RETENTION AND

RELAPSE

DR. CHIRAG SHARMA

IInd YEAR POSTGRADUATE

DEPT OF ORTHODONTICS
 CONTENTS
• INTRODUCTION
• HISTORICAL PERSPECTIVE
• THEOREMS OF RETENTION
• THE PERIODONTAL AND GINGIVAL TISSUES
• OROFACIAL SOFT TISSUES
• OCCLUSAL FACTORS AND FORCES
• ANDREWS SIX KEYS TO OCCLUSION
• POST TREATMENT GROWTH AND DEVELOPMENT
• RETENTION AFTER CLASS II CORRECTION
• RETENTION AFTER CLASS III CORRECTION
• STABILITY OF DEEP OVERBITE
• RETENTION OF OPEN BITE
• STABILITY AND RELAPSE OF DENTAL ARCH ALIGNMENT
• LONG TERM STABILITY OF ORTHOGNATHIC SURGERY
• PREVENTION OF RELAPSE IN SURGICAL ORTHODONTIC
TREATMENT
• INTER PROXIMAL STRIPPING
• ELIMINATING LOWER RETENTION
• RETENTION APPLIANCES
• REMOVABLE APLLIANCES
• FIXED RETAINERS
• CONCLUSION
• REFERENCES
 INTRODUCTION
• The requirements for retention often are decided at the time of diagnosis
and treatment planning.

• Retention is not a separate problem

in orthodontia but is a continuation
of what we are doing during
treatment. (Hellman M )
• A satisfactory balance of utility, beauty, and stability often simplifies (and
may even avoid) retention by mechanical appliances. However, incorrect
diagnosis or treatment complicates the requirements for retention.
What does Retention mean??

• According to Moyer’s (1973): “the holding of teeth following

orthodontic treatment in the treated position for the period of time
necessary for the maintenance of the result.”

• According to Riedel (1985): “the holding of teeth in idealistic and

functional positions.”
 What does Relapse mean??

• According to Moyers (1973): Loss of any correction achieved by

orthodontic treatment.

• Relapse is the slip back or fall back to a former condition, especially after
improvement or seeming improvement.

Riedel believed that the word was too harsh a description of the changes that
follow orthodontic treatment and he preferred the term "posttreatment
adjustment" for these changes.

Rossouw. Terminology: Semantics of Postorthodontic Treatment Changes in

the Dentition. Semin Orthod 1999
Rebound
• Rebound refers to spring or bounce back after hitting or colliding with
something; a recoil. This biology can be ascribed to the elasticity of
tissues.
• This term can also be used for the behavior of the mandible post-
treatment. There is a tendency for the mandible when rotated during
treatment, to return in the opposite direction by the forces of the
musculature in approximately 70% of patients.

Rossouw. Terminology: Semantics of Postorthodontic Treatment Changes in

the Dentition. Semin Orthod 1999
 Stability
Stability is the condition of maintaining equilibrium. This refers to the
quality or condition of being stable; the fixity of position in space or the
capacity for resistance to displacement.

Stability of the orthodontic outcome can only be achieved and maintained

once the factors influencing relapse are identified and taken care of, right
from the step of diagnosis, and continuing throughout the treatment.

Rossouw. Terminology: Semantics of Postorthodontic Treatment Changes in

the Dentition. Semin Orthod 1999
 HISTORICAL PERSPECTIVE
• Hellman : "We are in almost complete ignorance of the specific factors
causing relapses.“
• Over the years various philosophies have been put forward to explain
post treatment stability. These are referred to as the schools of retention.

The Occlusion School

Norman Kingsley(1880) : “The occlusion of teeth is the most important
factor in determining the stability in a new position." .”
• At the end of active orthodontic treatment there should be proper
intercuspation and interdigitation.
 The Apical Base School
• Alex Lundstrom (Middle 1920s): “The apical base was one of the most
important factors in the correction of malocclusion and maintenance of a
correct occlusion.”
• McCauley suggested that intercanine width and intermolar width should
be maintained as originally presented to minimize retention problems.
• Hay's Nance in 1947 further researched the topic and concluded that:
• If a stable permanent result is to be attained following orthodontic
treatment, mandibular teeth must be positioned properly in relation to the
basal bone.
• Arch length may be permanently increased only to a limited extent.
• Excessive lingual as well as labial tipping must be avoided.
The Mandibular Incisor School
• Grieve and Tweed suggested that the mandibular incisors must be
kept upright or slightly retroclined over basal bone .

The Musculature School

• Paul Rogers introduced a consideration of the necessity of establishing
proper functional muscle balance.
• He advocated the use of myofunctional therapy during the retention
period to strengthen the weak muscles and to assure their proper
function.
 THEOREMS -RIEDEL (1960)

Theorem 1
• Teeth that have been moved tend to return to their former positions.
Theorem 2
• Elimination of the cause of malocclusion will prevent recurrence.
Theorem 3
• Malocclusion should be overcorrected as a safety factor.
 Theorem 4
• Proper occlusion is a potent factor in holding teeth in their corrected
positions.

Theorem 5
• Bone and adjacent tissues must be allowed to reorganize around newly
positioned teeth.

Theorem 6
• If the lower incisors are placed upright over basal bone they are most
likely to remain in good alignment.
 Theorem 7
• Correction carried out during periods of growth are less likely to
relapse.

