ORIGINAL ARTICLE

Stability of orthodontic treatment

outcome in relation to retention status:
An 8-year follow-up
Jeanett Steinnes,a Gunn Johnsen,a and Heidi Kerosuob
Tromsø, Norway

Introduction: Our aim was to evaluate the stability of orthodontic treatment outcome and retention status 7 or
more years after active treatment in relation to posttreatment or postretention time, type of retention appliance,
and duration of retainer use. Methods: The subjects were former patients who completed orthodontic treatment
with fixed appliances from 2000 to 2007. The pretreatment eligibility criteria were anterior crowding of 4 mm or
more in the maxilla or the mandible and Angle Class I or Class II sagittal molar relationship. Acceptable pretreat-
ment and posttreatment dental casts were required. A total of 67 patients participated, 24 men and 43 women,
with a mean age of 24.7 years (range, 20.0-50.0 years). All participants had a follow-up clinical examination,
which included impressions for follow-up casts, and each completed a questionnaire. Data were obtained
from pretreatment, posttreatment, and follow-up (T2) casts as well as from the patients' dental records.
Treatment stability was evaluated with the peer assessment rating (PAR) index and Little's irregularity index.
Results: The participation rate was 64%. The average posttreatment time was 8.5 years (range, 7.0-11.0).
All participants had received a retainer in the mandible, maxilla, or both after active treatment. At T2, the PAR
score showed a mean relapse of 14%. The majority (78%) of participants still had a fixed retainer at T2 (retainer
group), and 22% had been out of retention for at least 1 year (postretention group). The relapse according to the
PAR did not differ significantly between participants with and without a retainer at T2. From posttreatment to T2,
the irregularity of the mandibular incisors increased almost 3 times more in participants with no retainer in the
mandible compared with those with an intact retainer at T2 (P 5 0.001). In the maxilla, no corresponding differ-
ence was found. Conclusions: Our results suggest that occlusal relapse can be expected after active orthodon-
tic treatment irrespective of long-term use of fixed retainers. Fixed canine-to-canine retainers seem effective to
maintain mandibular incisor alignment, whereas in the maxilla a fixed retainer may not make any difference in the
long term. (Am J Orthod Dentofacial Orthop 2017;151:1027-33)

M
aintaining the stability of orthodontic treat- relapse.5,6 The evidence indicates that intercanine and
ment outcome in the long term is a challenge. intermolar widths tend to decrease during the
Studies have shown that even when a good, postretention period, especially if these widths were
well-functioning occlusion is achieved, there is a ten- expanded during treatment.7-9 One recommendation
dency toward relapse.1-4 to obtain the best treatment stability has been to
The influence of different occlusal characteristics on maintain patients' pretreatment arch form.10 Although
treatment stability has been widely studied. High quality early arch expansion in the mixed dentition has shown
of the orthodontic finishing does not seem to prevent better long-term treatment stability, the arch form still
tends to return to its pretreatment shape.11 Mandibular
a
Institute of Clinical Dentistry, Faculty of Health Sciences, Arctic University of intercanine and intermolar arch widths have been
Norway, Tromsø, Norway; Public Dental Health Service Competence Centre of considered accurate indicators of a patient's muscle bal-
Northern Norway, Tromsø, Norway.
b
Institute of Clinical Dentistry, Faculty of Health Sciences, Arctic University of
ance, thus dictating the limits of arch expansion during
Norway, Tromsø, Norway. treatment.12
All authors have completed and submitted the ICMJE Form for Disclosure of According to the evidence, a good interincisal contact
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Jeanett Steinnes, Skarvegen 53, Tromsdalen 9020,
angle may prevent the relapse of overbite corrections, and
Norway; e-mail, jeanett.steinnes@tromsfylke.no. good posterior intercuspidation can help to prevent
Submitted, June 2016; revised and accepted, October 2016. relapse of both crossbite and sagittal corrections.7,13
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
When evaluating postretention changes in occlusion,
http://dx.doi.org/10.1016/j.ajodo.2016.10.032 it is important to consider natural growth changes.
1027
1028 Steinnes, Johnsen, and Kerosuo

