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Important aspects of long-term stability
Article in Journal of clinical orthodontics: JCO · September 1997

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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1997 Sep(562 - 583): Important Aspects of Long-Term Stability BJORN U. ZACHRISSON
Important Aspects of Long-Term Stability

BJORN U. ZACHRISSON, DDS, MSD, PHD
There is a consensus in the profession that the long-term results reported by the Seattle group
constitute the gold standard for stability of traditional edgewise orthodontics. For more than 35
years, members of the Department of Orthodontics at the University of Washington have collected
diagnostic records of more than 600 patients, a decade or more after the completion of orthodontic
treatment.1-3 The long-term alignment in these cases is highly variable and largely unpredictable.
Arch length and width typically decrease as crowding increases. Satis factory mandibular alignment
was maintained 10 years after retention in less than 30% of the patients, with nearly 20% of the
cases demonstrating marked crowding many years after the removal of retainers. Changes
continued well into the patients’ 20s and beyond, 2 but the rate of change diminished after age 30.
These seemingly pessimistic findings should not generate a negative attitude among
orthodontists.4 Instead, they should stimulate even greater efforts to provide the best possible results
for our patients by paying more attention to detail. The key to the successful practice of
orthodontics is to reexamine our treated patients, carefully evaluate the results, and learn from
previous mistakes.
This article will examine my own experiences regarding the long-term stability of orthodontic
cases, as well as results reported by others. My purpose is to provide some guidelines on how
improvements can be made, and to demonstrate that excellently finished cases have better stability
than cases that, upon closer examination, appear to have been undercorrected or expanded.
Rotational Relapse
Broken Contact Points and Undercorrection of Rotations
A common mistake in orthodontics is incomplete correction of all rotations in the original
malocclusion. This can be observed in several cases from the Seattle material5 and, in fact, in the
treated cases of most orthodontists. Slight undercorrections of previously rotated teeth (“9/10
orthodontics”) are not easy to detect clinically. Fine details can only be detected during and toward
the end of treatment by careful comparison with the pretreatment plaster models.5 A mouth mirror
should be used to check the maxillary anterior region (Fig. 1). If these steps are not taken, an
undercorrected case may look good, or even excellent, on clinical examination in the chair. I use
individualized archwire bends to secure early and full correction of rotated teeth5 (Figs. 2,3).
Several studies of the maturation of untreated normal occlusions demonstrate that children with
normal occlusions can develop noticeable mandibular incisor crowding during adolescence and
young adulthood.6-8 Inter estingly, the in creased crowding tends to be located largely in areas of
broken contact points (Fig. 4). This indicates that slightly broken contact points in both untreated
and treated cases may be starting points for later crowding.
Article Text 1
Furthermore, a contact point is not very stable because, as discussed by Tuverson, a small
contact point has the potential for slippage and subsequent rotations of the teeth.9 Tuverson
recommended reshaping the incisors by slight grinding to obtain small contact areas, while still
maintaining a good anatomical contour (Figs. 2,3).
Placing 2-2 Outside 3-3
The mandibular anterior region is the most common area for post-treatment relapse and
crowding. Moderate crowding can be masked if the four incisors are positioned as a block outside
the mesial contacts of the mandibular cuspids (Fig. 5). Small, meticulous archwire bends will help
ensure that all previous rotations of the four mandibular incisors are fully corrected, that the distal
contact areas of the lateral incisors are placed slightly labial to the mesial contact points of the
mandibular cuspids, and that the teeth are retained in these positions (Fig. 6). This is particularly
important when the distal aspects of one or both lateral incisors are lingually displaced at the start of
treatment (Fig. 6A).
Early Correction of Rotations
Some clinicians claim that the answer to incisor stability is early treatment. Dugoni and
colleagues recently demonstrated satisfactory long-term stability of the mandibular incisors in 19 of
25 cases treated in the early mixed dentition by the preservation of leeway space with passive
lingual arches.10 These positive results may be related to the stage of development of the transseptal
fibers. Kusters and colleagues showed that the transseptal fibers do not develop until the
cementoenamel junctions of erupting teeth pass the bony border of the alveolar process.11
Therefore, derotation of teeth just after emergence in the mouth implies correction before the
transseptal fiber arrangement has been established. When the corrected teeth erupt further, a normal
anatomical arrangement of the transseptal fibers can develop.11 Although early derotation will
probably reduce the amount of relapse, several other factors are also involved, including the
transosseous fibers, the initial degree of rotation, the effectiveness of fiberotomy procedures, the
retention appliance, and the length of retention.
The merits of fiberotomies in alleviating rotational relapse were confirmed by Edwards, but this
