ORIGINAL ARTICLE

Occlusal changes in orthodontically

treated subjects 40 years after treatment
and comparison with untreated control
subjects
Karina Maria Salvatore Freitas,a,b Camila Massaro,b Felicia Miranda,b Marcos Roberto de Freitas,b
Guilherme Janson,b and Daniela Garibc
Maring
a, Paran
a, and Bauru, S~ao Paulo, Brazil

Introduction: The objective of this study was to compare the aging changes of the dental arches in
orthodontically treated and untreated subjects after a 4-decade follow-up period. Methods: This retrospective
study analyzed 2 groups. The treated group comprised 29 patients (11 male, 18 female) presenting with Class
I or Class II malocclusions orthodontically treated with extractions of 4 first premolars. Dental models taken at
pretreatment (12.84 years), posttreatment (14.95 years), and long-term posttreatment (51.37 years) were
evaluated. The untreated (control) group consisted of 22 untreated patients with dental models taken at
13.32, 17.82, and 60.95 years of age. The dental models were digitized, and the following variables were
evaluated: Little irregularity index, intercanine, interpremolar and intermolar widths, arch length, arch
perimeter, overjet, and overbite. Interphase comparison of the treated group was performed with repeated
measures analysis of variance and Tukey tests. Intergroup comparisons were performed using t tests
(P \0.05). Results: Crowding was corrected with treatment but relapsed significantly in the long term.
Intercanine width increased with treatment and decreased in the long term. Interpremolar and intermolar widths,
arch perimeter, and length decreased with treatment and continued to decrease long-term posttreatment.
Overjet and overbite were corrected with treatment and remained stable in the long term. From posttreatment
to long-term posttreatment, a greater crowding increase was observed in the treated group than in the
untreated group. The treated group demonstrated a greater decrease in mandibular intercanine and maxillary
and mandibular interpremolar widths than the untreated sample. Overbite increased in the treated group and
decreased in the untreated group. The multiple regression analysis showed that previous 4-premolar
extractions orthodontic treatment is significantly associated with anterior crowding in the long term.
Conclusions: In the long-term, the treated patients showed relapse of crowding and a decrease in arch form.
Long-term changes of treated patients were different from untreated subjects. Relapse might have
contributed to greater changes in incisor crowding and arch widths observed in the treated patients. (Am J
Orthod Dentofacial Orthop 2021;-:---)

a
Department of Orthodontics, Uning
a University Center, Maring
a, Paran
a, Brazil.
b
Department of Orthodontics, Bauru Dental School, University of S~ao Paulo,
Bauru, S~ao Paulo, Brazil.
c
Department of Orthodontics, Bauru Dental School, and Hospital for Rehabilita-
tion of Craniofacial Anomalies, 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
Orthodontics, Bauru Dental School, University of S~ao Paulo, Alameda Oct
avio
Pinheiro Brisolla 9-75, Bauru, S~ao Paulo 17012-901, Brazil; e-mail, kmsf@
uol.com.br.
Submitted, June 2019; revised, April 2020; accepted, May 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.05.027
T
here is consensus in the literature that some
occlusal changes will inevitably occur after the
end of orthodontic treatment, known as
relapse.1-3 Prediction of these posttreatment changes
and underlying causes are of great value to
orthodontists, and the incessant search for these
answers is seen in the orthodontic literature.4-12 The
continuous occlusal posttreatment changes sometimes
cannot be distinguished from the normal process of
aging of the occlusion that occurs regardless of
whether the individual has been orthodontically
treated or not.13
The physiological and maturational changes of the
dentition, from childhood to adolescence and from