A longitudinal study by Thilander14 showed continuous of 67 former patients participated, 24 men and 43
changes, with individual variations, in the dental arches women, with a mean age of 24.7 years (range, 20.0-
from the deciduous dentition until the end of growth 50.0 years).
and to some extent even into adulthood. These changes The follow-up examinations, including impressions
could be interpreted as a biologic migration of the denti- for follow-up dental casts, were performed by 2 ortho-
tion, often resulting in anterior crowding, especially in dontic postgraduate students between October 2013
the mandible, even in subjects with congenitally missing and June 2014 at the Public Dental Service Competence
third molars.14 Centre of Northern Norway.
The peer assessment rating (PAR) index was devel- Pretreatment (T0) and posttreatment (T1) data,
oped to assess occlusal and dental changes from pre- including treatment start, treatment end, type of reten-
treatment to posttreatment and has proven to be a tion appliance, and retention control visits, were
reliable and reproducible method to evaluate orthodon- collected from the patients' dental records. Data from
tic treatment outcome.15-18 The PAR index can also be the follow-up examination (T2), including presence
used to measure treatment stability, since it objectively and type of retention appliance, instructions given after
measures changes in the occlusion.3,19 However, the treatment, patient's compliance with retention appli-
PAR index does not give specific information about ance use, and satisfaction with treatment, were obtained
the alignment of the incisors; this is the major concern via a questionnaire administered at T2. Occlusal and
of many patients. To describe the displacement of dental information at T0, T1, and T2 was obtained
incisors and to quantify anterior crowding, the index from dental casts.
introduced by Little20 has been largely used. Treatment outcome (difference between T0 and T1)
After treatment with fixed appliances, fixed retainers and treatment stability (difference between T1 and T2)
in the mandibular and maxillary anterior teeth are were evaluated with the PAR index and Little's irregu-
commonly used. If the maxillary arch has been expanded larity index (LII) on dental casts. The PAR index scores 7
or the treatment included extractions, a combination of traits in the occlusion: alignment of maxillary and
fixed and removable retainers is a common choice in the mandibular anterior segments, right and left buccal
maxilla.21,22 In Norway, fixed retainers were reported to occlusions, overjet, overbite, and center line.15,16 A
be the most commonly used in the mandible, and a fixed PAR score of 0 indicates ideal occlusal alignment,
retainer combined with a removable retainer appeared to and increased scores (rarely beyond 45) indicate
be the most commonly used retention method in the increased deviations from the ideal occlusal
maxilla.23 alignment. All PAR scores were weighted with the
The aim of this study was to evaluate the stability of British weighing factors. A PAR reduction at T1 (T0-
orthodontic treatment outcome and retention status 7 T1) greater than 70% was considered greatly
or more years after active treatment in relation to post- improved, 70% to 30% was considered improved,
treatment or postretention time, type of retention appli- and less than 30% was considered not improved or
ance, and duration of retainer use. worse. LII describes crowding and displacement of
the maxillary and mandibular anterior teeth.20 The
linear distances between anatomic contact points of
MATERIAL AND METHODS 2 adjacent anterior teeth were measured from canine
The study population consisted of former patients to canine, and the index was the sum of the 5 measure-
who completed active orthodontic treatment with fixed ments. The index was used for both mandibular and
appliances at the Public Dental Service Competence maxillary anterior teeth.
Centre of Northern Norway from 2000 to 2007. To be All dental casts were measured by 2 examiners (J.S.,
eligible, patients had to fulfil the following pretreat- G.J.) to the nearest 0.1 mm using a caliper. The exam-
ment criteria: crowding of the anterior teeth of 4 mm iners were calibrated in the use of the PAR index and
or more in the maxilla or mandible and an Angle Class LII before the study, both with each other and with an
I or Class II sagittal molar relationship. All patients experienced orthodontist certified in the use of the
had to have acceptable pretreatment and posttreatment PAR index. In cases of disagreement, the measurements
dental casts available. Patients with anterior open bite were repeated by both examiners together until agree-
and Angle Class III molar relationship were excluded ment was reached. To determine the intraexaminer
due to small numbers. The eligible patients (n 5 105) and interexaminer agreement values for the PAR and
were first sent a letter that included information about LII, both examiners measured 10 randomly selected pairs
the study and an invitation to a follow-up examination; of casts twice, with a minimum of 2 weeks between mea-
later, they were contacted by phone (J.S., G.J.). A total surements.