surgical procedure appeared more successful in reducing relapse in the maxillary anterior segment
than in the mandibular anterior segment.12 The finding by Riedel13 that 19% of fiberotomized teeth
rotated away from their original positions may be explained by the inherent tendency of the
mandibular incisors to respond to pressure by moving in the direction of least resistance. A recent
study by Redlich and colleagues, using SEM and TEM analyses in dogs to study orthodontic
rotation of teeth and the effect of supra-alveolar fiberotomy on relapse, indicated that rotational
relapse was not due to the effect of “stretched” collagen fibers pulling the teeth back, as may be
indicated by their appearance under a light microscope.14 Instead, the ultrastructural data indicated
that the relapse may have been caused by the elastic properties of the whole compressed gingival
tissue.
Clinical Implications
Article Text 2
A logical goal of orthodontic treatment would be to make sure that all rotations in both arches are
completely corrected. A prerequisite is to know how to check that all the teeth are, in fact, fully
corrected. One safe, although not necessarily simple, way to achieve this goal is to use
individualized archwires with bent-in corrections (Figs. 2,3,6).
Transverse Relapse
Mandibular Intercuspid Width
Many authors have demonstrated the importance of avoiding an increase in “normal” mandibular
intercuspid width (24-26mm) during orthodontic treatment.15-21 In most studies, this width has been
found to decrease from post-treatment to post-retention, even when minimal expansion occurred
during therapy. Apparently, the greater the increase in this dimension during treatment, the greater
the decrease after treatment.
In an interesting discussion of the long-term results in the Seattle and Sandusky16 materials,
Gorman claimed that better stability was found in the latter sample.17 The Sandusky extraction
cases, 10-15 years out of treatment, had acceptable results 90% of the time, with only minor
crowding and an Irregularity Index of less than 3mm. As many as 60% of the patients in the Seattle
material showed mandibular intercuspid expansion of more than 1mm during treatment.17 Since the
criterion for inclusion in the Sandusky material was excellence of finished results (the sample
includes 85 of Tweed and Merrifield’s best cases), Gorman assumed that the more satisfactory
long-term results were due, at least in part, to less mandibular cuspid-to-cuspid expansion, more
complete correction of rotations, and a longer average retention period. In addition, two recent
independent follow-up studies have demonstrated more optimistic long-term results than those of
the Seattle material.19-21 The original mandibular intercuspid widths were respected during
treatment in both of these studies.
Mandibular Archform
Some excellent recent investigations have indicated that not only the mandibular intercuspid
distance, but also the patient’s pretreatment mandibular archform, should constitute a guide to arch
shape.3,20-22 Felton and colleagues conducted a long-term computer analysis of the shape and
stability of the mandibular archforms of 30 Class I and 30 Class II nonextraction cases, with 30
untreated normal cases as controls.22 The observation period comprised two years of orthodontic
treatment and four years of retention, with the cases reexamined seven to nine years later. The
authors demonstrated that changes in mandibular archform were frequently unstable after
nonextraction treatment. Nearly 70% of the cases showed significant long-term post-treatment
changes, relapsing toward their original shapes by the time of the long-term evaluation.
Prefabricated archforms with the closest fits were useful in about 50% of the cases; the re mainder
showed a wide variety of archforms. Be cause of the great individual variability in archform, no
single prefabricated archform can be ex pected to fit every dental arch. Customizing mandibular
archforms appears to be necessary in many cases to obtain optimum long-term stability. 22
Article Text 3
Similarly, Franklin and colleagues, in a study of 114 cases treated by the same clinician, with a
mean post-retention time of 12 years, found satisfactory long-term stability in 79% of the patients.
Sound treatment principles, including maintenance of the original mandibular archform, were
claimed to be essential in achieving these long-term results.20,21
Maxillary Archform
Although minimal alteration of mandibular archform may be important for stability, there are
certain situations when maxillary archform should be purposely changed by orthodontic treatment.
A good example is a patient with a Class II, division 1 malocclusion, in whom it may be necessary
to coordinate the maxillary archform with the mandibular arch. The long-term consequences of
such changes were recently evaluated by De La Cruz and colleagues.23 Extraction patients were
selected for the study, since their archforms were presumably changed more during treatment than
those of nonextraction patients. Dental casts of 45 Class I and 42 Class II, division 1 malocclusions
were evaluated before treatment, after treatment, and 10-15 years after retention.
Computer-generated archforms were used to assess the changes in arch shape over time. The study
demonstrated a rounding of maxillary archform during treatment, followed by a change to a more
tapered form after retention (Fig. 7). The greater the treatment change, the greater the tendency for
post-retention change. However, individual variation was considerable. 23
Rapid Maxillary Expansion
Few studies have evaluated the long-term skeletal effects of rapid maxillary expansion. The
evaluation of skeletal expansion is problematic because of the difficulty of identifying landmarks on