1
2 Freitas et al
young adulthood to late adulthood, constitute a gradual
process.13 Longitudinal studies in untreated sub-
jects1,14,15 showed that the arch dimensions change
over the years. It is also known that the aging process
slightly deteriorates some occlusal features of patients
with normal occlusion.16-18
From 21 to 28 years of age, patients with a Class I
malocclusion with good occlusion showed significant
changes in overbite, incisors irregularity, and arch
perimeter.19 From late adolescence until about half a
century of life, dental arch dimensions tend to decrease,
and incisors irregularity tends to increase in untreated
occlusion patients.15,16,20,21 Changes of the dental
arches are continuous as well as physiological mesial
migration of the permanent dentition that results in
anterior crowding, especially in the mandible.18 Overbite
and overjet are generally stable during adulthood.15,20,21
Evaluation of qualitative occlusal changes in patients
with normal occlusion over 47 years showed
deterioration of the anteroposterior occlusal relation-
ship.17 However, the marginal ridges, buccolingual
inclination, and interproximal contacts improved.17
The occurrence of dental crowding was the most
frequently detected change throughout life in untreated
patients and caused dissatisfaction with this occlusal
feature in 35% of the sample.17
Comparisons between untreated normal occlusions
and treated patients to clarify the differences of the
aging process and the relapse or posttreatment changes
are extremely important.22 Some changes in transverse
arch dimensions appear to be similar in patients treated
without extractions and in untreated subjects aged up to
18 years.23 The short-term posttreatment occlusal
relapse and maxillary irregularity are greater than the
physiological changes caused by the natural
development of untreated patients from 12 to 20 years
of age.22 Mandibular incisor irregularity increases
similarly in both treated and untreated groups from 12
to 20-28 years of age.22,24
To our knowledge, there is no long-term
comparison between treated subjects and untreated
occlusions followed into late adulthood. Therefore,
the objective of this study was to compare the aging
changes of the dental arches in orthodontically
treated and untreated subjects after a 4-decade
follow-up.
MATERIAL AND METHODS
This study was approved by the Ethics Committee in
Human Research of the Bauru Dental School, University
of S~ao Paulo. Sample size calculation was based on an a
significance level of 5% and a b of 20% to detect a min-
imum difference of 0.8 mm, with a standard deviation
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(SD) of 0.74 for the maxillary irregularity index.16 The
sample size calculation showed the need for 22 patients
in each group.
Two study samples were analyzed. The orthodonti-
cally treated group comprised retrospective records of
subjects treated by graduate students at Bauru Dental
School, University of S~ao Paulo, chosen according to
the following criteria: Class I or Class II Division 1 maloc-
clusion at the beginning of orthodontic treatment; pa-
tients with skeletal Class II malocclusion were not
included in the sample; treatment protocol with extrac-
tions of 4 first premolars; complete orthodontic treat-
ment with full maxillary and mandibular fixed
edgewise appliances (0.022 3 0.028-in slot); all perma-
nent teeth erupted up to the first molars, at the pretreat-
ment stage; absence of tooth agenesis and anomalies;
and no retention at the time of the follow-up records.
Pretreatment (T1), posttreatment (T2), and long-term
follow-up of at least 25 years after the end of orthodon-
tic treatment (T3) dental models should be available at
the time of the study. The sample comprised 29 subjects
of both sexes (11 male; 18 female), with a mean pre-
treatment age of 12.84 years (SD, 0.98; range, 11.50-
15.30). The mean final age was 14.95 years (SD, 1.24;
range, 12.77-18.09), and the mean treatment time was
2.10 years (SD, 0.65; range, 0.99-3.33). The mean age
at the long-term evaluation was 51.37 years (SD, 4.22;
range, 42.10-59.09). The mean time of long-term
posttreatment follow-up was 36.42 years (SD, 3.94;
range, 27.47-43.05). Sixteen subjects presented with
Class I malocclusions, and 13 had Class II malocclusions
(severity: 8 half-cusp Class II and 5 full-cusp Class II), all
treated with extraction of the 4 first premolars. As
retention, at the end of active orthodontic treatment,
all patients used a removable Hawley plate in the
maxillary arch, and 0.028-in stainless steel round wire
fixed retainer was bonded canine-to-canine in the
mandibular arch. The maxillary removable and the
mandibular canine-to-canine fixed retainer were used
on average 1.77 years (SD, 0.67; range, 0.79-3.33). All
maxillary removable and mandibular fixed retainers
were removed no later than 3.3 years after the end of
active orthodontic treatment. At T3, all subjects of the
treated group were free of retainers for more than
30 years.
Orthodontic mechanics for patients with Class I and II
malocclusions in the treated group was similar and
included fixed edgewise appliance 0.022 3 0.028-in
slot; extraoral headgear was used as anchorage to
maintain Class I relationship or to correct the Class II
molar relationship; the anterior teeth were retracted to
the extraction spaces with a rectangular archwire and
elastic chains, by sliding mechanics; Class II elastics
Freitas et al 3

Table I. List of patients from the untreated group showing the missing/rehabilitated teeth at the T3
Subject Sex Age at T3 (y) Tooth missing Rehabilitated with implant Rehabilitated with crown/prosthesis
1 F 60.08 – – 27, 37
2 F 63.08 17, 47 – –
3 F 60.91 26, 47 – 16, 24
4 M 61.25 16, 17, 36 22 –
5 M 58.41 – – –
6 M 61.66 – – 36
7 F 59.16 – – –
8 F 61.50 36 – 12, 22, 25, 26, 47
9 F 58.66 24, 27, 47 – 15, 16, 25, 26, 35, 36, 37, 45, 46
10 F 60.08 27, 37, 47 45, 46 14, 16, 25, 35
11 M 62.08 26, 34, 37, 46, 47 – 14, 25, 36
12 F 60.33 25, 47 46 14, 15, 24, 26, 36, 37, 43, 44, 45
13 M 61.41 16, 36, 45 34, 35, 37 46, 47
14 M 61.25 16, 17, 25, 26, 36, 47 – –
15 F 62.25 25, 37, 47 26, 35, 36, 44, 46 27
16 M 61.75 16, 26 – –
17 M 63.41 – – –
18 M 59.41 16, 17, 24, 26, 27, 36, 37, 46, 47 – 14, 15, 22, 25, 35, 45
19 F 60.08 – 45, 46, 47 17, 24, 25, 26, 27, 35, 36, 37
20 M 59.00 15, 26 36, 37 46
21 M 62.00 – – 26, 27, 46
22 M 63.25 27 16, 36, 46 45, 47
F, Female; M, male.

