SEMINAR ON,

RETENTION AND RELAPSE

Presented by
Dr Rajul khare
 INTRODUCTION :
Retention period is the most important

phase of orthodontic treatment ,which is often neglected.

Success of orthodontic correction depends on stability

of the achieved results and prevention of relapse.

This seminar focuses on

clinical guidelines for Retention appliance selection

for various types of malocclusions treated.

 RETENTION :
Definition according to Moyers:

Maintaining the newly moved teeth

in position long enough to aid in stabilizing their correction.

Working definition :

According to Richard A Riedel.

Holding the teeth in ideal esthetic and

functional positions.
 HISTORY OF RETENTION :

Different philosophies and school of thoughts had

developed , and our present day concepts generally combine several of
these theories.
THE OCCLUSAL SCHOOL : Kingsley stated that The occlusion of
teeth is the most potent factor in determining the stability in new
position.

Marielle Blake stated that Adequate inter incisal angle and good
posterior intercuspation are essential to prevent relapse.

THE MANDIBULAR INCISOR SCHOOL:

Grieve and Tweed suggested

that Mandibular incisors must be kept upright and over basal bone.
THE MUSCULATURE SCHOOL :

Rogers introduced a consideration for

necessity of establishing proper functional muscle balance for stability.

THE APICAL BASE SCHOOL: In 1920 Lundstorm

suggested that The apical base was one of the most important factors
in correction of malocclusion and maintenance of correct occlusion.

Mc cauley suggested that Inter canine width and inter molar width
should be maintained as originally presented to minimize retention
problems.

Nance noted that Arch length may be permanently increased only to

a limited extent. ….
 BASIC THEORIES OF RETENTION
THOMAS G GRABER and ROBERT L. VANASDRALL.
THEOREM 1:Teeth that have been moved tend to return to their formal
positions.

Discussion: There is little agreement as to the reason for this tendency,

the suggested influences include,
1. Musculature .
2.Apical base.
3.Trans septal fibres.
4.Bone morphology.
THEOREM 2:Elimination of the cause of malocclusion will prevent
recurrence.

Discussion: Abnormal habits like Tongue thrusting , Thumb sucking ,

Mouth breathing , lip biting habits should be corrected to prevent
relapse.
THEOREM 3: Malocclusion should be over corrected as a safety
factor.

Discussion: It is a common practice to over correct

1. Class II malocclusions to edge to edge incisor relation.
2.Class III malocclusion .
3.Deep over bite .
4. Rotations ( there is no evidence to indicate that over
rotation is successful in preventing relapse).

THEOREM 4: Proper occlusion is a potent factor in holding teeth in

their corrected positions.

THEOREM 5: Bone and adjacent tissues must be allowed time to

reorganize around newly positioned teeth.
Discussion: Histological evidence show that bone and tissue around
the teeth which have been moved are altered and considerable time
elapses before complete reorganization occurs.
THEOREM 6: If the 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 the tooth have been moved , the less the
likely hood of relapse.

THEOREM 9:Arch form particularly in the mandibular arch cannot be

permanently altered by appliance therapy.

Discussion: Therefore ,treatment should be directed towards maintaining

the archform presented by original malocclusion. Dallas Mc cauley made
the following statement since these two mandibular dimensions, Molar
width and cuspid width, are of such an uncompromising nature , one
might establish them as fixed quantities and build arches around them.
WHY IS RETENTION NECESSARY?

According to proffit 3 major reasons for necessity

of retention.

1. Gingival and periodontal tissues are affected by

orthodontic tooth movement and require time for reorganization
when appliances are removed.

2.Teeth may be inherently in unstable positions

after treatment ,so the soft tissue pressures constantly produce a
relapse tendency.

3.Changes produced by growth may alter the

orthodontic treatment result.
CAUSES OF INSTABILITY OF ORTHODONTIC CORRECTIONS:

Stability is related to forces that act on teeth and hence

it is a neuromuscular problem, there are countless factors that affect
stability , some of the important factors effecting stability are :

a) Growth considerations and rotation of jaws.

b)Arch dimensions.

c) Incisor position.

d)Intra arch factors

.
e)Functional occlusion
GROWTH CONSIDERATIONS AND ROTATION OF JAWS IN STABILITY:
According to Bjork 1955, (Implant studies).

