 Introduction

 History
 Need for retention
 Theorems
 6 keys RELAPSE
 Relapse
-soft tissue
-Functional RETENTION

-Skeletal
 Retainers
 No matter how good things look for one team late in the
game, the saying is "It's not over till it's over."

 In orthodontics, although patient may feel that treatment is

complete when appliances are removed, an important stage
lies ahead.
 Orthodontic control of tooth position and occlusal
relationships must be withdrawn gradually, not abruptly, if
excellent long-term results are to be obtained.

 The type of retention should be included in original treatment

plan
 According to Webster RETAIN – (re+tenere – to hold)
means to “hold back or to hold secure”

 RELAPSE: “to slip or fall back to a former condition,

especially after improvement or seeming improvement”
 Retention has been defined by Moyers as “the holding of
teeth following orthodontic treatment in the treated
position for the period of time necessary for the
maintenance of the result”

 Riedel “the holding of teeth in ideal aesthetic and

functional position.”

 According to Graber working definition of retention in

relation to orthodontics might be stated as follows: the holding
of teeth in optimal aesthetic and functional positions.
 Clinicians did not agree about the need for retention

 Hellman : “We are in almost complete ignorance of the

specific factors causing relapse”

 No mention of retention appliance or need for retention upto

1860

 Difference philosophies/schools of thoughts have existed over

time, and present-day concepts generally combine several of
the following historic concepts regarding retention.

 1860 - Emerson C. Angell- retention of space after opening
of maxillary median suture.

 After more than 19 centuries, concept of retention appliance

was born.

 Alfred Coleman (1865)

“ restoration of the former condition by muscular pressure “-
relapse

 Brown-Mason (1872) - Described a retaining plate for

surgically rotated teeth.
 The Occlusion School

› The problem of maintaining teeth in their new position after

treatment was first recognized by Kingsley in 1880, who
advocated use of ‘retaining plates’ to maintain positions of
teeth

› He stated that "the occlusion of the teeth is the most potent

factor in determining the stability in a new position”

Based on this concept, he developed “occlusion school” of

retention.
 James W. Smith (1881) -A simple vulcanite plate with a
bar extending over the labial aspect of the maxillary incisor
teeth.

 Victor Hugo Jackson- 1904- “ Not infrequently cases are

presented that require more skill in retaining the teeth than
in regulating them”
 Hahn- “Retention in orthodontics is like a neglected step-
child

 This concept was well supported by Angle in 1907 who

stated : “every person can maintain full complement of
dentition and stability will depend on how fine occlusion
has been achieved”
 1900 – Edward H Angle

› "normal occlusion" during eruption period- relapse .

› Cutting gingival fibers to counteract rotations.

› In doubtful cases, wearing delicate and efficient

appliances indefinitely.

› Pin and tube appliance. (working retainer)- uprighting

teeth that have been tipped outward during expansion
 1919- Hawley “give half his fee to anyone who would be
responsible for the retention of his results when the active
appliance was removed”

 1920 AJO- Calvin Case

 "Principles of Retention in Orthdontia"
› Compromised stability due to Angle’s philosophy of arch
expansion lead to development of “The apical base
school”

› Axel Lundstrom (1920)

“ Apical base was one of the most important factors in the
correction of malocclusion and maintenance of a correct
occlusion”
› McCauley (1944)
“ Intercanine and intermolar width should be maintained as
originally presented to minimize retention problems ”

› Strang (1946)- further confirmed and substantiated this

concept.

› Nance (1947)
“ arch length may be permanently increased only to a
limited extent”
Mandibular Incisor School

 Grieves (1944)
“ mandibular incisors must be kept upright and over
basal bone”
Cause : forward translations of teeth

 Tweed (1954)
 5 yrs retention and even longer when needed
 the Musculature school

 Rogers (1951)
“Care must be exercised to establish a proper occlusion within
the bounds of normal muscle balance with careful regard to
the apical bases and their relationship to one another”

 Hellman- retention, not a separate problem, continuation of

what we are doing during treatment.
 How many teeth have been moved and how far.
 Occlusion and age of the patient.
 Cause of the particular malocclusion.
 Rapidity of corrections.
 Length of cusps / relationship of the inclined planes.
 Health of the tissues involved.
 Cell metabolism
 Arch harmony.

