O tratamento ortodôntico em uma perspectiva a longo prazo: avaliação da estabilidade oclusal e do grau de satisfação dos pacientes

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(1)UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE CENTRO DE CIÊNCIAS DA SAÚDE PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE. O TRATAMENTO ORTODÔNTICO EM UMA PERSPECTIVA A LONGO PRAZO: AVALIAÇÃO DA ESTABILIDADE OCLUSAL E DO GRAU DE SATISFAÇÃO DOS PACIENTES. NAIR GALVÃO MAIA. NATAL/RN 2011.

(2) UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE CENTRO DE CIÊNCIAS DA SAÚDE PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE. O TRATAMENTO ORTODÔNTICO EM UMA PERSPECTIVA A LONGO PRAZO: AVALIAÇÃO DA ESTABILIDADE OCLUSAL E DO GRAU DE SATISFAÇÃO DOS PACIENTES. NAIR GALVÃO MAIA. Tese apresentada ao Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal do Rio Grande do Norte, para obtenção do título de Doutor em Ciências da Saúde.. Orientadora: Maria do Socorro C. Feitosa Alves Coorientadora: Maria Ângela Fernandes Ferreira. NATAL – RN 2011.

(3) Catalogação na Fonte. UFRN/ Departamento de Odontologia Biblioteca Setorial de Odontologia “Profº Alberto Moreira Campos”.. Maia, Nair Galvão. O tratamento ortodôntico em uma perspectiva a longo prazo: Avaliação da estabilidade oclusal e do grau de satisfação dos pacientes / Nair Galvão Maia – Natal, RN, 2011. vii, 51 fl. Orientador: Profa. Dra. Maria do Socorro C. Feitosa Alves. Co-orientador: Profa. Dra. Maria Ângela Fernandes Ferreira. Tese (Doutorado em Ciências da Saúde) – Universidade Federal do Rio Grande do Norte. Centro de Ciências da Saúde. Programa de Pós-Graduação em Ciências da Saúde. 1. Ortodontia - Tratamento - Tese 2. Satisfação do Paciente - Tese. 3. Resultado de tratamento - Tese. I. Alves, Maria do Socorro C. Feitosa. II. Título. RN/UF/BSO. Black D4.

(4) UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE CENTRO DE CIÊNCIAS DA SAÚDE PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE. Profa. Dra. Técia Maria de Oliveira Maranhão Coordenadora do Programa de Pós-Graduação em Ciências da Saúde. iii.

(5) UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE CENTRO DE CIÊNCIAS DA SAÚDE PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE. BANCA EXAMINADORA. PRESIDENTE DA BANCA. Profa. Dra. Maria do Socorro Costa Feitosa Alves – UFRN. MEMBROS TITULARES. Prof. Dr. Pedro César Fernandes dos Santos - UFCE (Membro externo). Prof. Dr. Fábio Henrique de Sá Leitão Pinheiro – UNP (Membro externo). Profa. Dra. Delane Maria Rêgo – UFRN (Membro interno). Profa. Dra. Kathia Maria Fonseca de Brito - UFRN (Membro interno). iv.

(6) “O sucesso não consiste em jamais cometer erros, mas em jamais cometer o mesmo erro duas vezes.”. George Bernand Shaw. v.

(7) Dedicatória. A Deus pela presença e proteção que sempre me foi dada, guiando e iluminando meu caminho e decisões;. Ao meu pai Rosalvo Pinheiro Galvão (in memoriam) meu grande incentivador e espelho na escolha profissional. Pai presente que, com amor e carinho, sempre me orientou e me ensinou o caminho da vida;. A minha mãe Zilah, sempre presente nas horas difíceis que, com seu apoio e dedicação, muito me ajudou na conquista de meus objetivos;. Aos meus filhos Najwa, Nayara e Ajalmarzinho, razão do meu viver, que muito me estimularam a transpor os obstáculos que a vida nos impõe;. A Ajalmar, pela ajuda, apoio e incentivo que sempre me deu para conseguir alcançar meus objetivos e tornar meus sonhos realidade.. vi.

(8) Agradecimentos. À Profa. Socorro que, com sua sábia orientação e especial atenção para comigo, me aceitou como orientanda e abriu uma janela para minhas realizações; À Profa. Ângela que, com sabedoria, atenção e solicitude, me orientou e apoiou, o que foi fundamental para a execução deste trabalho; Ao Prof. Dr. David Normando, amigo de longa data, com quem sempre pude contar. Sua contribuição segura e competente para a análise estatística e desenvolvimento desta pesquisa, foi-me essencial para concretização deste trabalho; À “Faculdade” de Odontologia, minha segunda casa, onde consegui dedicar toda uma vida profissional, agradeço, através de seus dirigentes, a conquista deste importante título acadêmico; Ao Programa de Pós-Graduação em Ciências da Saúde da UFRN e aos seus professores que me abriram uma oportunidade para complementar a carreira profissional dentro de um programa de Doutorado avançado; Às colegas de disciplina Leda, Kátia, Sonemy, Isabelita e Juliana, pela compreensão e presteza que foram imprescindíveis para a conclusão deste trabalho; A Vilane, pela ajuda na localização dos pacientes pesquisados; A Maura Lúcia, pela ajuda na digitação dos dados; Aos funcionários da biblioteca, em especial Cecília pela inestimável ajuda e sempre disponibilidade para comigo. Aos pacientes, pela grandeza em entender que sua participação nesta pesquisa contribuiu para o enriquecimento da ciência e da coletividade.. vii.

(9) Sumário. RESUMO .............................................................................................................. ix. 1. INTRODUÇÃO ............................................................................................ 1. 2. REVISÃO DE LITERATURA ....................................................................... 3. 2.1 Alterações oclusais pós-tratamento ortodôntico .................................... 3. 2.2 O grau de satisfação do paciente .......................................................... 6. ANEXAÇÃO DOS ARTIGOS PUBLICADOS .............................................. 8. 3.1 Artigo publicado no World Journal of Orthodontics ……………………. 9. 3.2 Artigo publicado no Angle Orthodontist ................................................. 15. 3. 4. ARTIGO PARA SER SUBMETIDO À AVALIAÇÃO PARA PUBLICAÇÃO ............................................................................................. 19. 4.1 Clinical Assessment of the stability of orthodontic outcomes in Angle Class I and II: A systematic review ……………………………………………. 20. 5. COMENTÁRIOS, CRÍTICAS E SUGESTÕES ............................................ 35. 6. REFERÊNCIAS ........................................................................................... 41. 7. APÊNDICE................................................................................................... 44. 8. ANEXOS....................................................................................................... 46. 9. ABSTRACT ................................................................................................. 50. viii.

(10) RESUMO Este estudo objetivou avaliar os fatores relacionados à estabilidade do tratamento ortodôntico e o grau de satisfação dos pacientes em longo prazo. Foram selecionados 209 pacientes (88 classe I e 121 classe II), tratados com aparelhagem fixa “straigth-wire” com, pelo menos, 5 anos pós-tratamento. Seiscentos e vinte e sete modelos foram examinados através do índice PAR no pré-tratamento (T1) no final do tratamento (T2) e em longo prazo (T3) – média de 8,5 anos. O questionário do índice Dental Impact Daily Living (DIDL) foi aplicado em T3 para avaliar a satisfação do paciente com sua oclusão em longo prazo. Foram utilizados o teste de Friedman e a análise de regressão linear múltipla para avaliar as mudanças ocorridas nos períodos de avaliação e os fatores associados com a estabilidade e com o grau de satisfação, respectivamente. As variáveis predictoras para o exame da oclusão foram: índice PAR em T1 e T2, idade em T1, tempo sem contenção 3x3, tempo de uso da contenção de Hawley, duração do tratamento, tempo de acompanhamento pós-tratamento, gênero, tratamento com e sem extração dentária e presença ou ausência de terceiro molar. Para o grau de satisfação, as variáveis foram: mudanças produzidas pelo tratamento (PAR T2-T1), estabilidade póstratamento (PAR T3), idade no início do tratamento (T1), duração do tratamento (T2T1), gênero e extração dentária. O tratamento produziu uma melhora de 94,2% no índice PAR (T2-T1), porém isso não estava associado ao grau de satisfação quando o paciente foi questionado em (T3). Nenhuma mudança significativa foi observada entre T2 e T3, entretanto, quando a amostra foi dividida de acordo com o grau de finalização (PAR T2), evidenciou-se que pacientes bem finalizados mostraram alguma alteração no resultado do tratamento (P< 0,001), enquanto os casos não tão bem finalizados apresentaram algum grau de melhora (P< 0,05). Entretanto, mesmo com alguma alteração os casos bem finalizados ainda apresentaram um índice PAR ix.