anteroposterior radiographs.24 Some authors have tried to overcome this limitation by using
metallic implant markers. As discussed recently by Dermaut and Aelbers, there is no scientific
evidence to indicate that an orthodontist can induce a stable enlargement of maxillary basal bone
that exceeds normal growth.25,26 Apparently, any short-term, simple mechanical interference with a
complex biological system has little long-term impact.27
Based on the careful studies cited above, the best guides to future dental and archform stability
may be the patient’s pretreatment mandibular intercuspid width and mandibular archform. The
maxillary archform should be respected, but frequently has to be adapted to occlude properly with
the mandibular teeth (Fig. 8). Fullness of smile should not be sought through lateral expansion and
tipping of the maxillary dentition, but rather through adjustment of the crown torque of the
maxillary cuspids and bicuspids to the most esthetic appearance, by pivoting these teeth around
their centers of resistance (Figs. 8-10).
Vertical Relapse
Deep Overbite
Excessive or deep anterior overbite is a common characteristic of many malocclusions. Deep
overbite may be caused by overeruption of the maxillary incisors, overeruption of the mandibular
Article Text 4
incisors, or a combination of both. In many patients, the incisors are retroclined. To achieve ideal
functional and esthetic orthodontic results, it is important to determine which teeth are overerupted,
to analyze the lower lip-maxillary incisor relationship,28-30 and to establish an optimal interincisal
angle.
Relationship Between Vertical Relapse and Mandibular Anterior Crowding
The long-term stability of deep overbite correction after orthodontic treatment is not well
understood.28,31 In many cases, the deep overbite returns as the maxillary and/or mandibular
incisors overerupt following appliance removal. According to several authors, the maintenance of
overbite is related to the torque or axial inclination of the incisors.28,32,33 If the maxillary and
mandibular incisors are positioned too upright relative to one another after orthodontic treatment,
they will have an increased tendency to overerupt after appliance removal.28 An important factor is
the demonstration by Swain that the available space for the mandibular anterior teeth decreases as
overbite increases 34 (Fig. 11).
If the deep bite returns in a treated malocclusion, the incisal edges of the mandibular incisors will
occlude against a labiolingually thicker portion of the maxillary incisors (Fig. 11). This will restrict
their space and produce mandibular incisor crowding or, more rarely, spacing of the maxillary
incisors with the mandibular arch intact.
Mandibular First Bicuspid Extractions, Vertical Relapse, and Anterior Crowding
The relationship between anterior vertical relapse and mandibular incisor crowding is not always
readily apparent. For example, when mandibular first bicuspids have been extracted as part of an
orthodontic treatment plan, it is not uncommon for the mandibular cuspids to be retracted too far.
The combined posterior anchorage of the root surface areas of one bicuspid and two molars is
indeed a solid block in comparison with the anterior anchorage of only one cuspid and two
more-or-less-crowded incisors. Excessive retraction can easily occur if Class II elastics are not worn
properly, if there is a root resorption problem that prevents their use, or if the first and second
molars do not move mesially as much as expected. Excessive retraction of the mandibular cuspids
starts a vicious cycle (Table 1). Since the maxillary cuspids must occlude properly with the
mandibular cuspids, these teeth will also be excessively retracted. Next, the maxillary and
mandibular incisors will move too far back, increasing the need for anterior crown and root torque.
Such torque is not always easy to achieve, and at best takes a long time. Therefore,
mandibular-first-bicuspid extraction cases can end up with larger-than-intended interincisal angles
(Fig. 12). As discussed above, upright incisors may cause anterior vertical relapse and mandibular
incisor crowding.
At present, many more orthodontists seem to choose extraction of mandibular first bicuspids than
of second bicuspids. In a recent survey, maxillary and mandibular second bicuspids were removed
in only 7% of U.S. orthodontic extraction cases, and maxillary first and mandibular second
bicuspids in 8%.35 Undoubtedly, one reason for selecting the mandibular first bicuspids for
extraction is their generally poorer morphology—a diminutive lingual cusp compared to that of the
Article Text 5
second bicuspid. There is one way to get around this problem in a case with mild-to-moderate
crowding and a weak facial profile.36 If the first bicuspid is extracted, the second bicuspid can be
moved mesially, with coil springs, against the first (and second) mandibular molars during the first
phase of treatment. The molars will probably not move distally, due to lack of space and the
presence of thick cortical bone in the retromolar area. When the second bicuspid contacts the
mandibular cuspid, the case can then be treated similarly to a mandibular-second-bicuspid
extraction case in terms of anchorage.
To correct and maintain the correction of an excessive overbite, the orthodontist should intrude
the overerupted teeth and establish an ideal lower lip-to-maxillary incisor relationship and
interincisal angle (Fig. 8B). The mechanical means include selecting proper bracket torque, bending
additional torque into rectangular wires, and using auxiliary torquing springs to deliver extra lingual