Graber vanasdall
 Rotation should be corrected by overrotation in the opposite
direction.
 Slight movement is more difficult to retain than extensive
movement.
 Occipital retention is most desirable for certain cases.
 Function is the most important factor in retention.
 Retention depends on bone change, which in turn is related to
endocrine dysfunction.
 Use of mild forces is desirable.

Graber vanasdall
 Mandibular incisors should be maintained upright over basal
bone.
 Discrepancies in tooth sizes may cause problems in retention.
 Early treatment is more desirable than treatment at a later
age.
 Intercanine and intermolar widths should be maintained as in
the original malocclusion
 Richard A Riedel – 1960

Riedel proposed some basis for holding teeth

in their treated position as:

› (1) allowing for periodontal and gingival reorganization

› (2) to minimize changes from growth
› (3) to permit neuromuscular adaptation to the corrected
tooth position
› (4) to maintain an unstable tooth position, if such
positioning is required.

Classified retention according to the requirements of various types

of cases and given 9 Theorems
 Theorem - 1

Teeth that have been moved tend to

return to their former positions.
› Reasons :
 Musculature
 Transseptal fibers
 Bone morphology
 Theorem - 2

Elimination of the cause of

Malocclusion will prevent recurrence.
Habits, Tongue posture, mouth breathing
 Theorem - 3

Malocclusion should be
overcorrected as a safety factor

 Class II: edge-to-edge

over-corrections may be the result of overcoming muscular
balance rather than absolute tooth movement
 Theorem - 4

Proper occlusion is a potent factor in

holding teeth in their corrected
positions.
› Maintain health of the periodontium.
› Functional occlusion.
 Theorem - 5

Bone and adjacent tissues must be

allowed time to reorganize around newly
positioned teeth

 Fixed retention- “G wire,” band and spur type of attachment and

bands soldered together’

 No positive fixation- retainers should be only inhibitory and should

have no positive fixation to allow for the natural functioning of teeth
 Mandibular lingual arch can be used
Gottlieb (1935), Oppenheim (1935) and Orban (1936) - First
orthodontic literature on microscopic studies of bundle and
lamella bone spicules.

Oppenheim – appliances should only be inhibitory and that

repair of tissues around the teeth occurs much more rapidly
if no fixed retaining appliance is used

Hixon – Muscular balance

 Theorem - 6

If the lower incisors are placed upright

over basal bone, they are more likely to
remain in good alignment.
› Better - towards the lingual than labial inclination.
› Physiologic migration of lower anterior in distal direction.
› Maintaining arch form.
 Several steps during fixed appliance to eliminate need for
lower retention

 20 yrs postretention

 6 treatment keys
Eliminating lower retention.

JCO May 1985

 KEY 1
Incisal edge of lower incisor should be placed on A-P line
or 1mm in front of it.
 KEY 2

 The lower incisor apices should

be spread distally to the crowns

 The apices of lateral incisors

incisors should be spread more
than those of the central incisors
 KEY 3

The apex of the lower cuspid should be positioned distal

to the crown.
 Occlusal plane- positioning guide
 KEY 4

All four lower incisor apices must be in same labio-lingual

plane
 KEY 5

The lower cuspid root apex must be positioned slightly buccal

to the crown apex.

KEY 6

The lower incisors should be slenderized as needed after treatment

 Theorem - 7

Corrections carried out during periods

of growth are less likely to relapse.
 Theorem - 8

The farther teeth have been moved,

the less likelihood there is of relapse.
 Theorem - 9

Arch form, particularly in the

mandibular arch, cannot be
permanently altered by appliance
therapy.
› Mc Cauley “Since molar width and canine width are of
such an uncompromising nature, one might establish
them as fixed quantities and build arches around them”
Proffit-

 Reorganization of gingival and periodontal tissues after

orthodontic treatment.

 Soft tissue pressure – relapse tendency.

 Changes produced by growth may alter treatment results.

 Reorganization of gingival and periodontal tissues
after orthodontic treatment.