(11) melhor em T3 quando comparado com os pacientes não tão bem finalizados. A análise de regressão mostrou que o índice PAR em T1 e T2, a idade em T1 e a duração do uso da contenção tiveram uma moderada associação com a estabilidade oclusal (R²= 0,27). Com relação ao grau de satisfação, apenas o índice PAR em T3 apresentou uma relação significante (R² = 0.125, p < 0,0001). Pode-se concluir que, embora o tratamento ortodôntico seja relativamente estável, em longo prazo, os casos mais bem finalizados tendem a uma pequena alteração dos resultados, enquanto aqueles não tão bem finalizados tendem a alguma melhora, porém esses casos ainda são piores que os bem finalizados em longo prazo. O grau de satisfação do paciente não está relacionado com o resultado do tratamento ortodôntico, porém há uma suave associação com a oclusão presente em longo prazo.. Descritores: Ortodontia, resultado do tratamento, satisfação do paciente..

(12) 1. 1 INTRODUÇÃO. Não obstante o indiscutível apelo estético dentofacial esperado pelos pacientes que buscam tratamento ortodôntico, a normalização anatomofuncional da oclusão dentária constitui uma das principais metas da terapia ortodôntica. Entretanto, um resultado considerado satisfatório no final do tratamento pode sofrer alterações no decorrer do tempo. Uma multiplicidade de fatores pode estar associada a essas alterações pós-tratamento, levando a mudanças indesejáveis, causando uma insatisfação do paciente com sua oclusão. A literatura pertinente é contraditória em relação aos fatores que têm influência significante sobre as mudanças observadas após a terapia ortodôntica, e possivelmente muitos são desconhecidos. Os estudos com acompanhamento em longo prazo de casos tratados ortodonticamente revelaram que, embora a oclusão “ideal” e o alinhamento dentário sejam alcançados, há uma tendência à recidiva da má oclusão original no período pós-tratamento1-4. Diversos métodos têm sido utilizados para examinar essas alterações, entre eles o índice PAR5 foi utilizado por alguns autores para mensurálas20,11,4,30. A literatura registra que as mais frequentes evidências de instabilidade dos resultados se apresentam nas rotações dos dentes anteriores, no apinhamento dos incisivos inferiores, nas mudanças no overjet e no overbite, na recorrência de diastema interincisivos maxilares, e ainda no crescimento de uma mandíbula prognática6,7 . No que concerne ao grau de satisfação do paciente com o tratamento ortodôntico, geralmente os estudos realizados enfocaram apenas o exame no final da terapia, e alguns fatores foram relatados como predictores da satisfação do.

(13) 2 paciente logo após a remoção do aparelho ortodôntico8-11 . Todavia, existem poucas informações cientificas sobre a satisfação do paciente em longo prazo31. Uma revisão sistemática12 acerca da estabilidade do tratamento ortodôntico em longo prazo e da satisfação do paciente observou que há poucos estudos sobre o tema, e eles, em sua maioria, mostraram um nível de evidência científica muito baixa e, portanto não foram conclusivos. Os autores alertaram sobre a grande necessidade de futuras pesquisas nessa área. Diante do exposto, o presente trabalho se propõe a avaliar os fatores associados à estabilidade do tratamento ortodôntico e ao grau de satisfação do paciente com sua dentição, pelo menos cinco anos após a conclusão do tratamento corretivo..

(14) 3. 2 REVISÃO DE LITERATURA Este capítulo é constituído dos tópicos: alterações oclusais pós-tratamento ortodôntico e grau de satisfação do paciente.. 2.1 Alterações oclusais pós-tratamento ortodôntico. Uma revisão sistemática sobre a estabilidade dos resultados ortodônticos das classes I e II de Angle13 mostrou que ainda há muitos pontos obscuros em relação aos fatores que podem ou não favorecer a estabilidade dos tratamentos. Essa revisão evidenciou que a alteração mais frequente no pós-tratamento ocorreu no alinhamento dos incisivos inferiores, observado na maioria dos trabalhos consultados. A estabilidade dos resultados ortodônticos constitui-se, até hoje, uma das preocupações dos ortodontistas que têm buscado, através de pesquisas, respostas a respeito dos fatores associados às mudanças. Embora o número de trabalhos científicos seja considerável, ainda existem muitos questionamentos sobre os fatores desencadeantes. Os trabalhos com avaliações em longo prazo são mais escassos, e a maioria mostra uma evidência científica deficiente. O apinhamento dos incisivos inferiores é um fenômeno anatomofisiológico de adaptação em casos tratados ortodonticamente ou não14. Essas irregularidades póstratamento estão relacionadas mais ao crescimento mandibular, do que mesmo à movimentação dentária,15 e a sua ocorrência pós-tratamento é maior no arco inferior,16,17 o que se explica, em parte, pelo tipo de inclinação condilar18.. Quanto. ao gênero, o apinhamento anterior se fez mais presente no pós-tratamento de pacientes do sexo masculino3,19,20 dimorfismo sexual Alguns. ,. embora existam relatos da ausência. de. 11,16,21-23 .. fatores. pré-tratamento. têm. sido. associados. à. recidiva. do. apinhamento, tais como a severidade da má oclusão, 11,19 a deficiência de comprimento de arco, a largura dos incisivos inferiores, a deficiência de largura de arco (intermolar e intercanino), a severidade do apinhamento, irregularidade dos incisivos e overbite aumentado.16Moderada associação foi encontrada também com overjet pré-tratamento.23.

(15) 4 Uma fraca correlação foi observada entre o apinhamento inicial e o grau de irregularidades em longo prazo,20 embora tenha sido observado que grandes irregularidades nos incisivos e largura intercanina estreita são predictores significantes.24 No arco superior observou-se que o deslocamento do ponto de contato, a rotação dos incisivos, assim como o espaçamento interdentário antes do tratamento são fatores de risco significante para recidiva de alinhamento pós-contenção.25 Com relação aos casos tratados com e sem extração dentária, a literatura tem divergido no que diz respeito à presença do apinhamento pós-contenção e sua associação com extração e não extração, principalmente de pré-molares. Relação significante foi observada entre os casos de não extração e a presença de apinhamento.19 Contudo, outros achados apontam que os casos de extração exibiram maior grau de aumento no apinhamento no período pós- contenção.16,24 Ainda notou-se que existe pouca diferença entre os casos de extração e os sem extração com relação ao apinhamento pós-contenção, e que as extrações não influenciaram significantemente o sucesso do tratamento. 17,20,26 Ainda sobre a extração e não extração, os pacientes que foram tratados com extração de 1os pré-molares em um período mais cedo demonstraram menos irregularidade anterior e desvio de linha média.23 Também não se observou diferença entre extração seriada e extração após completa erupção dos primeiros pré-molares.27 Os segundos pré-molares também não mostraram diferença em relação à época de extração.3 Estudo sobre as mudanças ocorridas na forma do palato em casos de extração e não extração, observou-se que as maiores alterações verticais e sagitais, ocorrem no período pós contenção e os casos de extração são menos estáveis 28 . Avaliando os problemas horizontais e verticais, observou-se frequentes mudanças ocorridas no período pós-contenção, no overjet e no overbite, e que elas eram significantes.4,17,19,20,24,26 Nos casos de mordida aberta, foi encontrado um percentual de 36,5% de recidiva, e que nenhuma medida pré e pós-tratamento pode ser predictiva de estabilidade de tratamento.29 A Ortodontia, desde seus primórdios, se preocupa em estabelecer perfeitas relações oclusais no final do tratamento, com a intenção de manter a estabilidade oclusal, o que tem sido confirmado por alguns estudos que encontraram correlação.

