LD Retention and Relapse

Retention and relapse in orthodontics
Introduct
ion
The problem of retention and relapse was born with the science of Orthodontics
and continues to persistently plague Orthodontic researchers and clinicians. Most authors of
Orthodontic textbooks, from Angle to the present-day writers, have included the chapters on
retention and relapse in their publications. In spite of all the advances in the active treatment
procedures, very few practitioners underrate the significance of retention. We are yet puzzled
how to solve the problem?
With the establishment of concept of normal occlusion and the classification scheme
that incorporated the line, by the early 1900s orthodontics was no longer just the alignment
of irregular teeth, instead it had evolved into the treatment of malocclusion. Since precisely
defined relationships require a full complement of teeth in both arches, maintaining an intact
dentition becomes an important goal of orthodontic treatment. Angle and his followers
strongly opposed extraction for orthodontic purposes. Treatment goal during this period was
Ideal Occlusion.1
With the entry into 21st century, the goals have somewhat appeared to change. The
goal of Modern Orthodontics is creation of best balance among occlusal relations, dental and
facial esthetics, stability of the results and its long term maintenance and restoration of
dentition (TWEED)1. Aims of orthodontic treatment have been summarized by Jackson as
Jacksons triad. The three main objectives are:
(a) Functional efficacy
(b) Structural balance
(c) Esthetic harmony
Retention is that part of orthodontic treatment during which a passive appliance is
used to maintain orthodontic correction of dental and skeletal structures and thereby
counteract relapse or the tendency for return of characteristics to original malocclusion.2
Retention was defined by Moyers 3 as the holding of teeth followed by orthodontic treatment
in the treated position for the period of time necessary for the maintenance of the results.
Riedel4 defined retention as the holding of teeth in ideal esthetic and functional
position.
Relapse may be defined as return of the corrected malocclusion towards the original
condition.
Moyers3 defined relapse as loss of any correction achieved by orthodontic treatment.
The retention period has even been called Secondary orthodontic treatment. 5 Although it
has been stated that correct diagnosis and planning of treatment, followed by a careful
stabilization of the final result, would minimize the importance of retention, relapse
tendencies still exist in a fairly high percentage of cases treated. Even if these precautions are
taken, however, relapse after tooth movement still remains a complex problem, with a
varying number of factors involved.
Orthodontists have been concerned by relapse process for decades. Several studies
have been carried out to determine the changes taking place several years after orthodontic
treatment and the influencing factors. Factors including growth, periodontium, age, third
molars, tooth dimensions etc have been held responsible for post treatment relapse. Several
procedures have been devised to ensure stability and prevent or at least avoid post treatment
changes so as to reduce relapse. To achieve this purpose, a proper understanding of the
changes occurring, various factors affecting relapse and retention procedures is important.
Thus our Orthodontic forefathers faced the problems of retention and the continued
trend, which owes to the biological and mechanical limitations, demands every Orthodontic
student to go through the state of art of this perineal problem Retention and Relapse which
also is the purpose of this library dissertation.
Historical background 6
A look back at the origins of orthodontics (Weinberger) has shown that the necessity
of retention was not mentioned until about 19 centuries after the first treatment modality was
described and would provide a clue to establishing the priority of the esthetic needs of the
prospective orthodontic patient. As Weinberger states, Although orthodontics had its origins
in medicine, it had its beginnings in aesthetics. Likewise, the modern well-trained clinical
orthodontist has recognized that the most desirable facial-dental esthetics may be just as
important as excellent posterior occlusion and good function-possibly more so from the
standpoint of the patients needs. However, there appears to be as much controversy over the
present treatment methods of achieving facial-dental objectives as there was in the Case,
Dewey, Cryer extraction-nonextraction controversy in 1911, which still persists three fourths
of a century later in the writings of Tweed, Ricketts, Begg, Ten Hoeve, and Williamson.
Additional insight into the retention problem may be gained and our present day
limitations in achieving predictable stability appreciated when we learn about the antiquity of
some of our still current modes of orthodontic treatment. In the beginning, says Weinberger,
people sought relief because of the disfigurement of the crooked and irregular placed teeth;
the first century Roman writer Pliny & Galen, his countryman in the second century who was
the founder of experimental medicine, both recommended filing when a tooth projected from
trauma and other reasons. Five centuries later, Paul of Agina (625-690), the classical Greek
author, was first to consider that if supernumerary teeth cause irregularity of the dental
arches, they may be corrected by resection of each tooth or by extraction.
It was not until ten centuries later that Pierre Diones (1658-1718) appeared to be the
first to open or widen the teeth when they were set too close together. Indeed, while
significant works on orthodontic etiology, classification and mechanical treatment techniques
were published by Pierre Fauchard (1728), Bourdet (1757), Fox (1803), Delabarre (1819),
Schange (1841), and Harris (1842), we gained little, if any, knowledge as to the concern
about stability of treatment until 1860. In that year Emerson C. Angell (1860), as a byproduct
of his palate-splitting procedure, mentions the necessity to preserve or retain space. Angell

described his method of employing a jackscrew forrapid opening of the maxillary median
suture or to enlarge the face in the maxillary dental arches, in order to establish occlusion
without extraction of teethThe time for this expansion need not exceed two weeks, after
which it is only necessary to preserve or retain the space until complete eruption and
development of teeth in question.
Only 5 years later in England, Alfred Coleman (1865) wrote about restoration of the
former condition by muscular pressure-in other words, the first illusion to relapse. More than
a century later, clinicians still refer to abnormal muscular pressure as a dominant factor in the
cause of relapse. In the following year, C.A. Marvin (1866) described the physiologic reasons
for retention. Indeed, he went a step further in his writing and emphasized the necessity of
the preservation of correct facial expression or aesthetics as one of the objectives of
orthodontic treatment. Not long after, Brown-Mason (1872) (in England) described a
retaining plate for surgically rotated teeth. Thus, after more than 19 centuries of some kind of
mechanical orthodontic intervention, recognition of the possible instability of treatment
emerged and the concept of a retaining appliance was born.
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. In
1883, H.C. Quinbey described a slightly more sophisticated maxillary retaining plate that had
strips of metal extending from the vulcanite plate over the anterior teeth.
Jackson (1904) mentioned the importance of retention and designed many retaining
devices-some permanent when necessary. Also, to prevent the tendency of the teeth to change
their positions after the removal of the retainer, he suggested that after they have been
rotated as far as desired, the soft tissue be separated from the neck of the tooth and allowed to
reunite in the new location, depending upon the cicatrix thus formed to prevent their
retrograde movement-in short fiberotomy.
Angle stated that obtaining normal occlusion (with steep cusp height) during the
eruption period would decrease retention time, but added that when habits are not overcome
and the rotations and disturbance to the fibers of the periodontal membrane are very marked,
he described cutting gingival fibers to counteract this in his sixth edition publication (1900).
He warned that most appliances were removed too soon before teeth were thoroughly

established in occlusion, and he advised, In doubtful cases, wearing delicate and efficient
appliances indefinitely may be far less objectionable than a malocclusion.
Finally Angle devised and described many ingenious mechanical combinations of
cemented bands and spurs, the action of which were, to quote his uniquely descriptive phase,
to antagonize the movement of teeth only on the direction of their tendencies. Also in his
quest for the ultimate retainers, it is interesting to note that Angles intricate pin and tube
active treatment appliance was developed primarily as a working retainer to achieve bodily
movement or uprighting of teeth that had been tipped outward in expansion.
In his article, Principles of Retention, Case listed the following principles: Post
treatment influence of surrounding tissues would return to their former irregular position
after retention primarily because of the more important factor of hereditary; stretched and
bent fiber structures would be brought to equilibrium in their changed positions by the
physiologic process of nature; retention should be of adequate force to antagonize reactive
tendencies for relapse and held, often indefinitely by a fixed appliance, unless teeth are
brought to positions of what he called positive self-fixation by occlusion; over correction
and slower movement of teeth; use of inconspicuous fixed retainer, incorporation of strong
intermaxillary and vertical elastics with chin cups to overcome the reactive or relapsing
forces of the corrected mesial or distal occlusion as well as open or closed bites; for retaining
diastemata of both the maxillary and mandibular anterior teeth, gold staples were cemented
into drilled preparations in all lingual cingula, which remained in place for more than 20
years.
A hundred years ago, Bonwill described an ideal morphologic arrangement of teeth
and jaws based on his study of more than 2000 skulls. He placed study models in anatomic
articulators, used wax set-ups of plaster teeth for extraction decisions; and thoroughly
informed his patients on the limits of treatment and the necessity of adequate retention.
Normal Kingsley (1908), who is referred to as the Father of Orthodontia, in a letter
(his last published article) to the alumni of the Angle School of Orthodontia written 50 years
after his first article appeared, had these prophetic words to say about retention.
It is not so difficult to straighten crooked teeth, to get the dental system into a position
acceptable to your patients and yourself, but to hold it there until it becomes permanently

settled, is a much more serious problem. It is the one important consideration in all your
prognosis, and the success of orthodontia as a science and as art lies in the [retainer]
Ferrar (1831-1913), also referred to as one of the fathers of orthodontics-that is,
scientific orthodontics-the man who introduced the term intermittent force and wrote,
according to Weinberger, the greatest text on orthodontia in his experience, said (about
retention) that when the teeth are fully regulated they should be retained in position for a
year, perhaps longer.
In summary, in the little more than one half century following Angells use of a
retaining plate in his palate-splitting technique, there was general adherence to the necessity
of retention and even a similarity of appliances, but the knowledge gained was based solely
on the clinical experience and observation of the aforementioned pioneer orthodontic
masters.
The next quarter century witnessed the much needed addition of a more scientific
dimension to the retention literature as the clinical reports of the duration of a variety of
retaining appliances and the observations and opinions advocated by (1) the following
orthodontic innovators and clinical scholars: Hawley (1919), Hahn (1944), Lundstrom
(1929), Hellman (1936), Mershon (1936), Marcus (1938), McCauley (1944), Tweed (1954),
and Grieves (1944); (2) experimentally trained research-oriented orthodontists, Skogborg
(1929) and Oppenheim (1935) and (3) the research-oriented periodontists, Gottlieb (1938)
and Orban (1936), who published histologic studies of alveolar tissue and periodontal
membranes during tooth movement and retention in animals.
Hawley (1919), whose name is synonymous with retainers, said that because of the
difficulty, he would give half of his fee to anyone who would be responsible for the
retention of his results when the active appliance was removed.
Lundstroms (1929) clinical studies on apical base limitation did much to counteract
the dominance of the expansionists led by Angle. Lundstroms work appears to have been
fundamental in helping to reduce the relapse problem created by the overexpansionists.
Hellman, the leading scientific spokesman of orthodontists of his generation, admitted
he was in complete ignorance of retention in the individual case.
Mershon (1936), who is credited with the introduction of the lingual arch in clinical
orthodontics, thought alternating rest periods with active treatment would aid retention, but

likened the final positioning of teeth to an argument in which mother nature always had the
last word.
Hahn (1944), dismayed by the apparent lack of will of the majority of the profession
to study the retention problem adequately, observed that retention in orthodontics is like a
neglected step child.
In another view, McCauley (1944) a prophet before his time, proclaimed the
importance of canine position and referred to the canine rise as a protective mechanism for
maintaining arch stability.
Concurrent with the above-mentioned work of clinical scholars, Orban (1936),
Gottlieb (1935), and Oppenheim (1935) presented the first American orthodontic literature on
microscopic studies of bundle and lamella bone specules, describing the bone reorganization
that occurs during active treatment and retention. However, the fulfillment of the expectation
that there would be clinical evidence and some predictability on a biologic basis for treatment
stability or for the duration of retention was not forthcoming.
In the absence of well-designed clinical studies, it is noteworthy that in the latter part
of the second quarter of the century and even into the 50s and 60s, there was a dichotomy of
the thinking and approach to the problems of retention and treatment instability. An
examination of the writings of Anderson (1942), Fischer (1943) (who quotes Hirdlicka), and
Schwartz (1967) will tend to show a theoretical similarity in their belief in the inevitability of
the dominance of the original facial-dental growth pattern in which active treatment is only
an interlude. Enlow (1980) reiterated this idea and Horowitz and Hixon (1966) did likewise,
but referred euphemistically to any posttreatment change as physiologic recovery.
On the other hand, there was an individual or unique stance by Rogers, Skogsborg,
Wallace (1927), Lundstrom, Grieves, Tweed, McCauley, and later Strange, who advanced
scientific solutions to the retention problem if certain tenets of active treatment were
controlled, adhered to, or not exceeded. All of the above investigators espoused limited
duration of retention except for Strange, who disclaimed the need for an immediate
posttreatment retainer.
Specifically, Fischer (1943), a believer in the dominance of the original growth
pattern, strongly emphasized the importance of retention in his writings. In his textbook,
Fischer quotes the anthropologist Hirdliekas generic statement that If regular growth of any

part of the body is interfered with by any cause, related parts tend towards compensation.
Thus, Fischer believed that a compensatory adjustment of facial growth would occur after
orthodontics since there has been an interference in the unfolding of the face. He continues:
Very often the orthodontic forces are but an interlude in the continuous development of the
face, and pre-treatment and post-treatment stability is a result of an equilibrium between the
component parts of the dental- facial complex and in the random and dynamic changes
occurring posttreatment, the denture must be protected or retained during the active period
of facial-dental growth changes or at least until cessation of major growth changes.
Schwartz reiterated this theme and described internal oppositional forces or
electric effect that was beyond the control of the orthodontist. During the posttreatment
period, Schwartz said Internal and external forces playing on the denture lead to zero and
stability. It is only a momentary static situation, because growth and change is occurring and
the equilibrium that results must somehow anticipate and include both growth and change to
insure stability.
In direct contrast, George Grieves (1944) believed that the cause of most
malocclusions was the forward translations of teeth (in agreement with a similar proposal in
the earlier work of J. Simms Wallace, 1927) and that when teeth have been placed backward
and upright over basal bone they would be stable and hence have no need for retention.
Although Tweed advocated placing teeth back and upright over basal bone, he prescribed 5
years retention in most cases and even longer periods when needed.
George Andersons (1942) observations led him to the conclusion that nothing was
stationary in the human masticatory field.
There has been stability worthy of the name in the developing masticatory field or in
the fully erupted denture, and that retention was not a minor but a very serious matter and a
basic part of orthodontic therapy.
During this same period, the application of facial, jaw and body muscular exercises
(myofunctional therapy) with fixed appliances for successful treatment and retention was
brought forth in a series of publications from 1935 to 1951 by Alfred P. Rogers (1951).
In contrast, Dallas McCauley (1944) placed great emphasis on maintaining canine
position, arch form, and width as related to functional jaw movements to achieve
posttreatment stability.

Stedman (1961, 1967), in a comprehensive approach to retention, referred to an
enlarged pharyngeal space, emotionally initiated mentalis or mimetic muscle hypertension,
and anterior component of force of mandibular third molars because of insufficient growth as
factors in bringing about undesirable posttreatment changes or relapse.
Stedman advocated the use of specially constructed, fixed and removable retainers
and he may have implied their long-range use when it was not the case in his theoretical
statement:
Lasting occlusal changes occur only in these particular patients whose internal forces
have changed in such a manner during treatment and retention as to support those particular
teeth in the newly acquired positions, with new functional and emotional habits.
Riedels (1960) comprehensive review of retention was a forerunner of his subsequent
10-year post-retention relapse studies and those of his graduate students at the University of
Washington in Seattle. These and the multitude of postretention relapse studies by others
report their extensiveness, unpredictability, and severity, and are the grim realities facing the
orthodontic clinician.
In essence, these relapse tendencies were graphically described by Graber (1966) and
by King (1974).
Very often the characteristics of the malocclusions by which we determine
classification seem to reoccur in an alarming degree post-retention. Relapses of crowding,
rotations, mesio-distal relations, overbite, overjet and arch width and form reappear
subsequent to retention. There is no assurance that relapse will not happen even when surgery
is combined with orthodontic treatment.
King describes the characteristics of post-retention relapse as an overall slipping
back or dental changes, very much in agreement with Graber.
In specific postretention relapse studies, attention has been focused on the stability or
relapse of canines and molar width, mandibular arch form, mandibular incisor crowding,
rotations, overbite and overjet, and the presence or absence of mandibular third molars. In all
these studies, extraction or nonextraction, there appears to be sufficient unpredictability of
which cases will or will not relapse for all but a minority of treatment procedures.
The relapse tendencies reported in the above-mentioned studies have occurred with
treatment using what has been considered to be conventional orthodontic forces. It is

important to know whether there is a difference in the effect of the orthopedic palate-splitting
forces reintroduced clinically by Derichsweiler (1956) and continued by Korkhaus (1960) in
Germany. Soon after Graber and Haas reported clinical (extraoral and palate- splitting)
studies, and McNamara reported experimental studies. Experimental and clinical reports on
the effect of high-pull orthopedic forces by Watson (1972), Thompson (1974), Elder and
Tuerge (1974), Cleal (1974), and Wislander (1974) differ on the extent of skeletal stability,
but show high agreement to the effect that dental instability or relapse, especially mandibular
incisor changes following orthopedic forces, is consistent with the continuing changes that
occur in conventional force treatment.
There is a recent trend of orthodontists in the United States to report the use of
activators and/or functional appliances, alone or as a preliminary to a secondary period of
treatment, using a multibracketed fixed appliance. Along with this trend, there is also the
belief that the results will be more stable.
Reitans (1959, 1966, 1967) microscopic studies of postretention treatment changes
excited the orthodontic community worldwide. He demonstrated in animal studies that the
supracrestal gingival fibers (collagenous) appear histologically taut and directionally
deviated after tooth rotation, and that this condition did not lessen even after years of
retention.
In response to Reitans work, many surgical approaches with experimental animals
and human subjects to control or lessen rotational relapse in orthodontic treatment have been
reported in the literature.
Kole (1959) removed the buccal and lingual cortical plates on human patients before
initiating orthodontic movement, somewhat reminiscent of the septotomy of Talbot (1896)
and Skogsborg (1927). Thompson (1958) (repeated by Boese in 1969) removed all the
attached gingival tissue on experimental animals, leaving only the mucosa surrounding
rotated teeth.
Edwards (1970) clinical orthodontic study was based on Bauers (1963) thesis
describing mesial and distal incisions of transseptal fibers of rotated teeth in experimental
animals and Edwards own similar animal study (1968).
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Parker (1972), in a clinical study of transseptal fibers, states: Rotational relapse is a
normal, predictable, physiological response to abnormal forces The paralleling of tooth
roots, discriminate transection of free gingival fibers and adequate retention time are very
important and useful adjuncts to stability in treated orthodontic cases.
With the growing evidence that the presence of intact transseptal fibers was the major
villain in rotational relapse, Kaplan (1976) undertook a natural survey of 1000 orthodontists
to determine the extent of circumferential supracrestal fiberotomy as an adjunct to retention
procedures. He concluded:
While it appears that this surgical technique is not widely prescribed, it seems
reasonably problem free and its use will probably be increasing in the future. [He cautions,]
There are as yet no follow-up studies of the efficacy of this treatment procedure.
Finally, Schacter and Bernicks (1974) conclusion, in an experimental study on
nonhuman primates that their study did not answer the problem of why certain rotations do
not occur even after surgical transection of the fibers must be pertinent to all
aforementioned fiberotomy studies.
Almost in lieu of retention or in retreatment, there have been studies of stripping
either to prevent rerotation of the mandibular incisor or to correct the relapse of the
mandibular incisors, followed with or without retaining appliances. Kelston (1969) presented
a technique for realignment with wires and ligatures after stripping of crowded lower incisor
teeth. Paskow (1970) reported self-alignment following interproximal stripping of lower
incisors and was indefinite about retainers. Boese reported a combined procedure of stripping
and circumferential supracrestal fiberotomy with no lower retainer placed. In his 4-9 years
follow up, he noted that the lower incisor segment did move, but moved in a unit rather
than each tooth individually. He concluded:
CSF and reproximation is not a guarantee for permanent ideal lower anterior tooth
alignment, but was perceived as a useful process, which appears to work within a framework
of natural changes that inevitably will occur.
Williams (1985), in addition to stripping, added five other treatment keys, which he said
will eliminate the need for lower retainers, but he showed a 2-year follow-up of one case.
These approaches and that of Peck and Pecks (1972) reproximation studies are seemingly
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based upon the theoretical concept of polished broad contact areas described by Begg in
Stone Age men. Begg made the deduction that it was the primitive rough diet of the
Australian aborigines that was responsible for well-aligned teeth. On the other hand, it was
believed that failure to achieve polished broad contact areas during and following orthodontic
treatment of modern civilized man with a lack of comparable attrition would require a
technique for realignment and stripping of crowded lower incisors to prevent or correct
relapse.
Waldron (1942) designed his retaining appliances on the basis of the rationale of
Oppenheim, the researcher, and Mershon, the clinician, who had emphasized the need to
allow for functional adaptation of muscles and bones during the retention period. Waldron
advocated removable appliances, empirical retention time, myofunctional therapy, bilaterally
balanced occlusion based on true centric denture and jaw relationship, and extraoral
appliances in many class II and class III cases to supplement the customary removable
retainers.
Ten years after Riedels classic review article on retention (1960), and nearly three
decades after Hahns (1944) reference to the neglect of the importance of retention, Muchnic
(1970) informed his patients:
In most cases the retention period was planned with expected growth and maturation
in mind, because the forces which work so efficiently in treatment to inhibit growth in one
area while allowing growth to continue in another should not necessarily be discontinued
because the bands have been removed and the teeth are in proper occlusion.
In 1970, Fogel & Mcgill carried out a retrospective study on progressive dental-facial
changes after treatment and retention of 21 cases-seven nonextraction and 14 extraction
showing good stability. It was a small sample with some mandibular and maxillary crowding,
although of a degree not entirely objectionable.
In an interview by Brandt, Tweed (1968) replied to questions on orthodontic relapse
that the crowding of lower incisors can and does occur especially in type C growth trendsthat is where the mandibular growth direction is downward and forward and usually
outspaces the maxilla, although not to the extent that it becomes a class III.
In anticipation of this growth trend, Tweed advocated a lower canine-to-canine lingual
bar retainer and replacement of the labial bow of the maxillary removable retainer with
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anterior hooks using latex elastics and a bite-plate, which would permit the maxillary incisor
teeth to tip slightly labially.
Tweed referred to a retrospective study (25 years posttreatment) on retention that he
had conducted on a follow-up group of his own patients consisting of 100 extraction and 100
nonextraction cases. He said that in general while many patients (had) lovely faces & teeth,
in others, the picture [was] the opposite and that the extraction cases seemed to be nicer
than nonextraction cases many years after treatment.
Tweed acknowledged that in his opinion abnormal muscle function was a major
factor in relapse even though he did not know how much one could change muscle function
as a result of orthodontic procedure. Nevertheless, he said he would try to overcome the
perverse muscle and tongue habits.
Sandusky (1984) reported a postretention relapse study (10-year average) of 85 Tweed
treated cases-45 by Tweed himself and 40 by Tweed foundation members. The mandibular
incisor relapse was shown to be quite small less than 10% using the Little index-but other
changes occurred, namely, forward movement of lower incisors and change of occlusal
plane.
At the same time, Little (1984) reported on a 10-year postretention relapse study of
450 cumulative cases from the University of Washington group at Seattle, led by Riedel.
Little showed that 66% of these cases exhibited mandibular incisor relapse with no statistical
support of predictability of which cases would relapse and which would remain stable.
Philosophies or schools of thought of retention
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For many years clinicians did not agree about the need for retention. Over the years,
different philosophies or schools of thought have developed in regard to the retention and our
present-day concepts generally combine several of these.7
1)
The occlusion school:

Kingsley (1880) stated, The occlusion of the teeth is the most potent factor in
determining the stability in a new position. Many early writers considered that proper
occlusion was of primary importance in retention and has been repeatedly stressed in the
literature (Reitan, Schudy, Kahl Nieke). Angle believed that permanency of treatment result
could be ensured by creating a normal occlusion with a full complement of teeth, provided
there was adequate retention and vigorous masticatory function.
2) The apical base school:
In the middle 1920s a second school of thought formed around the writings of Axel
Lundstrom, who suggested that the apical base was one of the most important factors in the
correction of malocclusion and maintenance of a correct occlusion. His clinical studies on
apical base did much to counteract the dominance of the expansionists led by Angle. He
stated that occlusal function alone could not control the form and amount of apical base
rather the apical base is in largely capable of affecting the dental occlusion. Dallas McCauley
(1944) placed great emphasis on maintaining canine position, arch form and width as related
to functional jaw movements to achieve post treatment stability. He suggested that
intercanine width & intermolar width should be maintained as originally presented to
minimize retention problems. Strang further enforced and substantiated this theory. Nance
(1947) noted that, arch length may be permanently increased to a limited extent. This
school of thought suggested that mandibular intercanine width and intermolar width
dimensions show a strong tendency to relapse and should be considered inviolate.
3) The mandibular incisor school:
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George Grieves (1944) stated that cause of most malocclusions was the forward
translation of teeth and that when teeth have been placed backward and upright over basal
bone they would be stable and hence have no need for retention. Tweed (1944,1952) also
suggested that the mandibular incisors must be kept upright and over the basal bone.
4) The musculature school:
Alfred P. Rogers (1922) introduced a consideration of the necessity of establishing
proper functional muscle balance. Other corroborated this theory. Strang (1956) stated as
follows-The width as measured occurs from one canine to another in the mandibular
denture, is an accurate index to the muscular balance inherent to the individual and dictates
the limits of the denture expansion in this area of treatment. Adverse / abnormal muscle
activity has been variously proposed by many authors including Coleman, Angle, Case,
Strange, Tweed, Stedman and Rogers as, if not the cause, then atleast a major contributing
factor of relapse.
Orthodontists have come to realize that retention is not separate from orthodontic
treatment but that it is part of treatment itself and must be included in treatment planning.
Stability has become a primary objective in orthodontic treatment, for without it
either ideal function or ideal esthetics, or both, may be lost. Retention depends on what is
accomplished during treatment. Care must be exercised to establish a proper occlusion within
the bounds of normal muscle balance and with careful regard to the apical base or bases
available and the relationships of these bases to one another.
Basic theorems of retention7, 8
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Theorem 1: Teeth that have been moved tend to return to their former positions.
There is little agreement as to the reason for this tendency; suggested influences
include musculature, apical base, transseptal fibers, and bone morphology. Whatever the
reason, there seems to be general agreement that teeth should be held in their corrected
positions for some time after changes are made in their positions. Only a few orthodontists
have suggested that retention is routinely unnecessary. The question of why teeth have a
tendency to return to their former positions has, to this date, no real answer.
Theorem 2: Elimination of the cause of malocclusion will prevent recurrence.
Until more is known about the causative factors that are related to particular types of
malocclusion, little can be done about their elimination. Therefore, a proper diagnosis based
on determining the cause of the malocclusion is invaluable.
When obvious habits such as thumb or finger sucking or lip biting or tongue thrusting
are the causes of malocclusion, little difficulty is presented in diagnosis of the determining
cause. Unfortunately many of our malocclusions appear with apparently unknown origins or
at least origins about which we can do little. Certainly heredity plays a most important part in
determining the presence of many malocclusions. It is important, however, in regard to
retention, that the causative factors for a given malocclusion be prevented for recurring.
Theorem 3: Malocclusion should be overcorrected as a safety factor.
Therefore, it is well to overcorrect the various malpositions and malrelations of teeth
and jaws. It is common practice on the part of many orthodontists to overcorrect class II
malocclusions into an edge-to-edge incisor relationship. Orthodontists must be aware,
however, that these overcorrections may be the result of overcoming muscular balance rather
than absolute tooth movement. The unrestricted use of class II elastics sometimes produces a
mesial displacement of the mandible, which is almost impossible to detect until elastics have
been discontinued long enough to allow normal mandibular posture.
The same phenomenon may be seen in the use of class III elastic forces. The use of
elastics must be likened to the use of traction forces in orthopedic surgery, in which muscular
forces are overcome by constant pull. However, absolute overcorrection is possible and has
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been demonstrated in many instances. Overcorrection of deep overbite is an accepted
procedure in many practices.
Certainly, satisfactory maintenance of overbite correction depends on the
establishment of satisfactory correction during treatment.
One of the most irritating types of relapse is the tendency for a previously rotated
tooth to rotate towards its former position. Little evidence is available to show that
overrotation has been carried out and there is even less evidence to indicate that such
overrotation is successful in preventing the return to the former position.
Theorem 4: Proper occlusion is a potent factor in holding teeth in their corrected
positions.
An orthodontist should attempt to produce the best possible occlusion of the teeth.
The influence of occlusion is a factor in retention which has often been mentioned and
certainly the best possible occlusion is a factor in the retention of corrected malocclusions.
Whether or not it is the most important factor is certainly debatable. In too many instances
we have seen teeth, even with high cusps, locked into normal occlusion that will still tend to
return to their former positions. It is evident that many orthodontists consider the denture
from a static viewpoint, i.e., with the teeth in occlusion. The functional relationships of teeth
are certainly important factors in retention and this has been recently emphasized by
numerous authors directing our efforts toward proper occlusal equilibration. From the
standpoint of reducing the potential of irritations to the periodontium, an excellent functional
occlusion is certainly to be desired.
Orthodontists often blame overfunction or pounding of the mandibular canines by the
maxillary canines as a cause of relapse in the mandibular anterior area. The everyday
evidence presented by the tremendous wear that may teeth undergo would indicate that they
do not move in response to repeated grinding and tapping until the bone has either been so
thoroughly destroyed that it allows their migration, or until fibrous tissue builds up to a
degree where it actually moves the teeth and function on these teeth is actually not possible.
Certainly instances of mandibular anterior irregularity or collapse are common, in which
canines either have not yet erupted or are not actually in occlusion. No doubt, we can say that
a perfectly normal denture functions best.
17
Theorem 5: Bone and adjacent tissues must be allowed to reorganize around newly
positioned teeth.
Some type of retaining appliance should be used either fixed and rigid or an appliance
that is inhibitory in nature and not dependant on the teeth for some length of time.
Histological evidence indicates that both bone and tissue around teeth which have been
moved by orthodontic appliances are altered and that considerable time must elapse before
complete reorganization occurs. Some authors have indicated that retainers should be fixed
and rigid such as Angle, who suggested G wire, band and spur type attachments, bands
soldered together etc. Others have indicated that retainers should only be inhibitory and have
no positive fixation to allow for the natural functioning of teeth. It has been suggested that
the mandibular lingual arch admirably suits this description. Oppenheim suggests that
appliances should be only inhibitory in nature and that repair of tissues around the teeth
occurs much more rapidly if no fixed type of retaining appliance is used.
All these suggestions are based on the presumption that mature bone will ensure
greater stability for the teeth. Present-day orthodontic concepts, however, regard bone as
being a plastic substance and consider tooth position to result from equilibrium of the
muscular forces surrounding the teeth. The placement of retentive appliances is an admission
of inadequate orthodontic correction or of a predetermined decision to place teeth in
relatively unstable positions for esthetic reasons. Whether stability increases with prolonged
retention is one of the most interesting points of discussion in regard to retention planning
and is the phase of treatment that is most difficult to quantify. Documentation and control of
such variables as cooperation, length of retention time, growth, and appliance design make
this type of investigation difficult to interpret.
Theorem 6: If the lower incisors are placed upright over basal bone, they are more
likely to remain in good alignment.
Therefore, our attention should be directed towards the proper angulation and
placement of the mandibular incisor segment.
The difficulty in evaluating this contention revolves around proof of the fact that
incisors have been placed upright over basal bone. The term upright is definable:
18

perpendicular to the mandibular plane, or a plus or minus 5 from mandibular plane, or a
relation to occlusal plane, or Frankfort horizontal plane. As to what is basal bone, there is no
experimental evidence to indicate that anyone can specify that where this bone begins or
ends, and there seems to be no satisfactory method of measuring it.
It has sometimes been assumed that teeth that are upright are also over basal bone.
However, in certain cases the roots of mandibular incisors have been moved labially to a
considerable degree in the process of uprighting these teeth. It is significant that many
malocclusions present with mandibular incisors upright and over basal bone, and yet these
teeth are both crowded and rotated. Hence the teeth that supposedly have the attributes of
stability can actually be in a state of malocclusion.
From a purely mechanical standpoint a certain amount of virtue exists in inclining the
mandibular incisors slightly to the lingual. Those who have set mandibular anterior teeth
during fabrication of a diagnostic set up have noted that if the teeth are aligned with a labial
inclination, attempts to push them lingually results in expansion in the canine area or collapse
of the teeth. On the other hand, if the anterior teeth are inclined lingually, further pressure to
the lingual does not cause collapse, and tipping to the labial only creates spacing. Hence, if
we are to make any errors in positioning our mandibular incisor teeth, it is probably well to
err in the direction of a lingual rather than a labial inclination.
If the patient is growing, the mandibular anterior segment may exhibit a physiologic
migration in relation to the mandibular body in a distal direction that is apart from the
orthodontic treatment. Mandibular arch form plays a more important role in stable
mandibular tooth alignment than does the relative antero-posterior relationship of mandibular
denture to base.
Theorem 7: Corrections carried out during periods of growth are less likely to relapse.
Therefore orthodontic treatment should be instituted at the earliest possible age.
There seems to be little possible evidence to substantiate this statement; however, it has a
good deal in its favor from a logical standpoint if orthodontists are in any way able to
influence the growth and development of the maxilla and/or the mandible. It is certainly
logical to presume that the growth of maxilla or mandible can only be influenced while the
individual is growing and that once growth has been completed this potential is no longer
19

available. When treatment depends on a retardation or change of direction of growth,
treatment must be instituted early during periods of active growth.
Early diagnosis and treatment planning appear to afford certain advantages in longterm stability. Institution of early treatment can prevent progressive, irreversible tissue or
bony changes, maximize the use of growth and development with concomitant tooth
eruption, allow interception of the malocclusion before excessive dental and morphologic
compensations, and allow correction of skeletal malrelationships while structures are
morphologically immature and more amenable to alteration.
Much has been said about the change in muscular balance established by changing
the positions of teeth, which in turn will promote rather than retard normal growth. Whether
malrelations in muscle balance have as much influence on growth and development as has
been supposed is very difficult to say. Changes in muscle balance in a normal direction allow
for more normal development of the dentition; in relation to retention, normal muscle balance
should allow for normal arch alignment.
We can say here, however, that where treatment depends on retardation or change in
direction of growth such as is effected in headgear therapy, treatment must be instituted
during a period of growth.
Theorem 8: The further teeth have been moved, the less likelihood of relapse.
Thus, cases in which it has been necessary to move teeth a great distance are in need
of lesser retentive attention or it is desirable to move teeth farther in the process of
orthodontic treatment.
It is possible that positioning far from the original environment will produce
equilibrium states permitting more satisfactory occlusions, but the wisdom of this rule has
not yet been put to the test. For e.g.: in bimaxillary protrusions produced during orthodontic
treatment have not shown a tendency to relapse inspite of the fact that there is a pronounced
labial axial inclination of both maxillary and mandibular incisor teeth. It might well be that in
some of these cases the teeth are moved far enough to be outside of the influence of labial
musculature, actually there is little real evidence to support the statement that the farther
teeth have been moved the less relapse tendency they will have. In fact, the opposite may be
true. It may be more desirable through guidance of eruption and early interception of skeletal
20

dysplasias to minimize the need for future extensive tooth movement with the resultant
influence on the functional environment and such local factors as supracrestal fibers.
Theorem 9: Arch form, particularly in the mandibular arch, cannot be permanently
altered by appliance therapy.
Therefore, treatment should be aimed at maintaining, in most instances, the arch form
presented by the original malocclusion as much as possible.
The evidence brought to the authors attention by Nance that attempts to alter arch
form in the human dentition generally met with failure has been accepted realistically by
most orthodontist. Studies of treated orthodontic cases out of retention have lent credence to
this type of thinking. In 1944, McCauley made the following statement: Since these two
mandibular dimensions, molar width and canine width are of such an uncompromising
nature, one might establish them as fixed quantities and build the arches around them.
Strang said essentially the same thing in 1946: I am firmly convinced that axiom of the
mandibular canine width may be stated as follows: The width as measured across from one
canine to the other in mandibular denture is an accurate index to the muscular balance
inherent to the individual and dictates the limits of denture expansion in this area of
treatment.
Several instances of three or more millimeters of expansion of intercanine width were
found, but in these instances mandibular canines had been considerably constricted and were
blocked lingually to the general outline form in the mandibular arch. Certainly there are
exceptions to the rule of inviolability of mandibular arch form and intercanine width, but we
cannot expect all our patients to be exceptions. Extraction of two mandibular incisors
sometimes satisfies the requirements of the arch form without intercanine expansion (with
removal of two maxillary bicuspids).
Of these theorems the following seem to be the most important:
1) Teeth do tend to move back toward their former position;
2) The arch form of the mandibular arch cannot be permanently altered by appliance
therapy;
3) Bone and adjacent tissues probably should be allowed time to reorganize around newly
positioned teeth; and
21

