ORIGINAL ARTICLE

Association between incisor positions

and amount of interdental stripping in
patients undergoing orthodontic
treatment
Taner Ozturk and Ahmet Yagci
Kayseri, Turkey

Introduction: The study aimed to investigate the effect of a nonextraction treatment approach with interdental
stripping (IDS) on the dentofacial structures in patients with dental and skeletal Class I, II, and III malocclusions.
Methods: A total of 60 patients with mild-to-moderate crowding of the teeth and nonsevere skeletal malocclusion
were included and divided into 3 groups: Class I, Class II, and Class III groups (n 5 20 per group). In all patients,
nonextraction orthodontic treatment was administered, and those who underwent IDS at the jaw quadrants as
needed were evaluated. For pretreatment and posttreatment evaluation, lateral cephalometric radiography
and 3-dimensional dental model scans were acquired for each patient. For statistical analysis, paired-
samples t test and 1-way analysis of variance with Tukey post-hoc test were used for parametric variables,
whereas the Wilcoxon paired signed rank test and Kruskal-Wallis test with Dunn post-hoc test were used for
nonparametric variables. Results: An increase in the maxillary incisor angle was observed in patients with Class
I and Class III malocclusions, whereas a decrease was observed in patients with a Class II malocclusion
(P \ 0.05). Mandibular incisor angles were significantly increased in the Class II malocclusion group
(P \ 0.05) but unchanged in the other groups. IDS was more frequently applied to the posterior aspect of the
maxilla and mandible in patients with a Class II malocclusion than in patients with other malocclusion types,
and the amount of IDS at the anterior aspect of the mandible was significantly higher in the Class III group.
Conclusions: Combined nonextraction orthodontic treatment and IDS yielded successful treatment outcomes.
IDS application was localized to different jaw regions according to the different malocclusion types. (Am J Orthod
Dentofacial Orthop 2021;-:e1-e10)

V
arious orthodontic treatments have been associated with significant problems in terms of stability;
developed to achieve a good facial profile and nevertheless, only a few studies evaluating the effect of
occlusion.1 Treatment of borderline patients of nonextraction orthodontic treatment on dentofacial
a nonsevere skeletal malocclusion and mild-to- structures under different classification types of
moderate crowding without adverse effects is a malocclusion are reported in the literature.4-6
challenge,2 and in these patients, orthodontists face The use of nonextraction orthodontic treatment op-
difficulty in making a decision between an extraction tions such as various expansion or nonexpansion, strip-
or nonextraction treatment approach for prevention of ping, distalization, and surgical or nonsurgical methods
poor stability and protrusive profile.3 Some reports in a wide range of indications is gaining popularity
indicated that nonextraction treatment was not among patients and many orthodontists.6-9 Many
methods for gaining space during the procedure of
orthodontic treatment and dental alignment are
From the Department of Orthodontics, Faculty of Dentistry, Erciyes University,
Kayseri, Turkey. available, of which, stripping called interdental
All authors have completed and submitted the ICMJE Form for Disclosure of stripping (IDS), is widely used by many clinicians and
Potential Conflicts of Interest, and none were reported.
researchers.2,8-12 Previous studies recommended IDS as
Address correspondence to: Taner Ozturk, Department of Orthodontics, Faculty
of Dentistry, Erciyes University, 38039, Melikgazi, Kayseri, Turkey; e-mail, an option for tooth extraction and reported that it
[email protected] or [email protected]. could contribute to stability after orthodontic
Submitted, December 2019; revised, June 2020; accepted, July 2020.
treatment in borderline patients.8,13,14 IDS achieves
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved. preservation of the transverse arch width without
https://doi.org/10.1016/j.ajodo.2020.07.038

