ORIGINAL ARTICLE

Overjet, overbite, and anterior crowding relapses

in extraction and nonextraction patients, and
their correlations
Manoela Fa
varo Francisconi,a Guilherme Janson,b Karina Maria Salvatore Freitas,c
Renata Cristina Gobbi de Oliveira,a Ricardo Ce
sar Gobbi de Oliveira,a Marcos Roberto de Freitas,b
and Jose
Fernando Castanha Henriquesb
Bauru, S~ao Paulo, and Maring
a, Paran
a, Brazil

Introduction: In this study, we aimed to compare the relapse of maxillary and mandibular anterior crowding,
overjet, and overbite 5 years after treatment in subjects with Class I and Class II malocclusions treated with
and without extractions, and also to evaluate the correlations among these factors. Methods: The sample
comprised 84 subjects with Class I and Class II malocclusions, treated with and without extractions. Group 1
comprised 44 subjects with an initial mean age of 12.96 years treated without extractions. Group 2 included 40
subjects with an initial mean age of 13.01 years treated with 4 premolar extractions. Data were obtained from dental
casts at the pretreatment, posttreatment, and long-term posttreatment stages. Intergroup comparisons were
performed with t tests. To verify the correlations among the relapse of overjet, overbite, and anterior crowding,
the Pearson correlation test was used. Results: Maxillary incisor irregularity and its relapse in the nonextraction
group were signicantly greater at the long-term posttreatment stage and the long-term posttreatment period,
respectively. Long-term postreatment overjet changes were similar in the groups. Overbite and its relapse were
signicantly greater in the extraction group in the long-term posttreatment stage and period, respectively. There
was a positive correlation of the relapse of mandibular incisor crowding with the relapse of overjet and overbite,
and also a correlation of overjet and overbite relapses. Conclusions: There was greater maxillary crowding
relapse in the nonextraction group and greater overbite relapse in the extraction group. There were signicant
and positive correlations of overjet and overbite relapses with mandibular anterior crowding relapse and conse-
quently between overjet and overbite relapses. (Am J Orthod Dentofacial Orthop 2014;146:67-72)

