Retention maintenance—Conclusion

P. Emile Rossouw

The orthodontic retention period is often treated with lesser importance;

however, it is in this concluding presentation emphasized as a phase of great
importance to ensure long-term success. Recommendations are presented,
the present status reflected on and a brief look provided into the future with
possible additional management options to the continual changes observed
in our occlusions. (Semin Orthod 2017; ]:]]]–]]].) & 2017 Elsevier Inc. All rights
reserved.
If anyone would take my cases when they are Clinical treatment recommendations on
finished, retain them and be responsible the way to successful retention
afterward, I would gladly give them half the
The degree of dental arch changes such as arch
fee.—Hawley (1919)1
length reduction, constriction, and resultant
crowding is quite variable and unpredictable, but

T his Edition on Retention of Seminars in

Orthodontics hopefully will provoke significant
discussion as the topic of retention is addressed
during seminar discussions where the students of
orthodontics gather to ensure that this topic con-
tinues to develop, more research be contemplated
or conducted and clinical expertise shared.
The goal was to provide an overview of the
retention phase of treatment and how it should be
managed to ultimately obtain some form of sta-
bility of the dentition. There is ample evidence to
show that there will be continual changes taking
place over time. Long-term change and retention
is thus a fact of life, a biological occurrence and it
is natural to expect patients to return to a practice
with the request to perform some revision due to
changes that may have occurred as a result of no
retention, a retention regimen being stopped too
soon or no compliance to the retention protocol
following treatment.
However, to some patients, a very minor
change impacts on their quality of life. An
example of this long-term maintenance can be
seen in the following revision case (Fig.).
Division of Orthodontics and Dentofacial Orthopedics, University
of Rochester Eastman institute for Oral Health, Rochester, NY.
Address correspondence to P. Emile Rossouw, BSc, BChD, BChD
(Hons-Child Dent), MChD (Ortho), PhD, FRCD(C), Division of
Orthodontics and Dentofacial Orthopedics, University of Rochester
Eastman institute for Oral Health, 625 Elmwood Avenue, Rochester,
NY 14620. E-mail: emile_rossouw@urmc.rochester.edu
& 2017 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.12.012
it occurs longitudinally in both treated and
untreated malocclusions; a normal physiologic
process. The final result of these changes is often
expressed more specifically in the mandibular
arch; most often as irregularity in tooth align-
ment. An orthodontic philosophy or technique
equipped to deal with this phenomenon and
ultimately be conducive to stability should not
include only brackets and wires! Moreover, it
should include the followings:
(1) A complete orthodontic system that is
focused on
a. diagnosis and
b. a detailed treatment plan.
(2) It must obey the laws of nature, which
provide a limit or border for our treatment.
(3) Treat to ideal standards; utilize the con-
temporary clinical and radiological param-
eters to obtain the best possible occlusion,
oral health and function.
(4) Maintain lower arch dimensions whenever
possible; consider enlargement only if a
narrow arch width with lingually tipped
teeth are due to a treatable etiologic factor,
if mandated by facial profile concerns or to
harmonize the occlusion with maxillary
palatal expansion for crossbite correction.
(5) Use the patient's pretreatment archform as
a guide for the future treated arch shape.
(6) Retain the archform long-term and con-
tinue to monitor patient response into and
throughout adult life.

Seminars in Orthodontics, Vol ], No ], 2017: pp ]]]–]]] 1

2 Rossouw

Figure. An example of long-term maintenance; revision or a Phase 3 where no retention was in place following
treatment. (A) An adult patient consults the author with a request to align the irregular lower incisors that seem to
have changed and is now causing an irritation to her tongue. The occlusion presents in a stable Class I relationship
with accompanying soft tissue health and harmony; in general, the average adult patient with good occlusion and
acceptable long-term physiologic stability. The research data showed that this is an acceptable long-term change;
however, our commitment to excellence is long-term care. Hence, evaluation of the occlusion and determination
of a concomitant treatment plan is recommended. (B) An evaluation of the morphology of the teeth showed the
followings: (1) Minor irregularity of the lower central incisors. (2) Maxillary incisors show enlarged lingual mesial
and distal ridges. (3) Upper palatal irregularity and especially the mesial and distal ridges match lower incisor
irregularly, in particular the buccal irregularity. (4) A Bolton tooth size discrepancy2 exists with the mandibular
anterior segment (canine–canine) fractionally larger compared to the maxillary anterior segment. (5) The Little
Irregularity Index3 measures a clinically very acceptable long-term result. (6) The treatment plan for this revision
or phase 3 was set to (a) focus on revision of the alignment and adjustment of the maxillary incisor palatal anatomy,
(b) lower interproximal enamel reduction to correct the Bolton discrepancy, and (c) clear aligner treatment
(Invisalign, CA) to provide alignment of the teeth. (C) The end of successful treatment following uncomplicated
clear aligner treatment (Invisalign). Note the corrected incisor palatal anatomy attained through enameloplasty
that allows the establishment of an ideal upper palatal to lower incisor relationship. This is a showcase of successful
long-term orthodontic care within the realm of physiologic stability. Note the difference in interincisor occlusion
between (B) and (C). Clear retainer options as discussed instigated. (Adapted with permission from Rossouw.4).

