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1
INTRODUCTION
TERMINOLOGY OF POSTORTHODONTIC CHANGES
RETENTION AND RELAPSE-DEFINITIONS
DIFFERENT SCHOOLS OF THOUGHT FOR RELAPSE
BASIC THEORMS FOR RELAPSE
CAUSATIVE FACTORS FOR RELAPSE
TREATMENT CHANGES IN DENTITION AND
STUDIES FOR ITS RELAPSE
EXTRACTION VS NON-EXTRACTION TREATMENT
– RELAPSE STUDIES
ANTERIOR OPEN BITE AND RELAPSE STUDIES
ORTHOPEDIC TREATMENT AND RELAPSE
FUNCTIONAL APPLIANCE TREATMENT AND
RELAPSE
ORTHOGNATHIC SURGERY AND RELAPSE
STUDIES
CONCLUSION 2
INTRODUCTION
4
A major objective of orthodontic treatment is to achieve
long-term stability of the occlusion. Most studies of
relapse have examined patients within 5 years of
orthodontic treatment; few studies of people treated a
decade or more in the past have been published.
5
TERMINOLOGY OF POSTORTHODONTIC
CHANGES
PHYSIOLOGIC RECOVERY
Horowitz and Hixon (1969) explain physiologic
recovery as the change to the original physiologic state
after completing treatment.
DEVELOPMENTAL CHANGES
Developmental changes are those which occur
irrespective of whether orthodontic treatment was
implemented or not. These changes could easily be
overlooked when assessing posttreatment relapse.
6
GROWTH RECOVERY
7
POSTRETENTION SETTLING
Settling can be described as the establishment of a
desired position, the act of ceasing to move or “settling
down” and maintaining a correctly balanced position.
This term thus indicates the posttreatment changing
process versus a term such metaposition, which refers to
the meticulously planned changes after the removal of
the orthodontic appliances.
METAPOSITION
Metaposition denotes the desirable and expected
posttreatment changes that are anticipated (Ricketts,
1993). These changes are not relapse and must be part
of thet treatment itself.
8
RECIDIEF
The term “recidief” has been used to describe changes
that occur from the end of treatment back to the
original situation (Dermaut, 1974).
IMBRICATION
Imbrication is the term often used to describe incisor
irregularity or crowding whether seen before or after
treatment.
9
RELAPSE AND RETENTION - DEFINITIONS
RELAPSE
Robert Moyers states that relapse is the term applied to the
loss of any correction achieved by orthodontic treatment.
Horowitz and Hixon (1969) defined relapse in general as
‘changes in tooth position after orthodontic treatment’.
Riedel (1976) believed that the word ‘relapse’ was too harsh a
description of the changes that follow orthodontic treatment
and he preferred the term “posttreatment adjustment” for these
changes.
10
Enlow (1980) defined relapse as “ a histogenetic and
morphogenic response to some anatomical and
functional violation of an existing state of anatomic
and functional balance.” It is usually thought of as a
“rebound” movement in which teeth recoil back
somewhere close to their original positions once
retentive forces are moved.
11
RETENTION
12
THE APICAL BASE SCHOOL
13
THE MANDIBULAR INCISAL SCHOOL
14
BASIC THEORMS FOR RELAPSE
CRANIOFACIAL GROWTH
19
As the maxillary growth is completed on average 2 to 3
years before mandibular growth, dentoalveolar structures may
have difficulties in compensating for this discrepancy, which
may result in an increased overbite.
21
Tooth size The mesiodistal tooth size has been
discussed as a causative factor of the late crowding.
Begg (1954) analyzed interproximal attrition in old
Australian aborigines and concluded that teeth in modern
man are too large for the dental arches and hence become
crowded. Corrucini (1990) showed that small jaws rather
than large teeth underlie tooth-arch discrepancy.
22
Arch width changes Richardson (1995) showed that
increased lower arch crowding could be found in
association with both increased and decreased arch width,
depending on the direction of movement of the canines.
Decrease of the mandibular intercanine width is generally
considered to be associated with late lower crowding.
23
SOFT TISSUE MATRIX
The dentoalveolar changes are not only the result of the
influence of growth on tooth movements but also a function of
the soft tissue matrix surrounding the hard tissue structures. It
has been stressed that in the absence of muscular imbalance, a
well-established interdigitation may greatly assist in maintaining
the end result of tooth movement.
25
PERIODONTAL FORCE AND RELAPSE
29
He found that,
The percentage of overbite relapse was clearly greater
than that of overjet relapse.
The maxillary intercanine width was more stable than
the mandibular intercanine width.