(16) 5 entre a Classe II e a Classe III residuais com o aumento do apinhamento, e afirma que uma perfeita relação molar é um fator significante no alinhamento dos incisivos.16 Avaliações usando o índice PAR confirmaram que a oclusão ideal é importante para um bom resultado em longo prazo. 26 Contudo, outros estudos mostraram que, mesmo em casos tratados com sucesso, ocorriam mudanças póstratamento.20,24 Os Escores do índice PAR, após a fase ativa de tratamento, não foram predictivos de mudanças oclusais pós-tratamento.30 Verificou-se que, durante a terapia ortodôntica, pode ocorrer um aumento da largura intercanina, principalmente nos casos de mandíbula com apinhamento, e a diminuição dessa largura pode ser vista no período pós-contenção. A diminuição tem sido associada ao apinhamento dos incisivos mandibulares pós-contenção. 24. ,. porém não se encontrou significância estatística quando se relacionou a diminuição da largura intercanina ao apinhamento anterior pós-tratamento.3,16,17,26 Em casos de extração seriada, notou-se que ocorreu uma diminuição da largura intercanina e do comprimento do arco e a presença de alinhamento insatisfatório.27 A largura intermolar também pode ser aumentada durante a terapia e diminuída na pós-contenção, porém, as expansões moderadas podem ser relativamente estáveis.16O aumento da largura intercanina e intermolar persiste mais no arco maxilar e na região de molares, quando não forem muito expandidos. 17 No que se refere ao tipo de terapia empregada, observou-se que os tratamentos ortodônticos com aparelhos removíveis funcionais podem produzir resultados mais estáveis19. Contudo, outros estudos afirmaram que os pacientes com más oclusões severas, onde se objetiva buscar uma oclusão ideal, devem ser tratados preferêncialmente com aparelhos fixos.26 A relação entre a duração da terapia e a estabilidade do tratamento foi avaliada em vários estudos e verificou-se que um curto tempo de tratamento estava associado a taxas de recidivas maiores.19 Porém outros estudos não encontraram significância na inter-relação do tempo de terapia e da recidiva.20.

(17) 6 2.2 O grau de satisfação do paciente. Os trabalhos sobre estabilidade são amplamente encontrados na literatura ortodôntica, como foi demonstrado anteriormente. Entretanto não tem havido por parte dos pesquisadores a mesma preocupação com o nível de auto-satisfação dos pacientes em relação aos resultados ortodônticos imediatos ou em longo prazo. Os estudos sobre satisfação pós-tratamento ortodôntico têm-nos mostrado uma variação em torno de 34%8 a 75%,9,10 e o maior grau de satisfação encontrado em criança foi 94,4%.26 A idade do paciente e o sexo têm sido relacionados com a satisfação da aparência dentária em indivíduos que não receberam tratamento. 31-35 Estudos têm relatado que a satisfação com a aparência facial decresce com a idade, 31,32 ou seja, os adultos são mais exigentes com sua aparência, assim como o sexo feminino. Contudo, também foi observado que a idade, o gênero e a necessidade ortodôntica pré-tratamento não têm relação com o grau de satisfação do paciente. 8 Constatou-se ainda que os pacientes sem extrações apresentam maior insatisfação com sua dentição do que aqueles para os quais foram indicadas extrações com finalidade ortodôntica.8 Alguns outros fatores têm sido relatados como predictores da satisfação do paciente logo após a finalização do tratamento, como traços de personalidade e escores mais altos de neurocitismo8 . Um estudo procurando avaliar a auto-imagem do aspecto bucal dos pacientes numa escala de satisfação, para verificar o componente psicológico, observou que nenhum dos índices até então utilizados mede adequadamente o componente psicológico envolvido na má oclusão. Entretanto, os resultados asseguram que há perspectiva de que existe um envolvimento psicológico mensurável, apontando quais características devem ser trabalhadas, e demonstrando claramente o valor dos tecidos moles da face em perfil e/ou o posicionamento dos dentes anteriores especificados pela classificação de ANGLE36 .Essa pesquisa confirma o que o senso comum ditaria: que a auto-satisfação pessoal com sua aparência bucal está relacionada aos fatores que são mais visíveis e os mais facilmente avaliados pela população leiga..

(18) 7 A literatura ortodôntica registra poucos estudos com acompanhamento de mais de cinco anos de pós-tratamento que mostre associação entre resultado de tratamento e satisfação do paciente, daí o nosso interesse em efetuar este estudo, já que dispúnhamos de uma amostra com pacientes.que tinham de 5 a 25 anos de pós tratamento..

(19) 8. 3 ANEXAÇÃO DE ARTIGOS PUBLICADOS 3.1 Artigo publicado no World Journal of Orthodontics. Título: FACTORS ASSOCIATED WITH ORTHODONTIC STABILITY: A RETROSPECTIVE OF 209 PATIENTS. 3.2 Artigo publicado no Angle Orthodontist. Título: SATISFACTION. FACTORS. ASSOCIATED. WITH. LONG-TERM. PATIENT.