Mandibular rotations:

Anterior or Counter clockwise rotations.

Downward or clock wise rotations.

Anterior rotation or Counter clock wise rotation:
This type of rotation occurs due to
Upward and forward growth of condyles.

Treatment goals in these patients :

•Maintain normal Over jet and overbite with fulcrum point at

incisors.

• Inter incisal angle not too obtuse, and lower incisors not too
upright and proper amount of torque in maxillary incisors.

•Bring the Mandibular dentition forward on the jaw base and

maintain anterior teeth in their forward positions (to prevent
secondary crowding).
Downward and backward rotation :
This type of rotation is associated with upward and
backward condylar growth.

Features: Tendency for Late lower crowding ( since lower incisors

erupt more vertically with tendency for retroclination).

Retention Protocol : Long term stabilization of lower incisors is

absolutely necessary.

In patients with more pronounced forward rotation of jaws there is

natural tendency to become more class II with time

 CLINICAL CONSIDERATIONS:
Selection of retention appliance is based on growth
pattern and Duration based on Maturation status of patient and
anticipated future growth.

In individuals with short face syndrome with continued growth after

treatment require dentoalveolar compensations ( anterior bite plate)
during retention phase until maxillo Mandibular growth is completed.

Whereas in long face syndrome patients require high pull head gear to
hold the positions of molars to prevent further dentoalveolar growth.

Individuals having deep bite are usually late maturers than open bite
patients , so they require longer retention periods until their pubertal
growth spurt is completed.
ARCH DIMENSIONS:
Mandibular dimensions decrease over time in both
treated as well as untreated malocclusions , this is a normal physiological
phenomenon , this includes

a )Reduction in arch length and arch width .

Several clinical guide lines are suggested,

1.Avoid enlargement of lower arch unless mandated by facial profile

concerns or to harmonize the occlusion with maxillary palatal expansion
accomplished for cross bite correction or unusual narrowness.
2.Use pretreatment arch form as a guide to arch shape.
3. Treat to ideal standards of perfection to obtain the best possible
occlusion , oral health and function.
4.Retain the arch form long term, and continue to monitor patient
response into and throughout adult life.
INCISOR POSITION:
In order to establish stable position of incisors
number of dogmas have developed , the three commonly stated dogmas
are,
A) First dogma states that , Most stable position for lower
incisor is a Cephalometric mean ( IMPA of 90 deg with standard
deviation of 5).

B)Second dogma states that Best position of lower incisor is its

original position i.e. (original malocclusion position).

C) Third dogma states that there is only one stable position of

lower incisor.
TWELVE KEYS TO STABILITY OF LOWER INCISORS:
MARIELLE BLAKE , NANDA AND BURSTONE.
1.Whenever possible allow the lower incisors to align themselves either
through serial extraction or the use of lip bumper in early mixed
dentition.

2.Over correct lower incisor rotations as early in treatment as possible.

3.Reproximation of incisors early in treatment and again at retention

enhances stability.

4.Avoid increasing the inter canine width during active treatment.

5.Extract bicuspids in cases where mandibular arch discrepancy is 4mm

or greater ,except where facial esthetics dictate otherwise.

6.Recognize that the more the tooth is moved , the more likely it is to
relapse , and over correct accordingly.
7.Upright lower incisors to at least 90deg whenever the profile
permits.

8.Create a flat occlusal plane during treatment and overcorrect the

overbite.

9.Prescribe supracrestal fiberotomy for severely rotated teeth.

10.Retain the lower arch until all growth is completed.

11.Place the retainers the same day , the appliances are removed.

12. Recognize that, compromise is often necessary in the interest of

facial esthetics and that sometimes life time retention is necessary.
INTRA ARCH FACTORS :
Intra arch factors causing relapse can be
attributed to Soft tissue pressure (cheek, lip, and tongue) and elastic
recoil of gingival fibers.
Teeth tend to move back in the direction from which they come
primarily because of elastic recoil of gingival fibers and unbalanced
tongue and lip forces.

These problems can be minimized by

Early correction of rotations and other types of tooth to tooth alignment.

Fibrotomy may be helpful but should not replace procedures of early

treatment and over correction.

