This Presentation tells 4th Stage of Comprehensive Orthodontic Treatment in Orthodontics, Retention, which is used to Prevent Relapse after Orthodontic Treatment.

1. RETENTION
in Orthodontics
S a r a n g S u r e s h H o t c h a n d a n i

2. INTRODUCTION
▪ If excellent long term results are to be obtained, the orthodontic
control of tooth position & occlusal relationship must be withdrawn
gradually, not abruptly.
▪ Retention is method of minimizing or
preventing RELAPSE.
▪ DEFINITIONS OF RELAPSE
▪ Return following corrections.
▪ Any change from final tooth position at the end of treatment.
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3. WHY is Retention Necessary?
▪ The gingival & periodontal tissues are affected by orthodontic tooth
movement and require time for reorganization when appliance are
removed.
▪ The teeth may be in an inherently unstable position after the
treatment, so that soft tissue pressure constantly produce relapse
tendency.
▪ Changes produced by growth may alter the orthodontic treatment
results after removal of appliance.
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4. CAUSES of Relapse
• The major causes of relapse after
orthodontic treatment include the
• elasticity of gingival fibers
• cheek/lip/tongue pressures,
• jaw growth.
• Gingival fibers and soft tissue
pressures are especially
potent in the first few
months after treatment ends,
before PDL reorganization has
been completed.
• Unfavorable growth is the
major contributor to changes
in occlusal relationships.
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5. Reorganization of the Periodontal & Gingival
Tissues.
▪ Passive archwire used for stabilization of multiple teeth during orthodontic treatment
cannot be considered the beginning of retention.
▪ Restoration of PDL structures will not occur as long as tooth is strongly splinted to
its neighbours with help of orthodontic arch wire.
▪ Once each tooth can be displaced slightly relative to its neighbour as the patient chews,
reorganization of PDL will start.
▪ Reorganization of PDL occurs over 3 – 4 month period.
▪ Reorganization of Gingival Fibers occurs slowly than PDL.
▪ Collagen fibers of gingiva take 4 – 6 months.
▪ Elastic Supra crestal fibers takes approx. 1 year.S.S Hotchandani 5