 Widening of pl space – disruption of fibers

 Teeth respond individually to forces of mastication

 Reorganization 3-4 months

 Slight mobility disappears

 Soft tissue pressure
 Active stabilization
Collagen 4-6 month
 Gingival fibers
Elastic- 12 months

 Slow turnover of periodontal ligament fibers Especially
supracrestal elastic fibers has been cited as a principle factor
for post orthodontic treatment instability in relation to
rotational tooth movement

 Edwards demonstrated circumferential supracrestal

fibrotomy (CSF) as an effective strategy to reduce
irregularity index relapse after active orthodontic treatment at
5 years (1.03 mm) but was less effective at 13 years (2.56
mm).

 This shows short term(1-year) effectiveness of CSF in

reducing posttreatment recrowding
 Elastic Recoil
of Gingival Fibers
Intra-Arch
Irregularity

Cheek / Lip / Tongue

Pressure Changes in
Occlusal
Relationship

Differential Jaw
Growth
 Haruki and Little (1998) during an evaluation of differences
in the long-term stability after a minimum of 10 years
between patients who received early orthodontic and those
treated late; both groups treated with 4 first bicuspid
extractions. They found late treatment group had greater
mandibular anterior irregularity and deviation of
midline.

 Little et al (1981) and Richardson et al stated that: “Treated

cases should be viewed as dynamic and constantly changing,
at least through the third and fourth decade and perhaps
throughout life.”
 Burlington study

a) Late developmental crowding is a process which

continues throughout life.

b) The rate of increase in crowding or irregularity of the

lower incisors seems to decrease with increasing age
(≥40 years).

 Sadowsky et al suggested that prolonged retention

of lower labial segment until end of facial growth
may reduce severity of lower incisor crowding.
 Dugoni et al (1995) defended post-retention stability in early
orthodontic treatment in patients who had early mixed
dentition treatment using a passive lingual arch for
alignment of lower incisors.

 These cases had no appliance therapy in permanent

dentition or circumferential supracrestal fiberotomy or
interproximal enamel reduction after removal of the
bonded retainers
1) Overbite, overjet, and other dental changes

2) Maintenance of the natural space for lower incisor alignment

3) Anterior component of force resulting in mesial migration of

teeth—a retention nightmare

4) Role of third molars in the development of mandibular incisor

crowding—the easy answer, but so controversial

5) Mandibular growth and its effect on late mandibular incisor

crowding
 Overbite, overjet, and other dental changes

 Overbite and overjet increase significantly from mixed to

permanent dentition. Decreases in overbite and overjet were
observed by Barrow and White,Björk, Moorrees and Sinclair
and Little.

 Arch length decreases over time.

 Longitudinal data show that changes in arch dimensions, as
well as lower incisor crowding occur as part of the normal
aging process.
Maintenance of the natural space for lower
incisor alignment

 Lower incisors procline relative to mandibular plane by an

average of between 5 and 11 years.

 This gain in space is enhanced by an increase in arch width

across canines caused by alveolar growth just before and
during the eruption of permanent incisor
Anterior component of force resulting in mesial
migration of teeth—a retention nightmare

 Mesial migration of posterior teeth during adolescence

has been recognized by Hunter.

 Thus responsible for increase in crowding during

teenage years.

 Mesial migration caused by -physiological mesial drift,

by anterior component of force of occlusion on mesially
inclined teeth
 Mesial vectors of muscular contraction
 Contraction of transseptal fibers of periodontal ligament
 Role of third molars in the development of mandibular
incisor crowding—

 Removal of second molar effectively isolates third molar

from rest of arch.

 Reduction in crowding and distal movement of first molars

in patients whose second molars have been extracted was
compared with increase in crowding and mesial movement
of first molars in nonextraction subjects provide convincing
evidence of effects of developing third molars on the anterior
part of arch.
 Ades et al. compared four groups of patients who were a
minimum of 10 years out of orthodontic retention.
 Patients studied had one of the following bilateral mandibular
third molar status:
 (1) third molars erupted into good alignment and function.
 (2) third molar agenesis
 (3) third molar impaction
 (4) third molar extraction at least 10 years before postretention
records.

