ORIGINAL ARTICLE

Influence of the quality of the finished

occlusion on postretention occlusal relapse
Karina Maria Salvatore de Freitas,a Guilherme Janson,b Marcos Roberto de Freitas,b Arnaldo Pinzan,c
José Fernando Castanha Henriques,b and Célia Regina Maio Pinzan-Vercelinoa
Bauru and São Paulo, Brazil

Introduction: In this study, we aimed to evaluate the influence of the quality of the finished occlusion on
postretention occlusal stability. Methods: The sample comprised 87 patients with Class I malocclusion, treated
with extraction of the 4 first premolars and edgewise mechanics; they were divided into 2 groups, according to
the quality of their finished occlusions. Group 1 included 44 subjects (23 boys, 21 girls) with posttreatment peer
assessment rating (PAR) scores from 0 to 5. The mean pretreatment age was 13.74 years (SD 2.14). The mean
treatment time was 1.92 years (SD 0.57), the mean retention time was 1.75 years (SD 0.96), and the mean time
of posttreatment evaluation was 5.17 years (SD 1.82). Group 2 included 43 subjects (22 boys, 21 girls) with
posttreatment PAR scores greater than 5. The mean initial age was 13.34 years (SD 1.35). The mean treatment
time was 2.20 years (SD 0.66), the mean retention time was 1.77 years (SD 0.78), and the mean posttreatment
evaluation was 5.47 years (SD 1.60). The PAR and the Little irregularity indexes were measured on the dental casts
at pretreatment, posttreatment, and postretention. Intergroup comparisons were made with independent t tests,
and the Pearson correlation coefficient was applied to the PAR score for the whole sample at the times evaluated.
Results: Well-finished patients had lower posttreatment and postretention PAR scores and greater changes
during the treatment and posttreatment periods than did the poorly finished patients. For the Little irregularity
index, the only difference between the groups was at the posttreatment stage; group 1 had a smaller irregularity
score than group 2. The correlation coefficients showed that the greater the treatment changes, the smaller the
posttreatment PAR score and the greater the relapse. But the higher the posttreatment PAR score, the higher the
postretention PAR score. Conclusions: It was concluded that the greater the quality of the orthodontic
finished occlusion, the greater are the treatment changes and the amount of relapse and the better is the
occlusal status at the postretention stage in Class I malocclusion treated with 4 premolar extractions. (Am J
Orthod Dentofacial Orthop 2007;132:428.e9-428.e14)

I
t is widely believed that some occlusal changes
after orthodontic treatment are inevitable.1-4 There-
fore, it would greatly benefit orthodontists to be
able to accurately predict the likelihood of various
occlusal changes occurring after treatment. For that
reason, the effects of many diagnostic and treatment
factors on short- and long-term occlusal stability have
been broadly investigated.5-11
Despite the many investigations in this matter, there
From the Department of Orthodontics, Bauru Dental School, University of São
Paulo, Bauru, São Paulo, Brazil.
a
Graduate student.
b
Professor.
c
Associate professor.
Based on research by the first author in partial fulfillment of the requirements
for the doctor degree in orthodontics at Bauru Dental School, University of São
Paulo.
Reprint requests to: Karina Maria Salvatore de Freitas, Department of Orth-
odontics, Bauru Dental School, University of São Paulo, Alameda Octávio
Pinheiro Brisolla, 9-75 Cep 17012-901, Bauru, SP, Brazil; e-mail, kmsf@
uol.com.br.
