ORIGINAL ARTICLE

Changes of bite force and occlusal

contacts in the retention phase of
orthodontic treatment: A controlled
clinical trial
Suzana Varga,a Stjepan Spalj,b Sandra Anic Milosevic,c Marina Lapter Varga,c Senka Mestrovic,c Magda Trinajstic
Zrinski,b and Mladen Slajc
Split, Rijeka, and Zagreb, Croatia

Introduction: We aimed to determine whether appliance type affects changes in maximum voluntary bite force
(MVBF) and the number of occlusal contacts (NOC) during retention, controlling for sex, age, and body mass
index. Methods: The sample comprised 176 examinees (70 male, 106 female) aged 14 to 20 years: 30 had
maxillary and mandibular Essix retainers, 30 had wrap-around retainers, and 30 had a combination of fixed
mandibular canine-to-canine retainers bonded on each tooth separately (double twisted, 0.254 mm in
diameter, stainless steel ligature wire) and Essix retainer in the maxillary arch; 86 with normal occlusion were
not treated. MVBF and the NOC were measured immediately after removal of preadjusted edgewise
appliances (Roth prescription), 6 weeks after that, and after the next 4 weeks. Results: Increases in MVBF
and the NOC were demonstrated, but subjects with 2 Essix retainers showed lower values than did the others.
Changes were related to type of appliance, sex, and age (P \0.05) but not to body mass index. The increase in
NOC occurred faster than the increase of MVBF, more and sooner with the wrap-around retainer and in male
subjects than with the Essix and in female subjects. MVBF and NOC nearly reached the values of the control
subjects. Conclusions: Settling of the occlusion depends on appliance type: it takes longer in female patients
and with Essix in both dental arches than with the other tested appliances. (Am J Orthod Dentofacial Orthop
2017;152:767-77)