were used when necessary. All patients finished in Class I
molar and canine relationships, with adequate overjet,
overbite, and teeth alignment. The mean Peer
Assessment Rating index at the end of treatment was
2.68 (SD, 1.52), indicating a good orthodontic
finishing.25,26
The untreated group (with untreated occlusion)
comprised 22 subjects (12 males, 10 females) assessed
at 3 time points (T1, T2, and T3), with a mean age of
the subjects of 13.32 (SD, 1.00; range, 11.91-15.16),
17.82 (SD, 1.35; range, 16.08-22.08), and 60.95 years
(SD, 1.47; range, 58.41-63.41), respectively. The mean
period between the first and second evaluation (T2
T1) was 4.50 years (SD, 0.89; range, 4.08-8.25), and
the mean follow-up time was 43.12 years (SD, 1.51;
range, 39.58-45.33). The initial untreated sample group
was obtained from 1967 to 1974 and comprised 82
White subjects (39 men, 43 women). Dental models
were obtained at 13 (T1) and 17 years of age (T2). At
T1, all subjects had a clinically acceptable occlusion16,17
in the complete permanent dentition, dental and skeletal
Class I relationships (molar and canine Class I
relationship) in the permanent dentition, no crossbite,
positive overjet and overbite (ranging from 2 to
4 mm), and a maximum 2 mm of incisors’ crowding
with no previous orthodontic treatment. From April
2015 to May 2016, the sample was recalled, and dental
models were obtained (T3). Thirty-eight subjects were
contacted, and 27 were enrolled. Five of them were
excluded because of the following exclusion criteria:
orthodontic treatment performed until the follow-up
evaluation, complete tooth loss, and no dental models
at any of the 3 time points.
In the treated group, the only extracted teeth were
the 4 first premolars for orthodontic reasons. Patients
with other missing teeth were excluded from the sample.
However, for the untreated group, most patients missed
teeth from T2 to T3 and were not excluded from the
sample. Out of 22 patients of the UT group, 15 showed
at least 1 permanent tooth loss, but several missing teeth
were already rehabilitated with implants/prostheses.
Table I describes each missing/rehabilitated tooth of
the patients from the untreated group at T3. All subjects
at T3 presented good oral health, no periodontal disease,
and good overall health condition, without any systemic
disease.
Dental models from 3 stages of each individual were
used: T1, T2, and T3 for the treated subjects and in
similar stages for the untreated sample. All dental
models were digitized using an R700 3-dimensional
(3D) scanner (3Shape, Copenhagen, Denmark). Dental
model measurements were performed using the
OrthoAnalyzer 3-dimensional software (3Shape) by a
single examiner (K.M.S.F.).
The Peer Assessment Rating index, as described by
Richmond et al27 and scored with the American

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Table II. Results of the intergroup comparability of sex distribution (chi-square test) ages and observation times (in-
dependent t tests)
Variables Treated group, N 5 29 Untreated group, N 5 22 P value
Sex 0.237y
Males 11 12
Females 18 10

Treated group, N 5 29 Untreated group, N 5 22

Variables, y Mean SD (range) Mean SD (range) P value

Age T1 12.84 0.98 (11.50-15.30) 13.32 1.00 (11.91-15.16) 0.094z
Age T2 14.95 1.24 (12.77-18.09) 17.82 1.35 (16.08-22.08) 0.000*,z
Age T3 51.37 4.22 (42.10-59.09) 60.95 1.47 (58.41-63.41) 0.000*,z
Treatment/evaluation 2.10 0.65 (0.99-3.33) 4.50 0.89 (4.08-8.25) 0.000*,z
time T2 T1
Long-term posttreatment/ 36.42 3.94 (27.47-43.05) 43.12 1.51 (39.58-45.33) 0.000*,z
follow-up time T3  T2

*Statistically significant at P \0.05; yChi-square test; zIndependent t test.

weightings28 was assessed in the posttreatment dental
casts of the treated group to indicate the quality of the
orthodontic finishing.
The Little irregularity index for maxillary and mandib-
ular arches29,30 was measured to evaluate anterior
crowding. Arch dimensions measurements included in-
tercanine, interpremolar and intermolar widths, arch
perimeter, and arch length. Overjet and overbite were
also measured in the dental models. Missing teeth and
prostheses were not considered for measurements.
The differences between the final and initial stages
(T2 T1) were calculated to express the amount of
correction with treatment and amount of changes
from T1 to T2 in the untreated group. The differences
from the long-term posttreatment stage with the
posttreatment stage (T3  T2) were calculated to
express the amount of changes after treatment in the
long-term follow-up evaluation for the treated group
and from T2 to T3 to express the long-term follow-up
changes in the untreated group.
After a month from the first measurement, the dental
models of 15 subjects (45 pairs of dental casts) were
randomly selected and remeasured by the same
examiner (K.M.S.F.). The intraexaminer reliability was
assessed using intraclass correlation coefficients31 and
the Bland-Altman method.32 Normal distribution of
data was evaluated by the Shapiro-Wilk test. In contrast,
intergroup comparability of sex distribution and the age
and period of the evaluation was performed using
chi-square and t tests, respectively. Interphase
comparisons of the treated group were performed with
repeated measures analysis of variance and Tukey tests.
Intergroup comparisons at T1 and interphase changes
were evaluated using t tests.
A multiple regression analysis was performed to
verify the predictive factors for the long-term changes
of maxillary and mandibular anterior crowding
separately. Only variables with significant differences
between the groups at T3  T2 were considered for
the analysis. This way, the long-term changes of Little
irregularity index (Little T3-2) was considered as the
dependent variable for the following independent
variables: long-term overbite change (overbite T3-2),
long-term intercanine width change (3-3 T3-2),
long-term interpremolar width change (5-5 T3-2), and
treated/untreated group (T/UT).
All tests were performed with Statistica software
(version 7.0; Stat Soft, Tulsa, Okla), at P \0.05.
RESULTS
Intraclass correlation coefficients of the variables varied
from 0.92 to 0.99, indicating excellent intrarater agree-
ment.33 The variable with the widest limit of agreement
was the maxillary arch perimeter (1.12 and 1.19).
The groups were comparable regarding sex
distribution (Table II) and initial age (Table II). The
untreated group was older in the T2 and T3 time points
and had a greater follow-up period than the treated
group (Table II).
Because groups were not comparable regarding
follow-up time from T2 to T3, the untreated group
changes (T3  T2) were therefore annualized to the
corresponding treated group follow-up time.34-36
Therefore, all subjects in the untreated group had their
follow-up changes, for each variable, divided by their
follow-up time (of each patient individually), and then
multiplied by the mean long-term posttreatment time
(T3  T2) of the treated group.