Theorem 8
• The farther the teeth have been moved, the lesser the risk of relapse.

Theorem 9
• Arch form, particularly in the mandibular arch, cannot be permanently
altered by appliance therapy.
Moyers added the tenth theorem of retention

Theorem 10
• Many treated malocclusions require permanent retaining devices.
 Stability can only be achieved if the forces derived from each of these
are in equilibrium.

Periodontal
&

ssu l
sof facia
es
Gingival
tissues

o
t ti
Or
Occlusion
Post
-trea
facia tmen
l g ro t
wth

Toward a perspective on orthodontic retention? Melrose AJODO1998

 THE PERIODONTAL AND
GINGIVAL TISSUES
• Even if tooth movement stops before the orthodontic appliance is
removed, restoration of the normal periodontal architecture will not
occur as long as a tooth is strongly splinted to its neighbours.

• Once the teeth can respond individually to the forces of mastication,

reorganization of the periodontal ligament (PDL) occurs.

• This PDL reorganization is important for stability because of the

periodontal contribution to the equilibrium that normally controls tooth
position.
• The teeth normally withstand occlusal forces because of the shock-
absorbing properties of the periodontal system.

• Small but prolonged imbalances in tongue lip- cheek pressures or

pressures from gingival fibers that otherwise would produce tooth
movement are resisted by active stabilization due to PDL metabolism.

• The gingival fiber networks are also disturbed by orthodontic tooth

movement and must remodel to accommodate the new tooth positions
• Both collagenous and elastic fibers are present in the gingiva, and the
reorganization of both occurs more slowly than that of the PDL itself.

• Newly formed bone spicules will be rearranged so as to form a

layer of bone containing clefts and future marrow spaces around the
capillaries.
• If the tooth is not retained, it may relapse and cause compression, and
occasionally also hyalinization, on the former tension side.
• This is then followed by rearrangement and compression of the more
or less calcified bundle bone layer.
• It is thus important to retain the tooth until fibrous tissue has
become rearranged and the new bone layers have been calcified.
• Pdl fibers take 3-4 months whereas gingival fibers take 4-6 months
for reorganization.
 OROFACIAL SOFT TISSUES

• It is wise to carry out treatment within the limits imposed by the soft tissue
environment.

Lower labial segment

• Movement of the lower labial segment beyond its narrow zone of
labiolingual balance is unlikely to be stable.
• Proclination of lower incisors may be stable in a few Class II cases in
which the lower incisors have been retroclined.
 
Arch width
Although Riedel emphasized that mandibular arch form should not be
expanded as it compromises stability, maintenance of the original intercanine
width does not guarantee stability.
Indeed, a modest amount of intercanine expansion may be maintained more
successfully in Class II Division 2 cases than in Class I and Class II Division
1 cases.
Overjet
For the best prospect of overjet stability, a lip seal should be possible.
Differential vertical and horizontal growth of the lips occurs in early
adolescence, with more growth observed in boys than in girls, possibly
promoting stability.
 OCCLUSAL FACTORS AND FORCES

• Angle recognized the relevance of occlusal factors to posttreatment

stability.

• A well-interdigitating occlusion prevents tooth migration and a Class I

molar relationship may aid stability, although it is no guarantee because
posttreatment growth may alter significantly the sagittal molar relationship.
Andrews Six Key’s to Normal occlusion (AJO 1972)

• Total scheme of occlusion are viewed as essential to successful

orthodontic treatment
Key I. Molar relationship
• The distal surface of the distobuccal cusp of the upper first permanent
molar occluded with the mesial surface of the mesiobuccal cusp of the
lower second molar
Key II. Crown angulation (tip)
• The gingival portion of the long axes of all crowns was more distal than
the incisal portion.

Andrews .The six keys to normal occlusion AJODO 1972

Key III. Crown inclination
• Properly inclined anterior crowns contribute to normal overbite and
posterior occlusion, when too straight-up and -down they lose their
functional harmony and overeruption results.
Key IV. Rotations.
• The fourth key to normal occlusion is that the teeth should be free of
undesirable rotations.

Andrews .The six keys to normal occlusion AJODO 1972

 Key V. Tight contacts.
• The fifth key is that the contact points should be tight (no spaces).

Key VI. Occlusal plane.

• The planes of occlusion found on the non-orthodontic normal models
ranged from flat to slight curves of Spee. Flat plane should be a
treatment goal as a form of overtreatment.

Andrews .The six keys to normal occlusion AJODO 1972

 RETENTION AND STABILITY
FACTORS
RALEIGH WILLIAMS proposed
Six treatment keys during finishing to enhance
stability of most unstable part of dental arch
i.e lower anterior segment.(JCO 1985)

First Key
The incisal edge of the lower incisor should
be placed on the A-Pog line or 1 mm in front
of it. This is the optimum position for lower
incisor stability
Second Key
• The lower central incisor apices should be
spread distally to the crowns more than is
generally considered appropriate (parallel
roots)

• 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. (because of great
variation in mandibular plane angle)
 25/05/2022

Fourth Key
All four lower incisor apices must
be in the same labiolingual plane.

Correct labiolingual position

of roots.

