ORIGINAL ARTICLE

Relapse of anterior crowding 3 and

33 years postretention
Karina Maria Salvatore Freitas,a Willian Juarez Granucci Guirro,b Daniel Salvatore de Freitas,b Marcos Roberto de
Freitas,b and Guilherme Jansonb
Maring
a, Paran
a, and Bauru, S~ao Paulo, Brazil

Introduction: The aim of this study was to evaluate the relapse of occlusal characteristics and maxillary and
mandibular anterior crowding 3 and 33 years postretention. Methods: The sample comprised 28 patients, 15
Class I and 13 Class II, treated with 4 premolar extractions, with a mean initial age of 12.72 years (SD, 0.99), a
mean final age of 14.74 years (SD, 1.26), and a mean treatment time of 2.02 years (SD, 0.66). The mean short-
term postretention age was 20.15 years (SD, 1.34), and the mean long-term postretention age was 49.40 years
(SD, 4.54). The mean time of short-term postretention evaluation was 3.70 years (SD, 0.87) and the mean long-
term postretention evaluation was 32.95 years (SD, 4.31). The maxillary and mandibular irregularity indexes
were assessed on the initial, final, short-term, and long-term postretention stage dental casts. Peer Assessment
Rating and the Little indexes were compared among the 4 stages by repeated measures analysis of variance
and Tukey tests. Results: Peer Assessment Rating index and maxillary anterior crowding were significantly
improved with treatment, had significant relapses in the short term, and a slight and not statistically significant in-
crease from short-term to long-term postretention evaluation. The mandibular irregularity index significantly
decreased with treatment, and then significantly and progressively increased in the postretention stages.
Conclusions: The occlusal characteristics and maxillary anterior crowding had significant relapses in the short
term and remained stable from the short-term to the long-term postretention stages. Mandibular anterior
crowding significantly decreased with treatment, showed a significant relapse in the short term, and continued to
significantly increase in the long-term postretention stage. (Am J Orthod Dentofacial Orthop 2017;152:798-810)

