ORIGINAL ARTICLE

Long-term stability of combined rapid palatal

expansion–lip bumper therapy followed by full
fixed appliances
Tyler Ferris,a R. G. Alexander,b Jimmy Boley,c and Peter H. Buschangb
San Antonio and Dallas, Tex

Introduction: The purpose of this study was to evaluate the long-term postretention stability of rapid palatal
expansion–lip bumper therapy followed by full fixed appliances. Methods: The sample included 20 treated
patients (11 women and 9 men) who were recalled to obtain postretention records. The subjects were out of
retention for a minimum of 4 years and an average of 7.9 years. They had begun treatment in the late mixed
dentition at a mean age of 11.1 with considerable incisor crowding but, on average, no tooth size-arch length
discrepancies. Pretreatment, posttreatment (mean age, 13.6 years), and postretention (mean age, 24.3 years)
models were digitized, and the computed measurements were compared with untreated reference data.
Results: The majority of treatment increases in maxillary and mandibular arch dimensions were statistically
significant (P ⬍ .05) and greater than expected for untreated controls. Although many measurements
decreased postretention, net gains were maintained for 21 of the 30 measurements evaluated. The notable
exception was arch perimeter, which decreased to less than pretreatment values. Postretention incisor
irregularity increased 0.5 ⫾ 1.2 mm in the maxillary arch and 1.1 ⫾ 1.5 mm in the mandibular arch.
Conclusions: Based on the good long-term stability observed in this study, we concluded that use of rapid
palatal expansion–lip bumper expansion therapy in the late mixed dentition followed by full fixed appliances
is an effective form of treatment for patients with up to moderate tooth size-arch length discrepancies. (Am
J Orthod Dentofacial Orthop 2005;128:310-25)