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Freitas et al 5

Table III. Results of the interphase comparison of the treated group (repeated measures analysis of variance and
Tukey tests)
T1 T2 T3

Variables, mm Mean (SD) Mean (SD) Mean (SD) P value

Maxillary dental casts measurements
Mx Little 10.02 (3.80) A 0.93 (0.50) B 4.04 (1.47) C 0.000*
Mx 3-3 width 33.33 (3.13) A 34.54 (2.02) B 33.29 (2.27) A 0.000*
Mx 5-5 width 43.81 (3.09) A 42.91 (2.05) AB 41.30 (2.60) B 0.000*
Mx 6-6 width 48.58 (3.47) A 47.62 (2.43) AB 46.65 (2.92) B 0.000*
Mx arch perimeter 78.02 (6.15) A 64.59 (3.62) B 62.29 (3.10) C 0.000*
Mx arch length 30.03 (3.84) A 23.01 (2.82) B 21.89 (2.48) B 0.000*
Mandibular dental casts measurements
Md Little 8.92 (3.74) A 1.11 (1.01) B 5.39 (2.49) C 0.000*
Md 3-3 width 25.59 (1.75) A 27.00 (1.68) B 25.25 (1.79) A 0.000*
Md 5-5 width 37.83 (3.19) A 36.01 (1.65) B 34.07 (2.27) C 0.000*
Md 6-6 width 43.27 (2.97) A 41.12 (2.32) B 40.14 (2.74) C 0.000*
Md arch perimeter 65.34 (3.18) A 53.79 (2.39) B 51.13 (3.34) C 0.000*
Md arch length 22.74 (1.75) A 17.77 (1.30) B 16.91 (1.77) C 0.000*
Anterior relationships
Overjet 7.24 (3.04) A 2.70 (0.59) B 3.85 (1.84) B 0.000*
Overbite 3.38 (1.65) A 2.55 (0.51) B 2.86 (1.07) B 0.041*

Note. Different letters in the same row indicate the presence of a statistically significant between the groups indicated by the Tukey test.
Mx, Maxillary; Md, mandibular.
*Statistically significant at P \0.05.

In the treated group, crowding was corrected with
treatment and showed statistically significant relapse
in the long term. Intercanine width increased with treat-
ment and decreased in the long term. Interpremolar and
intermolar widths, arch perimeter, and length decreased
with treatment and continued to decrease long-term
posttreatment. Overjet and overbite were corrected
with treatment and remained stable in the long term
(Table III).
The comparison of the starting forms demonstrated
that the treated group presented greater crowding and
overjet than the untreated group (Table IV). Maxillary

Table IV. Intergroup comparison of the starting forms (independent t tests)

Treated group, N 5 29 Untreated group, N 5 22

Variables, mm Mean SD Mean SD P value

T1
Maxillary dental casts measurements
Mx Little 10.02 3.80 0.37 0.74 0.000*
Mx 3-3 width 33.33 3.13 33.24 2.08 0.905
Mx 5-5 width 43.81 3.09 46.91 2.22 0.000*
Mx 6-6 width 48.58 3.47 52.01 2.97 0.000*
Mx arch perimeter 78.02 6.15 73.56 3.41 0.004*
Mx arch length 30.03 3.84 27.01 1.71 0.003*
Mandibular dental casts measurements
Md Little 8.92 3.74 2.26 1.96 0.000*
Md 3-3 width 25.59 1.75 25.50 1.48 0.842
Md 5-5 width 37.83 3.19 39.95 2.08 0.009*
Md 6-6 width 43.27 2.97 45.13 3.50 0.053
Md arch perimeter 65.34 3.18 64.42 3.15 0.316
Md arch length 22.74 1.75 22.96 1.78 0.672
Anterior relationship
Overjet 7.24 3.04 2.87 0.66 0.000*
Overbite 3.38 1.65 3.13 0.98 0.551
Mx, Maxillary; Md, mandibular.
*Statistically significant at P \0.05.