A
phase of retention after orthodontic treatment
is imperative to allow the reorganization of peri-
odontal fibers, minimizing changes in the
achieved tooth positions due to growth, and to enable
neuromuscular adaptation to the new occlusal situa-
tion.1
a
Department of Orthodontics, School of Medicine, University of Split, Split,
Croatia.
b
Department of Orthodontics, School of Medicine, University of Rijeka, Rijeka,
Croatia.
c
Department of Orthodontics, School of Dental Medicine, University of Zagreb,
Zagreb, Croatia.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Supported by the Ministry of Science, Education and Sports of the Republic of
Croatia (project number 065-0650444-0436) and the University of Rijeka (grant
number 13.06.2.1.53 to Stjepan Spalj).
Address correspondence to: Magda Trinajstic Zrinski, Department of Orthodon-
tics, School of Medicine, University of Rijeka, Kresimirova 40, Rijeka-51000,
Croatia; e-mail, magda.zrinski@medri.uniri.hr.
Submitted, April 2016; revised and accepted, March 2017.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2017.03.028
There is no consensus on the duration of the reten-
tion period. Although it has been shown that on average
232 days are needed for the reorganization of peri-
odontal and gingival fibers,2 sometimes a long-term
relapse can occur even after following this recommenda-
tion.3 Thus, some clinicians prolong the retention period
and sometimes opt for permanent retention.4 In addi-
tion to these undesirable effects, positive movement of
teeth during retention also occurs in the form of settling
of the occlusion, which leads to better intercuspation
and masticatory function.5 Research has shown that
the number of occlusal contacts may increase during
the retention period6,7 and that the choice of retention
appliance may affect settling.4 The wrap-around
retainer is advantageous for settling due to the absence
of retentive elements that reach across the occlusal sur-
faces or contact points; its downsides are proneness of
its wire to deformation8 as well as discomfort. The Essix
retainer is a removable thermoplastic appliance that is
well accepted by patients, and it is used more often
because of its hardness, esthetics, size, and
767
768
affordability.8 However, it may not allow for settling of
the occlusion,9 and it lacks the durability of acrylic re-
tainers.8,10 Fixed retainers bonded to anterior teeth are
esthetically more pleasing than removable retainers,
and patient compliance is a lesser issue.11 Accidental de-
bonding occurs in 6% to 20% of patients, depending on
the bonding technique and retention duration.12,13
During active treatment, the orthodontic appliance
does not completely allow for functional occlusion, since
groups of teeth may be tied together. After removal of
the appliance and setting disconnected teeth into func-
tion, slight movements of teeth occur. This process hap-
pens to achieve a balanced position in the oral
musculoskeletal environment. Changes are more pro-
nounced in posterior teeth; this improves masticatory
performance and efficiency in terms of capacity to grind
food. One indicator of the functional state and health of
the masticatory system is maximum voluntary bite force
(MVBF).14 Its values vary in accordance to the location of
measurement (highest at the first molar, lower at the in-
cisors).15 Various physiologic and morphologic factors
affect MVBF. It reaches its peak around the age of
12 years, stabilizing after 14,16,17 and then decreasing
after age 25 in women and after age 45 in men.18 In gen-
eral, men have higher MVBF than do women.14 There is
contradictory evidence on the effect of periodontal
health on bite force; some studies have shown that peri-
odontal status has little influence,19,20 whereas others
found that patients with chronic periodontitis have
decreased biting ability21 and that attachment loss re-
sults in reduced control of bite force.22 The number of
teeth and number of occlusal contacts are important
factors influencing MVBF.14 People with pronounced
horizontal craniofacial growth have somewhat higher
values of MVBF, and those with vertical growth have
lower values than do those with an average growth
pattern.23 On the other hand, no difference was found
in MVBF between children with long faces and those
with “normal” patterns.24
One factor that is usually investigated in studies of
bite force is body mass index (BMI), calculated according
to this formula: BMI 5 mass/height2 (kg/m2). Body
weight and height are considered possible factors that
could influence the value of MVBF.25-28 In obese
persons, a proposed underlying mechanism that
reduces muscle strength is the accumulation of free
fatty acids in skeletal muscular tissues.29 Also, a recent
study found reduced bite force in obese adolescent
boys.30 Although Linderholm and Wennstr€ om26 found
a positive correlation between MVBF and body height
and weight, some studies have shown low “correlations”
or the absence of correlation.25,27,28 Since some of the
aforementioned studies demonstrated that BMI can
December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Varga et al
influence MVBF, it would be useful to determine
whether BMI also affects the number of occlusal
contacts, the other parameter that can be measured
during settling.
Modern electronic instruments measure MVBF based
on electric resistance of the material under tension.14
Bilateral measurement results in higher values of bite
force than does unilateral measurement.31,32 It is
believed that a protective mechanism causes forces
produced and recorded by masticatory muscles not to
be of the same magnitude during unilateral and
bilateral measurement due to inhibition caused by
receptors in the periodontium and temporomandibular
joints.32
On the other hand, quantitative assessment of
occlusal contacts can provide useful information about
the distribution of bite forces in the dental arches.33
Several methods of occlusal registrations are available.
The use of plastic foil is the simplest, yet it requires mul-
tiple opening and biting by the subject to obtain data for
the entire dental arch.34 Certain modern systems, such as
T-Scan and the Dental Prescale System, can be used to
determine both occlusal contacts and bite forces; how-
ever, they may interfere with the occlusion, and the re-
sults obtained are 2-dimensional.35,36 Addition
silicones cause minimal interference, but the
quantification of data remains problematic.33 Although
translucent segments can be considered “contacts,”37
the results are subject to the orientation of the registra-
tion toward the light source.38
The aim of this research was to determine the extent
to which MVBF and occlusal contacts are related to the