O
rthodontic treatment has several objectives, and
stability of the corrections achieved is one of the
most important. There is consensus in the
orthodontic literature that some occlusal changes will
inevitably occur after treatment.1,2 It would be a great
benefit to orthodontists to have a detailed prediction of
these occlusal changes so that they can be prevented.
For this reason, the effects of various diagnostic and
treatment factors on occlusal stability in the short and
long terms have been extensively investigated.3-9
Only 3 studies have evaluated relapse of anterior
crowding in the long term. Little et al10 found that
crowding continues to increase from 10 to 20 years
a
Department of Orthodontics, Uninga University Center, Maring
a, Paran
a, Brazil.
b
Department of Orthodontics, Bauru Dental School, University of S~ao Paulo,
Bauru, S~ao Paulo, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Karina Maria Salvatore Freitas, Department of Or-
thodontics, Uninga University Center, Rod PR 317, 6117, Maringa, PR, 87035-
510, Brazil; e-mail, kmsf@uol.com.br.
Submitted, November 2016; revised and accepted, May 2017.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2017.05.022
798
postretention, and only 10% of the patients had a clin-
ically acceptable mandibular anterior alignment in the
last evaluation. Vaden et al4 assessed the changes in ir-
regularity of the maxillary and mandibular incisors and
dental arch dimensions 6 to 15 years after removal of
the retainers. Fifty-eight percent of the mandibular
incisor crowding correction was maintained; 15 years
after treatment, the mandibular incisor irregularity
index averaged 2.6 mm, within the range of “minimal
irregularity,” and there was a reduction of only
0.3 mm in the irregularity of the maxillary incisors, which
corresponded to 96% stability. Dyer et al7 conducted a
25-year, long-term study and found that irregularity
of the mandibular incisors was less than 3.5 mm in
77% of the patients. Correction of maxillary crowding
was relatively stable in the long term.
As mentioned above, long-term stability of ortho-
dontic corrections has been widely studied. However,
most studies evaluated stability only a few years after
treatment and mainly focused on mandibular anterior
crowding relapse. There is a lack of long-term studies,
comparing the long-term with the short-term postreten-
tion changes, regarding maxillary and mandibular
anterior crowding stability. Therefore, we aimed to
Freitas et al
evaluate the relapse of maxillary and mandibular
anterior crowding at 3 and 33 years postretention.
MATERIAL AND METHODS
This study was approved by the ethics committee in
human research of the Bauru Dental School, University
of Sao Paulo in Bauru, SP, Brazil.
The sample size calculation was based on an alpha
significance level of 5% and a beta of 20% to achieve
80% test power to detect a mean difference of
0.96 mm, with a standard deviation of 1.26 for the
mandibular irregularity index (Fig 1).7 Thus, the sample
size calculation showed the need for 28 subjects.
The sample comprised retrospective records of
subjects treated by graduate students at Bauru Dental
School, University of Sao Paulo, Bauru, SP, Brazil chosen
according to the following criteria: (1) Class I or Class II
malocclusion at the beginning of orthodontic treatment;
(2) treatment protocol with extraction of 4 first premolars;
(3) complete orthodontic treatment with full maxillary
and mandibular fixed edgewise appliances
(0.022 3 0.028-in slot); (4) all permanent teeth erupted
up to the first molars at pretreatment; (5) no tooth
agenesis or anomalies; (6) maxillary removable appliance
(Hawley plate) worn for 1 year, and mandibular fixed
canine-to-canine retainers worn for at least 1 year, and
a maximum of 3 years posttreatment, without retention
at the time of the follow-up records; (7) pretreatment
(T1), posttreatment (T2), and 3-year postretention (T3)
dental casts available for the study, and when the subjects
were called for a new follow-up that should be at least
20 years after the orthodontic treatment (T4).
The sample comprised 28 subjects of both sexes (9
male, 19 female), with a mean pretreatment age of
12.72 years (SD, 0.99; minimum, 10.58; maximum,
14.85). The mean final age was 14.74 years (SD, 1.26;
minimum, 12.58; maximum, 18.09), and the mean
treatment time was 2.02 years (SD, 0.66; minimum,
0.99; maximum, 3.33). The mean age at the short-term
evaluation was 20.15 years (SD, 1.34; minimum, 17.75;
maximum, 24.08), and the mean age at the long-term
evaluation was 49.40 years (SD, 4.54; minimum, 35.76;
maximum, 55.12). The mean time of short-term postre-
tention evaluation was 3.70 years (SD, 0.87; minimum,
3.02; maximum, 5.35), and the mean time of long-term
postretention follow-up was 32.95 years (SD, 4.31;
minimum, 21.10; maximum, 38.01).
As retention, at the end of active orthodontic treat-
ment, all patients used a removable Hawley plate in
the maxillary arch and a canine-to-canine fixed bonded
retainer in the mandibular arch. The mandibular canine-
to-canine retainer was used, on average, for 1.70 years
(SD, 0.60; minimum, 0.79; maximum, 3.33).
American Journal of Orthodontics and Dentofacial Orthopedics
799
Fig 1. Maxillary and mandibular Little irregularity
index 5 A 1 B 1 C 1 D 1 E.
Fifteen subjects had Class I and 13 had Class II mal-
occlusions (severity, 8 half-cusp Class II and 5 full-cusp
Class II11); all were treated with extraction of the 4 first
premolars. Because of this, the sample was divided into 2
groups to evaluate any difference in stability between
these types of malocclusion in a pilot study.
Group 1, with Class I malocclusion patients, consisted
of 15 subjects (5 male, 10 female) with a mean initial
age of 12.63 years (SD, 0.94), a final age of 14.41 years
(SD, 0.90), a short-term follow-up age of 19.91 years
(SD, 1.02), and a long-term postretention evaluation age
of 50.17 years (SD, 3.20). The mean treatment time was
1.78 years (SD, 0.42). The mean time of short-term evalu-
ation was 3.87 years (SD, 0.74), and the mean time of long-
term postretention was 34.12 years (SD, 3.20) (Table 1).
Group 2, with Class II malocclusion patients,
comprised 13 subjects (4 male, 9 female) with a mean
initial age of 12.82 years (SD, 1.09), a final age of
15.12 years (SD, 1.53), a short-term evaluation age of
20.41 years (SD, 1.64), and a long-term postretention
age of 48.51 years (SD, 5.74). The mean treatment
time was 2.29 years (SD, 0.79). The mean time of
short-term evaluation was 3.50 years (SD, 0.99), and
the mean time of long-term postretention follow-up
was 31.60 years (SD, 5.10) (Table 1).
Figures 2 to 5 show the models of the 4 stages (T1,
T2, T3, and T4) of the patient with the worst long-
term postretention relapse, and Figures 6 to 9 show
the models of the 4 stages (T1, T2, T3, and T4) of the
patient with the best long-term postretention outcome.
December 2017  Vol 152  Issue 6
800 Freitas et al