6. Why REORGANIZATION OF PDL is Important
for Stability ofTooth in Preventing Relapse.
▪ PDL contribute to equilibrium that normally CONTROLTOOTH
POSITION within its socket.
▪ Teeth tolerate occlusal forces because of SHOCK ABSORBING
CAPACITY of PDL.
▪ RESISTANCE OFTOOTH MOVEMENT caused by prolonged
imbalance in tongue – lip – check pressure or pressure from gingival
fibers occur by ACTIVE STABILIZATION OF PDL.
▪ Orthodontic force reduces the active stabilization of PDL to cause tooth
movement.
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7. PRINCIPLES of Retention
▪ The direction of potential relapse can be identified by comparing the position
of teeth at the end of treatment with their original position.
▪ Teeth will move tend to move back in the direction from which they came, primarily
because of elastic recoil of gingival fibers but also because of unbalance tongue – lip
force.
▪ Teeth require essentially FULL TIME RETENTION after comprehensive
orthodontic treatment for FIRST 3 – 4 MONTHS after fixed orthodontic
appliance removed.
▪ To promote reorganization of the PDL, however, the teeth should be free to move
individually during mastication, as the alveolar bone bends in response to heavy
occlusal load during mastication.
▪ This can be achieved by removable retainer appliance worn full time except during
meals.
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8. PRINCIPLES of Retention
▪ Retention should be continued for at least 12 months (because of slow
response by gingival fibers) if teeth were too much irregular initially.
▪ But this retention can be performed in parts as under;
▪ Full time wear initially for 3 – 4 months
▪ Part time wear after 3 – 4 months.
▪ Retention should be discontinued after approx. 12 months in non
growing patient.
▪ Permanent retention is provided in those cases in which you think
tongue – lip – cheek pressure inevitably cause relapse.
▪ In growing patients, retention should be provided until growth stops.
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9. Occlusal Changes Related to Growth
▪ Malocclusion caused by skeletal growth pattern always
tend to relapse as long as patient is growing.
▪ Long term relapse in transverse dimension are less of clinical
problem because transverse growth completes 1st.
▪ Clinical changes from later antero posterior & vertical growth are
more problematic in growing patient.
▪ Following are conditions mentioned which tend to relapse
in their life after completion of orthodontic treatment;
▪ Class II, Class III
▪ Deep Bite, Anterior Open Bite
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10. RETENTION in CLASS II
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11. Retention in CLASS II
▪ Causes of Relapse in Class II
▪ Tooth movement (forward in maxilla, backward in mandible)
▪ Differential growth of maxilla relative to mandible.
▪ Methods to Control Relapse in Class II Patient;
▪ Overcorrection of occlusal relationship to
control tooth movement.
▪ Fixed appliance approach.
▪ Functional appliance.
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12. Overcorrection of Occlusal Relationship
▪ Even with good retention 1 – 2 mm of antero posterior relapse always
occurs, that’s why we have to overcorrect the position of teeth to prevent it.
▪ Too forward movement of lower incisors is avoided because;
▪ Lip pressure will cause uprighting of protruding incisors, leading quickly (within few months) to
crowding, overbite & overjet.
▪ If MORETHAN 2 MM FORWARD MOVEMENT OF LOWER INCISORS occurred
during treatment, PERMANENT RETENTION will be required.
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13. Fixed Appliance Approach
CONTINUE HEADGEAR to the
upper molars on reduced basis
(at night for instance) in conjunction to
WITH A RETAINER to hold the
teeth in alignment.
Remove all brackets except molar band in which head gear will be placed.
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14. Functional ApplianceTherapy
▪ Use a functional appliance of activator & Bionator type
along with conventional retainer to hold both tooth
position & occlusal relationship.
▪ The construction bite is taken without
any mandibular advancement for
retention.
▪ Goal is to prevent Class II malocclusion
from recurring, not to treat one that is already treated.
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15. RETENTION in CLASS III
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16. Retention in CLASS III
▪ If the face height is normal or excessive after orthodontic treatment
& relapse occurs from mandibular growth, SURGICAL
CORRECTION after growth is completed is only option.
▪ In MILD CLASS III, A FUNCTIONAL APPLIANCE OR POSITIONER
may be enough.
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17. Retention after DEEP BITE Correction
▪ Using a removable upper
retainer made so that the
lower incisors will contact the
acrylic base plate of upper
retainer & upper incisor teeth
contact the facial surface of
lower retainer.
▪ Patient should wear only at night to
maintain the bite depth
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18. Retention after Anterior Open Bite Correction
▪ Relapse into anterior open bite results from Any Combination Of Intrusion
(Depression) Of Incisors & Extrusion (Elongation) OfThe Molars
from;
▪ Thumb sucking, tongue thrusting, placement of objection b/w anterior teeth, downward & backward
rotation of mandible.
▪ In patients who do not place some object b/w front teeth, in them return of open bite results from
elongation of upper molars.
▪ Controlling the eruption of posterior teeth during late vertical
growth is the key to preventing open bite relapse.
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19. Retention after Anterior Open Bite Correction
There are two major approaches to accomplishing this:
▪MAXILLARY RETAINERWITH
BITE BLOCKS
▪HIGH-PULL HEADGEAR.
▪ either must be continued as a nighttime retainer through the late teens.
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20. Retention after Anterior Open Bite Correction
▪ MAXILLARY RETAINER WITH BITE BLOCKS (or a functional
appliance)
▪ Open Bite Activator or Bionator appliance is
used.
▪ to impede eruption, as shown here in a patient
soon after his severe open bite was corrected.
▪ Create separation b/w posterior teeth
▪ better choice for most patients for two reasons:
▪ controls eruption of both the upper and lower molars, and
▪ usually it is better accepted because it is easier to wear.
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21. Retention after Anterior Open Bite Correction
A patient with sever open bite problem is particularly likely
to benefit from having conventional maxillary and
mandibular retainers for daytime wear and open bite
Bionator as night time wear.
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22. Retention of Lower Incisor Alignment
▪ Continued skeletal growth also affects the position of teeth along
with occlusal relationships.
▪ If mandible grows forward or rotates downward due to continued
growth, the effect will be that lower incisors will be carried into lips,
which creates a force causing tipping of lower incisor lingually or
distally.
▪ so that’s why we place retainer in lower incisor crowding treatment
also - FIXED LINGUAL BAR
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23. Timing of Retention: SUMMARY
▪ Retention is needed for all patients who had fixed orthodontic appliance to
correct their malocclusion.
▪ Patient should wear retainer full time for first 3 – 4 months. Continued on
part time basis for at least 12 months to allow remodelling of gingival
tissues. If growth is remaining, wear until growth stops.
▪ Removable retainer should be removed during eating.
▪ Fixed retainer should be flexible so that individual tooth movement can occur.
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24. Timing of Retention: SUMMARY
▪ NO RETENTION CASES;
▪ Anterior cross bite, with positive overbite and overjet following correction; and
▪ Spontaneous alignment following extractions and no active treatment.
▪ MEDIUM-TERM RETENTION: Medium-term retention usually means a period that
allows reorganization of the soft tissues and periodontal ligament, and for adolescent
growth and dental development to be completed, including eruption of the third molars
▪ De-rotation
▪ Diastema
▪ Deep Over Bite
▪ Sk. Discrepancies
▪ Expansion cases
▪ ALMOST ALL CASESS.S Hotchandani 24