e1
e2 Ozturk and Yagci

marked change in the anterior tooth position, self- secondary missing tooth; (4) no restorative treatment
alignment of crowding, and decrease in both treatment performed, and no wear on the mesial and distal sides
time and chair time9,15,16; therefore, it is generally used of any teeth; and (5) good quality models and lateral
for the elimination of black triangles after orthodontic cephalometric radiographs at pretreatment and post-
treatment, adjustment of the tooth shape, fixing dis- treatment in the malocclusion groups.
crepancies of the Bolton ratio and tooth size, treatment Orthodontic treatment was performed using Roth
of borderline patients, and increasing stability.2,9,17,18 In prescription brackets with 0.018-in slot (Mini Master;
addition, although IDS is a potential risk factor for caries American Orthodontics, Sheboygan, Wis). After transi-
development, reports have indicated that preventive tion to the rectangular stainless-steel wire phase, the re-
procedures and patient motivation can overcome the sidual amount of crowding and dental relationships was
associated risk.19-21 resolved by IDS with single-sided diamond discs (Galaxy
We conducted a retrospective study to clarify the IDS Diamond Discs; OrthoTechnology, Lutz, Fla)
effectiveness of treatment in patients with borderline mounted on a handpiece with smooth enamel sur-
dental and skeletal Class I, II, and III malocclusions. faces.12,22 Subsequently, in each tooth treatment, a
The study aimed to determine the location of the jaw re- wooden wedge was placed between the target tooth
gion and incisor positions in patients with Class I, II, and and adjacent tooth, and polishing was carried out with
III malocclusions with mild-to-moderate crowding and diamond finishing burs and medium and extra-thin pol-
nonsevere skeletal discrepancies who underwent nonex- ishing discs (Sof-Lex, 3M Dental Products, St Paul,
traction treatment. Minn). The IDS quantities were measured during the
treatment using stripping thickness gauges (ContacEZ
IPR Thickness Gauge; OSE Company, Inc, Gaithersburg,
MATERIAL AND METHODS
Md). Topical fluoride gel was applied after each IDS, and
The study was approved by Erciyes University Clinical the patient was advised on oral hygiene practice with
Researches Ethics Committee, Kayseri, Turkey (Approval toothpaste and mouth rinse containing fluoride. In
no. 2019/857). The sample size was determined by po- each malocclusion group, IDS was performed to obtain
wer analysis with G*Power software (version 3.1.3; Franz appropriate dentofacial relationships and resolve the
Faul University, Kiel, Germany): twenty patients were need for interdigitation. Over application was avoided
required for more than 95% power to detect significant by careful evaluation of the dental interactions at each
differences with an effect size of 0.85 at a significance follow-visit. In addition to IDS, Class II elastics were
level of a 5 0.05. A total of 60 patients with nonsevere applied in the Class II group, whereas Class III elastics
skeletal and dental Class I, II, and III malocclusions who were applied in the Class III group. All patients were pro-
underwent nonextraction treatment on the basis of vided instructions on oral hygiene and use of intermax-
minimal-moderate dental arch crowding, good facial illary elastic at each visit; at the end of the treatment
profile, and acceptable dentofacial relationships at the course, no diastemas or crowding was observed, while
Department of Orthodontics, Faculty of Dentistry, good alignment of the interdigitation dental arches
Erciyes University, were randomly selected. The patients and Class I canine and molar relationship was attained.
were divided into 3 groups (each, 20 patients) as All dental models were scanned with a 3-dimensional
follows: Class I, 11 female patients and 9 male patients (3D) model scanning device (3 Shape R700 3D Scanner;
with a mean age of 15.82 6 1.54 years and 3 Shape A/S, Copenhagen, Denmark) and submitted for
16.00 6 3.04 years, respectively; Class II, 12 female analysis with Orthoanalyzer software (3 Shape A/S)
patients and 8 male patients with a mean age of (Fig 1). The mesiodistal crown diameter was defined as
14.47 6 2.10 years and 14.80 6 1.64 years, respectively; the largest interdental distance between the mesial and
Class III, 12 females and 8 male patients with a mean age distal contact points (Fig 2) according to the method
of 14.64 6 1.36 years and 15.00 6 1.73 years, respec- of Jensen et al.23 Bolton analysis was performed for
tively. The selection criteria were as follows: (1) balanced the values obtained in individual teeth. To calculate
facial profile and minimum-moderate dental arch the tooth sizes, mesiodistal dimensions of the anterior
crowding (Class I: maxillary arch, 2.29 6 1.25; mandib- (from the distal side of the canine on 1 side to the distal
ular arch, 1.73 6 1.75; Class II: maxillary arch, side of the canine on the other side) and posterior (from
2.18 6 1.51; mandibular arch, 1.66 6 1.00; Class III, the distal side of the first molar tooth on 1 side to the
maxillary arch, 2.07 6 1.11; mandibular arch, distal side of the first molar tooth on the other side) teeth
1.82 6 0.94; Table I); (2) borderline skeletal and dental were measured on the dental models acquired before
Class I, II and III malocclusions; (3) no narrowing of the and after treatment. However, the amount of anterior
maxillary or mandibular dental arch and congenitally or stripping was determined by the difference in the teeth

