ORIGINAL ARTI CLES

Resolution of mandibular arch crowding in growing

patients with Class I malocclusions treated nonextraction
Mi c ha e l We i n b e r g , DMD, a a n d Cyri l Sa dows k y , BDS, MS b
C h i c a g o , I l l .
The pur pose of t hi s st udy was t o det er mi ne t he manner in whi ch mandi bul ar arch cr owdi ng was
resol ved in Cl ass I gr owi ng pat i ent s who wer e t r eat ed nonext r act i on. A r et r ospect i ve st udy was
compl et ed wi t h 30 pat i ent s f rom a post gr aduat e or t hodont i c clinic, t r eat ed wi t h a vari et y of
t r eat ment modal i ti es. Ei ght st udy model s and si x cephal omet r i c par amet er s wer e exami ned bef ore
t r eat ment and at t he end of act i ve t r eat ment (posttreatment). The resul ts showed t hat st at i st i cal l y
si gni f i cant i ncreases in arch wi dt h occur r ed at t he cani ne (0.9 mm), fi rst pr emol ar (1.6 mm), second
pr emol ar (1.8 mm), and fi rst mol ar (1.2 mm). The i nci sors wer e advanced an aver age of 2.1 mm and
pr ocl i ned 6.1. The mol ars showed no ant er opost er i or movement . Arch per i met er i ncreased 2.3
mm and arch dept h i ncreased 1.6 mm. Mul t i pl e l i near regressi on anal ysi s reveal ed t hat 52% of t he
var i ance in cr owdi ng resol ut i on was account ed f or by an i ncrease in arch perimeter. It was
concl uded t hat t he resol ut i on of cr owdi ng, in t hi s gr oup of pat i ent s wi t h Cl ass I mal occl usi ons, was
achi eved by gener al i zed expansi on of t he buccal segment s, al ong wi t hadv anc ement of t he l ower
i nci sors. In some cases, t hese changes may be consi st ent wi t h t r eat ment obj ect i ves; in others, t hey
may be undesi rabl e. It is t her ef or e i mpor t ant f or pract i t i oners t o caref ul l y eval uat e t r eat ment
out come i r r espect i ve of t he t r eat ment modality, t o det er mi ne whet her t r eat ment obj ect i ves are bei ng
met. (Am J Or t hod Dent of ac Or t hop 1996; 110: 359-64. )
Be c a u s e of the current propensity for nonex-
traction treatment, it is important to be aware of the
usual outcomes that can be expected f r om such a
treatment strategy. The degree of mandibular arch
crowding is probabl y the single most important factor
in determining treatment strategy for crowded mal oc-
clusions.
Resolution of crowding can be achieved by distal
movement of the posterior teeth, advancement of the
anterior teeth, and expanding the arch transversely.
Flattening of an excessive curve of Spee, which is
often necessary to reduce a deep overbite, may require
additional arch circumference. 1.2 The tooth movement s
that are produced in the three planes of space are
important measures of satisfying treatment objectives,
including facial esthetics and possibly l ong-t erm sta-
bility. Various treatment modalities can be used to
From the Department of Orthodontics, University of Illinois at Chicago,
College of Dentistry.
~This article is based on research submitted by Dr. Weinberg in partial
fulfillment of the requirements for a Certificate in Orthodontics at the
University of Illinois at Chicago.
bProfessor.
Reprint requests to: Dr. Cyril Sadowsky, University of Illinois at Chicago,
Department of Orthodontics, 801 S. Paulina, Chicago, IL 60612.
Copyri ght 1996 by the Ameri can Association of Orthodontists.
0889-5406/96/$5. 00 + 0 8/1/64533
resolve mandibular arch crowding in Class I malocclu-
sions, which produce tooth movement s in the three
planes of space. These include a l ower lip bumper,
maxillary headgear with Class III elastics as in tandem
mechanics, 3 and arch wi re-di rect ed tooth move-
ment, indirectly through maxillary expansion, possibly
including a removabl e acrylic appliance or lingual
arch.