O
rthodontic treatment has several goals, and one of
the most important is the stability of the achieved
corrections. It is a consensus in the literature that
some occlusal changes will inevitably occur after ortho-
dontic treatment.1,2 It would be greatly interesting if
orthodontists could precisely predict the occlusal
changes that occur after treatment. For this reason, the
effects of different diagnosis and treatment factors in
a
Graduate student, Department of Orthodontics, Bauru Dental School, University
of S~ao Paulo, Bauru, S~ao Paulo, Brazil.
b
Professor, Department of Orthodontics, Bauru Dental School, University of S~ao
Paulo, Bauru, S~ao Paulo, Brazil.
c
Associate professor, Department of Orthodontics, Ing
a Dental School, Maring
a,
Paran
a, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conicts of Interest, and none were reported.
Address correspondence to: Manoela F
avaro Francisconi, Department of Ortho-
dontics, Bauru Dental School, University of S~ao Paulo, Alameda Oct
avio Pinheiro
Brisolla 9-75, Bauru, S~ao Paulo 17012-901, Brazil; e-mail, manuff@usp.br.
Submitted, October 2013; revised and accepted, April 2014.
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.04.012
long-term treatment stability have been extensively stud-
ied.1,3-5 It is well accepted that the stability of tooth
alignment is highly variable and unpredictable.1 Many
authors have considered stability of the mandibular inci-
sors after orthodontic treatment as an unreachable ideal
and suggested long-term retention as the most plausible
solution.1,2,6
Recent research has also shown that overjet is often
corrected during treatment; however, a signicant post-
treatment relapse of this characteristic is often
observed.7,8 Relapse is related to the amount of overjet
at the beginning of treatment, the initial inclination of
the maxillary incisors, the labial inclination of the
maxillary incisors in the postretention period, the
lingual inclination of the mandibular incisors in the
postretention period, and the increase of the interincisal
angle at the end of treatment.8,9
Several factors are related to overbite relapse,
including overjet, movement of the incisors and molars,
interincisal angle, anterior face height, pattern of
craniofacial growth, initial incisor crowding (the Little
67
68
irregularity index), and even the amount of overbite
correction during orthodontic treatment.10 Because
relapse seems to be a constant, some authors recommend
overcorrection.11 Many studies have been conducted on
the subject but focused on only 1 factor or variable.12-16
Because stability is a fundamental key to the success-
ful outcome of orthodontic treatment, in this study we
aimed to compare the relapse of maxillary and mandib-
ular anterior crowding, overjet, and overbite 5 years after
treatment in subjects with Class I and Class II malocclu-
sions treated with and without extractions, and also to
evaluate the correlations among these factors.
MATERIAL AND METHODS
The sample comprised the retrospective dental casts
of 84 patients obtained from the les of the Orthodontic
Department at Bauru Dental School, University of S~ao
Paulo, Brazil. The patients were treated with xed appli-
ances and selected according to the following criteria:
(1) Class I or Class II malocclusion at the beginning of
orthodontic treatment; (2) treatment protocol with or
without extractions; (3) at least 4 mm of overjet and 3
mm of overbite, and maxillary and mandibular crowding
from slight to severe; (4) all permanent teeth erupted up
to the rst molars before treatment; (5) no tooth agen-
esis or anomalies; (6) maxillary removable Hawley plate
worn for 1 year, mandibular xed canine-to-canine
retainers worn for at least 1 year, a maximum of 2 years
posttreatment, and no retention at the follow-up re-
cords; (7) pretreatment (T1), posttreatment (T2), and
long-term posttreatment (T3) dental casts available for