He pointed out that this may be explained by the fact
that “whereas the mandible continues to grow
downward and forward, the maxilla is more stable” and
that “the lower dentition is confined within the
maxillary arch thereby assuming a smaller arch length
over time.”
30
Sadowsky and Sakols in AJO 1982 evaluated the long-term
stability of orthodontic treatment in a group of ninety-six
former patients who were treated between 12 and 35 years
previously with a full-banded edgewise appliance prior to
adulthood, with an average posttreatment time of 20 years.
Patients had Class I and Class II malocclusions only.
31
They concluded that,
It was apparent that many years after orthodontic treatment
a large number of cases (72 percent) exhibited dental
relationships that were outside an ideal range.
In most cases, however, patients showed an improvement in
their occlusions over the long term.
In contrast, the long-term result as compared to the original
malocclusion exhibited increased overbite in fourteen cases
(16 percent), increased mandibular anterior crowding in nine
cases (9 percent), and increased overjet in five cases (5
percent).
It is suggested that orthodontists should be well aware of
long-term changes in dental relationships many years after
treatment and take these into account when advising patients
as to the potential benefits of orthodontic treatment.
32
Uhde et al (Angle 1983) examined the posttreatment
changes in 72 patients treated with edgewise mechanics,
of which 27 had extractions and 45 were treated by non-
extraction means.
Retention of the teeth was done with an upper Hawley
type appliance and a lower fixed lingual retainer.
The patients were from 12 to 35 years out of retention
when the study was performed.
33
The findings were that,
Overbite and overjet tended to increase irrespective of the
initial malocclusion.
The molar relationships shifted slightly toward Class II
with time, and the intercuspid width was in general unstable
in the lower arch and more stable in the upper arch.
All groups showed some posttreatment crowding in the
lower arch, but less than the pretreatment.
No difference was found in the amount of postretention
crowding between patients with extractions and those
without extractions.
34
Vaden and Harris in AJO 1997 quantified changes in tooth
relationships in a series of 36 patients who were treated with
premolar extractions and fixed conventional edgewise
appliances and evaluated at 6 years and again at 15 years after
treatment. They concluded that,
The maxillary and mandibular arches became shorter and
narrower with age.
More than half (58%) of the mandibular incisor irregularity
index correction was maintained. At the second recall
examination, 15 years after treatment, the mandibular incisor
irregularity index averaged 2.6-well within the range termed
"minimal irregularity" by Little.
35
Most of the posttreatment mandibular incisor irregularity
in this sample was at the lateral incisor-canine contact area,
with the canine slipping anterior to the lateral incisor, giving
the arch a square appearance. This slippage at the lateral
incisor-canine contact area may have resulted from the
canine's return to the pretreatment intercanine width or from
the anterior component of force.
Most (96%) of the maxillary incisor irregularity
correction was maintained. At the second recall, the
maxillary irregularity index was only 1.8.
More than 90% of the patients in this study were better off
15 years after treatment than they were before treatment.
36
Burleigh in AJO 1998 used a case-control study
design to test whether pretreatment malalignment in
terms of irregularity and spacing of the maxillary
anterior teeth and the quality of the orthodontic
alignment are of significance for postretention
relapse of alignment.
Sets of study models made before and after
orthodontic treatment, and long-term out of retention
of 745 patients were screened.
37
The results suggest that,
Anatomic contact point displacement of the maxillary
anterior teeth and maxillary incisor rotation relative to the
dental arch, as well as interdental spacing before treatment,
are significant risk factors for postretention relapse of
alignment.
The pattern of postretention contact point displacement
and interdental spacing may be random relative to the
pattern of initial tooth positions, whereas the pattern of
rotational displacement relative to the dental arch has a
strong tendency to repeat itself.
38
Al Yami et al in AJO 1999 studied the stability of
orthodontic treatment after 10 years postretention. Dental
casts of 1016 patients were evaluated for the long-term
treatment outcome using the Peer Assessment Rating (PAR)
index. The PAR index was measured at the pretreatment
stage, directly posttreatment, postretention, 2 years
postretention, 5 years postretention, and 10 years
postretention.
39
The results indicate that 67% of the achieved orthodontic
treatment result was maintained 10 years postretention.
About half of the total relapse (as measured with the PAR
index) takes place in the first 2 years after retention. All
occlusal traits relapsed gradually over time but remained
stable from 5 years postretention with the exception of the
lower anterior contact point displacement, which showed a
fast and continuous increase even exceeding the initial score.