type of appliance in the 10 weeks of retention after
removal of edgewise appliances, controlling for the ef-
fects of sex, age, and BMI.
MATERIAL AND METHODS
This was a controlled clinical trial that included 176
white subjects (70 male, 106 female) aged 14 to 20 years
(median, 16 years; interquartile range, 15-18 years).
Subjects in test groups (n 5 90) were patients of the
dental clinic at Zagreb University in Croatia assigned
to 1 of the 3 test groups using quota sampling for this
experimental prospective study. The untreated control
group (n 5 86) comprised subjects of similar age and
sex distribution with normal occlusion who had not pre-
viously had orthodontic treatment. Controls were re-
cruited during the epidemiologic survey in the area of
Zagreb. All subjects were recruited between 2007 and
2009. Exclusion criteria were extractions, hypodontia,
extensive carious lesions, prosthodontic restorations,
and large fillings on the permanent first molars, as well
as systemic muscular and joint diseases to prevent
Varga et al
possible impacts of the aforementioned factors on the
stability of the occlusion and MVBF. The minimum sam-
ple size was calculated in the following manner:
assuming that the mean difference in changes of
MVBF (T2-T1) between 2 appliances could be
0.050 kN, and that the standard deviations of changes
of MVBF in both groups could be 0.050 kN, a minimum
of 17 subjects were needed in each appliance group to
obtain a detectable difference. Assuming that the differ-
ence in mean values of MVBF in the same appliance
group between 2 time periods could be 0.100 kN with
a standard deviation of 0.130 in both time periods, to
obtain a detectable difference, 28 subjects were needed
(with the level of significance at P 5 0.05 and power
beta 5 0.8). Since 3 appliances were tested, it was
decided to triple the minimal number of subjects for
the control (28 3 3 5 84). Calculations were performed
with software (version 14.8.1; MedCalc Software,
Ostend, Belgium).
Subjects from the test groups had their preadjusted
edgewise appliance, Roth 0.018 in, removed immedi-
ately before the first measurement. They were randomly
assigned to 1 of 3 test groups: the first comprised 30
subjects with Essix retainers in both dental arches, the
second had 30 subjects with wrap-around retainers in
both arches, and the third included 30 subjects with a
combination of a directly bonded multistranded retainer
in the intercanine region of the mandibular arch and an
Essix retainer in the maxillary arch. The Essix retainers
were made from 1-mm thick Essix ACE plastic foil
(Dentsply Raintree Essix, Sarasota, Fla) and were
extended to full crown coverage of all erupted teeth to
half occlusal coverage of the second molars. The wrap-
around retainers had the acrylate base placed orally,
and the labial archwire was made from round, 0.8-mm
diameter, stainless steel wire (Dentaurum, Ispringen,
Germany). The labial arches surrounded all erupted teeth
including the second molars and formed a U-shaped
loop between the canines and first premolars. The
bonded retainer was made from double twisted, 0.254-
mm diameter, stainless steel ligature wire (Rocky Moun-
tain Orthodontics, Denver, Colo); it was the standard
material used at the dental clinic at Zagreb University
when applying bonded retainers. The retainer was
bonded to oral surfaces of individual teeth with Adper
Single Bond Plus bonding agent (3M ESPE, Monrovia,
Calif) and Filtek Supreme Ultra flowable composite resin
(3M ESPE).
During the bite force measurements, all subjects were
in habitual occlusion with natural head posture (sitting
and looking straight forward). All measurements were
performed by the same examiner (S.V.) on 3 occasions:
T1, immediately after removal of the edgewise
American Journal of Orthodontics and Dentofacial Orthopedics
769
appliance; T2, after 6 weeks of retention; and T3, after
10 weeks of retention. All subjects were instructed to
wear their removable appliances for 24 hours a day dur-
ing the first 2 weeks (removing them only during meals),
for 16 hours a day during the next 4 weeks, and only
during sleep in the last 4 weeks of the study. This was
the standard protocol used in Croatia, based on the
retention regimen of the dental clinic. The control sub-
jects had MVBF recorded in 1 session. Weight and height
for the calculation of BMI were self-reported at T1.
MVFB was determined using the Occlusal Force-Meter
GM10 (Nagano Keiki, Tokyo, Japan) on the mandibular
permanent first molar unilaterally, according to the
standard procedure.39 The subjects of the control and
test groups bit into the instrument on each side of the
dental arch 4 times and repeated the process in reverse
order after 3 minutes of rest. Measurement reliability
of MVBF was statistically processed with a method sug-
gested by Bland and Altman.40
Occlusal contacts were determined using plastic foil,
6 mm in width and 0.05 mm in thickness: Hawe Trans-
parent Strips No. 690, straight (Kerrhawer Sa, Bioggo,
Switzerland). Contacts were registered in places where
the foil could not be drawn out by strong pulling during
habitual occlusion. The previously reported method error
is 10% of the mean value.41
The normality of distribution of the data from each
group was tested with the Shapiro-Wilk test, the homo-
geneity of variance with the Levene test, and the sphe-
ricity with the Mauchly test. For the analysis of
differences in MVBF and the number of occlusal con-
tacts between retention appliances, mixed analysis of
variance (ANOVA) and analysis of covariance (ANCOVA)
for repeated measures with Bonferroni post-hoc tests
were used in a stepwise manner. MVBF and number of
contacts were outcome variables; type of appliance,
sex, and assessment period were categorical predictors,
and age and BMI were used as covariates measured on
a continuous scale. Generally, appliance type and
reading were entered first in the statistical model and
then supplemented with sex, age, and BMI. Partial eta
squared was used for the evaluation of effect size. In
asymmetric distributions, Kruskal-Wallis and Mann-
Whitney tests were used for analysis. Multivariate
discriminant analysis was used for the assessment of
changes in MVBF and number of contacts between
time periods that discriminated the most between sex
and appliance type. For this purpose, new variables
were created: ratio of the second and first readings,
and ratio of the third and second readings, for both
MVBF and number of contacts. Canonical discriminant
analysis is a dimension-reduction technique that derives
a linear combination of several interval variables (in this
December 2017  Vol 152  Issue 6
770 Varga et al