4) Early corrections are less likely to relapse.
At this point we can be certain that orthodontic case analysis has come to include a
plan for retention, not as a separate posttreatment period demanding different or unusual
appliances, but rather as a part of active treatment inseparable, dependent and intimately
associated with the changes brought about during treatment.
Why is retention necessary?
22

Although a number of factors can be cited as influencing long-term results,
orthodontic treatment results are potentially unstable, and therefore retention is necessary, for
three major reasons: 1
1) The gingival and periodontal tissues are affected by orthodontic tooth movement and
require time for reorganization when the appliances are removed;
2) The teeth may be in an inherently unstable position after the treatment, so that soft tissue
pressures constantly produce a relapse tendency;
3) Changes produced by growth may alter the orthodontic treatment result. If the teeth are
not in an inherently unstable position, and if there is no further growth, retention still is
vitally important until gingival & periodontal reorganization is completed. If the teeth are
unstable, as often is the case following significant arch expansion, gradual withdrawal of
orthodontic appliances is of no value. The only possibilities are accepting relapse or using
permanent retention. Finally whatever the situation, retention cannot be abandoned until
growth is essentially completed.
Elastic recoil of
gingival fibers
Intra-Arch
Irregularity
Cheek/Lip/Tongue
pressure
Changes in
Occlusal
relationship
Differential jaw
growth
Classification of retention
23

Retention planning is divided into various categories, depending on the type of case
and type of treatment instituted: 6,8
1) Cases that require limited (minimum) or no retention
A) Corrected crossbites
(i)
Anterior: when adequate overbite has been established.
(ii)
Posterior: when axial inclinations of posterior teeth remain reasonable after

corrective procedures have been completed.
B) High canine or blocked out canines in Class I extraction cases with no incisor crowding.
C) Class II cases slightly overtreated with headgear to restrict maxillary growth with
sufficient arch length indicated by mandibular anterior spacing and absolutely no mandibular
incisor rotations.
D) Cases in which maxillary or mandibular molars have been tipped distally or bicuspids
tipped mesially to provide space for the eruption of second bicuspids. Once the second
bicuspid has erupted no further retention is necessary.
2) Cases that required moderate retention
A) Class I nonextraction cases, characterized by protrusion and spacing of maxillary incisors.
These require retention until normal lip and tongue function has been achieved.
B) Class I or Class II extraction cases probably require that the teeth be held in contact,
particularly in the maxillary arch, until lip and tongue function can achieve a satisfactory
balance, as in the nonextraction group.
C) Corrected cases of deep overbites in either Class I or Class II malocclusions usually
require retention of an indeterminate length of time with the object of attaining the greatest
possible vertical development in the buccal segments while the anterior teeth are held in a
minimum amount of overbite.
24

(i)
If anterior teeth were depressed to achieve overbite correction, a bite plane on a

maxillary retainer is desirable.
(ii)
If overbite correction was achieved as a result of bite opening and the mandible
was forced away from the maxilla, vertical dimensions should be held until
growth (i.e., mandibular ramal height) can catch up.
(iii)
Severe occlusal plane tipping may also require extended retention protocols and
possibly additional maxillary restraint as well.
D) Early correction of rotated teeth to their normal positions.

(i)
Perhaps before root formation has been completed.
(ii)
In the mandibular incisor area a removable type of appliance with a labial bow is
probably best. In this area, the occlusal splint type retainer or cast lower partial, as
suggested by Lande, may be useful. More recently gingivectomy procedures have
offered hope for increased stability of corrected rotations. Early correction of
rotations or severing of transseptal fibers may prove to be more satisfactory.
E) Cases involving ectopic eruption of teeth or the presence of supernumerary teeth require
varying lengths of retention planning.
(i)
Supernumerary teeth are frequently encountered in the maxillary anterior area and
on their removal; the maxillary incisors often erupt slowly and incompletely.
When the latter have been brought to a normal level through orthodontic therapy,
it is probably desirable to leave the appliance in a passive state for several months
before retaining this area because these teeth have a tendency to reintrude when
released.
(ii)
Excessive spacing between maxillary incisors requires prolonged retention after

space closure.
(F) The corrected Class II, division 2 malocclusion generally requires extended retention to
allow for the adaptation of musculature.
3) Cases that required permanent or semi-permanent retention in one or both arches.
25

(A) Cases or instances in which expansion has been the choice of treatment in one or both
arches, particularly in the mandibular arch to maintain normal contact alignment.
(B) Class II or Class III relationships which have been corrected by creating a dual bite.
Muscular adaptation will allow the mandible to be positioned forward after strong Class II
elastic therapy and the patient seemingly cannot retract the mandible any farther; yet if Class
II therapy is discontinued, in a matter of several weeks the patient will again be able to retract
his or her mandible farther posteriorly.
(C) Cases of considerable or generalized spacing may require permanent retention after space
closure has been completed.
(D) Instances of severe rotations (particularly in adults) or severe labiolingual malpositions
particularly of the maxillary and mandibular anterior teeth and mandibular bicuspids may
require permanent retention, as provided by bonded retainers.
(E) Spacing between maxillary central incisors in otherwise normal occlusions sometimes
requires permanent retention, particularly in adult dentitions.
4) Cases that require operative procedures with indefinite retention.
(A) Treatment limitations such as tooth size discrepancies (that is, larger maxillary teeth)
may result in increased overbite or super Class I.
(B) Reversely, larger mandibular teeth will result in end-to-end incisor relationships,
maxillary spacing, or buccal end-on occlusion.
(C) Stripping or reproximation of oversized teeth and esthetic bonding of malshaped or
undersized teeth may help to resolve this problem.
(D) A very vertical incisor relationship, which for any reason cannot be corrected, will lead to
deepening of overbite unless retained.
26
5) Cases requiring special construction and/or renewal of removable retaining

appliances or acrylic on the labial bows.
(A) Posttreatment adolescent palatal changes.
(B) Late mandibular growth spurt and Tweed type C growers.
(C) To maintain torque and overbite correction.
6) Routine cases, extraction or nonextraction, should have retaining appliances-fixed or
removable.
(A) Atleast until the destiny of the third molar teeth is determined [or]
(B) Until the growth process has slowed in late teens and early twenties [and]
(C) Afterward at the option of the patient.
27
Time for the initiation of retention

After malposed teeth have been moved into the desired position they must be
mechanically supported until all the tissues involved in their support and maintenance in their
new positions shall have become thoroughly modified, both in structure and in function, to
meet the new requirements (Angle). 2
R.G. Alexander (1983) 19 coined a phrase Countdown to Retention, which he gave
to describe the time when retention should begin. The countdown begins when the patients
teeth have been properly positioned Centric relation achieved, roots at extraction sites
parallel, mandibular canine width not expanded, proper buccal and labial torque, normal
overbite/overjet relationships, and Class I relationships.
Any retention procedure before beginning should fulfill the following criteria:
1) Correction and overcorrection of the A-P jaw relationship:
Considerations of anteroposterior skeletal and dental corrections are very essential
part of any appliance systems.
Overcorrection of the Class II case is the greatest challenge in this area. If corrected
only to the desired end position, many Class II cases will show a relapse of overjet and a
deepening of the bite. These patients benefit from overcorrection to an edge-to-edge position
and maintenance of that position with nighttime Class II elastics for 6 to 8 weeks, followed
by setting into an ideal Class I relationship.20
2) Establishing correct tip of the upper and lower anterior teeth:
It is necessary to establish correct tip of the upper and lower anterior teeth at the end
of the treatment by mode of any appliance system. For all teeth, the gingival portion of long
axis of each crown should be distal to the occlusal portion of the long axis of each crown.20
3) Establishing correct torque of the upper and lower anterior teeth:
It is often necessary to adjust the torque in the upper and lower anterior segments at
various stages of treatment.
28
A. Moderate-to-severe Class II case before treatment. B. After overjet reduction, torque

has been lost in upper anterior segment and lower incisors are angulated forward. C.
Additional torque needed in archwires to recover correct incisor angulation.
The most common example is during overjet correction of the moderate-to-severe

Class II cases, when the torque is frequently lost in the upper anterior segment while the
lower incisors are angulated forward. In this situation, it may be necessary to compensate by
adding lingual root torque to the upper anterior teeth and labial root torque to the lower
anteriors.20
4) Coordinating arch widths and archform:
Careful coordination of archwires from the beginning of treatment through the
rectangular wire phase will prevent unwanted and troublesome crossbites from developing. If
the patients archwidths are not properly coordinated at the start of treatment, this can be
compensated for by narrowing or widening the appropriate archwires from the earliest stages
of treatment. 20
A. Cross-elastics in cuspid areas used to
compensate for asymmetrical upper
archform (symmetrical arch indicated by dashed
line).
B.
Modified upper
archform (dotted line): archwire canted in direction
opposite
to asymmetry.
5) Establishing correct posterior crown torque:
29

Correct posterior crown torque is essential to prevent posterior interferences from
developing and to allow the seating of centric cusps. The torque built into preadjusted
posterior brackets usually eliminates the need for wire bending. 20
30

6) Establishing marginal ridge relationships and contact points:
Marginal ridges of adjacent teeth should be at the same level or within 0.5 mm of the
same level. Radiographically, the cementoenamel junctions should be at the same relative
height, resulting in a flat bone level between adjacent teeth.
Proper marginal ridge relationships in the finishing stage are primarily a function of bracket
height. With the standard edgewise appliance, the most common method of determining
bracket height involved is by placing the brackets a specified distance from the incisal or
occlusal surfaces of the teeth. The brackets were thus located relatively more incisally or
occlusally on large teeth than on small teeth, which could result in torque or in-out errors.
A. Brackets placed 5mm above incisal edges,

according to standard edgewise technique. With 8mm
central incisor (left), bracket is 62 percent of distance
up crown surface. With 12mm central incisor (right),
bracket is 42 percent of distance up crown surface. B.
Same teeth with brackets positioned in center of
clinical crowns, according to Andrews.
A more reliable guideline is the center of the clinical crown, as described by Andrews,
which provides a consistent bracket position regardless of tooth size.
Incorrect bracket height becomes apparent early in the leveling and aligning stage of
treatment. Hence, it is effective to reposition brackets as early as possible, so that time is not
wasted stepping archwires or repositioning brackets during the finishing stage. 20
A. Upper central incisor with incorrect bracket height and
compensating step
in .014" archwire. B. Bracket repositioned at next
appointment, with .016" archwire.
31

7) Correction of midline discrepancies:
Most minor midline discrepancies of 3 mm or less can be corrected with rectangular
wires in the finishing stage, whereas greater discrepancies require attention earlier in
treatment. There are five methods of elastic wear for specific situations:
(A)
(A)
A single class II elastic on one side and a double class II elastic on the other, for cases
with a bilateral class II component.

(B)
A single class II elastic on one side only, when the overjet results in a slight class II
relationship on that side and the opposite side is in a class I position.

(C) Class III elastics on one side and class II elastics on the other, for cases with the
corresponding dental relationships.
Methods of elastic wear to correct minor midline

discrepancies during finishing stage. A. Case with
bilateral Class II component: double Class II elastics on
right side, single Class II elastic on left. B. Case with
Class II molar relationship on right side and Class I on
left: single Class II elastic on right side. C. Case with
Class II molar relationship on right side and Class III on
left: corresponding intermaxillary elastics.
(D)
A single class III elastic on one side only, when that side is in a class III position and
the opposite side has a class I dental relationship.

(E)
An anterior cross-elastic, when the discrepancy occurs primarily in the anterior
segments.
D. Case with Class I dental relationship on

right side and Class III on left: single Class III
32

elastic on left side. E. Case with discrepancy primarily in anterior segment: anterior
cross-elastic.
Asymmetrical elastics should be used for a minimum period of time, and only with
rectangular archwires, because of their tendency to cant the occlusal plane. The archwires
should be tied back while these elastics are worn so that the wires do not slide around the
arch, causing unwanted space opening and distortion of the archform.20
8) Establishing the interdigitation of teeth:
Maximum intercuspation should be established between the buccal cusps of the
mandibular posterior teeth and the lingual cusps of the maxillary posterior teeth. Each
functional cusp should be in contact with the opposing arch.
When the rectangular wires have been placed for a long period, the teeth are often
unable to settle into an ideally finished position. It is helpful to allow each case to settle
before debonding by using a lower .014 round archwire and an upper .014 round sectional
wire from lateral incisor to lateral incisor. This is accompanied by vertical triangular elastics.
Vertical triangular elastics used in settling phase before debonding.
If the teeth have settled properly after two to four weeks, then the patient can be
scheduled for debonding. If the teeth are not properly positioned, the patient can return to
heavier archwires for additional finishing.
The retainers will fit more properly after settling than if they immediately follow
rectangular wires. 20
33

9) Checking cephalometric objectives:
Progress headfilms should be taken about halfway through treatment to allow time for
reassessment of anchorage and possible changes in the division of treatment time. Taking a
headfilm in the end of treatment may be important for the orthodontists education and for
evaluating the success or failure of treatment, but it provides no practical advantage to the
patient.
Important factors to evaluate with progress and final cephalometric x-rays include the
anteroposterior position of the incisors, the incisor angulations, changes in the occlusal plane,
the degree to which vertical development has occurred or been restricted, and the success of
the correction of horizontal and skeletal components of the case. Superimposition of the
progress and final x-rays on the pretreatment x-ray will help determine the orthodontic
changes that have occurred. 20
10) Checking the parallelism of the roots:
Generally, the roots of the maxillary and mandibular teeth should be parallel to each
other and perpendicular to the occlusal plane, as viewed in the panaromic radiograph. Hence,
a panaromic x-ray should be taken before debanding to evaluate root parallelism. If roots are
properly angulated, sufficient bone will be present between adjacent roots, an important
consideration in periodontal health. If crown-root angulation is beyond normal standards,
bracket repositioning or archwire bending may be required to modify the root positions. 20
11) Maintaining the closure of all spaces:
All spaces within the dental arches should be closed. It is important that space closure
be maintained, particularly in extraction cases, by using passive tiebacks in the finishing
stage.
34

Maintenance of lower arch space closure with passive wire tieback between molar
bracket and soldered archwire hook.
Otherwise, spaces frequently open during finishing and must be reclosed. Open
spaces not only are unaesthetic, but also may lead to food impaction. 20
12) Evaluating facial and profile esthetics:
Esthetic evaluation is an ongoing process during all stages of orthodontic treatment. A
projection of esthetic goals should be made as part of the treatment plan. The facial and
profile esthetics can then be monitored clinically, as well as with progress and final
cephalometric x-rays. 20
13) Checking for TMJ dysfunctions such as clicking and locking:
TMJ dysfunction is a broad subject and the following are some of the recommendations
given which a clinician should take into account:
(i)
Document any evidence of TMJ dysfunction prior to treatment, and inform the
patient that such symptoms exist.
(ii)
Monitor the patient for symptoms of TMJ dysfunction during treatment. If

problems are managed before the development of true internal derangement, then
joint function can often be re-established without permanent damage with the help
of a short phase of splint and physical therapy, concurrent with the orthodontic
treatment, until the symptoms are eliminated. Headgears and elastic forces should
be stopped while managing the TMJ problems.
(iii)
Monitor the patient for symptoms of TMJ dysfunction during retention. Taking
tomographic x-rays before treatment, as well as 2 to 3 months before debonding,
is helpful in detecting irregularities within the joint and in evaluating the clinical
position of the condyle.
A. Patient showing anterior
skid with corresponding
anterior condylar position.
Headgear or Class II
mechanics should be
35

continued to eliminate anterior skid and allow condyle to seat in fossa. B. Patient
showing significantly posterior condylar position with no evidence of anterior skid. Slight
amount of anterior skid should be provided by ceasing headgear or Class II
Elastics, or using Class III elastics, to achieve more centered position
The orthodontic patients generally benefit from the establishment of a seated and
reasonably concentric condylar position. A forward or retruded condyle can often be
corrected during the finishing stage, in conjunction with minor changes in antero-posterior
and vertical jaw position. 20
14) Checking functional movements:
Before debonding, the patient should be checked for interferences during protrusive
movements and lateral excursions. It is important that the lower eight most anterior teeth
make contact with the upper six most anterior teeth during protrusive movements. This
normally requires a slight widening of the archform in the bicuspid area, so that the mesial of
the lower bicuspids contacts the distal of the upper cuspids.
In lateral excursions, the patient should experience cuspid rise with slight anterior
contact and disclusion of posterior teeth on both the working and balancing sides. Second
molars should normally be banded to prevent interferences in this critical area during lateral
excursions. 20
15) Determining if all habits have been corrected:
Habits such as tongue thrusting will usually have been corrected before the finishing
stage is reached, because as the patient grows, airway size increases and the tongue can
assume a more posterior position. Also, as the dental environment that that supported the
habit is improved orthodontically, the tongue and lip musculature adapt to the improved
environment and normal function begins to occur. 20
16) Correction of rotations and overcorrection where needed:
Most rotations will have been eliminated before the finishing stage, particularly if
force levels are kept low. Any remaining rotations can be corrected during finishing by one of
three methods:
36

(i)
Rubber rotation wedges under the rectangular archwire.
(ii)
Steiner rotation wedges these are useful because they can be placed after the
archwire is in position.
(iii)
Lingual elastics most effective method.

These rotations should be slightly overcorrected during finishing to minimize relapse,
particularly in extraction cases. 20

17) Establishing a relatively flat plane of occlusion:
Reasons for completing cases to a relatively flat occlusal plane to a slight arc in the
second molar region, according to Andrews, include the proper fit of the upper dentition
against the lower dentition. When a curve of spee is left in the lower arch, for example, there
is a tendency towards increased overjet, since the lower teeth occupy less room than the
opposing upper teeth. Deep bite cases also benefit from overcorrection of the curve of spee,
because most deep bites tend to relapse.
If the occlusal planes are not leveled before finishing and detailing, the archwires will
not slide easily through the bracket slots during space closure with sliding mechanics. 20
37
Duration of retention
How long should the orthodontist continue retention? The answer to this question
varies from not at all to forever. The answer also depends on the type of case treated, the age
of the patient, what the parent and the patient expect of the orthodontic treatment, all of the
limitations inherent in the case, and finally, what the orthodontist himself expects of his
treatment. In the average adolescent, when considerable growth and remodeling of the bony
environment can be expected, it is reasonable to expect that retention should logically be
continued until the effect of these changes has slowed down. Generally, this occurs at the
time the third molars erupt; hence it has been a rule for many to continue retention until these
teeth have erupted or have been removed.21
So, to conclude some form of retention will probably be maintained until evidence of
completion of growth is forthcoming, and consideration should be given to the use of
retainers on and as needed basis indefinitely to ensure maintenance of tooth relationships. It
should be: 1
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 12 months, to allow time for remodeling of
gingival tissues.
If significant growth remains, continued part-time until completion of growth.

For practical purposes this means that nearly all patients treated in the early
permanent dentition will require retention of incisor alignment until the late teens, and in
those with skeletal disproportions initially, part-time use of a functional appliance or
extraoral force probably will be needed.
38
Physiologic recovery or relapse

For a successful result to an orthodontic experience, retention must be anticipated and
planned as a very important part of treatment of the dentition rather than as an apathetically
undertaken aftermath or necessary evil to the patient and orthodontist alike, which would
otherwise lead to a relapse process.
In orthodontics it is important to differentiate between relapse and normal
developmental changes in order to resolve our responsibilities during retention.
Relapse is a return of detrimental features of the original malocclusion; while
developmental changes refer to the individuals maturation process. To make this distinction,
we should have a general understanding of growth, development, maturation to old age,
response to treatment techniques, and those factors necessary for an improved or healthier
dentofacial environment.
Horowitz and Hixson21, 22 suggested that the term relapse should be replaced by the
term physiologic recovery as the dentition continuously changes throughout life. Biologically
these changes represent a recovery and rebound of individual dental development pattern.
Growth and remodeling are German factors of physiologic adjustments after active
treatment; this remodeling never stops, but the balance between apposition and resorption
change with ageing. In addition to physiologic recovery, normal growth changes must be
included as contributing to continuous adaptation process that sustains the long-term stability
of dental apparatus.
A malocclusion represents natures best effort to approach balance under the handicap
of asymmetric parts and disharmony. It is as stable as the existing balance between muscle
and bone but can change until growth and maturation, just as in normal occlusion.
To establish an esthetically harmonious, functionally efficient and structurally balanced
dental arches in the area of functional tolerance various cardinal points like establishment of
proper static functional occlusion, archform and intercanine width maintenance, lower
incisors positioning, proper understanding of growth and development etc are very important.
Violation of the law of optimality is likely to reject the alteration imposed on an existing
orofacial environment leading to relapse.
39
Causes of orthodontic relapse

The complexity of the dento-maxillofacial organ, the marked changes that have taken
place in its environment since the time it evolved to its present form, and many other
influences some of them understood and others not understood contribute to instability of
the end results of active orthodontic appliance therapy.
Among the goals of orthodontic treatment beyond facial and dental aesthetics,
function, and the health and longevity of the dentition is the achievement of stable or
relatively stable results. The reality of our present knowledge is that no form of treatment
guarantees absolute stability, nor does a well-treated case treated by the highest standards by
itself assure stability.
Stability is not an absolute, and what one tries to do for a patient is to obtain
acceptable stability. The concept of acceptable stability is not an alibi for treatment but
recognition of biological limitations. The success of our treatment should be measured based
upon some type of ratio between the magnitude of patient improvement and the relapse.
Success index10 = Magnitude of Improvement
Magnitude of Relapse
Fear of relapse is very real to most orthodontists and some are affected to a degree
that causes them to institute retention ad infinitum to all treated cases without regard to
individual conditions.
Why do successfully treated malocclusions fail? The subject of failure is as vast as
the field of orthodontics itself. In fact, every time we as orthodontist undertake to treat a
malocclusion we assume that the odds favor success but the possibility of failure, if not total,
exists in some degree.23
Causes of relapse:
The tendency of the teeth to undergo change of position immediately upon the
removal of the orthodontic appliances can be attributed to various factors like bone changes,
periodontal ligament tension, general metabolism, endocrine dysfunction, functional
adaptation of occlusion, inherent growth, tooth-size discrepancies, axial inclinations, soft
tissue maturation, connective tissue changes and interference with the trajectorial forces
40

established in function. When the aforementioned factors react favorably, the changes on
completion of treatment actually may help as time elapses to produce better esthetic tooth
arrangement and occlusion.
1) Late mandibular growth:
Late mandibular growth may result in increased pressure at the front of the mouth.
Typically, the mandible grows and displaces forward at a faster rate than the maxilla
(measured to occlusal plane) and the lower basal bone more than alveolar bone. Tooth
compensations include the tendency of the lower incisors to move lingually. If the
mandibular incisors are not free to move forward because of the restraining influence of the
upper arch, it is likely that they will become retroclined and, could be a contributing factor to
crowding in the lower anterior region. However, no direct relationship between the increase
in crowding and the change in incisor inclination or position has been demonstrated.
Lundstrom24 examined 25 pairs of twins between the ages of 12 and 15 years and 23 and 26
years. He found no relationship between anterior growth of gnathion and increased crowding,
or between changes in lower incisor inclination and increased crowding.
Richardson24 measured changes in lower incisor inclination and position of the incisal
edge relative to the maxillary plane in 51 subjects with intact lower arches. Between the ages
of 13 and 18 years, the average change was proclination of just over 1 with forward
movement of 1.0 mm. Incisor inclination was measured on the most procumbent lower
incisor. As contacts slip to permit imbrication, one or more incisors may procline as the
others retrocline in response to increased lingually directed force. This may mask any
relationship between increased crowding and incisor angulation.
3)
Facial growth and occlusal development:

Dentoalveolar adaptation tends to maintain occlusal relationships even when skeletal
relationships change with growth. However, if the intercuspation of the teeth is poor or if
dentoalveolar compensation is already at its limits, occlusal changes can occur, particularly
where skeletal growth changes are marked. For e.g; class III occlusion will often deteriorate
if the underlying class III skeletal relationship becomes more severe; and a skeletal open bite
often becomes worse with growth in lower face height. Although the arch relationship
41

remains stable in most cases, increase in labial segment crowding is often associated with
dentoalveolar adaptation. Mesial drift of buccal teeth contributes to the development of labial
segment crowding. Many causes of mesial drift have been postulated, including the anterior
component of force, tensions in the supra-alveolar connective tissues and impactions of third
molars.25
Nanda and Nanda26 found that the pubertal growth spurt for patients with skeletal
deep bite occurs on average 1.5 to 2 years later than is the case for open bite cases. For this
reason, a longer retention period for the skeletal deep bite patients is advocated to counteract
the continuing effect of dentofacial growth after the completion of orthodontic treatment.
4)
Mandibular incisor dimensions/ Tooth structure:

Crowding is slightly more common in persons whose teeth have large mesiodistal
dimensions than in those with smaller teeth. Small but statistically significant correlations
between crowding and tooth width have been found by some. Others found nonsignificant
correlations between these variables.
No direct relationship has been established between an increase in lower arch
crowding and tooth structure. It might be argued that teeth with large labiolingual dimensions
and broader contacts would be more stable and less likely to slip under pressure or tension.
The notation that mandibular incisor dimensions were correlated with lower incisor
crowding was reintroduced by Peck and Peck 26,
27
after a study of 45 untreated normal
occlusions. They concluded that the ratio of mesiodistal (MD) to faciolingual (FL)
dimensions of lower incisors was an important factor in producing well-aligned mandibular
incisors. Hence, they advocated reduction of mandibular incisors to a given faciolingual/
mesiodistal ratio to increase stability. Peck and Pecks work, however, was criticized for the
following reasons. Their recommendations were based on a study involving untreated rather
than treated cases. Young patients with ideal lower incisor alignment were used in the study.
It is possible that these cases would show crowding if followed long term.
To evaluate whether the Peck and Peck ratio had long-term value, Gillmore and
Little26, 27 studied 134 treated and control cases a minimum of 10 years presentation. They
showed a weak association between long-term irregularity and either incisor width or the
faciolingual/mesiodistal ratio. Less than 6% of crowding can be explained by this ratio. In
42

addition, the actual mean difference in incisor widths between crowded and uncrowded cases
was only 0.25 mm.
Smith et al.24 found nonsignificant correlations between crowding and labiolingual
incisor width in 100 untreated orthodontic subjects and 100 untreated adults, and low
significant correlations between crowding and mesiodistal/labiolingual incisor ratio.
Punky et al.24 found nonsignificant correlations between labiolingual lower incisor
dimensions, or their labiolingual/ mesiodistal ratio and lower arch alignment in 77 treated
cases or 86 untreated adult malocclusions.
Glen et al.24 could find no relationship between mesiodistal/labiolingual ratio and
incisor irregularity in 28 nonextraction orthodontically treated cases, either before treatment
or 3 years after-retention.
Evidence from these studies suggests that tooth structure plays only a minor role (if
any) in the etiology of late mandibular incisor crowding.
Boese28,
29
introduced a concept of lower incisor reproximation to provide broader
contact points and increase the available arch space in the mandibular anterior region. He did
a retrospective study that involved continued intervention during the retention period, even in
the presence of minor relapse. Hence, we are unable to compare the results of this study with
results from other retention studies.
5)
Occlusal factors:
The attachment apparatus of all teeth is an effective hydrodynamic damping system,
like an automobile shock absorber, and is well-designed to withstand occlusal forces. If teeth
did reposition themselves in response to occlusal forces, it would not be necessary for
dentists to be so careful with occlusal relationships. The teeth would make minor corrections
for themselves. This does happen just after the completion of orthodontic treatment, when the
teeth are hypermobile and the attachment apparatus is reorganizing. Alterations in functional
occlusion may produce a different pattern of masticatory forces or an occlusion with
premature contacts. The importance of functional and stable occlusion posttreatment is
repeatedly stressed in the literature.
Brodie24 suggested that with each stroke of mastication, the upper incisors receive a
separating impulse, whereas the lowers tend to come into closer contact. This implies
43

retroclination of lower incisors. The principle may also be applied to individual teeth coming
into premature contact, being displaced by the force of occlusion, and allowing adjacent teeth
to move toward each other, thus creating a crowded situation. Canine guidance in lateral
excursion may cause a lingually directed force on lower canines, with a reduction of intercanine width.
On the other hand, Proffit24 pointed out that the supporting structures of the teeth are
designed to withstand heavy, short acting, forces, such as those of occlusion. Nevertheless, it
seems possible that these forces, in combination with other factors, may contribute to tooth
movement and crowding. Parafunctional activity could exacerbate this phenomenon.
Occlusal relations may be altered by orthodontic treatment of the upper arch. Different types
of upper arch treatment may have differing effects on the lower arch.
Lombardi24 suggested that there may be a relationship between overcorrection of
maxillary canines and mandibular incisor crowding.
Occlusal changes may also be caused by restorations, tooth loss with drifting, or the
development of grinding habits.
Adequate interincisal contact angle may prevent overbite relapse and good posterior
intercuspation prevents relapse of both crossbite and anteroposterior correction. Less relapse
of mesiodistal movement occurs in the absence of occlusal stress.
6)
Influence of the elements of the original malocclusion:

The most basic cause of relapse to occur is the persistence of the elements of original
malocclusion or the etiology. If the underlying etiology is not removed, the treatment is
destined to relapse. It is mandatory for all clinicians to first diagnose a case properly, and
plan the treatment and retention initially itself, keeping the etiology in mind. The removal of
the etiologic factor before finishing is mandatory.
Overbite increase postretention is related to the amount reduced during treatment,
although generally 30% to 50% of the correction is retained. It is suggested that overbite
relapse tends to occur in the first 2 years posttreatment and maintenance of the intercanine
width is thought to increase stability. In the anterior open bite correction evaluated in 41
patients, 40% showed marked relapse and the other 60% showed stability of the result. The
relapse subgroup showed a greater increase in lower anterior face height during the
44

postretention period than did the stable group, but no posttreatment variable could be used to
predict posttreatment relapse or stability.
Most studies do not support a greater relapse in class II division 1 cases when
compared with other malocclusion groups, however, a slight change in overjet toward
pretreatment values was demonstrated in all malocclusion groups. Labially inclined incisors
pretreatment tend to be associated with less long-term crowding. It is postulated that the
weaker labial muscular forces do not induce lingual movement of the dentition and
subsequent arch length shortening.
When teeth are aligned by orthodontic treatment, there is a documented tendency for
a return toward the original pattern of malocclusion. For this reason, rotational overcorrection
has been advocated. Little et al., however, note that there are many exceptions to this rule
with greater than 50% of the rotations or displacements relapsing in an opposite direction.26
Udhe et al.14 formed a multiple regression analysis of overjet, overbite, intercanine
width, and intermolar width changes. They revealed that 41% of late lower incisor crowding
could be explained by these variables. The relative contribution by these variables varies
between individuals with a similar degree of irregularity.
7) Alteration of arch form:
It is generally agreed that arch form and width should be maintained during
orthodontic treatment.7,
26
In certain cases, where arch development has occurred under
adverse environmental conditions, arch expansion as a treatment goal may be tolerated.