June 2017
Vol 151
Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Steinnes, Johnsen, and Kerosuo 1029

Statistical analysis
Table I. Retainer status in the maxilla and the
The data were analyzed with SPSS software for Win- mandible in the participants (n 5 67) at T1 and T2
dows (version 19.3; IBM, Armonk, NY). Means (contin-
uous variables) and distributions (categorical variables) Retainer at T1 Retainer at T2
were calculated. Differences between T0, T1, and T2 n % n %
were analyzed with the Student t test and the chi- Retainers in maxilla
square test. The Wilcoxon signed rank test was used to No retention 3 4 41 61
test changes in the PAR score and the LII at the different Only fixed 2 3 25 37
Only removable 26 39 0 0
time points. Interexaminer and intraexaminer agree- Fixed and removable 36 54 1 2
ments were analyzed using the intraclass correlation co- Retainers in mandible
efficient. P values less than 0.05 were considered No retention 7 10 22 33
significant. Fixed 60 90 45 67
Removable, Vacuum-formed retainer (Sta-Vac).
RESULTS
The participation rate was 64% (67/105). Of the
nonparticipants, 19 could not be reached in spite of
several attempts, 11 refused to participate, and 8 did
not attend their appointments. Mean ages did not differ
significantly between the participants and the nonpar-
ticipants.
The interexaminer agreement for the PAR and LII as-
sessments resulted in intraclass correlation coefficients
of 0.96 and 0.98, respectively. Intraexaminer agreement
for the PAR and LII ranged from 0.98 to 0.99. All intra-
class correlation coefficients indicated excellent reli-
ability of measurements.
The average time between T1 and T2 was 8.5 years
(range, 7.0-11.0 years). At T1, all participants received
a retainer in either 1 jaw or both jaws. At T2, 15 partic- Fig 1. Distribution of PAR improvement (%) from T0 to
ipants (22%) had been out of retention for 1 year or T1, and from T0 to T2.
longer (postretention group), and 52 participants
(78%) still had a retainer in either the maxilla, the The mean PAR scores in the whole study sample were
mandible, or both (retention group). At T1, the majority 27.2 (SD, 8.7) at T0, 6.7 (SD, 5.2) at T1, and 10.5 (SD,
(90%) received a fixed retainer in the mandible (Table I). 6.5) at T2.
In the mandible, a fixed canine-to-canine retainer At T1, the average PAR improvement was 75%
attached to all 6 anterior teeth was most commonly (greatly improved). At T2, the average PAR improvement
used (61%). The second most common was a fixed had decreased to 61% (improved), indicating a mean
retainer attached only to the canines (27%). No remov- relapse of 14% from T1. At T1, more than half of the par-
able retainers were used in the mandible. In the maxilla, ticipants were categorized as greatly improved, and 3
most participants (93%) received a removable clear vac- (5%) were worse or no different. At T2, the worse or
uum-formed retainer (Sta-Vac; Sheu-Dental, Iserlohn, no different category had increased to 12 participants
Germany); 36 (54%) received a fixed retainer in addition (18%), and the greatly improved group had decreased
to the Sta-Vac, and 2 (3%) received only a fixed retainer from 40 to 29 participants (43%) (Fig 1). The mean
(Table I). In the maxilla, 32 (48%) received a fixed PAR relapse from T1 to T2 did not differ significantly be-
retainer from right to left lateral incisor; 6 (9%) received tween the retention and postretention groups (13% and
some other type of fixed retainer. Three participants had 15%, respectively). No significant differences in PAR
no retention in the maxilla at T1, and 7 had no retention scores were found between the groups at T0, T1, or T2
in the mandible. At T2, 15 participants (23%) reported to (Table II).
have lost or broken their mandibular fixed retainers. Less At T0, the mean LII values were 9.6 mm in the maxilla
than half of the participants (39%) still had the fixed and 7.4 mm in the mandible. From T0 to T1, the mean
retainer in the maxilla, and 1 participant was still using LII values had decreased to 7.9 mm in the maxilla and
the removable Sta-Vac retainer (Table I). 6.3 mm in the mandible. Between T1 and T2, an increase