Table I. Sample breakdown with regard to sex and age

Group Sex n % Age (y) average 6 SD (95% CI) BMI average 6 SD (95% CI)
Control Male 36 41.9 16.6 6 1.9 (16.0-17.3) 22.2 6 2.5 (21.4-23.0)
Female 50 58.1 16.8 6 2.0 (16.2-17.3) 21.2 6 2.5 (20.6-21.9)
Total 86 100 16.7 6 2.0 (16.3-17.1) 21.6 6 2.5 (21.1-22.2)
Essix Male 13 43.3 16.1 6 1.5 (15.1-17.2) 21.6 6 2.8 (20.3-22.9)
Female 17 56.7 16.4 6 2.2 (15.4-17.3) 19.6 6 2.0 (18.5-20.8)
Total 30 100 16.3 6 1.9 (15.6-17.0) 20.5 6 2.5 (19.5-21.4)
Wrap-around Male 11 36.7 15.9 6 1.3 (14.8-17.1) 20.5 6 2.6 (19.0-21.9)
Female 19 63.3 16.1 6 1.9 (15.2-17.0) 20.5 6 2.1 (19.4-21.6)
Total 30 100 16.0 6 1.7 (15.4-16.7) 20.5 6 2.3 (19.6-21.3)
Bonded 1 Essix Male 10 33.3 17.7 6 2.2 (16.5-18.9) 22.9 6 2.0 (21.4-24.4)
Female 20 66.7 16.1 6 1.9 (15.2-16.9) 19.9 6 2.2 (18.9-21.0)
Total 30 100 16.6 6 2.1 (15.8-17.4) 20.9 6 2.6 (20.0-21.9)
Total Male 70 39.8 16.6 6 1.8 (16.1-17.0) 21.9 6 2.6 (21.3-22.5)
Female 106 60.2 16.4 6 2.0 (16.1-16.8) 20.6 6 2.4 (20.1-21.1)
Total 176 100 16.5 6 1.9 (16.2-16.8) 21.1 6 2.5 (20.7-21.5)