Reshaping the contact areas so that the force can be better distributed
throughout the arch.
FUNCTIONAL OCCLUSION :
The Success of orthodontic patient
cannot be evaluated in centric occlusion alone , but centric relation
must be achieved .
Study conducted by Beyron in Sweden suggested that

Patients who exhibited multi directional chewing ( patient chewing

right ,left and protrusive) shows minimal migration of teeth.

Patients showing bilateral chewing there was migration in bicuspid and

cuspid region.

Patients that were saggital chewers (Easily protruding the jaws but
locking them laterally ) tend to show flaring of upper incisors.
WHEN DOES RETENTION PHASE BEGIN ?
NANDA AND BURSTONE:
Ten criteria must be met in order for a case to be
deemed ready for retention, these are as follows,

1. Coincidence of centric relation and centric occlusion.

2.Class I cuspid relation and normal cuspid function.
3.Maintenance of mandibular cuspid width.
4.Inter incisal angle close to normal, with proper torque in both
maxillary and mandibular incisors.
5.Normal anterior overjet and overbite.
6.Normal buccal overjet.
7.Leveled upper and lower arches.
8.All spaces closed , all rotations eliminated.
9. Roots parallel near extraction sites.
10.Cusp inter digitation.
CLINICAL APPLICATIONS:
Retention planning is divided into
three categories depending upon the type of treatment instituted .

1.No retention required:

a) Corrected cross bites:
1. Anterior cross bite when adequate overbite has been established.
2.Posterior cross bite where axial inclinations of posterior teeth remain
reasonable after corrective procedures have been completed.
B) Dentitions treated by serial extraction:
1. High cuspid extraction cases.
2.Occasionally the extraction of one or more teeth( as in subdivision
types of malocclusion).
C) Corrections achieved by retarding maxillary growth
whether skeletal or dental.
D) Dentitions in which maxillary and mandibular teeth have been
separated to allow for eruption of previously blocked out teeth, usually
partially impacted mandibular second bicuspids and maxillary canines.
MODERATE RETENTION: Most typical orthodontic cases
probably fall into this category.
1. Class I non extraction cases characterized by protrusion and
spacing of maxillary incisors, they require retention until normal lip
and tongue function has been achieved.
2. Class I and class II extraction cases probably require that teeth to
be held in contact , particularly in maxillary arch until lip and
tongue functions can be achieved
3.Corrected deep overbites, either in class I or class II malocclusions
4. Early correction of rotated teeth to their normal position (perhaps
before root formation has been completed.
5. Cases involving in ectopic eruption of teeth or the presence of
supernumerary teeth.
6. Class II div 2 type of corrected malocclusion generally require
extended periods of retention to allow for adaptation of musculature.
These cases allow for some increase in mandibular inter canine
width which is maintained out of retention.
PERMANENT OR SEMIPERMANENT RETENTION:

1. Cases in which expansion has been choice of treatment ( particularly

in the mandibular arch) may require permanent retention or semi
permanent retention to maintain normal contact alignment.

2.Cases of considerable or generalized spacing may require permanent

retention after space closure has been completed.

3.Instances of severe rotations ( particularly in adults) and severe

labiolingual mal position some times require permanent retention.

4.Spacing between maxillary central incisors in other wise normal

occlusions some times require permanent retention.
 RELAPSE:
Definition :Enlow defined relapse as A histogenic and morphogenic
response to some anatomic and functional voilation of an existing
state of anatomic and functional balance.

The changes and problems that arise after the most active orthodontic
treatment fall roughly into three groups,

1.Phase one changes.

2.Phase two changes.

3.Phase three changes.

PHASE ONE CHANGES ( IMMEDIATE POST TREATMENT CHANGES)
These changes are those occurring in first few weeks , largely as a
result of band and arch wire removal, the problems encountered are
closure of band spaces and settling of occlusion. Management in this
phase usually with Tooth positioner ( elastic or semi elastic).
Occlusal equilibration is done in this phase to eliminate cuspal
interference
SECOND PHASE (SHORT TERM CHANGES): These are succeeding
changes possibly unfavorable, in response to tissue tensions and
unbalanced functional relationships, these occur in first few months
of following treatment and may even persist for year or two.