 They found no differences in mandibular incisor crowding,

arch length, intercanine width, and eruption patterns of
mandibular incisors and molars between the groups.

 In majority of cases, some degree of mandibular incisor

crowding took place after retention but it was not statistically
significantly different between third molar groups.
Mandibular third molar
removal with sole
objective of alleviating
or preventing
mandibular incisor
irregularity may not be
justified
 Mandibular growth and its effect on late mandibular
incisor crowding

 Changes in mandibular growth direction and rotation

during post-treatment and postretention periods have
implicated in etiology of late incisor crowding.
 Vertical development of mandibular ramus continues
until late adolescence

 Buschang et al - Crowding of mandibular incisors was

observed in vertical growers as a result of chronic airway
obstruction
 Wear the removable retainers during the first month as much as
possible.

 After the first month, the retainers only have to be worn at home
and at night.

 Retention visits are initially scheduled at 6 weeks; 3 months; 6

months; 1 year and then annually.
 Retainer should be in place at least for the same duration as
the treatment time(depending on the age)

 A classic regimen is to wear retainers full time for half of

treatment time. Then divide remainder of treatment time in
two periods; first period is for at home wear and second
period is for night-time wear;

 It is recommended to maintain night wear until the

longterm changes have minimal effect
 Expansion appliance must be maintained passively for
approximately 16 weeks followed by removable retention
appliance.

 Storey - slow separation with continued growth of mature

bony serrations within suture provides the best retention with
the least potential for relapse

Graber vanasdall
 Measuring linear distance from anatomic contact point to
adjacent anatomic contact point of mandibular anterior teeth,
sum of five measurements

 Perfect alignment from the mesial aspect of left canine to

mesial aspect of right canine have a score of 0, with increased
crowding represented by greater displacement and, therefore,
a higher index score.
1) Alteration of arch form
2) Periodontal and gingival tissues
3) Mandibular incisor dimensions
4) Influence of environmental factors and neuro musculature
5) Post treatment tooth positioning and establishment of
functional occlusion
6) Consideration of continuing growth
7) Role of developing third molars
8) Influence of the elements of the original malocclusion

Blake and Bibby; Retention and stability: A review of the literature; 1998; AJODO
 Do not move lower incisors too far forward because lip
pressure will tend to upright the protruding incisors, leading to
crowding and return of both, overjet and overbite.

 If more than 2 mm of forward repositioning of the lower

incisors occurred during treatment, permanent retention will
be required

 Relapse result from some combination of tooth movement

(forward in the upper arch, backward in the lower arch, or
both) and differential growth of the maxilla relative to the
mandible .
 Overcorrection of the occlusal relationships as a finishing
procedure is important step in controlling tooth movement
that would lead to Class II relapse.

 Even with good retention, 1 to 2 mm of anteroposterior

change caused by adjustments in tooth position is likely to
occur after treatment, particularly if Class II elastics were
employed
 In Class II patients, this relapse tendency can be controlled in
one of two ways.

1) Fixed appliance approach of 1970s is to continue headgear

to upper molars on reduced basis (at night, for instance) in
conjunction with retainer to hold teeth in alignment

2) Use functional appliance of activator-bionator type to hold

both tooth position and occlusal relationship
 Shapiro’s :

 Class II, Division 2 malocclusions demonstrated significantly

greater ability to maintain intercanine width expansion
compared with Class I and Class II, Division 1 treated
malocclusions

 Arch length reduction in Class II, Division 2 was significantly

less than in Class I and Class II, Division 1 during treatment
and from pretreatment to 10 years postretention.
 Relapse from continuing mandibular growth is very likely to
occur and such growth is extremely difficult to control.

 Applying restraining force to mandible, as from a chincup, is

not nearly as effective in controlling growth in a Class III
patients.

 Chincup tends to rotate the mandible downward, causing

growth to be expressed more vertically and less horizontally,
and Class III functional appliances have the same effect.
 If face height is normal or excessive after orthodontic
treatment and relapse occurs from mandibular growth,
surgical correction after growth has expressed itself

 In mild Class III problems, functional appliance or a

positioner may be enough to maintain occlusal relationships
during posttreatment growth.
 Control of the vertical Position of teeth
 in retention is as important as controlling alignment,
especially in patients who had a deep bite or open bite
initially.

