RETENTION RELAPSE

After malposed teeth have been moved

into the desired position they must be

mechanically supported until all tissues
involved in their support and
maintenance of their new positions
shall have become thoroughly
modified, both in structure and in
function, to meet the new
requirements

Angle (1907)
 CONTENTS

INTRODUCTION
SCHOOLS OF THOUGHT FOR RETENTION
SEMANTICS OF POST ORTHODONTIC TREATMENT CHANGES
THEOREMS OF RETENTION
FACTORS INFLUENCING RETENTION AND STABILITY
FACTORS THAT MODIFY THE RETNTION PROTOCOL
CAUSATIVE FACTORS FOR RELAPSE
RETENTION AFTER CLASS II CORRECTION
CLASS III CORRECTION
DEEP BITE CORRECTION
ANTERIOR OPENBITE CORRECTION
LONG TERM RETENTION STUDIES
RETENTION PLANNING
TIMING OF RETENTION
RETENTION APPLIANCES
RECOVERY AFTER RELAPSE
CONCLUSION
 Orthodontists have long since been aware
of the fact that teeth that have been moved
in or through bone by mechanical appliances
have a tendency to return to their former
positions. It is the purpose of Retention to
counteract this tendency. Although it has
been stated that correct diagnosis and
planning of treatment, followed by a careful
stabilizing of the final result, would
minimize the importance of retention,
Relapse tendencies still exist in a fairly high
percentage of cases treated. Our ability to
achieve long term Stability and our
understanding of the factors underlying
stability may be the least well founded in
this triad, clear indication being our need
 DIFFERENT SCHOOLS OF THOUGHT FOR
RETENTION

THE OCCLUSION SCHOOL

Kingsley (1880) stated, The occlusion of the teeth is the
most potent factor in determining the stability in a new
position.

THE APICAL BASE SCHOOL

In the middle 1920s a second school of thought formed
around the writings of Axel Lundstrom (1925), who
suggested that the apical base was one of the most
important factors in the correction of malocclusion and
maintenance of a correct occlusion. McCauley (1944)
suggested that intercanine width and intermolar width
should be maintained as originally presented to minimize
retention problems. Strang (1958) further enforced and
substantiated this theory. Nance (1947) noted, Arch
length may be permanently increased only to a limited
extent.
THE MANDIBULAR INCISAL SCHOOL
Grieve (1944) and Tweed (1952) suggested that the
mandibular incisors must be kept upright and over
basal bone.

THE MUSCULATURE SCHOOL

Rogers (1922) introduced a consideration of the
necessity of establishing proper functional muscle
balance.
 SEMANTICS OF POSTORTHODONTIC TREATMENT
CHANGES
[Semantics: the study of language
meaning]

RETENTION
Moyers (1973) defined retention as the holding of teeth
following orthodontic treatment in the treated position for
the period of time necessary for the maintenance of the
result.
Joondeph and Riedel (1985) explain retention as the holding
of teeth in ideal aesthetic and functional positions.
Retention is accomplished by a variety of mechanical
appliances.
RELAPSE
Robert Moyers states that relapse is the term applied to
the loss of any correction achieved by orthodontic
treatment.
Horowitz and Hixon (1969) defined relapse in general
as changes in tooth position after orthodontic
treatment.
Enlow (1980) defined relapse as a histogenetic and
morphogenic response to some anatomical and
functional violation of an existing state of anatomic and
functional balance. It is usually thought of as a
rebound movement in which teeth recoil back
somewhere close to their original positions once
retentive forces are moved.

STABILITY
Stability is the condition of maintaining equilibrium.
This refers to the quality or condition of being stable;
the fixity of position in space or the capacity for
resistance to displacement.
PHYSIOLOGIC RECOVERY
Horowitz and Hixon (1969) explain physiologic recovery
as the change to the original physiologic state after
completing treatment.

DEVELOPMENTAL CHANGES
Developmental changes are those which occur
irrespective of whether orthodontic treatment was
implemented or not. These changes could easily be
overlooked when assessing post treatment relapse.

POSTRETENTION SETTLING
Settling can be described as the establishment of a
desired position, the act of ceasing to move or settling
down and maintaining a correctly balanced position.
This term thus indicates the post treatment changing
process versus a term such as metaposition, which
refers to the meticulously planned changes after the
removal of the orthodontic appliances.
METAPOSITION
Metaposition denotes the desirable and expected post
treatment changes that are anticipated (Ricketts,
1993). These changes are not relapse and must be part
of the treatment itself.

RECIDIEF
The term recidief has been used to describe changes
that occur from the end of treatment back to the
original situation (Dermaut, 1974).
 WHY IS RETENTION NECESSARY?

The proposed basis for holding the teeth in their

treated position is to:
1) Allow for periodontal and gingival reorganization;
2) To minimize changes from growth;
3) To permit neuromuscular adaptation to the corrected
tooth position; and
4) To maintain unstable tooth position, if such
positioning is required for reasons of compromise or
esthetics.
 BASIC THEOREMS FOR RETENTION

Richard A Riedel (AO 1960) had discussed a

number of possible explanations of Retention and
Relapse.

THEOREM 1: Teeth that have been moved tend to

return to their former positions.
THEOREM 2: Elimination of the cause of malocclusion
will prevent recurrence.
THEOREM 3: Malocclusion should be overcorrected as
a safety factor.
THEOREM 4: Proper occlusion is a potent factor in
holding teeth in their corrected positions.
THEOREM 5: Bone and adjacent tissues must be
allowed to reorganize around newly positioned
teeth.
THEOREM 6: If lower incisors are placed upright over
basal bone, they are more likely to remain in good
alignment.
THEOREM 7: Corrections carried out during periods of
growth are less
likely to relapse.
THEOREM 8: The farther teeth have been moved, the less
likelihood of relapse.
THEOREM 9: Arch form, particularly in the mandibular
arch, cannot be permanently altered by appliance
therapy.

To Riedels theorems might be added the following:

THEOREM 10: Many treated malocclusions require
permanent retaining devices.
This is less true for cases treated to
meticulous occlusal goals and with respect for the
dynamics of growth and occlusal functionRobert E
Moyers (1970).
FACTORS INFLUENCING RETENTION AND
STABILITY
 Factors that affect post treatment stability
include..
Alteration of arch form

Periodontal and gingival tissues

Mandibular incisor dimensions

Influence of environmental factors and

neuromusculature

Consideration of continuing growth

Post treatment tooth positioning and establishment of

functional occlusion

Role of developing third molars

Influence of the elements of the original malocclusion

ALTERATION OF ARCH FORM

It is generally agreed that arch form and width should be

maintained during orthodontic treatment. In certain cases,
where arch development has occurred under adverse
environmental conditions, arch expansion as a treatment goal
may be tolerated.