These include Rotations, Spacing , Crowding, cross bites(anterior or

buccal), overbite etc to reoccur after correction. The appliances
commonly used in this phase are :
Usually a removable retainer in upper arch and fixed lingual retainer
in lower arch.
 THIRD PHASE (LONG TERM CHANGES):This phase begins roughly
one to three years after intensive therapy.
These are due to post treatment growth or persistent habits or
dysfunction's with life time effects , these are the problems that may be
unrelated to prior orthodontic treatment are often incurable but usually
benefit from careful management.
These problems fall in to three classifications.
1.Residual treatment problems.
2. Growth.
3.Function ( including habits).

1.Residual treatment problems include,

a) Over optimistic diagnosis ( like over expansion) .

b) Incomplete treatment (e.g. incomplete correction of

class II molar relationship)
2.Growth changes:
These are changes in growth that cause problems after treatment

1. skeletal class II or class III malocclusions corrected

before the growth completion.

2.Lower incisor crowding due to late mandibular growth.

3. Functional aberrations:
Irregularities in function include situations like,

Bruxism, Tongue thrust, lip biting

These largely unconscious habits are seldom amenable to dental

measures alone.
Third phase Treatment:

This includes,

1.Extra oral anchorage (to control continuing class II tendencies) .

2.Mandibular osteotomy for extreme prognathism.

3.Molar extractions ( mainly lower 3rd molar extractions)

4.Bruxism guard (for night grinding patients)

5.Vestibular shield ( to curb mouth breathing or lower lip habits).

CONDITIONS PRONE FOR RELAPSE:
The conditions more liable for relapse can
be divided according to 3 planes of space,

1.SAGITTAL PLANE.

2.VERTICAL PLANE.

3.TRANSVERSE PLANE.
RELAPSE IN SAGITTAL PLANE:
Sagittal corrections liable for relapse are:
•Class II corrections.

•Class III corrections.

•Molar distalization.

•Incisor retraction .

•Reopening of extraction spaces.

RELAPSE AFTER CLASS II CORRECTION:
Relapse after class II relationship can be result due to:
1.Tooth movement:(Short term problem):
2.Continued growth pattern:(long term problem-more important)
Differential growth of maxilla relative mandible.
Relapse tendency depend on:
1.severity of initial class II problem.
2.Growth remaining after orthodontic treatment
Procedures to overcome relapse due to tooth movement:
During active treatment: Over correction of occlusal relationships .
2.post treatment : Permanent retention of lower anteriors.
Methods to overcome relapse due to differential jaw growth:
A.By continuing head gear on a reduced basis in conjunction with a
retainer.
B.Functional appliances like activator or bionator with out
mandibular advancement can be used to hold tooth position and occlusal
stability.
RELAPSE OF CLASS II :

Growth related relapse in patient

treated to correct class II malocclusion.
RELAPSE OF CLASS III CORRECTIONS:
Cause :
1. Due to late mandibular catch-up growth.

2.Skeletal class III corrected by hinge opening of mandible.

Stable result for class III correction can be expected by

A) Surgical correction.

B)Antero-posterior tooth movement than by rotating the

mandible.

Methods of retention:

With functional appliances or positioner to maintain occlusal

relationship.
RELAPSE AFTER MOLAR DISTALIZATION:
Molar distalization is mainly accomplished in non
extraction therapy.

Causes for relapse:

A) Distalization achieved with distal crown tipping.

B) Inadequate retention after distalization.

Methods to minimize relapse :

1.Bodily movement of molars.

2.After molar distalization is achieved the molars should be held in
place with passive appliance or with TPA for 4-5 months before space
closure .
3.Distalization prior to second molar eruption .
REOPENING OF EXTRACTION SPACE CLOSURE
Guide lines to prevent extraction space reopening:

•Space closure by bodily movement of surrounding teeth( root parallelism)

•Remove any wedging force from opposing teeth.

•Bring about proper contact area and not contact point between the teeth.

•Using a retainer that does not have occlusal cross over( wrap around
retainer)
RELAPSE IN VERTICAL PLANE :

Vertical corrections liable for relapse are ,

1. Open bite corrections.

2. Deep bite corrections.

RELAPSE OF OPEN BITE CORRECTIONS:
Open bite malocclusion can be either
Skeletal or Dental.
Relapse of Dentoalveolar open bite correction can be mainly due to
1. Elongation of molars
2.Depression of Incisors (due to persistent habits).
3. Combination.
Precautions to be taken are,
During active treatment ,
a)Parallelism of occlusal planes should be achieved .
B)Control of active habits.
Post treatment appliances for retention includes,
1.High pull head gear with conventional retainers .
2.Open bite activator or Bionator.