However, treatment out come may not always be
consistent with the original treatment objectives, be-
cause of variable response, patient compliance, appli-
ance manipulation. Therefore this study examined the
general, overall effects of treatment in a postgraduate
orthodontic clinic, irrespective of the mechanot herapy
used. It sought to describe the changes in the mandibu-
lar arch and their order of predominance, concurrent
with the resolution of mandibular arch crowding dur-
ing orthodontic treatment of Class I crowded mal oc-
clusions in growing patients.
MAT E RI AL S A N D M E T H O D S
S a mp l e
The sample consisted of the records of the most recently
retained 30 orthodontic patients (17 males and 13 females)
treated in the Post-graduate Orthodontic Clinic, University of
Illinois at Chicago, that satisfied the following criteria: (1)
Class I malocclusion, (2) the presence of mandibular arch
359
360 Weinberg and Sadowsky American Journal of Orthodontics and Dentofacial Orthopedics
October 1996
Fig. 1, Mandibular arch perimeter =A +B +C +D.
crowding, (3)anticipated growth during treatment, and (4)
good quality pretreatment and posttreatment study models
and lateral cephalometric radiographs. Potential for growth
was determined by examining hand-wrist radiographs taken
within 4 months before treatment. The criterion for accep-
tance was nonunion of the proximal phalanx of the third
finger (PP3), as described by Bjork and Helm?
Fifteen patients received maxillary cervical headgear,
eight of whom also used Class III elastics to a mandibular
arch wire engaging the molar tubes and ligated to the
incisors ~ (tandem mechanics). Sixteen patients had palatal
expanders, including a quadhelix (6), an acrylic fixed rapid
palatal expander (5), a transpalatal arch (4), and a wire
framework fixed rapid palatal expander (1). Only one
patient received a lip bumper. Several patients used more
than one appliance. Eight patients had unilateral posterior
crossbites.
STUDY MODELS
From photocopies of the study models of the mandibular
arch before treatment (T 0 and after treatment (T2), several
dental landmarks were digitized for subsequent computer
generation of the following measurements:
Arch crowding
The degree of mandibular arch crowding was determined
by measuring the combined mesiodistal widths of teeth from
mesial of first molar to mesial of first molar (space required)
and subtracting the arch perimeter.
Arch perimeter
The sum of the two posterior segments (mesial first perma-
nent molar contact to the distal canine contact) and the two
anterior segments (distal canine contact to the mesial central
incisor contact) (Fig. 1).
Arch width
Intercanine width: The distance between cusp tips of the
contralateral canines.
Interpremolar widths: The distance between both the first and
second premolar buccal cusp tips.
B
Fi g. 2. A, Co n s t r u c t i o n of x - a n d y - a x i s c o o r d i n a t e s f o r me a -
s u r e me n t s t o ma n d i b u l a r f i r st mo l a r s and i nci sor s. B, Dent al
me a s u r e me n t s f r om ma n d i b u l a r s u p e r i mp o s i t i o n s , Ver t i cal : 1.
L1 Cr o wn Vert . , 2. L6 Cr o wn Vert . Hor i zont al : 3. L1 Cr o wn Hor.,
4, L6 Cr o wn Hor. Angul ar : 5. L1 angl e, 6. L6 angl e.
Intermolar width: The distance between the mesiobuccal
cusp tips of the first molars.
Arch depth
The perpendicular distance from the incisor midpoint to a line
constructed between the mesial contact points of the first
molars.
Curve of Spee depth
With life-size (actual) photographs of models, the sums of
the distances were measured from the tips of the buccal cusps
of the canine, first premolar, second premolar, mesiobuccal
cusp of the first molar, and lateral incisal edge to a line
connecting the tip of the distobuccal cusp of the first molar
with the incisal edge of the lower central incisor, s Only cusp
tips below the line were included in the calculation. Decidu-
ous canines and molars were measured when the permanent
counterparts were missing.