Table I. Descriptive statistics of the ages, times, and periods evaluated (n 5 28)
Variable (y) Mean SD Minimum Maximum
Initial age (T1) 12.72 0.99 10.58 14.85
Final age (T2) 14.74 1.26 12.58 18.09
Age at short-term postretention evaluation (T3) 20.15 1.34 17.75 24.08
Age at long-term postretention evaluation (T4) 49.40 4.54 35.76 55.12
Treatment time (T2-T1) 2.02 0.66 0.99 3.33
Retention time 1.70 0.60 0.79 3.33
Time of short-term postretention evaluation (T3-T2) 3.70 0.87 3.02 5.35
Time of long-term postretention evaluation (T4-T2) 32.95 4.31 21.10 38.01

Fig 2. Pretreatment (T1) models of the patient with the worst long-term postretention relapse.

Dental casts from T1, T2, T3, and T4 were used.
The Peer Assessment Rating (PAR) index, as described
by Richmond et al12 and scored with the American
weightings,13 was used.
The irregularity index of Little14 for the maxillary and
mandibular arches was measured on the dental casts, with
a 0.01-mm precision digital caliper (Mitutoyo America,
Aurora, Ill) by a calibrated examiner (K.M.S.F.) (Fig 1).6
The differences between the final and initial values of
the PAR and Little indexes (T2–T1) were calculated to
express the amount of correction with treatment. The
differences from the short-term and long-term postre-
tention stages with the final stage of the PAR and Little
indexes (T3–T2 and T4–T2) were calculated to express
the changes after retention in the 2 follow-up evalua-
tions. The differences between the long-term and
short-term postretention stages (T4–T3) were also
calculated.
For the error study, a month after the first measure-
ment, the dental casts of 10 subjects (40 pairs of dental
casts) were randomly selected and remeasured by the
same examiner. The random errors were calculated
according to Dahlberg's formula15 (Se2 5 Sd2/2n),
and the systematic errors were evaluated with dependent
t tests, at P \0.05.
STATISTICAL ANALYSIS
Descriptive statistics were performed (means, stan-
dard deviations, maximums, and minimums) for the
initial, final, short-term, and long-term postretention
stages; treatment times; retention times; and time of
short-term and long-term postretention evaluations;
and for the PAR and maxillary and mandibular Little
irregularity indexes at T1, T2, T3, and T4 and also in
the evaluated periods (T2-T1, T3-T2, T4-T3, T4-T2).

December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Freitas et al 801

Fig 3. Posttreatment (T2) models of the patient with the worst long-term postretention relapse.

Fig 4. Short-term postretention (T3) models of the patient with the worst long-term postretention
relapse.

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802 Freitas et al

Fig 5. Long-term postretention (T4) models of the patient with the worst long-term postretention
relapse.

Fig 6. Pretreatment (T1) models of the patient with the best long-term postretention outcome.

December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Freitas et al 803

Fig 7. Posttreatment (T2) models of the patient with the best long-term postretention outcome.

Fig 8. Short-term postretention (T3) models of the patient with the best long-term postretention
outcome.