American Journal of Orthodontics and Dentofacial Orthopedics June 2017
Vol 151
Issue 6
1030 Steinnes, Johnsen, and Kerosuo

Table II. Distribution of mean PAR scores at T0, T1, and T2, and PAR improvement (%) in the retention and post-
retention groups
Mean PAR score PAR improvement

n T0 (SD) T1 (SD) T2 (SD) T0-T1 (%) T0-T2 (%)

Retention group* 52 27.5 (8.7) 6.7 (5.2) 10.3 (6.6) 76 63
Postretention groupy 15 26.3 (8.8) 7.0 (5.5) 11.1 (6.2) 73 58
P value (between groups) 0.66 (NS) 0.82 (NS) 0.67 (NS)

NS, Not significant.

*Participants with a retainer at T2; yParticipants without a retainer at T2.

Table III. Mean LII at T0, T1, and T2

Maxilla, mean (SD) Mandible, mean (SD)
T0 9.6 (4.6) 7.4 (3.5)
T1 1.7 (1.5) 1.1 (1.2)
T2 2.8 (1.8) 2.1 (1.7)

Changes from T0 to T1 and from T1 to T2 are statistically significant

in both the maxilla and the mandible (P .0.001).

Table IV. Mean increase (mm) in LII in the maxilla and

the mandible from T1 to T2 in relation to a fixed
retainer at T2
Maxilla Mandible

Increase, Increase,
n T1-T2 n T1-T2
Retainer at T2 26 0.76 mm 45 0.65 mm
Fig 2. Distribution of answers to 3 questions on the ques-
No retainer at T2 41 1.15 mm 22 1.82 mm
tionnaire completed at T2.
P 0.33 (NS) 0.001

NS, Not significant.

dissatisfied. More than half of the participants noticed
that their teeth had moved after treatment. Fifty-eight
of 1 mm was seen in both jaws. All changes were statis- percent reported that they had followed the instructions
tically significant (P \0.001) (Table III). From T1 to T2, given at T1 (Fig 2). When asked how long they were in-
the irregularity of the mandibular incisors increased structed to use the vacuum-formed retainer after treat-
almost 2 times more in participants with no retainer in ment, 46% did not remember, 31% reported 1 year, and
the mandible compared with those with an intact 15 % reported 2 or more years. When asked how long the
retainer at T2 (P 5 0.001) (Table IV). In the maxillary in- fixed retainers were supposed to stay in the mouth, 39%
cisors, no difference was found between those with and reported lifelong, 7% reported 1 to 5 years, 3% reported
without retainers in the maxilla at T2. 6 to 10 years, 3% reported 11 to 20 years, and 46% did
In participants who had their mandibular retainers not remember. Participants with an LII of more than
only attached to the canines, LII increased somewhat 3.5 mm in the maxilla or the mandible at T2 were not
more from T1 to T2 compared with participants with re- significantly less satisfied with their treatment than
tainers attached to all anterior teeth (1.3 and 0.9 mm, those with an LII less than 3.5 mm. However, those
respectively), but the difference was not significant. with a maxillary LII of more than 3.5 mm showed a ten-
Sex had no significant influence on treatment outcome dency to be more dissatisfied (P 5 0.074).
or the stability of treatment assessed by the PAR or LII,
nor did the extraction vs nonextraction treatment
strategy. DISCUSSION
At T2, most participants reported that they were After repeated efforts to locate and contact patients,
satisfied with their treatment outcome; only 4.5% were we reached a 64% participation rate, which can be