(20) 9. Nair Galvão Maia, DDS, MS1 Antonio David Corrêa Normando, DDS, MS2 Francisco Ajalmar Maia, DDS, MS, PhD3. FACTORS ASSOCIATED WITH ORTHODONTIC STABILITY: A RETROSPECTIVE STUDY OF 209 PATIENTS. Maria Angêla Fernandes Ferreira, DDS, MS, PhD4. Aim: To assess the long-term stability of orthodontic treatment and some factors associated to posttreatment changes. Methods: Six hundred twenty-seven dental casts of 209 patients were examined with the PAR Index at pretreatment (T1), end of treatment (T2), and at long-term follow-up (T3, mean 8.5 years posttreatment). Friedman test and multiple regression analysis at P < .05 were used to evaluate changes among the time points and factors associated with stability. Results: After orthodontic treatment, the PAR Index improved by 94.2%. No significant change was observed between T2 and T3 (P > .05). However, when the sample was divided into a well- (PAR Index ≤ 3) and a less well-finished (PAR Index > 3) group, it was observed that well-finished patients experienced some deterioration (P < .001), whereas the less well-finished ones showed some improvement (P < .05). Even with the deterioration, the well-finished patients still had a better PAR Index at T3 compared to the less well-finished ones. Regression analysis showed that PAR Index at T1 and T2, age at T1, and length of retainer wear had a slight association with occlusal stability (R2 = 0.27). No significant association was observed between stability and length of treatment, length of follow-up, sex, extraction, or third molar status on the other side. Conclusion: Orthodontic treatment is quite stable. Not so well-finished treatments tend to show some improvement and well-finished ones deteriorate some. Wellfinished patients still have better occlusal characteristics. Retention contributes to maintenance of the final orthodontic results. World J Orthod 2010;11:61–66.. Maria Socorro Costa Feitosa Alves, DDS, MS, PhD4. 1Assistant. Professor, Federal University of Rio Grade do Norte, Brazil. 2Assistant Professor, Department of Orthodontics, Federal University of Pará, Faculty of Dentistry, Belém, Brazil. 3Chair, Department of Orthodontics, Paraíba State University, Campina Grande, Brazil; Associate Professor, Federal University of Rio Grande do Norte, Natal, Brazil. 4Federal University of Rio Grande do Norte, Brazil. CORRESPONDENCE Dr Antonio David Corrêa Normando Rua Boaventura da Silva, 567-1201 Belém-Pa Brazil Email: davidnor@amazon.com.br, davidnormando@hotmail.com. Key words: relapse, stability, retention, PAR Index, treatment. reatment stability is a main goal of orthodontic treatment. A multiplicity of factors can interfere with posttreatment results, leading to undesirable changes. Several authors have used the PAR Index1 to measure occlusal changes during and after orthodontic treatment. PAR Index improvements reported range from 75% to 85%. 2,3 Although most. T. orthodontic treatment results are maintained in the long term, some are lost.2,3 However, the relevant literature is contradictory regarding what factors have a significant influence on any changes observed after therapy. Therefore, the crucial question is why some treatment results improve while others get worse in the long run.. 61 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(21) WORLD JOURNAL OF ORTHODONTICS. Maia et al. Table 1 Median, 25 to 75 quartile (Q25–75), and mean (SD) at the beginning (T1) and end (T2) of treatment and at follow-up (T3) plus statistical significance of the differences between T1–T2 and T2–T3 (Friedman test) Median T1 T2 T3. 17 1 2. Q25–75 12.0 0.0 0.0. 25.5 2.0 4.0. Mean (SD). T2–T1/T3–T2. 19.5 (10.2) 17.0 (2.1) 2.5 (3.1). –17.8* +0.8 NS. Table 2 T2 score. Descriptive statistics of the sample T2 mean (SD) T3 Mean (SD). 0–1 (n = 111) 0.39 (0.5) 2–3 (n = 75) 2.27 (0.5) > 3 (n = 23) 6.17 (2.9). 1.37 (1.8) 3.63 (3.9) 4.48 (3.0). Mean Diff T3-T2 0.97 1.36 –1.7. P < .0001 .006 .0386. n = number of patients.. * Significant (P < .001), NS = not significant, SD = standard deviation.. MATERIALS AND METHODS Two hundred nine of 4,102 patients with an Angle Class I or II relationship from a private clinic more than 5 years after orthodontic treatment were selected for this study. Posttreatment time ranged from 5 to 25 years with a mean of 8.5 years. Class III patients and those treated in combination with orthognathic surgery were excluded. From all patients, dental casts were available for three time points: start of treatment (T1, mean age 14.3 years), end of treatment (T2, mean age 16.2 years), and follow-up (T3, mean age 24.9 years). Sample size was calculated in a pilot study involving the first 20 consecutive patients. The minimum regression coefficient (r2) was considered to be 0.2, the primary variable (PAR Index T3–T2) as having a standard deviation of 2, and an ␣ level of 5% in a two-tailed model with a power of 80%. The estimated sample size was 194 individuals. Eighty-eight patients had a Class I and 121 a Class II relationship. All were treated with straight-wire appliances. Class I occlusion was obtained by headgear or functional appliances according to mandibular size and position. The occlusal changes during and after orthodontic treatment were determined on study casts with the PAR Index.1 The score difference between T1 and T2 defined the occlusal improvement produced by the treatment, while the difference between T2 and T3 reflected the long-term changes. The dif ferences between the various PAR Index scores were evaluated using the Friedman test (P < .05).. Multiple regression analysis was used to assess the association between the primary variable (PAR T3–T2) and the independent variables: sex, age at T1, PAR Index at T1 and T2, length of treatment, length of retention, extractions, and third molar extraction or absence. The PAR Index was defined by two previously calibrated orthodontists. Intraand interexaminer reliability examination were tested with the intraclass correlation coefficient. The research protocol was approved by the research ethics committee of the UFRN (Federal University of Rio Grande do Norte) under no. 110/2005.. RESULTS The intraclass coefficient for the intraand interexaminer reliability was 0.91 and 0.89, respectively. These results indicate excellent method reliability. The initial median PAR Index was 17. At T2, it was improved by 94.2% on average. Generally, this change remained stable, because no overall significant difference was observed between T2 and T3 (Table 1). An interesting finding is noted when the whole sample is divided into three subgroups according to the PAR score at T2 (Table 2). Patients who had a PAR Index ≤ 3 presented minor relapse, while those with a PAR score > 3 improved slightly (Table 2, Figs 1 and 2). Relapse and improvement balanced each other, which explains the absence of a significant net change in the entire sample. However, the well-finished treatments were still better than those finished not as well.. 62 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(22) VOLUME 11, NUMBER 1, 2010. Maia et al. Fig 1 Dental casts of a patient at T2 (top) and T3 (bottom) (14 years after treatment) with extreme improvement (T2 PAR score = 15; T3 PAR score = 0). Fig 2 (right) Graphical representation of the regression analysis of the PAR change between T3–T2 and PAR score at T2.. 25 20. PAR change (T2–T3). 15 10 5 0 –5 –10 –15 5. 10. 15. 20. PAR T2. In the total sample, PAR improvement at T3 was observed for the buccal occlusion, on the right (P < .001) and on the left side (P = .045), while the condition in the anterior region worsened (mandibular anterior crowding = P < .001, overbite = P < .001). In the PAR group with score 0 to. 1, overbite and mandibular anterior crowding deteriorated significantly. In the less well-finished group (PAR > 3), significant improvement was observed for the buccal posterior occlusion (right side, P = .04; left side, P =.02), but no significant deterioration was observed.. 63 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(23) WORLD JOURNAL OF ORTHODONTICS. Maia et al. Table 3. Multiple regression analysis (dependent variable = PAR score T3–T2) ␤ coefficient. PAR T2 PAR T1 Age at T1 Years without 3-3 retainer Years Hawley retainer Duration of treatment (y) Time span of follow-up period (y) Sex Treatment with/without extraction Third molar presence/absence. The factors that influenced treatment stability significantly were, in descending order: excellence of treatment result (␤ = –0.555, P < .001), length of maxillary Hawley retainer wear (␤ = –0.213, P <.001), length without mandibular fixed retainer (␤ = 0.211, P < .001), age at the beginning of treatment (␤ = 0.053, P <.001), and initial malocclusion severity (␤ = 0.052, P < .01). All other variables, ie, treatment length, follow-up duration, sex, extraction, and third molar status, did not show any significant association with relapse (Table 3). Treatment stability is influenced by so many factors that the aforementioned variables can explain only 27% of the relationship (r2 = 0.27).. DISCUSSION The 209 patients in this study were treated at the same clinic with the same method. The time since the conclusion of treatment (at least 5 years, mean 8.5 years) seems adequate enough to assess long-term or thodontic stability. The insignificant increase of 0.8 in PAR scores from T2 to T3 indicates good stability considering data published in the literature.2–5 Some relapse in well-treated patients was previously reported in the literature,2–6 but the improvement observed in less well-finished treatments was either hardly mentioned5 or flatly denied.6 Even with some minor relapse, the well-finished treatment outcomes were still superior to the the less well-finished. –0.555 0.052 0.053 0.211 –0.213 0.015 –0.056 0.146 –0.442 0.338. t value –6.07 3.13 3.49 3.09 –2.49 1.00 –0.73 0.24 –0.54 0.61. P value .000 .002 .000 .002 .013 .320 .470 .810 .590 .540. ones. This result is confirmed by a previous study 7 using the ABO OGS score. However, it should be taken into consideration that the improvement occurred in the posterior occlusion, while the situation in the anterior region deteriorated. To examine the factors that could have some association to relapse, multiple regression analysis was applied. Although 10 variables were examined, only five were significantly related to changes after orthodontic treatment. Yet, these five entities explain only 27% of the observed phenomenon. This indicates that many more unknown variables are related to changes after orthodontic treatment. PAR score at T2 can be considered one of the most important factors associated with posttreatment changes. The statement that well-finished treatments with ideal occlusions at the end of orthodontic therapy are more stable2,8 is not corroborated by this study.5,9 The fact that the examined sample displayed good stability could be explained by the fact that about 60% of patients had a mandibular fixed retainer. Mandibular incisor misalignment is considered by many authors to be the most susceptible symptom to posttreatment change. This aspect was confirmed by the analysis of the effect each of the assessed factors had independently. To a lesser degree, this also applied to the length of maxillary Hawley retainer wear, which is confirmed by the findings of Lang et al.10 However, Ormiston et al5 did not observe any relationship between stability and time and type of retention.. 64 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(24) VOLUME 11, NUMBER 1, 2010. Maia et al. Older patients had better results after treatment. This was verified by two studies,10,11 whereas Little et al,12 Ormiston et al,5 and Harris et al13 declined such a relationship. Present findings support the fact that in older patients, the orthodontist cannot rely on the effective growth of craniofacial structures anymore. This treatment will be more restricted to dental movements, sometimes using less stable dental compensations. Previous reports 2,5 have established that the severity of initial malocclusion (PAR T1) was associated with posttreatment changes. Findings confirm these reports, as a significant association between stability and the initial malocclusion level (PAR T1) was observed. However, it seems that orthodontic stability depends most on the orthodontic finishing (PAR T2) than severity of initial malocclusion (PAR T3) (Table 3). The influence of extractions on changes after treatment has been widely investigated. The literature shows conflicting findings regarding this topic. Some studies reported a higher degree of crowding during postretention in patients who had extractions.9,14 This is in contrast to Lang et al, 10 who found that patients without extractions had more postretention crowding. Uhde et al,15 Ormiston et al,5 and Birkeland et al2 saw little or no difference at all in stability between patients treated with or without extractions. In this study, 15% of the patients were treated with extractions, but no correlation was noticed between extraction/nonextraction and posttreatment changes. In this study, extraction or genetic absence of third molars did not have any significant relation with stability, which is in accordance with the experience of Little16 but in contrast to Kahl-Nieke et al’s findings.14 Although the present investigation did not reveal any significant association between posttreatment changes and sex, a good number of studies2,5,10–12,14,17,18 reported higher posttreatment crowding in males and linked this to their longerlasting facial growth. In this study, the time span between the end of orthodontic treatment and. posttreatment examination was not significantly associated with any changes. This finding contradicts previous papers.4,10 Finally, it should be reiterated that many other factors can influence posttreatment stability, ie, residual growth and lack of posttreatment control, which were not scrutinized in this investigation.. CONCLUSION Overall, orthodontic treatment is stable. Not so well-finished therapies tend to improve along the time, whereas excellently finished treatments tend to experience minor relapse. That said, well-finished patients are still better off in a long-term perspective. Retention regimen contributes to the stability of orthodontic results.. REFERENCES 1. Richmond S, Shaw WC, O’Brien KD, et al. The development of the PAR Index (Peer Assessment Rating): Reliability and validity. Eur J Orthod 1992;14:125–139. 2. Birkeland K, Furevik J, Boe OE, Wisth PJ. Evaluation of treatment and posttreatment changes by the PAR Index. Eur J Orthod 1997;19:279–288. 3. Wood M, Lee D, Crawford E. Finishing occlusion, degree of stability and the PAR index. Aust Orthod J 2000;16:9–15. 4. Al Yami EA, Kuijpers-Jagtman AM, van’t Hof MA. Stability of orthodontic treatment outcome: Follow-up until 10 years postretention. Am J Orthod Dentofacial Orthop 1999;115:300–304. 5. Ormiston JP, Huang GJ, Little RM, Decker JD, Seuk GD. Retrospective analysis of long-term stable and unstable orthodontic treatment outcomes. Am J Orthod Dentofacial Orthop 2005; 128:568–574. 6. Freitas KMS, Janson G, Freitas MR, Pinzan A, Henriques JFC, Pizan-Vercelino CRM. Influence of the quality of the finished occlusal on the postretention occlusal relapse. Am J Orthod Dentofacial Orthop 2007;132:428.e9–14 7. Nett BC, Huang GJ. Long term posttreatment changes measured by the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop 2005;127:444–450. 8. Pavlow SS, McGorray SP, Taylor MG, Dolce C, King GJ, Wheeeler TT. Effect of early treatment on stability of occlusion in patientes with Class II maloccusion. Am J Orthod Dentofacial Orthop 2008;133:235–244. 9. Årtun J, Garol JD, Little RM. Long-term stability of mandibular incisors following sucessful treatment of Class II, Division 1, malocclusions. Angle Orthod 1996;66:229–238.. 65 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(25) WORLD JOURNAL OF ORTHODONTICS. Maia et al. 10. Lang G, Alfter G, Göz G, Lang GH. Retention and stability—taking various treatment parameters into account. J Oraofac Orthop 2002;63:26–41. 11. Haruki T, Little RM. Early versus late treatment of crowded first premolar extraction cases: postretention evaluation of stability and relapse. Angle Orthod 1998;68:61–68. 12. Little RM, Wallen TR, Riedel RA. Stability and relapse of mandibular anterior alignment—first premolar extraction cases treated by traditional edgewise orthodontics. Am J Orthod 1981;80: 349–365. 13. Harris EFVJ, Dunn KL, Behrents RG. Effect of patient’s age on post-orthodontic dentofacial orthopedics. Am J Orthod Dentofacial Orthop 1994;105:25–34. 14. Kahl-Nieke B, Fischbach H, Schwarze CW. Postretention crowding and incisor irregularity: A longterm follow-up evaluation of stability and relapse. Br J Orthod 1995;22:249–257.. 15. Uhde MD, Sadowsky C, BeGole EA. Long-term stability of dental relationships after orthodontic treatment. Angle Orthod 1983;53:240–252. 16. Little RM. Stability and relapse of mandibular anterior alignment: University of Washington studies. Semin Orthod 1999;5:191–204. 17. Freitas KMS, de Freitas MR, Henriques JF, Pinzan A, Janson G. Postretention relapse of mandibular anterior crowding in patients treated without mandibular premolar extraction. Am J Orthod Dentofacial Orthop 2004;125:480–487. 18. McReynolds DC, Little RM. Mandibular second premolar extraction—Postretention evaluation of stability and relapse. Angle Orthod 1991;61: 133–144.. 66 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(26) 15. Original Article. Factors associated with long-term patient satisfaction Nair Galvão Maiaa; David Normandob; Francisco Ajalmar Maiac; Maria Ângela Fernandes Ferreirad; Maria do Socorro Costa Feitosa Alvese ABSTRACT Objective: To identify factors associated with patient satisfaction at least 5 years after orthodontic treatment. Materials and Methods: A total of 209 orthodontic patients were included in the study. All subjects were treated with upper and lower fixed orthodontic appliances. Dental casts (n 5 627) were examined using the Peer Assessment Rating (PAR) Index pretreatment (T1), at the end of treatment (T2) and at a long-term follow-up (mean, 8.5 years; T3). At T3, a Dental Impact on Daily Living questionnaire was used to assess the long-term effects of orthodontic treatment on daily living and satisfaction with the dentition. Multiple regression analyses were used to quantify associations between patient satisfaction and changes produced by the orthodontic treatment (PAR T2-T1), posttreatment stability (PAR T3), age at the start of treatment (T1), treatment duration (T2-T1), gender, and extraction. Results: Orthodontic treatment produced a significant improvement of 94.2% in the PAR Index (T2-T1), but this change was not associated with the level of satisfaction when the patient was questioned at least 5 years after treatment. Regression analysis showed that satisfaction was significantly associated only with the long-term posttreatment PAR index (r 2 5 0.125, P , .0001). No significant association was observed with the severity of malocclusion at the beginning (PART1) or end of the orthodontic treatment (PAR-T2), age at T1, the amount of time taken during orthodontic treatment, gender, or extraction. Conclusions: Over the long term, patient satisfaction is slightly associated with the stability of the orthodontic treatment regardless of the initial occlusal condition or the final result of the orthodontic treatment. (Angle Orthod. 2010;80:1155–1158.) KEY WORDS: Long-term stability; Patient satisfaction; Orthodontic treatment. INTRODUCTION The final goal of orthodontic treatment is to obtain normal or ideal occlusion. Follow-up studies of treated cases have shown that although ‘‘ideal’’ occlusion and dental alignment have been achieved, there is a tendency for posttreatment relapse toward the original malocclusion.1–5 The quality and stability of orthodontic treatment outcomes have traditionally been assessed by established metrics or categorical scales. As health services exist primarily to benefit the patient, an important variable for measuring outcome should be overall patient satisfaction with the care provided. Patient satisfaction with orthodontic treatment is poorly covered in the literature. Satisfaction with dental appearance has been correlated with age and sex in individuals who have not received orthodontic treatment. It has been reported that satisfaction with dentofacial appearance decreases with age.6,7 Therefore, adults are expected to be less satisfied with their dentofacial appearance than are. a Assistant Professor, Department of Pedodontics, Federal University of Rio Grande do Norte, Faculty of Dentistry, Natal, Brazil. b Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Federal University of Pará, Belém, Brazil. c Associate Professor and Department Chair, Department of Orthodontics, Faculty of Dentistry, Paraı́ba State University, Campina Grande, Brazil. d Associate Professor, Department of Public Health, Federal University of Rio Grande do Norte, Faculty of Dentistry, Natal, Brazil. e Associate Professor, Department of Public Health, Federal University of Rio Grande do Norte, Faculty of Dentistry, Natal, Brazil. Corresponding author: Dr Francisco Ajalmar Maia, UEPB/ Federal University of Rio Grande do Norte, Dentistry–Orthodontics, Rua Manoel Machado 683, Petropolis, Natal, RN 59012320 Brazil (e-mail: coi@digi.com.br). Accepted: March 2010. Submitted: December 2009. 2010 by The EH Angle Education and Research Foundation, Inc.. G. DOI: 10.2319/120909-708.1. 1155. Angle Orthodontist, Vol 80, No 6, 2010.

