Terminology: Semantics of Postorthodontic

Treatment Changes in the Dentition

P. Emile Rossouw

Correct terminology eliminates confusion in communication between clini-

cians, as well as between clinician and patient. Long-term stability seems to
be an elusive goal, because the terminology in this respect eludes to the
various changes occuring in the posttreatment dentition. However, a stable
orthodontic result can be achieved when the physiologic changes that
naturally occur in the dentition are considered as part of the long-term result.
Standardization of terminology is therefore important. (Semin Orthod 1999;
5:138-141.) Copyright© 1999by W.B. Saunders Company

he choice of a term to describe the changes
T that may occur in a dentition after orthodon-
tic treatment has received attention in the litera-
ture. Hellman 1 distinguished between "failure"
(operator incompetence) a n d / o r factors outside
the control of an operator, and "relapse"
(changes in successfully treated dentitions).
Horowitz and Hixon 2 used the term "relapse" to
describe detrimental changes that occur after
active orthodontic treatment. There are many
factors that may influence treated, as well as
untreated occlusions. The same terms are used
to describe the changes that can occur in both
situations.
The question may thus be asked: "How clearly
are the terms relapse and failure really defined?"
Theoretically and practically, it is important to
distinguish between these two entities, because
posttreatment and " a g i n g " changes can be
caused by one or more factors. 3,4 Objective exami-
nation to determine the exact etiologic factor is
extremely difficult.
The literature with respect to terms describ-
ing relapse is incomplete. 5 Therefore, it was
d e e m e d necessary to define some of those terms
to clarify some of the semantic problems these
terms engender. Terms that are c o m m o n l y used
From the University of Toronto, Faculty of Dentistry, Discipline of
Orthodontics; 124Edward Street, Toronto, Ontario, Canada.
Address correspondence to P. Emile Rossouzo, BSc, BChD, BChD
(Hons), MChD, PhD, Head oJDiscipline of Orthodontics, Faculty of
Dentistry, 124 Edward St, Toronto, Ontario M5G 1G6, Canada.
Copyright © 1999 by V~B. Saunders Company
1073-8746/99/0503-0002510. 00/0
and others less universally known include: re-
lapse, physiologic recovery, d e v e l o p m e n t a l
changes, growth recovery, rebound, postreten-
tion settling, "Recidief," crowding or recrowd-
ing, imbrication, stability, retention, metaposi-
tion, c o m p e n s a t i o n , adaptation, iatrogenic
changes, and physiologic stability.
Relapse
Relapse is the slip back or fall back to a f o r m e r
condition, especially after improvement or seem-
ing improvement. Riedel 6 believed that the word
was too harsh a description of the changes that
follow orthodontic treatment and he preferred
the term "posttreatment adjustment" for these
changes. A multiplicity of factors cause posttreat-
merit adjustment.
Relapse is defined as follows: "to fall back into
or to revert to a f o r m e r habit or state, a falling
back into error, heresy or wrong-doing; back-
sliding; the fact of falling back again into an
illness after a partial recovery. ''7
Horowitz and Hixon 2 defined relapse in gen-
eral as changes in tooth position after orthodon-
tic treatment. They also mention that these
changes can take place even t h o u g h no treat-
m e n t was instigated. Therefore, it is necessary to
distinguish between relapse, physiologic recov-
ery, and developmental changes. The term "re-
lapse" has been used, perhaps erroneously, when
referring to all posttreatment changes, s This
word is usually sensed as a failure. However, it
means an undesirable return to a previously
corrected malocclusion. Minor changes are to be