June 2017
Vol 151
Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Steinnes, Johnsen, and Kerosuo 1031

regarded as acceptable considering that there was an to a slow physiologic mesial migration of the dentition.
average of over 8 years between the end of active ortho- In the maxilla, however, no change in the arch perim-
dontic treatment and the follow-up examination. Partic- eter was found between the ages of 5 and 31 years
ipation rates from 47% to 80% have usually been (measured mesial to the permanent first molars), while
reported in follow-up studies, depending on follow-up a decrease of 4 mm was seen simultaneously in the
times, age, and population groups studied.24-26 Several mandible.14 According to this, the long-term stability
factors may have contributed to nonparticipation in of anterior incisor alignment in the maxilla would
our study. Our invitees were in their midtwenties, and probably be better than in the mandible. Our results
many of them no longer lived at the address in their showed that the irregularity of the anterior incisors in
patient files. The main reason for nonattendance was the mandible increased considerably more in partici-
that we could not reach the patients because of a pants without a retainer compared with those who
change of either address or phone number. For those had a fixed retainer in place at T2. This suggests
who declined our invitation, a general reason was that that, although the fixed retainer did not prevent a
they had moved from the area, and some did not give certain amount of unwanted occlusal changes, it had
a reason. However, the age and sex distributions of a significant role in maintaining the alignment of the
nonparticipants did not differ from participants, mandibular anterior teeth. However, in the maxilla,
suggesting no sample bias. long-term use of a fixed retainer seemed to have no in-
After active orthodontic treatment, the average PAR fluence on changes of maxillary anterior irregularity.
improvement among the participants was 75%; this The difference in the increase of irregularity between
indicated a high standard of treatment.16 Our results the maxillary and mandibular incisors in our study is
corresponded well with previous reports on orthodontic most likely due to the physiologic decrease of the
treatment with fixed appliances.3,6,19,27 arch length, which is more pronounced in the mandible
All study participants received some type of retainer than in the maxilla, resulting in better long-term stabil-
at T1, and most (78%) still had a retainer in place at ity of anterior incisor alignment in the maxilla than in
T2. In spite of that, treatment stability according to the mandible.14
the PAR index, which evaluates the entire occlusion, Most participants in this study were satisfied with
showed an average relapse of 14% in the whole study their treatment outcome. According to the evidence,
sample during the follow-up period. Unexpectedly, the patients are more aware of their anterior teeth than
amount of relapse did not differ between participants the rest of their occlusion.31 Although the PAR index
with or without retainers in place at T2, indicating that in this study showed clear relapse, the participants
long-term use of a fixed retainer did not prevent the or- may not have noticed that, since this index comprises
thodontic treatment from relapsing. Our results do not changes in overjet, overbite, and molar occlusion on
support the previously reported finding that a fixed top of the incisor alignment. Therefore, the LII is prob-
retainer has a positive effect on the PAR score in long ably more relevant from a patient-satisfaction point of
term.3 The amount of relapse in our study is in line view. The mean increase of anterior irregularity in the
with a previous study from Norway,19 where a relapse total study sample after treatment was only about
of 13% was reported among 224 patients treated at 1 mm in both jaws, indicating small, clinically irrelevant
the postgraduate clinic at the University of Bergen. How- changes in general. This may be why so many partici-
ever, in contrast to our study, the subjects in that study pants were satisfied with their treatment outcome.
had been out of retention for more than 5 years, and the However, participants with a LII increase of 3.5 mm
mean retention period was considerably shorter (less or more in the maxilla at T2 tended to be more dissat-
than 2 years) than that in our study. Our results suggest isfied. This may indicate that the alignment of the
that long-time wear of fixed retainers may not prevent a maxillary anterior teeth is an important factor in pa-
certain amount of unwanted occlusal changes after or- tient satisfaction.
thodontic treatment. It is difficult to predict treatment stability on an in-
Perfect stability cannot be expected in the long dividual level. Therefore, retainers are considered
term. Many studies have reported postretention common practice after treatment with fixed appli-
changes in tooth position, overjet, and overbite.28,29 ances. In Norway, fixed retainers are most commonly
Long-term changes have also been found in untreated used in the mandible, and fixed retainers combined
persons.14,30 Thilander14 stated that the occlusion is with removable retainers are the most common prac-
the result of a developmental process that continues tice in the maxilla.23 Our study shows that the retainer
throughout life, with significant individual variations. practices at the Public Dental Health Service Compe-
During life, the dental arches decrease gradually due tence Centre of Northern Norway follow common