There is evidence to show that intercanine and intermolar width decreases during the
postretention period, especially if expanded during treatment (Amott, Arnold, Welch, and
others). For this reason, the maintenance of arch form rather than arch development is
generally recommended. Expansion is thought to be better tolerated in class II division 2
cases that show a significantly greater ability to maintain intercanine expansion than class I
and class II division 1 cases. This statement, however, was based on a sample of 6 patients
and was not accepted by Little et al30 who maintained that intercanine and intermolar width
will relapse if expanded in class II division 2 cases as much as in other Angle classifications.
Another exception to the maintenance of arch width may be found in cases of
mandibular expansion concurrent with rapid palatal expansion. Haas 31 and Sandstrom et al. 32
45

found that maintenance of 3 to 4 mm intercanine width and up to 6 mm intermolar width was
possible when expansion was carried out concurrently with maxillary apical base expansion.
These two studies, however, are quite misleading. Haas study was based on 10 cases and
primary canines were present in the initial records for two of these. Hence, one cannot
extrapolate on the amount of canine expansion achieved, when in 20% of this small sample,
the permanent canines were not present at the time of the original records. Sandstroms
statement that mandibular incisor stability is increased when the mandibular intercanine
width is expanded in conjunction with maxillary expansion is based on a sample of 17
patients only 2 years postretention.
Moussa et al.33 reported on a sample of 55 patients who had undergone rapid palatal
expansion in conjunction with edgewise mechanotherapy a minimum of 8 years
postretention. Their results showed good stability for upper intercanine and upper and lower
intermolar widths. Stability of the mandibular intercanine width, however, was poor with the
posttreatment position closely approximating the pretreatment dimension.
De La Cruz et al.34 carried out a 10-year postretention study on 87 patients to
determine the long-term stability of orthodontically induced changes in maxillary and
mandibular arch form. The results showed that although there was considerable individual
variability, arch form tended to return toward the pretreatment shape. They concluded that the
patients pretreatment arch form appeared to be the best guide to future stability.
8) Periodontal forces:
In series of experiments on monkeys, Picton and Moss 24 and Picton24 demonstrated
that the teeth are joined together by a system of transeptal fibers under tension.
Proffit24 claimed that a slight imbalance of force between the tongue on one side and
the lips and cheeks on the other is normally present. He suggested that the teeth are stabilized
against this slight imbalance by forces produced in the periodontal membrane by active
metabolism.
Southard et al.24 demonstrated the presence of a continuous periodontal force on the
mandibular dentition, acting to maintain proximal contacts in a state of compression. This
force was increased after occlusal loading. They found significant correlations between
46

interproximal force and mandibular anterior malalignment. They concluded that periodontal
forces could contribute to the development of late lower arch crowding.
9) Periodontal and gingival tissues:
Orthodontic tooth movement to correct tooth rotations is proposed to result in
stretching of the collagen fibers. These stretched fibers (transeptal/collagen) have been
implicated in rotational relapse by pulling the teeth back toward their pretreatment position. 35,
36
Brain and Edwards26 advocated gingival fiber surgery (Circumferential Supracrestal

Fiberotomy) to allow for the release of soft tissue tension and reattachment of the fibers in a
passive orientation after orthodontic tooth rotation.
The theory of stretched collagen fibers as the cause of rotational relapse has recently
been questioned by Redlich et al.37 who analyzed gingival tissue samples obtained from
rotated incisors in dog. They found that the rotational forces caused significant changes in the
integrity and spatial arrangement of the gingival tissues, changes that are inconsistent with
stretching. After fiberotomy, reorganization of the fibers similar to the control group was
evident. They concluded that the rotational relapse may actually originate in the elastic
properties of the whole gingival tissue rather than stretching of the gingival fibers as
previously believed.
10) Soft tissue maturation:
It is generally accepted that dentoalveolar structures are responsive to soft tissue
pressures and adapt to a position of balance between the muscles of the lips, cheeks and
tongue.
Frankel and Loffler24 showed that the reduction in mandibular arch length found in an
untreated control group was prevented in subjects treated with the functional regulator (FR)
appliance. They claimed that the vestibular shields of the functional regulator appliance
favorably influence the saggital development of the mandibular dental arch by eliminating
the restraining forces of the external muscular environment.
Woodside et al.24 and Linder-Aronson and Woodside 24 showed that the lower incisors
of children who were mouth breathers were more retroclined and crowded compared with
47

controls, and proclined after adenoidectomy and a changed mode of breathing that altered the
muscular environment.
These studies show that lower arch alignment can improve after the removal of
adverse muscular forces and, although no direct relationship has been found between changes
in soft tissue forces and increased lower arch crowding, it is likely that such changes may
adversely affect arrangement of the teeth.
Late mandibular growth changes may bring the lower incisors into a different soft
tissue environment.
Subtently and Sakuda24 compared 25 patients who were orthodontically treated and
developed late lower incisor crowding with 25 patients who did not. They found a strong
tendency to maintain the original intercanine width in all cases. The crowded cases had a
narrower intercanine width before treatment, which returned to its original dimension after
treatment expansion. They surmised that the lip musculature did not permit the necessary
intercanine expansion to maintain incisor alignment. They claimed as the mandible increases
in size, the lips exert greater pressure than the tongue, creating a lingually directed force that,
counteracted the mesial forces, causes incisor crowding.
Bench24 studied growth of the cervical vertebrae, hyoid bone, and tongue in relation to
the facial skeleton and denture. He found that the hyoid bone and tongue descend with age,
relative to surrounding structures, and continue to do so after facial growth slows down. He
claimed that this was particularly true in persons with long faces and with lack of forward
growth and suggested that it could explain the development of late lower arch crowding.
Cohen and Vig24 studied tongue growth on serial cephalograms of 50 subjects from
ages 4 to 20 years. They found that tongue size relative to the intermaxillary space increased
with age. This might imply more forward pressure on lower teeth. They pointed out that the
descent of the tongue, as it grows, may compensate for any possible increase in forward
pressure because of larger tongue size.
Vig and Cohen24 examined lip growth on the same sample and found that it continued
up to 19 years and exceeded growth of anterior lower face height.
In a longitudinal study of soft tissue growth, Nanda et al. 24 found that the lips were
still growing, in height and thickness, at 18 years in male subjects, whereas in female
subjects the lips had reached their full adult dimensions by age 13 years.
48

These investigations show that changes in soft tissue structure are taking place during
the teenage period, which may alter the pressure balance on the lower incisors, causing them
to become crowded.
Changes in soft tissue function may alter the muscular environment of the teeth.
Teenagers with incompetent lips, becoming more aware of their appearance, may make a
conscious effort to hold their lips together causing an increase in perioral pressure.
11) Connective tissue changes:
Engel et al.24 claimed that bone and periodontal membrane are biologically labile in
response to hormonal changes. Laskin et al. suggested that hormonal changes during
adolescence or pregnancy may cause increased plasticity of bone. Bone loss as result of
aging or periodontal disease may allow teeth to move under pressures that they previously
resisted. These factors are more likely to be the cause of crowding that develops in later life,
after a period of relative stability, than those responsible for increasing crowding during the
teenage years.
12)
Influence of environmental factors and neuromusculature:

Strang38 theorized that the mandibular intercanine and intermolar arch widths are
accurate indicators of the individuals muscle balance and dictate the limits of arch expansion
during treatment. Weinstein et al. and Mills26 stated that the lower incisors lie in a narrow
zone of stability in equilibrium between opposing muscular pressure, and that the
labiolingual position of the incisors should be accepted and not altered by orthodontic
treatment. Reitan claimed that the teeth tipped either labially or lingually during treatment are
more likely to relapse.
The initial position of the lower incisors has been shown to provide the best guide to
the position of stability in two separate studies. In over 50 % of cases the lower incisors
ultimately stabilized at a point between the pretreatment and posttreatment positions. These
results indicate that if lower incisor advancement is a treatment objective, permanent
retention is essential for maintenance of the result.
49

13) Role of developing third molars:
The role of third molars in lower incisor crowding has been debated for more than a
century. The literature is almost equally divided with arguments for both sides.
One theory commonly reported is that of the third molars creating space to erupt by causing
anterior teeth to crowd. Woodside39 postulated that in the absence of third molars, the
dentition could settle distally in response to forces generated by growth changes or soft tissue
pressures. This implies a passive role of the third molars in the development of late crowding
by hindering that adjustment.
Broadbent40 was an early advocate of the insignificant role played by third molars in
late lower incisor crowding. Several studies show a reduction in arch length and an increase
in crowding with age. However, no difference in incisor crowding could be found in groups
with impacted, erupted, missing, or extracted wisdom teeth.41 Richardson demonstrated a
significant forward movement of first molars between the ages of 13 and 17 years. This was
correlated with the increase in lower arch crowding that occurred during the same period.
There was no difference, however, in the forward movement of the first molar, in cases with
or without impacted third molars. A recent study on 42 patients from the Belfast Growth
Study confirmed these findings.
In summary, all of the conflicting data regarding third molars tends to indicate that if
third molars were a contributing factor in the development of late lower incisor crowding,
their role is likely to be one of minor importance.
50
Proper occlusion and stability

Kingsley stated That occlusion of the teeth is the most potent factor in determining
the stability in a new position. Many other earlier writers considered that proper occlusion
was of prime importance in retention.
The six keys to normal occlusion as put forth by Andrews 42 in 1972 contributes
individually and collectively to the total scheme of occlusion and, therefore, are viewed
essential for successful orthodontic treatment and post treatment stability.
Key I: Molar relationship:
The distal surface of the distobuccal cusp of the upper first permanent molar made
contact and occluded with the mesial surface of the mesiobuccal cusp of the lower second
molar. The mesiodistal cusp of the upper first permanent molar fell within the groove
between the mesial and middle cusps of the lower fist permanent molar. (The canines and
premolars enjoyed a cusp-embrasure relationship buccally, and a cusp fossa relationship
lingually).
Improper molar relationship
1, Improper molar
relationship.
relationship.
2, Improved molar
3, More improved molar relationship.
4, Proper molar relationship.
51
52

Key II: Crown angulation:
The term crown angulation refers to angulation (or tip) of the long axis of the crown, not to
angulation of the long axis of the entire tooth. The gingival portion of the long axis of each
crown was distal to the incisal portion, varying with the individual tooth type. The long axis
of the crown for all teeth, except molars, is judged to be the mid developmental ridge, which
is the most prominent and centermost vertical portion of the labial or buccal surface of the
crown. The long axis of the molar crown is identified by the dominant vertical groove on the
buccal surface of the crown.
Normally occluded teeth
demonstrate
Crown angulation (tip)
gingiva portion of crown more
distal
long axis of crown measured
than occlusal portion of
crown.
from line 90 degrees to occlusal plane.
Key III: Crown inclination (labiolingual or buccolingual inclination):

The third key to normal occlusion is crown inclination.
Crown inclination is determined by the

resulting angle between a line 90 degrees to
the occlusal plane and a line tangent to the
middle of the labial or buccal clinical crown.
53

Proper crown inclination should be established. The maxillary central incisors are
inclined so that the gingival portions of the crowns of teeth are lingual to the incisal surfaces.
The gingival portions of all the other crowns are inclined labially or buccally, although the
mandibular incisor roots are inclined lingually.
Improperly inclined anterior crowns result

Demonstration, on an overlay, that when the
in all upper contact points being mesial, leading
crowns are properly inclined the contact
to improper occlusion.
distally, allowing for normal occlusion
anterior
points move
In the maxillary arch from canine to molar, all crowns are lingually inclined,
progressively increasing in inclination from canine through the molars.
A lingual crown inclination generally

lingual crown inclination of
occurs in normally occluded upper posterior
normally occluded lower posterior teeth
crowns. The inclination is constant and similar
progressively increases from the canines
from the canines through the second premolars
and slightly more pronounced in the molars.
The
through the second molars.
Key IV: Rotations:

The fourth key to normal occlusion is that
the teeth should be
free of undesirable rotations.

54
A rotated molar occupies more mesiodistal space,

creating a situation unreceptive to normal occlusion.
55

Key V: Tight contacts:
The fifth key is that the contact points should be tight (no spaces). Persons who have
genuine tooth-size discrepancies pose special problems, but in the absence of such
abnormalities tight contact should exist.
Key VI): Occlusal plane:
The planes of occlusion should range from flat to slight curves of spee. The
intercuspation of teeth is best when the plane of occlusion is relatively flat.
A, A deep curve of Spee results in a more confined area for the

upper teeth, creating spillage of the upper teeth progressively
mesially and distally.
B, A flat plane of occlusion is most receptive to normal

occlusion.
C, A reverse curve of Spee results in excessive room for the

upper teeth.
Bolton43 found that in excellent occlusions the angles of the labial surfaces of the
maxillary and mandibular central incisors to their occlusal plane totaled approximately 177.
In other words, the labial surfaces of these teeth in profile formed almost a straight line.
It is evident that the orthodontist often considers the denture from a static viewpoint, that is,
with the teeth in occlusion as seen on a study cast. It is doubtful that proper intercuspation or
interlocking is the most potent factor in retention. From the standpoint of reducing the
potential of irritation to the periodontium, a good functional occlusion is certainly to be
desired.
56
Considerations of dentofacial growth in long-term retention and

stability
Vagary and orthodontic pseudoscientific ambiguity attribute shortcomings in
orthodontic treatment to poor growth patterns. The terms good and poor growth patterns
are orthodontic clichs and actually are meaningless crutches to support the rationalizations
of treatment inadequacies. A good growth pattern is one in which the face grows in the
directions in which we wish it to grow. A poor growth pattern takes different directions.
Clinical experience supported by cephalometric data associated the best-treated
malocclusions that offered the best retention possibilities with faces having horizontal growth
gradients. These became known as good growth patterns. Those malocclusions offering the
poorest prospects usually grow more vertically than horizontally; thus, from the standpoint of
clinical achievement, malocclusions associated with these growth distinctions were called
poor growth patterns. The terms poor growth and good growth actually became
associated with clinical achievement rather than with physical modes of growth. How much
can orthodontic discipline change the directions and the modes of growth? There is no real
evidence to show it to be significant.9
General facial growth:
The high variability of normal facial growth was demonstrated by Bjork in 1955 in
one of the first articles describing the use of metallic
implants. In this limited study of only 6 patients he showed
that there is great individual variation not only with respect
to the direction of general facial growth, but also with
respect to the growth of the maxilla and mandible and to
the eruption of the teeth within each jaw. Prior to the
studies using implants the general feeling had been that
growth was a fairly uncomplicated process and that the
57

general direction of facial development was downward and forward. It was only after these
studies that their was a little change in the concept of growth.10
Normal mandibular growth:
The normal growth changes of the lower jaw have been studied extensively with the
use of metallic implants by Bjork and Bjork and Skeiller 11, who examined normal mandibular
growth longitudinally in a large number of subjects. Their studies of patients, using metallic
implants showed great individual variation in the growth pattern of the lower jaw.
In a detailed study of mandibular growth Bjork showed that the range of variation of
condylar growth in untreated normal subjects may be as much as 42 with a slight upward
and forward growth direction being the most common, others show an almost posterior
growth direction. Associated with this variability in condylar growth were distinct variations
in the direction of eruption of teeth.
In the subjects with pronounced forward condylar growth, the lower posterior teeth
erupt and migrate mesially. If, anyhow, the lower incisors are prevented from moving
forward (e.g., by a deep bite)-increased crowding in the lower arch often develops. In cases
showing pronounced increase in the tendency of mesial migration, the intercanine width in
the lower arch also tends to decrease because the teeth move into a more narrow part of the
arch. The degree to which this secondary crowding develops is dependent upon several
local factors, such as the extent of overbite, overjet, available space in the arch, and
inclination of the maxillary and mandibular anterior front teeth, as well as the extent of
mesial migration of the posterior teeth.
Facial growth and occlusal development in an

untreated subject with pronounced forward
rotation of the mandible. The occlusion has
remained stable during this six-year growth
period without any crowding developing in the
lower arch.
58
Facial growth and occlusal development in

an
untreated subject with pronounced
forward
mandibular growth rotation and a stable
anterior
occlusion. This subject developed
crowding of
the mandibular incisors with time. The posterior
occlusion change from an end-on relationship at
age 9 years, 10 months to a full Class II
malocclusion at age 15 years, 10 months.
In contrast, patients with upwards-backwards growth of the condyles, consistently

show a more vertical direction of eruption of the posterior teeth. However, these patients also
present secondary crowding as the lower incisors erupt in most posterior direction, uprighting
in the jaw base. The extent of uprighting of the incisors is influenced and modified by the
balance between the lower lip and the tongue, by the space conditions in the arch, and by the
growth changes of the mandible.10
Stability of occlusion and mandibular growth rotation:
1) Anterior rotation:
Bjork in 196912 reported that pronounced upward and forward growth of the
mandibular condyles is associated with anterior or counterclockwise rotation of the lower
jaw. This rotation can occur with the fulcrum point located at incisors or further back in the
occlusion. When the occlusion remains stable over time, the fulcrum point is located and
maintained at the incisors, presumably by the function of the lips and tongue. However, if the
fulcrum point is lost, as a result of dysfunction of the lips or tongue or because of oral habits,
a skeletal deep bite will normally develop.
59
Facial growth and occlusal development in a subject with an extreme deep bite. The lack
of a fulcrum point at the incisors in combination with the growth pattern has resulted in
continuous deepening of the bite. The general superimposition shows that the
mandibular molars continued to upright while the maxillary molars became more
mesially inclined over time. The maxilla in this patient rotated forward, similar to the
mandible. Notice the increasing crowding in the maxillary arch resulting from mesial
migration of the posterior teeth and retroclination of the anterior teeth. This occlusal
development is characteristic of the Class II, Division 2 malocclusion.
In these subjects, the posterior facial height is greater than anterior facial height. 13 In
patients in which anterior rotation is to be expected the goal of orthodontic treatment is to
establish and maintain normal overbite and overjet relationships by creating a solid fulcrum
point at the incisors. By positioning the teeth so that the interincisal angle is not too obtuse,
the lower incisors are not too upright, and there is a proper amount of torque of the maxillary
incisors, a more stable result can be anticipated.
In addition to creating an optimal anterior and posterior occlusion, at the end of active
treatment it is also necessary to maintain and support this occlusion with retention
appliances. In extreme cases, retention must be continued until growth of the condyles is
completed because following active treatment there is often an even greater tendency toward
anterior rotation than during treatment.
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Patients with severe malocclusions (for e.g., Class II skeletal malocclusions and a
deep bite), where early treatment may be indicated and who have a more extreme growth
pattern, present additional stability problems. In these cases the mandibular anterior teeth
must be maintained in their new position for a long time because the continuing forwardgrowth rotation usually is accompanied by uprighting of the teeth. Stabilizing the lower
incisors presents a practical problem, however, because the stability of the anterior mandible
is compromised when the primary canines are lost. When the permanent mandibular canines
are fully erupted in the late mixed dentition, retention is often simpler. The canines can then
aid in supporting the lower anterior teeth against the uprighting tendency of the mandibular
incisors.10
2) Posterior rotation:
In these subjects, an increase in the anterior facial height exceeds than increase in the
posterior facial height, which results in backward or posterior rotation of the mandible. 13 This
type of growth rotation is, much less common than anterior rotation seen in the majority of
our patients during growth. This type of rotation has a strong tendency towards late lower
crowding, because the direction of eruption of the lower incisors is more vertical, with
additional potential for retroclination of these teeth. Hence, long-term stabilization of the
lower anterior teeth is absolutely essential.
Maxillary growth and stability:
Maxillary growth shows similar rotations as those observed in the mandible. In
untreated subjects these rotational changes are normally in the same direction as in the lower
jaw but of less intensity. There is continuous mesial migration of the upper posterior teeth
concomitant with the rotation of the maxilla similar to that seen in the mandible. Similar to
that of the mandible, there is often less forward movement of the anterior than of the
posterior teeth which ultimately leads to the increase in anterior crowding. As in the
development of the lower crowding, the function of the lips may also play an important role
in the development of the maxillary anterior crowding. It may be hypothesized that the lips
are preventing the upper front teeth from following the mesial migration of the posterior
teeth. Another possibility is that normal lip function, in combination with a more extreme
61

tendency toward anterior rotation of the maxilla, may be sufficient to redirect the eruption of
the incisors. These mechanisms, may be responsible for the posttreatment relapse of
maxillary anterior crowding.10
In subjects with more pronounced forward-growth rotation of the jaws, as observed
by Uhde14, there is a natural tendency for the molar relationship to become more Class II with
time. This can also be attributed to the natural growth changes, where the posterior teeth in
both arches tend to follow the growth rotations of the jaws, and therefore become more
mesially inclined in the maxilla and more distally inclined or upright in the mandible. 11
Because molars shift in opposite directions, the occlusion gradually shifts toward a Class ii
malocclusion. These changes can be more or less pronounced, depending on the
intercuspidation and the function of the soft tissue matrix.
Dysplastic and compensatory development:
Skeletal discrepancies are often to a great extent marked by dentoalveolar
compensations.15 In the subjects, however, abnormal function of the lips and tongue can
cause dysplastic dentoalveolar changes that make the dental malocclusion worse than the
underlying skeletal problem. The extent of compensation not only influences the occlusal
correction necessary to treat the case but also affects posttreatment stability. Just as
compensatory and dysplastic development is greatly dependent upon the soft tissue matrix
surrounding the skeleton, posttreatment stability is dependent upon the adaptability of these
structures.
Dentoalveolar development and occlusion:
The continuous forward movement of the posterior teeth in patients with forward
rotation of the mandible is necessary to maintain the stability of the anterior occlusion.
Anteriorly this migration is reflected primarily as proclination of the lower incisors. The goal
of orthodontic treatment in this type of growth pattern should be to bring the mandibular
dentition forward on the jaw base and maintain the anterior teeth in their forward position so
as to counteract the natural tendency of the incisors to upright.10
Stability of extraction and nonextraction treatment:
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In the patient with growth pattern in which there is a pronounced tendency toward
anterior rotation, extractions, especially of teeth in the lower arch, should normally be
avoided. Before any decision is made to remove bicuspids, the potential for saggital and
transverse expansion must be examined carefully.
When extractions are necessary to alleviate crowding, they should not be carried out
too early but rather during the growth spurt or even later when the growth pattern in the
patient is more clearly expressed. Following treatment, retention is even more critical in
these extraction cases because the lower incisors often are more upright at the end of
treatment than in nonextraction cases and therefore must be maintained until growth of the
condyles is completed.
Where condylar growth is primarily directed posteriorly, the natural tendency of the
mandibular incisors to become more crowded with time continues throughout the growth
period. It is therefore critical that extraction decisions not be made too early. In most
instances where posterior rotation is anticipated, extractions should be delayed until the
patient is past maximum pubertal growth. The degree of growth rotation and associated
natural tooth migration in these cases is unpredictable, and additional late crowding, resulting
from growth pattern, will often develop even after extraction therapy. Following treatment,
the mandibular anterior teeth in these patients should be supported lingually until growth in
the mandible is finished.10
Treatment timing:
The majority of orthodontic treatments are carried out immediately prior to or during
the pubertal growth spurt. In some cases, however, treatment during the early mixed dentition
stage may be indicated. One of the reasons behind this is that these cases are often associated
with even greater instability posttreatment than when treatment is done in the late mixed or
permanent dentition stage. The lack of support from the posterior teeth in the arch, when the
deciduous teeth are lost, increases the chances for uprighting of the anterior teeth, resulting in
a deep bite. Hence, the mandibular anterior tooth needs to be supported until the permanent
canines are fully erupted.
The majority of malocclusions are primarily related to skeletal differences between
the maxilla and mandible, and this discrepancy by so-called growth adaptation. To obtain
63

maximum effect, treatment is often carried out during the pubertal growth period, when the
intensity of growth is at its greatest. Whereas facial growth can be of great help during
treatment of a skeletal problem, it can also be the cause of instability of the treatment result.
As growth in most orthodontic patients is not completed at the end of the growth spurt but
continues for several years beyond the pubertal spurt, retention of the treatment result should
also continue for a period of several years.
The maxillary growth on average is completed 2 to 2 years prior to mandibular
growth. The timepoint for completion of sutural growth again varies by as much as 6 years,
with the earliest completion of maxillary growth at age 14 years and the latest at age 20
years. This differential in timing, between completion of upper and lower jaw growth, is yet
another factor that influences posttreatment stability.10
Dentofacial skeletal changes with growth:
Relapse of the corrected position of the teeth after successful orthodontic treatment is
fully recognized by the clinician. However, skeletal changes that occur during retention may
attenuate, exaggerate, or maintain the dentoskeletal relationship. Relapse of the teeth is a
source of annoyance to all concerned; yet the outcome of skeletal changes is left to the fate of
the patients so called growth pattern. Despite the fact that clinical manifestations of
skeletal relationships are given considerable importance before the initiation of and during
orthodontic treatment, little or no consideration is given to posttreatment skeletal changes
due to growth and the effect on the final outcome. This attitude is based on two assumptions.
First of all it is often assumed that the responsibility for the skeletal supervision is secondary
to the dental relationships during active treatment. Further, when teeth are brought into
proper interdigitation, the treatment is usually terminated, regardless of the skeletal
maturation status of the patient. Second, it is generally assumed that not much can be done
during the posttreatment phase to modify the growth pattern of the patient. The truth of the
matter is that many patients at the completion of orthodontic treatment may still be going
through the pubertal growth spurt, and there may be others who have not even entered the
period of accelerated pubertal growth. This observation is of particularly greater significance
in boys than in girls, since boys generally mature later. Hence failure to recognize the
continuing effect of dento-facial growth after the completion of orthodontic treatment and its
64

resultant favorable or unfavorable effects on the physiognomy and its dental relationships
may jeopardize long-term stability of the orthodontic result.
The major focus during retention is placed on maintenance of the corrected positions
of the teeth, and no compensations are made for the future dentoalveolar and skeletal growth
of the jaws in either the horizontal or the vertical direction.
The retention devices should be differentially selected on the basis of dento-facial
morphology and the anticipated magnitude and directions of growth instead of simply using
the clinicians favorite procrustean-bed retention appliance for all cases.10, 16
In persons with short face syndrome, the effect of continued growth after successful
treatment is critical.17, 18 These persons may require dentoalveolar compensations, such as an
anterior bite plane during the retention phase until maxillomandibular growth is completed.
Failure to recognize the dominant morphogenetic horizontal pattern of growth of the person
may result in a dished-in-face, with or without extractions of teeth. Hence the concave
facial pattern accentuates.
In persons with long-face syndrome, a high-pull face-bow headgear to hold the
position of molars and to prevent further dentoalveolar growth downward and backward,
autorotation, and worsening of the physiognomy may be required.
It is extremely important to pay attention to the persons growth pattern, and a
distinction must be made in the selection of retention devices on the basis of the nature and
the extent of dentofacial dysplasia (growth pattern). The nature and duration of retention
should depend on the maturation status of the patient and on anticipated future growth.
Retention guide is necessary for the adjustment of the dentition to late growth changes and
maturation of neuromuscular balance. Active retention is a concept we accept as readily as
orthopedic surgeon does for his scoliosis patients.
There is some merit in the philosophy of those clinicians who advocate permanent
retention guidance. Without always being aware of the biomechanics of growth change, they
are in fact carrying the patient through active stages of growth with their retention
appliances.
Finally, one may philosophize that nothing about the human
morphology is stationary. Aging is a well-documented process of change. Lifetime
dentitional adjustment changing dental relationships are known to all, even in otherwise
65

healthy persons. Then why do we expect long-term stability in every case? The answer to the
question of long-term stability is long-term retention dynamic, not static.16
Arch width changes

The long-term resolution of arch length deficiencies is not easily achieved. Sillman 46
concluded that maxillary and mandibular arch length and width dimensions usually decrease
with time in untreated individuals. In general, one can expect a moderate increase in width of
the dental arches, particularly in the anterior region, until permanent canines erupt. After this
time, however, arch width usually decreases in the transition from the deciduous to the
permanent dentition and then continues to decrease with increasing age. These changes occur
more markedly in the mandibular than in the maxillary dental arch and more consistently in
length than in width. The intercanine width is established in the lower arch by 10 years for
both sexes and in the upper arch at 12 years for females and 18 years for males, which
according to Graber acts as a safety valve for the final increments of saggital growth of the
mandible.
Lower incisor crowding is a common clinical
problem, which is often corrected by extraction of the
premolars and retraction of the canines and thus aligning
the incisors. In cases of mild crowding, reproximation is
done and hence alignment is resorted. Peck and Peck44
Mesiodistal/Faciolingual (M.D./F.L.) ratio and Boltons
anterior tooth size ratio give us the guidance whether the
anterior interocclusal problems and crowding could be
corrected by reproximation alone. Some cases require
extensive treatment by extraction of the premolar, and
retraction of the canine, which brings the canine into the
wider part of the arch.
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In many arch length deficiencies, however, the extraction of permanent teeth is
contraindicated due to the negative effect on the facial profile. In those cases the dental
arches must be expanded, thus increasing the liability for future dental irregularity. Arch
expansion is not always feasible and also stable solution to the intra arch and inter arch
problems.2
In the middle of the 1920s a school of thought formed around the writings of AxelLundstrom who suggested that the apical base was one of the most important factors in the
correction of malocclusion and maintenance of the corrected occlusion. McCauley47
suggested that intercanine and intermolar width should be maintained as originally presented
to minimize retention problems. Strang48 further enforced and substantiated this theory.
Nance49 noted that arch length may be permanently increased only to a limited extent. Arch
form, particularly in mandibular arch, cannot be permanently altered by appliance therapy.
Therefore, treatment should be directed towards maintaining the arch form presented by the
original malocclusion.
Hayesnance pointed out that alterations in the mandibular arch forms generally ended
in failures. This has been accepted realistically by some orthodontists.
Dallas and McCauley47 made the following statement since these two mandibular
dimensions, molar width and cuspid width are of such an uncompromising nature, one might
establish them as fixed quantities and build the arches around them.
Strang48 said essentially the same thing as follows I am firmly convinced that the
axiom of Mandibular canine width may be stated as follows: The width as measured across
from canine to the other in the Mandibular denture is an accurate index to the muscular
balance inherent to the individual and dictates the limits of the denture expansion in this
area.
In almost every orthodontically treated cases well out of retention, the mandibular
intercanine and intermolar width tended to return or maintain the original dimensions. Since
1950s it has been brought to the orthodontic world that the most stable and non-changeable
portion or dimension of the dental arches is the arch width. Many studies carried out during
this period proved this fact with differences found in extraction and non-extraction cases.
Walters50 in 1962 was the only one to give a conflicting report, who reported in 62
percent of both the extraction and non-extraction cases the maintenance of slight increase in
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mandibular intercanine width after all retention had been removed for what he termed as an
adequate period.
It has frequently been suggested that if the mandibular canines are moved into a more
posterior position in relation to the mandibular basal arch, the increase intercanine width can
be expected to hold. While this explanation may be presumed to be logical, all of the
evidence collected to date would indicate that distal mandibular canine movement, whether
by tipping or bodily repositioning, has little to do with increasing intercanine width. In this
context, Shapiro51 in 1974 measured mandibular dental casts of eighty extraction and nonextraction cases (10 years postretention) at pretreatment, end-of-treatment, and 10 years
postretention stages and changes in mandibular intercanine width, and arch length were
examined. On the basis of findings of this study, Shapiro gave the following conclusions:
1) Mandibular intercanine width demonstrated a strong tendency to return to its
pretreatment dimension in all groups, but subjects in the Class II, division 2 group
demonstrated a significantly greater ability to maintain treatment intercanine width
expansion than did the Class I and Class II, division 1 groups.
2) Mandibular arch length decreased substantially in every group during the
postretention period.
3) Mandibular arch length reduction in the Class II, division 2 group was significantly
less than in the Class I and Class II, division 1 group during treatment and from
pretreatment to 10 years postretention.
4) From pretreatment to postretention, mandibular intermolar width decreased more in
extraction cases than in nonextraction cases.
Donald Gardner and Chachonas52 in 1976 reported essentially the same findings as
regards to the intercanine and intermolar width. One more important finding in their study
was that, the incisor to molar distance decreased with treatment and had a slight tendency to
continue to decrease post treatment.
Uhde found that intermolar and intercuspid width persisted more in the maxillary than
in the mandibular arch. In both cases, intertooth width increase was least tolerated in the
cuspid region regardless of the type of extraction therapy. Although relapse tendencies were
same for extraction and nonextraction cases much of the intermolar width increase in
nonextraction case were maintained. In the extraction cases the mean intermolar width was
68

only slightly increased during treatment and decreased beyond the original intermolar width
after the treatment.
So, it can be concluded that the original intercanine and intermolar width when
intelligently and judiciously employed, can serve as a valuable clinical guide to orthodontic
diagnosis.
Mandibular incisor crowding

Irregularity of mandibular incisors frequently occurs following orthodontic treatment.
Several studies reported a relation between mesio-distal dimensions of lower incisors and
their irregularity prior to orthodontic therapy while other studies have found lack of such an
association. Peck and Peck44 in 1972 stated that ratio of mesiodistal to faciolingual
dimensions was important in producing well-aligned mandibular incisors. Boese28,
29
advocated the use of Peck and Peck index as a guide for interproximal tooth reduction in
conjunction with Supracrestal fiberotomies so as ease of enhancing stability of lower
incisors.
Kuftinec45 however raised the question over interproximal stripping and found no corelation between incisor crowding and Peck index. He stated that both the cases with high
and low Peck index relapsed after treatment.
Causes of late mandibular anterior crowding:
The following are the different causes of late mandibular anterior crowding:24
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1) Late mandibular growth
2) Skeletal structure and complex growth patterns
3) Soft tissue maturation
4) Periodontal forces
5) Tooth structure
6) Occlusal factors
7) Connective tissue changes
8) Third molar eruption
9) Anterior component of force
Mandibular incisor crowding is frequently observed after retention is discontinued.
This occurs in patients treated with or without extraction. There may be an intrusion of
incisor teeth and an extrusion of the buccal series of teeth when the dental arch is being a
leveled. Intruded mandibular incisors have a tendency to regain their original height when
pressure is released and recrowding may result.
To reduce the likelihood of relapse of the lower incisors, Nanda and Burstone have
developed the following Twelve Keys to Stability:
1) Whenever possible, allow the lower incisors to align themselves either through serial
extraction or the use of a lip bumper in the early mixed dentition.
2) Overcorrect lower incisor rotations as early in treatment as possible.
3) Reproximation of incisors early in treatment and again at retention enhances stability.
4) Avoid increasing the intercanine width during active treatment.
5) Extract bicuspids in cases where mandibular arch discrepancy is 4 mm or greater,
except where facial aesthetics dictates otherwise.
6) Reorganize that the more a tooth is moved, the more likely it is to relapse, and
overcorrect accordingly.
7) Upright lower incisors to at least 90 whenever the profile permits.
8) Create a flat occlusal plane during treatment, and overcorrect the overbite.
9) Prescribe Supracrestal fiberotomy for severely rotated teeth.
10) Retain the lower arch until all growth is complete.
11) Place retainers the same day appliances are removed.
70

12) Recognize that compromise is often necessary in the interest of facial aesthetics and
that sometimes lifetime retention is necessary.
Following these Keys will certainly not eliminate relapse: The only sure way is to
prescribe lifetime retention for everyone.
Role of Third Molar in Post retention Crowding

The role of third molar in the relapse of lower anterior crowding following the
cessation of retention in orthodontically treated cases has provoked much speculation in the
dental literature over the past 125 years. In a modern population, there is a strong tendency
for crowding of mandibular incisor teeth to develop in the late teens and early twenties. Mild
crowding of the incisors tends to develop in well-aligned arches, or it increases if mild
crowding is already present. Increased crowding of mandibular incisors takes place at about
the time of third molar eruption. Although the mean age for third molar eruption is 20 years,
mandibular anterior crowding continues well beyond the eruption of third molars in both
untreated and treated individuals. It is considered as a normal physiological process of
maturation.
In 1859 Robinson41 wrote . The dens sapientae . is.... frequently the immediate
cause of irregularity of the teeth by the pressure exerted towards the anterior part of the
mouth.
Broadbent41 in 1941, on the basis of the cephalometric evidence collected by the
Boltons study, indicated that third molar impaction was not the cause of mandibular
crowding, but both were the result of inadequate mandibular growth. According to Nance 41,
the co-incident occurrence of third molar eruption with the cessation of retention was the
reason for the indictment of third molar in the relapse of mandibular crowding. As late as
1989, Richardson24 implicated the role of unerupted third molar in lower arch crowding.
Several studies have been conducted to find out the association between the third molar and
late mandibular incisor crowding and have varied findings and interpretations.
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Bjork and Skiller11 studying facial development and eruption in subjects during the
circumpubertal period could find on clear evidence that secondary crowding was due to
eruption of third molar.
Bergstrom and Jenson (1961)67 studied sixty dental students with unilateral third
molar aplasia and found greater crowding in the quadrants with third molars present than
those where third molars were missing. Vego (1962)
68
concluded from his study that the
erupting third molar can exert a force on approximating teeth.