LATERAL CEPHALOMETRI C RADI OGRAPHS
Lateral cephalometric radiographs were used before
treatment (T 1 stage) and after treatment (T 2 stage) to evaluate
American Journal of Orthodontics and Dentofacial Orthopedics Weinberg and Sadowsky 361
Volume 110, No. 4
Tabl e I. Study model data in millimeters before treatment (T1), after treatment (T2), and treatment changes (T2-T1)
Variable
r~
Mean [ SD
T2 r 2 - r l
Mean SD Mean [ SD
I
Crowdi ng 4.3 2.24
Curve of Spee 2.3 1.89
Ar ch depth 25.3 2.30
Ar ch perimeter 66.5 4.45
Cani ne width 27.3 2.01
First premol ar wi dt h 34.8 2.56
Second premol ar wi dt h 40.7 2.43
First mol ar wi dt h 46.5 2.69
2.0 0.79 - 2. 3 2.50*
1.2 1.72 - 1. 1 1. 24'
26.9 1.76 1.6 1. 63"
68.8 3.82 2.3 3.24*
28.2 1.43 0.9 1. 51"
36.4 0.16 1.6 1.83"
42.5 2.11 1.8 1.74"
47.7 2.28 1.2 2.07*
*Statistically significant (p < 0.05).
incisor and molar movements anteroposteriorly and vertically
as follows:
Mandibular superimpositions were clone with Dibbets'
modification of Bj ork' s structural method. 6'7 Two fiducial
points were arbitrarily marked on the T 1 cephalometric
tracing to simulate metallic implants (Fig. 2, A). The two
holes were spiked through the tracing sheet, 70 mm apart,
along the palatal plane and outside the image of the palate.
The T~ and T 2 tracings were superimposed by best fit on the
inner contour of the mandibular symphysis, lower border of
the molar crypts, and the mandibular canals. With the T 2 film
superimposed on the mandible, the fiducial points were
transferred from the T a to the T 2 tracing and digitized. The
computer generated a coordinate system, using as the hori-
zontal axis (x-axis), a line drawn through the two fiducial
points. A vertical axis (y-axis) was extended through the
posterior fiducial point and perpendicular to the horizontal
axis. The distances of the mandibular molar and incisor teeth
from the x-axis and y-axis were used to measure the change
in vertical and horizontal position from TI to T 2 (Fig. 2, B).
Angular measurements (long axis of the tooth to the x-axis)
were used to measure the inclination changes of the man-
dibular molar and incisor teeth from T t to T 2.
DATA ANALYSI S
Mean, standard deviation, and range were calculated for
all study model variables at T 1 and T 2 stages. The mean
change in each of the study models and cephalometric
parameters was subjected to paired t tests to determine
whether the change was significant. To analyze the relation-
ship between reduction of mandibular arch crowding and the
factors responsible for the resolution of crowding, a multiple
linear regression was performed with the change in crowding
as the dependent variable.
RESULTS
Reproducibility
Me a s ur e me nt s wer e c ompl e t e d t wi ce f or 10 set s o f
mode l s and r adi ogr aphs wi t h 2 weeks be t we e n t ri al s.
Ma t c he d pai r t t est s wer e used t o t est f or si gni f i cant
di f f er ences bet ween t r i al s to det er mi ne r epr oduci bi l i t y.
Ma t c he d pai r ed t t est s s howed t hat t her e wer e no
st at i st i cal l y si gni f i cant di f f er ences ( p < 0. 05) bet ween
Table I I . Cephalometric changes (T 2 - T1) for molars
and incisors based on mandibular superimpositions
Variable Mean [ SD
Incisor vertical (ram) - 1. 8 2.09*
Incisor horizontal (nun) 2.1 1.56"
Incisor angulation (degrees) - 6. 1 5.08*
Mol ar vertical (ram) - 2. 4 1.61 *
Mol ar horizontal (mm) 0. 6 1.77
Mol ar angulation (degrees) 3.5 4.20*
(Negative Values = advancement/extrusion/mesial tipping).
*Statistically significant (p < 0.05).
t he t wo t ri al s. Fur t her mor e, t he i ncr eas e i n ar ch dept h,
usi ng st udy model s , was s i mi l ar t o t he advancement
seen wi t h t he l ower mol ar and i nci s or on t he cephal o-
met r i c r adi ogr aph ( model 1.64 mm vs. r adi ogr aph 1.51
mm) . Me a s ur e me nt i n t hi s di r ect i on, usi ng model s or
cephal omet r i c r adi ogr aphs , ma y be i nt er changeabl e.
Study model data: Cr owdi ng and t he dept h of t he
cur ve o f Spee s howed si gni f i cant decr eases ( Tabl e I).