Submitted, November 2006; revised and accepted, February 2007.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.02.051
has been little detailed study of the relationship between a
well-detailed occlusion and long-term posttreatment sta-
bility, although a well-detailed occlusion, with the best
esthetic and occlusal results possible, has been recom-
mended for some time.12,13 Orthodontic treatment out-
comes can be assessed with occlusal indexes.14-17 Al-
though these indexes are not entirely satisfactory, they
provide a more objective, reliable, and reproducible way
of assessing occlusal relationships.4
Although most researchers had suggested that a well-
finished orthodontic treatment minimizes relapse,12,13,18
recent studies did not show that better occlusal results
were correlated with increased stability (the greater the
stability, the smaller the relapse), when simultaneously
evaluating several malocclusion types and treatment pro-
tocols.3,4,19,20 These authors found that a better occlusal
finish does not ensure stability,3,4,19,20 and well-treated
cases tended to deteriorate, and poorly finished cases
tended to improve after retention.4,19 It was speculated
that simultaneously evaluating several malocclusion types
and treatment protocols could have impaired the evalua-
tions and contributed to these results.19
428.e9
428.e10 de Freitas et al
Therefore, in this study, we aimed to evaluate the
influence of the quality of the finished occlusion on the
amount of postretention relapse with the peer assessment
rating (PAR)14 and the Little irregularity indexes21 in
Class I malocclusion patients treated with 4 first-premolar
extractions.
MATERIAL AND METHODS
The sample comprised the retrospective records of
87 subjects treated by graduate students at Bauru
Dental School, University of São Paulo, Brazil. The
subjects were chosen according to the following crite-
ria: (1) Class I malocclusion at the beginning of
orthodontic treatment; (2) treatment protocol included
extraction of the 4 first premolars; (3) complete course
of orthodontic treatment with full maxillary and man-
dibular fixed appliances (slot 0.022 ⫻ 0.025 in) with
edgewise mechanics; (4) all permanent teeth erupted up
to the first molars at the pretreatment stage; (5) no tooth
agenesis or anomalies; (6) maxillary removable (Haw-
ley) retainers worn for 1 year and mandibular fixed
canine-to-canine retainers worn for at least 1 year and
a maximum of 3 years posttreatment, with no retention
at the follow-up record; and (7) pretreatment (T1),
posttreatment (T2), and postretention (T3) dental casts
available.
Subjects of both sexes (45 boys, 42 girls) were
selected. The mean pretreatment age was 13.54 years
(SD 1.79), the mean treatment time was 2.08 years (SD
0.62), the mean retention time was 1.76 years (SD
0.87), the mean time of posttreatment evaluation was
5.32 years (SD 1.71), and the mean postretention time
was 3.56 years (SD 1.42).
To evaluate the influence of the quality of the
finished occlusion on the amount of postretention
relapse, the sample was divided into 2 groups, accord-
ing to the quality of the orthodontic finished occlusion,
evaluated by the PAR index at T2 (PAR T2).
Group 1 comprised 44 subjects (23 boys, 21 girls)
with PAR T2 scores from 0 to 5. This group included the
best-finished patients of the sample. The mean pretreat-
ment age was 13.74 years (SD 2.14). The mean treatment
time was 1.92 years (SD 0.57), the mean retention time
was 1.75 years (SD 0.96), the mean time of posttreatment
evaluation was 5.17 years (SD 1.82), and the mean
postretention time was 3.42 years (SD 1.45).
Group 2 comprised 43 subjects (22 boys, 21 girls)
with PAR T2 scores greater than 5. This group included
the worst-finished patients of the sample. The mean pretreat-
ment age was 13.34 years (SD 1.35). The mean treatment
time was 2.20 years (SD 0.66), the mean retention time
was 1.77 years (SD 0.78), the mean time of posttreat-
American Journal of Orthodontics and Dentofacial Orthopedics
October 2007
ment evaluation was 5.47 years (SD 1.60), and the
mean postretention time was 3.70 (SD 1.27).
The T1, T2, and T3 dental casts were used. All
measurements were made with a 0.01-mm precision
digital caliper (Mitutoyo America, Aurora, Ill) by a
calibrated examiner (K.M.S.F.). The assessed variables
were the Little irregularity index21 and the PAR index,
as described by Richmond et al14 and scored with the
American weights.22
The Little irregularity index21 is the summed dis-
placement of the 5 anatomic contact points of the
mandibular anterior teeth (from right mandibular ca-
nine to left mandibular canine). The irregularity index
scoring represents a planar distance between the verti-
cal projections of the anatomic contact points of adja-
cent teeth. To ensure recording horizontal displace-
ment, the caliper should be parallel to the occlusal
plane.