138 Seminars in Orthodontics, Vol 5, No 3 (September), 1999: pp 138-141

 Terminology of Postorthodontic Changes
expected, 9 and there are categories of acceptabil-
it'/, 1° but it is the major unacceptable reversions
that should be termed the true relapse. 8
Physiologic Recovery
Physiologic recovery is a return to a normal
condition that is characteristic of normal, func-
tioning, living organisms.
Horowitz and Hixon 2 explain physiologic re-
covery as the change to the original physiologic
state after completing treatment.
Developmental Changes
Developmental changes are those which occur
irrespective of whether orthodontic treatment
was implemented or not. These changes could
easily be overlooked when assessing posttreat-
m e n t relapse. The developmental changes occur-
ring in subjects who have not u n d e r g o n e any
orthodontic treatment are well d o c u m e n t e d in
the literature. 9,1>16
Growth Recovery
Skeletal alterations or orthopedic m e t a m o r p h o -
sis can be induced as part of phase 1 or early
treatment in the y o u n g patient when growth
processes are still active. Factors such as the
genetic characteristics, the forces of gravity, and
the skeletal pattern b e c o m e reoperative and
express themselves again. Subsequently, growth
patterns will "recover" from the original treat-
m e n t changes and a second metamorphosis back
to the originally d e t e r m i n e d genetic pattern is
seen to occur, especially in the mandible, s This
type of change is not relapse, but rather unfortu-
nate growth changes.
Rebound
R e b o u n d refers to spring or b o u n c e back after
hitting or colliding with something; a recoil. This
biology can be ascribed to the elasticity of tissues.
The retraction of the u p p e r incisors can be
responsible for a variety of changes in the mor-
phology of the u p p e r lip. The u p p e r lip may
become more retrusive in the absence of lip
strain, when the lip is thin or in adult patients.
The opposite effect is also possible, resulting in
no lip retraction or the further protrusion of the
"] 3 9
u p p e r lip. The u p p e r lip and u p p e r incisors are
of key importance when deciding on a treatment
plan. In planning a soft tissue visual treatment
objective, the r e b o u n d of the u p p e r lip, during
the postorthodontic period, should be taken
into account when the u p p e r incisor position is
determined. 17
This term can also be used for the behavior of
the mandible posttreatment. There is a tendency
for the mandible when open-rotated during
treatment, to return in the opposite direction by
the forces of the musculature in approximately
70% of patients. Ricketts 8 referred to the con-
cern of clinicians in the other 30% of patients in
whom there is a stabilization ~s or a continuation
of the bite-opening posttreatment, which is disas-
trous in open-bite malocclusions. The latter is a
guarantee for failure in achieving stable results.
Postretention Settling
Settling can be described as the establishment of
a desired position, the act of ceasing to move or
"settling down" and maintaining a correctly
balanced position. It leads to the a r r a n g e m e n t of
the teeth in a final or satisfactory form, which
may be more or less a p e r m a n e n t or unvarying
configuration. The teeth "sink" into occlusion
and thus b e c o m e comfortably adapted to a new
environment or situation. Retention appliances
should preferably be passive devices that allow
the teeth to settle or guide the teeth into their
final positions during function. In this way postre-
tention settling will be maximized. Settling is a
loosely used term; moreover, it may be false and
result in an undesired m o v e m e n t ) This term
thus indicates the posttreatment changing pro-
cess versus a term such as metaposition, which
refers to the meticulously planned changes after
the removal of the orthodontic appliances.
"Recidief"
Recidive is described as a tendency to relapse
into a f o r m e r pattern of behavior. 7 The concept
is more applicable to behavioral patterns; for
example a tendency to return to criminal habits
as is defined in the aforementioned dictionary.
The term "recidief" has been used to describe
changes that occur from the end of treatment
back to the original situation. 5
140 P. Emile Rossouw
Crowding or Recrowding
Crowding means to force tightly together. Lower
incisor crowding (recrowding) is often a signifi-
cant p r o b l e m n o t e d in a postorthodontic evalua-
tion. Crowding is a result of p o s t t r e a t m e n t
changes and was fully described by Little. 1<19
Imbrication
Imbrication refers to a regular overlapping of
edges often seen in tiles on a r o o f or the scales of
a fish. This overlap is often used to describe
incisor irregularity or crowding whether seen
before or after treatment.
Stability