Rose G. Kaplan41 in 1974 studied a sample of seventy-five orthodontically treated
Caucasian patients for an average of 9.3 years out of retention with a mean post retention age
of 26.6 years. 30 patients had bilaterally erupted mandibular third molars, 20 had bilaterally
impacted third molars, and 25 had bilateral third molar agenesis.
The following conclusions were drawn: 1) During the post treatment period no significant differences were apparent in the
changes in arch length, lower molar position, lower incisor position or lower incisor
inclinations between the three groups.
2) It does not appear that the presence of lower third molar has any significant influence
on post-treatment changes.
3) Some degree of lower anterior crowding relapse occurred in the majority of cases, but
this was not significantly different between the three groups.
4) The theory that the third molar exerts pressure on the teeth mesial to them could not
be substantiated in this study.
Schwarze (1975) 24 in a long term study compared a group of 56 patients with third
molar germectomy and 49 subjects whose third molars were allowed to develop. He found a
significant forward movement of the first molars associated with increased lower arch
crowding in non-extraction group.
Lindquist and Thilander (1982)
69
examined 23 boys and 29 girls with impacted third
molars on both sides of the mandible. The impacted molar on one side was removed and the
non-extraction side was used as a control. Average age at the time of operation was 15.5
years (13-19 years). They noted that the space change on the extraction side was improved in
72

relation to the control side in 70% of cases. They found a very small beneficial effect, 0.16
mm less crowding in the group without third molars compared with the group with third
molars. They concluded that extraction could be recommended in severe crowding. The
study was not able to predict which patients reacted favorably or unfavorably to removal of
third molars in cases of anticipated crowding.
Ades AG et. al., (1990)70 conducted a long term study to determine the relation of third
molar to changes in the mandibular dental arch. The sample for this study consisted of four
groups and sub groups. The groups consisted of premolar extraction, non-extraction with
initial generalized spacing, non-extraction, and serial extraction untreated subjects. The
subgroups were divided into persons who had mandibular third molars that were either
impacted, erupted into function, congenitally absent or extracted at least ten years before post
retention records. The mean post retention period was 13 years (10 -28 years). The mean post
retention age was 28 years 6 months (18 years 6 months 39 years 4 months). They found
that mandibular incisor irregularity increased while arch length and incisor width decreased.
The third molar subgroups revealed no significant differences in the parameter studied. No
significant difference in mandibular growth pattern was found in third molar subgroups.
Incisor crowding was not significant between third molar subgroups. They concluded that the
third molar removal with the objective of alleviating or preventing mandibular incisor
irregularity might not be justified.
Nieke et. at., (1995)71 in their study of post retention crowding and incisor irregularity
considered the presence or absence of third molars, dividing the sample of 226 cases into
subgroups; bilaterally erupted, impacted third molars, and bilateral third molars agenesis or
extraction. Lower arch crowding was found to be influenced by the presence of third molars.
In cases with missing mandibular third molars, less amount of relapse of crowding was seen
than in any case with impacted or erupted third molars. On the side of missing third molars,
1.2 mm of less crowding was seen. They concluded that the crowding was statistically
significant but clinically insignificant.
Little RM (1990, 1999) examined mandibular crowding during the post treatment phase
and concluded that mandibular crowding is a continuous phenomenon well into the 20 40
73

years age bracket and beyond. Third molar presence, absence, impacted or fully erupted,
seemed to have little effect on the occurrence or degree of relapse.
Southard et. al., (1991)72 measured the mesial force exerted by unerupted mandibular
third molars using a technique similar to measuring the anterior component of occlusal force.
The sample consisted of 14 males and six female patients. Their hypothesis was that the
mesial force exerted by unerupted third molar increases tightness of all proximal posterior
tooth contacts and that surgical removal of third molar relieves tightness by eliminating this
force. They were unable to detect a mesial force exerted by unerupted third molars. They
observed that the change of posture relieves the proximal contact tightness dramatically.
Pirttiniemi et. al., (1994)73 evaluated the effect of impacted third molar removal on 24
individuals in the third decade of life. Casts were examined before and one year after
extraction of third molar. They found slight distal drift of second molar but no significant
change in the lower incisor region.
As the literature indicates, there is still no agreement or definite conclusions drawn about
the effect of third molars on post retention crowding or proclination of the lower anterior
segment. Since at least 60-70% of the investigators believe that third molars could cause
problems post retention, it is advisable to prophylactically extract the third molars either
prior to or immediately after orthodontic treatment so that it will not cause any undesirable
effect on the results achieved by treatment.
74
Concept of overbite relapse

The general tendency for incisal overbite to Relapse or return toward its pretreatment relationship is well accepted. A good diagnostic discipline is warranted in choosing
the treatment modality in the correction of overbite. A school of thought led by Schudy
advocates the correction of deep bite by extrusion of molars. Another school of thought
consisting of Rickets, Burstone and others believes in genuine intrusion of incisors for the
correction of overbite. Choosing the ideal line of treatment for each individual case could
eliminate relapse of the overbite. Pseudo correction of overbite by extrusion of molars and
proclination of lower anteriors, when a continuous arch wire is used would result in relapse.
Strang53 defined overbite as the vertical overlapping of the upper and lower incisor
teeth. Apparently this trait has not always been present in man. Rowlett 54 described how the
incisors of primitive man occluded in edge-to-edge relationship when the molars were in
normal occlusion. This vertical overlapping of the incisors became prevalent in the human
dentition only about 2000 years ago in the Saxon era and may well have been associated with
the refinement in the diet of civilized man.
The relationship of overbite to post retention growth was examined by many. Payne 54
indicated that post retention ramus growth tended to decrease the mandibular plane angle,
resulting in an increased posterior face height and forward positioning of the symphysis. He
thought that these post retention growth changes were partially responsible for overbite
relapse. Hasstedt54 found a strong tendency for the incisors to return to their original overbite
relationship during post retention period. He could not, however, demonstrate any correlation
between overbite and vertical ramus height, interincisal angulation, changes in occlusal plane
or total face height. Many other studies are in agreement in finding a tendency for the incisal
overbite to return to its pre-treatment relationship following orthodontic treatment.
This relapse is associated with a number of variables. Corrections carried out during
periods of growth are less likely to relapse, and the maintenance of the post treatment result
is dependent on amount and direction of growth during the retention and post retention
periods. Over correction of incisal overbite should be considered as an aid in maintaining the
overbite reduction achieved during treatment. Considering the axial inclination of upper and
75

lower incisors Reidel8 believed that an upright incisor position, reflected by a higher than
normal interincisal angle, is more prove to overbite relapse.
Mark and Simons54 studied seventy orthodontically treated patients 10 or more years out
of retention. They tried to correlate incisal overbite relapse with other cephalometric
measurements. Their findings are interesting and are a valuable adjunct to our knowledge on
overbite relapse.
1) Patients who had a deep initial overbite prior to treatment also had deep initial
overbite post retention; however, they also maintained the greatest amount of
correction or overall net decrease in overbite.
2) A deep initial overbite was correlated with upright retrusive incisors in both the
maxilla and mandible, as an Angles Class I or Class II Div 2 malocclusions.
Protrusion of the mandibular incisors during orthodontic correction of overbite was
correlated with overbite relapse. This suggests that in order to enhance the long-term
stability of overbite correction, unnecessary protrusion of mandibular anterior
segment during treatment should be avoided.
3) Mandibular growth, containing the significant vertical component both during and
following orthodontic treatment were correlated with overbite stability. Lack of
mandibular growth in a predominantly horizontal direction was associated with
overbite relapse.
4) The overbite stability was correlated with an increase in anterior and posterior denture
heights during and following orthodontic treatment.
5) The occlusal plane angle was generally opened up during orthodontic treatment, and
during the post retention period it returned to approximately the original angulation.
This post retention closure or decrease in occlusal plane tipping should be avoided
during treatment if possible. No correlation was found between change in mandibular
plane and overbite stability.
6) Deep initial overbite was associated with a high interincisal angle, as in Angles Class
I and Class II, Div 2 malocclusions. However, there is no correlation between the
76

inter-incisal angle established following orthodontic treatment and post retention
changes in overbites.
7) Patients of either sex in whom overbite correction was accomplished during their
respective growth post retention seemed to maintain their correction 10 years out of
retention.
8) Post retention changes in overbites were not related to whether or not permanent teeth
were extracted during orthodontic treatment.
At present, genuine intrusion of incisors for the correction of overbite as suggested by
Ricketts is most widely accepted. Angle et al quotes Gordens study of cases treated by
Ricketts showing an average post treatment relapse of 1 mm for every 3 mm of intrusion.
77
Relapse related to Extraction / Nonextraction Cases

The last hundred and seventy years of orthodontic history shows that, with the
exception of Angle and Davenport, the feelings of the leaders in the profession was that
extraction, like amputation of any other part of the body, was not to be avoided if the
exigencies of the individual case demanded it and no other method of correction was
available - Hahn (1955). 55
Emotional battles still rage regarding tooth extraction in orthodontic therapy; however
with Hahns objectivity in mind, we should search for treatment rationales to substantiate the
role of tooth extraction. The controversy regarding the role of extractions in preventing
relapse of orthodontic treatment still exists after nearly a century of debate. Regarding
extraction of permanent teeth, orthodontists of this century have been clearly divided into
two camps: those who believed that mechanical alignment of crowded teeth would result in
the accommodation of bones and soft tissue to this new position and those who believed that
such adaptation did not necessarily follow. Unfortunately, the extraction versus nonextraction
debates of the pro- and anti Angle factions lacked the objective documentation of
postretention results. The most recent studies seem to indicate that extraction is not a panacea
and that long-term stability of lower incisor correction can be expected in only about 20% of
extraction cases. Other studies are not so pessimistic and suggest that treatment techniques
and retention plans may be major factors in long term stability.
The role of premolar extraction in orthodontics has been fiercely debated since the
turn of the century. Angle, Case, Dewey, Tweed, Ricketts, Begg, and Cetlin have each guided
the pendulum of our professional clock. 10 Extraction of the four first premolars enables the
orthodontist to effectively treat many cases of severe dentoalveolar protrusion as well as
many cases involving significant arch-length deficiencies. The rationale for extraction has
been extended to using it as a means of ensuring treatment stability. Unfortunately, many
studies have demonstrated that extraction cases are not immune to postretention relapse;
more specifically, and most obvious to the practitioner, the cases are as likely as not to
develop mandibular incisor crowding over the long term.
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While there appears to be general agreement that extractions are justified in
correcting bimaxillary protrusions or severe arch length deficiencies, the debate continues on
the role premolar extractions play in the long term stability of incisor alignment.
In his text Contemporary Orthodontics, Proffit1 states that first premolar teeth are
often extracted to allow better lip contours and to provide a more stable result. Yet the most
recent studies on relapse of the lower incisors in cases where the extraction of premolars was
performed indicate a discouraging result might be expected in atleast two thirds of patients.
Many of the cases of recrowding of incisors and space opening after orthodontic
treatment, which includes tooth extraction of first premolars or other teeth can be attributed
to intrinsic and extrinsic forces affecting the human dentition. Among these are the method of
chewing and swallowing; the type, and the degree of pressure when the teeth are brought into
occlusion. Dentofacial habits involving the teeth, the tongue, the lips and other facial and
masticatory muscles, psychic disturbances accompanied by certain orofacial tics, and other
untoward habits all may be causative factors.
Studies by little and others30,
55-59
, at the University of Washington concluded that
extraction of premolar teeth has little effect on long-term (10-20 years) post treatment
stability of lower incisor alignment.
Sandowsky60 reported on the stability of 96 cases examined an average of 20 years
after retention. These patients all exhibited 100 percent correction of the lower incisor
crowding present at the initiation of treatment. A comparison of long-term result to original
malocclusion showed there was increased mandibular crowding in 9% of the cases. At the
long-term follow-up, 15% of the cases had crowding beyond 3 mm, and only 1% had
crowding of 6.5 mm or more. There was no attempt to distinguish between cases treated by
the extraction or nonextraction approaches in Sandowskys study. In a later article by Uhde,
Sandowsky, and Begole61, the sample was broken down into 45 nonextraction and 27
extraction cases. The extraction sample showed more severe crowding at the beginning of
treatment and a smaller percentage of relapse postretention.
Glenn61 studied 28 cases of nonextraction treatment an average of 8 years
postretention. He found that incisor irregularity increased slightly postretention.
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Sandusky10 reported on postretention stability of 85 extraction cases treated by Tweed and
Tweed foundation members. He reported less than 10% relapse of the lower incisors using
Littles irregularity index. He found the lower incisors tended to move forward postretention
and the occlusal plane - Frankfort horizontal plane angle decreased.
Tweed10 talked in a 1968 interview about a study he was conducting with 100
extraction and 100 nonextraction cases examined 25 years postretention. While no scientific
data are available, Tweeds conclusion was that the extraction cases were more stable.
In a masters degree thesis at Loma Linda, Davis 10 reported that extraction cases
experienced less mandibular incisor crowding and were more stable than nonextraction cases
three to five years postretention.
Kuftinic and Strom45 examined 50 cases, 25 extraction and 25 nonextraction, four
months or more after discontinuing retention and found that lower incisor relapse was greater
in nonextraction cases.
Boese28, 29 published a study on 40 extraction cases that were orthodontically treated
but never retained. His findings were based on observations made four to nine years post
treatment. All patients had undergone fiberotomy and reproximation of the mandibular
incisors. Crowding was evaluated by Littles irregularity index and was found to be almost
nonexistent posttreatment. It should be noted that about one half of the cases required more
than 1.8 mm of enamel reduction, performed in several stages. It is also interesting to note
that the lower incisors were uprighted during treatment and continued to upright
posttreatment. The mean values for IMPA (89.5 at appliance removal, 88.6 postretention) are
within the range that Tweed suggested was necessary for stability. Those patients whose
growth would have been classified as type C by Tweed required additional amounts of
reproximation as growth occurred. Slight overcorrection of rotations was accomplished at
least six months prior to performing the fiberotomies.
Boese28, 29 felt that the practice of not utilizing any retention in the mandibular arch
played an important role in stabilizing the lower anterior teeth. He stated that lower
retention eliminates the need for reproximation, since it postpones natural arch length loss,
prevents any compensatory lower incisor movement, and allows for a build up of forces
80

during the retention period. The decision not to use lower retention will allow for natural arch
length loss, which occurs gradually and can be dealt with immediately.
The extraction of premolars does not assure long-term stability of the lower incisors.
Recent studies of postretention stability by different authors have produced significantly
different results. It may be that the treatment goals and the mechanics used to reach those
objectives differed in the populations studied.
Mandibular Incisor Extraction - For Stability:

Extraction of two mandibular incisors may satisfy the requirements of maintaining
arch form without expansion of intercanine width. Extraction of one mandibular incisor
usually does creates problem of deep overbite, at least when a normal tooth size relationship
is present before the extraction. If maxillary canines are related in their normal positions to
mandibular canines, then maxillary incisors must naturally fall into either a greater overbite
or overjet. However, when two mandibular incisors are removed, the mandibular teeth are so
rearranged that the mandibular canines become lateral incisors. If the central incisors are
removed, the mandibular lateral incisors become central incisors. The mandibular first
premolars assume the place of the mandibular canines and the maxillary canines must
occlude along the distal inclined planes of the mandibular first premolars. When two
mandibular incisors have been removed, the usual relationship of the anterior teeth is end to
end, for the mandibular arch in the anterior area is usually slightly larger than it would have
been with four incisors present instead of two incisors and two canines. It is usually
necessary to trim the mesiodistal widths of the mandibular centrals or laterals (whichever
remain), the canines, and the first premolars to create a harmonious tooth size relationship
between these teeth and the maxillary six anterior teeth.
When the mandibular first premolars are extracted, the simple realignment of the
mandibular anterior teeth and canines in normal arch form results in a greatly increased
intercanine width, which in all likelihood cannot be maintained. On the other hand, if
mandibular inter canine width is maintained as presented, the arch form cannot be anything
but pointed or V shaped. A satisfactory solution involves the extraction of two mandibular
central incisors. The consequent inter canine width is little changed, whereas mandibular arch
81

form has been maintained in a form similar to the original. Treatment by extraction of a
mandibular incisor tooth can show a tendency to cusp-to-cusp on one side of the dental
arches followed by what is known as slippage, or forward migration of buccal series of
teeth. There is a tendency for extracted incisor space to reopen when the basal arch is large,
and the tongue is large and active. In addition, it is conducive to maxillary incisor overjet and
deep overbite. Retainers are to be worn indefinitely.4, 24, 45
Contraindications for Mandibular Incisor Extraction:

This is not to suggest that all problems of mandibular anterior crowding can be solved
with the extraction of mandibular anterior teeth. There are three drawbacks to such treatment:
1) In instances of minimal crowding spaces tend to open between the canines or centrals
and canines or laterals (whichever are maintained). Spacing in this area can be
irritating to the patients, for food impaction is embarrassing and esthetics is
unpleasant.
2) Generally the most protruded mandibular incisors are removed, and then immediately
the mandibular denture becomes more posterior relative to the mandibular base. It is
difficult, if not impossible, to move the whole mandibular denture forward to assume
its previous relation to pogonion, and facial esthetics may suffer as a result of this
recessive positioning of the mandibular denture.
3) A third possible problem includes the anatomic differences in shape of the mandibular
canines as compared to the normal mandibular lateral incisors; occasionally there are
differences in the color of these teeth as well.
Non-extraction therapy in crowded cases is usually thought to lead to post retention
relapse. Mandibular arch length and inter canine width typically decrease during post
retention period regardless of whether they increase or decrease during treatment.
Restoring arch length deficiencies with extraction treatment has not eliminated the
problem of relapse. A number of etiological variables have been considered including
excessive intercanine expansion, arch from change, pretreatment crowding and length of
retention.
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Reidel62 has suggested that the patients with severely crowded mandibular arches,
removal of one or more mandibular incisors is the only logical alternative which may allow
for increased stability of mandibular anterior without continued retention.
Schwartz63 reported 20 years post retention records of a patient who had two mandibular
incisors removed. Riedel observed that the arches in these patients appeared less crowded
than patients who had been treated with premolar extraction.
Riedel62 stated that The extraction of two mandibular incisors may satisfy the
requirements of maintaining arch form without expansion of intercanine width. With nonextraction or premolar extraction, the intercanine width usually must be increased to gain
adequate alignment and arch form a strategy that might result in favorable result.
It is suspected that an increase in intercanine width contributes to incisor relapse and
crowding. It was noticed that intercanine width decreases after incisor extraction and
continued to decrease post retention. The post retention reduction was significantly less as
compared to premolar extraction. The study carried out by Riedel and Little suggested that
simply maintaining or reducing intercanine width does not guarantee completely stable long
term end result but may contribute to a lesser degree of relapse.
Patients should be carefully selected for this treatment plan of mandibular incisor
extraction. Success of treatment depends upon patient selection and mandatory diagnostic set
up before making extraction decision.24
83
Stability after Expansion

Although expansion of the maxilla is one of the oldest forms of orthodontic treatment,
its use has consistently evoked professional controversy. Debate is being done on the stability
and progress of expansion since the day the theory of expansion has been put forward. The
debate seems to have been all the more heated because little scientific evidence existed to
support any of these views. A most scientific study was carried out by Skieller in 1964 who
inserted metal implants into 13 girls and 7 boys using an expansion appliance. This was
opened at the rate of 0.5 mm. Skieller found that both the teeth and the vault widened during
retention and thereafter the teeth however commenced to relapse at the end of the expansion
and continued to do so out of retention, with the relapse amounting on average to about 25%
of the total opening. The other finding of Skiellers study was that the dental relapse was less
for the patients under 9 year old.74
Many more studies have been done more recently on the stability and relapse after
expansion. According to Storey the ideal rate of expansion should be 1 mm per week, which
has been recommended by other authors also.75
In recent years Hass (1980) 74 has put forward another concept in reducing the relapse after
expansion. According to him the retention phase after expansion is completed, should be
increased. Zimring and Issacson have demonstrated that forces to collapse the maxillary
expansion exist for approximately 6 months.
Hass also recommend the concept of over expansion. The environmental factors play
an important role in the stability of the arches after retention. Some amount of changes
should be anticipated due to forces action upon the dental arches. This can be counteracted
by slight over expansion.
Another finding was that stability of maxillary arch expansion was more than that of
mandibular arch and it was more easier to maintain the stability of molar expansion than
canine expansion.75
William Proffit compared the amount of relapse in case of orthodontic and orthopedic
expansion. He noted that in case of orthopedic expansion if 10 mm of total expansion would
84

have been produced, in the beginning 8 mm of skeletal and 2 mm of tooth movement was
seen. At 4 months the same 10 mm of dental (total) expansion could be present, but at that
point there would be only 5 mm of skeletal and 5 mm of dental expansion.
If a force across the midpalatal suture is applied more slowly, total force build up is
less. It appears that approximately 1 mm per week is the maximum rat at which the tissues of
the midpalatal suture can adapt. So tearing and hemorrhage are minimized. To produce
expansion at this rate, 2 to 4 pounds of force appear optimal, depending on the age of patient.
Higher level is needed in older patients. From the beginning the ratio of the dental to skeletal
expansion is about 1 to 1, so that 10 mm of expansion over 10 week period, at the rate of 1
mm per week would consist of 5 mm of dental and 5 mm of skeletal expansion. With
expansion at this rate the situation at the completion of the active expansion is approximately
analogous to rapid palatal expansion 2 to 3 months after rapid palatal expansion is completed
when bone filling has occurred.
Thus the over all result of rapid versus slow expansion is similar, but with slow
expansion a more physiologic movement is added.76
The farther the teeth must be moved laterally and the more rapidly they are move, the
more longer should be the period of retention. If a case is widened a short distance over a
clinically long period of time with slow expansion, the chance of major relapse is minimal. If
such occurs it is usually related to recurrence of the improper muscle function, which caused
the problem in the first place. If, however a case is widened over a relatively short period of
time with more clinically rapid technique, the chances of relapse after withdrawal of the
appliance are increased. Slight overexpansion is then also generally advisable.
The amount of retention needed for a given case is dependent on many factors. In
estimating the length of time required for active retention, it is better to overestimate and be
sure than underestimate and suffer possible relapse due to the withdrawal of the appliance too
soon. The second molar plays a key role in transverse expansion. We know that the powerful
mesial thrust of the second molars leads to the crowding of teeth in the bicuspid, and even
anterior regions. With the elimination of this forward thrust by means of second molar
extraction (when needed), stability is gained in an anteroposterior direction. The direction of
the relapse of the first molar once the second molar extraction is in the distolingual direction
85

rather than the mesiolingual direction. This in turn moves the teeth slight posteriorly back on
the wider part of the arch.
The age of the patient is also an important factor. The younger they are, the greater
the chances of stability in lateral development. The second concept to be kept in mind is that
of lateral development and not expansion. By this it means that the teeth are merely
being brought out to their full genetic potential, not past the point where the limit of basal
bone has been genetically programmed. Altoona et. al at the University of Toronto have
stated that though the shape of a bone may be affected by function, the volume is genetically
predetermined.77
With all these recent studies it is proved that expansion is a biologically and biomechanically sound procedure. The decision to gain space through expansion or by the
removal of teeth must be based on an understanding of the causes of the original crowding
with there potential for future influences, possible growth effects that may increase or
decrease arch length and the possibilities of functional adaptation to the proposed changes.74
86
Balance in the three tissue systems

Failure to understand the balance between the three tissue systems of the orofacial
region, namely, Dental, Skeletal and Neuromuscular could result in treatment failure and
relapse. As Graber points out, confining oneself to only dental system, ignoring the skeletal
and neuromuscular restricts the horizon of Orthodontic philosophy.
Most Orthodontic treatment is aimed at correcting skeletal and dento alveolar malrelationships and Orthodontists have generally become quite adept at achieving functionally
balanced occlusions. However, one concept is often over looked when considering the nature
of malocclusions; the craniofacial complex maintains a state of homeostasis regardless of its
structural configuration or whether or not it is skeletally balanced. Abnormal skeletal or
dento-alveolar configurations are counter-balanced both by atypical or abnormal patterns of
perioral and masticatory muscle function and by passive pressures of the other associated soft
tissues.65
Abnormal skeletal Configuration
Abnormal muscle function

BALANCE
Abnormal Dentoalveolar relationship
Passive soft tissues pressures
Therefore, the overall form function relationship is stable, even though each of the
individual components may have an abnormal configuration or pattern of activity. This
stability is demonstrated by the relative consistency evident in the overall skeletal and dentoalveolar relationship during growth period, for example, though maturation changes occur, an
individual at age 18 years generally resembles himself as he appeared at age 6 years.
Most current orthodontic therapy, particularly practical in the United States, is aimed
at correcting of skeletal and dento-alveolar mal-relationships with little or no attention paid
to the accompanying abnormal functional patterns. It is often assumed by the clinician that
87

these abnormal functional patterns will be corrected automatically if structural balance is
attained. However, in patients in whom such unilateral treatment is undertaken, the hard and
soft tissues of the face often do not achieve a state of balance, the result of which is a relapse
of the skeletal and dento-alveolar configurations toward their original relationships.
Treated skeletal and Dentoalveolar
BALANCE
Relationships
Abnormal Muscle
Function
Original skeletal and dentoalveolar
RELAPSE
Relationship
Passive soft tissue

pressures
In planning the ideal therapeutic regimen, the goals of treatment should include the
achievement of long-term stability, which can be obtained only if the balanced skeletal and
dento-alveolar configuration exists in harmony with associated musculature and other soft
tissues after treatment.
Balanced skeletal configuration
Harmonious Muscle function

LONG TERM
STABILITY
Harmonious Dentoalveolar Relationships
Passive soft tissue pressures
If this goal is achieved, relapse, as used in Orthodontics, can be limited primarily to

alterations in tooth positions. Theoretically there should be no need to mechanically retain a
structural relationship that has been achieved concomitant with the elimination of
compensatory muscle function. Mc Namaras experiments on muscle adaptation following
muscle lengthening, surgical detachment and surgical re-attachment are a concluding
evidence of not ignoring the muscle factor in the stability of orthodontic surgery cases.
88
Stability and efficiency of the Masticatory system

Altering the form and relationship during Orthodontic treatment could alter the
delicate balance between the various factors, which results in the form of the dental arches,
and their relationship to one another. The stability of the result will depend on the efficiency
of the masticatory system in the new relationship.
The Dental arch in man lies between the tongue and cheeks and lips. When teeth
erupt into the oral cavity they come under the influence of these soft tissues and, therefore, it
is commonly believed, into a position of balance. There are two distinct views regarding the
influence of the soft tissues on the teeth and the jaws. One was summed by Tomes (1873),
who said, The action of the lips and tongue is that which determines the position of the
teeth. The contrary point of view is put forth by Scott (1967) who said, The arch form was
determined prior to any muscular development and was independent of the functional activity
of the oral musculature.
In order to consider the effect of the soft tissue environment on the dental arches, the
various factors, which make up the oral environment, must be identified. It would appear that
equilibrium position of the teeth is the result of the influence of several factors66: 1) The cheeks and the lips.
2) The tongue.
3) The soft tissue, which suspend the teeth in the bone.
4) The eruption of the teeth.
5) The morphology of the crowns of the teeth.
6) The forces from the muscles of mastication.
7) The growth of the jaws.
The periodontal membrane, which differentiates as a result of the presence of the dental
structures, has a function of maintaining the integrity of the dental arches by keeping teeth in
contact with one another.
89

The cuspal interdigitation of the teeth is also important for transmitting the forces of the
muscles of mastication to the teeth, as Angle puts it, to give one another the greatest support
in all directions.
The muscles of mastication also work to prevent the disruption of the intact dental arch,
and studies in various groups of patients indicate that balance and harmony of the
musculature and the effort of patients with a malocclusion maintain the arch relationship.
Experiments in adult animals indicate the adaptability of the system, which endeavors to
provide an efficient masticatory system, even when the arch form is altered by moving
individual teeth.
90
Reorganization of Supporting Tissues