The results of this type of studies enable clinicians to
inform their patients about treatment limitations in order to
better meet their expectations.
40
ARCH LENGTH, ARCH WIDTH AND ARCH FORM
CHANGES
41
Shapiro (AJO 1974) studied the posttreatment stability of
patients with Class I and Class II malocclusions, treated with
and without extractions and found that Class II division 2
cases had a greater ability to maintain intercanine width
increases in the lower arch than Class II division 1 and Class I
cases. He further noted that the arch length reduction during
treatment in the Class II division 2 cases was less than in the
other types of malocclusions.
43
Simons (AJO 1973) found that patients with an initially
deep overbite had the deepest overbite 10 years
postretention and that protrusion of incisors was correlated
with overbite relapse but was not related to whether or not
extractions were performed. He believed that occlusal plane
changes during treatment tended to relapse to their original
angulation, and this correlated with deep bite relapse. He
concluded that mandibular growth, with a vertical
component, was correlated with overbite stability.
44
Most studies evaluating overbite stability are those in
which the overbite was corrected by molar extrusion.
45
Dake and Sinclair (AJO 1989) studied the stability of
incisor intrusion as a method of correcting deep bite. They
studied incisor intrusion with the utility arch in 30 Class II
patients with an overbite of more than 50 percent. All of
these patients were treated without extraction while they
were still growing. They found that after treatment,
Maxillary incisors uprighted and extruded about 2 mm
after being intruded an average of only 1.2 mm. Since all
measurements were made at the incisal edge, it is
questionable if true intrusion was achieved or just flaring
and molar extrusion.
46
However, deep overbite was successfully treated in
these patients since molar extrusion and growth did
occur during and following treatment.
Lower incisor intrusion during treatment was not
associated with posttreatment overbite relapse.
They also noted overbite relapse of 20 percent
using reverse curve of Spee wire mechanics and
overbite relapse of 34 percent in then group treated
with utility arch mechanics.
47
MANDIBULAR ANTERIOR CROWDING - RELAPSE
STUDIES
48
The conclusions derived were,
The crowding of the incisors was an anatomic-
physiologic phenomenon of adaptation observed in
orthodontically treated cases, as well as in untreated cases,
which resulted from the combination of several factors,
such as sex, anatomic predisposition dolichocephalic or
long-faced persons, tooth-size discrepancies, exaggerated
overbite, extrusion of the canines, reduction of the
intercanine width, age, muscle function, and, in some
cases, imperfect mechano-therapy.
There was less crowding of the incisors in the treated
group. Thus, it is assumed that treatment has a favorable
influence over the stability of the dental arches.
49
The larger the mesiodistal width of the incisors, the greater
the crowding will be, if there is a lack of proportion.
Maxillary and mandibular incisors were larger in males.
Crowding of the mandibular incisors was more noticeable
in males.
The third molars were not related to crowding of the
incisors.
Age was a positive but secondary factor in crowding of the
incisors.
In general, the values and differences of the variables
between sexes turned out to be more regular and significant in
females.
Positional changes of teeth were noted to be less in the
maxilla than in the mandible.
50
Little, Wallen in AJO 1981 evaluated the mandibular
anterior alignment, using serial long-term dental cast
records of cases treated by conventional edgewise
orthodontic means following removal of all four first
premolars. Sixty-five cases with complete records before
treatment, at the end of treatment, and a minimum of 10
years out of retention (at least 10 years after complete
removal of all retainer devices) were taken.
51
They concluded that,
Long-term alignment was variable and unpredictable.
No descriptive characteristics, such as Angle class, length of
retention, age at the initiation of treatment, or sex, and no
measured variables, such as initial or end-of-active-treatment
alignment, overbite, overjet, arch width, or arch length, were
of value in predicting the long-term result.
Arch dimensions of width and length typically decreased
after retention whereas crowding increased. This occurred in
spite of treatment maintenance of initial intercanine width,
treatment expansion, or constriction.
54
Long-term changes in incisor alignment are highly variable,
and chances of maintaining incisor alignment are less than
50%, despite successful occlusal results at the time of
appliance removal.
Narrow pretreatment intercanine width and high
pretreatment incisor irregularity were significant predictors of
relapse. Treatment increase of intercanine width and
postretention decrease of intercanine width and arch length
were associated with relapse.
These results may support a rationale for “semi-permanent”
retention of the mandibular anterior segment following
appliance removal.
55
Anwar Ali Shah in AJO 2003 reviewed the mandibular
incisor postretention stability outcomes in the setting of
different treatment techniques and different ages of
beginning orthodontic treatment. He reviewed
posttreatment studies by various authors and concluded
that,
All the studies reviewed demonstrate all the inherent
problems of a retrospective study.