Incorrect labiolingual
position of roots.
Fifth Key
• The lower cuspid root apex must be
positioned slightly buccal to the crown.
• If the apex of the lower cuspid is lingual
to the crown at the end of treatment, the
forces of occlusion can easily move the
crown lingually because of these
functional pressures plus a natural
tendency for the crown to upright over its
root apex.
 Sixth Key
• The lower incisors should be slenderized
as needed after treatment..

• Lower incisors without proximal wear

have round and small contact points which
are accentuated if the apices have been
spread for stability.
 POST-TREATMENT GROWTH AND
DEVELOPMENT
• Facial growth continues throughout adult life; it varies among individuals.
• A continuation of growth is particularly troublesome in patients whose
initial malocclusion resulted, largely or in part, from the pattern of skeletal
growth.
• Skeletal problems in all three planes of space tend to recur if growth
continues because most patients continue in their original growth pattern as
long as they are growing.
• Transverse growth is completed first, which means that long-term
transverse changes are less of a problem clinically than changes from late
anteroposterior and vertical growth.
Retention after class II correction
• Relapse toward a Class II relationship must result from combination of tooth
movement and differential growth of the maxilla relative to the mandible.
I) Control of tooth movement:
• Overcorrection of the occlusal relationships as a finishing procedure is an
important step in controlling tooth movement that would lead to Class II
relapse.
• Even with good retention, 1 to 2mm of anteroposterior change caused by
adjustments in tooth position is likely to occur after treatment, particularly if
Class II elastics were employed. This change occurs relatively quickly after
active treatment stops.
• It is important not to move the lower incisors too far ahead.
II) The relapse tendency due to differential growth can be controlled in one of
two ways:

• The traditional fixed appliance approach of the 1970s and earlier is to

continue headgear to the upper molars on a reduced basis in conjunction
with a retainer to hold the teeth in alignment.

• To use a functional appliance of the activator-bionator type to hold both

tooth position and the occlusal relationship.
• For patients with less severe probIems, in whom continued growth may
or may not cause relapse, it may be more rational to use only conventional
maxillary and mandibular retainers initially, and replace them with a
functional appliance to be worn at night if relapse is beginning to occur
after a few months.

• This type of retention is often needed for 12 to 24 months or more in a

patient who had a skeletal problem initially.

Guidelines:-
The more severe the initial Class II problem and the younger the patient at
the end of active treatment, the more likely that either headgear or a
functional appliance will be needed during post-treatment retention. It is
better, and much easier, to prevent relapse from differential growth than to
try to correct it later.
Retention after class III correction

• Retaining a patient after correcting a Class III malocclusion early in the

permanent dentition can be frustrating, because relapse from continuing
mandibular growth is very likely to occur and such growth is extremely
difficult to control.

• Applying a restraining force to the mandible, as from a chin cup, is not

nearly as effective in controlling growth in a Class III patient as applying a
restraining force to the maxilla is in Class II problems.
• If face height is normal or excessive after orthodontic treatment and
relapse occurs from mandibular growth, surgical correction after the
growth has expressed itself may be the only answer.

• In mild Class III problems, a functional appliance or a positioner may be

enough to maintain the occlusal relationships during posttreatment
growth.
 The stability of deep overbite correction
• Orthodontic correction of the overbite often involves leveling the curve
of Spee by anterior intrusion, posterior extrusion, or a combination of
these.

• Schudy advocated that deepbite and deep curve of Spee be corrected by

extrusion of molars, because the intrusion of anterior teeth has a high
potential for relapse.
• Most studies show that overbite decreases during treatment and has a
tendency to increase after treatment.

Schudy FF. The control of vertical overbite in clinical orthodontics. AO 1968.

• Andrews stated that there is a natural tendency for the curve of Spee to
deepen with time because the lower jaw’s growth downward and
forward sometimes is faster and continues longer than that of the upper
jaw.

• This causes the lower anterior teeth, which are confined by the upper
anterior teeth and lips, to be forced back and up, resulting in crowded
lower anterior teeth and/ or a deeper overbite and deeper curve of Spee.
• Build a potential bite plate into the retainer, which the lower incisors
will contact if the bite begins to deepen.
• The retainer does not separate the posterior teeth.
• Because vertical growth continues into the late teens, a maxillary
removable retainer with a bite plane often is needed for several years
after fixed appliance orthodontics is completed. Bite depth can be
maintained by wearing the retainer only at night, after stability in other
regards has been achieved
 Retention After Anterior Open Bite Correction

• Relapse into anterior open bite can occur by any combination of

depression of the incisors and elongation of the molars.
• Active habits (of which thumbsucking is the best example) can produce
intrusive forces on the incisors, while at the same time leading to an
altered posture of the jaw that allows posterior teeth to erupt. If
thumbsucking continues after orthodontic treatment, relapse is all but
guaranteed.
• In patients who do not place some object between the front teeth, return of
open bite is almost always the result of elongation of the posterior teeth,
particularly the upper molars, without any evidence of intrusion of incisor .
Controlling eruption of the upper molars therefore is the key to retention in
open bite patients.
• High-pull headgear to the upper molars, in conjunction with a standard
removable retainer to maintain tooth position, is one effective way to
control open bite relapse.
• A better tolerated alternative is an appliance with bite blocks between the
posterior teeth that creates several millimeters of jaw separation (an open
bite activator or bionator).
• This stretches the patient's soft tissues to provide a force opposing
eruption.
• A patient with a severe open bite problem
is particularly likely to benefit from having
conventional maxillary and mandibular retainers
for daytime wear, and an open bite bionator as a
nighttime retainer, from the beginning of the retention period.
Retention of Lower Incisor Alignment

• If the mandible grows forward or rotates downward, the effect is to carry

the lower incisors into the lip, which creates a force tipping them distally.