(27) 1156 adolescents. Females are more dissatisfied with the appearance of their dentition than are males.8–10 Investigations of patient satisfaction after orthodontic treatment have shown a wide range of satisfaction levels, ranging from 34%11 to 74–75%.12,13 Birkeland et al.14 recorded a high degree of satisfaction (95.4%) with orthodontic treatment results among children. In addition to the countless variables that could interfere with patient satisfaction, the use of different questionnaires to assess satisfaction after orthodontic treatment makes comparison difficult.11 The level of satisfaction of orthodontic patients has been examined just after the end of treatment. Some factors have been reported as predictors of patient satisfaction at this time. Personality traits were found to be correlated with patients’ satisfaction with their dentition after orthodontic treatment. In orthodontically treated patients, higher neuroticism scores were associated with lower levels of satisfaction with the dentition.11 Patients treated with nonextraction showed more dissatisfaction with their dentition, while age, sex, and pretreatment orthodontic treatment need had no relationship to patient satisfaction.11 A systematic review15 regarding the long-term stability of orthodontic treatment and patient satisfaction concluded that only a few studies have been conducted on long-term patient satisfaction; furthermore, most of these studies showed little scientific evidence, and no conclusions could be drawn. This review concluded that there is a great need for studies in this area. MATERIALS AND METHODS The sample (n 5 209) was selected from a total of 4102 Angle Class I or II patients treated in a private clinic with more than 5 years of postorthodontic treatment. Posttreatment time ranged from 5 years to 25 years, with a mean of 8.5 years (standard deviation [SD] 5 3.4 years). Subjects with facial anomalies and mental disorders, Class III patients, and those submitted to orthognathic surgery were excluded. The research protocol was submitted to the research ethics committee of the Federal University of Rio Grande do Norte and was approved under No. 110/2005. Sample size was calculated from a pilot study involving the first 20 consecutive cases. The minimum regression coefficient (r 2) was found to be 0.2, having a SD of 2 and an a level of 5% in a two-tailed model with a power of 80%. The estimated sample size was 194 individuals. Initially, 400 patients who still lived in town and who met the inclusion criteria were randomly called by phone. The response rate and attendance at the clinic was 62% (n 5 248). Thirty-nine patients refused to make new orthodontic records. Angle Orthodontist, Vol 80, No 6, 2010. MAIA, NORMANDO, MAIA, FERREIRA, ALVES. A total of 88 Class I and 121 Class II malocclusions were examined (n 5 209); these numbers included 70 males and 139 females. All of these patients were treated with straight-wire full appliances. Thirty patients (14.4%) had undergone tooth extractions for orthodontic reasons. Class II molar relationships were corrected through headgear or functional appliances, according to the mandibular deficiency. The mean ages were 14.3 years (range, 8.6–42.9 years) at pretreatment (T1), 16.2 years (range, 10.8–44.1 years) at the end of treatment (T2), and 24.9 years (range, 17.9–59.2 years) at long-term follow-up (T3). The Dental Impact on Daily Living (DIDL) Index was used to assess the degree of satisfaction. The DIDL questionnaire comprises five major categories and tackles five major dimensions of dental satisfaction, namely appearance, pain, oral comfort, general performance, and chewing and eating. The DIDL scale measures the effect and the proportional importance of each dimension to the patient. The scale yields a score ranging from 0 to 10 to show the relative importance of each dimension to the patient. The DIDL questionnaire is a reliable, valid, and comprehensive test for measuring patient satisfaction and the effects of dental disease on patient daily life.16 Orthodontic problems can affect many aspects of dental esthetics and function, and these aspects are well covered by the DIDL Index.11 The DIDL was collected using a questionnaire at T3 (at least 5 years posttreatment). To determine occlusal changes during and after orthodontic treatment, the Peer Assessment Rating (PAR) Index17 was used. This index was developed to provide a single score for all of the occlusal changes. Morphologic occlusion examinations were performed on the dental casts (n 5 627) of 209 subjects at three periods in time: T1, T2, and T3 (mean 8.5 years). Multiple regression analysis (at P , .05) was used to assess the association between the primary variable, satisfaction, and the following independent variables: PAR Index at T1, T2, and T3; age at the start of treatment (T1); gender; orthodontic extraction; and duration of treatment (T2 2 T1). The dental cast examination to collect PAR Index data was performed by one previously calibrated orthodontist. Intraexaminer reliability was assessed using the Intraclass Correlation Coefficient at P , .05. RESULTS The intraclass coefficient for the intraexaminer was 0.91. This result indicates an excellent reproducibility of the method. By considering the initial PAR Index at T1 to be 100% (median 5 17), the changes produced after orthodontic treatment led to a mean improvement of 94.2% in this index (T2). Detailed information about.