(7) Obtain the highest quality pretreatment
records to ensure proper diagnosis and treat-
ment planning; moreover, also pursue quality
posttreatment records and continue to use
them to assess patient progress and more
importantly, evaluate personal clinician growth
in the establishment of better treatment,
enhanced retention, and ultimately stability.
(8) Consider a Phase 3 of long-term care or
maintenance to ensure physiologic stability.
(9) Patients have the reasonable expectation
that their well-aligned teeth following treat-
ment will be maintained. Since change, to a
minor or a major degree, will occur in both
treated and untreated cases, orthodontists
need to ensure that patients are well
informed of these changes.
(10) Long-term care with or without retention,
which allows for maturational changes; thus a
management phase to evaluate these
changes and incorporate the needed refine-
ments in the retainers where applicable.
(11) Relapse should be reserved for poor treat-
ment or lack of adequate cooperation
during treatment and also following treat-
ment in the retention phase.
(12) Revision thus may be needed due to
longitudinal physiologic changes. Patients
can choose the removable or fixed retainers
to provide artificial stability or enhance this
by a management phase where corrections
are maintained with or without retention as
another phase of treatment or dental care.
Patients thus can elect to continue to see
the orthodontist indefinitely if they so wish.
Consider this in the same manner as
patients consulting their general practi-
tioner for a prophylaxis.
 Retention maintenance 3

The existing status which individuals have mentioned as possibly

more stable over the short term. However, more
Patients seem mostly satisfied with their treat-
studies in this respect must be completed to
ment. Most individuals (88%) indicated that they
provide substantial evidence that is a future
themselves were responsible for maintaining the
possibility in our quest for less retention and
alignment and fit of their teeth. Those who
more stability. Bisphosphonates16 have been
indicated that someone else was responsible were
experimentally used to provide anchorage in
nearly twice as likely to be dissatisfied with their
laboratory animals. It is still difficult to maintain
teeth (p ¼ 0.0496).5 Longer retention seems to
this in specific areas, but similar to the RAP this
be more beneficial than shorter retention.6 Clear
also may be a future consideration in respect to
vacuum-formed retainers (VFR) such as the Essix
retention and stability. Rody and Wheeler17 refer
retainer are very popular with patients and
to the emerging field of biomarkers in oral fluids
clinicians today and these were shown to be
as well as tooth vibration technology which may
sufficient for maintaining the results after
hold benefits in both tooth movement and
orthodontic treatment and that night-time wear
retention. Clinical excellence may only be
appeared adequate.7 Similar results were also
limited by our imagination; thus, the future
reported by Lindauer and Shoff,8 Rowland et al.,9
may bring exciting adjunct treatment to
and Gill et al.10 Patients receiving VFRs seem to
complement our existing armamentarium.
be significantly more likely to be “very satisfied”
currently (50%) compared to those with Hawley
(35%) or permanently bonded (36%) retainers.5 Conclusion
The fixed retainer placed with good clinical
It is therefore important to audit the results of
technique and well-maintained proves to be
our own clinical work, as well as being aware of
successful to maintain alignment and robust long-
the results of high quality research. It is also
term.10 Compliance with wearing removable
important that the treatment plan is fully cus-
retainers was initially better with VFRs but over
tomized to the patient and meets their desires
time compliance proved to be greater with Hawley
and expectations. There may be many different
retainers, and esthetics was not a determinant.
factors that relate to a specific patient that may
Determination of compliance was influenced by
affect the retention plan. This may include the
such factors as age, gender, and type of retainer.11
patient's attitude to relapse, their ability or desire
Patients who were the happiest with their treatment
to clean around fixed retainers, financial impli-
also appeared to be those who accepted
cations of different retainer regimens, or will-
more responsibility in the wear and care of
ingness to remember to wear their removable
their retainers and thus should play a contrib-
retainers as instructed.
utory role in formulating orthodontic retention
One must ensure that the retainer is not only
plans. Needless to say, the literature as shown in this
fulfilling its role of maintaining stability, but also
edition of Retention indicate that the approaches
not causing any harm. It is the clinician's
to retention vary significantly across the world.
responsibility to advise the patient on the
The emphasis was to show why we need
importance of this long-term maintenance and
retention and note our current understanding of
how best to do this. It is the patient's responsi-
the best practice approach to maintaining a
bility to follow this advice.
stable result. We need more evidence to support
Relapse is unpredictable and is a result of post-
several aspects of retention.
orthodontic changes in the occlusion, but also
normal age changes. The use of long-term
retention may be the best approach to reduc-
The future
ing this relapse. The patient needs to continue
The future holds additional promise—Retention wearing retainers for as long as they want to keep
and stability may be enhanced by the accelerated their teeth straight.
tooth movement created by alveolar corticoto- It is envisaged that the information provided
mies, and in some instances combined with in this edition of the journal will serve to
osteotomies, in an effort to produce the so-called engender discussion, enhance the clinical out-
regional acceleratory phenomenon (RAP),12–15 come of treatment in the long term and serve as a
4 Rossouw
basis for further investigations by all students of
orthodontics.
The years teach much that the day never
knows—Ralph Waldo Emerson
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