Mills (Br Dent J 1966) found stability after proclination in

cases with skeletal deep bites and retroclined incisors in
conjunction with a digit or lip entrapment habit.

rtun (AO 1990) stated that proclination may be

successful provided that the lower incisors are initially
retroclined, a reason for the retroclination determined, and the
cause eliminated during treatment. Evidence shows that
intercanine and intermolar widths decrease during the
postretention period, especially if expanded during treatment.
For this reason, the maintenance of arch form rather than arch
development is generally recommended.
 Little et al (AJO 1981) maintained that intercanine
and intermolar width will relapse if expanded in Class II
Division 2 cases as much as in other Angle
classifications. In cases of mandibular expansion
concurrent with Rapid Palatal Expansion Haas(AO 1980)
and Sandstrom et al.(AJO 1988) found that maintenance
of 3 to 4 mm intercanine width and up to 6 mm
intermolar width was possible when expansion was
carried out concurrently with maxillary apical base
expansion

De La Cruz et al. (AJO 1995) carried out a 10 year

postretention study on 87 patients to determine the
long-term stability of orthodontically induced changes in
maxillary and mandibular arch form. The results showed
that although there was considerable individual
variability, arch form tended to return toward the
pretreatment shape. They concluded that the patient's
pretreatment arch form appeared to be the best guide to
future stability.
PERIODONTAL AND GINGIVAL TISSUES

Orthodontic movement to correct tooth rotations is

proposed to result in stretching of the collagen fibers. The
PDL reorganization is important for stability because of the
periodontal contribution to the equilibrium that normally
controls tooth position. Within 4 to 6 months, the
collagenous fiber networks within the gingiva have normally
completed their reorganization, but the elastic supracrestal
fibers remodel extremely slowly and can still exert forces
capable of displacing a tooth at one year after removal of an
orthodontic appliance.

Brain(AJO 1969) and Edwards(AJO 1970) advocated

gingival fiber surgery (Circumferential Supracrestal
Fiberotomy) to allow for the release of soft tissue tension
and reattachment of the fibers in a passive orientation after
orthodontic tooth rotation. In 1971 a prospective study was
initiated by Edwards with 160 patients up to 14 years post
treatment. The results were published in 1988 (AJO 1988)
and show a significant difference in the irregularity index
MANDIBULAR INCISOR DIMENSIONS

The notion that mandibular incisor dimensions

were correlated with lower incisor crowding was
reintroduced by Peck and Peck (AO 1972) after a study
of 45 untreated normal occlusions. They advocated
reduction of mandibular incisors to a given
faciolingual/mesiodistal ratio to increase stability. Peck
and Peck's work, however, was criticized since their
recommendations were based on a study involving
untreated rather than treated cases. Young patients
with ideal lower incisor alignment were used in the
study. It is possible that these cases would show
crowding if followed long term.

To evaluate whether the Peck and Peck ratio had

long-term value, Gilmore and Little (AJO 1984) studied
134 treated and 30 control cases a minimum of 10 years
postretention. They showed a weak association between
long-term irregularity and either incisor width or the
faciolingual/mesiodistal ratio.
INFLUENCE OF ENVIORNMENTAL FACTORS AND

NEUROMUSCULATURE

Strang(AO 1959) theorized that the mandibular

intercanine and intermolar arch widths are accurate
indicators of the individual's muscle balance and dictate the
limits of arch expansion during treatment.
Weinstein et al. and Mills (Br Dent J 1966) stated that
the lower incisors lie in a narrow zone of stability in
equilibrium between opposing muscular pressure, and that
the labiolingual position of the incisors should be accepted
and not altered by orthodontic treatment. Reitan(AJO 1969)
claimed that teeth tipped either labially or lingually during
treatment are more likely to relapse.

The initial position of the lower incisors has been shown to

provide the best guide to the position of stability in two
separate studies (Little et al. AJO 1985 & Houston et al. EJO
1990). In over 50% of cases the lower incisors ultimately
stabilized at a point between the pretreatment and post
CONSIDERATION OF CONTINUING GROWTH

Litowitz (AO 1948) stated that cases exhibiting

greatest amount of growth during treatment showed less
relapse. Riedel (AO 1960) reflected on the fact that growth
may aid in the correction of orthodontic problems but may
also cause relapse of treated cases. Nanda and Nanda (AJO
1992) agree with this and maintain that any skeletal
changes that occur during retention may attenuate,
exaggerate, or maintain the dentoskeletal relationship.

Facial development may result in secondary crowding

especially in extreme growth patterns such as forward
mandibular growth rotation where increased lingual
movement of lower incisors may be seen. Others have
stated that growth is not a major influence in development
of mandibular anterior irregularity, (Sinclair & Little AJO
1985) and this is likely the case in an average grower.

Nanda and Nanda(AJO 1992) found that the pubertal

growth spurt for patients with skeletal deep bite occurs on
POSTTREATMENT TOOTH POSITIONING AND
ESTABLISHMENT OF FUNCTIONAL OCCLUSION

Adequate interincisal contact angle may prevent

overbite relapse and good posterior intercuspation prevents
relapse of both crossbite and AP correction. Less relapse of
mesiodistal movement occurs in the absence of occlusal
stress. A perfect molar relationship was found to be a
significant factor in maxillary incisor alignment in a study of
226 postretention cases, (Schwarze CW BJO 1995) and a
RCP - ICP slide was found to have a statistically significant,
though clinically only moderate, influence on mandibular
incisor irregularity postretention (Weiland FJ EJO 1994).
ROLE OF DEVELOPING THIRD MOLARS

The role of third molars in lower incisor crowding

has been debated for more than a century. One theory
commonly reported is that of the third molars creating
space to erupt by causing anterior teeth to crowd.

Woodside (JCO 1970) postulated that in the

absence of third molars, the dentition could settle
distally in response to forces generated by growth
changes or soft tissue pressures. This implies a passive
role of the third molars in the development of late
crowding by hindering that adjustment. Recent studies
show a statistically significant but not a clinically
significant role of third molars in postretention crowding.

..
 Broadbent(AO 1941) was an early advocate of the
insignificant role played by third molars in late lower
incisor crowding. Several studies show a reduction in arch
length and an increase in crowding with age. However, no
difference in incisor crowding could be found in groups
with impacted, erupted, missing, or extracted wisdom
teeth.

Richardson(AO 1982) demonstrated a significant

forward movement of first molars between the ages of 13
and 17 years. This was correlated with the increase in
lower arch crowding that occurred during the same period.

Ades et al. (AJO 1990) compared four groups of

patients who were a minimum of 10 years out of retention.
They found no difference in mandibular incisor crowding,
arch length, intercanine width, and eruption patterns of
mandibular incisors and molars between the groups.

In summary, all of the conflicting data regarding third

INFLUENCE OF THE ELEMENTS OF THE ORIGINAL

MALOCCLUSION

Overbite increase postretention is related to the

amount reduced during treatment, although generally 30%
to 50% of the correction is retained. It is suggested that
overbite relapse tends to occur in the first 2 years
posttreatment and maintenance of intercanine width is
thought to increase stability. Most studies do not support
a greater relapse in Class II Division 1 cases when
compared with other malocclusion groups, however, a
slight change in overjet toward pretreatment values was
demonstrated in all malocclusion groups.