Surgical maxillary impaction (lefort 1 osteotomy) is shown to be stable

solution for skeletal open bites.
RELAPSE OF OPEN BITE CORRECTION:

Relapse due to Excessive eruption

of Maxillary posterior teeth causing
downward and backward rotation of mandible.
RELAPSE AFTER DEEP BITE CORRECTION:
Deep bite corrections can be achieved either by
1.Extrusion of molars .
2.Intrusion of anteriors.
During growth period:
1 Stable results can be achieved through extrusion of molars since
growth shall catch up with supra eruption of molars (class II div I or div
II)
After growth period:
1.Deep bite corrections after growth should be corrected with intrusion
anterior teeth.
2. Deep bite with powerful masticatory musculature associated with
decreased anterior facial height should be corrected with intrusion of
anteriors.
Appliances used for retention :
Upper removable retainer with bite plate (should not separate posterior
teeth) should be used till the late teens.
RELAPSE IN TRANSVERSE PLANE :

Corrections liable for relapse in transverse plane are:

1.Maxillary expansions.

2. Mandibular expansions.

3.Mid line diastema.

4.Rotational corrections.
RELAPSE AFTER RAPID MAXILLARY EXPANSION:
Expansion generated factors are the most potent
factors in causing relapse in short term .

Causes of relapse:

1.Stretching of soft tissues.

2.Deformation of hard tissues due to powerful forces built up by RME.

Methods to overcome relapse post expansion are,

1.Elastic recoil due to soft tissue stretch requires passive fixed

appliance at least 3 months after completion of active expansion.

2.Long retention periods are required for bone remodeling and repair of
collagenous connective tissue i.e. ( full time removable retention plate
for 9 months and after that can be reduced to half time wear up to
2.5 years)
RELAPSE AFTER MANDIBULAR EXPANSION:
Studies have shown that

1.Inter canine width show a decrease regardless of mechanics and

methods used.
2.Inter molar width decreases to pretreatment dimensions after retention.

Retainers used are :

1.Fixed lingual arch for maintaining the inter molar width is preferred.
MID LINE DIASTEMA CORRECTIONS:
Midline diastema correction is one of the
conditions requiring permanent retention.

METHODS TO PREVENT RELAPSE AFTER MIDLINE DIASTEMA

CORRECTION:

1.Frenectomy procedures.( removal abnormal frenum)

2.Elimination of abnormal habits( using fixed tongue cribs)

3.Permanent retention of upper anteriors.

 RELAPSE OF ROTATIONAL CORRECTION:
Some of the most popular philosophies for retention of rotated teeth are
the following:

(1) rotations must be corrected by over rotation in the opposite direction;

(2) Rotated teeth must be retained over an especially long period of

time, preferably with a fixed retainer;

(3) Treatment of rotated teeth must be performed at an early age;

(4) Any rotational technique which produces sufficient amounts of

osteoid tissue in the root area will aid in retention of the rotated tooth;

(5) A properly equilibrated occlusion will practically eliminate retention

worries.
POST SURGICAL RELAPSE:
Primary etiological factors in surgical relapse include:

A) Stretching of muscles of mastication and supra hyoid musculature.

B) Condylar distraction during surgery.
C) Counter clock wise rotation of mandible.
D) Rotational positional changes between the proximal and distal
segments.

Numerous fixation techniques have been

advocated to reduce relapse post surgically are,
• Upper and lower border wiring of the mandible.
• Steinmann pins to stabilize the mandible.
• Skeletal wire fixation.
• Rigid fixation.
Various post surgical therapies have been advocated include,
•Supra hyoid myotomies.
•Cervical collars (to reduce muscle tensions after surgery)
CONCLUSIONS FROM VARIOUS STUDIES FOR
POST SURGICAL RELAPSE.
1) Maxilla was relatively stable for both fixation techniques, remaining
with in 1 mm of its post surgical position both horizontally and vertically.
2) Rigid fixation tends to improve maxillary stability primarily by
limiting relapse to less than 2mm.
3) Mandibular length was significantly more stable in rigid fixation
sample.
4)Rigid fixation produced significantly better control of the angulation
between the proximal and the distal segments.
5) The important difference in stability between wire fixation and rigid
fixation is that in rigid fixation the net changes are in anterior direction
direction rather than posterior direction compared to wire fixation.
6)Saggital split osteotomy was greater prone for relapse than transoral
vertical ramus osteotomy.
7)Mandibular advancements greater than 10 mm showed less stability.
METHODS AIDING IN RETENTION:
Various procedures and methods aiding in
retention are :
1.NATURAL MEANS

2.MECHANICAL PROCEDURES

3.SURGICAL PROCEDURES.