(28) 1157. FACTORS ASSOCIATED WITH PATIENT SATISFACTION. Table 1. Multiple Regression Analysis: Dependent Variable, Satisfaction—Dental Impact on Daily Living (DIDL) Index, F 5 5.267 (P 5 .0001)a Independent Variable PAR T1 PAR T2 PAR T3 Gender Extraction Age at T1 Time of treatment. b Coefficient. t-Value. P-Value. 20.001 20.092 20.209 0.162 20.205 0.005 0.007. 20.107 21.342 24.556 0.579 20.560 0.229 0.749. .915 (ns) .182 (ns) ,.001*** .563 (ns) .576 (ns) .819 (ns) .455 (ns). a PAR indicates Peer Assessment Rating; T1, pretreatment; T2, end of treatment; T3, long-term follow-up; and NS 5 no significance, *** P , .001.. Figure 1. T3 PAR Index correlation with DIDL Index.. the PAR findings can be obtained in a previous article.5 Patient satisfaction regarding dental occlusion at least 5 years posttreatment (T3) was examined by the DIDL Index with regard to the five major dimensions of dental satisfaction, namely appearance, pain, oral comfort, general performance, and chewing and eating. This revealed that 162 subjects (77.5%) reported being satisfied with their dentition, while 46 individuals (22%) were relatively satisfied. Only one individual (0.5%) reported being unsatisfied with his occlusion. The value of the level of satisfaction reported by this individual was 21.05, while the PAR Index at T1 was 17, and at T2 the level of satisfaction was reduced to 12. Nine years after treatment (T3) the PAR Index remained at 12. With regard to predictive variables, only the PAR Index at T3 showed a significant relationship with patient satisfaction (P , .001). Figure 1 shows that the higher the PAR Index at T3, the lower the patient’s satisfaction. However, the PAR Index at T3 only explained 12.5% of the variation in the DIDL Index (r 2 5 0.125). The other variables, such as PAR at T1 (P 5 .91), PAR at T2 (P 5 .18), age at beginning of treatment (P 5 .86), duration of treatment (P 5 .41), extraction (P 5 .58), and gender (P 5 .56), showed no significant association with the dependent variable satisfaction (Table 1). DISCUSSION This study showed that patients reported a high degree of satisfaction with their dentition in a long-term follow-up after orthodontic treatment. Around 77% of the patients reported being satisfied with their dentition when they were questioned at least 5 years after the. end of treatment. Orthodontically treated patients demonstrated high levels of satisfaction with their teeth in general. This might be due to the fact that orthodontic treatment can affect dental performance positively, which can lead to higher levels of satisfaction. The changes produced after orthodontic treatment in this sample led to a mean improvement of 94.2% (PAR T2 2 T1). Compared to previous studies,18,19 this finding can be considered a high standard of excellence in orthodontic finishing. There is a possibility that although some degree of dissatisfaction may be reported years after orthodontic treatment this level may be considerably more than it was at the beginning of treatment and less than at the end of the treatment. This cannot be determined from the collected data, and a longitudinal evaluation of patient satisfaction should be performed. Although the use of different questionnaires to assess satisfaction makes comparisons difficult, investigations of patient satisfaction after orthodontic treatment have shown a wide range of satisfaction levels, ranging from 34%11 to 95%.14 We used the same satisfaction questionnaire employed by Al-Omiri and Alhaija.11 These authors reported 34% satisfied and 62% relatively satisfied patients just after orthodontic treatment, while the percentage of dissatisfied patients was 4%. Given the differences in the timing during which the questionnaires were applied (immediately after treatment and long term) comparisons with previous results are difficult, because countless factors can be associated with these differences. Predictive factors related to patient satisfaction are controversial in the literature. A small number of studies have examined this issue. Untreated patients have reported that satisfaction with dentofacial appearance decreases with age,6,7 and females are more dissatisfied with the appearance of their dentition than are males.8–10 Our results showed that gender, age, and duration of treatment were not related to patient satisfaction. The lack of a relationship between gender and patient satisfaction seems to be a common Angle Orthodontist, Vol 80, No 6, 2010.