C
rowding of the dentition due to tooth size-arch
length deficiency (TSALD) is the most com-
mon form of malocclusion treated by orthodon-
tists.1 The National Health and Nutrition Estimates
Survey (NHANES III) showed that only 54.5% of
children aged 8 to 11 and only 34% of adults have
well-aligned mandibular incisors. Nearly 15% of ado-
lescents and adults have extremely irregular incisors
(⬎10 mm irregularity index), which require extractions
to correct.
The oldest debate in orthodontics pertains to the
treatment of TSALD. Depending on facial balance,
there are 2 basic approaches: reduce tooth mass or
create larger arches to accommodate the tooth size-arch
length discrepancies. Notions of how to treat TSALD
have vacillated between these 2 approaches. Angle2
advocated preserving the full complement of teeth; this
a
Private practice, San Antonio, Tex.
b
Professor, Baylor College of Dentistry, Dallas, Tex.
c
Associate, Baylor College of Dentistry, Dallas, Tex.
Reprint requests to: Dr Peter H. Buschang, Department of Orthodontics, Baylor
College of Dentistry, Texas A & M University System, 3302 Gaston Ave,
Dallas, TX; e-mail, phbuschang@tambcd.edu
Submitted, August 2003; revised and accepted, November 2005.
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.01.001
310
became the dominant treatment philosophy for many
years. Based on the work of Tweed,3 the pendulum
swung toward extraction during the 1950s. Tweed
advocated positioning the mandibular incisors upright
over basal bone and argued that expansion of dental
units off basal bone led to instability. By the 1980s, the
pendulum had swung back toward nonextraction as
orthodontists began using new appliances and technol-
ogies to increase arch length and width, making it
easier to treat crowded dentitions without extractions.
Most orthodontic patients are now being treated non-
extraction;4-7 and many clinicians are using rapid pal-
atal expanders (RPEs) and lip bumpers to increase arch
size.4
Rapid palatal expansion (RPE) has been shown to
be effective for expanding the maxillary arch. Its
stability has been well demonstrated8-10; even studies
noting significant relapse have reported substantial net
gains.11-13 Based on the notion of soft tissue equilibri-
um,14 we might expect concurrent maxillary and man-
dibular expansion to be more stable than mandibular
expansion alone because of the environment created
and maintained by the enlarged maxilla.
Lip bumpers are used to create space for the proper
alignment of teeth.15-20 The lip bumper’s vestibular
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 128, Number 3
shield and metal legs remove soft tissue pressure from
the mandibular dentition by holding the perioral tissues
away from the mandibular arch.1,21,22 Treatment effects
of lip bumpers alone include flaring of the mandibular
incisors, distalization and uprighting of the mandibular
first molars, and buccal expansion of the canines,
premolars, and molars.23-28 Whereas the effects of the
lip bumper have been well established, their long-term
stability remains untested. Short-term studies27,29,30
indicate that lip bumper therapy is relatively stable
within 2 years after orthodontic treatment.
The purpose of this study was to evaluate the
long-term, postretention stability of RPE–lip bumper
therapy followed by conventional fixed orthodontic
appliances. All subjects had been without retention in
either arch for at least 4 years. Although there is
sufficient evidence that expansion of the arches by
using RPE–lip bumpers is an effective method of
eliminating mild-to-moderate crowding, the important
question remaining unanswered is whether long-term
stability can be expected for subjects who have been
without retention for many years.
MATERIAL AND METHODS
Sample
The long-term, postretention stability of RPE–lip
bumper therapy followed by conventional fixed appli-
ances was evaluated by comparing the pretreatment,
posttreatment, and postretention records of 20 patients
(9 men and 11 women) treated for maxillary and
mandibular anterior crowding. The sample included
treated RPE–lip bumper patients selected by the pri-
mary investigator (T.F.) from the office of another
author (R.G.A.). To be included in the study, the