Randomized controlled trials would be the best solution;
these are currently difficult due to problems with ethical
approval, difficulty of a long term follow-up, and drop out
of patients from the study.
56
Unless a study can be designed in which both
groups, extraction and non-extraction, are equally
likely to make either decision, no valid conclusion can
be derived.
Mandibular incisor relapse seems to be minimal
when palatal expansion is combined with a prolonged
retention period.
In the future, it would be interesting to study
mandibular relapse in patients having palatal
expansion and also comparable retention periods as
patients having first premolar extractions.
57
ROLE OF MANDIBULAR 3RD MOLARS IN
MANDIBULAR ANTERIOR CROWDING
58
Studies Relating Third Molars to Crowding of the Dentition
60
Ades et al, Joondeph and Little (AJO 1990) in their
cephalometric study, found no significant differences in
mandibular growth patterns between the various third
molar groups whether erupted, impacted or congenitally
missing, also with and without premolar extractions.
They concluded that there is no basis for
recommending prophylactic third molar extractions to
alleviate or prevent mandibular incisor crowding.
61
Bishara in AJO 1999 reviewed the various pertinent
studies that studied the role of third molars in lower
anterior crowding. He concluded that,
The influence of the third molars on the alignment of
the anterior dentition may be controversial, but there is no
evidence to incriminate these teeth as being the only or
even the major etiologic factor in the posttreatment
changes in incisor alignment.
The evidence suggests that the only relationship
between these two phenomena is that they occur at
approximately the same stage of development, i.e., in
adolescence and early adulthood. But this is not a cause
and effect relationship.
If extraction is indicated, third molars should be removed
in young adulthood rather than at an older age.
62
CURVE OF SPEE AND ITS RELAPSE
63
Smaller mandibular plane angle, smaller FOP-MP angle,
mesially inclined first and second molars, deep overbite, and
increased overjet all correlated with deeper pretreatment
curve depth.
The mesiobuccal cusp of the first molar relapsed 20% and
continued to be the deepest part of the curve.
Patients with fixed retainers after treatment exhibited
significantly less relapse than those with removable
mandibular retainers.
This study found no relationship between skeletal
measurements (FMA, ANB, PFH, LAFH) to curve of Spee
relapse. This is in contrast to findings by Givins (1970), who
found more relapse in patients with low mandibular plane
angles.
64
No significant differences in curve of Spee relapse were
found between Class I, Class II division 1, or Class II
division 2 malocclusions and also between extraction and
non-extraction groups.
Patients with more second molar uprighting during
treatment exhibited more curve relapse than those with less
molar uprighting.
The more the curve of Spee was leveled with treatment,
the more it relapsed after treatment.
65
EXTRACTION VS NON-EXTRACTION
TREATMENT – RELAPSE STUDIES
66
Sandusky (1983) reported on postretention stability of 85
extraction cases treated by Tweed and Tweed Foundation
members. He reported less than 10 percent relapse of the
lower incisors using Little’s irregularity index. He found the
lower incisors tended to move forward postretention and the
occlusal plane-Frankfort horizontal plane-angle decreased.
67
Little and Riedel in Angle 1990 evaluated 30 patients who had
undergone serial extraction of deciduous teeth plus first premolars
followed by comprehensive orthodontic treatment and retention.
Records were taken for the stages pre-extraction, start of active
treatment, end of active treatment, and a minimum of 10 years
postretention. All cases were treated with standard edgewise
mechanics and were judged clinically satisfactory by the end of
active treatment.
Results showed that,
Twenty-two of the 30 cases (73%) demonstrated clinically
unsatisfactory mandibular anterior alignment postretention.
Intercanine width and arch length decreased in 29 of the 30
cases by the postretention stage.
There was no difference between the serial extraction sample
and a matched sample extracted and treated after full eruption.
68
McReynolds, Little in Angle 1991 evaluated the
dental casts and cephalometric radiographs of 46
patients, treated with mandibular second premolar
extraction and edgewise orthodontic mechanotherapy,
for changes over a minimum 10-year postretention
period. The sample was divided into two groups: early
(mixed dentition) extraction of mandibular second
premolars and late (permanent dentition) extraction of
mandibular second premolars.
69
Results showed,
No difference in long-term stability between the two
groups. Arch length and arch width decreased with time
and incisor irregularity increased throughout the
postretention period.