25. Timing of Retention: SUMMARY
▪ PERMANENT RETENTION
▪ Severe rotations;
▪ Midline diastema and spacing; and
▪ Periodontal compromised teeth with bone loss
▪ Proclination of the lower labial segment;
▪ Expansion of lower inter canine width;
▪ Alignment of palatally displaced maxillary lateral incisors in the absence
of a positive overbite at the end of treatment;
▪ Correction of an anterior open bite by extrusion of incisors; and
▪ Correction of an overjet with lip incompetence at the end of treatment.
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26. TYPES of
Orthodontic
Retainers
OrthodonticRetainer
RemovableRemovable
Hawley applianceHawley appliance
Begg RetainerBegg Retainer
Wraparound (Clip)
Retainer
Wraparound (Clip)
Retainer
Vacuumed Essix
Retainer
Vacuumed Essix
Retainer
PositionersPositioners
FixedFixed
ActiveActive
Functional
Appliances
Functional
Appliances
Barrer ApplianceBarrer Appliance
HeadgearHeadgearS.S Hotchandani 26

27. REMOVABLE RETAINERS
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28. Hawley Retainer
▪ The classic Hawley appliance consists of an acrylic baseplate with Adams clasps placed
on the first molars and a labial bow with U-loops
▪ It can be used in both the upper and lower arches and has the advantage of being durable.
▪ MODIFICATIONS EXIST INCLUDING USE OF;
▪ a labial bow with acrylic to maintain correction of rotations,
▪ a reverse U-loop to improve canine control, and a
▪ labial bow soldered to the bridge of the Adam clasps for holding the extraction site of
premolar closed.
▪ The baseplate can be modified into a U shape to minimize palatal coverage and
improve comfort and speech.
▪ An anterior bite plane can be included for maintenance of deep bite correction.
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29. Hawley
Retainer
Hawley
Retainer
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30. A. A Hawley retainer for a patient with
maxillary premolar extractions, with the
anterior bow soldered to Adams clasps on
the first molars so that the extraction site is
held closed.
B. The adjustment loop of the Hawley anterior
bow often keeps the wire from having full
contact with the canines. If good control of the
canines is needed, as in this patient whose
canines were facially positioned before
treatment, a wire that extends across the
canines can be soldered to an anterior bow
that crosses distal to the lateral incisor.
C. In a patient whose second molars have
erupted, a wraparound outer bow soldered
to C-clasps on the second molars provides
a way to avoid interference as the retainer
wire crosses the occlusion, but a bow with
such a long span will be quite flexible.
D. 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.
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31. Begg Retainer
is a modified version
of the Hawley retainer
that does not
incorporate Adams
clasps and therefore
allows greater molar
settling.
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32. Wraparound (Clip – on) Retainer
▪ Consists of plastic bar (usually wire reinforced) along
the labial and lingual surfaces of teeth.
▪ A removable clip-type retainer that controls
alignment of only the anterior teeth (3-3 clip or
as shown here, 4-4 clip) often is preferred as a
removable lower retainer because if the lower
posterior teeth were well aligned prior to treatment,
retention of these teeth usually is unnecessary, and
undercuts lingual to the lower molars make it difficult to
place a lower retainer that extends posteriorly.
S.S Hotchandani 32