root torque. When mandibular bicuspid extractions are necessary, the second bicuspids are often a
better choice than the first bicuspids. Orthodontic treatment then becomes easier and more
predictable with regard to anchorage control and achievement of proper anterior torque, and
undesired flattening of the facial profile is more easily avoided (Fig. 13).
Third Molars
Three-Dimensional Effects on Erupting Teeth
The etiology of postpubertal mandibular crowding in both treated and untreated subjects appears
to be multifactorial. Mesially directed force is the most important cause of late mandibular
crowding in the early teen-age years.37 However, the causes of reduced arch dimensions may vary
from one person to another, and several factors acting together or at different stages of development
may contribute to late mandibular crowding37 (Table 2). Direct cause-and-effect relationships have
been difficult to establish.
In particular, the relationship between erupting third molars and late mandibular crowding is a
controversial subject. Failure to neutralize all other influential factors while isolating the third
molars in a carefully controlled study is the main reason for the confusion. For example, two
well-known studies based on the Seattle material were unable to demonstrate that third molars exert
pressure on the teeth mesial to them.38,39 However, the illustrations in both reports showed cases in
which lateral expansion of normal mandibular intercuspid width had been performed. Such cases
are likely to relapse after treatment, with resultant anterior crowding, whether the third molars are
present or not. Furthermore, each study contained a negligible number of nonextraction cases in
which the third molars had erupted.
A more fruitful approach to the controversy may be to look at the effect of erupting second and
third molars on the continued eruption pattern of the mandibular first molars. Based on several
reports, it is evident that the “normal” average eruption path of the mandibular first molars is in an
upward and mesial direction32,40 (Fig. 14). This eruption continues during the time when the third
molars are emerging in the oral cavity. Iseri and Solow recently studied the average and individual
Article Text 6
eruption patterns of the maxillary incisors and first molars in a longitudinal sample of girls age 9 to
25, from the archives of the implant study by Björk.41 They found that tooth eruption continued
until the end of the observation period at 25 years of age, and showed no evidence of having
terminated at that time.42,43 Richardson, using measurements from 60°-angled cephalograms, which
provide more reliable structural superimposition on either side of the mandible than lateral
cephalograms (Fig. 15A,B), showed that mesial movement of the first molars was significantly
reduced when the second molars were extracted37,44 (Fig. 15C). More recently, she demonstrated
that during a three-year period following second molar eruption, there was a significantly greater
increase in M3 space, with forward movement of the second molars, in a group of 21 patients with
increased mandibular crowding, compared to another group of 21 patients with no increase in
mandibular crowding over the same period.45 Schwarze, using photodocumentation and computer
analysis of three-dimensional tooth movements in relation to the third palatinal rugae, showed less
mesial movement of the first molars when the third molars were extracted between 12 and 22 years
of age46 (Fig. 16).
Figure 17 indicates how mandibular third molar eruption or extraction may affect the continued
eruption path of the mandibular second and first molars. If pressure from an erupting third molar
changes the path of first molar eruption to a more mesial direction, and if the incisors do not come
forward to the same extent, mandibular anterior crowding will result. Of course, factors other than
the relief of pressure from an erupting third molar may play a role in cases of third (or second)
molar extraction. For example, spontaneous changes in molar eruption patterns may be expected
when more distal space becomes available in the arches44 (Fig. 17).
The scientific evidence available at present supports the following conclusions regarding the role
of third molars in orthodontics:
• Early extraction of mandibular third (or second) molars may make the first molars erupt in a
less mesial direction.
• Mandibular third molar germs occupy space. If they are extracted, this space can probably be
used for distal uprighting of the mandibular second molars in nonextraction therapy.
• Present studies of third molars are not optimally designed to establish any direct relationship
between mandibular third molar eruption and increased mandibular crowding.
Prolonged Retention
Retention Period
Based on information available in the literature, it appears prudent to prescribe a number of years
of fixed retention, and sometimes permanent retention, for many patients.17 It also appears
worthwhile to retain the mandibular arch until all growth is completed.17,40,47 However, there are
few scientific studies of the efficiency of prolonged retention. Sadowsky and colleagues recently
Article Text 7
reported on the long-term stability, five years after retention, of a small sample of 22 nonextraction
cases treated by the same clinician.18 All subjects had been treated with fixed edgewise appliances
and had been retained with mandibular fixed lingual retainers for an average of 8.4 years. The
mandibular anterior segments demonstrated relatively good alignment (mean Irregularity Index of
2.4mm) at the long-term follow-up appointments.
In an extensive overview of the clinical consequences of adult craniofacial growth, Behrents