American Journal of Orthodontics and Dentofacial Orthopedics December 2017  Vol 152  Issue 6
804
Fig 9. Long-term postretention (T4) models of the patient with the best long-term postretention
outcome.
The normal distribution of the data was checked and
confirmed using Kolmogorov-Smirnov tests for the
whole sample and for the groups.
To evaluate changes in the PAR and maxillary and
mandibular Little irregularity indexes among the 4
evaluated stages (T1, T2, T3, and T4), repeated measures
analysis of variance (ANOVA) and Tukey tests were used.
Intergroup comparability of sex distribution and ages
and times of evaluation was verified with chi-square and
t tests, respectively.
Intergroup comparisons of PAR and maxillary and
mandibular Little irregularity indexes in the stages and
periods evaluated were performed by t tests.
All tests were performed with software (Statistica for
Windows, version 7.0; StatSoft, Tulsa, Okla), at P \0.05.
RESULTS
There was no systematic error, and the random errors
varied from 0.12 mm for the final mandibular Little ir-
regularity index to 0.50 for the short-term PAR index.
Short-term relapses were 5.36 for the PAR index, and
2.18 and 1.58 mm for maxillary and mandibular anterior
crowding, respectively (Table II). Long-term relapses
were 7.89 for the PAR index, and 2.59 and 3.86 mm
for the maxillary and mandibular Little irregularity
indexes, respectively (Table II).
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Freitas et al
The PAR index was significantly reduced with treat-
ment, showed a significant relapse in the short term,
and remained stable in the long term (Table III). Maxil-
lary anterior crowding was significantly corrected with
treatment, had a significant relapse in the short term,
and remained stable from the short-term to the long-
term postretention evaluation (Table III). Mandibular
anterior crowding was significantly corrected with treat-
ment and then had significant and progressive relapses
in the short-term and long-term postretention evalua-
tions (Table III).
There was comparability of sex distribution, initial,
final, short-term, and long-term evaluation ages,
retention time, and times of short-term and long-term
postretention evaluations (Tables IV and V). Treatment
time was significantly longer for the Class II than the
Class I malocclusion group (Table V). The groups were
also comparable regarding the initial PAR and Little
maxillary irregularity index (Table VI).
There was no statistically significant difference for
the PAR index and the Little maxillary irregularity index
in all times and periods evaluated between the Class I
and Class II malocclusion groups (Table VI). The Little
mandibular irregularity index was significantly greater
in the Class I group in all 4 evaluated stages (Table VI).
The Little mandibular irregularity index showed greater
correction with treatment in the Class I than in the Class
Freitas et al 805

Table II. Descriptive statistics of the PAR index, maxillary and mandibular Little irregularity index in the stages and
periods of evaluation (n 5 28)
Variable Mean SD Minimum Maximum
Initial PAR (T1) 25.14 6.84 9.00 38.00
Final PAR (T2) 2.71 2.27 0.00 8.00
Short-term postretention PAR (T3) 8.07 3.38 4.00 16.00
Long-term postretention PAR (T4) 10.60 6.01 4.00 26.00
PAR treatment change (T2-1) 22.43 7.30 34.00 8.00
PAR short-term postretention change (T3-T2) 5.36 4.49 0.00 16.00
PAR long-term postretention change (T4-T2) 7.89 7.21 0.00 24.00
PAR short- to long-term postretention change (T4-T3) 2.53 4.32 0.00 14.00
Initial maxillary Little irregularity index (T1) 10.14 3.27 5.12 16.46
Final maxillary Little irregularity index (T2) 1.07 0.39 0.00 1.59
Short-term postretention maxillary Little irregularity index (T3) 3.25 1.21 1.58 5.34
Long-term postretention maxillary Little irregularity index (T4) 3.66 1.18 1.91 5.87
Maxillary Little irregularity index treatment change (T2-1) 9.07 3.27 15.34 4.24
Maxillary Little irregularity index short-term postretention change (T3-T2) 2.18 1.15 0.13 4.48
Maxillary Little irregularity index long-term postretention change (T4-T2) 2.59 1.07 0.46 4.80
Maxillary Little irregularity index short- to long-term postretention change 0.41 0.43 0.02 1.63
(T4-T3)
Initial mandibular Little irregularity index (T1) 8.66 3.88 2.35 15.31
Final mandibular Little irregularity index (T2) 1.20 1.00 0.00 3.52
Short-term postretention mandibular Little irregularity index (T3) 2.78 1.44 0.00 5.12
Long-term postretention mandibular Little irregularity index (T4) 5.06 2.39 0.00 9.61
Mandibular Little irregularity index treatment change (T2-T1) 7.46 3.59 14.06 1.03
Mandibular Little irregularity index short-term postretention change (T3-T2) 1.58 1.38 0.00 3.91
Mandibular Little irregularity index long-term postretention change (T4-T2) 3.86 2.61 0.00 8.62
Mandibular Little irregularity index short- to long-term postretention 2.28 1.62 0.00 5.24
change (T4-T3)