No predictors or associations could be found to help the
clinician in determining the long-term prognosis in terms
of stability. The sample was regrouped according to the
postretention degree of incisor irregularity.
Statistically significant differences in cephalometric
measurements were found between the minimally crowded
group and the moderately to severely crowded group.
70
Paquette, Beattie, and Johnston in AJO 1992 compared
the long-term effects of extraction and nonextraction
edgewise treatments in 63 patients with Class ll, Division 1
malocclusions. A lateral cephalogram, study models, and a
self-evaluation of the esthetic impact of treatment were
obtained from each of the 33 extraction and 30 nonextraction
subjects. The average posttreatment interval was 14.5 years.
They concluded that,
For the borderline patient, nonextraction treatment
produced a significantly more protrusive denture (about 2
mm), both at the end of treatment and at recall over a decade
later.
71
Despite the significant between-treatment differences,
the majority of the subjects in both groups showed less
than 3.5 mm of lower anterior irregularity.
In general, the pattern of relapse was unrelated to the
type of treatment or to the posttreatment position and
orientation of the denture and, instead, appears to
constitute a dentoalveolar compensation produced by the
differential growth of the jaws following treatment.
Ultimately, both the overjet and molar corrections
were derived almost entirely from the differential growth
of the jaws, rather than tooth movement relative to basal
bone
72
Luppanapornlarp and Johnston in Angle 1993 assessed
the anatomical basis of the extraction/nonextraction
decision and performed a long-term comparison of
outcomes in “clear-cut” extraction and nonextraction
Class II patients. They concluded that,
Premolar extraction reduces soft- and hardtissue
convexity by 2–3 mm, whereas nonextraction therapy has
little effect
In general, posttreatment changes (including an
additional convexity reduction) are about the same in both
groups
73
When growth is finished, clear-cut nonextraction
patients tend to have “flatter” profiles than do premolar-
extraction patients who present with ponderable
crowding and spacing
Pre- and posttreatment tooth movements tend to be
related to the pattern of jaw-growth; some forms of
relapse, therefore, may be a dentoalveolar compensation
for residual posttreatment growth.
In nonextraction treatment, the upper buccal
segments are commonly “distalized,” whereas they tend
to come forward if premolars have been extracted.
74
Elms, Buschang and Alexander in AJO 1996 evaluated the
long-term stability of Class II, Division 1 in 42 patients (34
females and 8 males) treated with nonextraction cervical face
bow therapy. Model analysis and cephalometric analysis were
performed. The results showed that,
Mandibular intercanine width decreased 0.3 mm during the
postretention period; the remaining width measures increased
or remained stable.
Arch length, which did not change during treatment,
decreased 1.0 mm after treatment.
Both overjet (0.5 mm) and overbite (0.4 mm) showed small
increases after retention.
Mandibular incisor irregularity was decreased 2.7 mm
during treatment and increased only 0.4 mm after treatment.
75
ANTERIOR OPEN BITE AND RELAPSE STUDIES
78
Kim et al in AJO 2000 evaluated the stability of
anterior openbite correction in 55 white patients
treated with multiloop edgewise archwire therapy. The
lateral cephalograms were analyzed for skeletal,
esthetic, and dentoalveolar changes. The results
suggest that,
The openbite was corrected by retraction and
extrusion of the anterior teeth and the uprighting
movement of the posterior teeth.
The upper and lower occlusal planes moved toward
each other.
79
There were some significant changes in the skeletal
variables in the growing group. The anterior LFH,
anterior TFH, and posterior LFH increased. The palatal
plane moved downward anteriorly, and the gonial angle
decreased. There were not any significant changes in
skeletal variables for the nongrowing group. There was
retraction of the upper lip in both the growing and the
nongrowing groups.
The correction of openbite obtained by the MEAW
therapy was proven to be very stable.
The relapse in the overbite during the 2-year follow-up
period was 0.23 mm for the growing group and 0.35 mm
for the nongrowing group; these figures were not
significant.
80
Freitas et al in AJO 2004 evaluated the stability of extraction
therapy for the anterior open bite in the permanent dentition an
average of 8.35 years after retention.
Records were obtained for pretreatment, posttreatment,
postretention stages from 31 patients who had undergone
orthodontic treatment with fixed appliances. The results
suggested that,
Eight patients (25.8%) showed a clinically significant
relapse of the open bite. Consequently, 74.2% of the patients
in the experimental group showed a clinically significant
stability of the anterior open bite correction in the long term.
During posttreatment period counterclockwise rotation of
the mandible occurred and this might have contributed to the
stability of the overbite after treatment
This study suggests that the extraction approach seems to be
more stable than non-extraction.