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Ozturk and Yagci e3

Table I. Distribution of patients according to the malocclusion groups

Mean age, n Initial crowding, mm

Groups n Age, y Treatment duration, y Female Male Maxillary arch Mandibular arch
Class I 20 15.91 6 2.27 1.26 6 0.85 15.82 6 1.54 (11) 16.00 6 3.04 (9) 2.29 6 1.25 1.73 6 1.75
Class II 20 14.55 6 1.96 1.89 6 0.92 14.47 6 2.10 (12) 14.80 6 1.64 (8) 2.18 6 1.51 1.66 6 1.00
Class III 20 14.78 6 1.48 2.01 6 1.12 14.64 6 1.36 (12) 15.00 6 1.73 (8) 2.07 6 1.11 1.82 6 0.94
Total 60 15.09 6 2.00 1.68 6 0.98 14.92 6 1.80 (35) 15.38 6 2.33 (25) 2.18 6 1.28 1.74 6 1.27
Note. Data was given mean 6 standard deviation.

Fig 1. A, Application of a 3D scanning device in which 3D scans of the models are acquired at the
beginning and end of the treatment. B-D, 3D scans of the dental models at the right profile, left profile,
and frontal views.

sizes between the distal faces of the right and left canine distances and angles at the sagittal view (Table II) were
teeth before and after treatment. The amount of poste- evaluated with Dolphin Imaging software (version
rior stripping was determined by subtracting the size dif- 11.0; Dolphin Imaging and Management Solutions,
ference of the anterior teeth from that of all teeth. Data Chatsworth, Calif) (Fig 3).
on the number of patients in each group, sex, mean age,
duration of treatment, and initial crowding amounts are Statistical analysis
shown in Table I. Lateral cephalometric radiographs SPSS (version 24.0; SPSS Inc, Chicago, Ill) software
were acquired digitally with an x-ray device (OP300; In- was used for statistical analysis. The Shapiro-Wilks test
strumentarium Dental, Tuusula, Finland) according to was used to test the normality of the obtained data.
the manufacturer's instruction. On lateral cephalometric Paired-samples t test and Wilcoxon paired signed rank
radiographs acquired before and after treatment, the test were used for comparisons between before and after

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Fig 2. A and B, Mesiodistal size of each tooth in the maxilla and mandible was measured individually
on the 3D dental model.

Table II. Measurements performed on the lateral cephalometry radiographs acquired during the study period
Cephalometric measurements Abbreviations Descriptions
Sagittal values
SNA ( ) Angle formed between sella, nasion, and A- The position of the maxilla relative to the
point cranial base is determined.
SNB ( ) Angle formed between sella, nasion, and B- The position of the mandibula relative to the
point cranial base is determined.
ANB ( ) Angle formed between A-point, nasion, and It is used to determine the relationship
B-point between the maxilla and mandibula.
Incisor position values
U1/SN ( ) Angle formed between maxillary incisor long The relationship between the maxillary
axis and sella-nasion line incisors and the head base is determined.
U1/PP ( ) Angle formed between maxillary incisor long The relationship between the maxillary
axis and palatal plane (anterior nasal spine- incisors and the palatal plane is
posterior nasal spine) determined.
U1-NA (mm) Perpendicular distance from the tip of the The position of the maxillary incisors relative
maxillary incisor to the plane between to the NA line (protrusive, normal,
points N and A retrusive) is determined.
U1/NA ( ) Angle formed by the intersection of the The angle (proclined, normal, retroclined)
maxillary incisor long axis to the plane between the NA line of the maxillary
between points N and A incisors is determined.
L1-APog (mm) Distance between mandibular incisor incisal The position of the mandibular incisors
tip and A-pogonion line according to the line between Pogonion
and point A (protrusive, normal, retrusive)
is determined.
IMPA ( ) Angle formed between mandibular incisor The angle of the mandibular incisors relative
long axis and mandibular plane (Gonion- to the mandibular plane (proclined, normal,
Menton) retroclined) is determined.
L1-NB (mm) Perpendicular distance from the tip of the The position of the mandibular incisors
mandibular incisor to the plane between relative to the NB line (protrusive, normal,
points N and B retrusive) is determined.
L1/NB ( ) Angle formed by the intersection of the The angle (proclined, normal, retroclined)
mandibular incisor axis to the plane between the NB line of the mandibular
between points N and B incisors is determined.