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Table V. Results of intergroup comparison of T2 T1, T3  T2, and annualized changes of T3  T2 (independent
t tests)
Treated group, N 5 29 Untreated group, N 5 22

Variables, mm Mean SD Mean SD n P value

T2 T1: treatment changes/first follow-up changes
Maxillary dental casts measurements
Mx Little 9.09 3.79 0.30 0.92 22 0.000*
Mx 3-3 width 1.20 2.90 0.26 1.02 22 0.152
Mx 5-5 width 0.90 2.32 0.02 1.11 22 0.115
Mx 6-6 width 0.96 2.48 0.26 1.25 22 0.266
Mx arch perimeter 13.43 5.48 1.53 1.42 22 0.000*
Mx arch length 7.02 4.05 1.11 0.48 22 0.000*
Mandibular dental casts measurements
Md Little 7.81 3.62 0.87 1.05 22 0.000*
Md 3-3 width 1.41 1.68 0.04 0.52 22 0.000*
Md 5-5 width 1.83 2.55 0.08 1.44 22 0.003*
Md 6-6 width 2.15 2.26 0.12 2.29 22 0.002*
Md arch perimeter 11.56 3.04 1.30 1.35 22 0.000*
Md arch length 4.96 1.54 0.78 0.68 22 0.000*
Anterior relationship
Overjet 4.53 3.04 0.45 0.51 22 0.000*
Overbite 0.83 1.64 0.73 0.79 22 0.807
T3  T2: long-term posttreatment changes/long follow-up changes
Maxillary dental casts measurements
Mx Little 3.11 1.49 0.81 1.06 22 0.000*
Mx 3-3 width 1.25 1.76 0.41 0.98 21 0.057
Mx 5-5 width 1.62 1.84 0.02 1.33 10 0.014*
Mx 6-6 width 0.97 1.74 0.49 1.20 6 0.059
Mx arch perimeter 2.30 2.91 2.64 1.04 12 0.689
Mx arch length 1.13 2.75 1.10 0.90 13 0.975
Mandibular dental casts measurements
Md Little 4.28 2.79 1.54 1.27 22 0.000*
Md 3-3 width 1.75 1.89 0.68 1.09 22 0.022*
Md 5-5 width 1.93 1.88 0.73 1.97 13 0.000*
Md 6-6 width 0.98 1.72 0.30 1.38 6 0.098
Md arch perimeter 2.66 2.12 1.85 1.46 13 0.221
Md arch length 0.86 1.06 1.06 1.00 13 0.574
Anterior relationship
Overjet 1.15 2.09 0.39 0.88 20 0.138
Overbite 0.31 1.10 0.61 0.93 20 0.004*
T3  T2: annualized long-term posttreatment changes/long follow-up changes
Maxillary dental casts measurements
Mx Little 3.11 1.49 0.68 0.90 22 0.000*
Mx 3-3 width 1.25 1.76 0.35 0.83 21 0.038*
Mx 5-5 width 1.62 1.84 0.04 1.17 10 0.011*
Mx 6-6 width 0.97 1.74 0.43 1.07 6 0.067
Mx arch perimeter 2.30 2.91 2.25 0.91 12 0.965
Mx arch length 1.13 2.75 0.94 0.79 13 0.814
Mandibular dental casts measurements
Md Little 4.28 2.79 1.29 1.05 22 0.000*
Md 3-3 width 1.75 1.89 0.57 0.92 22 0.010*
Md 5-5 width 1.93 1.88 0.63 1.68 13 0.000*
Md 6-6 width 0.98 1.72 0.25 1.20 6 0.100
Md arch perimeter 2.66 2.12 1.58 1.29 13 0.099
Md arch length 0.86 1.06 0.91 0.92 13 0.870
Anterior relationship
Overjet 1.15 2.09 0.33 0.75 20 0.104
Overbite 0.31 1.10 0.51 0.79 20 0.006*
Mx, Maxillary; Md, mandibular.
*Statistically significant at P \0.05.

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Freitas et al 7

Fig 1. Box plots with mean differences, standard deviations, maximum, and minimum values showing
the T3  T2 changes for the maxillary dental casts' measurements for the treated and untreated
groups. gr, group.

and mandibular interpremolar widths and maxillary
intermolar width were greater in the untreated group
than in the treated group (Table IV). Maxillary arch
perimeter and length were greater in the treated than
in the untreated group (Table IV).
From T1 to T2, the treated group showed a greater
reduction of crowding, a greater increase in mandibular
intercanine distance, and a greater decrease in maxillary
and mandibular arch perimeter and length and
mandibular interpremolar and intermolar distances and
overjet than the untreated group (Table V). From T2 to
T3, the treated group showed a greater increase in
anterior crowding than the untreated group (Table V;
Figs 1 and 2). Intercanine and interpremolar widths
showed a greater reduction in the treated group
(Table V; Figs 1 and 2).
Overbite increased in the treated group and
decreased in the untreated group (Table V; Fig 3).
Results of the multiple regression analysis for maxillary
and mandibular anterior crowding showed that only
the treated/untreated variable was significantly related
to the long-term changes of anterior crowding
(Table VI). No other factor considered was predictive of
long-term changes of maxillary and mandibular anterior
crowding.
Results of the multiple regression analysis for
maxillary and mandibular anterior crowding showed
that only the treated/untreated variable was significantly
related to the long-term changes of anterior crowding
(Table VI). No other factor considered was predictive of
long-term changes of maxillary and mandibular anterior
crowding.
DISCUSSION
Initial age was similar in both groups. However, the
treated patients were younger than untreated patients

Fig 2. Box plots with mean differences, standard deviations, maximum, and minimum values showing
the T3  T2 changes for the mandibular dental casts' measurements for the treated and untreated
groups. gr, group.