• For this reason, continued mandibular growth in normal or Class III

patients is strongly associated with crowding of the lower incisors.

• Incisor crowding also accompanies the downward and backward rotation

of the mandible seen in skeletal open bite problems.

• A retainer in the lower incisor region is needed to prevent crowding

from developing, until growth has declined to adult levels.
Timing of Retention:

• Retention is needed for all patients who had fixed orthodontic appliances
to correct intra-arch irregularities.
• It should be: Essentially full-time for the first 3 to 4 months, except that
the retainers not only can but should be removed while eating (unless
periodontal bone loss or other special circumstances require permanent
splinting) .
• Continued on a part-time basis for at least l2 months, to allow time for
remodeling of gingival tissues ' If significant growth remains, continued
part-time until completion of growth.
Long term stability of orthognathic surgery
• There are two basic conditions in the surgical correction of dentofacial
deformities— deficiencies and excesses.
• In the correction of deficiencies, soft tissues (muscles, tendons,
periosteum, subcutaneous tissues, and skin) are stretched and must undergo
hypertrophy, hyperplasia, and neuromuscular adaptation to adjust to the
new position of the skeleton. Meanwhile, forces continue to be transmitted
to the repositioned skeletal components that tend to return them toward
their original positions. These forces can be effectively counteracted by
proper surgical technique.
• Conversely, in the correction of skeletal excesses, these soft tissue factors
are minimal, and relapse will usually be less.
 Prevention of Relapse in Surgical-Orthodontic Treatment:

Mandibular Advancement
• Presurgical Orthodontic Treatment
• Eliminate dental compensations.
• Properly manage tooth size discrepancies.
• Adequately level both arches
• Avoid bimaxillary protrusion.
Mandibular Advancement
• Immediate Presurgical Treatment Planning
• Take accurate presurgical records.
• Make an accurate cephalometric prediction tracing
• Determine the magnitude of suprahyoid muscle lengthening.
• If the suprahyoid musculature is lengthened by less than about 30 %, it
does not contribute to relapse. If it is lengthened more, then often a release
of the anterior digastric and geniohyoid musculature is performed to reduce
relapse.
• Inadequate bone contact is the major factor in vertical relapse of maxillas
repositioned superiorly with a LeFort I ostectomy
• Vertical relapse can occur as a downward and backward rotation of the
mandible that generally manifests itself as an open bite relapse.
ADJUNCTIVE PROCEDURES TO
ENHANCE STABILITY
• Pericision, or Circumferential Supracrestal Fiberotomy (CSF).

• Surgical gingivoplasty &/or gingivectomy.

• Frenectomy.

• Interproximal stripping.
 Circumferential Supracrestal Fiberotomy
(CSF)

• Relapse of severely rotated teeth due to rebound of elastic fibres in the

supra-crestal tissues can be reduced by pericision.
• Inserting a surgical blade into the gingival sulcus and severing the
epithelial attachment surrounding the involved teeth.
• The blade also transects the trans-septal fibres by interdentally entering
the periodontal ligament space.
Indications of CSF:

• Moderately to severely rotated teeth

• Markedly crowded or bunched teeth

• Displaced/impacted teeth

• Severely tipped teeth

• In cases of bodily retraction of teeth through an extraction space,

surgical intervention as an adjunct to retention was also reported to have a
definite positive effect on the stability of these teeth.
(Boese AO 1980)
 FRENECTOMY

Frenectomy, as described by Edwards (1977) involves apical repositioning

of the frenum with denudation of alveolar bone, destruction of the
transseptal fibers, and gingivoplasty/recontouring of the labial or palatal
gingival papilla in cases of excessive tissue accumulation.

It has been shown to dramatically reduce the tendency for space to open in
the upper midline.
(Melrose AJO1998)
 Interproximal stripping
• Interproximal stripping to create a mesiodistal/faciolingual ratio no greater
than 0.72 for lower-central incisors and 0.95 for lower-lateral incisors, has
been suggested to enhance stability ( Peck and Peck AJO 1972) but this
ratio has not been found to be an important determinant of lower-incisor
crowding.
Two main benefits:
• Broader contact point areas and thereby furnishes broader contact stability.
• Increases the amount of available space.
Every conscience orthodontist must be fully aware of its inherent dangers:
• Irreversible procedure
• Increased caries risk
• Increased sensitivity
• Associated periodontal problems

• The study evaluated long term clinical results of reproximation on

crowded mandibular anterior teeth after orthodontic treatment but were
never retained and observed from 4 to 9 years post treatment.
 Retention Appliances
• Any orthodontic appliance, fixed or removable, used to maintain the
position of the teeth and stabilize them following orthodontic treatment is
referred to as retainer (Glossary of Orthod. Terms, John).
• "Active retainer" is a contradiction in terms, since a device cannot be
actively moving teeth and serving as a retainer at the same time.
• It does happen, however, that relapse or growth changes after orthodontic
treatment lead to a need for some tooth movement during retention.
• This usually is accomplished with a removable appliance that continues as
a retainer after it has repositioned the teeth, hence the name.
• One of the earliest retaining appliances in the United States was described
by James W. Smith (1881) before the Harvard Odontological Society in
Boston.
• It was a simple vulcanite plate with a bar extending over the labial aspect
of the maxillary incisor teeth.
• Before deciding on the type or coverage of the retainer, it is helpful to re-
examine the original study models or photographs.
• Removable appliances can serve effectively for retention against intra-arch
instability and are also useful as retainers (in the form of modified
functional appliances or part-time headgear) in patients with growth
problems.