The PAR is an occlusal index designed and vali-
dated to measure how much a patient deviates from
normal occlusion.14 It was designed to measure the
success or the outcome of treatment by comparing the
severity of the initial malocclusion with the result on
pretreatment and posttreatment dental casts.14 The in-
dex measures tooth alignment (mandibular and maxil-
lary labial segment alignment, crowding, and spacing,
including impactions), buccal posterior segment rela-
tionship (right and left sides, anteroposterior, trans-
verse, and vertical), overjet (including anterior cross-
bite), overbite, and midline discrepancies. We used the
American PAR, validated with different weightings and
eliminating the mandibular anterior alignment compo-
nent.14,22 The weightings of the PAR components used
for malocclusion severity were 5 for overjet, 3 for
overbite and midline discrepancy, 2 for buccal occlu-
sion, and 1 for maxillary anterior alignment.22 The
weighted PAR scores for malocclusion severity could
be considered mild (mean 17.17; SD 2.34), moderate
(mean 39.79; SD 1.29), and severe (mean 53.56; SD
1.38).22 A posttreatment PAR score of 5 or less is
considered an excellent outcome,23 and a posttreatment
PAR score above 10 indicates a residual malocclu-
sion.24 The PAR index has been used widely for
evaluating the effects of treatment in various circum-
stances,25-27 even in untreated patients.28,29
The amount of improvement after orthodontic treat-
ment and the posttreatment changes were assessed by
the changes in the PAR and the Little indexes. Treat-
ment change is the difference between pretreatment
and posttreatment scores (T1-T2), and posttreatment
change is the difference between postretention and
posttreatment scores (T3-T2).
A month after the first measurements, the dental
American Journal of Orthodontics and Dentofacial Orthopedics de Freitas et al 428.e11
Volume 132, Number 4

Table I. Casual and systematic errors between the first Table II. Descriptive statistics of the evaluated variables
and second measurements Variable Mean SD n
Measurement Measurement
1 2 Pretreatment age 13.54 1.79 87
Treatment time 2.08 0.62 87
Variable Mean SD Mean SD n Dahlberg P Retention time 1.76 0.87 87
Posttreatment time 5.32 1.71 87
Little T1 7.03 3.53 6.79 3.54 25 0.406 .502 Postretention time 3.56 1.42 87
Little T2 1.47 0.90 1.49 0.85 25 0.251 .676 PAR T1 25.47 7.33 87
Little T3 2.82 1.61 2.85 1.61 25 0.219 .536 PAR T2 5.65 3.16 87
PAR T1 27.20 6.52 26.93 6.50 25 1.322 .347 PAR T3 8.53 4.36 87
PAR T2 6.16 3.30 6.30 2.97 25 1.095 .572 PAR T1-T2 19.82 7.48 87
PAR T3 10.46 3.76 10.70 3.74 25 1.012 .281 PAR T3-T2 2.87 3.78 87
Little T1 7.13 3.52 87
Little T2 1.32 0.89 87
casts of 25 subjects (75 sets of dental casts) were Little T3 2.81 1.81 87
randomly selected and remeasured by the same exam- Little T1-T2 5.81 3.61 87
Little T3-T2 1.48 1.64 87
iner (K.M.S.F.). The casual error was calculated ac-
cording to Dahlberg’s formula (Se2⫽ ⌺d2/2n),30 where
Se2 is the error variance and d is the difference between Table III. Comparison of sex distribution between the
the 2 determinations of the same variable, and the groups (chi-square test)
systematic error was determined with dependent t tests, Male Female Total
at P ⬍.05.