Essix, Essix retainer; Wrap-around, wrap-around retainer; Bonded 1 Essix, combination of an orally bonded multistranded retainer in the inter-
canine region of the mandibular arch and an Essix retainer in the maxillary arch.

case ratios for MVBF and number of contacts) that has
the highest possible multiple correlation with the groups
(appliance type and sex). Statistical analysis was per-
formed with SPSS software (version 10.0; SPSS, Chicago,
Ill) and Statistica software (version 8.0; StatSoft, Tulsa,
Okla) at the P \0.05 level of significance.
The ethical committee of the School of Dental Med-
icine at University of Zagreb approved the research.
Informed consents were obtained from all participants
or their legal guardians before the study.
RESULTS
The results of measurement reliability of MVBF ac-
cording to Bland and Altman40 were as follows: intrases-
sion reliability was excellent, intraclass correlation
coefficients were 0.976 for the controls and ranged
from 0.953 to 0.986 for the test groups (lowest for
wrap-around and highest for bonded-Essix combina-
tion). The difference between 2 measurements for the
same subject was within limits of agreement for 96.5%
of the controls and for 93.3% to 100% of the test
groups. Intersession reliability for untreated subjects
was assessed by 2 consecutive measurements with a 1-
week interval on 10 subjects (with normal occlusion
and similar age and sex distribution as the test groups)
and were excellent (intraclass correlation coefficient,
0.890; 95% were within the limits of agreement). The
biologic variation of MVBF, assessed as the standard de-
viation, was always larger than the measurement error.
To prevent random error, the mean value of MVBF was
used for analyses.
The mean treatment duration in the test groups was
20.9 6 2.2 months, and pretreatment tooth size-arch
length discrepancies were –1.2 6 3.0 in the maxilla
and –1.3 6 2.5 mm in the mandible. Before orthodontic
treatment, the majority were Class I (53%); similarly,
both divisions of Class II—Class II Division 1 and Class
II Division 2—were 17% and 20%, respectively, and the
least were Class III (10%). The majority had a neutral
growth pattern (51%), and the least had a horizontal
one (14%), as evaluated with the Bjork polygon and
y-axis on lateral cephalograms. Distribution was similar
in the test groups. There were no significant differences
in age between the test groups; however, there were
significantly more female subjects in each group (Table
I; P \0.05). On average, male subjects had higher BMI
values than female subjects (P \0.001). In the sample,
69% had normal weight, and 39% were overweight.
Male subjects more often had normal weight (84.14%)
compared with female subjects (59.39%). The distribu-
tions were similar in all groups, and mean BMI did not
differ significantly between groups. Mmale subjects in
the control group had significantly higher forces than fe-
male subjects, with sex accounting for 15.3% of the vari-
ability in MVBF in untreated Class I subjects (Table II;
P \0.001), yet there were no differences in the number
of occlusal contacts between the sexes. The covariates
age and BMI did not significantly affect this finding.
Distributions of MVBF in the experimental and con-
trol groups are presented in Table III. In the first statisti-
cal model, 2-way mixed type ANOVA for repeated
measures was used for testing general differences in
the changes of MVBF at 3 readings depending on the
type of appliance. Sex and the covariates age and BMI
were not considered in this step. Since the Mauchley
test indicated a violation of the sphericity of data, the

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Varga et al 771

Table II. Breakdown of MVBF and number of occlusal contacts in the control group with regard to sex
Sex n Mean 6 SD (95% CI) P h2
MVBF (kN) Male 36 0.625 6 0.190 (0.565-0.685)
Female 50 0.471 6 0.174 (0.420-0.522) \0.001 0.153
Total 86 0.535 6 0.195 (0.494-0.577)
NOC Male 36 10.3 6 2.1 (9.6-11.0)
Female 50 10.3 6 2.1 (9.7-10.9) 0.975 \0.001
Total 86 10.3 6 2.1 (9.9-10.8)
h2, Effect size; NOC, number of occlusal contacts.