Kaplan. Logic of modern retention procedures AJO 1988

 Removable Appliances as Retainers(Tony, JCO 1998)
The ideal removable retainers should be:
1. Able to allow for functional occlusion.
2. Sturdy enough to withstand long-term use.
3. Convenient for the orthodontist to provide and maintain.
4. Patient-friendly in both comfort and wear routine.
 Hawley Retainers
Designed in the 1920s by C.A. Hawley as an active removable
appliance.
A labial bow 0.020” to 0.036” SS wire (Hawley wire) is made to contact
the labial surfaces of four incisors or six anterior teeth.
In the original design, there were no molar clasps. Use of clasps is
optional.
• For a mandibular retainer, the wire Hawley bow is less effective than a
wire-reinforced acrylic bar that tightly contacts the lower incisors.

• This Moore design has almost completely replaced the Hawley design for
lower removable retainers that extend to the posterior teeth.

• The palatal coverage of a removable plate like the maxillary Hawley

retainer makes it possible to incorporate a bite plane lingual to the upper
incisors, to control bite depth. For any patient who once had an excessive
overbite, light contact of the lower incisors against the baseplate of the
retainer is desired.
 Wraparound Retainers

• The wraparound or clip-on retainer consists of a plastic bar (usually

wire-reinforced) along the labial and lingual surfaces of the teeth
• An anterior clip retainer in the maxillary arch is particularly useful
when it is necessary to keep spaces from reopening.

• It also can be used to prevent re-rotation of maxillary incisors, but the

wider upper incisors allow a broad contact with just a retainer wire, and
contact of the lower incisors with a maxillary clip retainer often
becomes a problem.

• undercuts lingual to the lower molars make it difficult to place a lower

retainer that extends further posteriorly.
• A full-arch wraparound retainer firmly holds each tooth in position
often less comfortable than a Hawley retainer

• It may not be effective in maintaining overbite correction.

• Indicated primarily when periodontal breakdown requires splinting the

teeth together.
 Circumferential retainer

• Excellent retention with the added benefit of eliminating potential

occlusal interferences .
• The circumferential wire, formed from .030" SS, originates from the
palate and passes immediately behind the most distally positioned
molar.
• The clinician also can adjust labial bow tension efficiently because of
incorporation of recurved loops.
Palatal acrylic should be extended distally to retain second molar position.
This is particularly important in patients who have undergone changes in
transverse dimension during active treatment
• The clinician may place keeper wires (.020”SS) between the lateral
incisors and canines or distal to the canines to enhance the stability of the
labial wire.

Pontics should be included in the retainer design to enhance esthetics and

retain the edentulous areas during the transition from fixed appliances to
prosthetic replacement
 Ricketts Retainer

• Named after its developer Robert M. Ricketts.

• This type of retainer is useful in patients treated with extractions, as the

labial wire does not cross through the embrasure between the maxillary
canine and maxillary premolar.
 The Van der Linden Retainer
• The Van der Linden Retainer is constructed to offer complete control over
the maxillary anterior teeth, with firm fixation provided by clasps on the
canines .
• The continuous .028” labial arch and left and right three-quarter .032”
molar clasps are embedded in the palatal acrylic plate .
• The premolars and molars should be free of acrylic, except where there
are clasps.

Linden F. The Van der Linden Retainer. Journal of Clinical Orthodontics2003;37(5):260-7.

• If labial bow cannot be precisely adapted to surfaces of incisors, clear
acrylic strip can be added over wire to provide necessary control.

• Morphology of lateral incisors if does not allow wire to cross mesial to

canines without interfering with occlusion then Wire can cross distal to
canines.

• Van der Linden Retainer should be removed by pulling down with

fingernails on most superior portions of canine clasps.
• Removing retainer by labial bow may lead to deformation.
• Disadvantages:
• It does not retain changes in mesiodistal angulation. If such retention is
needed, a thin, bonded twisted-wire retainer should be considered.
Occasionally, a combination of the two retainers is a good solution.

• Extrusive movements of the incisors are not restrained, so that a

maxillary lateral incisor that has been extruded in treatment can move
back between the acrylic and the wire. Placing a small composite ridge
on the tooth cervical to the labial bow can prevent this movement.
 Tooth positioners as retainers
• Positioners are excellent finishing devices and under special
circumstances can be used to an advantage as retainers.

• A positioner does have one major advantage over a standard removable

or wraparound retainer, however-it maintains the occlusal relationships
as well as intra-arch tooth positions.
• Indication: For reestablishing normal tissue tone and firmness where
gingival hyperplasia has occurred during treatment.