.
RETENTION BY NATURAL MEANS:
These include,

1.Moving teeth into position of stable static equilibrium where they

exist in a state of minimum potential energy.

2.Correct root torque to ensure root parallelism.

3.Occlusal equilibrium..

4.Over correction of malocclusion.

5.Reshaping of incisors and restoration of contacts.

KEYS TO LOWER INCISOR RETENTION:
Raleigh Williams after extensive study to achieve
post treatment stability in the lower arch has given six treatment keys
to eliminate lower incisor retention.
FIRST KEY:
The incisal edge of lower incisor
should be placed on the A-P line or
1mm infront of it.
This creates optimum balance of soft tissue in lower third of face.
SECOND KEY:
The lower incisor apices should be spread distally to the crowns more
than is generally considered appropriate and the apices of the lower
lateral incisors must be spread more than those of the central incisors.
THIRD KEY: The apex of the lower
cuspid should be positioned distal to the
crown. The occlusal plane, rather than the
mandibular plane, should be used as a
positioning guide.

FOURTH KEY:
All four lower incisor apices must be in the
same labiolingual plane.

FIFTH KEY:
The lower cuspid root apex must be
positioned slightly buccal to the crown apex

SIXTH KEY:
The lower incisors should be slenderized as
needed after treatment.
MECHANICAL PROCEDURES OF RETENTION:
Mechanical means to achieve retention is by,
Retainers.

RETAINERS ARE CLASSIFIED INTO

1. Removable retainers.

2.Fixed retainers.

3.Esthetic retainers.
REMOVABLE RETAINERS:
The ideal removable retainers should be,
•Able to allow functional occlusion.

•Sturdy enough to with stand long term use.

•Convenient for the orthodontist to provide and maintain.

•Patient friendly in comfort and for routine wear.

Removable retainers can be effectively used for,

• Retention against intra arch instability.

•In patients with growth problems (in the form of modified functional
appliances or part time head gear)
HAWLEY RETAINERS:
Hawley retainer is the most commonly used
retainer , designed in 1920.

STANDARD APPLIANCE:

•Consists of labial bow with loops

from canine to canine.
•Adams Clasps on molars.
•Acrylic palatal coverage in upper arch.
•Because it covers the palate, it
automatically provides a potential
bite plane to control overbite.
MODIFICATIONS OF HAWLEYS
APPLIANCE:
Many modifications were performed for
various purposes,
1.Hawleys with bite plate (to control
bite depth).
2.Hawleys with labial bow soldered to
clasps on molars( to prevent reopening
of extraction space).
3.Hawleys with labial bow wrap around
entire arch with C clasps on second molars
( to prevent reopening of extraction space)
4.Tooth born Hawleys appliance ( without
acrylic by Lawrence Jerrold).
5. Hawleys with modified loops (Ali A
Bahreman .( in cases of cuspid rotational
tendencies)
REMOVABLE WRAP AROUND RETAINER:
This is the second most commonly used removable retainer.
Consists of plastic bar ( usually wire reinforced) along the labial and
lingual surfaces of teeth.
Indications:
1.Primarily when periodontal break down requires splinting the teeth
together.
2. Used mostly in premolar extraction cases
Disadvantages over hawleys :
1.Individual tooth movements are not allowed to stimulate periodontal
reorganization.
2.Less comfortable.
SPRING RETAINER APPLIANCE: (Active retainer)
It is a versatile appliance which can be used as ,
1.Anterior retainer in either arch.
2. Can be used as active appliance to re align incisors (post relapse)

Components : single piece of resilient spring wire (.022 to .029)

with the ends overlapped in the midline on
the lingual side of the teeth.
Acrylic covering labial and lingual surfaces of 4 mm width
from 2-2.
 REMOVABLE PLASTIC HERBST RETAINER:
It has property of both single arch
and dual arch retainers.
Components:
upper and lower plastic splints.
connected on each
side by the telescoping Herbst
mechanism.