stated that for ultimate stability, the retention period for both adolescent and adult patients should
be indefinite.47 As a general treatment policy, however, he did not consider this to be practical.
Instead, based on the level of growth activity and the maxillomandibular adjustments that had
occurred, he recommended retention for males into their mid-20s and for females until their early
20s.47 This would imply that the mandibular arch should be retained until the third-molar situation
has been resolved (Fig. 18).
Age-related changes in the dental arches do not cease to occur with the onset of adulthood.
Studies of late facial growth have shown continued eruption of the teeth into the third and possibly
the fourth decades of life.42,43,48,49 Arch-length and -width reductions with concomitant crowding,
which may continue into the third decade and beyond in both treated and untreated subjects, may be
regarded as a normal physiological phenomenon.2,50,51 Without long-term retention of
orthodontically treated adolescents and young adult patients, various degrees of anterior crowding
may be expected as part of the normal maturation process. In fact, a slow, gradual change is a
natural, common characteristic of any dentition, whether it is a treated malocclusion, an untreated
malocclusion, or a normal dentition.50,51 When incisor (or other) irregularity or spacing becomes
esthetically or functionally intolerable to an individual patient, the deficiency can be retreated or
otherwise corrected.52 Worldwide social developments, with an increasing focus on personal
appearance in television and other media, may shift patient awareness to a higher level and lead to
reduced tolerance for orthodontic relapse and post-treatment changes in the future.
Since long-term fixed retention must be constantly monitored, practical considerations mandate
that permanent retention be restricted to comparatively few patients.47,53 According to Joondeph
and Riedel, permanent retention is indicated primarily for expansion (particularly in the mandible),
generalized spacing, marked median diastemas in adults, and severe rotations in adults.53 In
addition, periodontal cases with advanced breakdown of supporting tissue may need permanent
retention, due to the loss of stabilizing forces from the periodontal membrane for counteracting
tongue-lip forces.54 Post-retention minor decreases in arch length may be accepted as normal and
are generally unrelated to the development of caries and periodontal disease.55
Fixed Retainers
Whenever prolonged retention is prescribed, it is important that simple, safe, and hygienic
procedures be used. A solid mandibular 3-3 bar bonded only to the cuspids, combined with a
removable maxillary plate, is my preferred method in adolescent and many adult patients.5,56-58 The
third-generation 3-3 retainer, which consists of a round .032" stainless steel or .030" gold-coated
Article Text 8
wire, sandblasted at the ends to provide microretention and bonded with a restorative composite
resin (Concise), is an excellent mandibular retainer (Figs. 19, 20). Not only is it solid, easy to place,
and hygienic, but equally important, it appears safer than mandibular retainers in which all six
anterior teeth are bonded. A patient notices immediately if a retainer comes loose when it is bonded
only to the cuspids. The patient can then call for a rebonding appointment and can remove the
retainer if necessary.
Since January 1994, my failure rate for 107 stainless steel third-generation 3-3 retainers, with
observation periods ranging from 1.9 to 3.7 years, has been only 8.4% (4.2% of the bonded sites).
With the gold-coated version (Figs. 6D,20), since September 1995, I have observed only 2.3%
loosening out of 87 retainers. Some initial problems with corrosion due to microleakage around the
gold plating have made it advisable to extend the sandblasting slightly beyond the area of composite
bonding (Fig. 20C,D).
There is no obvious need to bond every tooth in a mandibular anterior segment to a thinner