Huynh-Feldt correction of the degrees of freedom, mean
squares, and P values was performed. There was a signif-
icant increase of MVBF between readings (P \0.001)
that accounted for 57.1% of the variability. Differences
in MVBF increase between appliances and readings
(combination appliance 3 reading) were borderline sig-
nificant (P 5 0.051) and accounted for 5.5% of the vari-
ability.
The second model was ANCOVA for repeated mea-
surements, taking into account 3 time readings and
the type of appliance from the first step supplemented
with control of sex and the covariates age and BMI. Since
this model indicated that MVBF was significantly influ-
enced by a combination of reading, appliance type, and
sex (P 5 0.020; h2 5 0.070) and the covariate age
(P 5 0.037; h2 5 0.041) but not BMI (P 5 0.199;
h2 5 0.020), further analyses of MVBF were performed
taking into account sex and with a correction for age.
Significantly higher forces were always present in men
than in women (with each appliance type in every time
period). The covariate of age did not change this rela-
tionship. Only with the wrap-around retainer did
MVBF increase more rapidly in women after week 6,
thus nearly reaching the values in male subjects, and
there were no significant differences between sex in
weeks 6 and 10. Controlling for age, in male subjects
the increase of MVBF was more significant from the
removal of the fixed appliance until week 6 with the Es-
six retainer and the bonded-Essix combination
(P 5 0.002 and P 5 0.017). With the wrap-around
retainer, the increase was more significant between
weeks 6 and 10 (P 5 0.015; Fig 1).
Concerning female subjects, when controlling for
age, a significant increase in MVBF was present at
each retention check-up for the wrap-around and the
bonded-Essix combination (P\0.001), whereas in those
wearing Essix a significant increase was noticed in week
10 of retention in comparison with immediately after
removal of fixed appliances (P 5 0.009; Fig 1).
When sex was not taken into account, ANOVA
showed that MVBF values were significantly lower at
the first 2 readings in all test groups compared with
the control. In subjects wearing the wrap-around
retainer and the bonded-Essix combination, forces in
week 10 reached the control values. However, subjects
wearing Essix retainers in both arches still had lower
MVBF values than did the control at the third reading
(P \0.05). ANCOVA models for the 3 readings demon-
strated that neither the covariates age and BMI nor the
number of occlusal contacts affected the differences in
bite forces; however, there was a significant influence
of sex (P \0.05) on this parameter. Viewed separately
by sex, male subjects wearing the wrap-around retainer
and the bonded-Essix combination reached the control
group values already in week 6, whereas those wearing
the Essix retainer in both arches took the longest time
and only reached these values in week 10. There were
no differences between appliances at individual read-
ings. Female subjects wearing the wrap-around retainer
were the first to reach the MVBF values of women in the
control group (in week 6). Female subjects wearing the
bonded-Essix combination reached these values in
week 10, but the Essix group did not reach it even in
week 10 with the regimen adopted in this study.
In the first model, general differences in change of
the number of occlusal contacts between the 3 retainer
groups in regard to appliance type were tested with 2-
way ANOVA. Sex and the covariates age and BMI were
not taken into account. A significant difference in
change of occlusal contacts between the 3 readings
was found (P \0.001; h2 5 0.283) and for the combi-
nation appliance 3 reading (P \0.001; h2 5 0.135).
When we did not control for sex and age, no significant
differences were present in subjects wearing the Essix
retainer in both arches. In subjects wearing the wrap-
around retainer, as well as those with the bonded-
Essix combination, the number of occlusal contacts
significantly increased from the period of appliance
removal to week 6 after removal (P \0.05), yet not
significantly from weeks 6 to 10.
In the second model, using ANCOVA, differences in
the change of number of occlusal contacts between

American Journal of Orthodontics and Dentofacial Orthopedics December 2017  Vol 152  Issue 6
772 Varga et al

the 3 readings in regard to sex and appliance type and

0.516
0.274
0.530
0.769
0.601
0.681
0.129
0.082
0.578
0.463
0.574
0.613

*Values in the same row that do not share the same superscript letters significantly differ between periods at P \0.05 according to repeated measurements ANOVA with the Bonferroni post-hoc test.
Table III. MVBF and number of contacts in the test groups after removal of the edgewise appliance (T1) and after application of the retention appliance (T2,

h2 with the covariates age and BMI were tested. The inter-
action of the appliance and time of reading was signifi-
cant (P \0.001), as well as the interaction of appliance,
0.001
0.007
0.001
\0.001
0.005
\0.001
0.196
0.251
0.001
\0.001
\0.001
\0.001
time of reading, and sex (P 5 0.009), accounting for
P

15.7% and 7.8% of the variability, respectively. Age

and BMI did not influence the number of occlusal con-
tacts. In male subjects, there was generally a significant
0.507 6 0.170c (0.437-0.577)
0.326 6 0.095b (0.264-0.387)
0.516 6 0.142b (0.440-0.592)
0.440 6 0.113c (0.382-0.498)
0.565 6 0.131bc (0.485-0.645)
0.397 6 0.120c (0.341-0.453)

change in the number of occlusal contacts between

readings (P \0.001; h2 5 0.344) and for the
Mean 6 SD (95% CI)

7.7 6 3.0 (6.6-8.8)

6.7 6 1.7 (5.7-7.6)
6.7 6 1.1bc (5.6-7.9)
8.0 6 1.9c (7.1-8.8)
8.6 6 1.5b (7.4-9.8)
7.4 6 1.8c (6.5-8.3)
appliances-readings combination (P 5 0.006;
h2 5 0.205; Fig 1). In the Essix group, the number of
T3

occlusal contacts did not change significantly during

the retention period in either sex. In male subjects wear-
ing the wrap-around retainer, the number of occlusal
contacts significantly increased already at week 6
(P 5 0.004), and also increased in those with the
bonded-Essix combination between weeks 6 and 10
0.476 6 0.128bc (0.406-0.547)
0.300 6 0.101ab (0.238-0.361)
0.469 6 0.175a (0.392-0.545)
0.378 6 0.127b (0.320-0.437)
0.516 6 0.111b (0.436-0.597)