the study; and (8) treated with edgewise mechanics
and achieved acceptable posttreatment results.
The sample was divided into 2 groups.
Group 1, treated without extractions, comprised 44
patients of both sexes (17 boys, 27 girls). Twenty-one pa-
tients had a Class I malocclusion, and 23 had a Class II
malocclusion (4 half cusp, Class II; 6 three quarter cusp,
Class II; 13 full cusp, Class II). At the end of treatment,
all patients had Class I molar relationships. The mean
ages were 12.96 years (SD, 1.10) at T1, 15.12 years (SD,
1.23) at T2, and 20.37 years (SD, 1.20) at T3. The mean
treatment time was 2.16 years (SD, 0.75), the mean
long-term posttreatment time was 5.25 years (SD, 0.79),
and the mean retention time was 1.44 years (SD, 0.48).
The orthodontic mechanics included xed edgewise
appliances, with 0.022 3 0.028-in conventional
brackets and the usual wire sequence characterized by
an initial 0.014-in nickel-titanium alloy, followed by
0.016-in, 0.018-in, 0.020-in, and 0.018 3 0.025-in or
0.019 3 0.025-n stainless steel archwires. Deepbites
were corrected with accentuated and reversed curve of
July 2014  Vol 146  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Francisconi et al
Spee. Maxillary and mandibular crowding was corrected
with expansion of the leveling archwires. Class II maloc-
clusions were corrected with either extraoral headgear or
functional appliances. Class II elastics were also used to
aid in correcting the anteroposterior relationships.
Group 2, treated with extraction of 4 rst premolars,
comprised 40 patients of both sexes (15 boys, 25 girls).
Twenty-ve patients had a Class I malocclusion, and
15 had a Class II malocclusion (6 half cusp, Class II; 1
three quarter cusp, Class II; 8 full cusp, Class II). At the
end of treatment, all patients had a Class I molar rela-
tionship. The mean ages were 13.01 years (SD, 0.99) at
T1, 15.16 years (SD, 1.07) at T2, and 20.61 years (SD,
1.37) at T3. The mean treatment time was 2.15 years
(SD, 0.53), the long-term posttreatment time was 5.45
years (SD, 1.00), and the mean retention time was 1.63
years (SD, 0.69).
Orthodontic mechanics in this group also consisted
of xed edgewise appliances, with 0.022 3 0.028-in
conventional brackets. After the extractions, the initial
canine retraction was performed on a round continuous
0.014-in nickel-titanium alloy archwire until space was
obtained to align the anterior teeth, correcting their
crowding. Subsequently, the usual wire sequence, char-
acterized by an initial 0.014-in nickel-titanium alloy,
followed by 0.016-in, 0.018-in, 0.020-in, and 0.018 3
0.025-in or 0.019 3 0.025-in stainless steel archwires,
was used. Deepbites were corrected with accentuated
and reversed curve of Spee. After leveling and alignment,
the anterior teeth were retracted en masse with rectan-
gular archwires and elastic chains. Extraoral headgear
was used to correct the Class II relationship in Class II
patients, whereas in Class I patients it was used to
reinforce anchorage and maintain the Class I molar rela-
tionship, if needed. When necessary, Class II elastics were
used to help obtain a Class I molar relationship in the
Class II patients.
With the described numbers of patients in each
group, the statistical power of the test was of 80%, at
a signicance level of 5%, to detect a mean change of
0.61 mm (SD, 0.96) with the Little irregularity index
between T2 and T3.17
As retention, both groups used a maxillary Hawley
plate worn full time during the initial 6 months and
then worn at night for the next 6 months, on average.
Fixed canine-to-canine mandibular retainers were used
for mean periods of 1.44 years in group 1 and 1.63 years
in group 2 (Table I).
The maxillary and mandibular dental casts were
measured by 1 investigator (R.C.G.O.) to the nearest
0.01 mm with a digital caliper (500-143B; Mitutoyo
America, Aurora, Ill). The following linear measurements
were obtained for each pair of dental casts.
Francisconi et al 69

