181

12
Retention
Simon J. Littlewood
1
, BDS, FDS(Orth)RCPS, MDSc, MOrth
RCS, FDSRCS , Declan T. Millett
2
, BDSc, DDS, FDSRCPS,
DOrth RCS, MOrth RCS , David R. Bearn
3
, PhD, MSc, BDS,
MOrth RCS, FDS(Orth)RCPS, FDSRCS, FHEA ,
Bridget Doubleday
4
, PhD, MDentSci, BDS, MOrth RCS,
FDSRCPS , Helen V. Worthington
5
, BSc, MSc, PhD

1
Consultant Orthodontist, Orthodontic Department, St. Luke s Hospital, Bradford, UK

2
Professor of Orthodontics, Dental School, University College Cork, Cork, Ireland

3
Professor of Orthodontics, University of Dundee, Dundee, Scotland, UK

4
Consultant Orthodontist, Forth Valley Royal Hospital, Stirlingshire, Scotland

5
Professor of Evidence Based Care, School of Dentistry, The University of Manchester,
Manchester, UK
Introduction
Retention is an important part of any orthodontic treatment and is the process by which
orthodontists try to minimize relapse following treatment. This chapter will review the
causes of relapse and the best contemporary evidence behind attempts to reduce this
relapse using retainers and other adjunctive techniques. The section on contemporary
evidence is based on the ndings of a Cochrane review entitled Retention Procedures for
Stabilizing Tooth Position After Treatment with Orthodontic Braces (Littlewood et al.
2011 ), and the reader is directed to the Cochrane Library for the most up - to - date version
of this review.
Evidence-Based Orthodontics, First Edition. Edited by Greg J. Huang, Stephen Richmond and
Katherine W.L. Vig.
2011 Blackwell Publishing Ltd. Published 2011 by Blackwell Publishing Ltd.
182 PART 2 SELECTED TOPICS
What Is Relapse and What Are the Causes?
Relapse is any change from the nal tooth position at the end of treatment. This is often,
but not always, movement back toward the original malocclusion. There are broadly four
main causes of relapse (Melrose & Millett 1998 ):