When teeth are aligned by orthodontic treatment,

there is a documented tendency for a return toward the
original pattern of malocclusion (Kalplan AJO 1966). For
this reason, rotational overcorrection has been advocated.

Little et al. (AJO 1981) however, noted that there are many
 ROLE OF TRANSVERSE DISCREPENCIES

There is inevitably a tendency for relapse associated

with Rapid Palatal Expansion techniques. Typically the
clinician must significantly overcorrect in the transverse
dimension, anticipating that a more normal relationship
will occur during the relapse stages. Additionally the
expansion appliance must be maintained passively or
removable appliance placed to aid in transverse retention.

..
 Storey (AJO 1973) has documented experimentally
that rapid expansion results in a predominantly destructive
process in which the sutural connective tissue becomes
disruptive and edematous. This is followed by eventual
filling of immature bone as a healing response. The
growing of bone of sufficient maturity requires a slow
steady rate of formation with lateral separation of bones
on the order of 0.5 to 1mm per week. Results of Storeys
experiments show that slow separation with continued
growth of bony serrations within the suture provides the
best retention with the least potential for relapse.

Castro, Cotton, and Hicks (University of Washington,

AJO 1973, 1979) have further evaluated experimentally and
clinically the stability of palatal expansion with light
continuous forces and have concluded that this technique
is more stable than rapid expansion.

..
 Anatomically, the limitation of palatal expansion is
not the fusion of the midpalatal suture but rather changes
in morphology of suture caused by maturation. As the
patient ages, further intercuspation and interdigitation of
bony serrations take place until the suture becomes
mechanically difficult to expand at older ages. These
changes may occur as early as 13 to 14 years. Early
expansion with light forces, achieved before these
maturation changes will allow maximal skeletal separation,
with normal physiological bone deposition enhancing the
long term stability in this plane of space.
 GENDER AND SEX DIFFERENCES

Growth is an aid in the correction of many types of

orthodontic problems, but it also may cause relapse in
treated orthodontic patients. Orthodontists take
advantage of growth when treating patients in the
transitional dentition period with headgear anchorage or
functional appliances. With cervical traction the normal
forward movement of the maxillary molars seems to be
restrained while the mandible continues in its course of
growth, and a normal tooth relationship may eventually be
reached (Harris J AJO 1962, Lagerstrm AO 1967).

The forward translation of the mandibular denture

on its base after the use of class II elastics or functional
appliances is generally regarded as being undesirable, for
apparently the mandibular posterior teeth do not migrate
distally again. Mandibular anterior teeth in their attempt
to upright to their former positions, frequently break
contact and crowd to the lingual.
 PRINCIPLES OF RETENTION AGAINST INTRA-ARCH

INSTABILITY:

Comparing the position of the teeth at the conclusion of

treatment with their original positions can identify the
direction of potential relapse.
[Teeth will tend to move back in the direction from which
they came, primarily because of elastic recoil of gingival
fibers but also because of unbalanced tongue-lip forces.]
Teeth require essentially full-time retention after
comprehensive orthodontic treatment for the first 3 to 4
months after a fixed orthodontic appliance is removed .

[To promote reorganization of

the PDL, however, the teeth should be free to flex
individually during mastication, as the alveolar bone
bends in response to heavy occlusal loads during
mastication. This requirement can be met by a
removable appliance worn full-time except during meals
or by a fixed retainer that is not too rigid.]
Because of the slow response of the gingival fibers,
retention should be continued for at least 12 months if the
teeth were quite irregular initially but can be reduced to
part-time after 3 to 4 months. After approximately 12
months it should be possible to discontinue retention in
non-growing patients. Some patients who are not growing
will require permanent retention to maintain the teeth in
what would otherwise be unstable positions because of lip,
cheek, and tongue pressures that are too large for active
stabilization to balance out. Patients who will continue to
grow, however, usually need retention until growth has
reduced to the low levels that characterize adult life.
 OCCLUSAL AND OTHER FACTORS WHICH MAY MODIFY
THE RETENTION PROTOCOL

Comprehensive orthodontic treatment is usually

carried out in the early permanent dentition, and the
duration is typically between 18 and 30 months. This
means that active orthodontic treatment is likely to
conclude at age 14 to 15, while anteroposterior and
particularly vertical growth often do not subside even to
the adult level until several years later. Long-term studies
of adults have shown that very slow growth typically
continues throughout adult life, and the same pattern that
led to malocclusion in the first place can contribute to
deterioration in occlusal relationships many years after
orthodontic treatment is completed.
 The various factors include.

-Lower Incisor alignment

-Corrected Rotations of anterior teeth
-Changes in the anteroposterior lower incisor position
-Correction of Deep Overbite
-Correction of Anterior Open Bites
-Patients with a history of periodontal disease or root
resorption
-Growth Modification treatment
-Correction of Posterior and anterior Crossbites
-Adult Patients
-Spaced Dentitions
Lower incisor alignment:

Increases in lower incisor irregularity occur

throughout life in a large proportion of patients following
orthodontic treatment and also in untreated subjects.
Recent evidence suggests that most change will take
place by the middle of the third decade (Richardson ME
EJO 1998). It has been suggested that prolonged
retention of the lower labial segment until the end of
facial growth may reduce the severity of lower incisor
crowding (Sadowsky C AJO 1994).

Patients expectations of the stability of their lower

incisor alignment should be considered on completion of
orthodontic treatment. If an individual is unwilling to
accept any deterioration in lower incisor alignment
following orthodontic treatment then permanent fixed or
removable retention may have to be considered
Corrected rotations of anterior teeth:

As the supracrestal gingival fibres are known to take

the longest amount of time to reorganise, prolonged
retention of corrected rotations may be helpful in reducing
relapse. While the use of adjunctive circumferential
supracrestal fiberotomy has been shown to be effective in
reducing relapse within the first 4-6 years after debonding,
the additional long term clinical benefit from the
procedure is relatively small (Edwards JG AJO 1988).

Changes in the antero-posterior lower incisor position:

Any intentional or non-intentional change of more

than 2mm indicates the need for long-term or indefinite
retention (Proffit).
Correction of deep overbite:

Following the correction of a very deep overbite, the

use of an anterior biteplane until the completion of facial
growth has been recommended. This may be particularly
useful when there is evidence of an anterior mandibular
growth rotation. (Proffit, Burstone & Nanda)

Correction of anterior open bites:

While the use of retainers incorporating posterior

biteblocks has been recommended for prolonged retention
of anterior open bite malocclusions with unfavourable
growth patterns, there is currently a lack of scientific
evidence to support this. (Proffit)
Patients with a history of periodontal disease or root
resorption:

In patients with previously treated severe

periodontal disease, permanent retention is advised. For
those with minimum to moderate disease, a more routine
retention protocol can be used (Zachrisson) . There is
evidence of an increased risk of deterioration of lower
incisor alignment post-retention in cases with root
resorption or crestal bone loss (Sharpe W AJO 1987).
Growth modification treatment:
These cases may therefore benefit from prolonged
retention.
Following the use of headgear or functional
appliances, retention using a modified activator appliance
has been reported as effective in maintaining Class II
correction (Weislander L AJO 1993).
Correction of posterior and anterior crossbites:

When the incisor overbite and posterior

intercuspation are adequate for maintaining the
correction, no retention is necessary (Kaplan AJO 1988).