Advantages:
• It is clean and unlikely to be broken,
• tends to stimulate tissue tone,
• works constantly toward maintenance or improvement of tooth position.
• At the laboratory, each tooth in the maxillary and mandibular work model
is freed, carved, and reset in wax to an ideal occlusion . The bite then is
opened sufficiently to allow for the construction of the positioner.
• The positioner can be made from a number of clear elastomeric materials
including silicone, vinyl, and urethane.
 Osamu active retainer for correction of mild relapse

The transparent removable appliance that can correct individual tooth

position during the retention phase.

The retainer consists of two superimposed layers.

The inner layer, made of 1.5mm ethylene vinyl acetate copolymer adapts
to the interproximal areas and covers the palatal and lingual aspects of the
teeth.

The outer layer, made of 0.75mm hard elastic polycarbonate, covers the
occlusal aspects of the teeth and makes the retainer elastic and stable.
• The Osamu active retainer is inexpensive and simple to make.

• It is well accepted by patients because it is transparent and does not

impair speech.

• It can correct individual tooth positions while maintain close

adaptation to the remaining teeth.
 Clear retainer Trends Orthod 2017;7:54-60.

A clear retainer (Essix® retainer, thermoplastic retainer, or vacuum‑formed

retainer) is a removable retainer that was introduced in 1993 by Dr. John
Sheridan as an esthetic, comfortable, and
inexpensive appliance.
Advantages
• More esthetic and less visible.
• Inexpensive
• Ease of fabrication
• Ability to place on the day the fixed appliance is debonded
• Decreased chair time
• Capable of correcting minor tooth discrepancies due to flexibility and
positioner effect
• Provides better oral hygiene than fixed retainer
• Serves as a temporary bridge or crown for missing teeth
• Acts as night guard for bruxism
Disadvantages
• Demands good compliance
• Non-settling of occlusion due to occlusal surface coverage of clear
retainer.
• Prone to wear and needs replacement at least annually
• Easily lost due to transparency
• Looseness of retainer in case of gingival inflammation or puffy gum.

DESIGNS
The extension of clear retainers varies from canine to canine to all teeth in
both maxillary and mandibular arches.

However, a full posterior occlusal coverage design has been commonly

chosen because it can reduce the risk of posterior teeth eruption during
retention.
• The border of the appliance should extend gingivally 3–4 mm on both
facial and lingual sides.

• The gingival edge should be notched in the area of labial and lingual
frenums.

• Nowadays, there are various thicknesses of plastic sheet on the market.

• However, thicknesses ranging from 0.63 to 2.0 mm have been used in

previous studies and vacuum‑formed retainer sheet thicknesses of 1.0
mm (68%) and 0.75 mm (16%) were most commonly recommended by
orthodontists.
 FIXED RETAINERS
They are normally used in situations where intra-arch instability is
anticipated and prolonged retention is planned, especially the mandibular
incisor area.

There are mainly four major indications, they include the following:

1. Maintenance of lower incisor position

An excellent retainer to hold these teeth in alignment is a fixed lingual bar,

attached only to the canines and resting against the flat surface of the lower
incisors above the cingulum.

This prevents the incisors from moving lingually and is reasonably effective
in maintaining correction of rotations in the segment.

Proffit W, Fields H, Sarver D. Contemporary orthodontics: Mosby Inc; 2007.

The three different generations are:

• The first generation is designed in plain, round 0.032 to 0.036"blue

elgiloy wire with a loop at each end.

• In 1983, this was replaced by a twisted, three stranded 0.032"wire.

• The second generation retainer did not have terminal loops, since
adequate retention was provided by the wire spirals and was thus neater
and easier to fit.

• This second design has worked well for more than 10 years, with long-
term bond failure rates of about 10-15%.

• Although the twisted wire does not appear to be any more plaque-
retentive than the round wire, some disadvantages have emerged.

Zachrisson B. Third-generation mandibular bonded lingual 3-3 retainer.

Journal of clinical orthodontics: JCO1995;29(1):39-48.
• First, the largest-diameter twisted wire available (0.032") is not as stable
as would be desirable.

• In few cases, it has been dislodged, probably by the force of mastication

and has then become slightly distorted.

• Furthermore, the twists in the wire seem to be less comfortable to the

tongue than a smooth, round wire is.

• The third generation 3-3 retainer is more solid and easier to place than
the twisted 0.032" version.

• This allows the retainer to conform more closely to the lingual surfaces
of the incisors during bonding, reducing the risk of unwanted side
effects due to distortion in bonding of from mastication.
• The present design also has advantages over mandibular retainers in
which all six anterior teeth are bonded.

• The only disadvantage of the third generation 3-3 retainer may be that
even if the retainer bar is well contoured at the time of fabrication and
the incisors fit snugly against the wire, slight labial movement may
still be possible.

• However, labial movements are generally prevented by the maxillary

incisors when there is a normal horizontal overbite.
 Diastema Maintenance
• A second indication for a fixed retainer is a situation where the teeth must
be permanently or semi permanently bonded together to maintain the
closure of space between them.

• This is encountered most commonly when a diastema between maxillary

central incisors has been closed.

• Even if frenectomy has been done, there is a tendency for a small space to
open up between the upper central incisors.

• The best retainer for this purpose is a

bonded section of flexible wire.
• The wire should be contoured so that it lies near the cingulum to keep
it out of occlusal contact.