Periodontal and gingival factors


Occlusal factors


Soft tissue pressures


Growth
Periodontal and Gingival Factors
After tooth movement, the periodontium around teeth needs to remodel. The majority of
collagen bers of the periodontal ligament reorganize on average after 3 4 months.
However, elastic bers around the neck of the teeth, known as the dentogingival and
interdental bers, can take 8 months or longer to reorganize (Reitan 1959 ). Clinically, this
means that teeth have to be held in the corrected position until these bers have remodeled.
This is particularly important when these bers are stressed, for example after rotational
correction. An approach in those cases is to surgically sever the supracrestal bers using
a technique called pericision (see the section titled Pericision, below).
Occlusal Factors
The way the teeth occlude at the end of treatment may also affect the stability of the teeth.
Positioning the teeth in the correct occlusal relationship can reduce the relapse in deep
bite cases (Houston 1989 ). It has also been shown retrospectively that the better the quality
of the occlusal nish, the less relapse occurs (de Freitas et al. 2007 ).
Soft Tissue Pressures
The teeth lie in an area of balance between the tongue on one side and the cheeks and lips
on the other side (Proft 1978 ). This area of balance is sometimes referred to as the neutral
zone . Although the forces from the tongue are stronger, the activity of a healthy periodon-
tium will resist proclination of the teeth. However, the further the teeth are moved out of
this zone of stability, the more unstable they are likely to be.
The problem for the clinician is that it is not possible to visualize the neutral zone, so
as a guide it is acknowledged that the bigger the change in the arch form from the start
of treatment, the more unstable the treatment is likely to be. This would then need to be
taken into account when planning the retention stage of treatment.
Soft tissue pressures are affected by muscle and general soft tissue tone. As these may
change with age, the neutral zone and therefore forces on the teeth may alter as the patient
gets older.
CHAPTER 12 RETENTION 183
Growth
While the vast majority of growth is complete by the end of the second decade, it has been
suggested that growth may continue, unpredictably, throughout life (Behrents et al. 1989 ).
Subtle changes in the relationship between the maxilla and mandible may exert forces on
the teeth later in life, causing changes in tooth position.
Can the Orthodontist Prevent Relapse?
In cases with a healthy periodontium, the orthodontist has the ability to inuence the
periodontal factors, either by maintaining the teeth long enough for the bers to remodel
or by cutting the supracrestal bers. The orthodontist can also reduce relapse potential by
positioning the teeth in the correct occlusal relationship. Positioning the teeth in the correct
relationship with the soft tissues is less predictable, but generally maintenance of the
original lower arch form is advisable. The orthodontist may decide to deliberately alter
the original lower arch form for improved aesthetics and so increase the likelihood of
instability of the nal result.
The orthodontist cannot control age changes this includes soft tissues changes and
further growth. At the present time, we are unable to predict the nature of these age
changes, so there is the potential for unpredictable relapse throughout life. These late
changes may well have little or nothing to do with the orthodontic treatment, but the patient
will often attribute the unwanted relapse to it.
Contemporary Approach to Long - Term Relapse
Although some patients will be able to stop wearing retainers without suffering any
relapse, it is not possible to identify these patients, and therefore every patient needs to
be treated as if he or she has the potential for relapse (Little, Wallen & Riedel 1981 ). This
means there is a need for informed consent before treatment begins, letting patients know
about the unpredictable nature of relapse, and the need for some sort of life - long retention
to reduce the risk of the relapse. Whether patients choose to wear retainers forever is up
to them, but it is important that they are informed of the risk of unpredictable relapse if
they choose to discontinue retention.
Retainers
Retainers can be removable or xed. Removable retainers make oral hygiene easier for
patients, and they can be worn part - time if required. Clearly, their success is related to
patient compliance. The use of removable retainers means the responsibility for retention
is with the patient.
Fixed retainers are bonded in place, usually, but not exclusively, on the lingual surface.
They have the advantage that the patient does not need to remember to put them in, and
they are particularly useful when the nal result is so unstable that anything less than
full - time wear would be unacceptable. Examples of situations when bonded retainers are
indicated include
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1. teeth with periodontally compromised support,
2. malocclusions with initial spacing,
3. following correction of severely rotated teeth, and
4. where the lower labial segment has been signicantly moved during treatment