Can also be used as:

• Finishing appliance .
•Re treatment appliance.
•Post surgical retainer.
•Aid for obstructive sleep apnea.
•Anterior repositioning splint for Tmj disorders.
CROAZAT APPLIANCE: ( 4-4 APPLIANCE)

Components: Labial bow,

Re curved double-lapping lingual finger springs.
Cribs on 1st bicuspids.

Advantages: Firm retention, flexibility, Good labiolingual control,

Esthetics and Good oral hygiene.

Disadvantages: Expensive , require quality laboratory,

Breakable.
NON ACRYLIC REMOVABLE RETAINER:
(sarhan)

Components:
0.9 mm wire adapted to gingivo palatal surfaces of teeth.
Adams clasps on molars
U loops soldered to adams clasp
.
Advantages:
•Simple in design and construction
•Can be used in patients sensitive to acrylic resin.
TOOTH POSITIONERS AS RETAINERS:
Tooth Positioners can be used as removable
retainers.They should be worn at least 4 hrs
u daytime and full night time wear.
Problems:
•Difficulty in wearing the appliance due to its bulk.
• Difficulty in retaining incisor irregularities and rotations and
overbite corrections due to poor patient cooperation.
Advantages:
•Can be effective in maintaining occlusal relationships and intra
arch tooth positions.
Fabrication: It is necessary to separate the teeth by 2-4 mm ,
Articulator mounting that records patients hinge axis is
desirable.
•Positioner made with incorrect hinge axis leads to separation of
posterior teeth when incisors are in contact.
 ESTHETIC RETAINERS:
Essix retainer:

These are thermoplastic co polyester vacuum formed retainers.

Advantages:
1.Esthetic and absolute stability of anterior teeth.
2.Less expensive, good durability, oral hygiene maintenance.
3 Less bulk and thickness (0.015 inch).
Drawbacks:
•Cannot be used for expanded arches.
•Prolonged use can cause anterior open bite.
•Less durable when compared to Hawley retainer.
 FIXED RETAINERS:(BONDED).
The various forms of fixed bonded retainers
allow more differential retention than before,

ADVANTAGES OF BONDED RETAINERS :

1.Completely invisible from front.

2.Reduced risk of caries under loose bands.
3.Reduced need for long term patient cooperation.
4.Prolonged semi permanent and even permanent retention when
conventional retainers do not provide the same degree of stability.
MAJOR INDICATIONS OF FIXED RETAINERS

1. Maintenance of lower incisor

position during late growth

2. Diastema maintenance

3. Maintenance of pontic or implant

space

4. Keeping extraction spaces closed

in adults.
Various types of retainers and splints are available
the most commonly used bonded retainers are,

1.Mandibular canine-to-canine(3-3) retainers.

2.Flexible spiral wire retainers.
MANDIBULAR CANINE-TO-CANINE REATINERS:
In differential philosophy the purpose of a
bonded 3-3 retainer is
A)To prevent incisor re crowding.
B)To achieve lower incisor position in space.
C)To keep the rotation center in incisor area when Mandibular
anterior growth rotation tendency is present.

These are grouped into

1.First generation retainers
2.Second generation retainers.
3.Third generation retainers.
FIRST GENERATION 3-3 RETAINERS:
The retainer is made of plain 0.032-0.036” blue Elgiloy
wire with loop at each terminal end
adapted to lingual surface of anterior teeth and
bonded to canines.
SECOND GENERATION 3-3 RETAINERS:
The plain Elgiloy was replaced with Twisted 3 stranded 0.032
inch wire.
Difficulties encountered were:
•Distortion due to lack of rigidity.
•Difficult to bend to optimal fit.
THIRD GENERATION 3-3 RETAINERS:
It is made of round 0.032 inch stainless steel
wire or 0.030 inch gold coated wire,
with ends sandblasted to
mechanical retention.
FLEXIBLE SPIRAL WIRE RETAINERS:
Indications
:
A)Prevention of space reopening.
• Median diastemas.
•Spaced anterior teeth.
•Adult periodontal conditions with potential for post
orthodontic tooth migration.
•Mandibular incisor extractions.

B)Holding the individual teeth .