Group
Statistical analysis 1. Best finished 23 21 44
2. Worst finished 22 21 43
For the whole sample, means and standard devia- Total 45 42 87
tions for all variables were calculated: pretreatment
␹2 ⫽ 0.01; df ⫽ 1; P ⫽ .917.
age, treatment time, retention time, posttreatment eval-
uation time, postretention time, PAR index,14 and Little Table IV. Intergroup comparison of pretreatment age,
irregularity index21 at T1, T2, and T3, and for the treatment time, retention time, and posttreatment and
changes during the treatment (T1-T2) and the postre- postretention times (t tests)
tention (T3-T2) periods.
Group 1 Group 2
To check the groups’ compatibility, the chi-square (n ⫽ 44) (n ⫽ 43)
test was used to compare sex distribution, and indepen-
Variable (y) Mean SD Mean SD P
dent t tests were used to compare pretreatment ages,
treatment times, retention times, posttreatment evalua- Pretreatment age 13.74 2.14 13.34 1.35 .278
tion times, and postretention times, in addition to Treatment time 1.97 0.57 2.20 0.66 .074
malocclusion severity (PAR T1) and initial irregularity Retention time 1.75 0.96 1.77 0.78 .906
index (Little T1). For intergroup comparison of the Posttreatment time 5.17 1.82 5.47 1.60 .405
Postretention time 3.42 1.45 3.70 1.27 .341
variables PAR and Little indexes, independent t tests
were also used.
The Pearson correlation coefficient was calculated
by using the whole sample to investigate a significant Descriptive statistics of the whole sample for the
correlation between the PAR score in all stages and PAR index14 and the Little irregularity index21 in the
periods evaluated (T1, T2, T3, T1-T2, and T3-T2). The stages and periods evaluated are shown in Table II.
results were considered statistically significant at P ⬍.05. The groups were compatible for sex distribution,
All statistical analyses were performed with software pretreatment age, treatment time, retention time, time
(Statistica for Windows, version 6.0, Statsoft, Tulsa, of posttreatment evaluation, postretention time, pre-
Okla). treatment malocclusion severity, and pretreatment Lit-
tle index (Tables III to V).
RESULTS The intergroup comparison showed that group 2
The results of the systematic and casual error (worst-finished patients) had higher PAR scores at T2
analysis are shown in Table I. No systematic errors and T3 than group 1 (best-finished patients) (Table V).
were found, and the casual errors were within accept- Group 1 showed more treatment and posttreatment
able levels. changes than group 2 (Table V). For the Little irregu-
428.e12 de Freitas et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2007

Table V. Intergroup comparisons of the variables PAR postretention times. The sample was also compatible
and Little indexes at T1, T2, and T3, and changes for initial malocclusion severity (PAR T1) and pretreat-
during treatment (T1-T2) and posttreatment (T3-T2) ment incisor irregularity (Little T1). This compatibility
(t tests) regarding the characteristics of the initial malocclusion
was important in the study because we evaluated the
Group 1 Group 2
(n ⫽ 44) (n ⫽ 43) influence of orthodontic finishing on stability, which
can be affected by these pretreatment factors.11,26,31-33
Variable Mean SD Mean SD P
These sample selection criteria and the compatibil-
PAR T1 24.68 8.64 26.27 5.70 .293 ity of the groups seemed to be appropriate for the
PAR T2 2.95 1.36 8.36 1.85 .000* isolation of the quality of occlusal results as a predictor
PAR T3 6.63 3.73 10.42 4.15 .000* of stability.