Removable Retainers
The original removable retainer was the Hawley retainer (Figure 12.1 ). This was originally
an active removable appliance that was adapted as a retaining appliance. There are numer-
ous other designs including Begg (wraparound) retainers, Jensen retainers, positioners,
spring aligners and vacuum - formed thermoplastic retainers.
Is There an Advisable Daily Retention Regimen for Removable Retainers?
Hawley initially advised wearing his removable retainer for 6 months full - time then part -
time thereafter. The idea of wearing a removable retainer full - time for a period before
Figure 12.1 Hawley retainer: anterior view (A), occlusal view (B).
A
B
CHAPTER 12 RETENTION 185
reducing to part - time wear has been followed with a variety of removable retainers without
any high - quality evidence to support this. Randomized controlled trials have now been
completed to determine if full - time wear is necessary (Gill et al. 2007 ; Thickett & Power
2009 ; Shawesh et al. 2010 ). Hawley retainers worn on a part - time basis (at night only)
were shown to be equally effective at reducing relapse as Hawley retainers worn full - time
for 6 months then nights only thereafter (Shawesh et al. 2010 ). Similarly, studies compar-
ing vacuum - formed retainers worn on a part - time basis (at night) showed they were as
effective as vacuum - formed retainers worn full - time. It appears that in appropriately
selected cases, removable retainers need only be worn on a part - time basis from the start
of the retention period.
It is important to stress that in these studies patients were excluded if it was felt they
needed a permanent bonded retainer for the reasons listed at the beginning of this section.
Which Removable Retainer Is the Most Effective?
It is not possible to denitively answer this question, but following an increase in the use
and popularity of vacuum - formed retainers in the UK, a randomized controlled trial was
set up to compare vacuum - formed retainers to the traditional Hawley retainer (Rowlands
et al. 2007 ; Hichens et al. 2007 ). Vacuum - formed retainers (Figure 12.2 ) were rst
described in 1971 (Ponitz 1971 ), and their aesthetic appearance and ease of production
has led to their increased popularity, but it was not clear whether this increase in use was
appropriate. The clinical trial was set in specialist practice, comparing Hawley retainers
to vacuum - formed retainers over the rst 6 months of retention. It was shown that patients
preferred the vacuum - formed retainer (it was more comfortable and was less embarrassing
to wear). The vacuum - formed retainer was also found to be more cost - effective, not only
for the orthodontist and the national health system it was provided under but also for the
patient. Because it broke less often, the patient did not need to return as frequently to the
practice. Finally, although there was no difference in the effectiveness of the retainers in
the upper arch, the vacuum - formed retainers were found to be better at preventing relapse
in the lower arch.
Figure 12.2 Vacuum - formed retainer.
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Fixed Retainers
Fixed retainers are bonded to the teeth (Bearn 1995 ). There are various designs of bonded
retainers. They may be made from metal wire (usually stainless steel) or resin - reinforced
polyethylene ribbon. Metal retainers may be preformed with small bondable pads or
shaped individually for each patient. They may be manufactured from exible multistrand
wire bonded to each tooth in a segment (Figure 12.3 ) or made from rigid wire and bonded
only to selected teeth (e.g., canine - to - canine retainers extend across the lower labial
segment but are only bonded to the canine teeth).
Which Type of Bonded Retainer Is Best?
There is insufcient high - quality evidence to condently state that one type of bonded
retainer is better than another type. There is a suggestion that resin - reinforced ribbon
retainers are more prone to fracture than multistrand retainers (Rose et al. 2002 ). The
ribbon retainer is made from plasma - treated, polyethylene bers, which is then reinforced
and bonded with composite to the teeth. The composite creates a rigid retainer, and it is
possible that the lack of exibility means the teeth cannot move independently in function,
leading to fracture.
One study compared multistrand retainers bonded to the canines and all the incisors
in the lower arch with canine - to - canine retainers bonded on only the canines (Stormann
& Ehmer 2002 ). Although the evidence is weak, there is a suggestion that when using
canine - to - canine retainers, the incisors (which are not bonded to the retainer) are more
prone to relapse. The potential advantage of the canine - to - canine bonded retainers is that
if the bond fails on one canine it is obvious to the patient who can then return to have it
replaced. This contrasts with multistrand retainers, where individual teeth can debond from
the retainer, but by the time the patient realizes the bond has failed, the teeth may have
already relapsed.
Bonded Retainers or Vacuum - Formed Retainers?
The use of bonded and vacuum - formed retainers in the lower arch has been compared in