Stability is the condition of maintaining equilib-
rium. 7 This refers to the quality or condition of
being stable; the fixity of position in space or the
capacity for resistance to displacement. Some
orthodontists may be reluctant to evaluate their
patients in the postretention phase of treatment.
However, it is only t h r o u g h a retrospective view
of t r e a t m e n t that factors which cause undesir-
able postretention changes can be identified.
Such discoveries could lead to greater occlusal
stability after orthodontic treatment. Stability is
not retention.
Retention
J o o n d e p h and Riedel 9° explain retention as " t h e
holding of teeth in ideal aesthetic and functional
positions." Retention is accomplished by a vari-
ety of mechanical appliances.
Retention is defined as the action or fact of
holding or keeping in a place or position; retain-
ing in a fixed position; the condition of being
retained, the capacity to r e m e m b e r . 7
Metaposition
Metaposition denotes the desirable a n d ex-
pected p o s t t r e a t m e n t changes that are antici-
pated, s T h e word " m e t a " describes a later or
future change. These changes are not relapse
and must be part of the t r e a t m e n t itself. T h e
latter includes p o s t t r e a t m e n t adjustments and
o v e r t r e a t m e n t that is required to provide for
such tendencies, together with a correct under-
standing of the position of the incisal edges and
cusps of the teeth for best surety of stability. 21,22
O n e immediately recalls the work of Sandusky, 2a
who after the examination of a Tweed sample,
p r o p o s e d the uprighting of lower incisors to
allow for p o s t t r e a t m e n t proclination to a stable
position and the flattening of the Curve of Spee,
which, when it returns to its n o r m a l curvature,
will provide additional space in the dental arch
to a c c o m m o d a t e for any p o s t t r e a t m e n t crowding
or irregularity or mesial m o v e m e n t of the denti-
tion (decrease in arch length as part of the
anterior c o m p o n e n t of force).
Compensation
This could be nature's way of creating a mechani-
cal equilibrium when variable skeletal conditions
prevail. C o m p e n s a t i o n refers to something hap-
p e n i n g to correct a mistake elsewhere in the
system. This t e r m can thus be used to refer to
change in the position of the teeth as they adjust
relative to the skeletal and muscular craniofacial
environment. T h e r e is a tendency, for example,
for the lower incisor to be angled toward point A,
or " c o m p e n s a t e d " to the convexity and morphol-
ogy of the face. 8'23
Adaptation
Adaptation is the t e r m reserved for the condition-
ing of the n e u r o m u s c u l a r system. T h e m o v e m e n t
of teeth into new positions during treatment
requires new reflexes. T h e muscles n e e d to
" a d a p t " or "learn to function" to the estab-
lished occlusion, s A new functional pattern is
thus acquired in response to the treated tooth
positions.
Iatrogenic Changes
Poor clinical t r e a t m e n t should not be conducted
or c o n d o n e d u n d e r the designation of relapse or
u n d e r the auspices o f one of the o t h e r terms
n o t e d as part of the long-term stability problem.
It is imperative to be cognizant of the different
descriptions of long-term change to enable one
not only the interpretation of stability of the
finished result, but also c o m m u n i c a t i o n of pos-
sible p o s t t r e a t m e n t changes to prospective pa-
tients.
 Terminolo~ ofPostorthodontic Changes
Physiologic Stability
Theoretically, compensation and adaptation are
ubiquitous factors in this pool of semantic prob-
lems. They, as is the case with all the described
terms, must be dealt with in the retention pro-
cess. There is a need for standardization. Studies
show that clinically acceptable stability can be
attained. 24 MoreoveI, change is inevitable. 9,t6
The finalization process should include both
active stabilization and passive guidance proce-
dures, rather than rigid fixation of teeth, which
after treatment could be in unphysiologic posi-
tions. The purist orthodontist, or the true occlu-
sionist endeavors to produce a healthy, func-
tional, esthetic, and physiologic stable occlusion
that will last for the patient's lifetime. A sobering
thought for the future. 8
With the publication of the present series of
articles the objective is thus to introduce a term,
physiologic stability, which will not only bring
order to the confusing number of terms often
incorrectly used to describe all long-term
changes, but this new term will indicate that
stability can be achieved within the normal
physiologic range of changes normally described
as growth and development.
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141
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