(P 5 0.029). In female subjects, there were generally sig-

0.347 6 0.127b (0.29-0.404)
Mean 6 SD (95% CI)

nificant changes in the number of occlusal contacts be-

6.7 6 2.6 (5.6-7.8)
6.2 6 2.1 (5.3-7.2)
7.4 6 0.9b (6.2-8.5)
6.4 6 2.0ab (5.5-7.3)
7.2 6 1.8a (6.0-8.4)
6.8 6 1.7b (5.9-7.6)

tween readings and for the appliances-readings

combination (P \0.001), accounting for 29.3% and
T2

22.5% of the variability, respectively. In female subjects

wearing the wrap-around retainer, a significant increase
occurred between weeks 6 and 10 (P 5 0.018) and not
before. In the female bonded-Essix combination group,
the number of occlusal contacts significantly increased
in each retention period (P \0.05).
0.390 6 0.110a (0.325-0.455)
0.278 6 0.120a (0.221-0.335)
0.422 6 0.131a (0.352-0.493)
0.292 6 0.125a (0.238-0.346)
0.425 6 0.108a (0.351-0.500)
0.280 6 0.112a (0.227-0.332)

With sex not taken into account, the control group

Mean 6 SD* (95% CI)

showed significantly more occlusal contacts than did

6.8 6 2.3 (5.8-7.7)
6.8 6 1.7 (6.0-7.7)
4.7 6 1.6a (3.7-5.8)
5.7 6 1.9a (4.9-6.5)
6.1 6 0.7a (5.0-7.2)
5.7 6 1.7a (4.9-6.5)

the test groups at the first (P \0.001) and second

(P \0.05) readings; at the third reading, the control
T1

group had only significantly more occlusal contacts

week 6; T3, week 10) with regard to sex and appliance type

than subjects wearing the Essix retainer in both arches

(P 5 0.002). The groups of retention appliances did
not differ significantly from one another in regard to
number of occlusal contacts. Since the data were not
normally distributed, ANCOVA could not be used, but
Female

Female

Female

Female

Female

Female

analyses were performed separately by sex.

Sex
Male

Male

Male

Male

Male

Male

At the first reading, the control group differed by

h2, Effect size; NOC, number of occlusal contacts.

the number of occlusal contacts from all test groups

in both sexes (P \0.05), whereas there were no differ-
Bonded 1 Essix

Bonded 1 Essix

ences between appliance groups. Female subjects with

Wrap-around
Appliance

Wrap-round

the wrap-around retainers reached the values of the

control group in week 6 and in the bonded-Essix
Essix

Essix

group in week 10, but at that time only the Essix

group still had significantly fewer contacts than did
the control group (P 5 0.003). Regarding male sub-
Force MVBF (kN)

jects, at the second reading, the control group differed

only from the Essix test group (P 5 0.04). At the third
Parameter

reading, there were no differences in occlusal contacts

between the test groups and the control in male
NOC

subjects.

December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Varga et al 773

Fig 1. Changes of MVBF and occlusal contacts in appliance groups during retention (MVBF corrected
for covariate age 16.3 years).

Fig 2. Group centroids from 2 discriminant functions (model 1, discrimination of the appliance groups
in periods of changes in MVBF and number of contacts; model 2, appliance-sex groups).

Two discriminant analyses were performed: the first
model explored in which periods changes in MVBF and
numbers of contacts mostly discriminated the appliance
groups, whereas the second model also took sex into ac-
count (Fig 2). The first canonical discriminatory function
in the first discriminant model consisted of a ratio of the
number of occlusal contacts at the second and first read-
ings, and the ratio of MVBF at the third and second read-
ings, and accounted for 98.7% of the variability
(P 5 0.002). The second function was not significant.
Subjects wearing the wrap-around retainer showed the
largest increase in the number of occlusal contacts in
week 6 after appliance removal, and their MVBF
increased in week 10. Those wearing the Essix retainer
in both arches showed the least increase in both param-
eters (Fig 2). The subjects in the Essix group (76.7%)
were better classified by this canonical function
(54.4%) than the subjects in both the wrap-around
and bonded-Essix combination groups (43.3%). The re-
maining members of the groups were more similar to
members of other groups in changes of their occlusal
contacts and forces.
The second model demonstrated that the groups of
male and female subjects wearing 3 different retention
appliances were mostly discriminated by the changes
in the number of occlusal contacts up to week 6 after
appliance removal (P \0.001). This first and only inter-
pretable canonical function differentiates male subjects
wearing the wrap-around retainer, showing the largest
increase in the number of occlusal contacts, and female
subjects wearing the Essix retainer in both arches, in
which the largest decrease in number of occlusal con-
tacts was observed (Fig 2). Female subjects wearing the
wrap-around retainer, and both sexes wearing the
bonded-Essix combination, showed similar increases in
the numbers of occlusal contacts. However, it only