one study (McDermott et al. 2007, 2008 ; Millett et al. 2008 ). It would seem the patients
Figure 12.3 Multistrand bonded retainer.
CHAPTER 12 RETENTION 187
preferred the bonded to the vacuum - formed retainers because they found them more
acceptable to wear. However, the clinicians preferred the vacuum - formed retainers, as they
were easier to t. One of the common disadvantages described for bonded retainers is that
they break, leading to relapse. Although some bonded retainers did break in this study,
overall more vacuum - formed retainers cracked or were lost. As a result, more incisor
irregularity recurred with the patients wearing vacuum - formed retainers. In terms of dental
and periodontal health, there was slightly more gingival inammation and periodontal
pockets ( > 3 mm) with the patients wearing the bonded retainers, but for neither group did
any caries occur. The long - term clinical signicance for this is unclear. Certainly, however,
it would seem that good initial care instructions are important for bonded retainer patients,
and the need for long - term maintenance may be important.
Adjunctive Techniques to Reduce Relapse
Adjunctive techniques involving hard and soft tissue alterations have been used to enhance
stability: interproximal enamel reduction and pericision of gingival bers.
Interproximal Reduction
It has been suggested that interproximal reduction (Figure 12.4 ) of lower incisors may
contribute to increased stability by reducing the amount of excess tooth tissue (Aasen &
Espenland 2005 ) or perhaps by providing a more stable interdental contact. When compar-
ing patients who were tted with a rigid canine - to - canine retainer in the lower arch with
patients who had interproximal reduction but no retainer, no difference was demonstrated
in the amount of relapse after 1 year (Edman Tynelius, Bondemark & Lilja - Karlander
2010 ). It would seem that, at least in the short - term, interproximal reduction may have a
role to play in malocclusions without any underlying skeletal anomaly.
Figure 12.4 Interproximal reduction.
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Pericision
Pericision, also known as circumferential supracrestal berotomy , is the process of cutting
the interdental and dentogingival bers around the cervical region of the tooth. The quality
of evidence is much lower for this approach, but two nonrandomized, prospective con-
trolled clinical studies suggest that the technique may be successful in reducing the relapse
of rotated teeth (Edwards 1988 ; Taner et al. 2000 ). These studies are not included in the
most recent Cochrane review because they did not fulll the inclusion criteria of random-
ized controlled clinical trials. However, they were included here for completeness, as
currently providing the best available evidence for this approach. Pericision may reduce
the amount of rotational relapse by up to 30%, with no adverse effects on the health of
the periodontal ligament.
Conclusions
Relapse is an unpredictable risk factor for every patient. Before treatment begins, patients
need to be informed of the long - term risk of relapse and the ways that this may be reduced.
Some causes of relapse are within the control of the orthodontist. Others, such as soft
tissue changes and latent growth, are not, and may explain long - term changes in tooth
position.
Removable retainers offer the potential for better oral hygiene, and patients are respon-
sible for their wear. At least in the short - term, vacuum - formed retainers may be preferable
to Hawley retainers as they are more cost - effective, preferred by patients, and more effec-
tive at reducing relapse in the lower arch. Vacuum - formed retainers or Hawley retainers
can be worn on a part - time basis and do not require a period of full - time wear.
Bonded retainers may offer advantages over vacuum - formed retainers, as patients
prefer them and they provide better retention. This is because although bonded retainers
can break, vacuum - formed retainers are lost more frequently and therefore are not worn.
Bonded retainers have the disadvantage of needing long - term maintenance to ensure that
they are not compromising periodontal health and are still rmly bonded.
Interproximal reduction may have a role in reducing relapse in the lower labial segment,
and pericision may reduce rotational relapse. Further high - quality clinical trials would
resolve some of the uncertainties in post - treatment relapse and retention protocols.
References
Aasen , T.O. & Espeland , L. , 2005 . An approach to maintain orthodontic alignment of lower incisors
without the use of retainers . European Journal of Orthodontics 27 , pp. 209 214 .
Bearn , D.R. , 1995 . Bonded orthodontic retainers: a review . American Journal Orthodontics and
Dentofacial Orthopedics 108 , pp. 207 213 .
Behrents , R.G. , Harris , E.F. , Vaden , J.L. et al., 1989 . Relapse of orthodontic treatment results:
growth as an etiologic factor . Journal of the Charles H. Tweed International Foundation 17 ,
pp. 65 80 .
Edman Tynelius , G. , Bondemark , L. & Lilja - Karlander , E. , 2010 . Evaluation of orthodontic retention
capacity after one year of retention a randomized controlled trial . European Journal of
Orthodontics , DOI 10.1093/ejo/cjp145.