Adult Patients:

When the periodontal supporting tissues are normal

and no occlusal settling is required, there is no evidence to
support any changes in retention protocol for adult
patients compared with adolescent patients.
Spaced dentitions

Permanent retention has been recommended

following orthodontic treatment to close generalised
spacing or a midline diastema in an otherwise normal
occlusion (Graber & Vanarsdall).
 CAUSATIVE FACTORS FOR RELAPSE
Most of the causative factors may be related to,

-Craniofacial growth
-Dental development &
CRANIOFACIAL GROWTH
-Muscle function
-Bjork (1968) showed the high variability of normal
facial growth in one of his first studies describing the use
of metal implants in cephalometrics. Late growth changes
may be responsible for posttreatment relapse, especially
after correction of class III malocclusion.

-Growth and changes in muscles and surrounding soft

tissue structures are relatively well synchronized with the
growth of the skeletal framework. The craniofacial complex
is regarded as a structure with specific functions, classified
as functional cranial components, and consisting of a
functional matrix and a skeletal unit, which protects and
supports this matrix. It has been shown that parts of the
functional matrix have a direct influence on the bone
during orthodontic treatment.
 -Relapse of the overjet and overbite has been
observed and has been mainly due to changes in incisor
inclination. The tendency to relapse is slightly greater in
class II division 2 cases than in class II division 1 cases. As
the maxillary growth is completed on average 2 to 3 years
before mandibular growth, dentoalveolar structures may
have difficulties in compensating for this discrepancy,
which may result in an increased overbite.

-Bjork (1972) and Sakuda (1976) showed that the

dentoalveolar structures may be influenced by the facial
morphology. Permanent teeth in low angle cases should
have a more anteriorly directed path of eruption than in
normal individuals, which, together with a deep bite, might
unfavourably influence the stability in the lower anterior
region. Mandibular incisor crowding is also believed to be
related to anterior (upward) rotation of the mandible.
DEVELOPMENT OF THE DENTITION

Continuous eruption of teeth The physiologic

changes of the dentition from early childhood into
adolescence, and from young adulthood into adulthood are
gradual process. A slight continuous eruption of teeth has
been observed even after the establishment of occlusion
post adolescence.

Arch length changes The arches reduce sagittally

until the age of 14 years and even later. Crowding of the
lower incisors quite commonly develops in modern man and
coincides with this decrease in arch length.

Tooth size The mesiodistal tooth size has been

discussed as a causative factor of the late crowding. Begg
(1954) analyzed interproximal attrition in old Australian
aborigines and concluded that teeth in modern man are too
large for the dental arches and hence become crowded.
Corrucini (1990) showed that small jaws rather than large
teeth underlie tooth-arch discrepancy.
 Mandibular 3rd molars Richardson (1989)
stressed that the third molar plays a passive role in the
development of late lower arch crowding.

Arch width changes Richardson (1995) showed

that increased lower arch crowding could be found in
association with both increased and decreased arch
width, depending on the direction of movement of the
canines. Decrease of the mandibular intercanine width is
generally considered to be associated with late lower
crowding.

Because dental development continues at a slow

persistent rate from adolescence into adulthood, there is
no definitive method to distinguish between normal age-
related events and relapse after orthodontic treatment.
SOFT TISSUE MATRIX

-The dentoalveolar changes are not only the result of

the influence of growth on tooth movements but also a
function of the soft tissue matrix surrounding the hard
tissue structures.

-It has been stressed that in the absence of muscular

imbalance, a well-established interdigitation may greatly
assist in maintaining the end result of tooth movement.
Establishing the most precise intercuspal relationship
between dental arches will not prevent relapse from
occurring if a strong adverse muscular pressure exists.

-It is therefore important to stress that if a

malocclusion, caused or maintained by muscular or other
soft tissue dysfunction, has been morphologically
corrected without any alteration in muscular behaviour, a
stable posttreatment result is unlikely.
TREATMENT TIME & PATIENTS AGE

-Corrections carried out during periods of growth

and eruption of teeth is considered to be less likely to
relapse.

-According to Reitan (1967), there will be little or

no relapse following orthodontic movement of an erupting
tooth, because its supporting tissues are in a stage
proliferation as a result of the eruption process.

-New fibers will be formed as the root develops, and

these new fibers will assist in maintaining the new tooth
position.
PERIODONTAL FORCE AND RELAPSE

Southard and Tolley (AJO 1992) investigated the

interproximal force (IPF) at the mandibular first molar-
second premolar contact and determined that whether the
periodontium maintains the contacts of approximating
mandibular teeth in a continuous state of compression.
Results indicated that,

-Contacts of approximating mandibular teeth are

maintained in a continuous state of compression. This
compressive force is generated by the supporting
periodontium and acts through the dental contact points,
even when the dental arches are apart. Further, this force is
increased for a period after chewing.

 -If inter proximal force (IPF) does exert an influence
on dental alignment, it probably acts in conjunction with
lip and cheek forces to collapse the arch and is opposed by
tongue force, which tends to expand the arch. It follows
that the influence of IPF should be more evident in the
anterior region of the arch where the contact points are
narrower, the crowns more tapered, and the expansive
force from the tongue more intermittent than in the
posterior region of the arch.

-The existence of a continuous, compressive force

(IPF), originating in the periodontium and acting on
approximating teeth at their contact points, which is
increased after occlusal loading, may help to explain long-
term post treatment crowding of the mandibular anterior
teeth, physiologic drifting of teeth, and maintenance of
posterior dental contacts after interproximal wear.
RETENTION AFTER CLASS II CORRECTION:
 Relapse toward a Class II relationship must result
from some combination of tooth movement (forward in the
upper arch, backward in the lower arch, or both) and
differential growth of the maxilla relative to the mandible.
In Class II treatment, it is important not to move the lower
incisors too far forward, but this can happen with Class II
elastics. In this situation lip pressure will tend to upright
the protruding incisors, leading relatively quickly to
crowding and return of both overbite and overjet.

Overcorrection of the occlusal relationships as a

finishing procedure is an important step in controlling
tooth movement that would lead to Class II relapse. Even
with good retention, 1 to 2 mm of anteroposterior change
caused by adjustments in tooth positions is likely to occur
after active treatment stops. As a general guideline, if
more than 2 mm of forward repositioning of the lower
incisors occurred during treatment, permanent retention
would be required.

..
The slower long term relapse that occurs in some patients
who did not have inappropriate tooth movement results
primarily form differential jaw growth. This relapse
tendency can be controlled in one of two ways:

- The first is to continue headgear to the upper

molars on a reduced basis (at night, for instance) in
conjunction with a retainer to hold the teeth in alignment.
This is quite satisfactory in well motivated-patients who
have been wearing headgear during treatment and is
compatible with traditional retainers that are worn full-
time initially.