 Lower incisors contact palatal acrylic of upper retainer,

while upper incisors contact facial surface of lower retainer.
This prevents incisor eruption that would lead to return of
excessive overbite
 17-year-old has an anterior open bite.
5 mm of overjet with an end-on molar
severe crowding of mandibular incisors.
 Relapse of this type is associated with downward and
backward mandibular rotation and eruption of upper
posterior teeth during post-treatment growth

 The incisor crowding is due to uprighting and lingual

repositioning of the incisors as the mandibular rotation thrusts
them into the lower lip.
 Relapse into anterior open bite can occur by any combination
of depression of the incisors and elongation of the molars.

 Patient with 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.
 High-pull headgear to the upper molars with standard
removable retainer to maintain tooth position, is one effective
way to control open bite relapse.

 Appliance with bite blocks between posterior teeth that

creates several millimeters of jaw separation (an open bite
activator or bionator)

 Lower or lingual holding arch (LHA)

 Transpalatal arch (TPA)

 Hawley bite block can be used as retainer.


 Retainer in lower incisor region is needed to prevent
crowding from developing, until growth has declined to adult
levels.

 orthodontic retention should be continued, at least on a part-

time basis, until third molars have either erupted into normal
occlusion or have been removed.
 The implication of this guideline, that pressure from
developing third molars causes late incisor crowding, is
almost surely incorrect. (prolonged retention needed in
growing patients

 Retain lower incisor alignment until mandibular growth has

declined to adult levels (i.e., until the late teens in girls and
into the early 20s in boys
 Retention is needed for all patients who had fixed
orthodontic appliances to correct intra-arch irregularities. It
should be:

 Essentially full-time for first 3 to 4 months, except

retainers 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.
 Depending on the type and extent of retention treatment
instituted:

 (1) limited retention

 (2) Moderate retention in terms of time and appliance wearing

 (3) permanent or semipermanent retention.

 Corrected crossbites

 Dentitions that have been treated by serial extraction.

 Corrections achieved by retardation of maxillary growth,

dental or skeletal, after growth period

 Dentitions in which maxillary and mandibular teeth get

separated to allow for eruption of teeth previously blocked
out
 Class I nonextraction cases(protrusion and spacing of
maxillary incisors).
 Class I or Class II extraction cases
 Corrected deep overbites in Class I or Class II malocclusions
 Early correction of rotated teeth to their normal positions.
 Cases involving ectopic eruption of teeth or presence of
supernumerary teeth (fixed or permanent retentive device,
such as bonded lingual retainers)
 Corrected Class II, Division 2 malocclusion generally
requires extended retention to allow for adaptation of
musculature.
 Permanent or semipermanent retention

 Expansion cases particularly in mandibular arch

 Generalized spacing cases

 Instances of severe rotation, particularly in adults, or severe

labiolingual malposition may require permanent retention, as
provided by lingual bonded retainers.

 Spacing between maxillary central incisors in otherwise

normal occlusions sometimes requires permanent retention,
particularly in adult dentitions
 RELAPSE

Soft tissue Skeletal

Functional Surgical
Failure to remove the cause of malocclusion.
Incorrect diagnosis and treatment planning.
Lack of normal cuspal interdigitation.
Arch expansion
Incorrect axial inclinations.
Failure to manage rotations- over rotation
Tooth size disharmony- interproximal grinding
 Trabecular and cortical bone as risk factors for orthodontic
relapse.

 To evaluate whether the amount or the structure of mandibular

bone affects the potential for mandibular incisor relapse

 Sixty relapse and 263 stable subjects were identified.

Mandibular cortical thickness measured on both panoramic and
lateral cephalometric radiographs was used to assess the
amount of mandibular bone

 These results indicate that patients with thinner mandibular

cortices are at increased risk for dental relapse.
 Bishara et al (1989AJO and 1996 AO):

 Evaluated changes in lower incisor between 12 and 25 years

and again at 45 years – findings indicated :
 Increase in tooth size arch length discrepancy with age –
consistent decrease in arch length.
 Average changes 2.7mm in males; 3.5mm in females.