distribution, malocclusion types, and malocclusion

Table I. Intergroup comparisons of ages at T1, T2,
severity at T1 between the 2 groups were assessed with
and T3 stages; of duration of treatment, long-term
chi-square tests.
posttreatment, and retention; and of the Little irregu-
Treatment changes were calculated by subtracting
larity index, overjet, and overbite at T1 (t tests)
the T1 values from the T2 values. The amount of relapse
Group 1 Group 2 was calculated by subtracting the T2 values from the T3
(nonextraction) (extraction) values. Intergroup comparisons at the T2 and T3 stages
n 5 44 n 5 40
and during the treatment and long-term posttreatment
Variable Mean SD Mean SD P periods were performed with t tests.
Age at stage of treatment To evaluate whether, generally, there was any corre-
T1 age (y) 12.96 1.10 13.01 0.99 0.826
lation between maxillary and mandibular crowding
T2 age (y) 15.12 1.23 15.16 1.07 0.859
T3 age (y) 20.37 1.20 20.61 1.37 0.400 relapses, overjet and overbite relapses, and anterior
Duration of each evaluation period crowding relapse, and between overjet and overbite
Treatment time (y) 2.16 0.75 2.15 0.53 0.971 relapses, Pearson correlation tests were used. Results
Long-term posttreatment 5.25 0.79 5.45 1.00 0.330 were considered signicant at P \0.05. All statistical
time (y)
analyses were performed with software (Statistica for
Retention time (y) 1.44 0.48 1.63 0.69 0.138
Little irregularity index, overjet, and overbite at T1 Windows, version 6.0; StatSoft, Tulsa, Okla).
Maxillary Little index, 8.92 4.35 10.62 3.98 0.067
T1 (mm)
Mandibular Little index, 5.93 2.92 8.06 3.55 0.003* RESULTS
T1 (mm) No evaluated variable showed a statistically signi-
Overjet, T1 (mm) 6.78 2.69 6.83 2.47 0.926
Overbite, T1 (mm) 4.40 1.40 4.51 1.26 0.708 cant systematic error, and the random errors varied
from 0.38 (overbite) to 0.55 mm (the Little mandibular
*Statistically signicant at P \0.05. index).
The groups were comparable regarding ages at T1,
1. Overjet: the distance from the incisal edges of the T2, and T3; treatment time, long-term posttreatment
most labial maxillary incisor to the most labial time, and retention time; initial maxillary incisor irregu-
mandibular central incisor, parallel to the occlusal larity, overjet, and overbite; sex distribution; type of
plane, recorded in millimeters. malocclusion; and severity of Class II molar relationship
2. Overbite: the amount of vertical incisal overlap of (Tables I-IV). The initial Little mandibular irregularity
the maxillary and mandibular central incisors, index was greater in the extraction group (Table I).
recorded in millimeters. Maxillary incisor irregularity was similar in the post-
3. Incisor irregularity: the sum, in millimeters, of the 5 treatment stage in the groups, but at T3 it was signi-
distances between the anatomic contacts from the cantly greater in the nonextraction group. Treatment
mesial aspect of the left canine through the mesial produced similar decreases in both groups, and the non-
aspect of the right canine according to the method extraction group had a signicantly greater relapse than
described by Little.18 did the extraction group (Table V).
Treatment changes of mandibular incisor irregularity
Thirty dental casts were randomly selected and were signicantly greater in the extraction group
remeasured by the same examiner (R.C.G.O.) after 30 (Table V).
days. Random and systematic errors were calculated Overjet was similar at T2 and T3 and showed similar
comparing the rst and second measurements with, changes with treatment and in the long-term posttreat-
respectively, Dahlbergs formula19 and dependent t tests ment period in the 2 groups (Table V).
at a signicance level of 5%. Overbite was similar in the posttreatment stage in the
groups, but at T3 it was signicantly smaller in the non-
Statistical analysis extraction group. Treatment produced a similar decrease
Because all variables showed normal distributions in both groups, and the nonextraction group had a
according to Kolmogorov-Smirnov tests, intergroup signicantly smaller relapse than did the extraction
comparisons were performed with t tests. group (Table V).
Intergroup comparability evaluation regarding ages There was a positive correlation of the relapse of
at T1, T2, and T3; times at T1, T2, and T3; and T1 maxil- mandibular incisor crowding with relapses of overjet
lary and mandibular incisor irregularity index values, and overbite, and also a correlation of overjet and over-
overjet, and overbite were evaluated with t tests. Sex bite relapses (Table VI).

American Journal of Orthodontics and Dentofacial Orthopedics July 2014  Vol 146  Issue 1
70 Francisconi et al