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8 Freitas et al
Fig 3. Box plots with mean differences, standard
deviations, maximum, and minimum values showing the
T3  T2 changes for the anterior relationship measure-
ments (overjet and overbite) for the treated and untreated
groups.
in the second and third evaluations (Table II). Although
this is a limitation of our study, because no previous
comparison between treated and untreated patients
with a follow-up .30 years is known, the study results
are valid. The difference in T2 was approximately 3 years,
and at T3 was approximately 9 years. However, we
speculate that changes in the occlusion from the fifth
to the sixth decade of life is slight and could not impair
the present study findings.
Stage T2 was included only to show the amount of
correction obtained with orthodontic treatment in the
treated group and the minimal changes of the untreated
group. At T3, the difference of the mean ages was of
9.58 years; the treated group included patients from
42.10 to 59.09 years of age, whereas the UT group,
from 58.41 to 63.41 years of age (Table II). Despite
this numerical difference, at this age, the occlusal
changes are small and tend to decrease over time.37
From 11 to 17 years (most patients of the treated
group from T1 to T2), some growth can be seen;
however, we only evaluated changes in occlusion and
dental arches, and the changes of these features with
growth are less remarkable than in the craniofacial
complex.37 Bishara et al21 found that intercanine and
intermolar widths significantly increased between 3
and 13 years of age. After complete eruption of the
permanent dentition, there was no change or a slight
decrease in arch widths until 45 years of age.
The follow-up evaluation period (T2  T3) of the
treated group was 36.42 years after the end of the active
orthodontic treatment, and the follow-up of
the untreated occlusion group is 43.12 years after the
second observation. Because of this difference in the
follow-up period between the groups, the changes of
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the untreated group from T2 to T3, which presented
the longer follow-up period, were annualized to match
the corresponding period of follow-up of the treated
group.34-36 Annualization of data allows scientifically
reliable comparison that is very close to the actual
changes.34-36
A limitation of this study was the frequency of tooth
loss in the untreated sample (control) (Table I), whereas
the treated sample displayed no tooth loss except teeth
that were extracted (4 first premolars). The explanation
for these intergroup differences was the different
inclusion criteria used for each sample that was obtained
separately and independently. The initial sample universe
for untreated patients was more restricted (n 5 82, un-
treated occlusion subjects). Therefore, all patients who
agreed to participate in the study were selected and
included in the sample. In contrast, the initial sample uni-
verse for the treated group was the files of the university
displaying approximately 500 patients treated with 4 pre-
molar extraction in the 70s and 80s. Considering the
greater initial universe for sample selection in the treated
group, tooth loss was an exclusion criterion. In addition,
measurements were not performed on teeth replaced
with implants and prostheses to avoid error because of
tooth shape differences. For these reasons, in some of
the variables in the T2-T3 phase, the number of measure-
ments for statistical analysis was reduced, and the results
should be interpreted with caution. The number of pa-
tients included for measurement in the untreated group
for each variable in the T3  T2 phase is in the sixth col-
umn of Table V.
The orthodontic treatment was performed by
graduate students but supervised by expert professors,
but this did not influence the outcomes and the relapse
in the present study. Dyken et al26 evaluated the
orthodontic finishing of 5 orthodontists who completed
phase III of the American Board of Orthodontics and
compared patients treated by orthodontic graduate
students and found no difference in orthodontic
treatment outcome and quality of finishing.
Crowding was corrected with treatment and relapse
significantly in the long-term in the treated group
(Table III), confirming several previous studies in the
literature.8,10 Some studies showed less crowding
relapse,38-40 but with shorter follow-up time,38,40
less initial crowding,39 and evaluating different
malocclusions and treatment protocols.38,39
At the first observation (T1), the treated group
presented greater maxillary and mandibular crowding
than the untreated group (Table IV), as expected. The
anterior crowding was corrected during orthodontic
treatment in the treated group and showed a slight
increase in the untreated group (Table V).
Freitas et al 9

Table VI. Multiple regression analysis considering changes of anterior crowding (Little T3-2) as the dependent var-
iable and overbite change (overbite T3-2), intercanine and interpremolar widths change (3-3 and 5-5 T3-2), and T/UT
as independent variables
Multiple regression analysis: maxillary arch

SS DF MS F P value
Intercept 94.579 1 94.579 40.947 0.000*
Overbite T3-2 0.013 1 0.013 0.005 0.939
Mx 3-3 T3-2 0.730 1 0.730 0.316 0.577
Mx 5-5 T3-2 0.079 1 0.079 0.034 0.853
Group (T/UT) 28.839 1 28.839 12.485 0.001*
Error 80.841 35 2.309
Multiple Multiple Adjusted
R R2 R2 SS model MS model SS residual MS residual F P value
Mx Little 0.593 0.351 0.277 43.886 10.971 80.841 2.309 4.750 0.003*
T3  T2

Multiple regression analysis: mandibular arch

SS DF MS F P value
Intercept 174.149 1 174.149 31.566 0.000*
Overbite T3-2 21.997 1 21.997 3.987 0.053
Md 3-3 T3-2 4.057 1 4.057 0.735 0.396
Md 5-5 T3-2 0.072 1 0.072 0.013 0.909
Group (T/UT) 26.207 1 26.207 4.750 0.035*
Error 204.125 37 5.516
Multiple Multiple Adjusted
R R2 R2 SS model MS model SS residual MS residual F P value
Md Little 0.602 0.363 0.294 116.534 29.133 204.125 5.516 5.280 0.001*
T3  T2

SS, Sum of squares; DF, degree of freedom; MS, mean squares; Mx, maxillary; Md, mandibular.
*Statistically significant at P \0.05.