PAR T1-T2 21.78 8.47 17.87 5.79 .010*
Concerns that treatment by graduate students could
PAR T3-T2 3.68 3.54 2.06 3.88 .037*
Little T1 7.31 3.77 6.95 3.28 .623 compromise the quality of the final occlusion are not
Little T2 1.08 0.73 1.55 0.98 .010* substantiated because it was shown that there is no
Little T3 2.54 1.81 3.07 1.80 .152 significant difference in the quality of finished occlu-
Little T1-T2 6.22 3.68 5.39 3.52 .269 sions treated by students and specialists.3,27
Little T3-T2 1.45 1.65 1.52 1.66 .837
The patients had similar retention times because
*Statistically significant at P ⬍.05. this might affect the stability of the results.9,32,34 All
patients had the same retention protocol: a removable
Table VI. Results of the Pearson correlation coefficient
Hawley plate in the maxillary arch and a bonded
between the PAR index at all evaluated times
canine-to-canine retainer in the mandibular arch.
Variable r P The methodology should be based on the primary
objective of the study. Because our purpose was to
PAR T1 ⫻ PAR T2 0.158 .126
PAR T1 ⫻ PAR T3 0.475 .000*
verify the influence of the quality of the finished
PAR T1 ⫻ PAR T1-T2 0.906 .000* occlusion on postretention stability, the best evaluation
PAR T1 ⫻ PAR T3-T2 0.415 .000* of the final occlusion is performed on dental casts. Even
PAR T2 ⫻ PAR T3 0.533 .000* in the absence of clinic and radiographic evaluation, the
PAR T2 ⫻ PAR T1-T2 ⫺0.270 .008* dental casts give the most information about orthodon-
PAR T2 ⫻ PAR T3-T2 ⫺0.220 .032*
PAR T3 ⫻ PAR T1-T2 0.232 .024*
tic diagnosis and treatment.35
PAR T3 ⫻ PAR T3-T2 0.707 .000* Andrews12 defined the 6 keys to normal occlusion
PAR T1-T2 ⫻ PAR T3-T2 0.494 .000* based exclusively on data from 120 dental casts, and these
*Statistically significant at P ⬍.05.
keys are valuable parameters to the achievement of an
ideal static occlusion. In the same way, the occlusal
indexes are an important research method.3,26,36 There-
larity index, the only difference between the groups fore, the PAR index was used because it was especially
was at T2, when group 1 had a smaller irregularity designed to evaluate treatment changes and out-
score than group 2 (Table V). comes.26,27,36 It has been proven valid and reliable in
Table VI gives the results of the Pearson correlation these assessments.14,22
test, showing the correlation coefficients between the Both groups with the best- and worst-finished
PAR index at all evaluated times. patients had similar scores for the PAR T1 (Table V).
As expected from the criteria used to divide the sample
DISCUSSION into 2 groups, group 2 had greater PAR T2 scores than
Although the sample in this study appears to be group 1. At T3, the worst-finished patients still had
small, it is still substantial, because the patients were significantly greater mean PAR scores than the best-
evaluated more than 5 years after active orthodontic finished patients.
treatment. It was not a totally homogeneous sample The treatment and posttreatment changes in PAR
because it includes subjects with various facial patterns. scores were greater in the group with the best-finished
However, all patients had the same Angle Class I patients (Table V). Even though they were well fin-
malocclusion at the beginning of treatment and were ished, these patients had more relapse than the poorly
treated with fixed edgewise appliances and extraction finished patients of group 2. However, even though the
of the 4 first premolars. The groups had similar sex best-finished patients experienced more relapse than the
distributions, pretreatment ages, treatment times, reten- worst-finished patients, they still had better occlusal
tion times, times of posttreatment evaluation, and results at T3. Also, the PAR T3 score of 6.63 for the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 4
best-finished patients was only 1.63 points more than a
score of 5, the score for a well-finished patient.
Kashner33 found that a higher level of treatment
quality led also to higher quality in the long term. In our
study, patients treated to different levels of quality were
evaluated, and the higher level of treated patients
(group 1) showed higher quality at T3 than the poorly
finished patients (group 2).
Nett and Huang4 found that well-finished patients
still had better absolute occlusal relationships at post-
retention. Our results support these findings, because
the best-finished patients had better occlusal results at
both T2 and T3 than the worst-finished patients.