81
ORTHOPEDIC TREATMENT AND RELAPSE STUDIES
84
Mew in AJO 1983 studied twenty-five patients (10 boys, 15
girls) who were consecutively treated with maxillary
expansion. The cases were overexpanded 2 to 4 mm. The
expansion was measured 2 or 3 months out of retention to
allow the overexpansion to settle. Measurements were made
again 2½ years out of retention. The net expansion had been
3.5 mm., and this had subsequently not relapsed.
85
Moussa et al, O’Reilly in AJO 1995 evaluated the
long-term changes of maxillary and mandibular dental
arch measurements in patients who were treated with
the soft tissue-borne palatal expander and edgewise
appliances and its stability.
The sample comprised of 165 dental casts randomly
selected from patients who had been out of retention for
8 to 10 years at a mean age of 30 years.
86
They concluded that,
Maxillary intercanine width and maxillary and mandibular
intermolar widths after retention closely approximated the
posttreatment dimensions and were larger than their
pretreatment dimensions.
Mandibular intercanine width, arch length, and arch
perimeter after retention closely approximated pretreatment
dimensions.
Incisor irregularity after retention was minimum for both
maxillary and mandibular arch.
Treatment with the rapid palatal expander presented good
stability for upper intercanine width, upper and lower
intermolar widths and incisor irregularity.
Lower intercanine, arch length, and perimeter presented
poor stability.
87
Jeffrey L. Berger in AJO 1998 examined and
compared the stability of orthopedic and surgically
assisted rapid palatal expansion over time. Orthopedic
expansion group consisted of 14 males and 10 females
with ages ranged from 6 years to 12 years and
Surgically assisted rapid palatal expansion group
consisted of 12 males and 16 females with ages
ranging from 13 years to 35 years. Dental models and
PA cephalograms were obtained immediately before
and after expansion, at removal of the expansion
device, and 1 year after removal of the appliance.
88
From the study he concluded that,
Clinically, there is no difference in the stability of
surgically assisted rapid palatal expansion and
nonsurgical orthopedic expansion.
The length of time after appliance removal was a
year or slightly longer. These patients were kept in
retention during the 1-year period thus demonstrating
the importance of retainers to control perioral forces
and maintain stability. Both the orthopedic and the
surgical groups showed stable results.
89
CHIN CUP THERAPY
90
At the end of the follow-up period (an average of 9
years), only 6 of the 52 patients had clinical relapse
(overjet ≤0)
At the end of treatment, the best predictors of relapse
seem to be low Wits appraisal, ANB angle, and overbite,
and large SNB.
Significantly greater decreases of the Wits appraisal
and increases of ramus length during the follow-up were
further associated with relapse.
Relapse appears to be affected by increased growth of
the mandibular ramus and the ramus growth was
remarkable only in patients with reduced overbite, low
Wits appraisal and ANB angle, and high SNB angle.
91
FUNCTIONAL APPLIANCE TREATMENT AND
RELAPSE STUDIES
92
Pancherz and Hansen in EJO 1986 studied a group of
patients with malocclusions who were treated with the
Herbst appliance in the early permanent dentition 6 and
12 months after active treatment and found that
dentoalveolar and skeletal relapse was about 30% of the
accomplished treatment effect.
The relapse occurred primarily during the first 6 months
after treatment and resulted in the tendency toward
increased overjet.
93
Pancherz in AJO 1991 performed a long term
cephalometric investigation to analyze the nature of Class
II relapse after Herbst appliance treatment, comparing
stable and relapse cases at least 5 years after treatment. A
total of 118 patients with Class II, Division 1
malocclusions were treated with the Herbst appliance.
Lateral cephalograms taken before and immediately after
Herbst treatment, as well as 6 months and 5 to 10 years
after treatment, were analyzed.
94
The results revealed that,
Relapse in the overjet and sagittal molar relationship
resulted mainly from posttreatment maxillary and mandibular
dental changes.
In particular, the maxillary incisors and molars moved
significantly to a more anterior position in the relapse group
than in the stable group.
The interrelation between maxillary and mandibular
posttreatment growth was favorable and did not contribute to
the occlusal relapse.
It is hypothesized that the main causes of the Class II
relapse in patients treated with the Herbst appliance were a
persisting lip-tongue dysfunction habit and an unstable cuspal
interdigitation after treatment.
95
Wieslander in AJO 1993 investigated the long-term effect
of treatment with headgear-Herbst appliance in early
mixed dentition in children with severe Class II
malocclusions.