treatment. One-way analysis of variance and Tukey tests for the assessment of malocclusion type, Bolton ratio,
were used for parametric variables, and Kruskal-Wallis and association of IDS amount among the groups. In
and Dunn's tests were used for nonparametric variables addition, the Spearman correlation coefficient was

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the intersection of the maxillary incisor long axis to

the plane between the nasion and A-point (U1/NA)
was significantly increased in both Class I and Class III
groups, whereas it was decreased in the Class II group,
although without significance (Table III). The variables
of the mandibular incisors were not significantly
different in Class I and Class III groups, whereas it was
significantly increased in the Class II group. The tooth
sizes at pretreatment and posttreatment were similar
(Table IV).
The variation of cephalometric measurements and
comparison of IDS amounts among the groups are
shown in Tables V and VI; SNA, SNB, and ANB
changes were not significantly different in all 3 groups.
However, the variables of the maxillary and mandibular
incisors were significantly different among the groups.
The variation of all cephalometric variables was not
Fig 3. The values of angle and distance used for lateral significantly different between Class I and Class III
cephalometric analysis are shown in different colors. S, groups. In paired comparisons, U1/SN and U1/PP angles
sella; N, nasion; PNS, posterior nasal spine; ANS, ante- were significantly decreased in the Class II group
rior nasal spine; A, A-point; B, B-point, Pog, pogonion; compared with both Class I and Class III groups.
Go, gonion; Me, menton; Gn, gnathion. U1/NA and the perpendicular distance from the tip of
the maxillary incisor to the plane between the nasion
and A-point (U1-NA) were significantly increased in
used for correlation analysis to determine the relation- the Class III group compared with the Class II group.
ship between IDS amounts and incisor positions. A P Distance between mandibular incisor incisal tip and
value of \0.05 was considered statistically significant. A-pogonion line (L1-APog) distance was significantly
increased in the Class II group compared with both Class
RESULTS I and Class III groups. The angle formed between
It should be noted that there is no statistically signif- mandibular incisor long axis and mandibular plane
icant difference between each group in terms of initial (IMPA) was significantly increased in the Class II group
crowding amounts. For the relationships between the compared with the Class III group, whereas the value
first and repeat measurements after 4 weeks by the was similar to that of the Class I group. The perpendic-
same investigator (T.O) in 10 patients randomly selected ular distance from the tip of the mandibular incisor to
from each group, the intraclass correlation coefficient the plane between points N and B (L1-NB) and the angle
was 0.987 for the length measurements, 0.954 for the formed by the intersection of the mandibular incisor axis
distance measurements, and 0.915 for the angle mea- to the plane between nasion and B-point (L1/NB) were
surements, which indicated high reliability of the repeat significantly increased in the Class II group (L1-NB,
measurement values. 2.63 6 2.47; L1/NB, 6.40 6 6.14) compared with both
Pretreatment and posttreatment comparisons are Class I (L1-NB, 0.66 6 1.74; L1/NB, 0.31 6 5.14;
shown in Tables III and IV. The angle formed between P 5 0.017) and Class III (L1-NB, 0.01 6 1.41; L1/NB,
the sella, nasion, and A-point (SNA); the angle formed 1.37 6 3.53; P 5 0.004) groups. The amount of IDS
between the sella, nasion, and B-point (SNB); the angle was significantly different among all the groups
formed between A-point, nasion, and B-point (ANB), (Table IV). The amount of IDS at the anterior aspect of
and the angle formed between maxillary incisor long the maxilla was significantly higher in the Class II group
axis and sella-nasion line (U1-SN) were not significantly than the Class III group. The amount of IDS performed at
different in all 3 groups (Table III). The angle formed be- the posterior aspect of the maxilla and mandible was
tween the maxillary incisor long axis and palatal plane significantly higher in the Class II group than in both
(U1/PP) was significantly increased in Class I and Class Class I and Class III groups.
III groups, whereas it was significantly decreased in the The correlations between the incisor positions and
Class II group (P \ 0.05). U1-NA was significantly amount of IDS for the maxilla and mandible are shown
decreased in the Class II group, but it was significantly in Table VII. No significant correlation was observed be-
increased in the Class III group. The angle formed by tween the amount of IDS and incisor positions at the