patients must have:
1. Been in the late-mixed to early-permanent denti-
tion at the start of treatment.
2. Had Class I or Class II malocclusions with pre-
treatment anterior mandibular crowding and no
posterior crossbites.
3. Been treated with RPE–lip bumper therapy, fol-
lowed by comprehensive orthodontic treatment
with edgewise appliances.
4. Had good-quality models available at pretreatment
and posttreatment.
5. Had intact permanent dentition with or without
third molars when the postretention records were
taken.
6. Had no retention or implemented retention for at
least the past 4 years.
The charts of all patients with diagnostic records
taken from November 1983 through July 1992 were
Ferris et al 311
screened, and 296 patients meeting the first 4 criteria
were identified. Of these, 201 were not contacted
because of wrong phone numbers, changes of address,
incomplete dentitions, or other reasons. Ninety-five
patients were contacted, but 71 still had some form of
retention or had not been out of retention for at least 4
years. Twenty-four qualifying patients agreed to partic-
ipate in the study, and 20 actually became participants.
The average age of the patients in the sample at the
beginning of treatment was 11.2 ⫾ 0.9 years. Of the 20
patients, 20% had deciduous first molars present at the
beginning of treatment and 65% had deciduous second
molars. This is important because the maintenance of E
space is useful for the treatment of crowded malocclu-
sions. All patients were in the permanent dentition at
the end of treatment. The average age at the end of
treatment was 13.7 ⫾ 1.1 years, and the patients were
treated an average of 2.4 ⫾ 0.7 years. Based on the
patients’ charts and the questionnaires they completed,
it was determined that they had been out of retention for
an average of 7 years 11 months.
In the maxillary arch, these patients were first
treated with Hyrax RPEs. The jackscrew was placed at
the first molars, as high in the palate as possible. The
patients were asked to turn the screw once a day (0.25
mm) for 4 weeks. After 2 weeks, the patients returned
so investigators could determine whether expansion
was occurring as planned and again 2 weeks later so we
could see whether the expansion was sufficient. If it
was not, each patient was told how many more turns of
the screw were necessary. After adequate expansion
was achieved, the RPE screw was locked in position
with composite, and the RPE was left in place for
approximately 6 months as a retention device.
Concurrent with the above, lip bumpers were used
in the mandibular arch to create space for aligning the
mandibular dentition. The bumpers were prefabricated
with an acrylic shield extending from canine to canine
and adjusted for proper fit. Adjustments were made so
that the acrylic shield was 2 to 3 mm from the labial
surfaces of the incisors and 4 to 5 mm from the facial
surfaces of the buccal segments. The bumper was
activated to provide 3 to 4 mm of expansion at the
molars, adjusted at 3-to-4 week intervals, and left in
place for 8 to 10 months.
Immediately after RPE–lip bumper therapy, full
fixed appliances were placed and used until completion
of treatment. The clinician (R.G.A.) used .018 x .025-in
fully adjusted appliances and finished with .017 x
.025-in stainless steel archwires in both arches. Two
days after appliance removal, a maxillary wraparound
retainer and either a mandibular removable Hawley or
a bonded 3-3 retainer was placed. The patients were
312 Ferris et al
instructed to wear the retainers for 3 years (every night
during the first year, 3 nights per week during the
second year, and 1 night a week the third year). Regular
retainer checks were made by R.G.A. In most cases
(55%), the bonded 3-3 retainers were removed 3 years
posttreatment. Immediately after removal, interproxi-
mal reduction was performed on the incisors and mesial
aspects of the canines, removing approximately 1.75
mm of tooth structure per subject. About 30% of the
retainers were lost for various reasons, such as dental
cleanings, and some (20%) were removed by general
dentists.
Methodology
Informed consent was obtained from the parents of
the 20 patients who agreed to participate. They were