• The object of the retainer is to hold the teeth together while allowing
the some ability to move independently during function.

• An alternative is a solid wire to avoid the tooth contacts to facilitate

flossing, which also can incorporate stops to prevent deepening of the
bite.
 Maintenance of pontic or implant space
• A fixed retainer is also the best choice to maintain the space where a
bridge pontic or implant eventually will be placed.

• Using a fixed retainer for a few months decreases the mobility of the
teeth and often makes it easier to place the fixed bridge.

• Implants should be placed immediately after the orthodontic treatment is

completed, so that integration of the implant can occur simultaneously
with the initial stages of retention.

• The preferred orthodontic retainer for maintaining space for posterior

restorations is a heavy intra coronal wire, bonded to adjacent teeth.
 Keeping extraction space closed

A fixed retainer is both more reliable and better tolerated than a full time
removable retainer and spaces reopen unless a retainer is worn
consistently.
 Bonded flexible wire lingual retainer
The flexible spiral wire retainers were found to be excellent in the
following indication:
1. In midline diastema cases
2. Spaced anterior teeth
3. Adult cases with potential post orthodontic tooth migration
4. Accelerated loss of maxillary incisors, requiring the closure and
retention of large anterior space.
5. Severely rotated tooth.

Bearn D. Bonded orthodontic retainers: a review. American Journal of Orthodontics and

Dentofacial Orthopedics1995;108(2):207-13.
 4-4 Crozat retainer
• A 4-4 Crozat appliance has cribs on the first bicuspids, recurved
double lapping lingual finger springs and a labial bow.

• It combines many of the advantages of other types of retainers and has

been well received by patients. Its advantages include the following.

Firm retention, because of the Crozat clasping mechanism.

• Labiolingual control of anterior teeth to maintain or restore arch
form in the lower or upper arch.

• Flexible, because it is all wire. It can be left out for months and still
fit.
• Maintenance of adequate oral hygiene, because it is removable.

• Esthetic, because only a single labial wire shows.

•The major disadvantages of the appliance are:

- it must be fabricated at a quality laboratory, making it cost prohibitive
and
- it is breakable.
 Resin fiberglass bonded retainer
• The Resin fiberglass bonded retainer was developed by Michael a
direct technique that solves the major problem with cuspid to cuspid
retainer and takes 20 minutes or less with previsit preparation.

• The system uses glass fiber from woven fiberglass fabric or fiber
bond.

• The main advantages of the resin fiberglass retainer have proven rigid
and impervious. Patients appreciate the tooth colored material and the
comfort that is provided by smoothing the margins with rubber
abrasive points or wheels. Retainer sections can easily be recontoured,
removed or repaired in the mouth.

INTERNATIONAL JOURNAL OF DENTAL CLINICS VOLUME 2 ISSUE 3 JULY-SEPTEMBER 2010

• Because no metal wires are used, additional material can be applied to
the teeth or the fiberglass or both.

• Many patients need only the canines to be retained.

• In cases of severe incisor rotations, however, this technique is flexible

enough to allow the incisors to be bonded as well.
 Magic Clips for Fixed Retention
Magic clip used for holding the wire during bonding of retainer.

Wire bending of magic clip done with 0.018 AJW wire

Orthodontic Journal of Nepal, Vol. 5, No. 2, December 2015

ADVANTAGE
• Accurate , effective and predictable
• Easy to make and cost effective
• Wire used is resilient and easy to manipulate
• Reduces chair-side time
• Less armamentarium needed
• No laboratory work required
• It can be reused after sterilization.
 R-Retainer Clip for Lingual Bonded Retainers
Journal of Contemporary Orthodontics, April- June: 2019;3(22019;3(2)

The new “R retainer clip” is very simple to fabricate and stabilizes

retainer wire without interfering in its proper adaptation to the lingual
surface of the tooth to be bonded.
 Relapse in cleft cases
• Children with repaired unilateral or bilateral cleft of the palate have bony
deficient maxilla in the midline and also in the alveolus segments.
• These children also have palatal scars.
•The maxillary expansion in such cases is potentially unstable for the lack
of the bony structures in the midpalate and scarring of the palatal tissue.
• Dentoalveolar expansion is often carried out as pre-bone graft
orthodontics.
•The secondary alveolar bone graft integrates the split maxilla/alveolus to
one segment and therefore reduce tendency for transverse collapse.
• Restoration of missing teeth with removable prosthesis, followed by fixed
prosthesis, maintains the integrity of the arch and expansion. A rigid fixed
retainer with wire components extending to the lingual of all teeth is
recommended to combat the relapse.
The retention plan summarized by Kaplan.

Cases requiring minimum or no retaining appliances

1. Blocked out canines in class I extraction cases without incisor crowding.

2: Class I anterior crossbite with sufficient degree of overbite.
3. Posterior crossbites with very steep cusps and no anterior crowding.
4. Class II cases slightly over treated with Kloehn headgear to restrict
maxillary growth with sufficient archlength indicated by mandibular
anterior spacing and absolutely no mandibular incisor rotations.