Table III. Comparison of the PAR and maxillary and mandibular Little irregularity index in the 4 stages (n 5 28,
repeated measures ANOVA and Tukey tests)
Initial (T1) Final (T2) Short term (T3) Long term (T4)

Variable Mean (SD) Mean (SD) Mean (SD) Mean (SD) P

PAR 25.14 (6.84)A 2.71 (2.27)B 8.07 (3.38)C 10.60 (6.01)C 0.000*
Maxillary index (mm) 10.14 (3.27)A 1.07 (0.39)B 3.25 (1.21)C 3.66 (1.18)C 0.000*
Mandibular index (mm) 8.66 (3.88)A 1.20 (1.00)B 2.78 (1.44)C 5.06 (2.39)D 0.000*

Different letters in a row indicate a statistically significant difference.

*Statistically significant at P \0.05.

II malocclusion groups (Table VI). However, the amounts
of short-term and long-term relapses of the Little
mandibular irregularity index were similar between the
groups (Table VI).
DISCUSSION
For a more homogeneous sample, some selection
criteria were adopted. The initial malocclusion, the treat-
ment protocol, and the type of orthodontic mechanics
used were standardized. Accordingly, the stability results
achieved with orthodontic treatment could be evaluated
with increased reliability.
The time of short-term evaluation agrees with the
literature regarding evaluation of stability of
orthodontic correction, since approximately half of the
total relapse occurs in the first 2 years after active ortho-
dontic treatment, with good stability of the main charac-
teristics after 5 years.16
The long-term evaluation time of almost 35 years
posttreatment, 33 years postretention, is the longest
described in the orthodontic literature that we know
until now. Studies with longer follow-up times were
those of Vaden et al4 at 15 years posttreatment,
Little et al10 at 10 and 20 years postretention,
and Dyer et al7 with a follow-up of 25 years
posttreatment.
The groups were comparable regarding several
parameters that could influence comparisons: sex distri-
bution; initial, final, short-term and long-term ages;