The maxillary and mandibular crowding relapse
because of orthodontic treatment (T3  T2) in the treated
group was greater than the increase in anterior crowding
because of the aging of the occlusion in the untreated
group (Table V). This is similar to a previous study evalu-
ating short-term relapse and physiological changes in
crowding from 15 to 20 years of age.22 These findings
indicate that incisor crowding observed after orthodontic
treatment is a mixture of relapse with the occlusal phys-
iological maturational process. According to Vaden
et al,41 the continued change in incisors alignment gener-
ally cannot be distinguished from normal aging processes
that occur, regardless of whether a subject had been
treated orthodontically or not. The subjects of the treated
group were treated with 4-premolar extractions and pre-
sented moderate to severe crowding before the orthodon-
tic treatment. If patients with slight or no crowding were
evaluated, the results could be different because it is
known that relapse is correlated to the severity of the
initial anterior crowding.42-45
Mandibular anterior crowding relapse was
numerically greater than the maxillary crowding
relapse in the treated group (Tables III and V). This
was also found by several previous studies in the liter-
ature.10,40,44 In addition, individual variation in both
the maxillary and mandibular crowding relapse could
be found (Figs 4 and 5). Some patients relapsed
8 mm, and others showed alignment stability in T3.
Most patients showed more relapse of the mandibular
incisors when compared with the maxillary teeth, but
some showed more relapse of maxillary crowding.
This confirms the affirmation of Little that the degree
of postretention anterior crowding is both unpredict-
able and variable.9
According to Little,30 the treated sample showed a
moderate irregularity in the long-term follow-up in
maxillary and mandibular anterior teeth (4.04 mm and
5.39 mm, respectively). Considering the severe
irregularity of the pretreatment stage, orthodontic
treatment, even showing a long-term relapse, showed
positive effects on crowding correction.
The treated patients showed greater crowding in the
long-term follow-up stage than the untreated sample.
However, many characteristics must be taken into

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Fig 4. Some patients of the treated group illustrating different degrees of maxillary incisor crowding
relapse.
account when interpreting this result; the treated pa-
tients had severe crowding before the beginning of
treatment (maxillary Little 5 10.02 mm and
mandibular Little 5 8.92 mm) (Table III), and this is
probably one of the main reasons for this moderate
crowding in the long-term. In contrast, the untreated
sample showed minimal crowding in the first evaluation
(maxillary Little 5 0.37 mm and mandibular
Little 5 2.26 mm) (Table IV).
The comparison to the control group should be
looked at with caution because the untreated group
presented tooth loss, and still, the subjects were included
in the sample (Table I). In the treated group, patients
presented no tooth loss from T1 to T3, except for the
4 premolars extraction. This could have influenced the
results because untreated patients with tooth loss
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Freitas et al
present fewer incisors crowding throughout life because
the teeth migrate to the extracted tooth space.17
Because mandibular crowding is the occlusal feature
most prone to relapse in treated patients and increases in
untreated subjects with aging, a mandibular canine-to-
canine fixed retainer can be indicated to prevent it.17
However, because studies have shown that most patients
are highly satisfied with their smiles17,46,47 and few are
dissatisfied with the increase of crowding,17 this has to
be individually considered.
In the treated group, intercanine widths increased
with treatment and decreased long-term, returning to
the initial values, indicating relapse (Table III).
Interpremolar and intermolar widths, arch perimeter,
and length decreased with treatment and continued to
decrease in the long-term posttreatment (Table III).
Freitas et al
Fig 5. Some patients of the treated group illustrating different degrees of mandibular incisor crowding
relapse.
Maxillary and mandibular intercanine widths were
similar between the groups at T1 (Table IV). In addition,
maxillary and mandibular interpremolar and maxillary
intermolar widths were greater in the untreated group
than in the treated group (Table IV), probably because
of the constricted arches caused by malocclusion in
the treated group. Maxillary arch perimeter and length
were greater in the treated group (Table IV). This
difference is probably because of the maxillary canines
that are presented in many patients in buccoversion
and because of the distal rotation of some maxillary
central incisors with crowding, projecting the mesial
aspect of the incisal surface, increasing maxillary arch
perimeter and length.
From T1 to T2, the intercanine widths increased in
the treated group, but the difference with the untreated
group was only significant for the mandibular arch
American Journal of Orthodontics and Dentofacial Orthopedics
11
(Table V). This aligns with the literature showing an
increase in the intercanine distance during the
orthodontic treatment.5,12,40,42,48
With treatment, the mandibular interpremolar and
intermolar widths and maxillary and mandibular arch
length and perimeter decreased significantly more in
the treated group compared with the untreated group
(Table V). This was already expected because group
treated was treated with 4 premolar extractions causing
a mesial movement of the posterior teeth and a decrease
in the transversal and sagittal arch dimensions.12,40,42,48
From T2 to T3, the mandibular intercanine and
maxillary and mandibular interpremolar widths showed
a greater decrease in the treated group than in the
untreated group (Table V). For the intercanine widths,
this change can be considered relapse; however, the
maxillary and mandibular dental arches as a whole
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Fig 6. Some patients of the treated group illustrating different behaviors of overjet and overbite.