(29) 1158 outcome for patients who have received orthodontic treatment.11,12 Al-Omiri and Alhaija11 found that satisfaction with the dentition after orthodontic treatment showed no relationship to age. No association was observed between patient satisfaction and extraction for orthodontic reason in the present study. A previous study11 reported that patients treated with nonextraction showed more dissatisfaction with their dentition when the patient was examined immediately after orthodontic treatment. It is possible that the diagnostic criteria for tooth extraction and its impact on dentofacial morphology are more relevant than the procedure itself. Among the predictive factors investigated in this study, the only one able to produce any prediction of long-term patient satisfaction was the PAR Index at T3 (Figure 1). However, this variable explains only 12.5% of variations in the DIDL Index. Thus, patient satisfaction is not related to the improvement produced by the orthodontic treatment (PAR T1 and T2) when the patient is asked some years after the orthodontic treatment. A previous investigation14 showed that orthodontic treatment outcome (PAR T2) is related to 20% of the variability of children’s opinion of psychosocial benefits. The results of this study show that a few years after orthodontic treatment this feeling of benefit appears to be lost. Thus, for patients, the current status of the dentition is more relevant than the benefits obtained just after orthodontic treatment. A previous investigation5 examining this sample showed that the use of a lower fixed retainer was one important factor related to treatment stability (PAR T3) as well as the time of use of the Hawley upper retainer. Therefore, the use of orthodontic retention can contribute to a higher level of satisfaction in patients who have undergone orthodontic treatment. Since patient satisfaction were slightly associated with orthodontic variables and higher neuroticism scores were associated with lower levels of satisfaction with the dentition,11 further investigations are necessary in order to meet a wider range of factors able to predict patient satisfaction. CONCLUSIONS N From a long-term perspective, patient satisfaction is slightly associated with stability of the orthodontic treatment, regardless of the initial occlusal condition or the final result of the orthodontic treatment. N Neither gender, age, extraction for orthodontic reasons, nor the amount of treatment time has a significant relationship with long-term patient satisfaction.. Angle Orthodontist, Vol 80, No 6, 2010. MAIA, NORMANDO, MAIA, FERREIRA, ALVES. REFERENCES 1. McNamara JA Jr, Baccetti T, Franchi L, Herberger TA. Rapid maxillary expansion followed by fixed appliances: a long-term evaluation of changes in arch dimensions. Angle Orthod. 2003;73:344–353. 2. Little RM, Riedel RA, Artun J. An evaluation of changes in mandibular anterior alignment from 10 to 20 years postretention. Am J Orthod Dentofacial Orthop. 1988;93: 423–428. 3. McReynolds DC, Little RM. Mandibular second premolar extraction—postretention evaluation of stability and relapse. Angle Orthod. 1991;61:133–144. 4. Al Yami EA, Kuijpers-Jagtman AM, van’t Hof MA. Stability of orthodontic treatment outcome: follow-up until 10 years postretention. Am J Orthod Dentofacial Orthop. 1999;115: 300–304. 5. Maia NG, Normando ADC, Feitosa MS, Ferreira MA, Maia FA. Factors associated to orthodontic stability—a longitudinal retrospective study of 209 patients. World J Orthod. 2010;11:61–66. 6. Shaw WC. Factors influencing the desire for orthodontic treatment. Eur J Orthod. 1981;3:151–162. 7. Cunningham SJ, Gilthorpe MS, Hunt NP. Are orthognathic patients different? Eur J Orthod. 2000;22:195–202. 8. Sheats RD, McGorray SP, Keeling SD, Wheeler TT, King GJ. Occlusal traits and perception of orthodontic need in eighth grade students. Angle Orthod. 1998;68:107–114. 9. Gosney MBE. An investigation into some of the factors influencing the desire for orthodontic treatment. Br J Orthod. 1986;13:87–94. 10. Wheeler TT, McGorray SP, Yurkiewicz L, Keeling SD, King GJ. Orthodontic treatment demand and need in third and fourth grade school children. Am J Orthod Dentofacial Orthop. 1994;106:22–23. 11. Al-Omiri MK, Abu Alhaija ES. Factors affecting patient satisfaction after orthodontic treatment. Angle Orthod. 2006; 76:422–431. 12. Larsson BW, Bergsröm K. Adolescents’ perception of the quality of orthodontic treatment. Scand J Caring Sci. 2005; 19:95–101. 13. Anderson LE, Arruda A, Inglehart MR. Adolescent patients’ treatment motivation and satisfaction with orthodontic treatment. Do possible selves matter? Angle Orthod. 2009; 79:821–827. 14. Birkeland K, Bøe OE, Wisth PJ. Relationship between occlusion and satisfaction with dental appearance in orthodontically treated and untreated groups. A longitudinal study. Eur J Orthod. 2000;22:509–518. 15. Bondemark L, Holm A, Hansen K, Axelsson S, Mohlin B, Brattstrom V, Paulin G, Pietila T. Long-term stability of orthodontic treatment and patient satisfaction. Angle Orthod. 2007;77:181–191. 16. Leao A. The Development of Measures of Dental Impacts on Daily Living [PhD thesis]. London, UK: London University; 1993. 17. Richmond S, Shaw WC, O’Brien KD, Buchanan IB, Jones R, Stephens CD. The development of the PAR Index (Peer Assessment Rating): reliability and validity. Eur J Orthod. 1992;14:125–139. 18. Birkeland K, Furevik J, Boe OE, Wisth PJ. Evaluation of treatment and posttreatment changes by the PAR Index. Eur J Orthod. 1997;19:279–288. 19. Wood M, Lee D, Crawford E. Finishing occlusion, degree of stability and the PAR Index. Aust Orthod J. 2000;16:9–15..

(30) 19. 4 ARTIGO PARA SER SUBMETIDO À AVALIAÇÃO PARA PUBLICAÇÃO 4.1Clinical Assessment of the stability of orthodontic outcomes in Angle Class I and II:a systematic review.

(31) 20 ORTHODONTIC Clinical assessment of the stability of orthodontic outcomes in Angle Class I and II: A systematic review Avaliação clínica da estabilidade de resultados ortodônticos da classe I e classe II de Angle: Revisão sistemática Nair Galvão Maia*, Antonio David Correia Normando**Francisco Ajalmar Maia*** Maria Ângela Fernandes Ferreira**** Maria do Socorro Costa Feitosa Alves*****. ABSTRACT: This study aimed to evaluate morphologic stability of orthodontic results at least 5 years after orthodontic treatment of Angle Class I and II patients, via systematic review. An electronic database search was performed in Medline, Embase, Lilacs and Cochrane Library, as well as manual searches in reference lists of clinical studies and literature reviews. Prospective or retrospective longitudinal cohort studies that matched the pre-established quality evaluation criteria were included. From the 184 articles found, 18 were selected. Anterior alignment was the most present alteration in post-treatment. Overjet and overbite modification (increase) were frequent ly found. Intercanine and intermolar width and arch length showed a reduction in post-treatment. Extraction and nonextraction outcomes and their relationship to crowding were very heterogeneous. It was concluded as a result of the survey that after 5 years from the end of treatment a lot of outcomes did not remain stable, and the most frequent alteration occurred in anterior alignment. DESCRIPTORS: Class I malocclusion, Class II malocclusion, orthodontic appliances..