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Table III. Comparison of sagittal and incisor measurements between T0 and T1 in patients with Class I, Class II, and
Class III malocclusion groups
Class I Class II Class III

Variables Timepoint Mean 6 SD P value Mean 6 SD P value Mean 6 SD P value

Sagittal values
SNA ( ) T0 81.98 6 5.21 0.887 81.03 6 3.14 0.461 78.46 6 4.22 0.740
T1 81.73 6 5.85 81.84 6 3.67 79.98 6 5.16
SNB ( ) T0 79.94 6 5.42 0.873 75.69 6 3.00 0.626 80.76 6 3.58 0.701
T1 79.66 6 5.61 76.35 6 4.44 80.29 6 4.53
ANB ( ) T0 2.05 6 3.40 0.614 4.62 6 2.18 0.745 0.23 6 1.78 0.874
T1 1.53 6 3.13 3.49 6 1.77 0.41 6 1.96
Maxillary incisor values
U1/SN ( ) T0 108.12 6 5.91 0.204 106.09 6 6.52 0.509 106.12 6 7.44 0.801
T1 110.92 6 7.64 107.67 6 8.40 106.82 6 9.05
U1/PP ( ) T0 113.79 6 6.05 0.007 113.06 6 5.15 0.022 115.29 6 6.68 0.008
T1 117.94 6 7.52 109.48 6 5.29 120.60 6 6.52
U1-NA (mm) T0 4.40 6 2.23 NS 4.59 6 2.26 0.046 5.87 6 2.59 0.016
T1 5.26 6 2.44 3.54 6 1.80 9.31 6 4.71
U1/NA ( ) T0 24.22 6 5.39 0.049 24.33 6 4.91 NS 27.51 6 6.87 0.034
T1 27.38 6 6.97 23.59 6 5.37 32.86 6 8.96
Mandibular incisor values
L1-APog T0 4.29 6 6.94 NS 1.77 6 2.69 \0.001 3.69 6 2.87 NS
T1 3.37 6 2.04 3.60 6 3.10 3.32 6 2.12
IMPA ( ) T0 88.92 6 7.19 NS 91.29 6 6.80 0.003 87.96 6 8.23 NS
T1 85.62 6 19.31 96.37 6 7.08 87.70 6 4.76
L1-NB (mm) T0 9.49 6 21.37 NS 3.93 6 1.61 \0.001 4.13 6 1.63 NS
T1 5.64 6 2.49 6.56 6 2.57 4.14 6 1.44
L1/NB ( ) T0 24.71 6 6.53 NS 23.09 6 5.05 \0.001 24.57 6 7.47 NS
T1 25.02 6 6.13 29.49 6 5.54 23.65 6 4.85

Note. Statistical significance (P \ 0.05) was determined using a paired-samples t test.

SD, standard deviation; T0, before treatment; T1, end of the treatment; NS, not significant.

Table IV. Comparison of the tooth measurement values and Bolton ratios between T0 and T1 in Class I, Class II, and
Class III malocclusion groups
Class I Class II Class III

Percentile Percentile Percentile

Variables Median 25th 75th P value Median 25th 75th P value Median 25th 75th P value
Tooth measurements
Mx Ant T0 46.00 17.15 48.10 0.745 45.20 43.90 48.40 0.588 39.95 34.00 43.90 0.635
T1 45.70 17.10 47.90 44.60 43.40 48.00 35.70 33.80 43.80
Mx Post T0 48.80 29.10 51.10 0.705 47.90 47.00 49.40 0.606 55.90 46.00 56.20 0.785
T1 48.40 29.10 50.90 47.60 45.70 49.10 55.30 45.80 54.90
Md Ant T0 36.40 15.60 38.30 0.685 35.90 34.50 38.00 0.607 40.20 37.00 41.20 0.261
T1 36.20 12.40 38.10 35.60 33.70 37.80 36.35 35.00 38.60
Md Post T0 51.20 28.55 54.00 0.635 50.00 47.80 52.30 0.828 53.25 41.50 55.00 0.876
T1 51.10 28.55 53.10 49.60 48.00 51.80 52.80 41.10 54.20
Bolton ratios
Anterior teeth T0 80.73 77.08 82.05 0.435 77.93 76.02 78.92 0.257 83.11 74.89 87.95 0.028
T1 79.80 78.12 81.57 77.73 74.63 79.00 73.30 66.61 82.80
Overall teeth T0 93.37 90.12 93.99 0.931 91.67 89.87 91.92 0.212 95.96 90.87 99.93 0.004
T1 93.34 90.00 94.02 91.18 89.58 91.83 94.19 87.29 97.19
Note. Statistical significance (P \ 0.05) was determined using Wilcoxon paired signed rank test.
Mx, maxilla; Md, mandibula; Anterior teeth, 13-23 and 33-43; Posterior teeth, 14-16, 24-26, 34-36 and 44-46; Overall teeth, 16-26 and 36-46;
SD, standard deviation; T0, before treatment; T1, end of the treatment.