American Journal of Orthodontics and Dentofacial Orthopedics June 2017
Vol 151
Issue 6
1032 Steinnes, Johnsen, and Kerosuo

practices in Norway. However, a recent randomized 2. Little RM, Riedel RA,
Artun J. An evaluation of changes in mandib-
controlled trial showed that different retention ular anterior alignment from 10 to 20 years postretention. Am J
Orthod Dentofacial Orthop 1988;93:423-8.
methods had equally favorable clinical results in the
3. Al Yami EA, Kuijpers-Jagtman AM, van’t Hof MA. Stability of or-
long term, indicating that the actual method of reten- thodontic treatment outcome: follow-up until 10 years postreten-
tion may not be a key issue.13 Fixed retainers have the tion. Am J Orthod Dentofacial Orthop 1999;115:300-4.
disadvantage of needing long-term maintenance to 4. Lyotard N, Hans M, Nelson S, Valiathan M. Short-term postortho-
ensure that they are not compromising periodontal dontic changes in the absence of retention. Angle Orthod 2010;80:
1040-50.
health and that they are firmly bonded. A systematic
5. de Freitas KM, Janson G, de Freitas MR, Pinzan A, Henriques JF,
review from 2014 reported many maintenance prob- Pinzan-Vercelino CR. Influence of the quality of the finished oc-
lems, especially with fixed retainers, since they were clusion on postretention occlusal relapse. Am J Orthod Dentofacial
prone to frequent failures or fractures.32 This contrib- Orthop 2007;132:428.e9-14.
utes to an additional workload for the orthodontist, as 6. Freitas KM, Freitas DS, Valarelli FP, Freitas MR, Janson G. PAR
evaluation of treated class I extraction patients. Angle Orthod
well as a cost increase for the patient and society. In
2008;78:270-4.
our study sample, the average time between T1 and 7. Kahl-Nieke B, Fischbach H, Schwarze CW. Post-retention crowd-
T2 was 8.5 years; this is long enough to include ing and incisor irregularity: a long-term follow-up evaluation of
both immediate posttreatment relapse and some stability and relapse. Br J Orthod 1995;22:249-57.
long-term changes, although the definition of “long 8. Kahl-Nieke B, Fischbach H, Schwarze CW. Treatment and postre-
tention changes in dental arch width dimensions—a long-term
term” is rather diffuse in the orthodontic literature.
evaluation of influencing cofactors. Am J Orthod Dentofacial Or-
However, after this time, 78% of the participants still thop 1996;109:368-78.
had a fixed retainer in the maxilla, the mandible, or 9. Myser SA, Campbell PM, Boley J, Bushang PH. Long-term stability:
both. This seems to reflect the current concept of postretention changes of the mandibular anterior teeth. Am J Or-
keeping fixed retainers in place for the long term, thod Dentofacial Orthop 2013;144:420-9.
10. De La Cruz A, Sampson P, Little RM,
Artun J, Shapiro PA. Long-
10 years or more after treatment with fixed appliances
term changes in arch form after orthodontic treatment and reten-
or even lifelong. Our results suggest that provided the tion. Am J Orthod Dentofacial Orthop 1995;107:518-30.
retainer is properly maintained, a mandibular fixed 11. Ferris T, Alexander RG, Boley J, Buschang PH. Long-term stability
retainer may prevent posttreatment changes caused of combined rapid palatal expansion-lip bumper therapy followed
by relapse or the natural aging process in the align- by full fixed appliances. Am J Orthod Dentofacial Orthop 2005;
128:310-25.
ment of the incisors also in the very long term.
12. Lee RT. Arch width and form: a review. Am J Orthod Dentofacial
Another retainer option that deserves attention could Orthop 1999;115:305-13.
be removable retainers in both the maxilla and the 13. Edman Tynelius G, Petren S, Bondemark L, Lilja-Karlander E. Five-
mandible. This would reduce the need for maintenance year postretention outcomes of three retention methods—a ran-
and would give patients more responsibility for their domized controlled trial. Eur J Orthod 2015;37:345-53.
14. Thilander B. Dentoalveolar development in subjects with normal
own retention, thus relying heavily on each patient's in-
occlusion. A longitudional study between the ages of 5 and 31
terest in maintaining the stability of the treatment years. Eur J Orthod 2009;31:109-20.
outcome. 15. Richmond S. The development of the PAR index (peer assessment
rating): reliability and validity. Eur J Orthod 1992;14:125-39.
CONCLUSIONS 16. Richmond S, Shaw WC, Roberts CT, Andrews M. The PAR index
(peer assessment rating): methods to determine outcome of ortho-
dontic treatment in terms of improvement and standards. Eur J Or-
1. Our results suggest that occlusal relapse can be ex-
thod 1992;14:180-7.
pected after orthodontic treatment irrespective of 17. B€ackstr€
om H, Mohlin B. Quality assessment in orthodontics using
long-term use of fixed retainers. the IOTN and PAR indices. Tandl€akartidn 1998;90:49-57.
2. A fixed canine-to-canine retainer seems effective in 18. Shaw WC, Richmond S, O’Brien KD. The use of occlusal indices: a
keeping mandibular incisor alignment, whereas in European perspective. Am J Orthod Dentofacial Orthop 1995;107:
1-10.
the maxilla a fixed retainer may not make any differ-
19. Birkeland K, Furevik J, Bøe OE, Wisth PJ. Evaluation of treatment
ence in the long term. and post-treatment changes by the PAR index. Eur J Orthod 1997;
3. Retainer practice in our sample followed common 19:279-88.
practices in Norway. 20. Little R. The irregularity index: a quantitative score of mandibular
anterior alignment. Am J Orthod 1975;68:554-63.
21. Renkema AM, Sips ET, Bronkhorst E, Kuijpers-Jagtman AM. A sur-
REFERENCES vey on orthodontic retention procedures in The Netherlands. Eur J
1. McNamara JA Jr, Baccetti T, Franchi L, Herberger TA. Rapid maxil- Orthod 2009;31:432-7.
lary expansion followed by fixed appliances: a long-term evalua- 22. Lai CS, Grossen JM, Renkema AM, Bronkhorst E, Fudalej PS,
tion of changes in arch dimensions. Angle Orthod 2003;73: Katsaros C. Orthodontic retention procedures in Switzerland. Swiss
344-53. Dent J 2014;124:655-61.

