ONLINE ONLY

Crowding and spacing in the dental arches:

Long-term development in treated and
untreated subjects
Teitur Jonsson and Thordur Eydal Magnusson
Reykjavk, Iceland

Introduction: The purposes of this study were to

analyze long-term changes in anterior spacing and
crowding and to compare the development in
orthodontically treated and untreated subjects.
Methods: The sample comprised 308 adolescents in
the late mixed or early permanent dentition who were
examined clinically at the ages of 7 to 17 years and
again 25 years later. The treated subgroup of 58 subjects
had received orthodontic treatment with fixed or removable appliances or both. All subjects had a full complement of teeth, except for 19 who had premolar
extractions as part of their orthodontic treatment plan.
Results: The prevalence of maxillary anterior spacing was substantially and significantly reduced in both
the untreated and treated groups from the first examination to the second. The prevalence of mandibular crowding increased significantly in the untreated and the
nonextraction treated groups. The prevalence of mandibular crowding in patients treated without extractions
increased by 25.6%, significantly more than in the untreated controls. The prevalence of maxillary crowding
decreased by 15.8% in patients treated with maxillary
premolar extractions, significantly more than in the
untreated controls.
Conclusions: Long-lasting developmental factors
seem to result in universally reduced maxillary anterior spacing, orthodontic treatment notwithstanding.
Compared with untreated subjects, the long-term development of mandibular anterior crowding was
unfavorable in subjects treated without extractions.
Compared with untreated subjects, the long-term
development of maxillary anterior crowding was
favorable when treatment included extraction of the
maxillary premolars.
Read the full text online at: www.ajodo.org,
pages 384.e1-384.e7.

Am J Orthod Dentofacial Orthop 2010;138:384-6

0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.05.004

384

EDITORS COMMENT

When you meet with a prospective patient to discuss

the benefits of orthodontic treatment, do you try to support your advice with either sound experience or highlevel evidence? What do you say if there is limited
evidence? Will crowding continue to worsen with no
treatment? Or does orthodontic treatment lead to fewer
crowding problems in the long term? The purposes of
this study were to analyze the long-term changes in people with anterior spacing and crowding and to compare
their development in orthodontically treated and untreated subjects.
The original sample of randomly selected subjects
comprised 1641 primary schoolchildren in Reykjavk,
Iceland, examined clinically at the ages of 7-17 years.
This study was based on 832 subjects (50.7%) from
this sample who were available for a second examination 25 years later. The untreated control group comprised 250 subjects with complete dentitions at both
examinations.
The treated sample of 58 subjects was divided into
subgroups: 39 were treated without extractions, and 19
were treated orthodontically with premolar extractions.
In the developing dentition, available space in the
anterior region is at a minimum. But in subsequent
phases of eruption, differences in the sizes of deciduous
and permanent teeth, called leeway space, will alleviate
anterior crowding temporarily. The counteracting forces
will, however, prevail and eventually shorten the arches
and cause anterior dental crowding. In this long-term
follow up, the active skeletal and dental changes seen
during adolescence gave way to more gradual adjustments during adulthood. The details of these patients
occlusal examinations 25 years later is fascinating,
and you will want to read this entire article online. Perhaps the most intriguing result is the long-term status of
mandibular anterior crowding in subjects who were
treated nonextraction. The return of their crowding
was significantly worse than that observed in the untreated subjects. I seriously doubt that this is what the
unsuspecting patient had in mind 25 years earlier
when deciding to accept the doctors plan of treatment.

Jonsson and Magnusson

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 138, Number 4

MAXILLARY SPACING
N=250. No treatment. T1=29, T2=7
2.8%
N=58. Any treatment. T1=9, T2=2
3.4%
N=39. Non-extraction treatment. T1=7, T2=2
5.1%
N=19. Extraction treatment. T1=2, T2=0 0.0%
MAXILLARY CROWDING
N=250. No treatment. T1=11, T2=14
N=58. Any treatment. T1=6, T2=6
N=39. Non-extraction treatment. T1=3, T2=6
N=19. Extraction treatment. T1=3, T2=0 0.0%

385

11.6%
15.5%
17.9%
10.2%

4.4%
5.6%
7.7%

10.3%
10.3%
15.4%
15.8%

MANDIBULAR SPACING
2.8%
N=250. No treatment. T1=7, T2=5
2.0%
N=58. Any treatment. T1=2, T2=0 0.0% 3.4%
5.1%
N=39. Non-extraction treatment. T1=2, T2=0 0.0%
N=19. Extraction treatment. T1=0, T2=0 0.0%

T1%
T2%

0.0%

MANDIBULAR CROWDING
N=250. No treatment. T1=22, T2=39
N=58. Any treatment. T1=4, T2=13
N=39. Non-extraction treatment. T1=1, T2=11
N=19. Extraction treatment. T1=3, T2=2
0%

8.8%
6.9%

15.6%
22.4%

2.6%
10.5%

5%

10%

28.2%

15.8%

15%

20%

25%

30%

Fig. Prevalence of anterior spacing and crowding at T1 and T2 in percentages.