Bone and adjacent tissues must be allowed time to reorganize around newly
positioned teeth. The post treatment reaction of the periodontal structures (fiber system) has
been demonstrated by experimental evidence on human and partly on animal material. It has
been shown that a certain amount of contraction and re-arrangements of fibrous structures
occurs in every case. This contraction varies according to the type and degree of tooth
movement carried out. A factor to be considered in this connection is the highly individual
reaction of the fibrous structures of the supporting tissues. There are variations between
young and adult patient tissues, but there is more between the type of fibrous tissue observed
in various patients of the same age group.
Variations in tissue behavior are also apparent in practical orthodontics. In some patients,
the tooth movement may be completed without any appreciable degree of relapse, i.e.,
without contraction of previously stretched fibrous tissue. The periodontal tissues of these
patients are more readily transformed. The contraction of displaced and stretched fibrous
structures is less pronounced in some areas of the supporting tissues than the others.
Generally, in such cases, there are two areas in which the fibrous tissue reaction is somewhat
different.
1) The fibrous structures of the newly formed bone, including the principle fibers of the
periodontal ligament.
2) The supra-alveolar and trans-septal fibrous systems.
Post treatment changes in New Bone Layers: The reaction changes following tooth movement vary according to how the tooth has
been moved. For example, there is no marked displacement of the fibrous structures of the
new bone formed as a result of gradual migration of a tooth, or the fibrous structures of the
new bone formed around an erupting tooth. As in the case of the erupting second premolar
that is brought gradually into position following extraction of the first premolar. In this case
the fibrous structures of the bone will remain relaxed and re-arranged according to the new
91

position of the tooth moved. After treatment the three teeth canine, second premolar, and
first molar will remain in contact and there will be little or no tendency to secondary
migration. Thus, relapse of the teeth approximated following extraction may be largely
avoided by early treatment during tooth eruption and alveolar bone growth.
Contrary to this, when fully erupted teeth have been approximated after extraction,
there is always a certain tendency to secondary change in tooth position. The cause of this
relapse is contraction that occurs not only in the supra-alveolar tissues, but also as a result of
early re-arrangement of Sharpeys fibers of the newly formed bundle bone as well as the
principle fibers of the periodontal ligament. Unlike the supra alveolar structures, however,
the fibrous tissues of the new bone and the periodontal ligament will be arranged following a
fairly short retention period.
The Apical base: The circumferential lamellae of the bone and the supporting fibrous tissues are so
arranged as to withstand any great tooth movement in a labial or lingual direction. When
moved into imbalance, these structures tend to contract and relapse occurs. This reactive
movement of the teeth moved becomes dominant particularly after expansion of the dental
arches. In this connection, the apical base concept has given rise to a cardinal principle of
orthodontic philosophy, namely that treatment of malocclusion must not be based on
expansion if relapse is to be avoided. The apical base concept is correct as a principle.
However, a detailed observation of the behavior of the structures involved may disclose that
after retention there is less relapse tendency in the apical base area than in the structures of
the marginal third of the root. Torque of the root may be performed in either a labial or a
lingual direction. A gradual torque movement and also tipping of the tooth may result in
compensatory bone formation along the outer bone surface corresponding to the apical third
of the tooth. If the torque or tipping movement is carried out rapidly, the apical portion of the
root may be moved through the bone and partly outside the apical bone. In both instances, the
positional stability of the tooth moved is determined largely by whether the tooth is retained
or not. If the involved tooth is retained for a period of approximately 2 to 3 months, there is
relatively little relapse of the apical portion of the root. Even a root that has been moved
92

through the bone tends to remain outside the bony area. As in a bodily movement,
rearrangement and calcification of the new bone spicules on the tension side will result in a
fairly dense bone tissue, which initially resists any appreciable degree of relapse. The most
persistent relapse tendency is caused by structures related to the marginal third of the root.
From a practical standpoint it may thus be stated that only when retention is omitted
does any appreciable relapse tendency exist in the bone adjacent to the apical base area.
Post treatment changes in the supra alveolar structures: The free gingival and trans-septal fibers, which some decades ago were termed the
circular ligament, seem to have a special function. They are more active than other fibers in
maintaining the tooth in proper positions. The free gingival fibers interlace with the supraalveolar soft tissues of the proximal teeth and thus form a continuous fibrous system. There
are in addition, elastic and oxytalan fibers in the supra-alveolar tissues. These elastic fibers
will add to the contractive force of the fibrous system after displacement or stretch.
The effect of this contraction is observed on the tension side of the tooth, particularly
in cases where the tooth is tipped or rotated. If a tooth is tipped and not retained at all even
surgical removal of the supra alveolar tissue does not prevent some relapse from occurring.
Fiber bundles of the middle and apical thirds of the root will then enter into action.
Hyalinized areas may be observed as a result of tipping of human teeth without
subsequent retention. It is shown that most of the relapse occurred during the first 5 hours
after the appliance had been removed. It is a fact that re-arrangement of the alveolar bone and
the principle fibers occur when the fixed appliances are left on the teeth for atleast two
months. The supraalveolar structures, however, will not become rearranged until the tooth
has regained its physiological equilibrium.
Relapse caused by the trans-septal fibers is a result of their mode of attachment from
cementum to soft tissue. When connective tissue fibers under stress attach to soft tissue, there
is apparently no mechanism for their rearrangement. With bone serving as an attachment, readaptation is made possible.
93

Reitan35 demonstrated this on orthodontically rotated teeth. He compared the time
required for fibers in various areas of the root to recover from displacement. Recovery was
considered complete when the fibers were perpendicular to the root surface. A period of 83
days was required for re-arrangement in apical region. 147 days for the middle segment and
no physiologic rearrangement occurred after 232 days retention in the marginal areas. On
the basis of these reports some authors have said that the retainers should be only inhibitory
in nature and have no positive fixation to allow for the natural functioning of teeth.
Oppenheim116 argued that appliances should only be inhibitory and the repair of tissues
around the teeth occurs much more rapidly if no fixed retaining appliance is used.
All these suggestions are based on the presumption that mature bone will assure
greater stability for the teeth. Present day orthodontic concepts, however, regard bone as
being a plastic substance and consider tooth position.
The placement of retentive appliances is then, an admission of inadequate orthodontic
correction or of a pre-determined decision to place teeth in relatively unstable positions for
esthetic reasons. Whether stability increases with prolonged retention is one of the most
interesting points of discussion in regard to retention planning, and is the phase of stability
about which we know least.
94
The Long Term Stability of Orthognathic Surgery

The advent of orthognathic surgery has given the practicing orthodontist, in
conjunction with the oral surgeon, the ability to correct skeletal deformities that had
previously been camouflaged by orthodontics alone. Often these orthodontic treatment
results were unsatisfactory since they required severe dental compensations to accommodate
the poor skeletal relationship. With the recent advances in orthognathic surgery, however, it
has become possible for the surgeon to address many deformities that were previously
untreatable. Long term stability following these surgical procedures has been of major
concern since the early days of orthognathic surgery because the final long- term result, both
aesthetic and functional, is directly related to the post surgical stability.
The early studies of mandibular advancement78, 79 and maxillary LeFort I osteotomies
revealed that mandibular relapse tended to be greater than maxillary relapse. Therefore, many
studies of stability in the 1970s concentrated on mandibular advancements utilizing followup cephalometric radiographs in an attempt to identify the relapse patterns and their
etiology.80 These studies, as well as studies in the early 1980s by Schendel and Epker 81 and
by Lake et. al82 demonstrated that relapse primarily occurred during intermaxillary fixation
and immediately following the release of fixation, so that the long term results were not
always predictable. Some studies of the relapse patterns following maxillary LeFort I
osteotomies were also reported during this period 83 and demonstrated greater overall stability
than seen for mandibular advancements, but documented instances of instability for
individual patients. In the late 1970s further advances in surgical techniques allowed surgical
procedures to be performed simultaneously in both the maxilla and the mandible. Early
studies of double jaw surgery reported lesser amounts of mandibular relapse and greater
maxillary relapse than for single jaw procedures performed independently.84
Numerous theories regarding the primary etiologic causes of relapse have been advanced
and studied. These include:1) stretching of the muscles of mastication and the suprahyoid musculature,79
2) condylar distraction during surgery,81,85
3) counterclockwise rotation of the mandible,78 and
95

4) rotational position changes between the proximal and distal segments.82
Simultaneously, various surgical techniques and postsurgical therapies were advocated in
order to minimize relapse, and numerous studies were conducted to evaluate their results.
These technique included suprahyoid myotomies 86 and cervical collars utilized to reduce
muscle tension following surgery.78, 79, 84
Numerous fixation techniques have been advocated to reduce relapse post surgically.
These have included: 1) upper and lower border wiring of the mandible,87
2) Steinmann pins to stabilize the maxilla, 88
3) skeletal wire fixation,81 and
4) rigid fixation.89
Recently studies involving isolated mandibular advancements90 and maxillary LeFort I
procedures91 have indicated a strong potential for reduced relapse using the two most popular
of these alternate techniques: skeletal wire fixation and rigid fixation.
Although numerous papers have been published evaluating the stability of the major
surgical procedures (i.e. sagittal split, LeFort I osteotomy), no clear picture has as yet
emerged as to their overall long-term stability.
Most of the studies on stability have concentrated their evaluations on the short term (i.e.,
the first six to eight weeks) postsurgical period. Few studies have evaluated relapse out to
one-year post surgery. Among those who have examined stability at one-year post surgery,
many have used small sample sizes with heterogeneous groups, often including patients with
clefts or other including patients with clefts or other congenital deformities. In addition, the
fact that different surgical procedures were frequently carried out on patients in the same
sample has further reduced our ability to evaluate long term result.
96
Mandibular Advancement: A) Wire fixation:

Using the well conducted Lake (1981) 82 study as a baseline, one sees that there was
1.6 mm of posterior relapse during fixation and little change from eight weeks out to one
year. Kohn in 1978, with a larger mandibular advancement while seeing a similar amount of
short term relapse, also encountered a considerable amount of long - term relapse. The total
relapse seen over one year in these two studies (24% and 38%) is reflected of many studies
carried out during this period that utilized only interdental wiring for fixation. As reflected by
changes seen in the Sandor study (1984) 92, when skeletal fixation using circumzygomatic
and circumandibular wires was utilized the amount of relapse seen was considerably smaller.
Recently, Watske93 has noted a different pattern of changes, with the initial posterior relapse
being almost counterbalanced by a long - term forward movement, thus producing only a
small (6%) net relapse. Whether this pattern will be found in other contemporary studies or is
due to some specific feature of the surgical technique remains to be determined.
Author
T1-T2
T2-T3
T3-T4
Lake
52
+5.8
-1.6
+0.2
Kohn
17
+8.4
-1.4
-1.9
Sandor
20
+6.1
-0.6
-0.4
Watske
35
+5.1
-1.8
+1.5
Simmons
32
(T4-T5): -0.2mm
Tabular and graphical

representations of the changes
during and after mandibular
advancement with wire fixation as
measured at B-point.
B) Rigid Fixation: -
97

When comparing the stability of mandibular advancement with rigid fixation to that of wire
fixation some differences are immediately apparent.93, 94-96 Of prime importance is the finding
that the net changes for the rigid studies are in an anterior direction rather than in the
posterior direction previously noted for the wire fixation samples. The magnitude of the
relapse is less than half of that seen with the earlier interdental wire fixation studies, but it is
only moderately better than the contemporary skeletal wire fixation studies.
Author
T1-
T2-
T3-
T2
T3
T4
-0.3
+0.7
Caskey
20 +4.8
Barrer
43 +4.7 +0.1 +0.4
VanSickels 31 +4.6
Watske
-0.1
+0.4
35 +5.0 +0.8
-0.5
Tabular and graphical representations of the changes

during and after mandibular advancement with rigid fixation as measured at B-point
However, when the incidence of relapse in Watskes matched samples of

contemporary skeletal wire and rigid fixation groups are compared some interesting findings
emerge. During the first 6 weeks following surgery approximately 40% of the wire fixation
sample demonstrated between 2 and 4 mm of posterior relapse. An additional 5% showed
greater than 4 mm of posterior relapse, whereas a similar number underwent 2-4 mm of
anterior relapse. Thus, approximately 50% of the wire fixation sample demonstrated
instability during fixation, with the preponderance of change being in the posterior direction.
In contrast, only 25% of the rigid sample demonstrated significant relapse, with most of the
changes being between 2 and 4 mm in an anterior direction.
The incidence of relapse in Watskes rigid and
98

wire fixation samples over the first six weeks post-surgery
From 6 weeks to 1 year somewhat different findings were noted. About 40% of the
wire fixation sample now demonstrated a tendency to come forward whereas in the rigid
sample 25% of the cases continued to come forward and 20% were moving posteriorly.
The incidence of relapse in Watskes rigid and

wire fixation samples from six weeks to one year
post-surgery
The past decade has seen a considerable improvement in long term stability
following mandibular advancement as the transition from interdental to skeletal wiring for
postsurgical fixation occurred. The introduction of rigid fixation, while having halved the
incidence of relapse, has offered only a moderate improvement over current skeletal fixation
techniques in those cases showing postsurgical instability. Of prime importance to the
clinician is the fact that the mandibular advancement cases with rigid fixation that undergo
relapse frequently do so in an anterior direction rather than in the posterior direction usually
seen with wire fixation. Care should therefore be taken with the long term use of Class II
elastics in rigid fixation cases if a high relapse potential is suspected.
Mandibular Setback: -
99

The vast majority of studies evaluating mandibular setbacks have utilized wire
fixation. Kobayashi97 and Rosenquist98, with moderate setbacks of 5.4 and 8.4 mm, noted
18% and 22%, respectively, of anterior relapse after one year. Forward movement was seen
during both the short and long - term periods and totaled between 1.2 and 1.5 mm. In
contrast, Astrand and Vijayaraghavan reported considerably larger mean setbacks and noted
anterior relapse of 2.4 and 3.1 mm, respectively, after one year. This greater absolute amount
of relapse translated into 20% and 31% net change for the two studies and is reflective of
many studies suggesting that larger setbacks are more likely to undergo greater postsurgical
changes.
Author
T1-
T2-
T3-
T2
T3
T4
Kobayashi
34 -8.4 +0.9 +0.6
Rosenquist
14 -5.4 +0.7 +0.5
Astrand
35
+0.3 +2.1
12.0
Vijayaraghavan 16
+3.1
10.0
Phillips(SS)
19 -5.4
+2.1
Phillips(RO)
20 -6.2
-1.4
representations of the changes

during and after mandibular setback
with wire fixation as measured at Bpoint
Recently Phillips et al compared skeletal stability following sagittal split and transoral
vertical ramus osteotomies. Their findings indicated different patterns of relapse; with the
sagittal split coming forward post-surgery whereas the transoral vertical ramus osteotomies
showed continued posterior change. Also, the relapse seen in the sagittal splits (38% of the
surgical change) was considerably greater than that seen for the transoral vertical ramus
osteotomies (23% of the surgical change).
Unfortunately, comparison with setbacks carried out with rigid fixation is not possible
due to the lack of studies of this type. Of note, however, is the study by Franco et al,
99
in
100

which, with a sample of 14 patients, the researchers showed an average of 2.1 mm, or 43%,
anterior relapse following a mean of 4.9 mm of surgical setback.
Although it has received less publicity than mandibular advancements, the relapse of
mandibular setbacks with wire fixation appears to be similar both in incidence and amount.
Larger setbacks in particular seem to be prone to greater relapse, and as yet there are
insufficient data on the effects of rigid fixation to tell if it will have a significant effect. The
initial findings of different relapse patterns between saggital splits and transoral vertical
ramus osteotomies need further investigation because they have considerable clinical
implications, particularly in cases in which future mandibular growth is a possibility.
Factors influencing mandibular stability: Since the early days of orthognathic surgery it has been hypothesized that the greater
the amount of mandibular surgical movement, the greater the relapse. Although reported
numerous times in case studies and generally accepted to be true, little scientific data are
available to confirm this concept. Lake82 and Van Sickels96 as well as many other authors
have felt that advancements greater than 10 mm showed less stability and that factor such as
a high mandibular plane angle and poor proximal segment control during surgery were
significant predisposing factors to increased mandibular instability.
In her evaluation of the two techniques for mandibular setback, Phillips noted that the
sagittal split group showed a somewhat higher correlation between the magnitude of surgical
change and relapse than did the transoral vertical ramus osteotomies group. In general,
considerably more investigation of these interactions appears to be necessary to allow for the
identification and possible future control of factors likely to precipitate mandibular
instability.
Maxillary Impaction
Wire fixation:
Several long term studies have evaluated maxillary impaction when carried out as a
single, independent procedure. Overall, they demonstrated a net tendency for continued
101

superior settling following surgery. Whereas some studies suggest minimal long term
change (Greebe 0%, Proffit 7%100), others reflect a significant degree of relapse (Schendel
21%83, Bishara 30%101), although the actual amounts are quite small - often around only 1
mm.
Author
T1-
T2-
T3-
T2
T3
T4
Schendel
24
+5.7
+1.2
Bishara
31
+3.0
+0.9
Greebe
25
+4.5
0.0
Proffit
61
+3.8
+1.0
-0.7
Tabular and graphicalrepresentations of the changes during and after isolated maxillary
impaction with wire fixation as measured at A-point
When single versus multiple segment maxillary impactions with wire fixation were
compared by Proffit100, little difference was found between their long term stability. Both
groups showed continued superior settling in the short term followed by long term inferior
movement, resulting in a net of less than 1/2 mm of long-term superior relapse. This
produced overall relapse percentages of 9% for the one piece maxillas and 11% for the
segmental procedures.81, 101
102

The incidence of relapse in Proffits wire fixation maxillary impaction sample as measured
at A-point
Isolated maxillary impaction with wire fixation appears from the data to be a more
stable procedure than mandibular advancement, with only 20% of the cases showing
significant relapse compared to 40% for the mandibular surgeries. In addition, the amount of
change, often around only 1 mm, was considerably less than that seen in the mandible.
Proffits data seem to suggest that segmenting the maxilla has no effect on vertical stability.
However, more evaluation of changes in the transverse and anteroposterior planes, as well as
comparison of two - and three segment surgeries, is required before a definite conclusion
can be reached.
Author
Proffit /
T1-
T2-
T3-
T2
T3
T4
36
+4.6 +1.3 -0.9
25
+2.8 +0.7 -0.4
one piece
Proffit /
segmented
Tabular and graphical representations of the changes during and after one piece and
segmental maxillary impactions
Maxillary Impaction and Mandibular advancement:

Vertical Maxillary changes:
103

When maxillary impaction is carried out as part of a simultaneous double jaw
procedure a different pattern of relapse is found than that previously seen in isolated
maxillary impactions. In the wire fixation studies 84, 102, 103 there was a small but consistent
tendency for the maxilla to move inferiorly following surgery. These changes were well
under 1 mm and ranged from 13% up to 36% of the surgical change. Stability in the rigid
fixation sample104 was even better, with minimal (2% and 4%) postoperative inferior
movement being noted. Although these samples are small, they might be taken to suggest that
maxillary stability in double jaw cases, particularly when rigid fixation is used, is certainly
no worse and perhaps even a little better - than when maxillary surgery alone is performed.
Maxillary impaction and mandibular advancement - Wire fixation (mm)
Author
T1-T2
T2-T3
T3-T4
Bramer
12
A-(V) +3.1
- 0.4
Turvey
53
A-(V) +3.0
-0.5
Satrom
A-(V) +2.2
-0.8
Tabular representation of the vertical maxillary changes as measured at A point in the

wire fixation studies
Maxillary impaction and mandibular advancement - Rigid fixation (mm)

Author
T1-T2
T2-T3
T3-T4
Hennes
24
A-(V) +4.3
- 0.1
Satrom
26
A-(V) +2.5
- 0.1
Tabular representation of the vertical maxillary changes as measured at A point in the

rigid fixation studies
104
Graphic representation of the vertical maxillary changes as measured at A point

for the wire (W) and rigid (R) studies
Anteroposterior Mandibular Changes: The data from the group of three studies in which the patients underwent mandibular
advancement with wire fixation as part of a double jaw procedure84,
interesting comparison to the isolated mandibular advancements. 82,
102, 103
92, 93
provides an
Although they
underwent considerably larger advancements (probably due to the greater severity of the
malocclusions in the cases warranting double jaw surgery), both the average amount of
posterior relapse (1.4 mm) and the overall relapse percentages were very similar to those
found in the isolated mandibular advancement studies. In fact, the mandibular stability seen
in the double jaw rigid fixation studies 103 appeared to be superior to that seen in the isolated
rigid fixation mandibular advancements.
Hence, when maxillary impaction is carried out in conjunction with mandibular
advancement there appears to be no deterioration in maxillary vertical stability. In fact, in this
case rigid fixation appears to improve stability, primarily by reducing the clockwise rotation
Author
Brammer
Turvey
T1-
T2-
T3-
T2
T3
T4
12
- 1.8
(W)
12.8
53
+ 8.5
of the jaws frequently seen after two-jaw surgery

with wire fixation. Rigid fixation also improves
maxillary vertical stability by virtually eliminating
large relapses (i.e., those greater than 2 mm). The
findings
- 0.6
for
the
mandibular
advancement
component of the double jaw cases were similar,

with equal or slightly improved stability being
(W)
noted for both the wire and particularly the rigid

Satrom
+ 7.1
- 1.9
+10.3
fixation samples.
(W)
Hennes
24
(R)
Satrom
26
(R)
0.1
+ 8.6
- 0.5

representation of the
105
anteroposterior mandibular
changes seen in double jaw
Maxillary Advancement:
Quantifiable data for maxillary advancements are conspicuously lacking in the
current literature, particularly where long term evaluation are concerned. In the two wire
fixation studies available, 104, 105 long term posterior relapse ranged from a total of 0.5 mm to
1 mm, representing 7% and 20% of the surgical change, respectively. When rigid fixation is
used the data appear to be similar, with a moderate amount of posterior relapse being seen. 105,
106
With the small samples available it is difficult to reach any definitive conclusions,
particularly when the confounding factors of different types of grafting procedures (i.e., bone
versus hydroxylapetite) used in the various studies are included. Of interest, however is a
comparison between Weisss 105 two samples, both operated in the same fashion, which while
being somewhat different during the fixation period, show little long term difference.
Author
Teuscher
Weiss
Wardrop
Weiss
T1-
T2-
T3-
T2
T3
T4
16
(W)
7.1
0.4
0.1
24
(W)
4.6
0.1
0.9
10
(R)
5.8
14
(R)
4.8
0.4
+
0.4
1.2
Maxillary Downgraft: Historically,
maxillary
downgraft has been one of the least

stable orthognathic procedures; current
long term data (only 6 months
postoperative) suggest some improvement but still
107
leave many questions unanswered.Tabular
Hedemarks
78%
and graphical
representation of the changes
relapse figure is reflective of during

the findings
of many
and after
maxillary
advancement
early researchers who saw considerable superior
relapse following maxillary downgrafts. Once bone grafting and auxiliary fixation
procedures such as Steinmann pins88 were introduced, relapse rates with wire fixation (i.e.,
Bell 28%108) were considerably reduced. More recently, the addition of rigid fixation and
hydroxylapetite interpositional grafts offers the potential for improved stability.109
The long term - data for both maxillary advancements and maxillary downgrafts
suggest that with contemporary techniques one can expect relapse of about 20% in the
106

posterior and superior directions, respectively. The effects of rigid fixation and various
interpositional grafting techniques remain inconclusive at this time. As with all the other
procedures, considerably more long term data, preferably up to 5 years post surgery, are
required before an adequate picture of the long term stability of orthognathic surgery can be
painted.
Author
Hedemark
15
T1-T2 T2-T3 T3-T4

- 3.2
(W)
Bell
13
(6m)
- 6.8
(W)
Quejada
10
16
(R)
+ 1.9
(6m)
- 8.9
+ 1.1
(R)
Persson
+ 2.5
+ 1.0
(6m)
- 6.6
+ 1.5
0.0
(6m)
representation of the changes
during and after maxillary
downgrafts
Functional Stability of Orthodontic Treatment Occlusion as a

Cause of Temporomandibular Disorders
The orthodontic concept of occlusion is bound by the same physiologic parameters and
facts that bind all segments of dentistry. An important long term objective of orthodontic
treatment is to provide an oral environment, which will promote health of the periodontal
tissues, neuromuscular system, and temporomandibular joints. Stability of occlusion may be
defined in either structural or functional terms. Structural stability is the criterion used in
assessing the presence or absence of post-orthodontic relapse. The absence of post
107

treatment relapse is an indication of structural stability, both occlusal and skeletal. Andrews42
Six Keys of Occlusion are examples of structural criteria. Another concept of stability,
frequently used in dentistry, is that of good intercuspation, with multiple tooth contacts, so
that there are no slides in centric. This is a statement of functional stability. Functional
stability is a criterion used to assess a potential or presumed cause of dysfunction due to a
neuromuscular maladaptation. Gnathologically oriented orthodontists emphasize the
importance of functional stability in preventing maladaptations to occlusal interferences.
Although orthodontists have attempted to treat cases to an ideal static dental relation, it is
now generally recognized that orthodontic treatment should also attempt to achieve a
functional
occlusion
that is
in harmony with the neuromuscular
system
and
temporomandibular joints. The criteria for such an ideal functional occlusion, according to
most current concepts, have been described. It has been stated that failure to produce occlusal
harmony after orthodontic treatment, especially failure to eliminate centric prematurities and
nonworking contacts on mandibular excursions, may subsequently contribute to TMJ
disorders. However, no long term follow up of orthodontically treated patients has been
carried out to evaluate the status of TMJ function and its relationship to the functional
occlusion. Also, the idea that untreated malocclusions have a marked potential for the
development of TMJ problems has not been adequately investigated. Now, two questions
arise in ones mind that: 1) Can occlusal interferences cause relapse of dental and / or skeletal relationships? and
2) Can occlusal interferences cause temporomandibular disorders?
Can occlusal interferences cause relapse of dental and / or skeletal relationships?
Responses to occlusal interferences take several forms. In the absence of a reflex
response the interfering tooth may be moved out of the offending position. Evidence in
support of this assertion comes from an unpublished investigation examining the
consequences of a mild working side interference carried out in the laboratory of Professor
Hans Graf in Berne, Switzerland. The hypothesis to be tested was that over a period of
several weeks hypernormal biting forces on a mild working side interference would elicit a
reflex avoidance of the interference. The study entailed building up the buccal inclines of the
108

lingual cusps of a lower right first molar crown that had been placed on a postcore
preparation.
The subject was evaluated before (1 day and immediately prior to) insertion of the
interference, 6 hours and 2, 9, and 16 days following placement, and 30 days after removal of
the interference. Conclusions drawn from this investigation on this patient were that
1) The mild working side interference was not reflexly avoided.
2) The interference did not give rise to any signs or symptoms of temporomandibular
disorder.
3) The tooth became mobile and subsequently intruded.
Earlier studies by Schaerer, Stallard, and Zander, 110 using switches recording intercuspal
and interference positions, had established that mild working side interferences were not
reflexly avoided that is, closure into intercuspal position was guided solely by the occlusal
inclines. The adaptive response to mild working side interferences would appear to be by
tooth movement.
(A)
Long term Response
Occlusal
Passive
Interference
Guidance
(B)
Tooth
Movement
Long term Response
Occlusal
Passive
Interference
Guidance
Tooth
Wear
109

Occlusal interferences may give rise to passively mediated responses. In the absence of
a reflex response during chewing, teeth may move (A) or abrade (B).
Occlusal
Active
Guidance
Condylar
Displacement
Interference
Short-term response
Long-term response
Mandibular
growth
When reflex adaptations occur, the mandible shifts to avoid the interference(s) producing
condylar displacement(s).
Another passive adaptation that could account for reduction of mild occlusal
interferences is wear of the tooth in subjects eating abrasive diets. Canine-guided occlusions
gradually become group function occlusions due to wear of the maxillary canine.
Functional abrasion (in contrast to parafunctional abrasion), while considered normal by
anthropologists and paleontologists and crucial to hypothesis of jaw function in ancient man,
is considered pathological by gnathologists. Functional wear in another possible adaptation to
occlusal interferences.
An example of extensive wear leading to loss of

the clinical crowns of mandibular bicuspids and
110

molars, with exposure of the pulp in the molar in a skull of a Nubian of the early dynastic
period. Wear of teeth is common in skeletal remains of persons living along the Nile.
In contrast to these passive forms of adaptation to occlusal interferences are the active
or reflex responses. Under certain circumstances occlusal interferences are avoided. Such an
active response to occlusal interferences resulting in occlusal instability is used to explain
functional malocclusions for example, functional posterior and anterior cross bites. It has
been claimed that these functional malocclusions will become skeletal malocclusions and
therefore should be treated immediately. Evidence for a learned response to occlusal
interferences was first clearly demonstrated by Schaerer, Stallard, and Zander. 110 Bridges
were constructed with switches in bridge pontics that would signal tooth contact in the
intercuspal position and on balancing side interferences during mastication. Following
contact with the balancing interference, muscle activity stopped for about 20 ms (silent
period) followed by asymmetric jaw muscle activity, presumably leading to avoidance of
the interference. 40% of the balancing side interferences showed silent periods that is,
nearly half of the closures following contact on a balancing side interference were reflex
modulated as a consequence of occlusal feedback. On initial contact with the interference,
the levator muscles fell silent and then shifted the mandible laterally so as to avoid further
contact; the occlusal guidance was active. The response to initial contact is unlearned or
unconditioned. Following multiple contacts on the interference, the offending contact may be
avoided through conditioning.
There is a clinical perception that repeated avoidance of interference may lead to a
skeletal response in growing individuals.
Occlusal interferences may also give rise to actively mediated response. When reflex
adaptations occur, the mandible shifts to avoid the interference(s) producing condylar
displacement(s).
This active response may lead to condylar cartilage proliferation and mandibular
growth in growing animals.
111

Here one sees the interaction between structural and functional instability. In the
absence of neuromuscular adaptation, structural adaptations to occlusal interferences occur in
the dentition: With neuromuscular adaptation structural adaptations occur in the skeleton.
Conclusions that may be drawn from these experiments are that:
1) Occlusal interferences may result in passive adaptation such as tooth movement or
tooth wear, and
2) Occlusal interferences may result in active adaptations- that is, condylar
displacement(s), with the potential for condylar and fossa remodeling in the growing
individual.
Now, the answer to the question Can occlusal interferences cause relapse of dental and /
or skeletal relationships is yes occlusal interferences have the potential to cause relapse of
dental relationships and potentially alter skeletal development.
Can occlusal interferences cause temporomandibular disorders?

Occlusal
interferences
were
once
considered
to
be
major
cause
of
Temporomandibular disorder. Statements in the American Dental Association Presidents

report111 and the Consensus Statement of the American Academy of Pediatric Dentistry112
Strongly de emphasize and occlusal etiology. Numerous studies (e.g., Droukas, Lindee, and
Carlsson) have documented as high a prevalence of occlusal interferences in the
asymptomatic population as in patients suffering from Temporomandibular disorder. This has
led some people to believe that occlusal factors do not play a role, or play only a minor role,
in the causation of Temporomandibular disorder.
Whereas absent or low correlations between occlusal factors and signs and symptoms
of dysfunction indicate a minor role in the etiology of Temporomandibular disorder,
weaknesses in most of the epidemiological studies need to be recognized and corrected in
future studies. Even though multiple etiologies for Temporomandibular disorder are now
universally acknowledged, most studies have not attempted to segregate patients or subjects
so that those of possible occlusal etiology are not greatly outnumbered by those of traumatic
and parafunctional etiology.
112

In response to the question, Can occlusal interferences cause temporomandibular
disorders? The answer is yes for 50% of the subjects in which occlusal interferences are
artificially created. A logical extension of this question regarding etiology is that of
orthodontics causing Temporomandibular disorders. Posttreatment, balancing molar
interferences have been implicated as a cause by Roth, 113 as have lingually torqued maxillary
incisor crowns by Berry and Watkinson. Maxillary bicuspid extractions (supposedly leading
to excessive dorsal positioning of the Mandibular consequent to maxillary incisor retraction)
have been claimed as a cause of Temporomandibular disorder. Four European and three
North American114,
115
controlled clinical studies indicate that the prevalence of
Temporomandibular disorders is the same in patients 1 to 10 years following orthodontic

treatment as in the general population. The study of Dorph, Solow, and Carlsen on the
prevalence of orthodontic treatment in a Temporomandibular disorder clinical sample found
more orthodontic treatment among Temporomandibular disorder cases than in the general
population. This observation agrees with the less well controlled studies of Franks and
Berry and Watkinson. The finding may be due to the probability that patients seeking
Temporomandibular disorder treatment are more likely to have sought orthodontic treatment.
Franks statement that the majority [of the patients] regularly visited their dental
practitioner supports this hypothesis. The study of Janson and Hasund found fewer signs
and symptoms of Temporomandibular disorder in their non-extraction group compared to
their extraction group. Anecdotal claims of nonextraction patients being at lesser risk have
been made in the literature. Both the study of Gold and that of Dahl et al document fewer self
reported signs of Temporomandibular disorder in treated compared to untreated subjects
and no difference in clinically recorded signs and symptoms. Gold speculated that untreated
subjects over reported symptoms in the hopes of obtaining orthodontic treatment. While the
collective data suggests that prevalence is the same in treatment samples as in nontreatment
samples, the data do not rule out the possibility that these totals are the algebraic sum of
some subjects who are developing Temporomandibular disorder and some who are
recovering form Temporomandibular disorder.
113