flexible spiral wire (FSW), and there is a risk of some bond failures occurring without the patient
noticing if such retainers are used for prolonged periods.56,57 However, FSW retainers are quite
useful for a number of other retention requirements, both in the maxilla and in the mandible57,58
(Table 3). Since October 1986, my preferred wire for FSW retainers has been a five-stranded .0215"
stainless steel wire (Penta-One). However, since September 1995, I have used a gold-plated version
of this wire (Figs. 1,21), and have observed only four failures (one wire fracture and three loosened
sites) out of 326 bonded teeth in 73 patients.
From a theoretical perspective, prolonged retention is recommended in adolescents to help
withstand the effects of the postpubertal growth period, at least until the third-molar situation has
been resolved. For routine mandibular retention in children and in many adults, the third-generation
mandibular 3-3 bar may be a better option than a retainer in which all six anterior teeth are bonded.
Retainers in which all teeth within a segment are bonded are generally more suitable for use in the
maxillary arch (Table 3).
Conclusion
The high prevalence of residual malocclusion after orthodontic therapy in several long-term
follow-up studies may be due to any of the following reasons:
• Incomplete correction of some details of the initial malocclusion.
• Relapse of the treatment result, due to unintended or deliberate lateral or frontal expansion,
return of habits, inadequate retention, unfavorable growth pattern, tongue and orofacial muscle
activity, or imbalances between mandibular posture and occlusal or eruptive forces, among
other causes.
• Normal postpubertal growth activity and maxillomandibular adjustments after the retention
Article Text 9
period.
Cases treated to excellent results apparently have better long-term stability than cases that upon
close examination were undercorrected (“9/10 orthodontics”) or expanded (laterally or frontally)
during treatment. Key procedures in improving long-term stability include:
• Fully correct all rotations; compare the results with pretreatment models, using a mouth mirror
to check the maxillary teeth.
• Avoid even slight expansion of a normal mandibular intercuspid width, using the original
mandibular archform as a guide.
• Ensure a small interincisal angle by obtaining adequate torque of the maxillary incisors, thereby
reducing the risk of vertical relapse of deep overbite correction. For this and other reasons,
extract the mandibular second bicuspids rather than the first bicuspids when mandibular
bicuspid extractions are necessary.
• Use prolonged retention with fixed retainers in adolescent as well as adult patients.
Space does not allow me to deal with other aspects of stability, including sagittal relapse of Class
II and Class III malocclusions,13,25,26 vertical relapse of anterior open bite,30,59 and gnathological
factors.60,61 The reader is referred to reviews by other authors for stability of dental13 and
skeletal25,26 sagittal changes. According to Riedel, proclination of the mandibular incisors during
treatment (except where a habit pattern has held that segment to the lingual) can be expected to lead
to lingual collapse and crowding.13 Similarly, the possibility that mandibular arch-length increases
can be maintained after retention seems remote. In open-bite cases, inadequate interdigitation of
posterior teeth and lack of vertical contact in the anterior region are generally associated with a
positioning of the tongue between the teeth. Mouthbreathing and incompetent lip seal also affect the
position of the teeth and may have an effect on the morphology of the skeleton. The orthodontist
should not be blamed for failure to correct an open bite in a patient with deviating neuromuscular
function. Achieve ment of a normal occlusion and harmonious face should not be attempted in such
a patient without surgery. 30
BJORN U. ZACHRISSON
Dr. Zachrisson is a Contributing Editor of