given a 6-item questionnaire detailing their history of
retainer wear. Alginate impressions were taken and
immediately poured in vacuum-mixed plaster. After the
plaster had set, the models were trimmed to ABO
standards. Dental model analysis was performed by
using a Microscribe 3DX digitizer (Immersion, San
Jose, Calif). The 3D coordinates of 45 landmarks were
digitized twice on each model. From the digitized
landmarks, 2 sets of measurements were calculated for
each subject, including:
1. Maxillary and mandibular arch widths for the
canines, premolars, and first molars at the level of
the cusp tips.
2. Maxillary and mandibular arch widths for the
canines, premolars, and first molars at the gingival
margins. The gingival margin was measured at the
interface between tooth and gingiva on the facial
aspect of the dentition. The facial aspect chosen
was based on ease of measurement and reliability.
3. Maxillary and mandibular arch depth at the level
of the canines, premolars, and first molars. Arch
depth was defined as the distance measured
through the midline, perpendicular to a line drawn
across the midline from the mesial of the canines,
mesial of the premolars, and mesial of the first
molars.
4. Maxillary and mandibular arch perimeters, defined
as the sum of the distances from the mesial
contacts of the first molars to the distal contact
points of the canines plus the mesiodistal widths of
the canines plus the distance from the mesial
contact point of the canines to the interproximal
contact between the central incisors.
5. TSALD, defined as the difference between the
mesiodistal tooth sizes of the teeth (mesial of the
first molar to the mesial of the opposite first molar)
American Journal of Orthodontics and Dentofacial Orthopedics
September 2005
and the arch perimeter. The pretreatment TSALD
was calculated by using the size of the teeth at
posttreatment (T2) and the arch length at pretreat-
ment (T1). TSALDs at T2 and postretention (T3)
were calculated by using the tooth size at T2 and
the arch lengths at T2 and T3, respectively.
6. Maxillary and mandibular incisor irregularities,
defined as the sum of the linear displacement of the
maxillary and mandibular incisors as measured by
the digitizer in 3 planes of space.
Reliability
Reliability was assessed based on replicate mea-
surements of every dental model. Systematic error was
evaluated by comparing the mean difference with its
standard error. Random technical error was evaluated
using the method error.
Method error ⫽ 兹deviations Ⲑ 2n 2
Each subject’s replicate measurements were aver-
aged and electronically transferred to the SPSS pro-
gram (SPSS, Cary, NC) for statistical analysis. Treat-
ment (T2-T1) and postretention (T3-T2) changes were
calculated for each measurement. The normality of the
distributions of each variable was verified by using
kurtosis and skewness statistics. For each subject, age-
and sex-specific z scores were calculated for arch
width, arch depth, and arch perimeter by using estab-
lished reference data.31 Z scores provide the subjects’
deviations (in standard units) from values expected for
untreated subjects and obviate dimensional adjustments
due to arch changes that normally occur between the
mixed and permanent dentitions.
RESULTS
Maxillary arch
Maxillary arch widths at both the cusp tip and
gingival levels increased significantly (P ⬍ .05) during
treatment (Table I, Fig 1). The greatest increases
occurred between the cusp tips of second premolars; the
canines showed the least expansion. Gingival arch
widths showed progressively greater width increases
from the canines posterior to the first molars. The ratio
of the cusp tip width increase to the corresponding
gingival width increases, which provides a rough mea-
sure of tipping, was greatest for the first premolars
(1.4:1) and least for the first molars (1.1:1). Maxillary
depth at the first molars decreased 1.5 mm, and incisor
irregularity decreased 8.2 mm. Arch perimeter and
maxillary TSALD did not change during treatment. Z
scores, adjusted for age and sex, showed significant
treatment increases in arch width at the cusp tip level
American Journal of Orthodontics and Dentofacial Orthopedics Ferris et al 313
Volume 128, Number 3