33. Wraparound (Clip – on) Retainer
▪ 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
contact of the lower incisors with a maxillary clip
retainer often becomes a problem.
▪ Anterior clip retainers in both arches for this patient,
who had maxillary and mandibular anterior spacing
prior to treatment.
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34. Clear (Vacuum Formed) Retainers
▪ These retainers are clear, heat softened
plastic.
▪ Construct by heating a sheet of clear
plastic, which is then sucked down onto a
dental cast by a vacuum.
▪ The material of this retainer is transparent
& thin.S.S Hotchandani 34

35. Clear (Vacuum Formed) Retainers
▪ Advantages of Vacuum Formed Retainers;
▪ Superior aesthetics
▪ Less interference with speech
▪ More economical and quicker to make
▪ Ease of fabrication
▪ Superior retention of the lower incisors
▪ Both Hawley and vacuum-formed retainers are equally
successful in the upper arch, but the VACUUM-FORMED
RETAINERS ARE BETTER AT PREVENTING RELAPSE IN
THE LOWER ARCH.
Description in Notes
S.S Hotchandani 35

36. Clear (Vacuum Formed) Retainers
▪ Vacuum-formed retainers only need to be
worn at night, every night.
▪ It is important that the patient is instructed
never to drink with the vacuum-formed
retainer in situ , particularly cariogenic drinks
▪ The retainer can act like a reservoir, holding the
cariogenic drink in contact with the incisal edges
and cuspal tips and leading to decalcification
▪ Vacuum-formed retainers are CONTRAINDICATED
IN PATIENTSWITH POOR ORAL HYGIENE. This is
because these types of retainers are retained by the
plastic engaging the undercut gingival to the
contact point. If the oral hygiene is poor, then
hyperplastic gingivae can obliterate these areas of
undercut.
Cariogenic drinks and vacuum-formed retainers. It is vital
that patients are instructed not to wear vacuum-formed
retainers when eating or drinking. This patient wore a
vacuum-formed retainer full-time (a), while regularly
drinking fizzy drinks, leading to substantial tooth surface
loss and caries (b).
Cariogenic drinks and vacuum-formed retainers. It is vital
that patients are instructed not to wear vacuum-formed
retainers when eating or drinking. This patient wore a
vacuum-formed retainer full-time (a), while regularly
drinking fizzy drinks, leading to substantial tooth surface
loss and caries (b).
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37. Positioners
▪ They are excellent finishing devices
but sometimes can be used as retainers.
▪ For routine use they are not good retainers.
▪ It is a device with inherent
elasticity to move the teeth
slightly to their final position
as the patient bites into it.
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38. Disadvantages of Positioners
▪ Pattern of wear does not match the
pattern usually desired for retainers.
▪ Patients have difficult due to its bulk.
▪ They are worn less than 4 hours per day.
▪ Does not retain incisor rotation
▪ Increases overbite
▪ Good for open bite cases
▪ Not good for deep bite patients
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39. FIXED RETAINERS
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40. Indications of Fixed Retainers
Keeping Extraction Spaces Closed in adultsKeeping Extraction Spaces Closed in adults
of Pontic or Implant spaceof Pontic or Implant space
Diastema MaintenanceDiastema Maintenance
Maintainace of Lower Incisors Position during Late mandibular growthMaintainace of Lower Incisors Position during Late mandibular growth
S.S Hotchandani 40