I ncr eas es occur r ed wi t h ar ch dept h, ar ch per i met er , and
ar ch wi dt h at t he cani ne, pr emol ar , and mol a r r egi ons.
Cephalometric data: The l owe r i nci s or er upt ed/ ex-
t r uded ver t i cal l y and was a dva nc e d and pr ocl i ned
( Tabl e II). The l ower fi rst mol ar er upt ed] ext r uded
ver t i cal l y wi t h a mes i al angul at i on and no si gni f i cant
ant er opos t er i or movement .
Coefficients of correlation: The decr eas e ( r esol u-
t i on) of cr owdi ng was f ound t o be r el at ed (p < 0. 05) t o
fi ve par amet er s , i n t he f ol l owi ng order, bas ed on t he
st r engt h o f t he cor r el at i on ( Tabl e III): i ncr eas e i n ar ch
per i met er , ar ch dept h, i nt er f i r st pr e mol a r wi dt h, i nt er -
s econd pr e mol a r wi dt h, and i nt erfi rst mol ar wi dt h.
Ar c h per i met er i ncr eas e was cor r el at ed wi t h an i n-
cr ease i n i nt er f i r st pr emol ar , i nt er s eeond pr emol ar , and
i nt erfi rst mol a r wi dt hs; al so wi t h mes i al move me nt of
t he l ower i nci s or and pr ocl i nat i on of t he l ower i nci sor.
Ar c h dept h i ncr eases wer e cor r el at ed wi t h i n-
cr eases i n i nt er f i r st pr e mol a r wi dt h, i nt erfi rst mol a r
wi dt h, and wi t h pr ocl i nat i on of t he l owe r i nci sor. The
362 Weinberg and Sadowslcy American Journal of Orthodontics and Dentofacial Orthopedics
October 1996
Tabl e Ill. Correlation of changes from T 1 - T 2
Curve
of Arch Arch 3 4 5 6 1 1 1 6 6 6
Crowd Spee length depth width width width width hor vert ang hor vert ang
Crowding 1.00
Curve of Spee -0.24 1. 00
Arch length -0.68* 0.29 1.00
Arch depth -0.55* 0.30 0.91" 1.00
3 width -0.35 0.12 0.16 0.18 1.00
4width -0.45* 0.21 0.45* 0.49* 0.67*
5width -0.36* -0.06 0.39* 0.33 0.60*
6 width -0.45* 0.20 0.64* 0.47* 0.20
1 hor -0.36 0.34 0.60* 0.64* 0.11
1 ve~ -0.23 0.07 0.21 0.20 -0.18
1 ang 0.28 -0.46* -0.41" -0.53* -0.09
6 hor 0.28 -0.04 -0.46* -0.34 -0.13
6 ve~ -0.09 -0.34 -0.14 -0.09 -0.11
6 ang -0.08 0.29 0.21 0.14 0.05
1.00
0.57* 1.00
0.30 0.43* 1.00
0.23 0.19 0.33 1.00
-0.15 0.02 0.16 0.16 1.00
-0.17 -0.04 -0.29 -0.70* -0.43* 1.00
-0.19 -0.26 -0.41" 0.17 -0.01 -0.13 1.00
0.03 -0.07 -0.16 -0.32 0.38 0.16 0.00
0.13 0.00 0.02 0.05 -0.20 0.22 -0.06
1.00
-0.35 1.00
*Statistically significant (p < 0.05).
hor, Horizontal; vert, vertical; ang, angle.
levelling of the curve of Spee was correlated only with
proclination of the l ower incisor. There was a strong
correlation between the advancement and proclination
of the l ower incisor.
Stepwise linear regression: A stepwise linear re-
gression that used crowding as the dependent variable
showed that arch perimeter accounted for 52% of the
variability of the resolution of lower incisor crowding
(p < 0.001). No other parameters accounted for any
variability in the regression analysis.
DISCUSSION
The met hod of using four segments to measure
arch perimeter for determining arch crowding inher-
ently overestimates the amount of crowding and thus
would account for the residual 2 mm of crowding af t er
treatment (T2). The sample had very few mandibular
arches with a deep curve of Spee. The minimal flat-
tening of the curve of Spee during treatment was
correlated only with proclination of the lower incisor
but may have been too small to detect other statisti-
cally significant correlations.