American Journal of Orthodontics and Dentofacial Orthopedics December 2017  Vol 152  Issue 6
806
Table IV. Intergroup comparability of sex distribution
(chi-square test)
Group Males Females Total
Group 1, Class I 5 10 15
Group 2, Class II 4 9 13
Total 9 19 28
c2 5 0.02 df 5 1 P 5 0.884
retention time; and times of short-term and long-term
postretention evaluation (Tables IV and V).
Retention time comparability between the groups has
great importance, since it is reported in the literature
that duration of the use of retainers can affect stability
of the results.16-20 In addition, all patients received the
same retention protocol, a Hawley plate in the
maxillary arch and a steel wire bonded from canine to
canine in the mandibular arch.
Treatment time was significantly longer for the Class
II than for the Class I malocclusion group (Table V). This
was expected, since both groups were treated with 4
premolar extractions, and in the Class II group the
anteroposterior discrepancy had to be corrected, which
demanded more treatment time, because of the need
for more patient compliance.21-24
The initial malocclusion evaluated by the PAR index
and the maxillary anterior crowding were similar at the
initial stage in both groups (Table VI). This comparability
of the initial malocclusion and the crowding severity
allowed a reliable comparative evaluation of the short-
term and long-term postretention changes.
The initial PAR index was 25.14 (SD, 6.84); it was
significantly reduced with treatment to 2.71 (SD, 2.27),
showed a significant increase to 8.07 (SD, 3.38) in the
short term, and nonsignificantly increased to 10.60
(SD, 6.01) in the long term (Tables II and III). In other
words, the initial malocclusion was significantly
corrected with treatment, showed a significant relapse
in the short term, and remained stable in the long-
term postretention (Table III).
It was previously suggested that a good-quality or-
thodontic treatment should show a 70% or more reduc-
tion in the PAR index.25 In our study, the mean reduction
of the PAR index with treatment was 89.22%, character-
izing good patterns of orthodontic finishing.3,26,27 This
result is above the average percentages of PAR index
reduction with treatment—between 75.4% and
78.5%—found in most previous studies in the
literature.26-29 However, Otuyemi and Jones30 (82.2%)
and Woods et al31 (85.6%) found similar amounts of
PAR index reduction with treatment to ours.
Regarding stability, in the short-term postretention,
a loss of 23.89% of the correction obtained with
December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Freitas et al
treatment for the PAR index was observed. This relapse
was greater than that in other studies.3,27,32 Perhaps
the explanation for this difference in the relapse of the
PAR index is in the orthodontic finishing. The patients
in this study were well finalized, with reductions above
the average.26-31 Therefore, more deterioration of
these patients can also be expected.3,27,33,34
In the long-term postretention stage, there was a
slight relapse, with an increase in the PAR index of
11.28% and a relapse of the PAR index of 35.17%, in
relation to the correction achieved with treatment.
However, the highest and statistically significant relapse
of the PAR index was in the short-term postretention,
confirming the speculation that perhaps this deteriora-
tion is due to the excellent quality of finishing of the
subjects in this study.
There are no comparative data in the literature
regarding the occlusal stability of treated patients at
33 years postretention. However, it can be stated from
our results that there is long-term occlusal stability,
excluding mandibular anterior crowding, which follows
another postretention stability pattern.
The initial maxillary anterior crowding of 10.14 mm
was significantly corrected to 1.07 mm at the final stage
(reduction of 9.07 mm). Then, it had a statistically signif-
icant relapse in the short term, showing 3.25 mm of
crowding at this stage (increase of 2.18 mm from the
final to the short-term postretention stage). Finally, it
remained stable from the short-term to the long-term
postretention stage, increasing by only 0.41 mm,
showing 3.66 mm of maxillary irregularity, approxi-
mately 33 years after the removal of the retention
appliances (Tables II and III).
This agrees with the long-term study of Vaden et al,4
who found, at 15 years postretention, an increase of only
0.3 mm in maxillary incisor irregularity, which
corresponds to 96% of crowding correction stability.
Dyer et al7 also found that correction of maxillary
crowding was relatively stable at 25 years after treatment
in women.
There was 24.03% of maxillary anterior crowding
relapse in the short term and only 4.52% more relapse
until the 33-year, long-term evaluation, showing a
long-term total relapse of 28.55%. This relapse was
greater than previous reports; however, it can be consid-
ered long-term stability, mainly when contrasted with
the relapse of mandibular anterior crowding that is
always greater, even in the long-term evaluation.4,7
The small increase of 0.41 mm of maxillary irregular-
ity from the short-term to the long-term evaluation
stages—ie, evaluating patients from 20 to 50 years of
age approximately—is probably due to physiologic
changes observed with time even in untreated subjects.
Freitas et al 807

Table V. Intergroup comparability of ages, times, and periods (t tests)

Group 1, Class I (n 5 15) Group 2, Class II (n 5 13)

Variable (y) Mean SD Mean SD P

Initial age (T1) 12.63 0.94 12.82 1.09 0.630
Final age (T2) 14.41 0.90 15.12 1.53 0.144
Age at short-term postretention evaluation (T3) 19.91 1.02 20.41 1.64 0.338
Age at long-term postretention evaluation (T4) 50.17 3.20 48.51 5.74 0.343
Treatment time (T2–T1) 1.78 0.42 2.29 0.79 0.039*
Retention time 1.63 0.55 1.79 0.67 0.145
Time of short-term postretention evaluation (T3–T2) 3.87 0.74 3.50 0.99 0.278
Time of long-term postretention evaluation (T4–T2) 34.12 3.20 31.60 5.10 0.124

*Statistically significant at P \0.05.