Table I. Pretreatment maxillary arch dimensions (mm), treatment changes, posttreatment changes, and net changes
Posttreatment
Pretreatment Treatment changes changes Net changes

T1 T1-T2 T2-T3 T1-T3

Variable Mean SD Mean SD Mean SD Mean SD

Cusp tip widths

Canines 31.53 2.53 3.15* 2.60 ⫺0.44 1.03 2.65* 2.26
First premolars 37.92 2.37 5.03* 2.23 ⫺1.02* 1.31 4.01* 1.75
Second premolars 43.24 2.66 6.04* 2.32 ⫺1.47* 1.50 4.57* 1.73
First molars 49.45 2.07 5.13* 1.89 ⫺1.25* 1.32 3.88* 2.12
Gingival arch widths
Canines 34.42 2.84 2.76* 2.52 ⫺0.67 1.74 1.96* 3.27
First premolars 41.98 2.34 3.64* 2.58 ⫺1.38* 2.05 2.26* 3.27
Second premolars 47.35 2.55 4.75* 2.41 ⫺2.09* 2.02 2.67* 3.04
First molars 53.79 2.42 4.83* 2.66 ⫺2.06* 2.58 2.77* 3.55
Arch depth
Canines 7.19 1.87 ⫺0.82 1.70 ⫺0.21 1.13 ⫺0.91* 1.74
First premolars 13.31 2.00 ⫺0.29 1.66 ⫺0.16 1.15 ⫺0.46 1.45
Second premolars 19.83 2.26 ⫺0.06 2.02 ⫺0.25 1.11 ⫺0.31 1.73
First molars 28.07 2.45 ⫺1.53* 2.36 ⫺0.72* 1.19 ⫺2.26* 2.00
Arch perimeter 75.58 3.20 0.22 2.43 ⫺1.71* 1.11 ⫺1.49* 2.42
TSALD 1.24 2.30 ⫺0.22 2.43 1.71* 1.11 1.49* 2.42
Incisor irregularity 10.45 2.93 ⫺8.06* 2.75 0.47 1.19 ⫺7.54* 3.01

*Significant change, P ⬍ .05.

Fig 1. Treatment and posttreatment changes in cusp tip width of maxillary and mandibular arches.
314 Ferris et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2005