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Table V. Comparison of the changes of sagittal and incisor measurement values among the different groups
Class I Class II Class III Intergroup comparisons, P values

Variables Mean 6 SD Mean 6 SD Mean 6 SD P value Class I II Class I III Class II III
Sagittal values
SNA ( ) 0.76 6 2.20 0.33 6 2.14 0.58 6 2.43 0.261 0.180 0.619 0.152
SNB ( ) 0.03 6 2.84 0.41 6 2.39 0.38 6 1.73 0.999 1.000 0.965 1.000
ANB ( ) 0.17 6 1.45 0.55 6 1.68 0.21 6 1.98 0.231 0.172 0.725 0.125
Maxillary incisor values
U1/SN ( ) 3.54 6 6.79 3.53 6 5.36 5.56 6 8.72 \0.001 0.007 0.465 \0.001
U1/PP ( ) 4.15 6 6.07 3.58 6 6.40 5.31 6 7.48 \0.001 0.002 0.609 \0.001
U1-NA (mm) 0.86 6 2.33 1.05 6 2.20 3.44 6 5.44 0.002 0.454 0.113 0.001
U1/NA ( ) 2.66 6 5.58 1.19 6 5.37 5.35 6 9.87 0.023 0.211 0.481 0.018
Mandibular incisor values
L1-APog ( ) 0.92 6 6.31 1.83 6 1.64 0.37 6 2.51 0.001 0.045 0.114 \0.001
IMPA ( ) 3.30 6 9.34 5.08 6 6.66 0.26 6 5.01 0.022 0.212 0.759 0.036
L1-NB (mm) 0.66 6 1.74 2.63 6 2.47 0.01 6 1.41 \0.001 0.007 0.142 \0.001
L1/NB ( ) 0.31 6 5.14 6.40 6 6.14 1.37 6 3.53 0.004 0.017 0.781 0.004
Note. Statistical significance (P \ 0.05) using a 1-way analysis of variance test with Tukey post-hoc test.

Table VI. Comparison of the changes in IDS amounts at the maxilla and mandible among the groups
Percentile Percentile Percentile Intergroup comparisons, P values

Variables Median 25th 75th Median 25th 75th Median 25th 75th P value Class I II Class I III Class II III
Maxilla 0.00 0.00 0.30 0.40 0.15 0.90 0.00 0.00 0.10 0.016 0.367 0.454 0.005
anterior
Maxilla 0.00 0.00 0.00 0.35 0.15 0.95 0.00 0.00 0.00 0.002 0.012 1.000 0.012
posterior
Mandible 0.20 0.00 0.40 0.35 0.10 0.70 0.95 0.20 2.70 0.037 0.454 0.001 0.245
anterior
Mandible 0.00 0.00 0.10 0.50 0.20 0.80 0.00 0.00 0.00 \0.001 0.008 0.898 0.032
posterior
Note. Statistical significance (P \ 0.05) was determined using the Kruskal-Wallis test with Dunn post-hoc test.