(32) * Doctorate student in health sciences Postgraduate Program(PPGCSA), Federal University of , Federal University of Rio Grande do Norte (UFRN), Natal, Rio Grande do Norte, Brazil. **Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Federal University of Pará, Belém, Brazil. ***Associate Professor and Department Chair, Department of Orthodontics, Faculty of Dentistry, Paraíba State University, Campina Grande, Brazil. **** PHD, professor of the post graduation program in Dentistry - School of dentistry - Federal University of Rio Grande do Norte UFRN. ***** PhD, professor of the health sciences Postgraduate Program(PPGCSA), Federal University of , Federal University of Rio Grande do Norte (UFRN), Natal, Rio Grande do Norte, Brazil.. RESUMO: Este estudo objetivou avaliar a estabilidade de resultados ortodônticos, de pacientes Classe I e II de Angle com pelo menos 5 anos de pós-tratamento, através de uma revisão sistemática. Uma busca nas bases eletrônicas foi efetuada: Medline, Lilacs, e biblioteca Cochrane, além de pesquisa manual em listas de referências de estudos clínicos e revisões da literatura. Foram incluídos estudos do tipo coorte longitudinal, prospectivos ou retrospectivos, que se enquadravam de acordo com os critérios de avaliação de qualidade estabelecidos previamente. Dos 184 registros encontrados, 18 artigos foram selecionados. Mudanças no alinhamento anterior foi a alteração mais presentes no póstratamento. Aumento no overjet e no overbite foram também frequentemente observados. A largura intercanina, intermolar e o comprimento do arco sofreram uma diminuição no pós-tratamento. Os resultados com e sem extração e sua relação com o apinhamento, foram muito heterogêneos. Diante dos resultados pode-se concluir que, após 5 anos do final do tratamento, menos de 50% dos.

(33) resultados não se mantiveram. e a alteração mais freqüente ocorreu no. alinhamento anterior. DESCRITORES: Má oclusão de Classe I, má oclusão de Classe II, aparelhos ortodônticos. INTRODUCTION Occlusal relationship stability achieved by orthodontic treatment has been a concern to orthodontists since the early years of orthodontics, and has been discussed until today. The orthodontic literature presents a large number of scientific studies dealing with post orthodontic stability, however, the determinant factors of post-treatment alterations are still questionable and controversial. Angle1 (1907) had already stated that orthodontic correction would remain stable if there was dental alignment in normal occlusion, retained at post-treatment with adequate retention and if there was a good functionality. However, some studies have shown that changes in the orthodontic treatment outcome are expected even in successfully treated cases2,3. Therefore, the aim of this systematic review is to compile trustable information extracted from the published literature, with adequate methodology, regarding what has been proven about orthodontic treatment stability in Angle Class I and Class II non-surgical patients. MATERIAL AND METHODS Search strategy: A literature survey was performed in the following databases: Medline, Lilacs, BBO and Cochrane library. Reference lists of clinical studies and article reviews were hand searched for additional relevant studies. A search for specific fields was performed using the following descriptors: Class I malocclusion,.

(34) Class II malocclusion and orthodontic appliances, besides other related terms like: relapse, stability and cohort. Inclusion criteria: Articles included were primarily selected considering a follow-up period of at least 5 years post-treatment. On a second stage, the criteria used to assure the quality of included studies was the application of a check list4 which considered the following methodological aspects: sample size and significance, individual characteristics and group formation, validity of endpoint measurement and statistical analysis. Two reviewers with knowledge on the subject evaluated the studies, and any inter-examiner conflicts were resolved by discussing each study to reach a consensus. Language: Only articles written in Portuguese, Spanish, and English were considered. Type of studies: Prospective and retrospective cohort studies with a follow-up period of at least 5 years post-treatment were included. Type of participants: Subjects who presented non-surgical Angle Class I and Class II malocclusion, treated orthodontically with or without extraction, were included in the studies. Type of intervention: Patients were treated with fixed appliances in one or in both arches. In some cases functional appliances were associated. Endpoints: The clinical endpoints considered were: anterior crowding, overjet, overbite, intercanine and intermolar width, arch length, irregularity index and spacing, evaluated through measurements on dental casts and also by applying the PAR index5. The cephalometric assessment was also used in some articles,.

(35) however, they were not considered in this study. Besides the described variables, others referring to time and type of retention, Angle classification, time and type of therapy and premolar extraction were also assessed by some surveys. Exclusion criteria: Studies with a follow-up period of less than 5 years posttreatment, or with patients who underwent surgical treatment, as well as diagnosed Class III cases, were excluded from the analysis. Studies in which only cephalometric assessment was made were not considered.. RESULTS From the 184 studies that were found, 18 articles met the predetermined inclusion criteria for this research, where the post-treatment follow-up period varied from 5 to 35 years (Charts 1 and 2). Anterior alignment was assessed in most of the studies, revealing that post-treatment alterations on anterior alignment was the most frequent finding on the lower arch and varied from around 17% to 63%. All of the studies recommended anterior bonded retainers to be used, even though complete stability is not assured. Relapse of anterior incisor alignment seems to be induced by several factors. Overjet and overbite presented a post-treatment increase, with higher tendency affecting in Class II patients than in Class I patients. Intercanine and intermolar width were evaluated in more than 50% of the studies, exhibiting a tendency to decrease in post-treatment, which occurred mostly when orthodontic mechanics were used to expand these distances, which could be associated or not to post-retention crowding of anterior incisors. The male sex revealed itself as less stable than the female sex in some studies, but the majority.

(36) of the studies did not observe significant difference related to gender. The ideal occlusal relationships achieved by orthodontic therapy, assessed in a great part of the studies, may favor post-treatment stability, however, can not secure long-term stability, suggesting that other factors may interfere. In respect to extraction and non-extraction cases, no evidence-based conclusions could be drawn assuring a correlation with post-treatment crowding, as the results were very heterogeneous. Pre-treatment factors, such as initial severity of the malocclusions with higher PAR indexes and Class II, Chart 1 – Summary of 10 studies. AUTHOR. SAMPLE. Lang, G. et al12. 132 patients. POSTTREATMENT TIME 6 years post-retention. Endpoints Variables analyzed . retention type and period . angle classification . therapy type and period . extraction of pre-molars . overjet, overbite, arch length . irregularity index . intercanine and intermolar width PAR index gender age at the start of treatment treatment time. 18. 86 patients. Average retention time of 14,4 years post retention. Kahl-Nieke. B. et al11. 226 patients. Post retention average of 15.5 years ± 4.4. Uhde. M. D. et al12. 72 patients. Average 20 years post retention (varied from 12 to 35 years). 224 patients. 5 years post treatment. PAR Index. 78 teenagers. Average of 14 years. Irregularity index Arch length Intercanine and Intermolar width Overbite and Overjet. Ormiston, J.P. et al. Birkeland K. et al. Artun, J. et al2. 4. Irregularly index Crowding, Canine and molar relationship, Overjet, Overbite Gender, Type of therapy Amount of dental movement Presence of third molars Intercanine and intermolar width Arch length. Anterior-posterior relationship Molar relationship, Overjet, Overbite Maxilar intercanine width Mandibular intercanine width Maxilar intermolar width Mandibular intermolar width crowding. RESULTS Irregularity index relapsed (1mm) in 20% Inferior crowding cases relapsed (0,9mm) in 17%.. Class II less stable male sex presented less stability. Patients with more severe PAR index scores tend to be less stable. T2 a T3 – crowding increased over the acceptable rate  (3,0mm) in 68,8% of the cases. Maxilar crowding and mandibular anterior irregularity occur in almost half sample. Most of the orthodontic corrections were retained with mean changes tending toward pre treatment values. Reduction of malocclusion in 76,7% of the cases On follow-up 63,8% Moderate and severe relapse in 19,7% of the cases 4% of the cases presented some improvement The increase of the incisor irregularity and reduction of intercanine width and arch length were significant in post-retention..