Table II. Age- and sex-specific z scores for selected gingival-width expansion was least for the canines
measures of the maxillary arch based on reference data (1:0.5) and greatest for the first molars (1.7:1). Arch
reported by Moyers et al31 depths increased during treatment at all levels except
T1-T2 T2-T3 T1-T3
the first molars. Arch perimeter and TSALD did not
change significantly during treatment. Incisor irregular-
Variable Mean SE Mean SE Mean SE ity decreased 9.4 ⫾ 3.4 mm with treatment. Z scores
Cusp tip widths indicate that, with the exception of intercanine width at
Canines 1.10* 0.36 ⫺0.79* 0.19 0.21 0.28 the cusp tips, all mandibular arch dimensions increased
First premolars 1.76* 0.25 0.41 0.28 2.17* 0.34 during treatment significantly more than expected for
Second premolars 1.97* 0.22 ⫺0.61* 0.25 1.36* 0.23 untreated controls (Table IV).
First molars 1.70* 0.19 ⫺0.51* 0.11 1.19* 0.25
Cusp and gingival widths decreased significantly
Arch depth
Canines ⫺0.58 0.32 0.45* 0.22 0.02 0.32 over the postretention period (Table III). Approxi-
First premolars ⫺0.28 0.31 0.14 0.22 ⫺0.14 0.26 mately 21% to 59% and 26% to 73% of the treatment
Second premolars ⫺0.83 0.30 ⫺0.09 0.23 ⫺0.93* 0.29 increases were lost at the cusp and gingival levels,
First molars ⫺0.08 0.27 0.32 0.23 0.24 0.26 respectively. Width decreases were greater in the pos-
Arch perimeter 0.56* 0.14 0.15 0.10 0.71* 0.1
terior aspect of the mandibular arch. Arch depths
*Significant change, P ⬍ .05. decreased most at the first molars and least at the
canines. Mandibular arch perimeter decreased, and
TSALD increased 1.8 ⫾ 1.6 mm. Incisor irregularity
and relative decreases in second premolar arch depth showed no significant change during the postretention
(Table II). Although treatment increases in absolute period. Z scores showed greater than expected de-
maxillary arch perimeter were not statistically signifi- creases for posterior arch widths (0.5-0.8 z scores) and
cant, there was a significant relative increase (0.56 ⫾ anterior arch depths (0.7-1.5 z scores). Arch perimeter
0.14 standard scores), indicating less decrease of pe- decreased less than expected for untreated controls (Fig
rimeter throughout the treatment period than expected 2,B).
without treatment.
With the exception of intercanine widths, maxillary DISCUSSION
arch widths decreased significantly postretention (Ta- Treatment Effects
ble I). About 14% to 24% of the treatment increases in Treatment produced absolute increases in maxillary
width at the cusp levels were lost postretention. At the widths and limited decreases in arch depth but main-
gingival level, width decreases ranged from 24% of the tained maxillary perimeter. Expansion was greater in
treatment increases at the canine to 44% at the second the posterior than anterior aspect of the arch, as
molars. Arch depth at the first molars also decreased previously reported with RPE therapy.32,33 Width in-
significantly. Because arch perimeter decreased (1.7 creases were 60% to 70% greater than would have been
mm) over the postretention period, TSALD increased expected without treatment.31,34,35 Although some tip-
significantly. Maxillary incisor irregularity changes ping of the buccal segments occurred, much of the
were not statistically significant. Compared with un- expansion involved translation of teeth, reflecting the
treated controls (Table II), arch width decreased more orthopedic effect. Arch depth decreased at the first
than expected postretention. Maxillary z scores indi- molars only, indicating mesial movement of the molars
cated that arch depth at the canine level did not into the E space.29,36 Significantly, maxillary arch
decrease as much as expected for untreated controls. perimeter decreases during treatment were 30% less
Arch perimeter decreased less than expected for un- than expected for untreated subjects (Fig 2, A). If arch
treated subjects (Fig 2, A), but the differences were not perimeter increases 0.77 mm for every 1 mm of
statistically significant. premolar expansion,36 then the lack of perimeter in-
crease in our study must have been due to full fixed
Mandibular arch appliance therapy. This suggests that some width in-
Mandibular arch widths also increased significantly creases due to expansion were reversed during fixed
during treatment (Table III). At the cusp tip level, treatment. Decreases in maxillary incisor irregularity
intercanine widths increased the least (1.3 ⫾ 1.7 mm), similar to those observed in this study have been
and inter-first premolar widths increased the most (4.7 previously reported for nonextraction patients treated
⫾ 2.6 mm). Gingival arch widths increased most at the with RPEs and fixed appliances.10,29
first premolars (5.1 ⫾ 1.9 mm) and least at the first To properly understand the treatment effects ob-
molars (2.2 ⫾ 4.0 mm). The ratio of cusp-tip-to- served in the mandibular arch, it is important to
American Journal of Orthodontics and Dentofacial Orthopedics Ferris et al 315
Volume 128, Number 3