.
 - The second method is to use a functional
appliance of the activator-bionator type to hold both tooth
position and the occlusal relationship. If the patient does
not have excessive overjet at the end of active treatment,
the construction bite for the functional appliance is taken
without any mandibular advancement- the reason being to
prevent a Class II malocclusion from recurring. A
potential difficulty is that the functional appliance will be
worn only part-time, typically just at night, and day time
retainers of conventional design also will be needed to
control tooth position during the first few months. For
patients with less severe problems, in whom continued
growth may or may not cause relapse, it may be more
rational to use only conventional maxillary and
mandibular retainers initially, and replace them with a
functional appliance to be worn at night if relapse is
beginning to occur after a few months.

This type of retention is often needed for 12 to 24

months or more in patients with a severe skeletal problem
initially. The guideline is: the more severe the initial Class
II problem and the younger the patient at the end of active
RETENTION AFTER CLASS III
CORRECTION:
 Relapse from continuing mandibular growth is very
likely to occur and such growth is extremely difficult to
control. Applying a restraining force to the mandible, as
from a chincap tends to rotate the mandible downward,
causing growth to be expressed more vertically and less
horizontally, and Class III functional appliances have the
same effect. If face height is normal or excessive after
orthodontic treatment and relapse occurs from mandibular
growth, surgical correction after the growth has expressed
itself may be the only answer. In mild Class III problems, a
functional appliance or a positioner may be enough to
maintain the occlusal relationships during post treatment
growth.
 RETENTION AFTER DEEP BITE CORRECTION:

In correcting excess overbite, the majority of patients

require control of vertical overlap of incisors during
retention. This is accomplished most readily by using a
removable upper retainer combined with a bite plane so
that the lower incisors will encounter the baseplate of the
retainer if they begin to slip vertically behind the upper
incisors. The retainer does not separate the posterior teeth.
As vertical growth continues into the late teens, the
retainer often is needed for several years after fixed
appliance orthodontics is completed.
RETENTION AFTER ANTERIOR OPEN BITE
CORRECTION:
 Relapse into anterior open bite can occur by any
combination of depression of the incisors and elongation
of the molars. Active habits such as thumbsucking and
tongue-thrust swallowing are often blamed for relapse
into open bite, but the evidence to support this contention
is not convincing. In patients who do not place some
object between the front teeth, return of open bite is
almost always the result of elongation of the posterior
teeth, particularly the upper molars without any evidence
of intrusion of incisors. Excessive vertical growth and
eruption of posterior teeth often continue until late in the
teens or early twenties. Controlling eruption of the upper
molars is therefore the key to retention in open bite
patients.

..
 High pull head gear to the upper molars, in
conjunction with a standard removable retainer to maintain
tooth position, is one effective way to control open bite
relapse. A better alternative is an appliance with bite
blocks between the posterior teeth (an open bite activator
or bionator), which stretches the patients soft tissues to
provide a force opposing eruption. A patient with a severe
open bite problem is particularly likely to benefit from
having conventional maxillary and mandibular retainers for
daytime wear, and an open bite bionator as a nighttime
retainer from the beginning of the retention period.
 RETENTION OF LOWER INCISOR ALIGNMENT:

Continued skeletal growth can not only affect the

occlusal relationships, but also alter the position of the
teeth. If the mandible grows forward or rotates downward,
the effect is to carry the lower incisors into the lip, which
creates a force tipping them distally. For this reason
continued mandibular growth in normal or Class III
patients is strongly associated with crowding of the lower
incisors. Incisor crowding also accompanies the downward
and backward rotation of the mandible seen in open bite
problems.

A retainer in the lower incisor region is needed to

prevent crowding from developing, until growth has
declined into adult levels. It also has been suggested that
orthodontic retention should be continued, at least on a
part-time basis, until the third molars have either erupted
into normal occlusion or have been removed.
LONG-TERM RETENTION STUDIES

.
 TREATMENT MODALITIES

Several long-term retention studies evaluating the

stability of different treatment modalities have been
reported. The main center for much of this research is the
University of Washington. Most of the research is centered
on the mandibular arch with the assumption that alignment
of the lower arch serves as a template around which the
upper arch develops and functions.

Most of the studies report on the Irregularity index

(Little R AJO 1975), arch length, and intercanine width. It is
important to note that the terms crowding and arch length
deficiency are not synonymous with the irregularity index.
The irregularity index measures displaced anatomic contact
points of the teeth and gives an objective value to subjective
crowding of the case. Arch length deficiency on the other
hand represents the space needed for alignment of teeth.
The following treatment modalities have been studied:

Late extraction followed by full treatment

Serial extraction without treatment

Serial extraction followed by appliance therapy

Non extraction therapy with expansion

Early mixed dentition treatment without fixed

appliance therapy

Non extraction therapy with generalized spacing

Lower incisor extractions

LATE EXTRACTION FOLLOWED BY FULL TREATMENT

Little et al.(AJO 1981) reports on 65 first premolar

extraction patients at least 10 years postretention.
Mandibular arch shortening was seen in 63 of the 65
patients. The crowding posttreatment was not associated
with the degree of arch length reduction. Intercanine
width change during the treatment and the duration of
retention were not predictive of postretention crowding.
The overall success rate, defined as an irregularity index
of less than 3.5 mm, was less than 30% with 20% showing
marked crowding.

Shields et al.(AJO 1985) reevaluated 54 of the

patients from the 1981 study and failed to find any
clinically significant predictors or associations of value
between the dental-cast measurements and cephalometric
data. Any change in cephalometric parameters
postretention failed to explain postretention crowding.
SERIAL EXTRACTION WITHOUT TREATMENT

Kinne (University of Washington 1975) reported on

55 patients who had undergone serial extraction without
any appliance therapy. The patients, examined at least 10
year after the extraction of premolars, showed an increase
in post treatment irregularity.

Persson et al. (EJO 1989) reported on 42 patients

an average of 20 years after serial extraction therapy.
Most of the cases showed redevelopment of crowding,
however, it was less pronounced than pretreatment and
when compared with untreated normals there was no
difference in the crowding evident between the two
groups.
SERIAL EXTRACTION FOLLOWED BY APPLIANCE
THERAPY

Anticipated future stability is one of the objectives

of serial extraction therapy. Tweed(1966) postulated that
early self-alignment should result in improved stability.
Engst (University of Washington 1977) studied 30 patients
at 5 years postretention, and Little et al. (AO 1990)
reported on the same sample at least 10 years
postretention. Clinically unsatisfactory mandibular
anterior alignment occurred in 73% of the cases and
decreases in intercanine width and arch length was found
in 29 of the 30 cases.

