Review articles
 

By Dr. Debora Loli
Corresponding Author Dr. Debora Loli
Sapienza University of Rome - Department of Oral and MaxilloFacial Sciences, - Italy
Submitting Author Dr. Debora Loli
ORTHODONTICS

retention, orthodontic treatment, relapse

Loli D. Retention after orthodontic treatments: a systematic review. WebmedCentral ORTHODONTICS 2017;8(11):WMC005406

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Submitted on: 20 Nov 2017 10:32:21 PM GMT
Published on: 23 Nov 2017 12:17:05 PM GMT

Abstract


Orthodontists should work to achieve an occlusion that is functionally efficient, esthetic, and healthy. Long-term retention helps to ensure stability of the dentition. 

Introduction


Relapse is the change in tooth position toward the former location following active orthodontic treatment. Teeth have a stable position due to the equilibrium of forces of chewing, swallowing, tongue and cheek movements. There is a balance between the internal and external oral musculature. If a tooth is moved, there is an alteration in equilibrium that must be restored to prevent relapse. New fiber and hard tissue formation is dependent on retention. The gingival fiber networks must reorganize to accommodate the new tooth positions. Immediately after removal of orthodontic appliances, the teeth are unstable because of occlusal and soft tissue pressures1. For this reason, an orthodontic retainer must be worn by every patient for a minimum of 6 months to reestablish the equilibrium.

 

Methods


The aim of this review is to analyze the concept of post- orthodontic treatment stability orthodontic and retention. Pub Med and Scopus were used.

Used keywords were "stability", "relapse", "retention", "orthodontic retainer".  

Review


Little2 stated that the only way to have a good long-term alignment after treatment is to use a fixed or removable lifetime retention.

Interdigitation of the posterior occlusion plays a very important role for the control of anteroposterior and vertical facial growth and is a fundamental factor in jaw relationship3. Numerous authors stated that good intercuspidation and occlusal contacts are the key to a stable orthodontic result4-5.

Most of the current concepts in occlusion are derived from study by Andrews6 to determine the keys to normal occlusion, that are the goal to achieve a normal occlusion with a good esthetics and good occlusal function: molar relationships, crown angulation, crown inclination, no rotations, no spaces, flat occlusal plane.

Many factors have been discussed concerning stability of the orthodontic treatment results7. In particular, most important factors are the time needed for the gingival and periodontal ligament fibers to reorganize, the growth, especially of the jaw, and the soft -tissue pressure from the oral musculature.

Growth produces occlusal changes in all three skeletal dimensions. The transverse dimension is completed before and has less occlusal effects than the vertical and anteroposterior dimensions. However, if a patient has had transverse expansion, there is a degree of rebound even in the transverse dimension.

Retention is the last phase of orthodontic treatment but it’s also one of the most important, because it’s fundamental to maintain the stability of the occlusion and the esthetic and functional results

Retention should be continued until craniofacial growth is essentially completed in the early 20s.9 As most of the relapses occur in the first 6 months, following bracket removal, the maxillary retainer is worn fulltime for 6 months. After, the patient can go to night wear only and gradually reduce.

Johnston CD10 et al suggested the role of the general dental practitioner in orthodontic retention, informing potential orthodontic patients that wearing retainers after orthodontics is an essential part of orthodontic treatment, reinforcing the need for patients to wear their retainers as advised and how to look after them, , ensuring that patients are adhering to their retention regime, adjusting, repairing or replacing removable retainers and ensuring that they still fit well (responsibility for the replacement or repair may depend on whether the patient remains under care of the orthodontist who completed the treatment) and, for patients wearing bonded retainers, checking that retainers are still intact, bonded and that the patient is maintaining good oral hygiene around them. Fractured or de-bonded retainers must be repaired (with appropriate advice if required). Removable plates such as Hawley’s and Begg plate, vacuum-formed retainer and positioner and fixed retainers bonded on mandibular canine-to-canine region are available.