Corroborating the results of Fernandes,20 who
found no correlation between treatment quality and
stability, we can infer from our results that the quality
of the finished occlusion is not related to postretention
stability, and high-quality orthodontic finishing will not
ensure stability. Ormiston et al,19 evaluating a stable
group and an unstable group, also found that finishing
occlusal relationships to perfection might not ensure
greater postretention stability.
The Little irregularity index showed that the only
difference between the groups was at T2 (Table V). The
best-finished patients had smaller values of the Little
irregularity index than the worst-finished patients. The
irregularity index showed similar treatment changes
and postretention relapses for both groups. In other
words, mandibular anterior crowding did not have the
same pattern of relapse as the PAR index, confirming
the unanimous findings in the literature that relapse of
mandibular anterior crowding is highly variable and
unpredictable.2,5,9-11,37 At T3, more than 3 years with-
out retainers, the Little index values were 2.54 mm for
the best-finished group and 3.07 mm for the worst-
finished group; these values are well within the mini-
mum irregularity index as described by Little21 and
therefore are clinically acceptable.
The PAR index showed a significant correlation
between T1 and T3 stages, treatment, and posttreatment
changes (Table VI). In other words, the greater the
severity of the initial malocclusion, the greater the
treatment changes and the greater the relapse.
The PAR score at T3 showed a statistically signif-
icant correlation with the treatment and posttreatment
changes (Table VI), but with negative correlation co-
efficients, demonstrating that the greater the correction
during treatment, the smaller the posttreatment PAR
score and the greater the relapse. However, there was a
positive correlation between PAR T2 and T3 scores,
indicating that the better the treatment results, the better
the postretention occlusal status, despite greater re-
lapse. These results corroborate those of Nett and
de Freitas et al 428.e13
Huang,4 who evaluated 100 randomly chosen patients
with the PAR index and the objective grading system,
and concluded that settling occurs after orthodontic
treatment, and that the attainment of perfect occlusal
results does not ensure greater stability.19
Few studies have described the relationship between
posttreatment scores and long-term changes.3,4,19,20 Some
authors found no correlation between treatment quality
and long-term stability.3,20 Nett and Huang4 and Ormiston
et al19 found that high-quality treatment results tended to
deteriorate, and low-quality treatment tended to improve,
and both of them concluded that treating patients to a high
standard of quality might not increase long-term stability.
Our results on Class I malocclusions treated with 4
premolar extractions showed that high-quality patients
had greater amounts of relapse than low-quality treatment
results. Thus, our results are similar to those with several
malocclusion types simultaneously evaluated.4,19 How-
ever, the postretention occlusal status of the best-finished
patients was still significantly better than the worst-
finished patients. Therefore, it seems that this is the actual
behavior of the occlusal characteristics during treatment
and posttreatment, independent of malocclusion type and
treatment protocol.
One would have expected that the higher the
standard of occlusal finishing at the end of active
treatment, the smaller the postretention occlusal
change. However, this relationship was not shown in
this study of 4-premolar extraction treatment for Class
I malocclusion. This might seem insensate because a
high standard of occlusal finishing was previously
suggested to be associated to greater long-term stabil-
ity.12,13 It was shown that, to obtain a better occlusal
result, greater treatment changes are necessary, and the
greater the treatment changes, the greater the amount of
relapse. Nevertheless, this does not mean that patients
should not be finished to ideal standards because, even
with greater relapse, the postretention status of well-
finished patients was significantly better than that of
poorly finished patients.
CONCLUSIONS
The higher the quality of the finished occlusion, the
greater the treatment changes and the amount of relapse
and the better the occlusal status at T3 in patients with
Class I malocclusion treated with 4 premolar extrac-
tions.
Posttreatment incisor alignment was significantly
better in the well-finished patients than in the poorly
finished patients. However, treatment and posttreat-
ment changes, and postretention incisor alignment were
similar. Therefore, incisor alignment behaves differ-
ently than the other occlusal characteristics.
428.e14 de Freitas et al
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