the Jurnal of Clinical Orthodontics and a Professor of
Footnotes 10
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Sep
Orthodontics at the University of Oslo. He is in the private

practice of orthodontics at Stortingsgt. 10, 0160 Oslo,
Norway.
Revolution
Kerr Corp., 1717 W. Collins,

Orange, CA 92667.
gold-coated
Gold'n Braces, Inc., 2595 Tampa Road, Palm Harbor, FL

34684.
wire
Gold'n Braces, Inc., 2595 Tampa Road, Palm Harbor, FL

34684.
Concise
3M Unitek, 2724 S. Peck Road, Monrovia, CA 91016.
Penta-One
Masel, 2701 Bartram Road,

Bristol, PA 19007.
Footnotes 11
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Sep
FIGURES
Figure 1
Fig. 1 Use of mouth mirror to check maxillary rotation corrections. Case with overlapping left central and lateral
incisors (A) was not fully corrected with straight .016" × .022" archwire (B,C). Small archwire bends positioned incisors
correctly; tooth positions were retained with bonded, gold-plated .0215" Penta-One retainer (D).
Figures 12
Figure 2
Fig. 2 Full correction of crowded mandibular right central incisor (A) required marked archwire bends (arrows in B).
Mesiodistal stripping avoided incisor proclination and converted contact points to small contact areas (C).
Figure 3
Fig. 3 Small archwire bends made in .016" × .016" archwire (B) to fully correct overlapping maxillary left central
incisor (A). Case should be checked with mouth mirror for optimal contact point relationships.
Figures 13
Figure 4
Fig. 4 Increasing crowding during adolescence. Top row: 10-12 years of age. Bottom row: same cases at 24-26 years
of age. Note how broken contacts provide predilection sites for increased malalignment. (From Humerfelt, A. and
Slagsvold, O.: Changes in occlusion and craniofacial pattern between 11 and 25 years of age, Trans. Eur. Orthod.
Soc., 1972, pp. 113-122. Reprinted by permission.)
Figure 5
Fig. 5 Moderate degree of mandibular incisor irregularity (A) unnoticeable from front in untreated adult male with
lateral incisors positioned labially to cuspids (B).
Figures 14
Figure 6
Fig. 6 A. Case with mandibular lateral incisors lingual to cuspids before treatment (arrows). B,C. Small bends in .016"
× .022" archwire positioned lateral incisors optimally, slightly labial to cuspids. D. Gold-plated .030" third-generation
3-3 bar retained incisors securely.
Figures 15
Figure 7
Fig. 7 Typical changes in maxillary archforms during and after orthodontic treatment (1 = pretreatment; 2 =
post-treatment; 3 = post-retention; U = upper arch; L = lower arch; data shown include case number, intercuspid width,
arch length, eccentricity, age in years and months, intermolar width, and Irregularity Index). (From De La Cruz, A.R. et
al.: Long-term changes in arch form after orthodontic treatment and retention, Am. J. Orthod. 107:518-530, 1995.
Reprinted by permission.)
Figures 16
Figure 8
Fig. 8 A. High-angle Class II, division 1 four-bicuspid extraction case in which original archform was maintained during
orthodontic treatment. B. 10 years later (six years after removal of mandibular 3-3 retainer), with all four third molars
fully erupted. Note good maxillary incisor torque.
Figures 17
Figure 9
Fig. 9 Nonextraction Class II, division 1 case with impacted maxillary right cuspid before (A) and after (B) orthodontic
therapy. Fullness of smile was achieved by marked maxillary cuspid and bicuspid torque (arrows), while original
archform was maintained in both jaws.
Figures 18
Figure 10
Fig. 10 Young boy with broad face, Class I occlusion, and mild crowding (A) treated without extractions. Original
mandibular intercuspid width and archform were maintained (B), and fullness of smile was achieved by marked torque
of maxillary cuspids and first and second bicuspids (arrows).
Figures 19
Figure 11
Fig. 11 A. With relapse of deep overbite, incisal edges of mandibular incisors occlude against labiolingually thicker
portion of maxillary incisors. B. Small pieces of wire placed where six mandibular teeth occlude on maxillary model,
with various degrees of overbite relapse. Note dramatic difference in length of wires when stretched and measured
(reprinted by permission of Dr. B.F. Swain).
Figures 20
Figure 12
Fig. 12 Undertorquing of maxillary and particularly mandibular incisors in this case may increase likelihood of vertical
relapse of deep overbite.
Figure 13