Vacuum formed retainers (VFRs) are discreet and are well accepted by patients from an aesthetic and comfort perspective11-14. VFRs are more cost-effective and better in order to retain the alignment of the anterior teeth than Hawley-type retainers although the magnitudes of the differences are small. Full posterior occlusal coverage, including the most distal molars, is advisable in order to reduce the risk of over-eruption of these teeth during retention. It’s important to remind patients not to eat or drink with the vacuum formed retainers in place. This is a particular concern if the patient drinks cariogenic beverages with the vacuum-formed retainer in place.

Begg and Hawley retainers are robust and,unlike VFRs, can be worn when eating without becoming damaged. The advantage of Hawley retainers is the facilitation of posterior occlusal settling during retention 15. However, this action loses importance if good posterior intercuspation has been achieved by the time of appliance removal. The labial bow can be modified to accomplish simple active tooth movements if required and an anterior bite plane can be incorporated to help retain corrected deep overbites.

Fixed retainers are also effective and reduce the need of patient compliance. However, they are associated with a significant long-term failure rate.  A third of patients underwent to retainer failure within 30 months16 with de-bonding from at least one tooth in 22% of patients and 17% having total retainer loss. Fracture of the retainer wire was uncommon, with less than 1% of patients having this type of failure. Particular care is required when placing upper bonded retainers to minimize the occlusal contacts with the opposing lower teeth as such contacts have been shown to increase failure rates. A composite with high filler content is preferred to improve resistance to wear. Calculus and plaque deposition17 is greater than with removable retainers and concerns exist about the impact of fixed bonded retainers on long-term dental health. However, a review reported that studies completed up to 8.5 years after fixed retainers were placed have found no deleterious effect on the adjacent hard and soft tissues18. Nevertheless, meticulous attention to detail is required when placing fixed retainers to avoid contact with the gingival tissues by the bonding material. Any excess of composite should be removed with a tungsten carbide bur. It is important to show patients how to look after their bonded retainers and to maintain excellent oral hygiene around them. The use of small inter-dental brushes or superfloss may be a useful adjunct to tooth brushing to help maintain excellent oral hygiene around bonded retainers, since some patients wearing fixed retainers will be required to wear them indefinitely.

Al-Jewair TS19  et al said that Hawley’s plate in the maxilla, and fixed lingual in the mandible were the most common retention protocols prescribed. Lifetime retention was the most common choice for participants who used removable retainers, especially when extractions were carried out.

Pratt20 et al indicated that retention protocols of the surveyed population showed predominant use of Hawley or vacuum-formed retainers in the maxillary arch and fixed retention in the mandibular arch.

Singh P21 et al stated that vacuum retainers are popular in NHS, hospital and private practice. Bonded retainers are more commonly used in private practice than in other settings

Mai W et al22 suggested that additional high-quality, randomized, controlled trials concerning these retainers are necessary to determine which retainer is better for orthodontic procedures.

Littlewood SJ23,24 ,How Kau C25 and Al-Moghrabi D26. et al evidenced that the effectiveness of different retention strategies used to stabilize tooth position after orthodontic treatment is not determined because there are insufficient research data on which to base our clinical practice on retention at present. There is an urgent need for high quality randomized controlled trials in this crucial area of orthodontic practice.

Tynelius GE27 indicated that the most appropriate retention method should be selected on an individual, case to case basis, taking into account such variables as orthodontic diagnosis, the expected level of patient compliance, patient preferences and financial considerations.

Conclusions


Orthodontic therapy’s goals are to achieve a good esthetics, a good occlusal function with stable results over the years. Retention of the corrected malocclusion is important as the diagnosis and treatment plan. The type of retention should be determined at the beginning of treatment as well as any procedures to help retain the final functional and esthetic occlusion.