Similar findings by
 Lundstrom (1968)
 Sinclair and Little (1983 AJO)
 Little et al (1981AJO) observed that 90% of extraction
cases that were well treated orthodontically ended up with an
unacceptable lower incisor crowding.
Retainer- An appliance used to hold teeth in position after orthodontic
treatment.

Retainers

Passive Active
 RETAINERS

Active
Removable Retainers
Appliances as
Retainer Fixed Retainers

1) Hawley Retainers 1) Spring Retainers

2) Removable Wraparound 2) Modified Functional
Retainers Appliances as Active
Retainers
 Hawley Retainers

Maxillary premolar extractions

Anterior bow soldered to Adams
clasps on first molars so that
extraction site is held close

patient whose canines were facially

positioned before treatment, wire
extends across canines is soldered
to anterior bow
 wraparound outer bow
soldered to C-clasps on second
molars provides a way to avoid
interference retainer wire
crosses occlusion

Moore design

Control of second premolar and

extraction site
Canine-to-canine wraparound distally
on lingual only to central groove of
first molar

Mandibular retainer
 Removable Wraparound Retainers

Advantage
Esthetic
Periodontal breakdown requires
splinting the teeth together
Disadvantage
Less comfortable
Not effective in maintaining canine-to canine clip-on
overbite correction retainer
used to realign irregular
incisors, if mild crowding
has developed after
treatment
prevent re-rotation of
maxillary incisor
 Positioners as Retainers

Maintains occlusal relationships as well as intra-arch tooth

positions.

Patient with tendency toward Class III relapse, a positioner made

with jaws rotated downward and backward

Gingival stimulation

Positioner does not

make a good retainer
 The major problems are:

1) Difficulty wearing a positioner full-time so inability to

control intra-arch alignment

2) Positioners tend to be worn less than 4 hours per day after

first few weeks, they are reasonably well tolerated by most
patients during sleep.

3) It not retain incisor irregularities and rotations

4) Overbite tends to increase
 Canine-to-canine retainer in
lower arch is excellent way to
maintain alignment.

lt contains carrier to hold it in

position while being bonded.
Design with wire loops on
canines to provide retention
when retainer is bonded.

Bonded canine-to-canine retainer,

with retention pads in place.
 A lighter wire (r7.5 or r9.5mil twist)
should be used.

 Bonded wire used to maintain

alignment of maxillary teeth that
were severely displaced initially (as
in Class II division 2) or keep a
maxillary diastema closed.
 7.5mil twist wire contoured to fit

Wire retainer is held in place with

dental floss passed around the contact

composite resin is flowed onto the

cingulum of the teeth, over the wire
ends.
Wire contoured so that flossing is
not impeded, and bonded
attachment areas also serve to keep
bite from deepening

A-splint retainer
 Maintain space for eventual
replacement of missing second
premolar.
 Shallow preparation made in enamel
of marginal ridges adjacent to
extraction site

 21 x 25wire, stepped down away

from occlusion
Realignment of irregular Incisors:
Spring Retainers
Correction of Occlusal Discrepancies: Modified Functional
Appliances as active retainers

Activator or bionator as an active retainer is indicated if not

more than 3 mm of occlusal correction is needed
 Control of soft tissue recoil

Adjunctive periodontal Over treatment

surgery

Edwards-
circumferential
supracrestal fibrotomy "papilla split
(CSF)
Correction of
• overcorrected by at least 1 to 2 mm to
Class II or accommodate for expected rebound
Class III
Malocclusion

• overcorrected by at least 1 to 2 mm before the

Crossbite force system is released
Correction

• Over rotation
Irregular and
Rotated Teeth
 Principles of retention in Orthodontia. Calvin Case. AJO Nov
1920.
 Logic of modern retention procedures. Kaplan. AJO April
1988
 Changes in mandibular anterior alignment 10 to 20yrs post
retention. Little, Riedel, Artun. AJO May 1988
 Trabecular and cortical bone as risk factors for orthodontic
relapse. Lothe et al AJO 2006
 Willian R. Profitt 4 th edition
 Graber vanasdal 6 th edition