41. RETAINERS
for Maintainace of Lower Incisors Position during Late mandibular growth
▪ FIXED LINGUAL BAR
▪ Attached only to canines or canines & premolars.
▪ Rest against the flat lingual surface of lower incisors above
cingulum.
▪ Prevents lingual tipping & rotations of incisors.
▪ This bar is made From Heavy Wire Of 28 – 30 Mil
Stainless Steel with loop bend in the end of wire to
improve retention.
▪ Alternative is 17.5 – 19.5 mil stainless steel twisted/braided
wire. (Described in Next Slide)
Description in Notes
S.S Hotchandani 41

42. RETAINERS
for Maintainace of Lower Incisors Position during Late mandibular growth
Alternative to Fixed Lingual Bar (Braided Wire)
A. Bonding a wire to all the mandibular anterior teeth (canine-
to-canine or premolar-to-premolar) is indicated if spaces
existed in the lower anterior segment prior to treatment, or
if severe rotations were corrected. A light wire (17.5 or 19.5
mil twist) should be used. A retainer of this type must be
kept under observation because a bond failure on one
tooth is unlikely to be noticed by the patient and severe
decalcification can occur in that area.
B. A section of twist wire, usually bonded just on the four
incisors, also can be used to maintain alignment of
maxillary teeth that were severely displaced. Bonded
attachments on the lingual of the upper incisors also can
serve to prevent deepening of the bite as lower incisors
erupt.
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43. RETAINERS
Diastema Maintenance – Bonded Lingual Retainer OR SolidWire
Bonded lingual retainer for maintenance of
a maxillary central diastema.
A. 17.5 mil twist wire contoured to fit
passively on the dental case.
B. A wire ligature is passed around the
necks of the teeth to hold them tightly
together while they are bonded.The
wire retainer is held in place with dental
floss passed around the contact, and
C. composite resin is flowed onto the
cingulum of the teeth, over the wire
ends.
A. Note that the retainer wire is up on the
cingulum of the teeth to avoid contact
with the lower incisors.
B. A Hawley retainer can be worn to stabilize
other teeth and maintain vertical control in
the presence of a bonded segment of this
type.
S.S Hotchandani 43

44. RETAINERS
Diastema Maintenance – Bonded Lingual Retainer OR SolidWire
Solid Wire
▪ An alternative design for a bonded
retainer for the maxillary incisors, using a
heavier wire.
▪ The wire is contoured so that flossing is
not impeded, and the bonded attachment
areas also serve to keep the bite from
deepening, but the patient will have to
tolerate more tongue contact with a
retainer of this type, and
▪ overgrowth of palatal gingiva can become a
problem
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45. RETAINERS
Maintenance of Pontic or Implant Space
▪ For PosteriorTeeth missing space;
A – Splint.
▪ For anterior teeth missing space,
artificial tooth in a removable retainer.
DescriptioninNotes
S.S Hotchandani 45