Incidence of TMD (Hypothetical)
(Epidemiological Studies / Longitudinal)
Worse
Worse
Total
Total
General Population
Orthodontic Population
Epidemiological studies have shown the prevalence of Temporomandibular disorder

to be similar in patients who have received orthodontic treatment compared to the general
population. Were these subjects to followed longitudinally, it is postulated that the totals will
be made up of subjects developing symptoms
and subjects recovering from
Temporomandibular disorder. The proportions of those getting worse and those getting better
need not be same for both treatment and control samples.
As in the general population, some patients can be expected to develop
Temporomandibular
disorders.
While
orthodontic
treatment
may
precipitate
Temporomandibular disorders, it is important to remember that other factors may predispose

the patient to Temporomandibular disorder, whereas other factors can perpetuate
Temporomandibular disorder. In order to clearly identify orthodontic treatment as a cause of
Temporomandibular disorder it will be necessary to follow orthodontic cases prospectively.
The known cyclic pattern of Temporomandibular disorders is a complication also in need of
control. Careful monitoring of trauma and parafunction as initiators during and after
treatment will also be necessary.
Concept of over-correction
Orthodontic treatment begins with the teeth in a malaligned occlusion, most often
under abnormal function within disproportionate skeletal structures. Treatment proceeds to
align the teeth and normalize the function within the limits allowed by the skeletal
framework. Bony adjustments are occurring in the distant basic supporting structures, as well
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as the local remodeling occurring around the individual teeth. In unlocking the malocclusion
and establishing a more normal function, it is necessary for the clinician not only to
appreciate the changes necessary to bring the teeth into a properly aligned functional
occlusion, but to anticipate changes that follow when all appliances are removed and the post
treatment adjustments begin to occur. These adjustments and subtle changes will continue
under the dynamics of function. In order to help overcome the tendency for relapse,
provisions for the post-treatment rebound as well as post treatment growth changes need to
be appreciated and planned for. There are certain cases where under treatment may be needed
in light of special growth or deformity problems. There are 4 areas suggested where the
concept of over treatment may help compensate for the anticipated post treatment
adjustments.64
1) To overcome muscle forces against the tooth surfaces: - The muscular influence of the
tongue, lips and cheek against the surfaces of the teeth often require over treatment to
compensate for the post treatment changes, that are a result of the continued influence of
this musculature as it learns to support the new occlusion.
When the narrow, collapsed upper arch is being expanded out of crossbite, overtreatment is
necessary considering the relapse that may occur across the palate by the influence of the
buccal musculature. Over expansion is also needed to encourage the tongue to elevate and
function in support of the dental arches in their new occlusion.
An anterior open bite needs to be over-closed whenever possible to anticipate the
rebound effect of abnormal tongue function, and the excessive lower face height that
increases in the growth patterns of the extreme vertical facial types. This excessive lower
face height has the effect of encouraging the open bite tendency. Over treatment of the
incisor overjet back to a proper inter-incisal angle is critical in cases where lip sucking has
influenced the protrusion of the upper incisors and retracted the anterior portion of the lower
arch, and where short upper lip, mentalis habits, or sublabial contraction continue to
influence the position and stability of the incisors.
2). Root movements needed for Stability: - Overtreatment of the tooth movements in
locating the roots beyond the ideal in a position of overtreatment anticipates rebound change
in various areas. Incisor deep overbite treatment benefits in its stability by overintrusion and
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overtorquing. Paralleling the roots of the teeth adjacent to extraction sites is important to the
stability of space closure. Compressed tissue and fibers require time to reorganize to the new
alignment. Severe rotation, where periodontal ligaments exhibit elastic action that can have
prolonged post treatment influence, needs over rotation of the roots to help compensate
for the relapse effect. Reorganization of the fibers often requires extended time, unless
surgery is also used to assist or support the stability.
3) To overcome orthopedic rebound: - Where heavy forces have produced orthopedic
changes, the basic supporting structures are subjected to rebound as these heavy restrictive
forces are lessened or eliminated. These structures adjust as they are allowed to come under
the influence of normal growth and function in the new environment. These may still persist
functional influences that compounded this original malocclusion. Severe convexity in the
extreme vertical facial types has additive effects, which seem to require more overtreatment
and concern for stability of results.
Mandibular rotation or bite opening usually occurs in orthopedic correction by the
extrusive action of the posterior teeth. In Class II treatment, the rebound effect, which closes
the bite and rotates the chin forward, will help in the Class II correction and, therefore, this
rebounding is beneficial. In Class III treatment, forward rotation of the chin and closure of
the mandible would compound the Class III problem and make it worse. Some rebound
adjustments can be beneficial, but most tend to complicate or return to the original problem.
Therefore, overtreatment is in anticipation of these post-treatment adjustments.
4) To allow Setting in Retention: - Overtreatment of the individual teeth within the arches
allows them to settle into a functioning occlusion. The concept of retention at the
completion of active treatment or debanding is not to hold or retain that which has been
achieved, but to allow the teeth to settle back into occlusion from a point of overtreatment.
Retainers then are considered active appliances and are adjusted to allow this settling action
to take place, rather than to just hold or maintain the status quo. This not only anticipates the
expected rebound that will occur because teeth have been moved, but encourages it by
allowing them the freedom of movement back into their desired functioning position. It
would be almost impossible to prescribe the exact delicate location and function of each
incline, while this concept of guided adjustment anticipates it by overtreatment.
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Over treatment of the typical Class II correction begins with the molars by over treating them
into a super class I through distal rotation of the upper first molar behind an uprighted
distally rotated lower molar. Over-treatment proceeds along the buccal occlusion where the
upper bicuspids and cuspids are distal to their opponents in the lower arch. The incisor
overjet and overbite are overtreated by intrusion of whichever arch is over erupted.
Overtorquing of the upper incisors is necessary in those deep overbite cases where function
would allow the deep bite to return.
Post Treatment Stability

Post treatment stability can be achieved either by fixed or removable retainers given
over a considerable period of time or by positioning the teeth in harmonious relationship with
their surrounding.
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The frequency with which lower retainers are used after treatment to prevent lower incisor or
cuspid collapse suggests there is little understanding of how to avoid these posttreatment
events. However, several steps can be taken during fixed appliance treatment to eliminate the
need for retention in the lower dentition.
According to the study carried out by Williams R117 in which for the patients all the
lower retention was eliminated and constant observations were made to see what had to be
done to create post-treatment stability, especially in the lower incisors. Six treatment keys
have emerged as essential if lower retention is to be eliminated.
First Key:
The incisor edge of the lower incisor should be placed on the A-P line or 1 mm in
front of it. This is the optimum position for the lower incisor stability. It also creates optimum
balance of soft tissues in the lower third of the face for all the variations in apical base
differences within the normal range.
To achieve stability and soft tissue balance in the lower third

of the face, optimum position of lower incisal edge is on or 1
mm in front of A-P line.
To achieve stability and soft tissue balance in the lower third of the face, optimum
position of lower incisor edge is on or 1 mm in front of A-P line.
118
A. Moving lower incisor back 4mm to A-P line provided stability without lower retention
and improved facial harmony.
B. Lower incisor was moved forward 2mm to produce facial harmony. Because it moved
only to A-P line, the incisor remained stable and no lower retention was needed.
Appliance control is required to achieve optimal position of the lower incisor

consistently at the end of treatment. Point A on the upper end of the A-P line can be retracted.
Point P, at the lower end, will move forward or not depending on mandibular growth. With
experience, the clinician will know how each end of this line changes, which procedures will
place the lower incisor 1 mm in front of the line, whether extractions are necessary, and
which teeth should be extracted.
If the lower incisor is advanced too far beyond the A- P line, relapse and crowding
will occur. Lower incisors that are overly proclined in treatment- beyond one standard
deviation can only be maintained in such an untenable position with a fixed retainer. When
the retainer is removed, the incisors will move lingually and become crowded.
Second Key: The lower incisor apices should be spread distally to the crowns more than is
generally considered appropriate, and the apices of the lower lateral incisors must be spread
more than those of the central incisors.
119
Convergent Lower Incisor roots before being spread distally for stability .
Root apices in typically convergent position (top). Root apices insufficiently spread to
assure stability without retention (middle). Root apices sufficiently spread so that, if
other treatment keys are attained, stability of lower incisors without retention can be
expected (bottom).
The Begg technique is geared to achieve the necessary progressive spreading, but
none of the current straight wire systems provides adequate lower incisor slot angulations to
bring about sufficient progressive spreading of lower incisor apices. When the lower incisor
roots are left convergent, or even parallel, the crowns tend to bunch up and a fixed lower
retainer is usually needed to prevent posttreatment relapse.
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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. Use of the
mandibular plane might indicate that the apex is not sufficiently distal to the crown, when in
fact it is if the occlusal plane is used. Such a circumstance could occur when there are highly
divergent occlusal and mandibular planes in a steep mandibular plane angle case.
Apex of lower cuspid positioned distal to crown for protection of lower incisor stability
after treatment.
This angulation of the lower cuspid is important in creating post treatment incisor
stability because it reduces the tendency of the cuspid crown to tip forward into the incisor
area. If this happens, the lower incisors crowd up, even if their roots are spread and the
incisal edges are on the A-P line or 1 mm in front of it. Distal inclination of the lower cuspid
should be a standard treatment objective and is easily accomplished with the Begg or any
straight wire technique. Straight wire systems agree within 4-6 0 of inclination of the lower
cuspids to the occlusal plane.
Fourth Key: All four lower incisor apices must be in the same labiolingual plane. Spreading the
apices of the lower incisor roots distally causes a strong reciprocal tendency for the crowns to
move mesially. Moreover, as the roots are spread, the contact areas between the incisor
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crowns move upward toward the anatomical contact points, which are small, rounded, and
near the incisal edge. Because of the strong mesial pressure on the crowns during the root
spreading process, there is a tendency for these contact points to displace each other
labiolingually. This results in a reverse movement of the apices linguolabially.
A. Lower incisor apices well aligned in same labiolingual plane. If other treatment
keys are attained stability of lower incisors without retention can be expected.
B. Crowns aligned but lower incisor apices not aligned in same labiolingual plane.
Unless this is corrected, there is little likelihood of lower incisor stability.
The displacement forces are considerably augmented by the increasing width of the
lower incisor crown toward the incisal edge and contact point. This means that provision for
the additional space must be made during the spreading process. Otherwise, labiolingual
apical displacement of the lower incisors will tend to occur, and the degree to which it occurs
will affect lower incisor posttreatment stability.
Experience has shown that the labiolingual apical displacement of the lower incisors
can occur easily if round wires are used during the spreading process, because round wires
forfeit labiolingual control. To maintain labiolingual apical control during the spreading
process - using uprighting springs in the third stage of Begg treatment - an edgewise
sectional auxiliary in the incisor region along with the main round archwire is effective. With
the edgewise technique, spreading begins at the start of treatment, so any labiolingual apical
displacements occurring from the initial use of round wires can be corrected later when
rectangular arches are used.
Fifth Key: -
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The lower cuspid root apex must be positioned slightly buccal to the crown apex. This
is extremely important because of its influence on post-treatment stability. All sorts of
occlusal forces await their chance to exert lingual pressure on the lower cuspid crown. If the
apex of the lower cuspid is lingual to the crown at the end of treatment, the forces of
occlusion can more easily move the crown lingually toward the space reserved for the lower
incisors because of these functional pressures plus a natural tendency for the crown to upright
over its root apex. Even if a lower cuspid with abnormal lingual position of the apex were
supported for many years with a fixed retainer, the crown would eventually move lingually
when the restraint was removed.
Faulty lingual position of lower right cuspid apex. Old-style edgewise bracket
automatically created lingual positioning of lower cuspid apex unless clinician placed
adequate buccal root torque in rectangular archwire.
The old concept that lower intercuspid width cannot be increased permanently is only
true some of the time. After treatment, the newly acquired lower intercuspid width will be
maintained without retention if the lower cuspid crowns are moved distally into a wider part
of the jaw and if their apices are moved buccally so they are at least under the crown. If the
apex is not moved buccally along with the crown while distalizing the cuspid, lingual relapse
of the crown into the incisor area is likely.
Until the advent of straight wire brackets with built in torque, there was a tendency
for the old edgewise bracket to move the lower cuspid apex lingually whenever rectangular
wires were used. Unless the clinician took the precaution to place appropriate buccal root
torque into the rectangular wire, increased lingual root position of the lower cuspid was
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bound to result. Lower fixed retention was then routinely needed to prevent intercuspid
distance from diminishing and incisors from collapsing.
To torque the lower cuspid apex buccally, a Begg clinician can use a simple auxiliary.
An edgewise clinician can place the appropriate torque in the rectangular wire. There is a
bewildering range of lower cuspid buccal root torques in straight wire edgewise brackets,
from 11 0 to + 70, a total variation of 180. Between the lower right and left cuspids, the
combined variation can be 360. Variations in crown slopes to which the variously torqued
brackets are attached compound the dilemma.
Sixth Key: The lower incisors should be slenderized as needed after treatment. Lower incisors
that have sustained no proximal wear have round, small contact points, which are
accentuated if the apices have been spread for stability. Consequently, the slightest amount of
continuous mesial pressure can cause various degrees of collapse in the lower incisor
segment.
A. Small, round contact points of
lower incisors.
B. Small size and shape of contact points make it

easy for pressures from the rear, or inadequate space in
the jaw, to cause their dislodgment.
C. Flattening contact points and reducing

mesiodistal width of lower incisors makes it possible to
eliminate lower incisor retention, provided other treatment
keys have been attained.
There are two sources for post-treatment pressure on the lower incisors that may
bring about a shifting or collapse even though all other key treatment requirements have been
accomplished. One source is the molars. Current evidence indicates that natural mesial
pressure is limited to the upper and lower molars. Molar pressure can cause displacement of
lower incisor contact points. Removal of third molars does not eliminate the mesial pressure
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derived form the first and second molars, and there is little rationale, based on present
evidence, for the extraction of third molars solely to minimize present or future crowding of
lower anterior teeth.
The second source of hidden pressure is an adverse tooth - jaw relationship. Who can
say that the removal of two, four, six or eight teeth will provide the perfect solution for tooth
jaw discrepancy? It is conceivable that the right combination to provide balance and
stability in some instances should be the removal of 1 teeth or 3 teeth. But we can only do
our best by removing whole tooth units when indicated.
Flattening lower incisor contact points by slenderizing or stripping creates flat contact
surfaces that help resist labiolingual crown displacement. This treatment also helps eliminate
the need for lower incisor retention.
Begg said, Unless sufficient tooth substance is eliminated from mouths having it in
excess, neither artificial post treatment retention nor factors inherent in the dental apparatus
itself can prevent relapse after treatment. Even after reduction of tooth substance by
extractions, the balance between jaw accommodation and tooth size may not precisely match,
even with competent treatment, and slenderizing may be necessary.
If the posttreatment dentition displays pressure signs by developing irregularities
among the incisors, reduction of incisor width by slenderizing can be the answer. Usually
only minimal tooth structure has to be removed if the root apices have been adequately
spread. Occasionally, more than one slenderizing session may be necessary to bring the tooth
mass into harmony with the jaw size and to eliminate the need for lower incisor retention.
Some post treatment situations do not seem to have a detrimental effect on lower
incisor stability. One is the depth of the overbite, and another is prodigious mandibular
growth that carries the lower incisors forward against the upper incisors and tips them out.
Experience has shown that neither of these requires the protection of a lower retainer.
By observing the six treatment keys, it is possible to eliminate lower incisor retention
followed fixed appliance therapy. Clinicians who want to eliminate lower retention may find
that they have to increase their extraction percentage in order to achieve the six keys
adequately.
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Stable lower incisor segment two years

alter treatment and no retention.
Though Williams has given six keys for stability but other authors like Zachrisson,
Adenwalla, Artun, Axelsson, Carter etc had emphasized the need for permanent bonded
retention in the anterior arch. These authors have given considerable importance to the post
treatment retention procedures with fixed or removable appliances without which long-term
stability cannot be achieved.
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Problems Of Retention
Various concepts of retention require scrutiny depending on individual cases. The
problem of retention could arise from ability of the operator, inherent tendencies present in
the individual patients and limitations of the science of orthodontics itself.
The best of training and experience cannot be substituted for each other. Waging war
against or attempting to control the biological tissues could result in its own limitations. The
transseptal fibers of the periodontal ligaments demands a thorough understanding in the
management of annoying problems of relapse especially in cases of closure of midline
diastema, closure of generalized spacings and closure of extraction sites. The science of
orthodontics itself, though mechanistically advanced to very high levels, the understanding of
biological basis is far from complete. Not withstanding the remarkable instability, so called
collapse, of treated mal-occlusion continues to elude the practicing orthodontist.
I. Biological Problems of Retention: The transseptal fibers are considered by many orthodontic researchers as the culprits
of many of the orthodontic relapses.35, 119 The principle fibers traveling from tooth to tooth in
the dental arch are the transseptal fibers. First named by Black in 1886, they are part of the
gingival group of fibers of the periodontal membrane. The transseptal fibers are firmly
embedded in the cementum along the convexity of the cemento enamel junction, which
gives them a strong grip on the tooth. They also attach the tooth to bone as in the third molar
area and from tooth to subepithelial connective tissue. The arrangement of these fibers
indicate their need and function in maintaining mesio-distal relationship between neighboring
teeth and in stabilizing the tooth against separating forces.
The body responds to stress by orthodontic movement with increased resistance of
transseptal fibers as they seek to return and maintain original positions of the teeth. This is
the reason as to why good results following orthodontic treatment and retention cannot be
counted as successful treatment. It also explains why many investigators put them as culprits
of orthodontic relapses. Relapse caused by these fibers is a result of their mode of attachment
from cementum to soft tissue. When connective tissue fibers under stress attach to soft tissue,
there is apparently no mechanism for their rearrangement with bone serving as an
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attachment; readaptation is made possible by bony resorption and deposition. Reitan 35
demonstrated this on orthodontically rotated teeth.
Oppenheim (1911) was aware of the potential strength of these fibers. He stated, The
powerful fibers stretching across the septa, giving off strong bundles partly to the teeth and
partly to the gums, prove to be the most resistant tissues with which we are dealing in our
operation. Thompson described transseptal fibers as tiny tough, resistant fibers which act
slowly, but definitely to foil some beautifully treated orthodontic cases.
Skogsborg a strong advocate of Walkoffs theory of tension difference developed a
surgical procedure based on this theory in 1926. Walkoff believed that tension remains in
hard, elastic bone tissues long after the phenomena of resorption and deposition are
complete. He believed that this stored tension was the major cause of orthodontic relapse.
The septotomy procedure was designed to relieve this tension and allow settling by
removing the interdental septum between the teeth of the maxillary and mandibular arches.
Thompson119 in 1959 showed that the success of septotomy was not the result of bone
removal but of indurated transaction of transseptal fibers.
In summary, nature provided transseptal fibers for the maintenance and integrity of
the dental arches. As a result of this function, these fibers react rapidly and definitely to
interruption or stress. No mechanism is provided for the removal or reduction of the quality
or quantity of these fibers. Consequently, when orthodontic movements place these fibers in
un-natural states or under abnormal stress, the result is relapse.
II- Mechanical problem of Retention: Even with the advent of three-dimensional control of tooth movement, the ideal six
keys of static occlusion cannot be fully achieved in extraction cases. The buccolingual root
torque capabilities of the existing mechanical systems are limited. A prolonged or a
permanent retention is necessary where arch width is manipulated. A welcoming technical
trend in the current orthodontic field is the popularization of diphasic treatment, which
incorporates an orthopedic and neuromuscular training at an earlier age to be followed by
finer detail positioning of individual teeth after complete eruption of the permanent dentition.
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Adapting the dental arches to the preformed arch planks could deviate the archforms
into the areas out of functional tolerance.
The retaining of teeth in abnormal positions with fixed or removable appliances can
cause permanent damage to both teeth and investing tissues as the retainer attempts to hold
them in one position, achieved by tooth moving appliances and functional forces drive them
towards another. The Jiggling increases the thickness of the periodontal membrane, there is
alternate bone deposition and resorption and continued mobility of teeth in question. The
supporting structures sooner or later succumb to the inseparable demands of the artificially
established occlusion, and there is deterioration of teeth of these investing tissues.
In all fairness, it is not always possible for the orthodontic specialist to achieve a
satisfactory structural balance, full functional efficiency though he may achieve the desired
esthetic results.
129
Emotional Stress During Retention and Its Effect on Tooth

Position
While orthodontic correction has become increasingly more reliable, more effective,
and more certain, confidence in the outcome of the retention period of treatment is less than
absolute. Despite the abundance of efficient retention appliances and careful supervision,
varying amounts of relapse continue to occur, in many instances without satisfying
explanation. Because correction and retention are mainly mechanical, the importance of the
psychosomatic relationship of teeth and emotions, especially during the post orthodontic
treatment period, has not received adequate attention.
By far the greatest numbers of orthodontic patients are pre-adolescent and adolescent,
stages in development, which are marked by, frequent episodes of stress, moody
introspection, feelings of confusion, anxious moments of despair. In a personal
communication, Ruth Moulton, a psychiatrist, gave the following description:
Adolescents have a great deal of anxiety about changes in their bodies that go with
puberty which upset their previous body image of child instead of adult. Many fears of
adulthood and sexuality are evoked at this time. They are particularly sensitive to ridicule
about their bodies and this must influence their sensitivity about orthodontic procedures and
appliances. Throughout this time of life the stress level rises and falls but is particularly high
and sustained high during the first semester of college away from home.
Psychologically, there are several explanations why this early period of college is so
important when it involves living away from home. Reasons ranging from separation form
home to the fear of meeting strangers have been put forth.
Kenneth H. Fried120 observed changes in occlusion, which occurred in patients who
were still under retention or observation and involved in a known anxiety provoking
situation, namely, first semester of college away from home. Prior to this time retention had
been uneventful for one to three years, and oral habits, which had been present before
treatment, were no longer apparent during this same one to three year period.
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Interplay of Emotions, Muscles, and Teeth: One psychiatrist, Arnold Zucker, has stated that in an anxiety state, which is intense,
and of long duration there can be regression, and habits present from an earlier time in life
can come back.
In retention patients (under stress) the habit most frequently seen was bruxism and the
occlusal changes noted in many of these patients were deepening of the overbite, crowding of
the lower incisors, and attrition of the teeth.
Active tongue thrusting habit and lip sucking habits were observed in some of the
patients of this group within six months of college life. In addition to the effects overbite and
the alignment of incisors, grinding and clenching are involved in pain and trismus of the jaw
by causing spasm of the muscles of mastication.
Also evident at times during retention were periodontal abscesses in the maxillary
molar region.
Despite their awareness of the importance of their retainer they tend to omit wearing
them.
Lefer explains this as follows: Youngsters with extreme anxiety want their teeth to
relapse so that they can blame their failures in interpersonal relationship on their teeth rather
than their personalities. Lefer described a variation of bruxism: I noted rhythmic
contraction of the temporalis and masseter muscles, and a habit many of them had of
protruding the lower jaw, which brought the lower anterior teeth edge to edge with the upper
anterior teeth back to rest position and forward again. This causes soreness of the anterior
teeth and slight crowding of lower anteriors, which are attributed to hard contact with the
heavy marginal ridges of the upper incisors.
Another clearly visible habit in this group of college students was sucking, which
during retention generally involves the lower lip or tongue but occasionally the thumb or
finger. Crowding of the lower incisors and flared upper incisors are often seen in association.
Pearson, a psychiatrist, accounts for finger sucking in this way: Finger sucking is a
necessary part of the life of young children and is a method of obtaining instinctual
gratification. Some children relinquish finger sucking very early of their own accord. Others
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continue for a moderate length of time. Others continue to suck for a number of years, and
then of their own accord gradually give up first in the daytime, later after they get into bed,
and still later after they fall asleep. Eventually they relinquish it entirely when they are
emotionally ready to do so. In another type of finger sucking the child has relinquished his
finger sucking himself and without any need to conform to the parents dislike of it. Later,
after 4 or 5 years, the finger sucking starts again. This type of finger sucking has the same
etiology as any neurotic symptom. The child has met some difficulty in his present emotional
development, is unable to develop further, goes back to an earlier form of gratification.
Zucker notes that: Rubbing and thrusting of the tongue against the teeth occur as a
manifestation of anxiety in the tense, apprehensive, pent-up individual; it occurs particularly
when the person is subject to emotional stress. The response may become habitual and the
symptom may be experienced as compulsion in the more chronic states. Patients often
describe an attraction of the tongue to the teeth, and particularly to dental faults. Bruxism is
of a similar nature and may accompany the tongue reaction.
Tongue tic is an intermittent, involuntary spasmodic movement of the tongue, such
as a twitch, without demonstrable external stimulus. It represents the disguised expression of
a hidden emotional conflict.
Another condition of the tongue that is found mostly in females is glossodynia or
burning tongue. In such cases there is no structural damage or loss of function. Anxiety may
produce dental symptoms by being converted directly into subjective symptoms of pain or
paresthesias. The symptom stands in place of an awareness of an intolerable life situation,
which the individual feels unable to face directly.
Another category of anxiety behavior, hygiene neglect, can cause instability of the
teeth during retention by increasing inflammatory elements in the periodontal tissues.
Management and Prevention: The patient under retention who will be exposed to an anxiety-provoking situation
should be prepared in by the orthodontist.
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First, he should be made aware of the stressful situation he will enter and the effects it
could have on his teeth, and second, he should be provided with retainers, which will
counteract the muscular action of undesirable oral habits, should they reappear.
Many people react to fears and stresses by resorting to habits, which can cause the
teeth to shift. It may be that clenching the teeth, sucking or biting the lower lip, pushing the
tongue against the teeth will be happening especially before exams. Recognize them as a sign
of tension and try to control them by talking about inner fears to a trusted friend or to an
understanding teacher or to someone in the guidance department and by substituting some
other form of physical activity.
Retainers should be designed to prevent tooth shifting from habits that may reappear.
A bruxism appliance makes an excellent retainer; it covers the occlusal and incisal surfaces
of the maxillary teeth and provides uniform occlusal contact with all mandibular teeth. If
there is a possibility of mandibular retrusion, a tooth positioner may be indicated, although
this can induce additional bruxism and temporomandibular joint symptomology. Generally,
two Hawley retainers or an upper Hawley and a lower three - to three are effective if
muscle activity is not overly strenuous.
Except for minor shifting, the teeth in an original malocclusion are in a state of
equilibrium, which has developed over the lifetime of the individual during periods of
maximum growth and adaptability. Already included in this adjustment are the muscular
balance of lips, cheeks, and tongue, and the dynamic effects of oral habits. In contrast, the
teeth, after orthodontic correction, have existed in the revised state of balance for a short
period at a time when adaptability is on the wane and habits have come and gone. At best,
this young equilibrium is tenuous and vulnerable.
Emotional stress during retention in the forms of anxiety and fear can reactivate
dormant oral habits which may interrupt the maturation of this newly acquired equilibrium,
and, if of sufficient magnitude and duration, can bring about gradual relapse of the teeth.
Once relapse has begun the new, desirable equilibrium can no longer take hold. Hence, in
those cases where there has been a history of vigorous oral habits it is especially important to
establish adequate retention procedures as soon as active treatment is concluded, and should
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it be known that the patient will be entering into an anxiety provoking situation, to make
him aware how anxiety may affect his teeth.
The orthodontist should not attempt to play psychiatrist by delving into unconscious
material or by interpreting specific psychological mechanisms. When this is done, the patient
looks upon it as meddling and is resentful. On the other hand, explanation of the connection
between anxiety and shifting of the teeth via a specific mechanism can be quite reassuring to
the patient who feels that he may handle his anxiety better than when the mechanism is
unknown to him.
Although the orthodontist is in no position to suggest to the patient the answers to
his lifes problems, the fact that he has helped the patient to focus his attention on the proper
cause can be most useful. If the doctor remains sympathetic with the person who is anxious
or fearful, he can find a way of suggesting an emotion physical symptom relationship
without shocking or angering his patient.
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Retention Appliances or Retainers

Definition:
Retainers121 are passive orthodontic appliances that help in maintaining and
stabilizing the position of teeth long enough to permit reorganization of the supporting
structures after the active phase of orthodontic therapy.
The type of retainer to be used depends on various factors such as the type of
malocclusion treated, the esthetic needs, patients oral hygiene, patient co-operation, the
duration of retention, etc.
Requirements of Retaining Appliances:
According to Graber, 122 the requirements of a good retaining appliance are: 1) It should restrain each tooth that has been moved into the desired position in
directions where there are tendencies toward recurring movements.
2) It should permit the forces associated with functional activity to act freely on the
retained teeth, permitting them to respond in as nearly a physiologic manner as
possible.
3) It should be as self cleansing as possible and should be reasonably easy to maintain
in optimal hygienic condition.
4) It should be constructed in such a manner as to be as inconspicuous as possible, yet
should be strong enough to achieve its objective over the required period of use.
Classification of Retainers:
Retainers can be classified into1: 1) Removable retainers.
2) Fixed retainers.
3) Active retainers.
135
I) Removable Appliances as Retainers: Removable retainers are passive appliances that can be removed by the patient and
reinserted at will. Removable appliances can serve effectively for retention against intra-arch
stability and are also useful as retainers (in the form of modified functional appliances or part
time headgear) in patients with growth problems.
Various examples of removable retainers are as follows: 1) Hawley Retainers and its modifications.
2) Removable Wraparound retainers.
3) Non acrylic removable retainer.
4) Fitted labial bow.
5) Removable plastic Herbst Retainer
6) Essix Retainers.
7) Esthetic Removable retainer.
8) Positioners etc.
1) Hawley Retainers and its Modifications: By far the most common removable retainer is the Hawley retainer, designed in the
1920s by Charles Hawley, used following active orthodontic therapy. The basic appliance
incorporates clasps on molar teeth and a characteristic outer bow with adjustment loops,
spanning from canine to canine. Because it covers the palate, it automatically provides a
potential bite plane to control overbite.
Standard design of Hawleys retainer
136
When first premolars have been extracted, one function of a retainer is to keep the
extraction space closed, which the standard design of the Hawley retainer cannot do.
Hawleys retainer with long labial

bow
Even worse, the standard Hawley labial bow extends across a first premolar
extraction space, tending to wedge it open. A common modification of the Hawley retainer
for use in extraction cases is a bow soldered to the buccal section of Adams clasp on the first
molars, so that the action of the bow helps hold the extraction site closed.
Labial bow soldered to Adams

clasp
Alternative designs for extraction cases are to wrap the labial bow around the entire
arch, using circumferential clasps on second molars for retention; or to bring the labial wire
from the baseplate between the lateral incisor and canine and to bend or solder a wire
extension distally to control the canines. The latter alternative does not provide an active
force to keep an extraction space closed, but avoids having the wire cross through the
extraction site, and gives positive control of canines that were labially positioned initially
(which the loop of the traditional Hawley design may not provide).
The clasp locations for a Hawley retainer must be selected carefully, since clasp wires
crossing the occlusal table can disrupt rather than retain the tooth relationships established
137

during treatment. Circumferential clasps on the terminal molar or lingual extension clasps
may be preferred over the more effective Adams clasp if the occlusion is tight.
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.1
In cases where the canines have a tendency for rotation, especially toward the labial,
the standard Hawley retainer has difficulty in preventing this movement. To overcome this
and for better retention of cuspids, Ali-A. Bahreman 123 has adapted extra loops to the labial
bow of the Hawley retainer in the cuspid region. The loops can be made toward the mesial or
toward the distal to prevent or correct mesiobuccal or distobuccal rotation.
Extra loop toward mesial (left) and distal (right).
The extra loops can be used in both upper and lower arches.
Modified loops in both upper and lower

appliances.
They can also be used as hooks for an elastic in the incisor region if minor palatal
movement or space closure is required with a light continuous force. For this purpose, acrylic
material should be relieved behind the incisors at each adjustment. After using elastics for
some days to retract incisors, the labial bow can be contracted to retain the new position of
the incisors.
138
Elastic used in conjunction with

modified hooks.
Patients wearing the conventional Hawley retaining appliance complains that, it is too
bulky and uncomfortable, causes a speech impediment (usually lisping), causes a bad taste in
the mouth, causes a loss of taste sensation, causes difficulty in mastication, occasionally
discolors, occasionally warps to produce a poor fit and poor retention, occasionally involves
an allergic response etc. All of these problems, which discourage patient cooperation in
wearing the appliance, are associated with the acrylic plate, which has been routine in the
construction of an upper Hawley retainer. However, the acrylic plate is not needed in cases in
which prevention of lingual relapse is not a factor, and if stability of the appliance can be
attained by proper design and construction of an all wire, tooth-borne appliance.
In some cases, palatal coverage is not desirable because it may contribute to relapse.
For example, in tongue thrust cases the stability of a treated result may be related to the
ability of the patient to acquire proper lingual proprioception for proper tongue function.
Adequate space for lingual proprioception.
This may be somewhat compromised when the palate is covered. Tongue spurs, rakes,
and cribs can be added, or a hole placed in the plastic to influence tongue placement, but
these adjuncts may all be unnecessary in view of the alternative that exists.
Laurance Jerrold,
124
has designed an allwire, toothborne Hawley type retention
appliance without any acrylic palate. The appliance has a modified Crozat design. The crib
and crescent clasps are made of 0.028 Permachrome, the labial bow is made of 0.032 wire,
and the transpalatal arch is made of 0.051 wire.
139
Toothborne Hawley retainer.
They are soldered with heavy gauge. 0.025 silver solder. The transpalatal arch is
relieved 1.5 mm away from the palatal soft tissue. The abutment teeth are ditched
appropriately on the model to provide for undercut retention. With properly constructed
clasps, there are no occlusal interferences, and space is available for proper tongue
placement.
Clasps designed to avoid occlusal

interference.
In a case with a lingual relapse tendency, a lingual arch can be placed instead of a
labial one. This will give lingual support and still leave an open palate, and can be held in
place by the superior retentive ability of properly constructed Crozat clasps.
In properly selected cases, the all wire toothborne Hawley type appliance may be
the retainer of choice.
Hawley retainers of all types, classic and modified, remain the most widely used
retainers in orthodontics, especially following comprehensive orthodontic therapy. In
addition to their role in retention, they can be modified to achieve some limited active tooth
140

movement through the activation of the labial bow or incorporation of auxiliary springs
imbedded into the acrylic base or soldered to the labial bow or clasps.
Hawley retainers usually are worn 24 hours per day for the first 6 months following
removal of therapeutic appliances. Exception to the 24-hour constraint are for tooth brushing,
swimming and eating. Aside from some slight slurring of speech, especially S sounds, and
an increase in salivary flow for several days, patients find wearing Hawleys type retainers
rather benign. Because they are relatively small, they can be slipped out of the mouth and
placed in their box for important business and social events.
A Hawley retainer can be made for the upper or lower arch. The lower retainer with
the classic Hawley bow is somewhat fragile and may be difficult to insert because of
undercuts in the premolar and molar region. If the major reason for lower retention is
maintenance of incisor position, a retainer for that region only is a logical alternative, and a
wraparound design is preferred.1
2) Removable Wraparound Retainers: A second major type of removable orthodontic retainer is the wraparound or clip-on
retainer, which consists of a plastic bar (usually wire reinforced) along the labial and lingual
surfaces of the teeth. A full-arch wraparound retainer firmly holds each tooth in position. This
is not necessarily an advantage, since one object of a retainer should be to allow each tooth to
move individually, stimulating reorganization of the Periodontal ligament. In addition, a
wraparound retainer, though quite esthetic, is often less comfortable than a Hawley retainer
and may not be effective in maintaining overbite correction. A full-arch wraparound retainer
is indicated primarily when periodontal breakdown requires splinting the teeth together.
Begg wrap-around
A variant of the wraparound retainer,

canine-to canine clip-on retainer, is widely
retainer
the
used
in
141

the lower anterior region. This appliance has the great advantage that it can be used to realign
irregular incisors, if mild crowding has developed after treatment, but it is well tolerated as a
retainer alone.
Clip on retainer (labial and lingual views)
An upper canine-to-canine wraparound occasionally is useful in adults with long

clinical crowns but rarely is indicated and usually would not be tolerated in younger patients
because of occlusal interferences.
In a lower extraction case, usually it is a good idea to extend a canine-to-canine
wraparound distally on the lingual only to the central groove of the first molar. This provides
control of the second premolar and the extraction site, but the retainer must be made carefully
to avoid lingual undercuts in the premolar and molar region. Posterior extension of the lower
retainer, of course, also is indicated when the posterior teeth were irregular before treatment.1
3) Fitted labial bow: Fitted labial bow is also known as continuous labial bow. It is so called because in
this type of labial bow the wire is adapted to confirm to the contours of the labial surfaces of
the anterior teeth. The U loop is usually small. The fitted labial bow cannot be used to bring
about active tooth movement. They are used as retainers at the completion of fixed
orthodontic therapy.121
Fitted
labial bow
4) High labial retainer: -
142