Table III.
Pretreatment mandibular arch dimensions, treatment changes, posttreatment changes, and net
changes (in millimeters)
Posttreatment
Pretreatment Treatment changes Changes Net changes

T1 T1-T2 T2-T3 T1-T3

Variable Mean SD Mean SD Mean SD Mean SD

Cusp tip widths

Canines 25.26 2.07 1.31* 1.73 ⫺0.77* 0.92 0.49 1.32
First premolars 30.79 2.56 4.72* 2.56 ⫺0.99* 1.59 3.73* 2.20
Second premolars 37.93 1.90 3.66* 2.35 ⫺1.81* 1.36 1.85* 2.16
First molars 42.97 1.87 3.60* 1.61 ⫺1.03* 1.26 2.57* 1.88
Gingival arch widths
Canines 29.81 1.25 2.60* 1.04 ⫺0.91* 0.50 1.74* 1.08
First premolars 37.81 2.38 5.12* 1.94 ⫺1.34* 1.79 3.79* 1.99
Second premolars 47.06 1.92 2.46* 2.49 ⫺1.12* 1.93 1.33* 2.77
First molars 48.47 2.05 2.17* 3.97 ⫺1.58* 1.85 0.60 4.35
Arch depth
Canines 1.95 1.31 1.83* 1.43 ⫺0.87* 0.78 0.98* 1.35
First premolars 7.06 1.93 2.25* 1.96 ⫺1.17* 0.75 1.07* 1.97
Second premolars 14.12 2.05 1.56* 1.93 ⫺1.04* 0.87 0.52 2.07
First molars 23.13 2.08 ⫺0.17 2.16 ⫺1.53* 1.11 ⫺1.70* 1.80
Arch Perimeter 66.50 3.47 ⫺1.03 3.07 ⫺1.81* 1.62 ⫺2.83* 3.34
TSALD 1.32 3.45 1.03 3.07 1.81* 1.62 2.83* 3.34
Incisor irregularity 10.99 2.59 ⫺9.35* 3.35 1.11 1.53 ⫺8.25* 3.55

*Significant change, P ⬍ .05.

Table IV. Age- and sex-specific z scores for selected incisors usually tip forward and molars tip back,16,25-28
measures of mandibular arch based on reference data both of which were reversed during our fixed appliance
reported by Moyers et al31 therapy. In other words, lip bumpers produced only a
temporary increase in mandibular arch depth. Unfortu-
T1-T2 T2-T3 T1-T3
nately, the relative anteroposterior movements of the
Variable Mean SE Mean SE Mean SE incisors and molars of our sample are not known
Cusp tip widths
because cephalometric evaluations were not performed.
Canines 0.40 0.32 ⫺0.30 0.20 0.07 0.23 Compared with arch depth decreases normally ob-
First premolars 1.83* 0.34 ⫺0.75* 0.22 1.09* 0.30 served for untreated controls, the lip bumper more
Second premolars 1.07* 0.23 ⫺0.55* 0.19 0.52* 0.31 closely maintained mandibular arch perimeter (Fig 2,
First molars 1.27* 0.17 ⫺0.63* 0.11 0.65* 0.20 B). Increases in arch perimeter usually occur when
Arch depth
Canines 2.21* 0.36 ⫺1.52* 0.21 0.74 0.39
bumpers are used alone.25,27,28,30 This again empha-
First premolars 1.95* 0.55 ⫺0.71* 0.13 1.24* 0.52 sizes that the fixed appliance phase of therapy used only
Second premolars 1.81* 0.38 ⫺0.04 0.12 1.77* 0.40 as much of the space as needed to align the teeth.
First molars 1.81* 0.34 ⫺0.04 0.16 1.78* 0.30
Arch perimeter 0.64* 0.18 0.35* 0.07 1.00* 0.18
Postretention changes
*Significant change, P ⬍ .05.
Although the maxillary arch showed postretention
decreases, most treatment increases were maintained 8
distinguish between the effect of lip bumpers used years postretention. Moussa et al,10 who evaluated
alone and when used in conjunction with full fixed patients who had been treated with RPE and full fixed
appliances. The significant mandibular expansions at appliances and had been out of retention for 8 to 10
both the cusp tip and gingival levels observed in this years, reported similar postretention transverse de-
study are supported by other lip bumper studies.25-30 creases. Postretention decreases were not uniform:
Unlike the other depth measurements, first molar arch maxillary dimensions that had increased the most
depth did not change during treatment, whereas de- showed the greatest postretention reductions. Loss of
creases normally occur in untreated subjects over the arch depth after treatment was greater posteriorly,
same time span. During the bumper phase of therapy, suggesting that the molars had migrated anteriorly,
316 Ferris et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2005