Table VI. Intergroup comparisons of PAR and maxillary and mandibular Little irregularity index at the stages and
periods (t tests)
Group 1, Class I Group 2, Class II
(n 5 15) (n 5 13)

Variable Mean SD Mean SD P

Initial PAR (T1) 24.06 7.46 26.38 6.09 0.381
Final PAR (T2) 3.13 2.53 2.23 1.92 0.303
Short-term postretention PAR (T3) 8.00 2.32 8.15 4.41 0.907
Long-term postretention PAR (T4) 10.20 5.82 11.07 6.43 0.708
PAR treatment change (T2–T1) 20.93 7.76 24.15 6.59 0.251
PAR short-term postretention change (T3–T2) 4.86 3.17 5.92 5.36 0.545
PAR long-term postretention change (T4–T2) 7.06 7.50 8.84 7.04 0.525
PAR short- to long-term postretention change (T4–T3) 2.20 4.84 2.92 3.79 0.667
Initial maxillary Little irregularity index (T1) 10.30 3.20 9.95 3.46 0.784
Final maxillary Little irregularity index (T2) 1.00 0.38 1.15 0.41 0.361
Short-term postretention maxillary Little irregularity index (T3) 3.18 1.12 3.34 1.35 0.736
Long-term postretention maxillary Little irregularity index (T4) 3.68 0.98 3.64 1.43 0.929
Maxillary Little irregularity index treatment change (T2–T1) 9.29 3.25 8.80 3.41 0.701
Maxillary Little irregularity index short-term postretention change (T3–T2) 2.17 1.10 2.19 1.24 0.966
Maxillary Little irregularity index long-term postretention change (T4–T2) 2.67 0.86 2.49 1.29 0.230
Maxillary Little irregularity index short- to long-term postretention change (T4–T3) 0.50 0.50 0.30 0.31 0.662
Initial mandibular Little irregularity index (T1) 10.77 3.03 6.21 3.33 0.000*
Final mandibular Little irregularity index (T2) 1.55 1.06 0.80 0.80 0.047*
Short-term postretention mandibular Little irregularity index (T3) 3.54 1.02 1.89 1.37 0.001*
Long-term postretention mandibular Little irregularity index (T4) 5.93 1.91 4.06 2.56 0.036*
Mandibular Little irregularity index treatment change (T2–T1) 9.22 3.26 5.41 2.87 0.003*
Mandibular Little irregularity index short-term postretention change (T3–T2) 1.98 1.46 1.09 1.15 0.088
Mandibular Little irregularity index long-term postretention change (T4–T2) 4.37 2.68 3.25 2.49 0.266
Mandibular Little irregularity index short- to long-term postretention change (T4–T3) 2.38 1.58 2.16 1.72 0.724

*Statistically significant at P \0.05.

Variations of crowding from 18 to 50 years of age were
already evaluated by Richardson35 but only for the
mandibular arch, which showed crowding increases
from 0.2 to 2.5 mm. We speculated that, for the maxil-
lary arch, this increase in crowding would be small, and
probably similar to the changes observed in our treated
patients.
A clinically acceptable maxillary tooth alignment
(\3.5 mm of the maxillary Little irregularity index)
was found in 17 subjects (60.17% of the sample) in
the 3-year postretention stage and in 12 subjects
(42.85% of the sample) in the 33-year postretention
stage. No subject had severely crowded maxillary incisors
(.6.5 mm of the maxillary Little irregularity index) in
both postretention stages.
The pretreatment mandibular anterior crowding of
8.66 mm was significantly corrected to 1.20 mm at the
final stage. Then it had a statistically significant relapse
in the short term, showing 2.78 mm of crowding at this
stage (relapse of 1.58 mm from the final to the short-