Through force of habit or tradition, most orthodontists will insert a standard Hawley
retainer after the removal of fixed bands. Although minor adjustments may be made with this
appliance, they are not always easy to accomplish. Therefore many operators will resort to a
positioner for a final detailed tooth movement prior to the placing of this standard retainer.
The high labial appliance permits the orthodontist to achieve both objectives, minor tooth
movement plus retention, and thus is an excellent device to use during the retention phase of
orthodontic treatment.125
High labial
retainer
Appliance components: The appliance consists of the following component parts: a) Adams clasps 0.028 (21 gauge) stainless steel wire. These are the clasps of choice
and are usually placed on the first molars. They may, however, be placed on the bicuspids
if no movement of these teeth is required and / or if one or more of the first molars needs
some correction. Ideally one should clasp a first or second molar on one side of the arch,
and a first bicuspid on the opposite side in order to minimize rocking of the appliance.
b) High labial wire 0.036 (19 gauge) precious metal wire.
This is usually soldered to the buccal horizontal portion of the Adams clasps in order
to keep to a minimum the number (and size) of wires passing over the occlusal
embrasures, and thus to lessen the tendency for separation of teeth. The high labial wire
follows the contours of the alveolar bone and should be kept as close as possible to the
alveolar mucosa to prevent lip and cheek irritation.
(c) Labial and buccal springs 0.028 (21 gauge) precious metal wire or 0.025 (22 gauge)
is used when springs are very short.
143

These are soldered to the high labial wire and extend to within 1 or 2 mm of incisal
edge of anterior teeth and occlusal surface (or cusp tip) of posterior teeth. Their free end
is flattened to avoid irritation.
(d) Lingual springs 0.025 (22 gauge) stainless steel wire or 0.022 (23 gauge) is used
when springs are very short.
Occasionally 0.028 (21 gauge) may be used when springs are very long or when
considerable breakage is encountered. These springs are usually added for distal, mesial, and
labial (or buccal) movement of teeth. They are also used in conjunction with the labial or
buccal springs to correct minor rotations, or to maintain the correction of severe rotations that
had previously been corrected with fixed appliances. Lingual springs may occasionally be
used to intrude posteriors, especially second molars.
(e) Baseplate Clear, self-curing acrylic with palate rugae (ground-in) with a round
vulcanite bur). This serves the requirements of stability and anchorage. The acrylic
must be uniformly thin to minimize encroachment upon tongue space and to prevent
speech problems.
The rugae serve as a stop for the tongue. Occasionally, in serve tongue thrusters, a
large opening will be made in the acrylic to expose the patients own palatal rugae. A bite
plane may be added when necessary.
(f) Auxillary components: In this category we include any further devices that may be added to the appliance,
such as hooks for elastics, guide wires for springs, pontics, etc.125
Construction: 1) Adjust model Remove bubbles, and make gingival cuts for clasps. Apply separating
medium.
2) Construct Adams clasps and wax them in place.
High labial appliance after placement of Adams clasps,

lingual springs, and clearance for tooth movement.
144

3) Immerse model in room temperature water until all air is evacuated. Let model damp
dry.
4) Construct lingual springs. Hold them in place with red lab wax.
5) With red lab wax also block out undercuts, and place relief at gingival margins and
where clearance is needed for tooth movement.
6) Add self curing acrylic.
Appliance with acrylic
added.
7) Place model (while acrylic is still soft) into pressure-cooker with room temperature
water for 10 minutes. Cure at 20 psi.
8) Blend high labial wire, using no139 and 3- prong pliers. Solder to Adams clasps with
450 fine solder.
9) Solder the labial and buccal vertical springs to high labial wire.
10) Remove the appliance from model and wash carefully with hot water and detergent
to remove wax. Trim and polish acrylic and wires, and place rugae or palatal
opening.125
Finished
appliance. Two views showing high labial wire and labial spring construction and
soldering. Note palatal reinforcing wire to lessen chance of fracture.
145

Advantages: The advantages of the high labial retainer may be summarized as follows: 1) The orthodontist has complete control over each tooth separately.
2) The springs are easy to adjust.
3) Pressure on one tooth will not appreciably affect any of the adjacent teeth.
4) Closing of band spaces is simplified.
5) Finishing details are easily accomplished, and without the use of a positioner.
6) Rotations can be accomplished and / or retained by using lingual springs in
conjunction with the labial or buccal springs of the high labial appliance.
7) Additional springs may be soldered to the high labial wire for mesial or distal
movement.
8) Uprighting of mesially or distally tipped anteriors can sometimes be accomplished
through the use of both mesial and distal springs on teeth with long clinical crowns.
9) Buccally erupting second or third molars can be guided into the line of occlusion.
10) When desired, hooks may be soldered to the high labial wire (or to the Adams clasps)
for elastic traction.
11) The same appliance can be used during both the active and retention stages of minor
tooth movement cases.
12) Since the springs run vertically (in the direction of the long axis of the teeth), the
appliance is actually more esthetic than one with a horizontal retaining wire.
Disadvantages: The only disadvantages with respect to this appliance are the slightly higher cost of
construction, the possibility of the patient inadvertently bending the springs, and the fact
that the majority of patients at the present time are not educated to accept this different
retainer.125
146

5) A Removable Cuspid-to-Cuspid retainer: Retention of the lower teeth has been accomplished through many different methods:
tooth positioners, Hawley retainers, six-to-six and cuspid-to-cuspid fixed lingual retainers.
There are good and bad features with each type of retainer. The removable Hawley
works well but requires time and skill in its preparation.
Also, in those cases tori mandibularis are present, the Hawley is contraindicated. The tooth
positioner does a good job of finishing and retaining, but some patients can soon find it
objectionable and request that it be replaced by individual retainers. The fixed lingual
retainers are probably the most dependable, but still create brushing problems, take up some
arch length space with the bands, and in the fixed cuspid to cuspid are eventually
considered esthetically undesirable. In an attempt to incorporate the good features of each to
these retainers into one retainer and eliminate some of the bad features at the same time,
Douglas J. Shilliday developed a removable cuspid-to- cuspid retainer. This retainer can be
made relatively quickly and by untrained personnel.
Construction: Two 0.025 wires are bent and placed in the embrasure between the lower cuspids and
lateral incisors after separating medium is painted on the cast.
025 wire bent to shape.
Wires placed between cuspids
and
laterals after separating medium is painted on
cast
Apply a quick-cure acrylic covering the labial surfaces from cuspid to cuspid and the
lingual surfaces from first bicuspid to first bicuspid (or second bicuspids if firsts have been
extracted). When the acrylic has set, the retainer is removed from the cast, trimmed, pumiced
and polished.
147

After acrylic has cured retainer is finished and polished.
The acrylic should be cut down on the labial to avoid being struck by the maxillary
central incisors, but left at the incisal edge on the lingual.
Acrylic extends to incisal edges of incisors
on
the lingual, but is trimmed on labial side to avoid

interference with maxillary incisors.
The whole procedure requires about fifteen minutes of working time and produces a
smooth, inconspicuous, easily fitted retainer that will do a positive job of controlling
corrected lower rotations. Impression for the removable cuspid to cuspid retainer is not
taken until all lower anterior spaces left at appliance removal have closed.126
Finished
retainer in
place.
6) Removable 6-6 metal Retainer: Retention in the lower arch sometimes presents us with a dilemma. The cemented 3-3
or 6-6 lingual arch avoids the problems of loss and non-wear. They do have the drawbacks of
cement washout, visibility (of the 3-3), and constantly answering the question, Doctor, when
will the braces come off?
The lower Hawley appliance may avoid decalcification, but the plastic breaks
(usually while in a pocket); is bulky (which contributes to pocketing or, worse yet,
napkining); has potential adverse gingival effects; and is adjustable to a limited extent once
constructed.
An alterative which Dr. Carl S. Hoffman 127 have found useful is a metal 6-6
removable retainer.
148

Construction: A) The lingual arch is formed of 0.045 hard SS wire.
Lingual arch formed of .045
hard SS
wire.
B) Adams clasps are formed of 0.028 or 0.032 SS wire. Bend clasp tails over archwire so
that stress is wire-to-wire and not on solder.
Adams clasps formed of .028
or .032 SS
wire.
Note clasp tails bent over
lingual
archwire.
C) In soldering, use Hydroflame or electrosoldering. Heat expendable part of clasp tails.

Use solder as heat sink to avoid overheating clasp.
D) Add buccal wires, tubes, lingual finger springs, ball clasps, distal extensions to
second molars, or anything else that will do what one desires to be done.
7) Non Acrylic Removable Retainer: Removable appliances with an acrylic base may cause soft tissue inflammation in
patients who tend to accumulate plaque or are hypersensitive to free monomer, especially
when cold curing acrylic is used. A non-acrylic removable retainer is a simple, effective
alternative.
A special appliance was designed by Dr. I. Brin, Dr. Y. Zilberman, and H.
Tennenhaus128 to resolve the inflammation.
149
Non-acrylic removable retainer.
It was constructed of heavy wire (0.9mm, 0.351) adapted to the gingivopalatal

surfaces of the upper teeth. Retention was gained with Adams clasps on the first molars and
threequarter clasps on the first bicuspids.
The inflammation disappeared shortly after this appliance was inserted and the palate
was uncovered.
Case at time of removal of acrylic

retainer
and placement of non-acrylic
Case two weeks later of removal

of acrylic
retainer and placement of non-
8) Continuous Clear Retainer: Wires that cross from labial to lingual in a standard Hawley retainer tend to hold
spaces open, and to interfere with the occlusion and the ability to finish with cuspid or group
guidance and with anterior guidance. An allplastic retainer attempted to solve this problem;
but tended to interfere with the posterior occlusion, and the plastic would fracture easily
when that interference was eliminated. With the continuous clear retainer there are no wires
crossing from buccal to lingual and no interference with occlusion and settling. It offers
much greater control of the corrected positions due to circumferential retention from the
second molar through the central incisor and broad (5-6 mm) coverage on the labial side.
Because the continuous labial portion is made of cold-cure acrylic and finished to a high
shine, it does not stain and tends to be extremely accurate.
Construction: The wires are outlined on a stone working model and bent out of 0.030 stainless
steel wire. The two loops should be in the same horizontal plane, with no vertical component
that could unseat the appliance when it is activated. In patients with developing second
molars, it is important to carve the gingiva to permit the most posterior circumferential wire
150

to settle into the developing gingival embrasure, and this must be adjusted in the mouth. The
spur between the first molar and second bicuspid should fit snugly.
The model is coated with Al-Cote and the wires are stickywaxed into place.
Wires bent and sticky-waxed in place.
A strip of soft white wax is pressed on the occlusal surfaces as a barrier between the
inner and outer portions of the appliance.
Wax barrier between inner and outer elements.
The acrylic portions of the appliance are then fabricated using a cold-cure acrylic.
151
Acrylic portions completed.
The appliance is then finished and polished. The palate is relieved in a U-shaped to
avoid interference with taste and temperature perception, and to avoid gagging and speech
impediments. An 0.020 rubber ligature is used to connect the two wire loops, and the
appliance is ready for insertion.
Appliance finished and

polished.
Minor finishing corrections can be achieved by resetting teeth in wax, similar to the
positioner, or by relieving the acrylic on the buccal or lingual side to permit an adjusting
action.
Construction time of the continuous clear retainer is approximately 10-15 minutes
longer than for a standard retainer but the results achieved are effective of this retainer. The
continuous clear retainer permits normal vertical settling of the teeth without jiggling.
Results have been rewarding for esthetics and for settling into a good functional occlusion.129
9) Retainer Splint: The purpose of this retainer is, primarily, to replace the lower fixed cuspid to
cuspid retainer. It is easy to construct and rarely breaks.
The usual construction employs an. 0.036 SS wire around the six anterior teeth
embedded in acrylic.
152

Construction of retainer splint
(Horizontal and Vertical section).
Although it is basically a cuspid to cuspid appliance, it can be carried posteriorly

to hold buccal expansion. It can also be used effectively to accomplish minor tooth
movements. A tooth may be cut off the cast, over-rotated, set in plaster and the retainer made
to the new position.
The appliance can also be used to maintain space.
Retainer splints showing the use of an upper splint to maintain space for small,
malformed lateral incisors
It is only worn at night. It has been used as a nightly check on stability, only being
worn if needed. It has also been used over a period of years in less stable circumstances.130
10) Removable Plastic Herbst Retainer: A variety of fixed and removable single-arch retainers have been useful in
maintaining alignment, space closure, and rotation correction. However, single-arch retainers
are not effective for preventing anteroposterior relapse, which can result in the reappearance
of a Class II bite relationship. Frankel and bionator type appliances have been used, as
dual arch retainers to prevent anteroposterior relapse, but these are less predictable than
single-arch retainers in maintaining intra-arch stability.
In an effort to combine the useful properties of both single and dual arch retainers,
Raymond P. Howe131 have begun using a Removable Plastic Herbst (RPH) retainer.
153
Removable Plastic Herbst retainer, with upper and lower occlusal splints connected by
the herbst mechanism.
Its full upper and lower plastic splints function as conventional singlearch retainers.
At the same time, the removable splints are connected on each side by the telescoping Herbst
mechanism, which acts as a dual arch anteroposterior retainer.
Design: The design of the Removable Plastic Herbst retainer is similar to that of the
Removable Plastic Herbst treatment appliance. Upper and lower plastic splints are fabricated
over a supporting wire framework and connected by the Herbst mechanism.
The principal difference between the retainer and the treatment appliance is that the
retainer has full occlusal coverage on all teeth, including the upper incisors. This maintains
tooth positions and prevents passive eruption.
Alternative uses: 1) Finisher: A patients compliance with Class II elastics, headgear, diet, or hygiene occasionally
becomes unsatisfactory near the end of treatment. In such a case, in may be possible to
remove fixed appliances and use a Removable Plastic Herbst retainer as a finishing
appliance. If the patients hygiene does not improve, at least the potential for decalcification
and decay can be reduced with the removal of fixed appliances.
2) Retreatment Appliance: It is commonly assumed that if a proper cusp-fossa relationship is established, a
corrected class II malocclusion will remain in a proper anteroposterior archtoarch
relationship. Regardless of the treatment mode - extraction, class II elastics, headgear, or
orthopedic methods certain cases have a tendency toward anteroposterior relapse. These
patients can benefit from retreatment with a Removable Plastic Herbst retainer.
3) Post Surgical Retainer: -
154

The Removable Plastic Herbst retainer may have an application as a post-surgical
retainer in preventing skeletal relapse. This use is speculative and should be confirmed with
research and limited clinical trials before general application.
155

4) Aid for Obstructive Sleep Apnea: Early clinical trials suggest that the Removable Plastic Herbst appliance may be
useful in protruding the lower jaw to maintain an airway in patients who suffer from episodes
of obstructive sleep apnea.
5) Anterior Repositioning Splint: A form of the Removable Plastic Herbst appliance has been used as an anterior
repositioning splint for treatment of temporomandibular joint disorders. Preliminary results
seem favorable, but this is still an area of active inquiry.131
11) Essix Retainers: Orthodontists concept of retention is moving toward the idea that teeth will move
unless retained indefinitely. However, permanent retention implies permanent supervision,
and that is where reality clashes with stability.
When permanent retention is emphasized, the equilibrium is upset. The cornerstone of
Essix permanent retention is the complete delegation of responsibility to the patient. Essix
retainers132 have nothing to adjust; the only thing that could be done on a recall visit would be
to check the patients compliance and listen to any comments.
Essix thermoplastic copolyester retainers change the rules of permanent retention.
They are a thinner, but stronger, cuspid-to-cuspid version of full-arch, vacuum formed
devices.
Patient before and after

placement of
Essix retainers.
156
157

Advantages include: The ability to supervise without office visits.
Absolute stability of the anterior teeth.
Durability and ease of cleaning.
Low cost and ease of fabrication.
Minimal bulk and thickness (0.015)
The brilliant appearance of the teeth caused by light reflection.
Essix retainers can be placed the same day fixed appliances are removed. A single-arch
Essix retainer should be worn 24 hours a day (except for cleaning) for two weeks, and then at
night only. If both upper and lower retainers are placed, the patient should wear the lower
during the day and the upper at night for four weeks, then both at night only. The material is
so thin that accommodation to speaking and eating is not a problem. Essix retainers are
nearly impervious to fracture or distortion.
Labial contour of upper and lower
Essix
retainers.
Essix retainers have proven quite versatile. Their flexibility and positioner effect make
them an alternative to spring retainers in correcting minor tooth movements. They can be
used to reduce occlusal forces from the opposing arch when moving posterior teeth with airrotor stripping mechanics. They can serve as a temporary bridge for a missing anterior tooth,
when thermoformed over a pontic placed in the edentulous space on the cast. They can also
act as night guards for bruxism and as bite planes to relieve bracket impingement until the
bite can be opened.132
Palatal contour of upper Essix

retainer
Space cut at distogingival margin

of cuspid
to allow removal of retainer with
158

12) A New Thermoplastic Retainer: Clear thermoplastic appliances have been recommended for use as transitional
retainers, finishing appliances, 1) and even permanent retainers. 2) They are easy to fabricate,
inexpensive, esthetic, and comfortable, and thus have a high level of patient acceptance. 3)
The major drawbacks are their tendency to open the bite and their low durability.
Thermoplastic retainer
Most thermoplastic retainers133 are made from 1mm splint material. 1) The Essix
retainer, however, is fabricated from 0.75 mm (0.030) copolyester, which is thermoformed
to a thickness of 0.015. This appliance is thinner and stronger than other designs, but since it
covers only the six anterior teeth, it still has a slight tendency to open the bite. 2) The low
modulus of elasticity of polymeric materials is a major consideration in structural
applications of plastics. 3) To afford maximum stiffness, plastics must be designed for the
most efficient use of the material. 4) Corrugated and dimpled sheet surfaces are widely used
to enhance stiffness, as are shapes with specific and non-repetitive geometries, such as a
cylindrically curved plate. The resistance to deformation is related to the amount of curvature
of the plate.
A. Corrugated sheet.
B. Cylindrically curved plate.
This new clear thermoplastic retainer is both thin and strong. Patient cooperation and clinical
results are excellent. The enhanced flanges facilitate the removal and increase the stiffness of
the appliance.133
159

13) Positioners as Retainers: A tooth positioner1 also can be used as a removable retainer, either fabricated for this
purpose alone, or more commonly, continued as a retainer after serving initially as a finishing
device. Positioners are excellent finishing devices and under special circumstances can be
used to an advantage as retainers. For routine use, however, a positioner does not make a
good retainer. The major problems are:
1) The pattern of wear of a positioner does not match the pattern usually desired for retainers.
Because of its bulk, patients often have difficulty wearing a positioner full-time or nearly so.
In fact, positioners tend to be worn less than the recommended 4 hours per day after the first
few weeks, although they are reasonably well tolerated by most patients during sleep.
2) Positioners do not retain incisor irregularities and rotations as well as standard retainers.
This problem follows directly from the first one: a retainer is needed nearly full-time initially
to control intra-arch alignment. Also, overbite tends to increase while a positioner is being
worn, and this effect as well probably relates in large part to the fact that it is worn only a
small percentage of the time.
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. For a patient with a tendency toward class III relapse, a positioner made with
the jaws rotated somewhat downward and backward may be useful. Although a positioner
with the teeth set in a slightly exaggerated supernormal from the original malocclusion can
be used for patients with a skeletal Class II or open bite growth pattern, it is less effective in
controlling growth than part time headgear or a functional appliance.
Keslings tooth
positioner
160

In fabricating a positioner, it is necessary to separate the teeth by 2 to 4 mm.
Positioners ideally are worn for as close to 24 hours per day as possible for the first 2 days
after appliances are removed and then for 4 hours per day plus sleeping. For 4 hours per day
during the first two days then during the 4 working hours of wear, the patient is requested to
bite and clench into the appliance for 20 seconds, release for 20 seconds and repeat. If the
patient follows this schedule, after the first 2 to 3 weeks, all movement that might occur will
have done so and the appliance becomes a true passive retainer rather than an active
appliance.
Patients wearing a positioner, as a retainer should be checked carefully to see that
there is no separation of the posterior teeth when the incisors are in contact as it is the usual
sign of a positioner made to an incorrect hinge axis.
In addition to tooth positioning and enhancing the setting or fine tuning of the
dentition, these appliances act to stimulate and massage the gingiva during the exercise
aspects of their use.
II) Fixed Appliances as Retainers: Fixed orthodontic retainers1 are normally used in situations where intra-arch
instability is anticipated and prolonged retention is planned. Direct or indirect bonded or
band based orthodontic appliances can be used in one or more applications involving space
and / or rotation control. Their most important use is in the control of arch circumference and
alignment of mandibular anterior teeth. Other applications are holding space for pontics or
maintaining the closure of diastema, usually at the maxillary midline. The appliance usually
runs from canine-to-canine or premolar-to-premolar following contour of the lingual surfaces
of the involved teeth and resting on the incisors or, in some cases, all four incisors are
involved. Over the years acid-etch technique and various adhesive materials in combination
with stainless steel or wire mesh and even the fiber glass retainers have been used for
orthodontic retention purposes.
Two different types of bonded retainer are used routinely to prevent vertical anterior
relapse and secondary crowding of the lower incisors, and a 0.032-inch wire from canine-tocanine is used as a 3-3 retainer. With the round 0.032 inch multistranded wire, it is no longer
necessary to bend loops at the ends because the twists in the spiral wire give undercuts for
161

retention (Early bonded retainers were made with plain round or rectangular wires). The
other type of retainers is used to prevent space reopening and rotational relapse; it is made of
thin, flexible spiral wire of 0.0175 or 0.0215 inch and is bonded to each tooth of the anterior
segment.
A variety of methods have been suggested for fabrication and bonding of fixed
retainers to the lingual surface of anterior teeth. The importance of a passive and precise
positioning has been stressed because tension in the wire results in a failure of retention.
Failures that occurred were due to some degree of distortion during setting of adhesive, the
use of too little adhesive, or direct trauma to the retainer. Bonding thin, flexible spiral wires
lingually to each tooth in a segment has been proposed as an effective way to retain anterior
teeth in difficult situations, such as holding central incisors together after median diastema
closure, preventing space opening after closure, and holding teeth that are extensively
torqued. They are flexible enough to permit physiologic tooth movements, which are not
possible by tooth contact splinting, and the twist in the wire provides mechanical retention to
a composite resin.
Knierim (1973)
134
published the first report of a technique of making the lower
cuspid-to-cuspid retainer without bands. The basis of the technique was to acid etch the
lingual surface of the lower cuspids. A self-curing resin is then applied to the lingual of the
cuspids to hold a wire against the lingual of lower incisors (0.028 round stainless steel
wire). After application the patient is instructed to check retention of the wire every two
weeks. Instructions are given to apply pressure with a toothbrush handle on the resin mass on
the lingual of the cuspids to be sure it is not loose. The wire can be extended around the
second bicuspids in extraction cases to keep the extraction site closed.
Finished retainer with resin on lingual on

cuspids
162

Wolfson (1974) 135 gave a step-by-step procedure of Bandless but fixed retention by
placing the direct-banded mandibular lingual canine-to-canine retainer. The retainer has all
advantages of a fixed soldered canine-to-canine retainer. In addition, it does not require
bands, which in themselves, besides requiring space, compromise upon esthetics. It allows
for normal teeth contacts mesial and distal to canines and can be fabricated at the chair in one
appointment of approximately 30 minutes.
Reinhardt (1979) presented another technique for retention - a cast metal framework
attached with the acid etch technique and composite resins. The method is not indicated for
all situations but is an option with the practitioner. It consists of flattened retentive portions
with numerous poles, which are smoothly connected to stabilizing wires. The components
need not be greater than 0.5-1 mm in thickness. Use of this technique offers advantages of
patient comfort since the metal can be highly polished and well adapted outside the mouth
for a precision fit. Smooth controls are possible because there is not bulky wire. Strength of
the material prevents drifting or rotation. No preparation of teeth is necessary. Thus, the
procedure is easily reversible. Esthetics is readily acceptable, since the appliances are easily
hidden from a labial view.136
Diamond (1987) 137 developed a direct technique that uses glass fibers from woven
fiberglass fabric (sold in boating supply stores) or Fiberbond. These fibers are separated into
6 strips, sterilized with dry heat, and kept in inventory. After removing the brackets and any
material adhering to the teeth, prepare the mouth with cheek retractors, a saliva ejector, and a
tongue retractor or mouth mirror. Pumice, etch, wash, dry, and seal the lingual surfaces of the
teeth to be bonded to the retainer. A piece of fiberglass thread is measured from the distal
aspects of the canines, contacting the lingual surfaces of the incisors and soaked in lightcured bonding resin. A second mixture of resin and restorative paste to the consistency of
heavy cream is incorporated into the fiberglass thread to increase its strength. The resin-
163

soaked fibers are applied to the teeth and positioned with an explorer, plastic instruments, or
ligature director. Then a visible-light curing unit is used to cure the retainer to the tooth
surfaces. This system has following advantages: The resin fiberglass retainer is 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. Because no metal wires are used, additional
material can be applied to the teeth or the fiberglass or both.
Finished resin fiberglass retainer.
There are four major indications for fixed orthodontic retainers1: 1) Maintenance of lower incisor position during late growth: The major cause of lower incisor crowding in the late teen years, in both patients who
have had orthodontic treatment and those who have not, is late growth of the mandible in the
normal growth pattern. Especially if the lower incisors have previously been irregular, even a
small amount of differential mandibular growth between ages 16 and 20 can cause
recrowding of these teeth. Relapse into crowding is almost always accompanied by lingual
tipping of the central and lateral incisors in response to the pattern of growth. An excellent
retainer to hold these teeth in alignment is a fixed lingual bar, attached only to the canines (or
to canines and first premolars) and resting against the flat lingual surface of the lower
incisors above the cingulum.
Banded and bonded canine-to-canine fixed lingual retainer
164

This prevents the incisors from moving lingually and is also reasonably effective in
maintaining correction of rotations in the incisor segment.
A fixed lingual canine-to-canine retainer can be fabricated with bands on the canines or
can be bonded to the lingual surface. A bonded canine-to-canine retainer is preferred for two
reasons: (1) unless bands were used during the active treatment, band space can be a
problem; and (2) the labial part of a band tends to trap plaque against the cervical part of the
labial surface, predisposing this area to decalcification, and is also unsightly. Since their
introduction in 1977, direct-bonded lingual canine-to-canine retainers have been used to
improve the long-term stability of orthodontic treatment results. Because of technological
improvements, the design of the retainer bar has changed over the years.
The fixed bonded canine-to-canine retainer is attached only to the canines, resting
passively against the central and lateral incisors. If the retainer wire is fitted to a cast of the
lower arch, a silicone carrier of the type used for indirect bonding of brackets can be made to
assist in placing the retainer. An alternative approach is to tie the retainer wire in place with
wire ligatures or dental floss around the contacts, to hold it so that it can be bonded.
Steps in the fabrication of

canine-to-canine retainer
Fixed canine-to-canine retainers must be made from a wire heavy enough to resist
distortion over the rather long span between these teeth. Usually 30-mil steel is used for this
purpose, with the end of the wire sandblasted to improve retention when it is bonded to the
canines.
165
bonded
canine-to-canine
retainer
can
advantageously be made from a twist wire, which

improves retention of the bonded wire. 28 mil wire
is
recommended if only the canines are to be bonded.
If
the incisors also are bonded, a lighter wire should

be used.
It is also possible to bond a fixed lingual retainer to one or more of the incisor teeth. The
major indication for this variation is a tooth that had been severely rotated. Whatever the type
of retainer, however, it is desirable that teeth not be held rigidly during retention. For this
reason, if the span of the retainer wire is reduced by bonding an intermediate tooth or teeth, a
more flexible wire should be used. A good choice for a fixed retainer with adjacent teeth
bonded is a braided steel arch wire of 17.5-mil diameter.
Mandibular incisor retainer, with wire lightly

bonded to the canines, before the incisors
are bonded
Completed maxillary retainer,

with all four incisors bonded
2) Diastema maintenance: A second indication for a fixed retainer is a situation where teeth must be permanently
or semipermanently bonded together to maintain the closure of a space between them. This is
encountered most commonly when a diastema between maxillary central incisors has been
closed. Even if a frenectomy has been carried out, there is a tendency for a small space to
open up between the upper central incisors. Since this is unsightly, prolonged or permanent
retention usually is needed.
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
166

object of the retainer is to hold the teeth together while allowing them some ability to move
independently during function, hence the importance of a flexible wire.
Bonded lingual retainer for maintenance of a maxillary central diastema
A removable retainer is not a good choice for prolonged retention of a central

diastema. In troublesome cases, the diastema is closed when the retainer is removed but
opens up quickly. The tooth movement that accompanies this back-and-forth closure is
potentially damaging over a long period.
3) Maintenance of pontic or implant space: A fixed retainer is also the best choice to maintain a space where a bridge pontic or
implant eventually will be placed. Using a fixed retainer for a few months reduces mobility
of the teeth and often makes it easier to place the fixed bridge that will serve, among other
functions, as a permanent orthodontic retainer. If further periodontal therapy is needed after
the teeth have been positioned, several months or even years can pass before a bridge is
placed, and a fixed retainer is definitely required. Implants should be placed as soon as
possible after the orthodontics 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 in shallow preparations in the future abutment teeth.
Fixed retainer to maintain space for a missing second

premolar. A shallow preparation has been made in the
167

enamel of the marginal ridges adjacent to the extraction site, and a section of 21X25
wire is bonded as a retainer.
Obviously, the longer the span, the heavier the wire should be. Bringing the wire
down out of occlusion decreases the chance that it will be displaced by occlusal forces.
Anterior spaces need a replacement tooth, which can be attached to a removable
retainer. This approach guarantees nearly full-time wear and is satisfactory for short periods.
Often a better alternative is a fixed retainer in the form of a simple acid-etch bridge, such as a
replacement tooth held by twist wires bonded to adjacent teeth. If a healing implant is in the
area, or if a permanent bridge will be delayed for a long time, a temporary bonded bridge
decreases the chance of soft tissue inflammation and provides better stability.
Acid-etch bridge using segments of braided

orthodontic wire to attach the pontic to the abutment tooth
4) Keeping extraction spaces closed in adults: 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. It may be better in adults to
bond a fixed retainer on the facial surface of posterior teeth when spaces have been closed.
168

A bonded retainer maintaining the space closure in an adult with missing maxillary
lateral incisors in whom the space was closed and the canines substituted for the
laterals.
169

Some other types of fixed orthodontic retainers: 1) Direct-bonded labial retainers: Direct-bonded retainers136 are usually placed lingually, since one of the chief advantages
of such retainers is their invisibility. However, certain problems experienced with directbonded lingual retainers were: a) Short-or long-term inability to prevent some reopening of premolar extraction sites in
adults.
b) A tendency for some lingual crown relapse of canines that had been palatally
impacted.
c) Difficulty in holding premolars that had been severely rotated.
d) Various types of space reopening in cases where posterior teeth had been moved
mesially, in young or adult patients with previously excessive spacing.
Common to these situations was the desirability of adding some support to the premolar
areas for one or two years after treatment. It appeared preferable to bond the retainer wires
labially, based on earlier experience with bond failures at the enamel-adhesive interface when
bonding to the lingual surfaces of premolars.
Another alternative would be to bond the retainer in the occlusal fissure, which is usually
successful if there is no contact with antagonists. In most cases, however, a groove has to be
prepared with a bur to avoid such contact. This amount of enamel removal would not be
acceptable in routine situations.
Long direct-bonded labial retainer
Short direct-bonded labial retainer
Bonding success rates and patient acceptance appear to be excellent for labial retainers
bonded to two adjacent teeth. Such retainers may therefore be recommended for improved
stabilization of extraction sites in adults, and for added retention of palatally impacted
canines.
170