In general, the increase in arch width occurred
throughout the posterior segments. Expansion was
greatest at the second premolars (1.8 ram) and least at
the canines (0.9 rnm). Twenty-seven of the patients in
our sample used intraoral and extraoral auxiliary ap-
pliances that were designed to provide expansion of
the maxillary arch with reciprocal expansion in the
mandibular arch. Although it is generally beneficial
from a stability standpoint to have minimal expansion
at the cani nes, we would speculate that the small
intercanine width increase may be considered stable
because many of the patients also had expansion of the
maxillary apical base.
By using a variety of fixed expansion screw appli-
ances in 52 patients under the age 18 years, Wertz and
Dreskin 8 found that mandibular intermolar width in-
creased 0.4 mm (range - 0. 5 to 4.6 ram) at the comple-
tion of suture opening (4 months of treatment). Sand-
strom et al. 9 evaluated treatment with a Haas-t ype
rapid palatal expander, followed by fixed appliances, in
17 nonextraction cases. Their results showed that there
was a posttreatment increase in mandibular intercanine
width of 2.2 mm (SD = 1.3 ram) and an increase in
mandibular intermolar width of 3.3 mm (SD = 2 mm).
However, Adkins et al., l who used a Hyrax wire
framework rapid palatal expander, and Gryson 11, who
used the Haas-t ype acrylic rapid palatal expander,
found no significant change, from before treatment to
after expansion in mandibular intermolar width. Simi-
lar results were found after treatment by Frank and
Enge112 who examined the quadhelix, used in combi-
nation with full-fixed appliances.
Tandem mechanics, which is sometimes used to
treat Class I crowded malocclusions, is an appliance
designed primarily to move upper and l ower molars
distally. 3 Haas' study, 3 which used 45 lateral oblique
films, examined 57 nonextraction cases. The oblique
films showed distalization of the mandibular first mo-
lars, a mean 2.7 mm per side, with distal tip of the
mol ar after the t andem phase and a subsequent ten-
dency for the teeth to begin uprighting during the
edgewise phase of treatment.
Less dramatic results were shown by Williams 13 in
a study of 20 growing children with lower arch crowd-
ing and an anteroposterior discrepancy. After align-
ment of the mandibular arch, he reported distalization
of the mandibular first molars a mean of 1.2 mm (1.3
mm SD) with eruption of 1.2 mm (1.1 mm SD),
American Journal of Orthodontics and Dentofacial Orthopedics Weinberg and Sadowsky 363
Volume 110, No. 4
whereas, the lower incisors were retracted 1.3 mm (0.9
mm SD) with eruption of 1.2 mm (0.8 mm SD). lie
also found that the first premolars showed the most
eruption 3.3 mm (2.7 mm SD).
In a sample that used tandem mechanics (maxillary
headgear and Class II1 elastics to a mandibular arch
wire) followed by fixed appliances, Lisac 14 reported
that the mandibular first molars were moved distally an
average of 1.8 mm (1.4 mm SD) and extruded 3.4 mm
(1.9 mm SD). However, the incisors were also ad-
vanced 0.6 mm (2.3 mm SD) and extruded 3.3 mm
(2.2 mm SD) with significant proclination.
The lip bumper has been used for molar anchor-
age, 15'16 prevention of poor lip habits, 17'18 and creation
of space in the mandibular ar chJ 7'19-2~ Bergersen) 6
who examined 61 patients treated with only a lip
bumper for 2 to 10 months, found that 95% of the
patients showed forward migration of the mandibular
incisors and distal movement of the first molars. Bjer-
regaard et al.2~ studied 11 patients with lip bumpers
that used metallic implants and reported an average
increase of 6 mm in mandibular arch circumference,
2.9 mm increase in interfirst molar width, and approxi-
mately 5 labial tipping of the mandibular incisors.