46. Fixed Retainers
▪ Advantage
▪ they are not dependent on patient compliance for wear.
▪ Disadvantages
▪ difficulty with oral hygiene,
▪ localized relapse and
▪ Decalcification following partial debond.
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47. ACTIVE RETAINERS
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48. Active Retainer
▪ It is misnomer, since a device cannot actively move teeth & provide retention at the same
time.
▪ However sometimes relapse or growth after orthodontic treatment lead to change in
treated position, so in that case we will need a an appliance which initially correct the
relapsed tooth position followed by providing retention.
▪ That’s why active retainer are mostly given in following conditions;
▪ Realignment of irregular incisors with spring retainer (Barrer Spring)
▪ Management of class II or Class III relapse with functional appliance
▪ Headgear
▪ Activator or Bionator type
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49. Realignment of Irregular Incisors: Spring Retainers
▪ Re-crowding of lower incisor is the major indication for active retainer to correct the
incisors position.
▪ If the irregularity is moderate, spring retainer of choice is canine
to canine clip on retainer.
▪ If the irregularity is more than moderate, retreatment with fixed
appliance is treatment of choice.
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50. Canine – to – Canine Clip – On Retainer
for Realignment of Irregular Incisors (STEPS)
1) Reduce inter proximal width of
incisors & apply topical fluoride to the
newly exposed enamel surface.
▪ Enamel can be removed with following
devices
▪ Abrasive strips
▪ Thin discs in hand piece
▪ Thin flame shaped diamond stones
▪ Maximum enamel which can be
removed is 0.5 mm on each side
of tooth.
2) Prepare Laboratory Model on
which teeth can be reset into
alignment.
3) Fabricate canine to canine clip
on appliance.
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51. Removal of interproximal enamel to facilitate alignment of
crowded lower incisors.
A and B, Before and after use of a carbide coated
strip to remove enamel. The surfaces are polished after the
stripping is completed. Topical fluoride should be applied
immediately after stripping procedures because the fluoride-
rich outer layer of enamel has been removed.
C, A canine-to-canine clip-on retainer (now; initially an aligner)
immediately upon placement must be worn full time until the
teeth are back in alignment.S.S Hotchandani 51

52. Steps in the fabrication of a canine-to-canine clip-on appliance to realign lower incisors.
A. Re-crowded incisors in a patient who decided to “take a vacation” from retainer wear. After the teeth have been
stripped appropriately, an impression is made for a laboratory cast.
B. A saw-cut is made beneath the teeth through the alveolar process to the distal of the lateral incisors, and cuts
are made up to but not through the contact points.
C. The incisor teeth are broken off the cast and broken apart at the contact points, creating individual dies, and
the cast is trimmed to provide space for resetting the teeth; then the teeth are reset in wax in proper alignment
and 28 mil steel wire is contoured around the labial and lingual surface of the teeth as shown, with the wire
overlapping behind the central incisors. A covering of acrylic is added over the wire, completing the aligner,
which then looks exactly like a canine-to-canine clip-on retainer. As an aligner, however, full-time wear is
essential.
S.S Hotchandani 52

53. Fixed ApplianceTherapy
for Realignment of Irregular Incisors
For this patient, who was concerned about crowding of lower incisors several years after orthodontic treatment,
excessive stripping of interproximal enamel would have been required to gain realignment with a clip-on removable
appliance. In that circumstance, a partial fixed appliance with bonded brackets only on the segment to be realigned is
the most practical approach.
A, Bonded appliance from first premolar to first premolar, with a coil spring on 16 steel wire to open space for the rotated and
crowded right central incisor. B and C, Alignment of the incisors on rectangular NiTi wire after space was opened, which was
completed 4 months after treatment began. At this point a fixed lingual retainer can be bonded before the brackets and archwire
are removed. S.S Hotchandani 53

54. References
▪ Cobourne, M. T. (n.d.). Handbook of Orthodontics. Mosby.
▪ Gill, D. (n.d.). Orthodontics at a Glance.
▪ Mitchell, L. (n.d.). Introduction to Orthodontics (4 ed.).
▪ Proffit, W. R. (n.d.). Contemporary Orthodontics (6 ed.).
S.S Hotchandani 54

55. THANKS
Sarang Suresh Hotchandani
FinalYear BDS, Bibi Aseefa Dental College, SMBBMU.
Larkana, Sindh, PAKISTAN.
Email: hotchandanisarang@gmail.com
Twitter: www.twitter.com/fetusdentistaS.S Hotchandani 55