Fig 2. A, Treatment and posttreatment changes of maxillary arch perimeter (6mes – 6mes) of
combined RPE–lip bumper therapy (●—●) compared with control (⽧—⽧) (from Moyers et al31); B,
treatment and posttreatment changes of mandibular arch perimeter (6mes – 6mes) of combined
RPE–lip bumper bumper therapy (●—●) compared with control (⽧—⽧) (from Moyers et al31).

although the lack of cephalometric analyses makes it
impossible to know. Most important, arch perimeter
decreases during the postretention period were less than
expected for the untreated controls (Fig 2), suggesting
that space that would have been lost was maintained.
Postretention TSALD increases were due to the loss of
arch perimeter. However, postretention increases in the
incisor irregularity score were only about half those
previously reported by Moussa et al,10 whose long-term
results are among the most stable reported.
In the mandibular arch, postretention width de-
creases were greater than that expected for untreated
subjects,37,38 resulting in a 50% to 70% net gain in
posterior arch width. Horton29 reported small postre-
tention decreases in width at both the cusp tips and
gingival levels, but her subjects had been out of
retention only 2 years. Werner et al27 reported an actual
increase in mandibular arch widths at the canines,
premolars, and first molars for a small sample of
younger patients that continued 2 years postretention.
In comparison with untreated controls, the arch depth
decreases from the first premolars back were signifi-
cantly less than would be expected, indicating some
preservation of the E space. Whereas decreases in
postretention mandibular arch perimeter (⫺1.8 mm)
were at least partly due to corresponding decreases in
arch width and depth, perimeter decreased significantly
less than expected in untreated controls (Fig 2), even
though its final value was less than its pretreatment
value. The significant TSALD increase during postre-
tention was due to corresponding loss of arch perime-
ter. Although the postretention increase in the incisor
irregularity score was statistically significant, the aver-
age score increased only slightly (1.1 mm) and repre-
sented only 12% of the treatment decrease.
Because mandibular incisor irregularity after re-
moval of retention is commonly used to denote treat-
ment success or failure, it is important to emphasize
that the incisor irregularity score decreased 9 mm
during treatment and increased only 1.1 ⫾ 1.5 mm
during the 8 years after the removal of retention. The
postretention stability observed might be partially ex-
plained by the interproximal reduction performed on
some patients, providing additional space (⬇1.75 mm)
and, especially, broader contacts that apparently en-
hance incisor stability. The postretention incisor irreg-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 128, Number 3
Fig 3. Postretention incisor irregularity index increases. Present study compared with selected
nonextraction studies.
ularity increases of this study were similar to or less
than postretention increases reported for other nonex-
traction studies (Fig 3). However, the selected studies
pertain to various orthodontic problems, often with
minimal crowding, and to patients who did not undergo
active mandibular expansion. Figure 4 compares the
postretention incisor irregularity changes of our study
with those reported for extraction patients. Again, the
increases we report for combined lip bumper–RPE
therapy are similar to or less than posttreatment
changes for extraction patients who had been out of
retention for similar periods. This comparison is not
meant to suggest that lip bumper–RPE therapy is
superior to other forms of nonextraction and extraction
therapy; different problems dictate different ap-
proaches. However, it does indicate that this ap-
proach—when properly applied— can successfully re-
duce crowding and is at least as successful as other
forms of therapy at maintaining a stable arch form once
the patients are out of retention.
These results pertain to patients who had mild-
to-borderline TSALDs (Figs 5 and 6). Incisor irreg-
ularity, especially in this mixed dentition sample,
exaggerates the actual amount of crowding before
treatment and the amount resolved during treatment.
The average pretreatment TSALD was 1.3 ⫾ 3.4
Ferris et al 317
mm, but, because of the measurements (straight-line
distances) used, arch perimeter was probably under-
estimated, and TSALD was overestimated. Based on
arch perimeter treatment changes that occurred, we
suggest that there was on average approximately 1
mm of excess space available before treatment. By
using this adjustment, plus the observed standard
deviations, about 40% of our sample had some
TSALD, and about 16% had TSALD greater than 2.5
mm. Without pretreatment TSALD, a wire lip
bumper covered with shrink tubing or a lingual arch
might have been sufficient to maintain the leeway
space for the resolution of crowding. Giannelly39
noted that crowding can be resolved in approxi-
mately 73% of mixed-dentition patients simply by
maintaining the leeway space when there are no
facial considerations; however, this is not sufficient
for patients with TSALD, who require additional
space. For patients in the late mixed dentition with
up to moderate TSALD, lip bumper–RPE is an
effective approach to achieve adequate space; for
those with moderate-to-severe crowding, extraction
might be necessary depending on facial consider-
ations. Although this might be among the first studies
to support an expansion approach for certain patients
318 Ferris et al
Fig 4. Postretention incisor irregularity index increases. Present study compared with selected
extraction studies.
in the mixed dentition, expansion in the permanent
dentition is not supported by the literature.
CONCLUSIONS
1. Use of RPEs and lip bumpers followed by full fixed
appliances during treatment of TSALD malocclu-
sions results in significant absolute and relative
increases in maxillary and mandibular arch dimen-
sions.
2. Although postretention decreases in many arch
dimensions were statistically significant after RPE–
lip bumper therapy and full fixed appliances, sub-
stantial net gains remained for all measurements
American Journal of Orthodontics and Dentofacial Orthopedics
September 2005
except arch perimeter. Many of the postretention
decreases were less than expected when compared
with untreated controls.
3. Increases in incisor irregularity after removal of
retention were similar to or less than increases
reported for untreated subjects, those treated
nonextraction, and those treated with serial ex-
tractions or removal of all first premolars after
their eruption. Interproximal reductions might
have enhanced the postretention stability ob-
served.
4. The use of RPE–lip bumper therapy followed by
full fixed appliances is an effective method of
treating mild TSALD malocclusions in the
mixed-to-early-permanent dentition.
American Journal of Orthodontics and Dentofacial Orthopedics Ferris et al 319
Volume 128, Number 3

Fig 5. A-E, Pretreatment, posttreatment, and postretention models, together with associated ages,
mandibular arch widths, and mandibular perimeters of 5 patients with smallest TSALDs or excess
arch length at pretreatment.
320 Ferris et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2005

Fig 5.
American Journal of Orthodontics and Dentofacial Orthopedics Ferris et al 321
Volume 128, Number 3

Fig 5.

Fig 6. A-E, Pretreatment, posttreatment, and postretention models and associated ages, mandib-
ular arch widths, and mandibular perimeters of 5 patients with greatest TSALDs at pretreatment.
322 Ferris et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2005

Fig 6.
American Journal of Orthodontics and Dentofacial Orthopedics Ferris et al 323
Volume 128, Number 3

Fig 6.
324 Ferris et al
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