June 2017
Vol 151
Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Steinnes, Johnsen, and Kerosuo 1033

23. Vandevska-Radunovic V, Espeland L, Stenvik A. Retention: type, treated by traditional edgewise orthodontics. Am J Orthod
duration and need for common guidelines. A survey of Norwegian 1981;80:349-65.
orthodontists. Orthodontics (Chic.) 2013;14:e110-7. 29. Ormiston JP, Huang GJ, Little RM, Decker JD, Seuk GD. Retrospec-
24. Booth FA, Edelman JM, Proffit WR. Twenty-year follow-up of pa- tive analysis of long-term stable and unstable orthodontic treat-
tients with permanently bonded mandibular retainers. Am J Or- ment outcomes. Am J Orthod Dentofacial Orthop 2005;128:
thod Dentofacial Orthop 2008;133:70-6. 568-74.
25. Harradine NW, Person MH, Toth B. The effect of extraction of third 30. Sinclair PM, Little RM. Maturation of untreated normal occlusions.
molars on late lower incisor crowding: a randomized controlled Am J Orthod 1983;83:114-23.
trial. Br J Orthod 1998;25:117-22. 31. Espeland L, Stenvik A. Perception of personal dental appearance
26. Kerosuo H, Heikinheimo K, Nystr€ om M, V€akiparta M. Outcome and in young adults: relationship between occlusion, awareness,
long-term stability of an early orthodontic treatment strategy in and satisfaction. Am J Orthod Dentofacial Orthop 1991;100:
public health care. Eur J Orthod 2013;35:183-9. 234-41.
27. Richmond S, Andrews M. Orthodontic treatment standards in Nor- 32. Westerlund A, Daxberg EL, Liljegren A, Oikonomou C,
way. Eur J Orthod 1993;15:7-15. Ransj€o M, Samuelsson O, et al. Stability and side effects
28. Little RM, Wallen TR, Riedel RA. Stability and relapse of of orthodontic retainers—a systematic review. Dentistry
mandibular anterior alignment-first premolar extraction cases 2014;4:258.

American Journal of Orthodontics and Dentofacial Orthopedics June 2017
Vol 151
Issue 6