maxillary anterior and posterior regions in both Class I anterior and posterior regions and incisor position in the
and Class II groups. However, a significant, moderate Class III group.
negative correlation was observed between those at
the maxillary anterior region in the Class III group (U1/
SN, r 5 0.476 and P 5 0.046; U1/PP, r 5 0.406 DISCUSSION
and P 5 0.044; U1 NA, r 5 0.534 and P 5 0.023; A few studies have described the in vivo performance
U1/NA, r 5 0.525 and P 5 0.025). A significant nega- of IDS, and several other studies have investigated the ef-
tive correlation was observed between L1 APog (ante- fect of enamel reduction on tooth structures.9-11,19,20
rior, r 5 0.803 and P \ 0.001; posterior, However, the effect of IDS on the dentofacial structures
r 5 0.688 and P 5 0.001) and L1 NB (anterior, and its relationship with these structures remains unclear.
r 5 0.404 and P 5 0.047; posterior, r 5 0.302 On the basis of these facts, we conducted an in vivo study
and P 5 0.032) and IDS at the mandibular anterior on the relationship between the amount of IDS in the jaw
and posterior regions in the Class I group. A significant region and the position of the incisor teeth in patients
positive correlation (L1 APog, r 5 0.441 and with different classification types of malocclusion
P 5 0.048; IMPA, r 5 0.554 and P 5 0.011; L1-NB, undergoing nonextraction orthodontic treatment.
r 5 0.445 and P 5 0.043; L1/NB, r 5 0.542 and Changes achieved by the treatment can be evaluated
P 5 0.014) was observed between the mandibular by various methods,1 including dental model analysis. In
incisor positions and IDS at the mandibular posterior the analysis of the dental model, conventional methods
in the Class II group. No significant correlation was have disadvantages such as low reproducibility, poor
observed between the amount of IDS at the mandibular measurement accuracy, and storage problems.

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Table VII. Correlation of incisor variables between the IDS areas

U1/SN U1/PP U1-NA U1/NA

Groups Variables r P value r P value r P value r P value

Class I Maxilla anterior IPR 0.149 0.530 0.132 0.579 0.047 0.842 0.284 0.225
Maxilla posterior IPR 0.179 0.450 0.132 0.580 0.235 0.319 0.153 0.519
Class II Maxilla anterior IPR 0.197 0.404 0.336 0.148 0.002 0.993 0.101 0.670
Maxilla posterior IPR 0.252 0.283 0.095 0.691 0.065 0.785 0.007 0.975
Class III Maxilla anterior IPR 0.476 0.046 0.406 0.044 0.534 0.023 0.525 0.025
Maxilla posterior IPR 0.171 0.497 0.155 0.540 0.163 0.517 0.167 0.507

L1-APog IMPA L1-NB L1/NB

Groups Variables r P value r P value r P value r P value

Class I Mandible anterior IPR 0.803 \0.001 0.082 0.732 0.404 0.047 0.102 0.668
Mandible posterior IPR 0.688 0.001 0.063 0.783 0.302 0.032 0.118 0.621
Class II Mandible anterior IPR 0.018 0.941 0.125 0.600 0.124 0.601 0.080 0.737
Mandible posterior IPR 0.441 0.048 0.554 0.011 0.445 0.043 0.542 0.014
Class III Mandible anterior IPR 0.018 0.943 0.076 0.745 0.090 0.723 0.218 0.385
Mandible posterior IPR 0.210 0.402 0.086 0.733 0.092 0.717 0.212 0.399
Note. Statistical significance was set at P \ 0.05.
r, correlation coefficient.

