer-
ences of poor oral hygiene and poor elastic wear. The
patients pretreatment and posttreatment study models
were scored with the American weighted PAR index.7
The degree of improvement as a result of orthodontic
treatment was assessed in three ways. The first method
utilized the PAR change which is the difference
between the pretreatment and posttreatment scores. The
second was the percent PAR reduction, which reflects
the PAR change relative to the pretreatment score. The
last method involved the percent PAR reduction rate.
Recently it has been stated that when assessing the out-
come of orthodontic treatment, two factors are of para-
mount importance, namely, the effectiveness and dura-
tion of treatment.19 This study is unique in that it com-
bines these two factors into one variable, the % PAR
reduction rate, which is essentially the % PAR reduc-
tion per month.
Data for two independent groups were analyzed
with two-sample t tests with an alpha level of 0.05.
Multiple stepwise regressions were used to evaluate
which variables influence treatment effectiveness and
duration.
All PAR index scoring was done by the same exam-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 114, Number 4
Fig 1. Bar chart summarizes mean pretreatment PAR
score, posttreatment PAR score, and treatment duration
(months) for adults and adolescents.
Fig 2. Bar chart summarizes mean values as they reflect
treatment effectiveness for adults and adolescents.
iner who had been calibrated to use this index. Intrarater
reliability was evaluated with Pearsons correlation coef-
ficients using a subsample of study models that was ran-
domly selected and scored four weeks later. The calcula-
tions revealed excellent intrarater reliability (r = 0.96).
RESULTS
The Effectiveness and Duration of Treatment
No statistically significant difference (P > .05) was
found between adults and adolescents regarding the
pretreatment or posttreatment PAR scores. No differ-
ences were found regarding the duration of treatment
or any of the methods used to assess treatment effec-
tiveness (Table II, Figs 1 and 2).
Variables That Influence Orthodontic Treatment
Effectiveness and Duration
Multiple stepwise regression procedures were used
to evaluate whether any of the variables that reflect
patient compliance influence the effectiveness or dura-
tion of treatment. The results indicate that the number
of broken appointments and appliance repairs explain
24% of the variability in treatment effectiveness as
measured by the % PAR reduction rate (Fig 3). The
Robb et al 385
Fig 3. Variables reflect patient compliance as it influ-
ences % PAR reduction rate based on stepwise regres-
sion analysis.
Fig 4. Variables reflect patient compliance as it influ-
ences orthodontic treatment duration based on stepwise
regression analysis.
Fig 5. Variables reflect orthodontic treatment (% PAR
reduction) as it influences treatment duration based on
stepwise regression analysis.
same two variables also explained 46% of the variabil-
ity in treatment duration (Fig 4). The number of refer-
ences to poor oral hygiene and poor elastic wear did
not influence either model.
A multiple stepwise regression procedure was used
to identify how the treatment of individual PAR com-
ponents influences the duration of treatment. The
results reveal that treatment of the buccal occlusion and
the overjet explain 46% of the variability in duration
(Fig 5). Alignment of the maxillary anterior teeth and
midline discrepancy did not affect the model.
Analysis of variance was used to determine if there
were any differences between the adult and adolescent
groups within the individual practices regarding treat-
ment effectiveness and duration. No statistically signif-
icant differences were found for treatment effective-
ness or for treatment duration between the groups.
DISCUSSION
Clinical myth maintains that adult treatment is
more difficult, less effective, and takes longer than tra-
ditional adolescent treatment.2-5 The present study is
unique in its quantification of treatment outcomes
between adults and adolescents with predominantly
Class I malocclusions and treated with the extraction of
four premolars.
386 Robb et al
Adults and adolescents in this sample had similar
malocclusions with respect to severity and treatment
difficulty at the start of treatment and at the end of
treatment. There were no differences between the
groups with respect to the effectiveness or duration of
treatment.
The histologic differences during orthodontic tooth
movement have revealed a 2-week delay in adults to
reach a state of cellular proliferation.8 This delay has
been used by many authors to explain why, in their
opinion, adult treatment is less effective and takes
longer.2-5 It is important to note that this delay is prob-
ably of no clinical importance over a 30-month period.
Studies contrasting the dentoskeletal changes in
adults and adolescents with Class II Division 1 maloc-
clusions have revealed that adult treatment does not
necessarily take longer, the average treatment times in
both groups being comparable at 2.5 years.9,10
Variables that reflect patient compliance, the num-
ber of broken appointments, and appliance repairs play
an important role in treatment effectiveness (24% of
the variability) and the duration of treatment (46% of
the variability). The majority of the variability still
remains unexplained, however, the important contribu-
tion of patient cooperation supports previous stud-
ies.13-15 Treatment of the buccal occlusion and overjet
also play an important role in the duration of treatment
(46% of the variability). The treatment of maxillary
anterior alignment, overbite, and midline discrepancies
were not able to explain more of the variability in the
duration of treatment.
An attempt was made to predict treatment duration
with the use of the pretreatment PAR score, which
was the only variable known before treatment. The
results indicate that this explains 14% of the variabil-
ity in treatment duration. This positive association but
lack of predictive value supports the findings of other
investigators.18,19
This investigation has limitations due to the retro-
spective design and the measure of treatment effective-
ness. The limitations of a retrospective study are primar-
ily due to bias that may have arisen from factors that
determined the inclusion of subjects. Since pretreatment
and posttreatment study models were required, records
may only have been obtained for patients whose treat-
ment had progressed well, and therefore a bias toward
well treated cases may have been introduced. However,
this would probably apply to both groups that were
assessed.
The measure of effectiveness in this study involved
a valid and reliable occlusal index. It could be argued
that a thorough evaluation of the effectiveness of ortho-
dontic treatment should also involve improvement in
American Journal of Orthodontics and Dentofacial Orthopedics
October 1998
skeletal relationships, facial profile, self-perception,
and the lack of iatrogenic complications. Unfortunate-
ly, measures of this type that are accurate, valid, and
reliable have not yet been developed for assessing such
variables.7 Furthermore, the PAR index may be limited
in its ability to distinguish fine details in dental rela-
tionships with reference to an idealized outcome.20
CONCLUSION
On the basis of the results of this study of adult and
adolescent patients with predominantly Class I maloc-
clusions and treated with the extraction of four premo-
lars, the following conclusions may be drawn:
1. There were no statistically significant differences (P >
.05) between adults and adolescents with respect to
treatment effectiveness or treatment duration.
2. The number of broken appointments and appliance
repairs explained 46% of the variability in orthodontic
treatment duration and 24% of the variability in treat-
ment effectiveness.
3. Furthermore, orthodontic treatment of the buccal
occlusion and overjet explained 46% of the variability
in treatment duration.
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