Table II. Comparison of sex distributions between the Table V. Intergroup comparisons at the posttreat-
groups (chi-square test) ment (T2) and long-term posttreatment (T3) stages
and during the treatment (T2-T1) and long-term post-
Sex
treatment (T3-T2) periods (t tests)
Group Girls Boys Total
Group 1 Group 2
1 (nonextraction) 27 17 44
(nonextraction) (extraction)
2 (extraction) 25 15 40 n 5 44 n 5 40
Total 52 32 84
Variable Mean SD Mean SD P
Chi-square 5 0.07; df 5 1; P 5 0.782.
Maxillary Little index, 1.60 1.24 1.54 1.14 0.798
T2 (mm)
Maxillary Little index, 3.25 1.96 2.43 1.42 0.033*
Table III. Comparison of malocclusion types between T3 (mm)
the groups (chi-square test) Maxillary Little index, 7.31 4.40 9.07 3.83 0.055
T2-T1 (mm)
Class Maxillary Little index, 1.64 1.37 0.89 1.48 0.018*
T3-T2 (mm)
Group Class I Class II Total Mandibular Little index, 1.17 1.05 1.24 0.80 0.727
1 (nonextraction) 21 23 44 T2 (mm)
2 (extraction) 25 15 40 Mandibular Little index, 2.54 1.49 2.88 1.53 0.295
Total 46 38 84 T3 (mm)
Mandibular Little index, 4.76 3.05 6.81 3.50 0.005*
Chi-square 5 1.84; df 5 1; P 5 0.174.
T2-T1 (mm)
Mandibular Little index, 1.36 1.33 1.64 1.75 0.416
T3-T2 (mm)
Table IV. Comparison of Class II molar relationship Overjet, T2 (mm) 3.15 0.89 2.90 0.93 0.210
severity between the groups (chi-square test) Overjet, T3 (mm) 3.57 1.43 3.42 1.26 0.612
Overjet, T2-T1 (mm) 3.63 2.55 3.93 2.47 0.581
Molar Relationship Overjet, T3-T2 (mm) 0.42 1.06 0.52 1.11 0.671
Overbite, T2 (mm) 2.87 0.79 2.88 0.91 0.927
Half cusp, Three quarter Full cusp, Overbite, T3 (mm) 2.73 1.19 3.32 1.20 0.027*
Group Class II cusp, Class II Class II Total Overbite, T2-T1 (mm) 1.53 1.21 1.62 1.41 0.747
1 (nonextraction) 4 6 13 23 Overbite, T3-T2 (mm) 0.14 0.91 0.43 1.22 0.016*
2 (extraction) 6 1 8 15
Total 10 7 21 38 *Statistically signicant at P \0.05.

Chi-square 5 3.63; df 5 2; P 5 0.162.

DISCUSSION
The groups were matching regarding several aspects,
with the exception of the initial Little mandibular irregu-
larity index, which was signicantly greater in the extrac-
tion group (Tables I-IV). This was expected, since
crowding is a major reason for extraction treatment.20-23
All subjects used a similar retention protocol, so this
would not have interfered with the evaluation.5,24,25
The Class I and Class II patients were pooled because
they often displayed similar percentages of anterior
crowding relapse after treatment (Table III).14,25,26
Controversy exists as to which treatment decision
(extraction or nonextraction) will lead to stability. It is there-
fore important to investigate long-term changes in the den-
titions of patients treated with both treatment protocols.27
Maxillary incisor irregularity in the nonextraction
group was signicantly greater in the long-term post-
treatment stage because its relapse was greater than
in the extraction group during the long-term
posttreatment period (Table V). This probably occurred
because in the extraction group, maxillary alignment
was obtained with some canine distalization into the
extraction spaces to correct crowding, whereas in the
nonextraction group, crowding was corrected with the
transverse increase of the maxillary arch and some pro-
trusion of the incisors, which are more prone to
relapse.17 Because the initial amount of maxillary
crowding in the nonextraction group was numerically
smaller than in the extraction group, it seems that actu-
ally there is a greater crowding relapse tendency in the
maxillary arch when these patients were treated without
extractions. This amount of relapse was considered to be
small to moderate.18 Nevertheless, in this study it was
greater than in a previous report, probably because our
patients had a relatively shorter maxillary retention
with the Hawley plate, used for 8.4 years.6 This suggests
that similar to the mandibular arch, a prolonged reten-
tion time might be important for long-term stability.5,6
Because crowding at T1 was signicantly greater in
the extraction group, and the groups ended with similar