McReynolds and Little (AO 1991) found no

difference in postretention irregularity between first and
second premolar extraction cases. Both the first and
second premolar extraction cases showed a reduction in
arch length and width and were unpredictable relative to
long-term alignment. When compared to the late premolar
extraction group, the success rate of less than 30% was no
NONEXTRACTION THERAPY WITH EXPANSION

Twenty-six patients who had at least 1 mm of arch

development during the mixed dentition were studied at
least 6 years postretention (Stein UoW 1974 & Little AJO
1990). All the patients showed a reduction in arch length
after treatment and only five patients maintained an
overall increase of 1 mm.
Moussa et al. (AJO 1995) reported on a sample of 55
patients who had undergone rapid palatal expansion in
conjunction with edgewise mechanotherapy a minimum of
8 years postretention. Their results showed good stability
for upper intercanine, upper and lower intermolar widths,
and lower incisor irregularity. Stability of the mandibular
intercanine width, however, was poor with the
posttreatment position closely approximating the
pretreatment dimension.

..
 The stability of nonextraction treatment with
prolonged retention was studied by Sadowsky et al., (AJO
1994) who looked at 22 patients an average of 8.4 years
postretention (minimum, 5 years). The mandibular incisor
irregularity increased during the postretention period but
at 2.4 mm was still in the acceptable range.

Elms et al. (AJO 1996) recently reported on a sample

of 42 patients with Class II Division I malocclusion, who
were treated without extraction and with headgear and
fixed appliances. Final records were taken an average of
6.5 years postretention (minimum, 3 years). Some incisor
reproximation was preformed on removal of the
mandibular bonded retainer. Ninety percent of the sample
had incisor irregularity of less than 3.5 mm postretention.
They conclude that the factors responsible for the stability
seen are the application of proper mechanics, a
cooperative patient, and favorable downward and forward
mandibular growth.

The above cases showed only minimal crowding

EARLY MIXED DENTITION TREATMENT WITHOUT FIXED
APPLIANCE
THERAPY

Dugoni et al.(AO 1995) reported on the postretention

stability of cases who had early mixed dentition treatment
followed by the placement of a mandibular bonded retainer.
No appliance therapy was carried out in the permanent
dentition. Circumferential supracrestal fiberotomy or
interproximal enamel reduction was carried on removal of
the bonded retainers. The irregularity index in this sample
at the postretention stage showed satisfactory mandibular
incisor alignment in 76% of the cases. In contrast to other
studies, maintenance of postretention intermolar width was
also noted. It is suggested that the early establishment of
an intermolar width and improved occlusion in the mixed
dentition provides better long-term stability.
NONEXTRACTION THERAPY WITH GENERALIZED
SPACING

Thirty patients with mandibular spacing

pretreatment were studied 10 years postretention (Little
AJO 1989). Of all the treatment modalities studied, this
treatment displayed the most long-term stability with an
irregularity index value of 3.38 mm. This was still slightly
higher, however, than the value of 2.7 mm for untreated
norms. Minimal relapse of overjet and overbite was
evident. Some intercanine width reduction was evident in
most cases. The overall success rate in this group was
50% postretention.

Mandibular spaces did not reopen in any case. However,

the maxillary arch showed more variation; the midline
diastema was the most common areas of space
recurrence.
LOWER INCISOR EXTRACTIONS

Riedel (JCO 1976) observed an increase in post

treatment stability after an informal review of patients who
had two mandibular incisors removed. He then carried out
a long-term study to specifically determine the stability and
relapse of the mandibular incisor extraction therapy (AO
1992). Twenty-four patients who had a single mandibular
extraction followed 6.5 years postretention and 18 patients
with two mandibular incisor extractions followed for a
period of 9.75 years were studied. Twenty-nine percent of
the single incisor extraction group and 56% of the two
incisor extraction group demonstrated unacceptable
mandibular incisor alignment at the postretention stage.
This compares favorably to the results of previously
reported premolar extraction cases.
SUMMARY OF POSTTREATMENT CHANGES:

Intercanine width reduction is seen posttreatment

whether the case was expanded during treatment or not.
The intermolar width tends to return to the
pretreatment value during the postretention period in most
of the studies. These reported changes in intercanine and
intermolar width are greater in the mandibular arch than
the maxillary arch.
Although most of the arch changes are seen before
age 30, mandibular anterior crowding continues into the
fifth decade.
As summarized by Little et al. treated cases should
be viewed as dynamic and constantly changing, at least
through the third and fourth decade and perhaps
throughout life.
Of all the treatment modalities studied only three
showed acceptable long-term mandibular incisor alignment
postretention. These were the early mixed dentition
treatment with no fixed appliance therapy, the
 ORTHOGNATHIC SURGERY
MAXILLARY SURGERIES

Schuchardt (1959) first reported superior movement of the maxilla, who

used a two-stage approach and limited his surgical procedure to the
posterior maxilla. He reported relapse problems that in retrospect probably
were caused primarily by incomplete mobilization of the dentoalveolar
segments at surgery.

Willmar (1974) undertook the first quantitative follow-up study on LeFort I

osteotomy with the use of surgically placed metal markers. Although 106
patients were studied, only three had ''idiopathic long face.'' These cases
demonstrated stability of markers and occlusion throughout the 1-year
observation period, with an ''insignificant" 10% superior relapse occurring
at the anterior marker.

Bell and McBride (1977) examined 41 patients with vertical maxillary

excess who underwent maxillary superior repositioning by LeFort I
osteotomy. They evaluated their results clinically and noticed stability
without relapse in the cases examined.

Hartog (1982) evaluated skeletal stability and soft-tissue changes after

superior repositioning of the maxilla, and reported that good stability was
attained. The sample included multiple segments and combined procedures
with only three one-piece osteotomies.

Washburn, Schendel, and Epker (1982) reported their experiences with

superior maxillary repositioning in a group of 15 young patients and
indicated that the postsurgical jaw relationship was maintained even in
patients who experienced postsurgical growth.
MANDIBULAR SURGERIES

Lake, McNeill, Little (AJO 1981) evaluated surgical advancement of the

mandible by retrospective cephalometric and computer analysis for
longitudinal skeletal and dental changes an average of 3 years after
surgery. 52 patients (19 males and 33 females) underwent surgical
advancement of the mandible by means of bilateral sagittal osteotomy of
the mandibular vertical rami.
From the results, relationships between specific parameters and skeletal
relapse have been demonstrated:
-Positional change of the proximal segment was found to be the most
important parameter in determining stability or relapse of the advanced
mandible. -Anteroinferior condylar displacement and increase in
posterior facial height at the time of surgery or immediately
postoperatively were associated with subsequent skeletal relapse of the
distal mandibular segment.
-The magnitude of advancement was a primary factor in mandibular
stability. As the magnitude of advancement increased, the net amount of
relapse tended to increase.
-The dynamic function and variability of the mandible's musculoskeletal
system and its periosteal integument may play a dominant role in the
nature of the postsurgical response.
-Preoperative measurement of the mandibular plane angle did not prove
to be a reliable predictor of subsequent mandibular relapse. However,
patients with high mandibular plane angles did undergo more relapse
than did patients with either normal or low angles.
-No significant relationship was found between skeletal relapse and the
age of the patient. .
Huang and Ross (AJO 1982) evaluated the short-term and long-
term effects of surgical lengthening of the retrognathic, growing
mandible in children. Twenty-two patients 12 boys and 10 girls
underwent mandible-lengthening procedures at the mean ages of
14.1 years (boys) and 13.4 years (girls).