Computer-aided analysis methods using 3D scans of the much as in the past.37 The effect of IDS application on
dental models have overcome these disadvantages and posttreatment stability has been evaluated, and there
provided more accurate results, and thus, are being are 2 different views; whereas Little et al38 reported
used for their beneficial attributes.24,25 Accordingly, in that this application did not contribute to posttreatment
our study, we used 3D model analyses and cephalometric stability and retention, Sheridan,13,14 Paskow,15 and
radiography analysis, which is a valid and common tool Boese39 reported that IDS application might contribute
for the evaluation of dental and skeletal changes.26 to interdigitation by positioning the anterior teeth
Nowadays, the popularity of orthodontic treatments more easily through the provision of flatter and wider
without dental extraction is increasing.2,4,9,27 In the contact areas when there is an ideal occlusal relationship
case of mild-to-moderate crowding, procedures such with the posterior region. Previous studies have reported
as expansion, distalization, incisor proclination, or IDS the absence of an associated risk of caries because of
can be an option in the treatment strategy, as long as similar polishing quality derived from procedures for
it allows for dentofacial features.1,5,6 Previous reports protection in IDS at the anterior or posterior region.9,19
indicated that the size difference between the teeth Moreover, IDS achieved good retention, especially in
might cause orthodontic anomalies.19,28,29 Bolton pro- the lower anterior region.20 In a study by Joseph
posed that reproximation (IDS) could resolve the et al,37 it was stated that when patients undergo routine
mismatch between the teeth,29 and IDS procedure in cleaning procedures, oral hygiene, and plaque control
combination with nonextraction treatment provided procedures, adequate remineralization can be achieved
adequate results in patients with mild-to-moderate with the natural remineralization components of saliva
crowding.2,6 In a study by Agenter et al,30 it was reported in an appropriate oral environment. In this study, IDS
that one of the methods that can be used for decreasing was not limited to the lower anterior region but affected
crowding large tooth masses in patients with large tooth different areas in the other malocclusion groups; the pa-
sizes might be IDS. Lasher31 also stated that with the use tients with Class I malocclusion attained a good profile
of IDS, the teeth have wider and flatter contact points, with shorter treatment duration than the patients with
and this increases contact with each other and contrib- other classification types of malocclusion, which agrees
utes to stability. In addition, previous studies have re- with the results of Germeç and Taner.2 We observed a
ported that IDS may contribute to the stability of the significant change in the maxillary incisors according
dental positions and retention in the posttreatment to PP and NA which was uncorrelated with IDS. Patients
period.32-35 Furthermore, occlusal and interproximal with Class II malocclusion showed retraction of the
wear on the teeth, as demonstrated by Begg,36 is a nat- maxillary incisors and a higher amount of IDS at the pos-
ural process. However, artificial wearers such as IDS are terior region of both jaws, compared with those of the
used for these abrasions that have not been seen as other 2 groups; they also showed significantly higher

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Ozturk and Yagci e9

IDS amount at the upper anterior region than that of pa- CONCLUSIONS
tients with a Class III malocclusion, which may be due to Our study highlights that IDS is a potentially effective
the use of Class II elastics in patients with a Class II treatment option in patients of different malocclusion
malocclusion and anterior movement of the maxillary groups with good facial profile and mild-moderate
anterior teeth in patients with a Class III malocclusion. dental crowding. The maxillary incisors retroclined in
These findings support the finding of effective camou- patients with Class II malocclusion who underwent non-
flage treatment in Class II and III malocclusions, as extraction treatment but proclined in patients with Class
shown in previous studies.5,40 Nevertheless, we observed III malocclusion. Patients with Class II malocclusion at-
a positive correlation between IDS at the posterior region tained a higher amount of IDS in the posterior region
of the mandible and mandibular incisor positions in the of the jaws; in these patients, oral hygiene procedures
Class II group that may be due use of Class II elastics in should particularly target the posterior region. In pa-
those patients; the effect of Class II elastics can compen- tients with Class II malocclusion, IDS at the mandibular
sate for the position of the mandibular incisors which posterior region correlated positively with the mandib-
was similar among the different groups despite a signif- ular incisor positions, and in this region, IDS should be
icant amount of IDS at the anterior mandible. In agree- performed with caution. Patients with Class III malocclu-
ment, Battagel and Orton5 reported a higher amount of sion with nonextraction treatment attained the highest
IDS at the mandibular anterior region in patients with amount of IDS in the mandibular anterior region. In
Class III malocclusion who underwent nonextraction those patients, IDS at the maxillary anterior region corre-
treatment. However, we observed no correlation be- lated negatively with the maxillary incisor positions, and
tween the position of the mandibular incisors and IDS IDS application should be avoided in this region. In sec-
at the mandible, which may be explained by mild-to- ondary findings, polishing and fluoride treatment after
moderate crowding and Class III elastics’ effect. Because the IDS procedure prevented caries formation.
IDS can compensate for backward bending of the
mandibular incisors by Class III elastic, we delivered a AUTHOR CREDIT STATEMENT
significantly higher amount of IDS in the lower anterior
region in the Class III group than in the Class I group, and Taner Ozturk: conceptualization, methodology, data
consequently, patients with a Class III malocclusion at- curation, investigation, visualization, formal analysis,
tained a higher amount of IDS at the mandible anterior writing–original draft preparation; Ahmet Yagci:
region and significant change of the Bolton ratio of the conceptualization, methodology, writing–reviewing
anterior teeth. Moreover, we observed no significant and editing, supervision.
change between pretreatment and posttreatment in
terms of the tooth size and Bolton ratio and no excess
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