American Journal of Orthodontics and Dentofacial Orthopedics December 2017  Vol 152  Issue 6
808
term postretention stage). Subsequently, it continued to
significantly relapse from the short-term to the long-
term postretention stage, increasing by 2.28 mm,
showing 5.06 mm of mandibular incisor irregularity at
the long-term postretention stage (Tables II and III).
Orthodontic treatment provided an average correc-
tion of 86.14% of the amount of mandibular anterior
crowding, and during the short-term postretention
phase there was a relapse of 21.17% of treatment correc-
tion, which can be considered good stability for mandib-
ular incisor alignment.2,10,19,36,37 In the long-term
postretention stage, in relation to the short-term stage,
there was an increase in this percentage of 30.57%, i.e.,
at 32.95 years posteretention, 51.74% of the mandibular
anterior crowding correction had been lost.
Dyer et al,7 evaluating 35 women 25 years after treat-
ment, found an average mandibular crowding relapse of
35%; however, no patient had a mandibular irregularity
index greater than 5.5 mm in the last evaluation. In our
study, 10 subjects had a mandibular irregularity index
greater than 6 mm in the long-term postretention stage:
a considerably greater relapse.
Little et al,10 evaluating 31 subjects treated with
extractions of 4 premolars 10 and 20 years postretention,
found average mandibular irregularity values of 5.25 and
6.02 mm, respectively. That is, in 10 years, mandibular
anterior crowding increased only by 0.77 mm. In our study,
from the short-term to the long-term postretention stage,
between 20 and 50 years of age, the increase in mandibular
incisor irregularity was 2.28 mm. This increase was slightly
higher when compared with untreated subjects from 18 to
50 years of age, who had increases of mandibular anterior
crowding from 0.2 to 2.5 mm.35
At the 3-year postretention stage, 18 patients
(64.28%) had clinically acceptable mandibular anterior
tooth alignment (\3.5 mm of the Little irregularity
index), and no subject had severely crowded mandibular
incisors.
At the 33-year postretention stage, only 5 patients
(17.85%) had clinically acceptable mandibular anterior
tooth alignment. Seven subjects (25%) had severe
mandibular crowding at this stage: more than 6.5 mm
of the Little irregularity index. This result is slightly bet-
ter than a previous 20-year postretention study, where
only 3 subjects had clinically acceptable alignment,
and 10 had severely crowded mandibular incisors.10
There was no statistically significant difference in the
PAR index in all times and periods evaluated between the
Class I and Class II malocclusion groups (Table VI). The
occlusal stability evaluated by the PAR index in the short
and long terms was similar in Class I and Class II patients
treated with 4 premolar extractions. These results
December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Freitas et al
corroborate a previous study that found no differences
in the postretention occlusal changes between Class I
and Class II malocclusion patients.38
Maxillary anterior crowding was similar between the
groups in the 4 stages and also showed similar changes
with treatment (T2–T1) and in the short-term (T3–T2)
and long-term postretention (T3–T2) periods and from
the short- to the long-term stages (Table VI). These
results agree with previous studies that also found no
differences in maxillary crowding relapse in Class I and
Class II malocclusion patients.8,38
Mandibular anterior crowding was significantly
greater in the Class I malocclusion group in all 4 stages
evaluated (Table VI). Consequently, mandibular irregular-
ity showed a greater correction with treatment in the Class
I group than in the Class II group. However, intergroup
short-term and long-term relapses of mandibular anterior
crowding were similar. These results are similar to a
previous study that found no difference in postretention
changes between Class I and Class II malocclusions.38
Another investigation, evaluating patients with 4 premo-
lar extractions, also obtained similar results.19
However, the sample divided into 2 groups was not
large enough to confirm that there is no statistically sig-
nificant difference between Class I and Class II groups
regarding relapse, even though the differences were small.
This comparison of Class I and Class II malocclusions was
a pilot study, and more investigations are needed with
great numbers of patients to confirm this tendency.
In general, the occlusal and maxillary anterior crowd-
ing changes in the postretention period followed a
different pattern of long-term changes from mandibular
anterior crowding. The occlusal characteristics and
maxillary anterior crowding showed significant relapses
in the short term; they are then relatively stable in the
long term. Mandibular anterior crowding showed signif-
icant relapses in the short-term and long-term postre-
tentions and between these stages. Mandibular
anterior crowding continues to increase throughout life.
Interpretation of this 33-year, long-term postretention
evaluation should be performed with caution because the
occlusal changes were combined with the physiologic
changes of the occlusion, including the increase of anterior
crowding.35,39,40 It is difficult to distinguish the actual
relapse from changes due to the normal aging process
because crowding increases with time, even in untreated
subjects.35,39 Dental movement is a normal process of
occlusal aging and maturation.35,39-41
It seems that the only way to prevent an increase in
crowding of the mandibular incisors is to maintain a
permanent mandibular fixed retention for the patient's
entire life.2,39,42,43
Freitas et al
CONCLUSIONS
1. The PAR index and maxillary anterior crowding were
significantly corrected with treatment, had signifi-
cant relapses in the short term, and remained stable
from the short-term to the long-term postretention
stage, 33 years after the removal of retention;
2. Mandibular anterior crowding was significantly
corrected with treatment, showed a significant
relapse in the short term, and continued to relapse
significantly in the long-term postretention period.
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