Fig. 13 A. Extraction of mandibular second bicuspids in case with moderate mandibular crowding. B. Simple and
predictable outcome of treatment with elastomeric chains and light Class II elastics on straight .016" × .022"
mandibular archwire.
Figures 21
Figure 14
Fig. 14 A. Average eruption pattern of mandibular first molar from child- to adulthood, according to implant
superimposition by Björk and Skieller40 (reprinted by permission). B. Arcial growth analysis at 5, 8, 13, and 18 years,
according to Ricketts.32
Figure 15
Fig. 15 Superimposition (A) and cephalometric method (B) used by Richardson to analyze effect of mandibular second
molar extraction on continued eruption path of mandibular first molars37,44 (reprinted by permission). Mean forward
movement of mandibular first molars is reduced after mandibular second molar extraction.
Figures 22
Figure 16
Fig. 16 Photodocumentation method used by Schwarze for computer analysis of effect of mandibular third molar
extraction on three-dimensional positional changes during continued eruption of mandibular first molars46 (B =
beginning of orthodontic treatment; E = end of orthodontic treatment; F = follow-up seven to nine years later). Mean
forward movement of mandibular first molars is significantly reduced when third molars are extracted (reprinted by
permission.
Figures 23
Figure 17
Fig. 17 Spatial relationship between vectors of continued forward eruption of mandibular first and second molars and
eruption vs. extraction of third molars. When third molars are extracted, first and second molars may erupt in more
distal direction (ex) than “normally” (continuous black arrows). Conversely, when third molars are erupting, first and
second molars erupt in more mesial direction (er) than “normally”.
Figure 18
Fig. 18 Class II, division 1 case with extraction of maxillary first and mandibular second bicuspids, showing prolonged
retention for nearly seven years while waiting for eruption of third molar in close proximity to mandibular second
molar. A. Age 15 years, 10 months. B. Age 19 years, 5 months. C. Age 22 years, 8 months.
Figures 24
Figure 19
Fig. 19 Essential steps in making third-generation mandibular 3-3 retainer. A. Combined bite block/saliva ejector
(BB-SE) provides excellent moisture control. B. Ends of .032" stainless steel wire are sandblasted, then attached to
lingual surfaces of incisors with three steel ligatures. C. Tacking (arrows) with small amount of flowable, light-cured
composite resin (Revolution) assures undisturbed setting of adhesive. D. Final bonding with slightly diluted Concise
restorative composite resin.
Figures 25
Figure 20
Fig. 20 Three different gold-coated third-generation mandibular 3-3 retainers (A, B, C-D). Pilot studies with right end
sandblasted slightly beyond composite bonding area (left arrow in B) and left side flush with composite shows slight
darkening of left entrance (right arrow in B), probably due to corrosion caused by microleakage. To avoid this problem,
present design calls for extension of sandblasting slightly beyond bonding areas on both ends (C,D).
Figure 21
Fig. 21 Six-unit, bonded FSW retainer (gold-plated .0215" Penta-One wire) for holding maxillary spacing and rotations.
TABLES
Figures 26
Table 1
Tables 27
Table 2
Tables 28
Table 3
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References 32
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Important aspects of long-term stability

Article in Journal of clinical orthodontics: JCO · September 1997

Important Aspects of Long-Term Stability

In an extensive overview of the clinical consequences of adult craniofacial growth, Behrents

• Incomplete correction of some details of the initial malocclusion.

Dr. Zachrisson is a Contributing Editor of

Orthodontics at the University of Oslo. He is in the private

Kerr Corp., 1717 W. Collins,

Gold'n Braces, Inc., 2595 Tampa Road, Palm Harbor, FL

Gold'n Braces, Inc., 2595 Tampa Road, Palm Harbor, FL

3M Unitek, 2724 S. Peck Road, Monrovia, CA 91016.

Masel, 2701 Bartram Road,

9. Tuverson, D.L.: Anterior interocclusal relations, Am. J. Orthod. 78:361-393, 1980.

Am. J. Orthod. 110:667-671, 1996.

34. Swain, B.F.: Personal communication.

36. Diernberger, R.: Personal communication.

60. Roth, R.H.: Point/Counterpoint, Am. J. Orthod. 107:315-318, 1995.

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