Fall 2000 New Member Forum

Dr. Kami Hoss

In our office, the protocol for retention varies depending on the specific kind of retainer the patient has received. The design of the retainer itself is based on several factors, including but not limited to: initial malocclusion, specific orthodontic treatment, the patient's esthetic concerns, oral hygiene, periodontal condition, and phase of treatment.

Following the first phase of treatment, a lingual holding arch is typically placed to maintain arch length. In addition, depending on the kind of skeletal correction that has occurred, a maxillary retainer may or may not be used. (For example, an arch holding appliance following an RPE.) During this phase, removal retainers are not worn for long, but lingual arches are usually kept until patients are ready for their second phase of treatment. Meanwhile, we evaluate patients every four to six months and do not charge for these visits.

Patients who have been treated with esthetic appliances (clear brackets, lingual brackets, Invisalign) typically receive a maxillary "Essix" retainer and a manidubular fixed bonded retainer. The majority of our patients, however, receive a maxillary wrap and a mandibular anterior fixed retainer. The fee for one set of retainers and one year of retention is included in the total treatment fee. During the first year post-treatment, patients are seen three times (eight weeks, six months, and one year), and are only charged for broken appliances and/or replacements. After the first year, they are inactivated and are only seen when necessary, for which they are charged for each office visit in addition to any repair/replacement fees.

When a case requires some kind of active tooth movement after brackets have been removed, several options are available depending on the severity and the cause of the problem. If the movement is minor and is limited to the anterior teeth, we usually use a removable aligner. For more significant movements, tooth positioners or fixed appliances are used to achieve ideal results. If these dental changes (or relapses) occur during the first year post-treatment, usually patients are not charged unless the tooth movements are caused by poor cooperation with retainers. However, if minor dental changes have occurred years after their orthodontic treatment, we charge a fee for retreatment. We tell our patients that once retainers are discontinued, there may be minor changes in tooth position. We also explain that the position and fit of teeth change continually throughout life, both with and without orthodontic treatment.

Dr. Bridget M. Powers

The retention protocol in our office is as follows:

Appliances are completely removed and impressions taken for retainers. One week later the retainers are delivered. Patients are instructed to wear retainers full time. The first follow-up visit is in six to eight weeks. If the teeth are holding well and compliance is good, nighttime wear is recommended. The next visit is six months later, when we evaluate the stability of the result.

If everything has held well, patients are instructed to continue retainer wear indefinitely. Some may wear retainers just at night to hold the correction, paying specific attention to the lower incisors. We caution our patients that long-term commitment to the retainers is required to maintain the result. We generally deliver invisible retainers, since retention and compliance are excellent. This appliance selection can also protect the enamel from wear if bruxism is present. We deliver lower fixed retainers to patients who exhibit moderate pretreatment rotations and who demonstrate excellent hygiene.

A relatively small percentage of patients receive positioners. After the desired result has been achieved, final records are taken and retainers fabricated with the same instructions. At the completion of approximately one year of orthodontic correction and retention checks, the patient "graduates" and is dismissed from the office with a healthy, happy smile!

Dr. Bernard Chang

We all know that treatment does not end upon delivery of the retainers. In fact, it often seems like we are just beginning! In our office, retention protocol is based on the initial problem with which the patient presented.I like to use a Hawley type retainer on most patients. One variation I use is Crozat clasping on the first molars whenever possible. It provides better retention and also gives me the flexibility to use interarch elastics off the retainers when necessary. One problem that we all encounter is patient noncompliance with retainer wear. Therefore, I prefer to use fixed lower retainers. If the patient started out with significant crowding in the lower arch, I like to bond a lingual wire on each tooth 3-3 with Unitek's twist lingual wire. If there is minor crowding, I will use a lingual wire 3-3, but only bond the 3s.

Just recently I have started using "suck down" retainers with the Biostar machine. After trying various materials, I have found that Great Lakes Invisacryl C (.040) material and Raintree Essex materials work well. There are several benefits: Patients seem to be more compliant with these retainers, which offer comfort, less speech impairment, and pleasing esthetics. We make these retainers at the time of debanding so there is no turnaround time from the lab. And, they are very cost effective.

Patients who have diastemas associated with large frenums are referred to a periodontist for a frenectormy. When possible, this procedure is done just prior to debanding. We also use the periodontist to perform a circumferential fiberotomy on adult patients who have severe rotations of the upper anterior teeth. I believe these two procedures enhance the retention process.

In the past I have instructed my patients to wear their retainers 24 hours a day for six months after debanding. More recently I have decreased the full-time wear to one month or less, depending on the initial problem. Adults are asked to wear the retainers full time for 6 to 12 months depending on their situation.

I like to see the patients for the first retainer check six weeks after placement. This allows me to catch any minor relapse problems before they become too severe. After that, patients are usually seen at three months, six months, and one year. They are then dismissed from the practice. Before dismissal, I inform them that retention is a life-long process and that they are always welcome back for retainer checks.

Editor's Comment: 
Dr. Michael A. Sales

Retaining the achieved result at the conclusion of any stage of treatment is a fundamental aspect of good orthodontic care. I hope I am accurate in stating that every graduate orthodontic program teaches its residents to consider a retention plan when determining the intitial treatment - before any appliance has been placed. The option to modify the retention strategy is left open to reflect the needs of the patient when we actually conclude active treatment.

There is a broad array of thinking within the orthodontic community on this subject. I have heard respected clinicians claim they require no retention at all for most of their patients. Others say that the only sure bet is to have patients wear retainers for a lifetime. Because there is such a broad range of treatment modalities, goals, and clinical skill levels, treatment stability may well vary from one office to another. For this reason alone, I believe that it is important to watch cases over an extended period of time. The longer we follow our patients, the more information we will have regarding the stability of our cases. Another significant benefit of long-term observation is the insight we gain from seeing the cosmetic changes that take place over the years as our patients mature. I like to think that these observations help the practitioner gain "orthodontic wisdom."

Does the specific choice of retention appliance matter? I think it does. Do you want to place a fixed retainer on a patient with lots of decalicification and poor oral hygiene? Is it wise to place wire (clasps or bows) through areas of tight interdigitation or former extraction sites? Might the addition of posterior occlusal coverage be helpful in cases with a tendency toward anterior open bite? Can the incisal-gingival level of acrylic placement be altered to help control vertical as well as buccal/labial-lingual movements? Are "suck down" retainers counterproductive in cases with open bite tendencies?

Auxiliary springs can control many minor rotational concerns. A combination of fixed and removable retainers may be a good choice in a case where we want to prevent a diastema from reopening. Placement of an expansion screw may be useful in a maxillary retainer for cases that were expanded or had surgical maxillary widening. Bonding teeth that required considerable rotational correction to adjacent teeth, adding buccal or lingual buttons for extrusion stabilization, bite plates for bruxism, spring retainers for incisor control, positioners, and even head or neck gears can be part of a retention strategy.

Periodontal procedures can provide increased stability in some situations. Restorative care may also benefit cases with diastemas, poorly contoured, misshapen, or small crowns. The point is, the retention phase of orthodontic treatment will frequently determine the long-term benefit patients ultimately derive from our care. Careful consideration to and execution of the retention phase of orthodontic treatment will help reduce the risk that joyful short-term success will turn into agonizing long-term failure.

Orthodontics can be likened to the restoration of antique cars. It takes considerable time, effort, and cost to turn a car into a showpiece. You must then garage, polish, and maintain that vehicle to preserve its quality, functionality, and beauty. In orthodontics, we call that aspect "retention."

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