Q&A
Turpin: In what way have you added to your conclusions of 2007 and 2009 when you last published
articles describing this sample?

treatment with extraction counteracts long-term

development of crowding in both arches, whereas
nonextraction treatment is associated with increased
mandibular crowding.

Jonsson: In previous articles, we described the prevalence of malocclusion traits in a sample of middleaged people and long-term occlusal changes of fully
dentate subjects, undisturbed by tooth loss, agenesis,
or orthodontic treatment. The added perspective in
this article was the comparison between treated and
untreated subjects. In a forthcoming article dealing
with malocclusion traits and in this one describing
anterior crowding and spacing, we drew 2 conclusions. First, we confirmed the inevitable weight of
long-term general development, because most variables in all subject groups, treated and untreated,
change in the same direction. Second, we substantiated the lasting effect, mostly beneficial, of orthodontic treatment on several occlusal traits. In this
study in particular, we found that orthodontic

Turpin: Are orthodontists in Iceland unique in their

vision to see the value of gathering longitudinal
records over such a long time to study posttreatment
dental changes?
Jonsson: I think that longitudinal records of this kind
would be appreciated by any orthodontist in the
world. What is unique in Iceland, however, might
be the circumstances that make it possible to collect
longitudinal records. A small, uniform community
with high levels of education, health services, and
public registrations makes it possible to keep in contact with people and encourage them to participate in
repeated examinations.
Turpin: If you were just starting your professional
career, how would you design a long-term study to

386

Jonsson and Magnusson

Table II.

American Journal of Orthodontics and Dentofacial Orthopedics

October 2010

Anterior spacing and crowding at T1 and T2 in untreated and treated subjects

T1

T2

T1 %

T2 %

Difference %

P value

T1

T2

No orthodontic treatment n 5 250

Maxillary spacing $2 mm
Maxillary crowding $2 mm
Mandibular spacing $2 mm
Mandibular crowding $2 mm

29
11
7
22

7
14
5
39

11.6
4.4
2.8
8.8

2.8
5.6
2.0
15.6

8.8
1.2
0.8
6.8

7
3
2
1

2
6
0
11

17.9
7.7
5.1
2.6

5.1
15.4
0.0
28.2

12.8
7.7
5.1
25.6

T2 %

Difference %

P value

Any orthodontic treatment n 5 58

0.000
0.491
0.480
0.002

9
6
2
4

Nonextraction orthodontic treatment n 5 39

Maxillary spacing $2 mm
Maxillary crowding $2 mm
Mandibular spacing $2 mm
Mandibular crowding $2 mm

T1 %

0.025*
0.257
0.157
0.002

2
6
0
13

15.5
10.3
3.4
6.9

3.4
10.3
0.0
22.4

12.1
0.0
3.4
15.5

0.008
1
0.157
0.020*

Extraction orthodontic treatment n 5 19

2
3
0
3

0
0
0
2

10.5
15.8
0.0
15.8

0.0
0.0
0.0
10.5

10.5
15.8
0.0
5.3

0.157
0.083
1
0.655

Significance levels: *P \0.05; P \0.01; P \0.001.

T1-T2 differences within groups were analyzed with the Wilcoxon signed ranks test.
Negative signs for T1-T2 difference indicate reduced prevalence.

achieve greater understanding of the efficacy of our

approach to orthodontic treatment? In other words,
where are we most successful, and where do we fail?
Jonsson: The message from our studies is the importance of long-term retention. Since we now have the
option of bonded retainers to hold back at least some
unfavorable occlusal changes that can lie ahead, we

should focus our research on comparisons between

patients who keep their retainers for a long time and
those who do not. Research along these lines would
tell us about occlusal changes with or without retention and would help us answer questions such as
what happens if my retainer is removed? Information about harmful side-effects of permanent retainers
could additionally be derived from such a study.