These patients should follow scheduled checks during the post-treatment

adolescent period for any possible spacing or unfavourable growth changes
or TMJ symptoms.
Cases requiring indefinite retention

1. Class II, division 2 deep bite cases

2. Severe rotations with poor periodontal health.
3. Undue arch expansion treatment for aesthetic demands.
4. Patients with tongue thrust or uncontrolled muscular habits
Cases that require operative procedures with indefinite retention

1. Tooth size discrepancies such as larger maxillary teeth may result in

increased overbite
2. Conversely, larger mandibular teeth will result in end to-end incisor
relationships, maxillary spacing, or buccal end-on occlusion.
3. A vertical incisal relationship, will lead to deepening overbite and
should be retained.
4. Proximal recontouring of the mandibular incisor may resolve the
Bolton discrepancy if mandibular anterior tooth material is in excess or
vice versa for the maxillary teeth.
5. Microdontic tooth may require aesthetic build ups with tooth coloured
restorative or laminates to resolve this problem
6. Severe rotations would need circumferential supracrestal fibrotomy
(CSF) procedures
7. Frenectomy may be needed to prevent relapse of the midline diastema
Cases requiring special considerations and/or renewal of removable
retaining appliances or acrylic on the labial bows

1. Late mandibular growth spurt and Tweed’s type C growers.

2. Post-treatment adolescent palatal changes
3. To maintain torque and overbite correction Routine cases, extraction
or non-extraction, should have retaining appliances - fixed or removable,
until the growth process has slowed in late teens and early twenties.
 CONCLUSION
• Maintaining teeth in their corrected positions follow-ing orthodontic
treatment can be extremely challenging.

• Relapse after orthodontic treatment is the result of teeth moving back

towards the original malocclusion, but changes in tooth position may
also occur as a normal part of the growth and aging process.

• Relapse is also unpredictable, and so it should be presumed that

every patient has the potential for long-term changes.
• As part of the informed consent process for orthodontic treatment,
patients need to be fully aware of their commitment to wear retainers
for as long as they want to keep their teeth in their corrected positions.

• It is the clinician’s responsibility to ensure that patients are

appropriately instructed regarding the care of their retainers and
provided advice about the timing of retainer review.
 REFERENCES
• Retention and Stability in Orthodontics. Ravindra Nanda and Charles J
Burstone.
• Textbook of Orthodontics – Bhalajhi
• Orthodontics diagnosis and management of malocclusion- O.P Kharbanda
• Textbook of orthodontics- Gurkeerat Singh

• Proffit W, Fields H, Sarver D. Contemporary orthodontics: Mosby Inc;

2007.

• Kaplan H. The logic of modern retention procedures. American journal of

orthodontics and dentofacial orthopedics: official publication of the
American Association of Orthodontists, its constituent societies, and the
American Board of Orthodontics1988;93(4):325-40.
• Owen 3rd A. 4-4 Crozat retainer. Journal of clinical orthodontics:
JCO1985;19(3):194-7.

• Diamond M. Resin fiberglass bonded retainer. Journal of clinical

orthodontics: JCO1987;21(3):182-3.

• Sheridan J, LeDoux W, McMinn R. Essix retainers: fabrication and

supervision for permanent retention. Journal of clinical orthodontics:
JCO1993;27(1):37-45.

• Fernandez Sanchez J, Pernia Ramirez I, Martin Alonso J. Osamu active

retainer for correction of mild relapse. Journal of Clinical Orthodontics
1998; 32:26-8.
• Bearn D. Bonded orthodontic retainers: a review. American Journal of
Orthodontics and Dentofacial Orthopedics1995;108(2):207-13.

• Zachrisson B. Third-generation mandibular bonded lingual 3-3 retainer.

Journal of clinical orthodontics: JCO1995;29(1):39-48.

• Bonded orthodontic retainers: A review David Russell Bearn. AM J

ORTHOD DENTOFAC ORTHOP 1995; 108:207-13.

• Linden F. The Van der Linden Retainer. Journal of Clinical Orthodontics

2003;37(5):260-7.
• Different strategies used in the retention phase of orthodontic treatment.
Vinicius Schau de Araújo Lima et al. Dental Press J Orthod. 2012 July-
Aug;17(4):115-21

• Magic Clips for Fixed Retention.

Dr. Amit Prakash, Dr. Satish Chamania, Dr. Prabhuraj B.Kambalyal,
Dr.Shashi Bhusan Ekka Orthodontic Journal of Nepal, Vol. 5, No. 2,
December 2015

• Clear retainer. Chaimongkol P, Suntornlohanakul S. Clear retainer.

APOS Trends Orthod 2017;7:54-60.
• R-Retainer Clip for Lingual Bonded Retainers. Abhimanyu
Rohmetra,Pratik Chandra, Ragni Tandon - R- Retainer Clip for Lingual
Bonded Retainers. Journal of Contemporary Orthodontics, April- June
2019;3(2): 54-55.

• Retainer in orthodontics. Rahul Kumar Anand, Tripti Tikku, Rohit

Khanna, Rana Pratap Maurya, Snehlata Verma, Kamana Shrivastava.
IP Indian Journal of Orthodontics and Dentofacial Research, January-
March, 2019;5(1):11-15

• Smithpeter J, Covell Jr D. Relapse of anterior open bites treated

with orthodontic appliances with and without orofacial myofunctional
therapy. American Journal of Orthodontics and Dentofacial
Orthopedics. 2010 May 1;137(5):605-14.
THANK
YOU!!!