A group of children age 8 years 8 months was initially
treated for 5 months with a headgear-Herbst appliance
followed by a 3- to 5-year period of activator retention.
96
Positive findings of the study includes the following:
A rapid improvement of the anteroposterior jaw
discrepancy because of 24-hour wear of the appliance for 5
months.
A significant maxillary effect during active treatment and
retention resulting in a 2.3 mm posterior gain after
retention, which compensates for the mandibular relapse
tendency. It resulted in an average statistically and
clinically significant 2.9° reduction of the ANB angle and a
3.8 mm skeletal improvement of the sagittal jaw
relationship out of retention.
97
Negative findings include the following:
A prolonged retention ranging over several years of
activator wear was necessary to minimize relapse after
Herbst treatment.
A modest long-term effect on the mandible 8 years after
treatment. In many cases the long-term mandibular effect
was considerably larger and of clinical importance.
However, in other cases that cooperated poorly during
retention, it was less.
A rather small increase in mandibular length. The
significant average 2.0 mm increase in the condylion-
gnathion distance observed after 5 months of Herbst
treatment was reduced to 1.2 mm after retention and was
not statistically significant.
98
Somchai Satravaha in AJO 1999 examined the skeletal
changes produced by Class III activator during the
treatment of patients with skeletal Class III malocclusions
and characterized the stability of these changes in the years
after treatment (6.6 ± 2.1 years after the end of activator
treatment). The results indicated that,
During the treatment, the Class III activator produced a
statistically significant skeletal effect and this change
remained through the postactivator period.
The gonial angle exhibited a compensatory decline
during the postactivator period.
The skeletal profile was improved after the treatment
and was not lost during the posttreatment period despite
significant increase in maxillomandibular differential.
99
ORTHOGNATHIC SURGERY AND RELAPSE
STUDIES
100
Willmar (1974) undertook the first quantitative follow-up
study on LeFort I osteotomy with the use of surgically
placed metal markers. Although 106 patients were studied,
only three had ''idiopathic long face.'' These cases
demonstrated stability of markers and occlusion throughout
the 1-year observation period, with an ''insignificant" 10%
superior relapse occurring at the anterior marker.
101
Hartog (1982) evaluated skeletal stability and soft-tissue
changes after superior repositioning of the maxilla, and
reported that good stability was attained. The sample
included multiple segments and combined procedures
with only three one-piece osteotomies.
102
Proffit, Phillips, and Turvey in AJO 1987 analyzed the
cephalometric data from 61 patients who had undergone
superior repositioning of the maxilla via LeFort I osteotomy
by means of the downfracture technique and evaluated the
stability of skeletal and dental landmarks at various time
intervals up to 1 year.
None of these patients had concurrent mandibular ramus or
body osteotomy except genioplasty and all had at least 2
mm intrusion at the maxillary incisor or molar.
The results indicated that,
During the first 6 weeks postoperatively, the maxilla
showed a strong tendency to move farther upward in the
patients in whom it was not stable.
The posterior maxilla was vertically stable in 90% of the
patients, the anterior maxilla in 80%.
103
Horizontally, skeletal landmarks were stable in 80%,
but when changes occurred, there was a tendency for
the anterior maxilla to move back when it had been
advanced.
After the first 6 weeks, the posterior maxilla was
stable vertically in all patients, but in 20% anterior
maxillary landmarks moved downward, opposite to the
direction of movement during fixation.
In 11 of the 15 patients who demonstrated vertical
changes postsurgery, the movement from fixation
release to 1 year follow-up was opposite and
approximately equal to the initial change, so that the net
movement after 1 year was less than 2 mm.
104
Only 6.5% (four patients) demonstrated 2 mm or
greater net vertical movement for any of the variables
studied 1 year after surgical treatment.
105
MANDIBULAR SURGERIES AND ITS RELAPSE
106
From the results, relationships between specific
parameters and skeletal relapse have been
demonstrated:
Positional change of the proximal segment was
found to be the most important parameter in
determining stability or relapse of the advanced
mandible.
Anteroinferior condylar displacement and increase in
posterior facial height at the time of surgery or
immediately postoperatively were associated with
subsequent skeletal relapse of the distal mandibular
segment.
107
The magnitude of advancement was a primary factor in
mandibular stability. As the magnitude of advancement
increased, the net amount of relapse tended to increase.
The dynamic function and variability of the mandible's
musculoskeletal system and its periosteal integument
may play a dominant role in the nature of the
postsurgical response.