The results indicated that,

-The response to this mandible-lengthening surgery in the
growing child varied with the amount of lengthening performed
but did not appear to vary with age (after 11 years), sex, etiology
of the mandibular discrepancy, mandibular plane angle, deep- or
open-bite, or concomitant surgical procedures.

-Lengthening of more than 11 mm. was usually accompanied by

extensive relapse, with major remodeling of the condyle or
posterior symphysis or both.
Lengthening of less than 9 mm. was followed by little or no
relapse.

-No further clinically significant growth of the mandible

occurred following mandible lengthening as performed after the
age of 11 years.

-The mandible returned to its preoperative growth direction

within 2 years after surgery.
 FUNCTIONAL APPLIANCE TREATMENT

Pancherz (AJO 1991) performed a long term cephalometric

investigation to analyze the nature of Class II relapse after Herbst
appliance treatment, comparing stable and relapse cases at least 5
years after treatment. A total of 118 patients with Class II, Division 1
malocclusions were treated with the Herbst appliance. Lateral
cephalograms taken before and immediately after Herbst treatment, as
well as 6 months and 5 to 10 years after treatment, were analyzed.

The results revealed that,

-Relapse in the overjet and sagittal molar relationship resulted mainly
from posttreatment maxillary and mandibular dental changes.

-In particular, the maxillary incisors and molars moved significantly to

a more anterior position in the relapse group than in the stable group.

-The interrelation between maxillary and mandibular posttreatment

growth was favorable and did not contribute to the occlusal relapse.

-It is hypothesized that the main causes of the Class II relapse in

patients treated with the Herbst appliance were a persisting lip-tongue
dysfunction habit and an unstable cuspal interdigitation after
treatment.
..
Wieslander (AJO 1993) investigated the long-term effect of treatment with
headgear-Herbst appliance in early mixed dentition in children with
severe Class II malocclusions. A group of children age 8 years 8 months
was initially treated for 5 months with a headgear-Herbst appliance
followed by a 3- to 5-year period of activator retention. The patients were
studied out of retention at the mean age of 17 years 4 months and
compared with an untreated control group.

Positive findings of the study includes the following:

-A rapid improvement of the anteroposterior jaw discrepancy because of
24-hour wear of the appliance for 5 months.
-A significant maxillary effect during active treatment and retention
resulting in a 2.3 mm posterior gain after retention, which compensates
for the mandibular relapse tendency. It resulted in an average statistically
and clinically significant 2.9 reduction of the ANB angle and a 3.8 mm
skeletal improvement of the sagittal jaw relationship out of retention.

Negative findings include the following:

-A prolonged retention ranging over several years of activator wear was
necessary to minimize relapse after Herbst treatment.
-A modest long-term effect on the mandible 8 years after treatment. In
many cases the long-term mandibular effect was considerably larger and
of clinical importance. However, in other cases that cooperated poorly
during retention, it was less.
-A rather small increase in mandibular length. The significant average 2.0
mm increase in the condylion-gnathion distance observed after 5 months
of Herbst treatment was reduced to 1.2 mm after retention and was not
statistically significant.
 RETENTION PLANNING

Retention Planning is divided into three

categories, depending on the type of treatment
instituted:

(1) limited retention

(2) moderate retention ( in terms of both time
and appliance
wearing)
(3) permanent or semi permanent retention
 CONDITIONS WHERE LIMITED RETENTION IS
REQUIRED:

(a) Corrected Crossbites

-Anterior: when adequate overbite has been
established
-Posterior: when axial inclinations of posterior teeth
remain reasonable after corrective procedures have
been completed

(b) Dentitions that have been treated by serial extraction

-High canine extraction cases
-Cases calling for extraction of one or more teeth

(c) Corrections that have been achieved by retardation of

maxillary growth, whether dental or skeletal, after
the patient has passed through the growth period

(d) Dentitions in which the maxillary and mandibular teeth

have been separated to allow for eruption of teeth
previously blocked out.
 CONDITIONS WHERE MODERATE RETENTION IS
REQUIRED:

(a) Class I non extraction cases, characterized by

protrusion and spacing of maxillary incisors. These
require retention until normal lip and tongue function has
been achieved.

(b) Class I or Class II extraction cases probably

require that the teeth be held in contact, particularly in
the maxillary arch, until lip and tongue function can
achieve a satisfactory balance. It is generally desirable to
use a maxillary Hawley type of retainer until normal
functional adaptation has occurred. It is sometimes also
desirable to use either a maxillary Kloehn-type headgear,
whose force is directed to the permanent first molars, or a
labiobuccal type of appliance, with cervical or occipital
resistance applied at night.

.
 (c) Corrected deep overbites in either Class I or
Class II malocclusions usually require retention in a
vertical plane.

-if anterior teeth were depressed to achieve

overbite correction, a bite plane on a maxillary retainer is
desirable. To be effective in retaining overbite correction,
the bite plane should be worn continuously for perhaps the
first 4 to 6 months, including while the patient is eating.
In deep overbite cases overcorrection is usually desirable
and equilibration and adjustment to functional occlusion is
necessary.
-If overbite correction was achieved as a result of
bite opening and mandible was forced away from the
maxilla, vertical dimensions should be held until growth
(ie, mandibular ramal height) can catch up.
-Severe occlusal plane tipping may also require
extended retention protocols and possibly additional
maxillary restraint as well.

.
 (d) Early correction of rotated teeth to their normal
positions.
-Perhaps before root formation has been
completed
-In the mandibular incisor area a removable type
of appliance with a labial bow is probably best. In this
area, the occlusal splint type retainer or cast lower partial,
as suggested by Lande, may be useful.

(e) Cases involving ectopic eruption of teeth or the

presence of supernumerary teeth require varying retention
times, usually prolonged, and occasionally a fixed or
permanent retentive device.

(f) The corrected Class II div 2 malocclusion

generally requires extended retention to allow for the
adaptation of musculature.
 CONDITIONS WHERE PERMANENT OR SEMI
PERMANENT RETENTION
IS REQUIRED:

(a) Cases in which expansion has been the choice of

treatment, particularly in the mandibular arch, may
require either permanent or semipermanent retention to
maintain normal contact alignment.

(b) Cases of considerable or generalized spacing

may require permanent retention after space closure has
been completed.

(c) Instances of severe rotation or severe

labiolingual malposition may require permanent retention,
as provided by bonded retainers.

(d) Spacing between maxillary central incisors

(diastema) in otherwise normal occlusions sometimes
require permanent retention, particularly in adult
dentitions.
 TIMING OF RETENTION: SUMMARY

Retention is needed for all patients who had fixed orthodontic

appliance to correct intra-arch irregularities. It should be:

Essentiallyfull time for the first 3 to 4 months, except that the

retainers not only can but should be removed while eating
(unless circumstances like periodontal bone loss require
permanent splinting).