On the other hand, the results obtained with three-or four-unit bonded labial retainers
were unsatisfactory, particularly in the mandibular arches of young patients. Further technical
improvements will be required before these retainers can be routinely used on long buccal
spans.
2) 4-4 Crozat retainer: When a basic Crozat appliance138 is used as retainer, a tooth will sometimes rotate
away from the lingual wires, and crowding will return in spite of the appliance.
Basic Crozat appliance
Adding a closed labial wire with pins provides adequate retention, but the appliance is
bulky and unsightly as a retainer. The spring retainer and modified Hawley-spring retainer
afford labial and lingual control, but these appliances do not seat securely on the teeth.
Stability problems of these appliances lead to the fabrication of a bicuspid-to-bicuspid Crozat
appliance with a labial frame as a retainer.
A 4-4 Crozat appliance has cribs on the first bicuspids, recurved double-lapping lingual
finger springs, and a labial bow.
Mandibular 4-4 Crozat retainer
It combines many of the advantages of other types of retainers and has been well
received by patients. Its advantages include: A) Firm retention, because of the Crozat clasping mechanism.
B) Labiolingual control of anterior teeth (although rotational control of the canines is
limited) to maintain or restore arch form in the lower or upper arch.
171
Maxillary 4-4 Crozat retainer
C) Flexibility, because it is all wire. It can be left out for months and still fit.
D) Maintenance of adequate oral hygiene, because it is removable.
E) Esthetics, because only a single labial wire shows.
The major drawbacks of the appliance are that it must be fabricated at a quality
laboratory, which may cost more; and it is breakable, although breakage has been minimal. It
is possible to treat both arches simultaneously with 4-4 Crozat retainers. Occlusal
interferences from the crib wires are rare and do not pose a problem.
Once the teeth are aligned, full-time wear should be continued for at least three months,
after which nighttime wear is sufficient to maintain the corrected alignment. The 4-4 Crozat
retainer is flexible in design potential, and it is capable of individual tooth movements that
may be difficult even with fixed appliances. It can move teeth rapidly - usually requiring only
three to four months - to correct mandibular and maxillary anterior relapse and in special
cases involving Prosthodontics. However, the 4-4 Crozat is mainly a retention appliance,
especially for cases in which the incisors are resistant to ideal alignment. It is not a treatment
appliance, nor should it be used to maintain faulty treatment results.
Lower anterior
relapse
corrected
in
three-months
with
a
4-4
Crozat retainer
Upper anterior
relapse
corrected
in
four-months
with
a
4-4
172
Case in which 4-4 Crozat retainer was

used over a partial denture to improve
the alignment of anterior teeth prior to
placement of a fixed prosthesis
3) Prefabricated Bonded mandibular retainer: Previous report have presented techniques for direct bonded mandibular retainers
whose principal drawbacks included lengthy fabrication time, accumulation of plaque on the
bonded attachment areas, and potential irritation to the lingual soft tissues due to the
bulkiness of the attachment areas. The Prefabricated Lower Retainer (PLR)
139
minimizes
these deficiencies.
Appliance construction: The Prefabricated Lower Retainer is prefabricated of two mesh-backed attachment
bases, joined by a lingual bar with interbase lengths in four sizes - 20, 22, 24 and 26 mm.
The PLR
The attachment bases constructed of a stainless steel shield on a welded wire mesh,
are joined to the lingual bar with silver solder. The lingual bar may be constructed of gold,
brass, or stainless steel, with a diameter range of 0.025 to 0.036. Small gauge wire is
preferable. The only drawback to using brass wire is that it may tarnish in patients with poor
hygiene. The only drawback to stainless steel is that it takes more time and is more difficult
to adjust. Both were used successfully on patients in this study. Gold wire is probably the
ideal wire for the Prefabricated Lower Retainer, since it is strong, tarnish resistant, easy to
173

adjust, and a smaller, more comfortable wire can be used. It was found that 0.032-brass wire
can resist 40 ounces of pulling force without distortion, while 0.028 gold wire can resist 52
ounces. In normal circumstances, 40 ounces should be strong enough to retain mandibular
incisors and resist the force of mastication.
Buccolingual section of base
and mesh
Prefabricated Lower Retainer Size Selection and Placement: A measuring template is used, either on the model or directly in the mouth, to
determine the proper Prefabricated Lower Retainer size. The measurement is made 0.5 1
mm distal to the mesial marginal ridge of the canines, just lingually, with the arrows of the
gauge resting on the incisal edge of the mandibular incisors.
Using measurement gauge. In this
case, size 2
is correct.
The Prefabricated Lower Retainer is fabricated with ideal arch form and a welltreated case requires only minimal adjustment. The best time to place the Prefabricated
Lower Retainer is right after band removal, unless obvious band spaces are present between
the teeth. In patients with bonded brackets, the Prefabricated Lower Retainer can be placed
before appliance removal.
Any acceptable technique and materials for direct bonding may be employed for the
attachment of Prefabricated Lower Retainer to the abutment teeth.
174
Bonded PLR
The author Richard S. Chen prefers cotton pliers for carrying and holding the
Prefabricated Lower Retainer while the bonding resin is setting. A scaler is used to press the
bases firmly to the enamel surfaces and to remove excess resin. The optimum placement of
the stainless steel base is the center of the lingual surface of the cuspid below the prominent
cusp of the crown. This will minimize detachment due to mastication.
The patient can floss the mandibular anterior teeth with Prefabricated Lower Retainer
in place, oral hygiene can be maintained. It is possible that Prefabricated Lower Retainer can
be used as a permanent retainer when checked periodically. Prefabricated Lower Retainer can
be reused after reconditioning by burning out with low temperature, ultrasonic cleaning, and
sterilization.
The Prefabricated Lower Retainer is designed to save orthodontists chair time and to
obtain the best result for mandibular incisor retention esthetically and functionally.
III) Active Retainers: Active retainer1 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 will 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. A typical Hawley retainer, if used
initially to close a small amount of band space, can be considered an active retainer, but the
term usually is reserved for two specific situations: realignment of irregular incisors, and
functional appliances to manage class II or class III relapse tendencies.1
175

1) Realignment of irregular incisors: Spring retainers1: Recrowding of lower incisors is the major indication for an active retainer to correct
incisor position. If late crowding has developed, it often is necessary to reduce the
interproximal width of lower incisors before realigning them, so that the crowns do not tip
labially into an obviously unstable position. The cause of the problem in these cases usually
is late mandibular growth, which has uprighted the incisors, and they must be realigned in
their more upright position. Not only does stripping of contacts reduce the mesiodistal width
of the incisors, decreasing the amount of space required for their alignment, it also flattens
the contact areas, increasing the inherent stability of the arch in this region. As with any
procedure involving the modification of teeth, however, stripping must be done cautiously
and judiciously. It is not indicated as a routine procedure.
Interproximal enamel can be removed with either abrasive strips or thin discs in a
handpiece.
Stripping
of
lower
reduce
mesio-distal
Obviously, enamel reduction should not
incisors to
width
be
overdone,
but if necessary, the width of each lower incisor can be reduced up to 0.5 mm on each side
without going through the interproximal enamel. If an additional 2mm of space can be
gained, reducing each incisor 0.25 mm per side, it is usually possible to realign typically
crowded incisors.
If the irregularity is modest and if the teeth are to be realigned without moving
facially, a canine-to-canine clip-on is usually the active retainer used to realign crowded
incisors. The steps in making such an active retainer are:
1) Reduce the interproximal width of the incisors and apply topical fluoride to the newly
exposed enamel surfaces;
176

2) Prepare a laboratory model, on which the teeth can be reset into alignment; and
3) Fabricate a canine-to-canine clip-on appliance.
Steps in the fabrication of a canine-to-canine clip-on appliance to realign lower incisors
If there is more than a modest degree of relapse, however, placing a fixed appliance
for comprehensive retreatment must be considered. With bonded brackets on the lower arch
from premolar to premolar, superelastic NiTi wires can be used to bring the incisors back into
alignment quite efficiently. If the incisors are advanced toward the lip when this is done, a
bonded lingual retainer should be placed before the brackets are removed. Permanent
retention will be required after the realignment.
177

2) Correction of Occlusal Discrepancies: Modified Functional Appliances as Active Retainers1: It is possible to describe an Activator as consisting of maxillary and mandibular
retainers joined by an interocclusal bite block. A typical use for an activator as an active
retainer would be a male adolescent who had slipped back 2 to 3 mm toward a class II
relationship after early correction. If he still is experiencing some vertical growth (and almost
all adolescents fall into this category, even at age 17 or 18), it may be possible to recover the
proper occlusal position of the teeth. Differential anteroposterior growth is not necessary to
correct a small occlusal discrepancy - tooth movement is adequate but some vertical growth
is required to prevent downward and backward rotation of the mandible. For all practical
purposes, this means that a functional appliance as an active retainer can be used in teenagers
but is of no value in adults. Stimulating skeletal growth with a device of this type simply
does not happen in adults, at least to a clinically useful extent.
The Andresen-type activator
The use of an activator as an active retainer differs somewhat from its use to guide
skeletal growth during the mixed dentition or when it is used as a pure retainer. In the latter
circumstances, the object is to control growth, and tooth movement is largely an undesirable
side effect. In contrast, an Activator as an active retainer is expected primarily to move teeth
no significant skeletal change is expected. An activator as an active retainer is not
indicated if more than 3mm of occlusal correction is sought, and over this distance, tooth
movement as a means of correction is a possibility. The correction is achieved by restraining
the eruption of maxillary teeth posteriorly and directing the erupting mandibular teeth
anteriorly.
178

Any of the family of modified Activators designed to produce tooth movement is
most useful in this active retention mode, not in early mixed dentition treatment where
tooth movement for the most part is undesirable. On the other hand, the more flexible a
removable appliance becomes, the less suited it is for the retention part of active retention
and the more likely it would be to require replacement with another type of retainer when the
occlusal relationship had been reestablished. An Activator or Bionator with an acrylic
framework that contacts most teeth therefore is usually the best compromise when this type
of active retention is needed. The appliance is made like any other functional appliance, with
a slight advancement of the mandible into the correct occlusal relationship. In contrast to a
functional appliance that would be placed as a retainer immediately upon completion of
active treatment, some freedom eruption for posterior teeth normally would be provided.
179
Adjuncts to Retention
At times delivering only a retentive appliance may not be sufficient to prevent post
treatment relapse in all the cases. These special cases may require adjuncts to be maintained
in stabilized condition post treatment.
A number of adjuncts have been proposed that aid in retention. These include: 1) Circumferential Supracrestal Fiberotomy
2) Reproximation
3) Frenectomy and associated procedures
4) Septotomy
5) Corticotomy
6) Immediate torsion
7) Prosthetic retainers
Circumferential Supracrestal Fiberotomy: There is little doubt that relapse of orthodontically rotated teeth and also many other
types of post-treatment relapse are due to the displaced supra-alveolar connective tissue fiber.
In 1970, Edwards140,
141
described a surgical procedure to eliminate rotational relapse in
clinical orthodontic patients. This surgical procedure, now referred to as Circumferential

Supracrestal Fiberotomy (CSF), has become well documented.
Circumferential Supracrestal Fiberotomy is indicated for any case where the
supragingival fibers have been markedly displaced. Examples are found in moderately to
severely rotated teeth, markedly crowded or bunched teeth, displaced impacted teeth, and
severely tipped teeth. The procedure is contraindicated in the presence of bacterial plaque,
chronic gingivitis, chronic periodontitis and should avoid areas with little or no attached
gingiva. Circumferential Supracrestal Fiberotomy is not necessary or recommended in cases,
which exhibit mild to moderate displacement of incisors in a buccolingual direction. Patients
with systemic medical problems can be treated but should be covered with the appropriate
therapeutic agent.
180

Many articles have appeared concerning the efficacy of the Circumferential
Supracrestal Fiberotomy in preventing or minimizing tooth rotational relapse. To date,
however, there have been no reports in the literature concerning the long-term effectiveness
of Circumferential Supracrestal Fiberotomy and few assessments have been made of the
possible periodontal sequelae, which might result from these procedures.
Timing transection of the displaced supraalveolar fibers can best be accomplished
after band removal since there is usually a decrease in gingival inflammation and,
subsequently, a marked improvement in tissue tone following debanding.
In the case of closure of an extraction site although it is debatable to what extent the
transseptal fibers reorganize and adapt to a normal anatomic configuration it is important that
these fibers be surgically eliminated after closure of the space and also after closure of a
diastema. The orthodontic closure of an extraction site and the closure of a diastema affect
the transseptal ligament differently. It has been observed that upon final closure of an
extraction site and the approximation (paralleling) of the root structure of the adjacent teeth,
the more apical transseptal fiber appears relatively normal in histologic sections.
It is also not sufficient merely to transact the transseptal ligament, as is done in
eliminating a rotational relapse potential in the supracrestal fibers, since the total interruption
of the transseptal ligament is required before a new and functionally adapted ligament can be
formed. In fact the disruption of the transseptal fibers would be the sole surgical procedure
indicated in the case of a diastema with no associated aberrant frenum. Some researchers
have observed that only a 30-day period is sufficient for the formation of a completely new
transseptal ligament after dissection.
Following Circumferential Supracrestal Fiberotomy the most striking feature is an
increase in mobility of the surgerized teeth. 28, 29 This increased mobility is due to the cutting
of transseptal fibers which splint tooth to tooth. However, mobility gradually diminishes
within a two-four week period. If mobility does persist for more than four weeks, factors
other than Circumferential Supracrestal Fiberotomy should be considered; for example, the
occlusal prematurities which are due to prominent marginal ridges on the maxillary central or
lateral incisors. Another observable feature is slight degree of spacing between the surgerized
teeth. This spacing is transitory in nature and may be attributed to postsurgical edema, which
181

can occur within the periodontal space as a result of Circumferential Supracrestal
Fiberotomy. Postoperative bleeding has not been a problem and patient discomfort is
minimal.
When evaluating post-surgical relapse of Circumferential Supracrestal Fiberotomy,
one must realize that the primary purpose of this procedure is to eliminate rotational relapse.
In most cases, Circumferential Supracrestal Fiberotomy alone cannot stabilize the entire
lower anterior segment. The main factor in relapse of surgerized rotated teeth is an
insufficient period of axial stabilization immediately following rotational correction,
assuming that surgery has been properly performed.
Another significant factor in relapse is failure to completely correct the rotation prior
to Circumferential Supracrestal Fiberotomy. If normal contact point relationships cannot be
produced before surgery, a degree of relapse is inevitable. The clinician should attempt to
produce a slight overcorrection of a rotated tooth prior to band removal. Relapse following
Circumferential Supracrestal Fiberotomy has been observed in those cases where lower
incisors have originally been bodily-displaced labiolingually and subsequently aligned with
insufficient root torque. In addition, a small amount of relapse can be attributed to occlusal
prematurities that result from prominent lingual - marginal ridges on maxillary central and
lateral incisors.
Boese28,
29
investigated the long-term effects of Circumferential Supracrestal
Fiberotomy and Reproximation on the periodontal tissues in mandibular anterior region.

Clinical examination with a periodontal probe revealed gingival tissue with minimum pocket
depth, which appeared to be well within normal limits. The tissues had good morphology,
normal color and normal stippling. There was no evidence of gingival recession on any
mandibular incisors. Reproximation did not cause interdental bone loss in the lower incisor
area. His study demonstrated marked stability of the mandibular anterior segment 4 to 9
years post retention, which did not result from a refinement of orthodontic mechanics, but
rather developed from better understanding the biology of that area.
Now the clinician can readily accept the concept of Circumferential Supracrestal
Fiberotomy which severs displaced connective tissue fibers and can employ Reproximation
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which provides space and broad-contact point areas, thereby placing the mandibular anterior
segment more in harmony with the original arch form.
Reproximation: A subject of renewed interest is the reproximation or stripping of lower anterior

teeth and its purposed ability to reduce lower incisor re-crowding. This reduction of lower
incisor width is often the last resort at holding tooth alignment and is usually employed after
all conventional measures have failed. Its application has been empirical and its long-term
effectiveness questionable. The procedure often evokes the concern of many practitioners
who mention the possibility of associated periodontal destruction plus an increased caries
susceptibility in the mandibular anterior area.
However, in 1972 Peck and Peck44 reported that well-aligned mandibular incisors
possess distinctive dimensional characteristics; these teeth are significantly smaller
mesiodistally and significantly larger faciolingually, when compared with average population
tooth dimensions. Their report showed that a substantial relationship exists between
mandibular incisor shape and the presence and / or absence of mandibular incisor crowding.
It also described a mesiodistal (MD/FL) faciolingual index as a numerical expression of
mandibular incisor crown shape when viewed incisally. According to the standards
recommended by Peck and Peck, ideally shaped lower centrals have a MD/FL index of 88
92 percent, while the lower laterals recommended range is 90-95. They concluded that well
aligned mandibular incisors usually have MD/FL indices significantly lower than those of
crowded incisors and recommended reproximation as a mechanical method of reducing
unfavorable incisor shapes.
Based on these finding, clinical application of reproximation has become much less
empirical and more predictable.
Reproximation is indicated in all cases with crowded lower incisors, which exhibit
poor MD/FL ratios and on teeth with unfavorably shaped contact points. Serial reproximation
can also be employed to compensate for the natural loss of arch length, which appears to
occur in many patients especially during periods of marked horizontal mandibular growth.
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The significance of reproximation resides in two main benefits. It provides broader
contact point areas and thereby furnishes greater contact stability, plus reproximation
increases the amount of available space in the mandibular anterior area. The process of
providing space is extremely useful when working within a biologic framework that usually
limits our ability to increase arch length or drastically change basic mandibular arch form.
In spite of the benefits of the procedure, every conscientious orthodontist must be
fully aware of the inherent dangers. Reproximation obviously is not a reversible process;
once the enamel is removed and the shape of a tooth altered, the result is permanent. To being
with, reproximation should be employed only after the lower incisors have been completely
aligned because it is impossible to be both conservative and precise in establishing broad new
contact areas if the teeth are still malposed. Every effort must be made to avoid excessive
stripping. The removal of more than onehalf the enamel cap could be excessive since this
may lead to dental caries plus increased sensitivity to thermal changes and sweets. And of
course, clinicians should consider the positive correlation that exists between an increase in
anterior overbite with an increase in the amount of lower incisor stripping. Finally, excessive
reproximation could theoretically reduce the amount of transseptal bone between the lower
incisors which might predispose those areas to periodontal disease.
The timing of reproximation appears to fall in three distinct phases, based on the
clinical experiences gained from treating many crowded lower arches without use of lower
retention.28, 29
Most reproximation is done as soon as alignment of the mandibular anteriors has been
accomplished. This will provide good lower incisor shape early in treatment and allow for
ideal overbite correction, which can be maintained following band removal. Obviously, the
maxillary anterior tooth size relationships are affected by lower incisor stripping. Fortunately,
most cases with unfavorably large lower incisor MD/FL ratios usually possess lower anterior
tooth size excess.
The second phase of reproximation, if no lower retention is used, takes place shortly
after band or bond removal. If the intercanine width has been expanded or basic arch form
significantly altered, a periodic check of the mandibular anterior segment with dental floss
will often reveal an increase in contact point pressure. This is observed in both extraction and
184

nonextraction cases. Some degree of reproximation is usually performed serially over a foursix month period following band removal; at each maxillary retention visit the contact points
of the lower incisors are evaluated. If some movement appears to be taking place or contact
points become extremely tight, reproximation is performed.
The timing and degree of third phase reproximation is related to any significant
change in lower anterior arch form and to the amount and direction of mandibular growth.
Usually little reproximation is necessary after the first six months; however, Siatokowski,
Dekock, and Schudy recognize that uprighting of lower incisors is frequently seen during the
terminal phase of growth, especially in counterclockwise growers. The uprighting of these
teeth is responsible for secondary crowding, which often occurs following treatment. Prior to
beginning the third phase of reproximation, one must exercise sound clinical judgment and
consider the degree of stripping already performed, the amount of enamel remaining, shape
of the lower incisor, degree of overbite, and the anticipated amount and direction of
mandibular growth.
If the concept of Circumferential Supracrestal Fiberotomy and reproximation is
routinely employed on crowded mandibular arches, the choice of net utilizing mandibular
retention is most logical and less frightening.
Finally, we cannot look upon Circumferential Supracrestal Fiberotomy and
reproximation as a panacea for all our retention problems, but rather as an embellishment of
sound orthodontic treatment principles and good orthodontic therapy. The use of
Circumferential Supracrestal Fiberotomy and reproximation should not be accepted as a
guarantee for permanent ideal lower anterior teeth alignment, but perceived as a useful
process, which appears to work within a framework of natural changes that inevitably will
occur.
Frenectomy and associated procedures: The most frequently alleged etiologic agent in relapse of approximated teeth in a
previous area of diastema is the superior labial frenum.
Although most texts state that an abnormally large and marginally positioned labial
frenum may result in a persistent maxillary diastema, there is also apparent agreement in both
185

the orthodontic and pedodontic literature that rarely should any portion of even an
abnormal frenum be removed prior to eruption of the maxillary lateral incisors and the
canines, since it has been observed that most diastemas close autonomously with the final
eruption of the remaining anterior teeth. Moreover Dowel has stated that early preventive
frenectomies without prior orthodontic closure in diastema situations may result in scar
formation, which itself might tend to prevent normal mesial movement of the incisors.
Labial frenectomy
Gibbs found an intermingling of the frenal tissue with the transseptal fibers and
therefore, did not advocate early frenectomy for fear that the excision of the frenum would
also sever the transseptal fibers and reduce the natural forces acting to bring the central
incisors together. Most oral anatomists, however, would have difficult agreeing with such an
argument, since the fibers of the transseptal group have never been shown to possess elastic
properties. Baum in addition indicated that the transseptal fibers did not even span the
distance across a midline diastema but inserted into a relapse overlying the midline suture of
the maxilla.
Notwithstanding the fact that there exists little but empiric and arbitrary agreement
that the maxillary frenum plays an important role in causing the re-opening of diastemas after
orthodontic closure, a number of surgical techniques have been devised to eliminate this
undesirable relapse phenomenon. The terms frenectomy and frenotomy represent procedures
that differ in degree. Frenectomy is complete removal of the frenum, including its attachment
to underlying bone. Frenotomy is the partial removal of frenum, and is used extensively for
periodontal purposes to relocate the frenum, and is used to create an increased zone of
attached gingival between the gingival margin and the frenum.
186

In his textbook Archer depicts the classic frenectomy technique in which the frenum,
interdental tissues and palatine papillae are completely excised, leaving bone or periosteum
exposed. A number of modifications of the basic frenectomy operations have been described
including the addition of horizontal relaxing incisors at the mucogingival junction, and the
lateral undermining of the labial attached gingival adjacent to the excision area.
Bell142 has advocated the immediate closure of diastemas by interdental and subapical
osteotomies. Although one of Bells justifications for this surgical approach is the
indispectable unpredictability of retaining closed diastemas, most orthodontist would
seriously question his second justification that the conventional approach to the closure of
diastemas is lengthy treatment difficult. In addition, Bells conviction that the resistance to
active orthodontic movement of teeth and their final stability is alveolar bone, and not the
gingival and frenal tissues is in contradiction to recent oral anatomic and physiologic
research. If such osteotomies should alleviate relapse in diastema problem, it would more
plausibly be due to the surgical interference with the supra alveolar soft tissues and not the
direct manipulation of alveolar bone.
Another procedure to eliminate the alleged relapse potential of the maxillary midline
frenum is the two-plasty technique, which does not remove the frenum but is intended to
relax the pull of the frenum on the interdental soft tissues. Ewen and Pastermak were
encouraged by the use of reversebevel (inverted) gingivectomy procedure on the labial and
palatal tissues of all six maxillary teeth. Although their experimental group involved only six
patients and the researchers were not primarily interested in relapse caused by midline
frenum, their surgical intervention did appear to alleviate the tendency for the diastemas to
reopen.
Campbell, Moore and Mathews143 have attempted to increase the stability of
orthodontically closed diastema as by combining the standard excision type of frenectomy
and its removal of interincisal soft tissue with either1) the reverse bevel gingivectomy labial and palatal to the six anterior teeth or
2) the CSF technique developed by Edwards.
187

Their preliminary findings favored the combination of frenectomies and
Circumferential Supracrestal Fiberotomy procedures.
A technique advocated by some periodontists combine and frenectomy with no
excision of the marginal papillae and the labial curtain type of gingivectomy of the palatal
tissue behind the four incisor teeth as described by Frisch, Jones and Baskar.
Periodontal literature has stated that it makes little difference in the therapeutic result
whether the frenectomy incisions are made to bone in order to denude the alveolar plate or
whether the incisions partly penetrates the alveolar mucosa so that the bone remains covered.
It has been stressed that the therapeutic result is not dependent on whether bone is denuded,
but rather, on the lack of mobility of granulation tissue that covers the wound. Nevertheless,
in performance of a frenectomy for the alleviation of relapse of orthodontically closed
diastemas, the removal of periosteum under the excised portion of the frenum is advocated in
an attempt to remove the elastic fibers of the frenum which have been shown to penetrate the
periosteum. Such elastic fibers have not been demonstrated to adversely affect the increase in
attached gingiva following a frenectomy nor have they been shown to adversely affect the
alleviation of relapse of diastema cases. However, if the purpose of the surgical procedure is
to eliminate the undesirable frenal tissue and to establish a normal interdental soft tissue
anatomy, it is important to remove the elastic fibers impregnating the periosteum underlying
the frenum, since, nowhere in the human periodontium there is an elastic tissue involved with
attached gingiva.
Septotomy: Excessive reproximation could theoretically reduce the amount of transseptal bone
and predispose to periodontal disease.
Skogsberg (1926) 28,29 devised the rather radical surgical techniques of septotomy to lessen
the frequency of relapse in rotated teeth. This method, which employs vertical sections
through the entire alveolar process mesial and distal to the rotated tooth from a level parallel
with the apex of the root to the alveolar crest, is too poorly documented for credibility. These
188

septotomies were performed not with an idea of neutralizing forces within the soft tissue but
with the intention of elimination of the tensions remaining in the bone after tooth rotation.
Immediate Torsion: Hallett (1956), believed that chances for relapse are greatly reduced if the misaligned
tooth is rotated forcibly with surgical forceps. Evidently this immediate torsion treatment is
intended to destroy completely all-fibrous attachment to the tooth and allow new attachment
after rotation. Unfortunately this method does not appear to lesser relapse significantly and
has been proved to result in frequent pulpal degeneration (Harriet, 1962). 28,29
Corticotomy: Kole (1959)
144
removed the buccal and lingual cortical plates before orthodontic
movements in an effort to eliminate the relapse phenomenon. Braver and Tsopel (1967)
found that transecting the supracrestal fibers with vertical incisions mesial and distal to the
rotated tooth may reduce the danger of relapse. He was unable to prevent relapse by this
procedure.
Reitan (1969) 5, among others, has advocated the use of early rotation to lessen
relapse. He feels that such early treatment will ensure stability, since there will be formation
of new and stronger ligamentous fibers as the apical portion of the root as it complete its
growth after the tooth has already been rotated to its proper position. Such a postulation is
surprising, since Reitan himself was the first to report that alternations in the fibers and bone
attached to the tooth rapidly reorganize and adapt to the new positions of a rotated tooth.
Apparently there exists little evidence that the periodontal ligament and its alveolar tissue
play any significant part in rotation relapse after 2 to 3 months of mechanical retention.
Thompson (1958) 129 and Boese (1956) 28,29 removed all of the attached gingival fibers
leaving only the mucosa surrounding the rotated teeth in experimental animals and reported a
significant reduction in relapse after an initial retention of 4 to 8 weeks. They concluded that
two phases of orthodontic rotational relapse can be identified (A) During the first 4 weeks
189

following orthodontic rotation of a tooth; a significant proportion of relapse is caused by the
stretched principal fibers. This phase terminates before 8 weeks, when remodeling of alveolar
bone provides new attachment for the principal fibers. (B) After first 8 weeks, the relapse is
caused by the supraalveolar fibers. This phase continues until almost total relapse has
occurred, since the cemental attachment of the transseptal fibers remain unchanged.
Gingivectomy followed by a minimum of 8 weeks of retention significantly reduced relapse
to one tenth its normal. A retention of only 4 weeks marks the effectiveness of gingivectomy,
because the first phase of relapse is still in progress. The number of oxytalan fibers and the
amount of collagen in the supra-alveolar tissue appear increased by orthodontic rotation. This
proliferate response, combined with stable attachments of transseptal fibers, seems
responsible for the second phase of orthodontic relapse. They concluded that procedures of
overrotation and prolonged retention would be ineffective for preventing rotational relapse.
Prosthetic Retention Procedures: If one or more teeth are missing, the usual solution is to replace them with bridges,
which are designed according to the size and location of edentulous areas.
Sometimes, prosthodontic intervention may be required to improve the position of abutment
teeth for fixed prosthesis, e.g. in cases of mesially tilted molars, displaced teeth and in cases
of partial anodontia etc.
Precautions should be taken to deliver the fixed partial denture as early as possible
after crown preparation so as to avoid inadvertent tooth shifting during the waiting period.
So, temporary restoration should be delivered to the patient immediately after crown
preparation.145
Functional occlusion (Occlusal equilibration): It is desirable to have finished orthodontic cases where centric occlusion coincides
with centric relation for a stable orthodontic occlusion. Selective equilibration, splinting after
articulation and other procedures as advocated by the contemporary leader or functional
190

occlusion, Ronald Roth. Premature contacts and plunger cusps could be detrimental to the
stability and health of the stomatognathic system.
Myofunctional therapy: The proponents of the myofunctional therapy advocate the management of tongue
thrust and open bite cases with well-prescribed tongue exercises for stable results. Lip
exercises and other muscle exercises like the masseter exercise, temporalis muscle exercise
and others have been advocated since the time immemorial for stable results. Lip seal
exercises are strongly advocated by Frankel for open bite cases and he firmly believes that
when lip seal has not been established the correction of open bite cannot be stable.
191
Discussion
Time was when the Orthodontist regarded treatment of malocclusion as a static
mechanical procedure. Diagnosis restricted itself to the description of the malocclusion and
treatment to the correction of irregularities found in individual patients mouth, without
regarding the multifactorial etiological factors, resistance offering biological tissues,
functioning orofacial musculature and a proper dynamic functional occlusion. Advancements
in biotechniques, physical diagnosis, surgical orthodontics, computer case analysis, sociobiology and use of sophisticated armamentarium, though has helped the ongoing research in
the orthodontic practice, eliminating of relapse of treated malocclusions presents a persisting
annoying problem to the practicing orthodontist. The stomatognathic system is vulnerable to
various etiological factors and each of the components of the dentofacial complex follows its
own independent course of development. Hence, the etiology of dentofacial abnormality does
not lend itself readily to a cause and effect diagnosis, excepting cases with specific etiologies
like trauma, congenital and genetic malformations and pressure habits.
The positional changes of teeth affected alteration of maxillo-mandibular relation and
position of the mandible with the teeth in occlusion, a changed configuration of the zone of
tongue movement, when interfered with, disturbs the kinesthetics of the patients functional
pattern and the patient experiences dyskinesia. A changing kinesthetic functioning dynamics
is well tolerated by young children than by adults in which cases it is an invitation for
relapse. In order for the teeth to retain their position at rest and in function, the denture
should have a sound static occlusion, minimal interference from the periodontal tissues,
efficient masticatory system without violating the arch form and the soft tissue environment,
a coinciding centric occlusion and centric relation with all three tissue systems namely
skeletal, dental and neuromuscular in harmony with each other.
The state of orthodontics does not at present contain information on the extent and
limits of the area of tolerance, where the moved teeth will experience immediate functional
balance in the investing tissues. Retaining appliances are necessary as an aid in stabilizing
the moved teeth. At present, how long retention should be, is something the orthodontist
learns by trial and error.
192

The problem of retention and relapse is likely to continue to tense the Orthodontist
because of the complexities of the etiological factors and one has to be thorough with all the
implicating concepts. The choice of the type of retention, duration of retention, has a great
bearing on successful post retention cases. Any violation of the biologic limit, which
trespasses the low of optimality, will end in miserable failure.
193
Summary
Orthodontic history tells us that esthetics was the primary concern of treatment in its
beginning in the first century and from then onwards it has spawned controversy.
Establishment of proper static functional occlusion, maintaining arch form and
intercanine width, correct positioning of lower incisors, permitting reorganization of the
periodontal tissues, eliminating etiological factors, over-correction, establishing balance in
threetissue system and proper understanding of growth and development are cardinal points
in establishing an esthetically harmonious, functionally efficient and structurally balanced
dental arches in the area of functional tolerance. Violation of the law of optimality is likely to
reject the alteration imposed on an existing orofacial environment. The summary of various
theoretical models of stability and relapse are well tabulated by Enlow.
While it is essential to strive for an ideal result, orthodontics as an art and science
harbors subjective goals that are constantly changing. There can be no guarantee of results;
only probabilities expressed and these should be communicated realistically to the patient. In
analyzing some of the problem areas, we recognize insufficient case analysis prior to
treatment as the first step towards failure. A careful examination of the original records will
give valuable guidance concerning the duration and type of retention indicated for each case.
Retention is considered to be one of the most fascinating and on the other hand it is
considered the most important aspect of orthodontic treatment as far as treatment results and
stability from the patient and from the operators point of view. Long back it had been called
as the stepchild of orthodontics since no attention was paid towards this aspect. Even today
debate still continues regarding post treatment stability and the role-played by retainers in
providing this stability. Even after so much of advancement, great deal of studies; research is
still required on this subject.
Our results will improve as we strive for perfection and realistically balance the scale
with more planning for retention. A thorough knowledge of retention is necessary for those of
us with bruised egos and a desire to improve.
194
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LD Retention and Relapse

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Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Philosophies or schools of thought of retention

Retention and relapse in orthodontics

The occlusion school:

3) The mandibular incisor school:

Retention and relapse in orthodontics

Basic theorems of retention7, 8

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Why is retention necessary?

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Anterior: when adequate overbite has been established.

Posterior: when axial inclinations of posterior teeth remain reasonable after

Retention and relapse in orthodontics

If anterior teeth were depressed to achieve overbite correction, a bite plane on a

D) Early correction of rotated teeth to their normal positions.

Perhaps before root formation has been completed.

Excessive spacing between maxillary incisors requires prolonged retention after

Retention and relapse in orthodontics

Retention and relapse in orthodontics

5) Cases requiring special construction and/or renewal of removable retaining

Retention and relapse in orthodontics

Time for the initiation of retention

Retention and relapse in orthodontics

A. Moderate-to-severe Class II case before treatment. B. After overjet reduction, torque

The most common example is during overjet correction of the moderate-to-severe

5) Establishing correct posterior crown torque:

Retention and relapse in orthodontics

Retention and relapse in orthodontics

A. Brackets placed 5mm above incisal edges,

Retention and relapse in orthodontics

with a bilateral class II component.

relationship on that side and the opposite side is in a class I position.

Methods of elastic wear to correct minor midline

the opposite side has a class I dental relationship.

An anterior cross-elastic, when the discrepancy occurs primarily in the anterior

D. Case with Class I dental relationship on

Retention and relapse in orthodontics

Vertical triangular elastics used in settling phase before debonding.

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Monitor the patient for symptoms of TMJ dysfunction during treatment. If

Retention and relapse in orthodontics

Retention and relapse in orthodontics

Rubber rotation wedges under the rectangular archwire.