American Journal of Orthodontics and Dentofacial Orthopedics December 2017  Vol 152  Issue 6
774
accounts for 59.2% of the variability of data and
correctly classifies 44.4% of test group members (mostly
in Essix female and wrap-around male groups; 64.7%
and 54.5%, respectively).
DISCUSSION
This study confirmed that during the retention period
of 6 to 10 weeks after active orthodontic treatment and
after removal of the edgewise appliances, increases of
the number of occlusal contacts and MVBF in the lateral
segment occur. It also showed that the increase in MVBF
does not come about simultaneously with the increase in
the number of occlusal contacts; instead, forces rise
more slowly. These changes are related to the type of
retention appliance and to sex.
It has been recorded that the settling of the occlusion
reaches its peak within 3 months of the removal of the
orthodontic appliance, and the bite force increases in
subjects in the first 3 months after the removal of the
fixed orthodontic appliance but stabilizes after that
period.42 This agrees with contemporary knowledge on
temporary restraint of the muscles. The avoidance of
hard food during orthodontic therapy leads to decreases
in the thickness of muscle cells, reductions in numbers of
muscle fibers, and muscle atrophy. These changes return
to normal values in 10 weeks of physical therapy and
training.43,44 Because of that, this study was based on
the investigation in duration of 10 weeks.
Physical characteristics such as body weight and
height are often presumed to influence the value of
MVBF.25-27 Therefore, BMI was evaluated in this
investigation. The results showed no statistically
significant correlation between BMI and MVBF; thus
this factor was excluded in the periods of T2 and T3. It
may be argued that such results were because our
subjects were healthy young people, and extreme
values of BMI, indicating obesity or malnutrition, were
not found during the screening process.
In studying the retention period, changes in the irreg-
ularity index are often followed up, as well as changes in
the number of occlusal contacts, indicating settling of
the occlusion and stability of the relationship between
dental arches.45,46 A recent randomized controlled trial
demonstrated equally beneficial results in terms of
irregularity index from 3 retention methods: a bonded-
Essix retainer combination, Essix in the maxillary arch
combined with stripping of mandibular anterior teeth,
and a positioner.47 However, few studies have analyzed
MVBF.42,48 Similar forces as in our study are reported
after removal, followed by an increase during
3 months of retention, but not additionally up month
6.42 Our study shows that stabilization of forces does
not occur at 6 weeks of retention. An increase of forces
December 2017  Vol 152  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Varga et al
in the retention period accompanied by an increase of
occlusal pressure leads to improvement in the level of
satisfaction with mastication ability.48 Still, even after
1 year of retention, forces do not completely reach those
of pretreatment.48
The study shows a change in MVBF in the first
10 weeks of retention in general, and it indicates the
settling process in a measurable way. Patients were fol-
lowed, and measurements were performed prospec-
tively. Some selection bias is present because only
patients who agreed to participate in the research were
chosen as subjects. The retainer type was chosen
randomly regardless of the subject. Since both the sub-
jects in the treated group and those in the control group
were chosen randomly from the same population and
ethnicity, it can be presumed that the data are compara-
ble. The drawbacks of this study are the use of 1 reten-
tion regimen and its monocentric nature. It would thus
be wise to investigate the matter in the future using
different protocols and multiple centers. However, this
increases the costs and the duration of the research as
well as the control of agreement between members of
the inevitably larger group of personnel involved (thera-
pist, technician, examiner). Our results may be general-
ized to the population of retention patients, primarily
those under a retention regimen similar to the standard
one in Croatia.
Forces measured immediately before the removal of
the edgewise appliance are significantly lower than those
immediately after removal.42 Probably, subjects with the
edgewise appliance are more careful when biting to pre-
vent bracket failure and damage to other parts of the
appliance. Thus, the forces they present cannot be a
full expression of the activity of the muscles of mastica-
tion. Still, since MVBF increased during retention
regardless of the fact that the measurement was per-
formed after removal of the edgewise appliance, the
cause may be the same. Our measurements were per-
formed immediately after removal, and it is likely that
the subjects had not yet adapted to the new situation
in which additional care during mastication was no
longer necessary. Furthermore, decreased muscular ac-
tivity leads to atrophy and thus to reduced muscular
strength. Since orthodontic treatment lasts more than
1 year, reduced activity of masticatory muscles during
this period may be manifested as reduced bite force at
the aforementioned measurements.
The approaching of MVFB values among patients in
retention treatment toward levels in normal occlusion
may affect final stability and relapse. Research of
MVBF has mostly been focused on the general popula-
tion and subjects with prosthodontic rehabilitation,
whereas studies after orthodontic treatment did not
Varga et al
include different retainers or did not consider differences
in retention appliances. Thus, there is limited knowledge
of the changes of MVBF in the retention phase of ortho-
dontic treatment with different retention protocols. We
tried to overcome this by including and comparing the
most commonly used removable and fixed retention ap-
pliances. It is evident that occlusal changes are greater
and occur sooner with the wrap-around retainer and in
male subjects than with the Essix retainer and in female
subjects. The number of occlusal contacts with the
wrap-around retainer reached the level of the controls
after 6 weeks, whereas in female subjects this did not
happen even after 10 weeks. MVBF reached control
values with the wrap-around retainer and bonded-
Essix combination after 6 weeks in male subjects, but
not in female subjects wearing the Essix retainer after
10 weeks.
This signifies that the type of appliance affects mus-
cle recovery. MVBF can be used for determining the
functional state of the stomatognathic system. Ortho-
dontic treatment in our subjects resulted in visually ideal
occlusions. Bite forces in the 2 test groups that were
comparable twith the control after 10 weeks showed
that, apart from the obvious esthetic component, ortho-
dontic treatment plays a role in functional rehabilitation.
The increase of MVBF during retention may be linked to
the normalization of the response threshold of peri-
odontal mechanoreceptors.49
Due to its construction, the wrap-around retainer al-
lows for the contact of maxillary and mandibular teeth
and for their vertical movement. In the bonded-Essix
retainer combination, vertical movement of mandibular
teeth is enabled. Only when an Essix retainer is worn in
both arches, the occlusal surfaces of the maxillary and
mandibular teeth are covered by the retainer, and they
are not in contact. Also, the settling of the occlusion is
impeded. Subjects may feel less certainty when biting
and thus train their muscles less, leading to a longer
time of muscle recovery.43,44
This study did not provide data of occlusal contacts
and forces of each subject before treatment, but
compared them with an untreated normal occlusion
group that did not differ in age and sex distribution.
Ideally, subjects in the control group should have normal
sagittal skeletal relationships, proven by radiocephalo-
metric analysis. There is no ethical justification for radio-
graphic recording of healthy subjects. Instead, credible
data were obtained with the use of stern criteria of visual
morphologic examination: absence of craniofacial
anomalies, presence of neutral occlusion, presence of
all permanent teeth excluding third molars, and absence
of any malocclusion, even minor tooth rotation. The vi-
sual examination was performed by 2 authors, both
American Journal of Orthodontics and Dentofacial Orthopedics
775
orthodontists (S.V. and S.S.). A previous study conducted
on 60 subjects with normal occlusion demonstrated that
parameters of morphologic and functional occlusion
(overjet, overbite, maximum mouth opening, mandib-
ular deflexion during opening, discrepancy between ret-
ruded and intercuspal position) do not affect the
amount of MVBF.50 These parameters were not addi-
tionally evaluated. Although MVBF is sometimes dis-
cussed in relation to the facial growth pattern, it was
not considered in this study. Taking cephalograms of
the control group without treatment would be ethically
disputable, as mentioned earlier.
Although all subjects, regardless of sex and retention
appliance, had been given the same instructions
regarding wear, compliance with wear was not assessed.
The differences between sexes in reaching the MVBF
levels of the controls may be explained by the increased
caution of female subjects. The “objectification theory”
proposed by Fredrickson and Roberts51 hypothesizes
that prevailing cultural attitudes predispose women to
value their bodies in terms of physical attractiveness;
men, on the other hand, value their bodies on account
of physical effectiveness. Adolescent girls may be more
conscious of their physical appearance and eager to
affirm themselves before the opposite sex. The method
used in this study for assessing settling of the occlusion
determined changes in the number of antagonists in
contact during retention.18 Previous research into reten-
tion evaluated occlusal contacts regardless of retention
appliance or compared 2 appliances. Since methodolo-
gies vary between studies, it is difficult to compare
data for different retainers. Also, often instructions for
wearing the appliances differ from study to study.
Thus, studying 3 retention appliances with the same
method and instructions to subjects can produce impor-
tant clinical guidelines. Our results indicate that settling
of the occlusion is slowest in subjects wearing the Essix
retainer in both dental arches; this agrees with previous
findings.52 The increase in number of occlusal contacts
shown in subjects wearing the wrap-around retainer
can be attributed to its design. Differences between
sexes among subjects wearing the wrap-around retainer
are more difficult to account for. All subjects were given
identical instructions; however, since the wrap-around
retainer is large and the least comfortable, it may be pre-
sumed that male subjects showed less compliance. No
differences between the sexes were found in studies of
compliance that used microsensors incorporated into
Hawley53,54 and Essix53 retainers. Further research on
compliance with wear of the wrap-around retainer
may be necessary to address this issue.
During 3 months of retention, the Essix retainer worn
in both arches was the only appliance that did not allow
December 2017  Vol 152  Issue 6
776
for the subjects to reach the values of the control group
in terms of MVBF and number of occlusal contacts; yet,
changes were registered. Therefore, further research
should be conducted on the Essix retainer with a longer
retention period. An increase in the number of occlusal
contacts after 2.5 years of wearing Essix retainers in
both arches has been shown55; however, MVBF was
not measured. Therefore, wearing of Essix retainers in
both dental arches may not be the best option for the
short-term settling of theocclusion, and it could be use-
ful to leave the occlusal surfaces uncovered at least in 1
arch.
CONCLUSIONS
Settling of the occlusion depends on the type of
retainer used. It takes longer in female subjects and
with the Essix in both dental arches than with the other
tested appliances.
SUPPLEMENTARY DATA
Supplementary data related to this article can be
found online at http://dx.doi.org/10.1016/j.ajodo.
2017.03.028.
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