Continuedon a part time basis for at least 12 months, to allow time

for remodeling of gingival tissues.

Ifsignificant growth remains, continued part time until completion

of growth.

This would mean that nearly all patients treated in the early
permanent dentition will require retention of incisor alignment
until the late teens, and in those with skeletal disproportions
initially, part time use of a functional appliance or extra oral force
probably will be needed.
 RETENTION APPLIANCES

Requirements of Retaining Appliances:

1. It should restrain each tooth that has been moved into
the desired position in directions where there are
tendencies towards recurring movements.
2. It should permit the forces associated with functional
activity to act freely on the retained teeth, permitting
them to respond in as nearly a physiologic manner as
possible.
3. It should be as self-cleansing as possible and should be
reasonably easy to maintain in optimal hygienic
condition.
4. It should be constructed in such a manner as to be as
inconspicious as possible, yet should be strong enough
to achieve its objective over the required period of use.
 RETAINER DESIGN

Removable retainers with a labial bow (Hawley, Begg and

Barrer type
retainers):

Removable Appliances can serve effectively for

retention against intra-arch instability and are also useful
as retainers (in the form of modified functional appliances
or part-time headgear) in patients with growth problems.
These retainers are robust and can be worn during eating.
Hawley retainers have been recently shown to have the
advantage of facilitating posterior occlusal settling in the
initial three months of retention (Sauget E, AO 1997).
The labial bow can be used to accomplish simple tooth
movements if required, and an anterior biteplane can
easily be incorporated for retention of a corrected deep
overbite.
HAWLEY WRAP AROUND

BARRER
 Removable vacuum formed retainers (Transparent Plastic
Invisible Retainers):

Vacuum formed retainers are relatively inexpensive and can be

quickly fabricated on the same day as appliance removal. They
are discreet and can be modified to produce tooth movements
if required. Full posterior occlusal coverage (including second
molars if present) is advisable in order to reduce the risk of
overeruption of these teeth during retention.

The Essix retainer is an example of the invisible retainer that

only incorporates the six anterior teeth of each arch. These
appliances allow for the settling of the posterior teeth into
better occlusion. Due to their inherent flexibility, however,
they cannot be used to retain cases in which arches have been
expanded during orthodontic treatment.

Recent research has shown that vacuum formed retainers

were significantly less effective in promoting posterior
occlusal settling than Hawley retainers (Sauget E, AO 1997).
However this is likely to be of little importance if good
posterior intercuspation has been established by the time of
debonding.
ESSIX THERMOPLASTIC COPOLYESTER
RETAINERS
 Fixed bonded retainers (Smooth wire, Flexible Spiral wire):

Fixed retainers are indicated for long-term retention of the

labial segments, particularly when there is reduced
periodontal support, and for retention of a midline diastema
(Proffit). Fixed retainers are discreet and reduce the demands
on patient compliance. However they are associated with
failure rates of up to 47% (Bearn DR, AJO 1995), particularly
on upper incisors when there is a deep overbite. In addition,
calculus and plaque deposition is greater than with removable
retainers. Fixed retainers therefore require long term
maintenance.

There are four major indications:

1) Maintenance of lower incisor position during late growth
2) Diastema maintenance
3) Maintenance of pontic or implant space
4) Keeping extraction space closed in adults

Flexible spiral wire retainers allow differential tooth

movement and are particularly useful for patients with loss of
periodontal support. Current orthodontic opinion recommends
either the use of 0.0215 inch multistrand wire, (Heier EE, AJO
1997) or 0.030 - 0.032 inch sandblasted round stainless steel
wire (Zachrisson JCO 1995).
 Active Retainers:

Relapse or growth changes after orthodontic treatment

will lead to a need for some tooth movement during
retention. This usually is accomplished with a
removable appliance that continues as a retainer after it
has repositioned the teeth.

It usually used in two specific situations:

Realignment of Irregular Incisors (Spring Retainers) ,
and as
Functional appliances to manage Class II or Class III
relapse tendencies.

SPRING
RETAINER
 Positioners:

Positioners are elastomeric or rubber removable retainers that

are either preformed or custom made. Preformed positioners are
available for bicuspid extraction cases and non-extraction cases.
Sizes are determined by measuring the mesiodistal dimensions
of the six anterior teeth. These preformed positioners cannot
compensate for individual variation in the size of the teeth, arch
width, arch form or tooth size discrepancies. For these reasons,
they should only be used temporarily.

Custom-made positioners are fabricated on articulated models

in which teeth from both arches have been sectioned from the
models, realigned and waxed in an ideal configuration. This
incorporates minor corrections in tooth position and occlusal
relationship. The elastomeric or rubber material is then formed
around the teeth and the coronal portion of the gingiva.

POSITIONERS
 RECOVERY AFTER RELAPSE

Despite the utmost care in Treatment and Retention, if Relapse

occurs the following can be considered:

1) Retreatment may take the form of rebanding or rebonding most

if not all teeth. It is sometimes expedient to consider the
removal of certain teeth, particularly if the relapse occurs in the
form of crowding. In any case attempt should be made to
discover and eliminate factors that appear contributory to
relapse.

2) The mandibular lingual arch helps to realign the teeth in

instances of mandibular collapse or crowding. Light pressure
against mandibular anterior teeth may be used to realign them.

3) Springs and clasps can be added to maxillary Hawley retainer to

assist in repositioning and control of labiolingual deviations.

4) Spring retainers using both facial and lingual acrylic for added
leverage and labial bows for increased flexibility may be used
for minor realignment. Teeth are sectioned and aligned on the
retainer model and active retainer is fabricated to the realigned
relationship. Interproximal stripping is sometimes beneficial.
5) The maxillary labiobuccal retainer, Kloehn-type
headgear, or functional appliances may be used against
the maxillary arch to provide recorrection in instances
of relapse toward a Class II relationship.

6) Habit training in the form of tongue and lip therapy

may be beneficial when abnormal habit patterns have
caused orthodontic relapses. Removable appliances are
also helpful as tongue restraints.

7) Equilibration and trimming may be all that is necessary

to achieve esthetic and functional satisfaction for the
patient and orthodontist.

8) In certain cases it may be desirable to suggest that the

patient accept minimal relapses rather than continue
with prolonged treatment or retention.
 CONCLUSION

Maintaining the treatment result following

orthodontic treatment is one of the most difficult
aspects of the entire treatment process. Normal
maturational changes, together with post-treatment
tooth alterations, conspire against long-term
stability. All treated malocclusions must eventually
be returned from control by appliances to control by
the patients own musculature. Permanent retention
is increasingly being recommended as the only way
to ensure long-term stability of an orthodontic
treatment result. Proper goals of treatment, careful
mechanotherapy, precise occlusal equilibration, and
well-chosen retention procedures play a role in
achieving occlusal homeostasis.