July 2014  Vol 146  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Francisconi et al
Table VI. Correlationsbetween maxillary and
mandibular crowding relapses, overjet and overbite re-
lapses, and anterior crowding relapse, and between
overjet and overbite relapses (Pearson correlation
tests)
Correlation r P
Maxillary Little index, T3-T2 3 mandibular 0.166 0.130
Little index, T3-T2
Overjet, T3-T2 3 maxillary Little index, T3-T2 0.192 0.078
Overjet, T3-T2 3 mandibular Little index, T3-T2 0.216 0.047*
Overbite, T3-T2 3 maxillary Little index, T3-T2 0.128 0.243
Overbite, T3-T2 3 mandibular Little index, T3-T2 0.236 0.030*
Overjet, T3-T2 3 overbite, T3-T2 0.578 0.000*
*Statistically signicant at P \0.05.
mandibular irregularity index values, there were signi-
cantly greater treatment changes in the extraction group
(Tables I and V).
Mandibular incisor irregularity at T3 in both groups
was smaller than shown by other studies probably
because the long-term posttreatment observation period
was longer in those studies.25,28 There is a tendency of
mandibular anterior crowding to increase with time.29,30
A slight and similar mandibular crowding relapse
occurred in both groups, within clinically acceptable
standards (Table V).18 Rossouw et al31,32 and  Artun
et al28 also reported no signicant differences in
mandibular crowding relapse between groups treated
with and without extractions. However, there is some
controversy in this respect. Uhde et al33 and Paquette
et al34 found greater amounts of relapse in nonextrac-
tion patients, but Kahl-Nieke et al35 found the opposite.
The greater initial mandibular anterior crowding in our
extraction group might have been responsible for the
absence of a signicant difference in crowding relapse.17
The behavior of overjet during treatment and in the
long-term posttreatment period was similar in the
groups (Table V). There was a slight nonsignicant
relapse in both groups at T3. Hellekant et al,36 evalu-
ating Class II malocclusion patients treated with or
without extractions, observed signicant overjet relapses
in both groups. Perhaps this occurred because they eval-
uated only Class II subjects, who had accentuated initial
overjets.
Overbite was signicantly greater in the extraction
group in the long-term posttreatment stage because there
were signicantly greater overbite relapses in this group in
that period (Table V). This was probably because extrac-
tions usually tend to increase overbite.20,37 While the
appliances are still in place they can control the
overbite, but when the appliances are removed there is
a greater tendency of the overbite to increase.37
American Journal of Orthodontics and Dentofacial Orthopedics
71
There were signicant and positive correlations of
overjet and overbite relapses with mandibular anterior
crowding relapse and consequently between overjet
and overbite relapses (Table VI). According to Little,18
long-term posttreatment crowding of the mandibular
incisors is the rst evidence of progressive instability of
orthodontic treatment. Once mandibular crowding
relapse occurs, the mandibular incisors are lingually tip-
ped, and there are consequent increases in overjet and
overbite. The maxillary incisors are not directly involved
in the changes caused by this relapse. Regardless of the
relapse etiology, irregularity of the mandibular incisors
seems to be the precursor of maxillary crowding, over-
bite, and deterioration of treatment.18 However, these
results should be interpreted with caution, since the cor-
relation coefcients are low and relapse is multifactorial.
Correlations of the investigated factors were performed
in the whole sample because the objective was to eval-
uate whether these factors are generally correlated. It
was not our intention to determine the correlations
among these factors in the groups individually. This
can be investigated in future studies.
Long-term stability is a challenge for orthodontists
because it is almost impossible to guarantee absolute
posttreatment stability. This implies that orthodontists
and patients associate treatment success with long-
term stability.29 In this study, there was greater maxillary
crowding relapse in the nonextraction group and greater
overbite relapse in the extraction group. However, these
long-term posttreatment changes remained within
clinically acceptable limits for stability. These changes
could be described as physiologic adaptations,38,39 or
as part of normal developmental changes.38,40,41
Because orthodontists have little control over these
biologic processes,27 they should clearly explain to their
patients and parents these phenomena and also consider
them during treatment planning, regardless of whether
the patient will be treated with or without extractions.42
CONCLUSIONS
1. There was greater maxillary crowding relapse in the
nonextraction group and greater overbite relapse in
the extraction group.
2. There were signicant and positive correlations of
overjet and overbite relapses with mandibular ante-
rior crowding relapse, and consequently between
overjet and overbite relapses.
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