showed a decrease in the long-term, even in those
distances that showed a decrease with treatment
(Tables III and V). Nonetheless, the mandibular interca-
nine distance showed a decrease with aging in the un-
treated group.16 Other authors also showed a decrease
in the intercanine distance with aging in untreated
patients.20,21,49,50 In the present study, the 3-3 decrease
was greater in the treated group, but the difference was
around 1 mm from the UT group (Table V). This was, it is
difficult to distinguish relapse from the normal
maturational change of the occlusion.41
Maxillary and mandibular arch length and perimeter
showed similar decreases in both groups (Table V),
indicating that these features are more influenced by
maturational changes than relapse in the long term.
However, caution should be taken in interpreting this
result because arch perimeter and length were measured
in only 13 subjects of the untreated sample; the other

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Freitas et al
subjects presented tooth loss or implant/prosthesis in T3
and were not included in these measurements. Several
studies in treated and untreated subjects demonstrated
a reduction in arch perimeter and length over the years
because of the mesial shift of the posterior
teeth.5,12,15,16,20,42
The treated group showed significant correction of
overjet and overbite with treatment, and both remained
stable in the long term (Table III).
At T1, the treated group presented greater overjet
than the untreated group (Table IV). This was expected
because patients from the treated group presented
malocclusion and were orthodontically treated. Thirteen
patients from the treated group presented Class II
malocclusion, and this justifies the increased overjet.51
The untreated group presented normal overjet and
overbite. Changes in overjet from T1 to T2 were greater
in the treated group in consequence to correction with
treatment, and changes in overjet in the follow-up
period were similar in the 2 groups (Table V).
The overbite was similar in both groups at T1
(Table IV). From T1 to T2, the overbite change was similar
in groups treated and untreated, slightly decreasing in
both groups (Table V). From T2 to T3, the overbite
increased in the treated group and decreased in the un-
treated group (Table V; Fig 3). However, this change is
small and not statistically significant (Table III) (an in-
crease of only 0.31 mm on average) and would not dete-
riorate the occlusion,51 but indicates a slight tendency to
return of the characteristics of the initial malocclusion in
the treated group (Fig 6). Maturational changes with ag-
ing in untreated occlusions showed a decrease in overbite
with time.16 Our results are in agreement with
Driscoll-Gilliland et al24 that found a small reduction in
overbite in untreated subjects and an overbite increase
in treated patients from 14 to 28 years of age. However,
other studies showed no overbite change with aging in
untreated patients.15,20,21,52 During orthodontic
treatment, the overbite and the curve of Spee are
corrected with some degree of incisor intrusion. After de-
bonding, the incisors might extrude, causing a slight
relapse.51
The multiple regression analysis showed that
previous 4-premolar extractions orthodontic treatment
is significantly associated with anterior crowding in the
long-term (Table VI). No other factor considered was
predictive of long-term changes of maxillary and
mandibular anterior crowding in the present study.
There are studies reporting fewer posttreatment
changes than described in the present manuscript38-40;
however, there are no known studies with this long-
term follow-up. Probably the long-term changes
observed in the treated group are partly relapse,
American Journal of Orthodontics and Dentofacial Orthopedics
13
combined with the maturational changes related to
aging.13,16 Future studies are necessary to compare, in
the long-term, nonextraction treated patients showing
slight or no initial crowding with an untreated matched
sample.
CONCLUSIONS
1. The treated group showed significant crowding
relapse in the long-term, showing a moderate
irregularity in the long-term follow-up in maxillary
and mandibular anterior teeth.
2. Maxillary and mandibular arch forms tended to
decrease, and overjet and overbite remained stable
in the long-term in the treated group.
3. Long-term posttreatment changes of the treated
group showed a greater increase of maxillary and
mandibular anterior crowding than the untreated
group maturational changes.
4. Intercanine and interpremolar widths decreased
more in the treated group than in the untreated
group. Overbite increased in the treated group and
decreased in the untreated subjects.
AUTHOR CREDIT STATEMENT
Karina Maria Salvatore Freitas contributed to
conceptualization, methodology, formal analysis,
investigation, data curation, writing original draft,
visualization, and project administration; Camila
Massaro contributed to methodology, validation,
investigation, and data curation; Felicia Miranda
contributed to methodology, investigation, and data
curation; Marcos Roberto de Freitas contributed to
resources, data curation, manuscript review and editing,
and visualization; Guilherme Janson: resources, data
curation, manuscript review and editing, and
visualization; Daniela Garib: conceptualization, data
curation, manuscript review and editing, visualization,
supervision, and project administration.
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