•Severely rotated maxillary incisors.
•Palatally impacted canines.
FLEXIBLE SPIRAL WIRE RETAINERS:
ADVANTAGES:
1.They may allow safe retention of treatment results when proper
retention is difficult or even impossible with traditional retainers.
2.They allow slight movement of all bonded teeth and segment of teeth
3.They are invisible.
4.They are neat and clean.
5.They can be placed without occlusal interference.
6.They can be used alone or in combination with removable retainers.
DISADVANTAGES:
1.Good oral hygiene should be maintained.
2.Daily flossing should be recommended gingival to the wire.
3.Undesirable movement of bonded teeth may occur if the wire is too
thin or not passive while bonding.
4.Not indicated in deep bite cases where wire cannot be placed out of
occlusion.
FLEXIBLE SPIRAL WIRE RETAINERS:(CONT)

Maxillary 4-4 bonded Maxillary 3-3 bonded For holding

spiral retainers. spiral retainer. Mid line diastema
correction.

New design flexible spiral

wire retainer with v loops to floss into Mandibular 3-3 and 4-4 spiral wire
interproximal gingival crevices, retainer.
DIRECT BONDED LABIAL RETAINER:
Direct bonded labial retainers are indicated in,
1.Inability to prevent some space reopening in closed extraction
sites in adults.
2.A tendency of lingual relapse of previously palatally impacted
canines.
3.Space reopening when molars and premolars had been moved
mesially in cases with previous excessive space.

Short labial retainer bonded Long labial retainer bonded

over 1st premolar extraction over 1st molar extraction site.
site.
SURGICAL PROCEDURES AIDING IN RETENTION:
Most common surgical procedures employed
to aid in retention are,

1.Frenectomy procedure ( to remove abnormal frenum

preventing diastema closure).

2.Circumferential supracrestal fibrotomy ( to prevent

rotational relapse).
 FRENECTOMY PROCEDURE: Frank o clifford.

Abnormal frenal attachment Incisions are made on the left and right of the frenum
and parallel to the long axis of the teeth
.

Incised section of
frenum is removed
Horizontal incision from the lingual from between the incisors.
Incision from the labial
following the two vertical cuts.
joining the previous incisions.
ADJUNCTIVE PERIODONTAL SURGERY TO
PREVENT ROTATIONAL RELAPSE:
1.CIRCUMFERENTIAL SUPRACRESTAL FIBROTOMY (CSF):

In 1970, Edwards reported on a simple and apparently efficacious

surgical technique to alleviate the influence that the supracrestal
periodontal fibers ( gingival and transeptal fibers) presumably have on
rotational relapse.

Campbell, Moore, and Matthews termed the procedure a

circumferential supracrestal fiberotomy (CSF) procedure.

It is recommended at the time of appliance removal or just before the

time of appliance removal.
CSF procedure was shown to be more successful in reducing relapse in
maxillary anterior segment than mandibular anterior segment.
CSF PROCEDURE:
Under LA using no 11 BP blade is inserted into gingival
sulcus to sever epithelial attachment surrounding the
teeth.
Blade also transects transseptal fibers by interdentally
entering into PDL space.
Transection of more coronal
transeptal fibers is indicated.
No surgical dressing is indicated and
clinical healing completed in 7 to 10 days

CSF is not recommended in Level approximately 2 to 3 mm. Below

alveolar crest to which incision is extended
a) During active tooth movement
B) Gingival inflammation
because of unpredictability of regeneration of
.
epithelial attachment in these situations.
SUMMARY :
In order to avoid relapse , the following are often recommended

1.Lengthier retention periods (Parker, 1989: Nanda and Nanda, 1992)

2.Elimination of causes of malocclusion (Habits) . (Joondeph,2000).
3.Over correction of malocclusion. (Reitan, 1967)
4.Accomplishment of treatment during growth (Vaden 1994;Harris,1999)
5.Maintenance of original arch form. (Stead man 1961)
6.Moving teeth into a position of stable static equilibrium (Salzmann 1965)
7.Gingival surgery to transect supracrestal fibers in rotated teeth.,Edwards
8.Surgical removal of excessive tissue folds at gingival papillae.(Edwards)
9.Reshaping incisors and restoring contacts (Peck and peck 1972; Watson1979
10.Correct root torque to ensure root parallelism (Watson1979,Heasman,1996
11.Occlusal equilibrium.(Kahl-Nieke 1995 )