References


  1. Sandowsky C: Long-term stability following orthodontic therapy. In Burstone CJ , Nanda R, editors. Retention and stability in orthodontics. Philadelphia: WB Saunders, 1993, pp 107-113.
  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
  3.  Ostyn JM, Maltha JC, van’t Hof MA, van der Linden FP: The role of interdigitation in the sagittal growth of the maxilla-mandibular complex of Macaca fascicularis. Am J Orthod Dentofacial Orthop 1996;109:71-78
  4. Harris EF, Vaden JL, Dunn KL, Behrents RG: Effects of patients age on postorthodontic stability of the mandibular arch. Eur J Orthod 1994; 105:25-34
  5. Parkinson CE, Bushang PH, Behrents RG, et al: A new method of evaluating posterior occlusion and relation to posttreatment occlusal changes. Am J Orthod Dentofacial Orthop 2001; 120: 503-512
  6. Andrews LF: The six keys to normal occlusion. Am J Orthod 1972; 62:296-309
  7.  Nanda RS, Nansa SK: Considerations of dentofacial growth in long-term retention and stability: is active retention needed? Am J Orthod Dentofacial Orthop 1992; 101: 297-302
  8. Blake M, Bibby K: retention and stability: a review of the literature. Am JOrthod Dentofacial Orthop 1998; 114: 299-306
  9. Zachrisson BU: Important aspects of long term stability. J Clin Orthod 1971; 9; 563-583
  10. Johnston CD, Littlewood SJ Retention in orthodontics. Br Dent J. 2015 Feb 16;218(3):119-22.
  11. Hichens L, Rowland H, Williams A et al. Costeffectiveness and patient satisfaction: Hawley and vacuum-formed retainers. Eur J Orthod 2007; 29: 372–378. 9.
  12. Singh P, Grammati S, Kirschen R. Orthodontic retention patterns in the United Kingdom. J Orthod 2009; 36: 115–121. 10.
  13. . Mollov N D, Lindauer S J, Best A M, Shroff B, Tufekci E. Patient attitudes toward retention and perceptions of treatment success. Angle Orthod 2010; 80: 468–473. 11.
  14. Kumar A G, Bansal A. Effectiveness and acceptability of Essix and Begg retainers: a prospective study. Aust Orthod J 2011; 27: 52–56
  15. Sauget E, Covell D A, Boero R P, Lieber W S. Comparison of occlusal contacts with use of Hawley and clear overlay retainers. Angle Orthod 1997; 67: 223–230. 15.
  16. Scheibe K, Ruf S. Lower bonded retainers: survival and failure rates particularly considering operator experience. J Orofac Orthop 2010; 71: 300–307.
  17. Heier E E, De Smit, A A, Wijgaerts I A, Adriaens P A. Periodontal implications of bonded versus removable retainers. Am J Orthod Dentofacial Orthop 1997; 112: 607–616. 17
  18. Sadowsky C, Schneider B J, BeGole E A, Tahir E. Long-term stability after orthodontic treatment: nonextraction with prolonged retention. Am J Orthod Dentofacial Orthop 1994; 106: 243–249.
  19. Al-Jewair TS, Hamidaddin MA, Alotaibi HM, Alqahtani ND, Albarakati SF, Alkofide EA, Al-Moammar KA.Retention practices and factors affecting retainer choice among orthodontists in Saudi Arabia. Saudi Med J. 2016 Aug;37(8):895-901.
  20. Pratt MC, Kluemper GT, Hartsfield JK Jr, Fardo D, Nash DA. Evaluation of retention protocols among members of the American Association of Orthodontists in the United States. Am J Orthod Dentofacial Orthop. 2011 Oct;140(4):520-6.
  21. Singh P, Grammati S, Kirschen R Orthodontic retention patterns in the United Kingdom. J Orthod. 2009 Jun;36(2):115-21.
  22. Mai W, He J, Meng H, Jiang Y, Huang C, Li M, Yuan K, Kang N. Comparison of vacuum-formed and Hawley retainers: a systematic review. Am J Orthod Dentofacial Orthop. 2014 Jun;145(6):720-7
  23. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures for stabilising tooth position after treatment with orthodontic braces. J Orthod. 2006 Sep;33(3):205-12.
  24. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Orthodontic retention: a systematic review. Evid Based Dent. 2006;7(4):100.
  25. How Kau C. Orthodontic retention regimes: will we ever have the answer? Prog Orthod. 2016 Dec;17(1):24. doi: 10.1186/s40510-016-0137-x. Epub 2016 Jul 26.
  26. Al-Moghrabi D, Pandis N, Fleming PS. The effects of fixed and removable orthodontic retainers: a systematic review. Am J Orthod Dentofacial Orthop.
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