Cetlin and Ten Hoeve ~9 examined 50 lip bumper cases
and found an average increase in intercanine width of
2.5 mm, interpremolar width of 4.0 mm, intersecond
premolar width of 4.5 mm, and interfirst molar width
of 5.5 mm. Also, Osborn et al. 22 found smaller in-
creases in intercanine width of 2.0 mm (1.3 mm SD)
and interfirst premolar width increase of 2.5 mm (1.4
mm SD). Arch perimeter increased an average 4.1 mm
(2.0 mm SD), whereas, arch length, which increased
1.2 mm (1.3 mm SD) and was predominantly due to
incisor tipping, was most predictive of arch perimeter
changes. Nevant et a l . 23 examined two groups of 20
patients treated with lip bumpers. The first group
treated with acrylic lip shields showed a mean increase
of arch length 7.45 mm per year, whereas those
without acrylic shields showed an increase mean 2.66
mm per year. Interfirst premolar width increased 4.17
mm per year and interfirst molar width increased 4.22
mm per year with the shield, whereas without the
acrylic shield there were less dramatic increases of
interfirst premolar width (2.66 finn/year) and interfirst
molar width (0.75 ram]year). Both groups showed a
mean incisor advancement of 1.42 n~n per year, and
tipping of 3.8 per year to the occlusal plane and to the
2.8 per year mandibular plane.
Overall, studies that examined the use of a single
type of expansion appliance, such as the rapid palatal
expander, quadhelix, tandem mechanics, and lip
bumper, have shown greater mean changes in man-
dibular arch widths than in this study. This may be
because the objectives of treatment within our sample
(and therefore mechanotherapy) may have been more
varied than those used in previous studies of specific
appliances.
In a long-term stability study of a random sample of
cases treated with nonextraction, Glenn et al. 24 found
that among the 14 patients with Class I malocclusions
within the sample, the intercanine width increased 0.5
mm and intermolar width increased 0.8 mm after treat-
ment, with an increase in arch length of 1.4 ram. Their
findings showed smaller increases in arch width and
arch length than this study. This may be due to their
sample displaying less pretreatment crowding.
On the basis of coefficients of correlation (Table
III), the current study found that a 1 mm increase in
arch width at either the first premolars, second premo-
lars, or first molars resulted in a decrease of 0.3 to 0.5
mm in crowding. Expansion at the second premolars
showed the greatest correlation with a decrease in
crowding. A 1 mm increase in arch perimeter resulted
in a 0.7 mm decrease in crowding. With a mathemati-
cal model, Germane 25 evaluated increases in arch pe-
rimeter with expansion using a cubic spline mathemati-
cal model. He found that incisor advancement was
nearly four times as effective in increasing arch perim-
eter as was molar expansion; intercanine expansion
produced an increase in arch perimeter between those
of incisor advancement and molar expansion. The
current study found that advancement of the incisors
and expansion of the molars and premolars had similar
correlations with increasing arch perimeter. The lower
molar showed no distalization. Expansion across the
posterior segment, at the molars or premolars, and
advancement of the lower incisors all produced about
half the amount of increased arch perimeter. This
expansion and advancement within the mandibular
arch may predispose to future relapse.
Generally, when resolving crowding in the man-
dibular arch, the changes produced may not be consis-
tent with the original objectives of treatment and may
be undesirable. It is therefore important for each
practitioner to carefully evaluate treatment outcome
irrespective of the treatment modality, to determine
whether treatment objectives are being met.
CONCLUSI ON
In this sample of 30 patients with Class I malocclusions
and mandibular arch crowding who were treated nonextrac-
tion, it was shown that elimination of crowding was signifi-
cantly correlated with an increase in arch perimeter, advance-
ment of mandibular incisors, and transverse expansion of the
molars and premolars. Half of the variance in resolution of
the mandibular arch crowding was accounted for by changes
in arch perimeter.
364 Weinberg and Sadowsky American Journal of Orthodontics and Dentofacial Orthopedics
October 1 9 9 6
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AAO MEET I NG CAL E NDAR
1997 - - Philadelphia, Pa., May 3 to 7, Phi l adel phi a Convent i on Cent er
1998 - - Dallas, Texas, May 16 to 20, Dallas Convent i on Cent er
1999 - - San Diego, Calif., May 15 to 19, San Di ego Convent i on Cent er
2000 - - Chi cago, Ill., April 29 to May 3, McCor mi ck Pl ace Convent i on Cent er
2001 - - Toronto, Ontario, Canada, May 5 to 9, Toronto Convent i on Cent er
2002 - - Baltimore, Md. , April 20 to 24, Baltimore Convent i on Cent er