Preoperative measurement of the mandibular plane
angle did not prove to be a reliable predictor of
subsequent mandibular relapse. However, patients with
high mandibular plane angles did undergo more relapse
than did patients with either normal or low angles.
No significant relationship was found between
skeletal relapse and the age of the patient.
108
Huang and Ross in AJO 1982 evaluated the short-term
and long-term effects of surgical lengthening of the
retrognathic, growing mandible in children. Twenty-two
patients 12 boys and 10 girls underwent mandible-
lengthening procedures at the mean ages of 14.1 years
(boys) and 13.4 years (girls). The results indicated that,
The response to this mandible-lengthening surgery in the
growing child varied with the amount of lengthening
performed but did not appear to vary with age (after 11
years), sex, etiology of the mandibular discrepancy,
mandibular plane angle, deep- or open-bite, or concomitant
surgical procedures.
109
Lengthening of more than 11 mm. was usually
accompanied by extensive relapse, with major
remodeling of the condyle or posterior symphysis or
both.
Lengthening of less than 9 mm. was followed by little
or no relapse.
110
Ellis and Carlson (J Oral Maxillofac Surg 1983)
performed an experimental investigation of mandibular
advancement in Macaca mulatta monkeys. The skeletal
stability two years after mandibular advancement surgery
with and without suprahyoid myotomy was evaluated. The
results demonstrated that,
Mandibular advancement without suprahyoid myotomy
was associated with a statistically significant 13% relapse.
There was no relapse after mandibular advancement with
suprahyoid myotomy.
It was concluded that, the suprahyoid muscle complex
does play a significant role in relapse after mandibular
advancement.
111
Because of the fact that skeletal relapse after mandibular
advancement without myotomy occurred only during the
period of maxillomandibular fixation, that is, the first 6
weeks, it was hypothesized that,
(1) The surgical procedure caused a stretching of the
suprahyoid complex resulting in a posteriorly oriented
force on the distal bone segment, and
(2) This force was transitory in nature and became
diminished over time as the suprahyoid muscle complex
adapted to the initial stretch by permanently increasing in
length.
112
David Carlson in AJO 1987 performed an experimental
investigation as a sequal to the previous investigation by
Ellis and Carlson (J Oral Maxillofac Surg 1983).
113
The results for the nonmyotomy group showed that,
(1) The suprahyoid complex was elongated approximately
two thirds the amount of mandibular lengthening,
(2) The major immediate adaptations within the suprahyoid
complex after the surgical procedure occurred at the
muscle-bone interface and the muscle-tendon interFace,
(3) The change in length at the muscle-tendon junction was
maintained throughout the 2-year follow-up period,
indicating that significant long-term adaptations took place
primarily at that location, and
(4) No significant short-term changes or long-term
adaptations were seen within the anterior digastric muscle
or the intermediate digastric tendon.
114
Within the myotomy group, it was found that (1) the
suprahyoid complex recoiled immediately after myotomy such
that the anterior belly of the digastric muscle became separated
from the advanced distal mandibular segment by more than
twice the amount of mandibular lengthening,
(2) The anterior digastric muscle remained essentially at this
posterior position throughout the 2-year follow-up period, and
(3) Though not significant, there was a trend for a decrease in
the length of the anterior digastric muscle belly.
116
The results showed that,
Statistically significant differences existed in the amount and
pattern of relapse; the fixation produced a significant effect on
retention of the corrected chin position.
As a consequence, downward and backward rotation of the
distal fragment of the mandible and compensatory incisor
extrusion were notably controlled.
However, upward shift of the posterior end of the distal
fragment occurred persistently even in the fixation group,
causing considerable intrusion of the posterior teeth in
comparison with the control group.
118
Numerous fixation techniques have also been advocated
to reduce postsurgical relapse. These have included,
(1) Upper- and lower-border wiring (Booth1981)
(2) Steinmann pins to stabilize the maxilla (Bennett
1985)
(3) Skeletal-wire fixation (Schendel 1980) and
(4) Rigid fixation (Champy 1978)
119
Brammer (1980) studied the stability after bimaxillary
surgery to correct vertical maxillary excess and
mandibular deficiency.
120
Satrom, Sinclair in AJO 1991 compared the stability of
rigid fixation with that of skeletal-wire fixation in a sample
of 35 patients who had undergone maxillary impaction and
simultaneous mandibular advancement.
121
Mandibular length was significantly more stable in
the rigid-fixation sample.
Rigid fixation produced significantly better control
of the angulation between the proximal and distal
segments. This rotational control appeared to be a
major factor in the increased overall stability of the
rigid-fixation sample.
122
CONCLUSION