Retention & relapse

contents
Introduction
Need for retention
History
Theorems
6 keys
Relapse

-Dental
-Functional
-Skeletal
Retainers

 RETAIN (re+tenere to hold) means to

hold back or to hold secure

RELAPSE: to slip or fall back to a former

condition, especially after improvement or

seeming improvement

There is only one way to completely avoid relapse. At the

end of treatment, remove the braces, polish the teeth, make
study models and take photographs. And then take the
patient out the back door of the office and shoot him
- Dr Tom Graber DMD
South African Dental Congress. August 1992

Why is Retention necessary ?

Proffit Reorganization of gingival and periodontal
tissues after orthodontic treatment.
Soft tissue pressure relapse tendency.
Changes produced by growth may alter

treatment results.

Reorganization of gingival and periodontal tissues after

orthodontic treatment.

Widening of pl space disruption of fibers

Teeth respond individually to forces of mastication
Reorganization 3-4mts
Slight mobility disappears

Soft tissue pressure

Active stabilization from pl
Collagen 4-6mts
Gingival fibers
Elastic

12mts- part time after 3-4 mts

Changes produced by growth

Initial m-o-- pattern of skeletal growth
Early permanent dentition- 18-30mts
14-15yrs
Anteroposterior and vertical

Need for retention

Elastic Recoil
of Gingival Fibers

Cheek / Lip / Tongue

Pressure

Differential Jaw
Growth

Intra-Arch
Irregularity

Changes in
Occlusal
Relationship

HISTORY
No mention of retention appliance or need for

retention upto 1860

1860 - Emerson C. Angell

retention of space after opening of maxillary median

suture.
After more than 19 centuries, concept of retention

appliance was born.

Alfred Coleman (1865)

restoration of the former condition by muscular

pressure - relapse

HISTORY
Brown-Mason (1872)

Described a retaining plate for surgically

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

HISTORY
Victor Hugo Jackson- 1904

Not infrequently cases are presented that require more

skill in retaining the teeth than in regulating them
Angle- 1907

Retention is too often lightly considered

Hahn- Retention in orthodontics is like a neglected

step-child

HISTORY
1900 Edward H Angle
"normal

occlusion" during eruption period-

relapse .
Cutting gingival fibers to counteract
rotations.
In doubtful cases, wearing delicate and
efficient appliances indefinitely.
Pin and tube appliance. (working retainer)uprighting teeth that have been tipped
outward during expansion

Jacobson 1904 importance of retention and designed many

retaining devices
Fibrotomy- ''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,

HISTORY
1920 AJO- Calvin Case
"Principles of Retention in Orthdontia"

HISTORY

HISTORY
1919- Hawley

give half his fee to anyone who would be responsible for

the retention of his results when the active appliance
was removed

HISTORY
Retention time
Ferrar 1831 - 1913
when the teeth are fully regulated they should be
retained in position for a year, perhaps longer
George Grieves 1944
When teeth upright over basal bone- stable- no need for
retention
Tweed
Placed teeth upright over basal bone- 5yrs retention or
even longer when needed

JCO interviews, dr. Richard Riedel on retention and

relapse- JCO 1976

If teeth have never been allowed to become

malaligned they would be much less likely to tend to

become malaligned in later life- on serial extraction
Overcorrection is a kind of orthodontic safety valve
but not a perfect answer to post treatment problems
related to growth.
Severely crowded mandibular incisor casesextraction of incisors allows stability of mand arch
without continued retention but disadv- tooth size
discrepancy problem.

HISTORY
Clinicians did not agree about the need for

retention
Hellman : We are in almost complete
ignorance of the specific factors causing
relapse
Difference philosophies/schools of thought
Present day concept = combination

The Occlusion School

Norman

Kingsley (1880)

The occlusion of the teeth is the most

potent factor in determining their stability
in a new position.

Bonwill (1887)
Baker anchorage (1893)
Hawley (1919)
Dewey (1942)

Apical Base School

Axel

Lundstrom (1925)

Apical base was one of the most important

factors in the correction of malocclusion
and maintenance of a correct occlusion
Clinical

studies on apical base limitation.

Apical Base School

McCauley (1944)
Intercanine and intermolar width should be
maintained as originally presented to minimize
retention problems

Strang (1946)- enforced and substantiated this theory

Nance (1947)
arch length may be permanently increased only to
a limited extent

Mandibular Incisor School

Grieves (1944)
mandibular incisors must be kept upright and
over basal bone
Cause : forward translations of teeth
Tweed (1954)
5 yrs retention and even longer when
needed

the Musculature school

Rogers (1951)

Care must be exercised to establish a proper

occlusion within the bounds of normal
muscle balance with careful regard to the
apical bases and their relationship to one
another
Hellman- retention, not a separate problem,
continuation of what we are doing during
treatment.

Failures in retention
Failure

to remove the cause of malocclusion.

Incorrect diagnosis and treatment planning.
Lack of normal cuspal interdigitation.
Arch expansion.- Pre Rx arch dimensions to be
maintained
Incorrect

axial inclinations.
Failure to manage rotations- over rotation
Tooth size disharmony- interproximal grinding

Richard A Riedel 1960

Factors

affecting retention
9 Theorems
Classified retention according to the
requirements of various types of cases.

Factors affecting type and length

of retention
How many teeth have been moved and how far.
Occlusion and age of the patient.
Cause of the particular malocclusion.
Rapidity of corrections.
Length of cusps / relationship of the inclined planes.
Health of the tissues involved.
Arch harmony.
Cell metabolism.
Atmospheric pressure

Theorem - 1
Teeth that have been moved tend to
return to their former positions.
Reasons :
Musculature
Apical base
Transseptal fibers
Bone morphology
General agreement over holding teeth in their corrected
positions

Theorem - 2
Elimination of the cause of
Malocclusion will prevent recurrence.
Habits, Tongue posture, mouth breathing

Theorem - 3
Malocclusion should be
overcorrected as a safety factor
Class II: edge-to-edge
Class III
Open bite
Deep bite
Expansion
Rotations- provide space for eruption, surgical

intervention

Theorem - 4
Proper occlusion is a potent factor in
holding teeth in their corrected
positions.
Maintain health of the periodontium.
Functional occlusion.
Parker (1965)- Opposing forces no role to play in
lower arch crowding.

Theorem - 5
Bone and adjacent tissues must be allowed
time to reorganize around newly positioned
teeth
Fixed retention
No positive fixation- allow natural functioning

Gottlieb (1935), Oppenheim (1935) and Orban (1936) - First

orthodontic literature on microscopic studies of bundle and
lamella bone spicules.
Oppenheim appliance should be inhibitory
Hixon Muscular balance

Theorem - 6
If the lower incisors are placed
upright over basal bone, they are
more likely to remain in good
alignment.
Better

to err towards the lingual than labial

inclination.
Physiologic migration in distal direction.
Secondary to maintaining arch form.

Raleigh Williams
Several steps during fixed appliance Tx to

eliminate need for lower retention

20 yrs postretention
6 treatment keys

Eliminating lower retention. JCO May 1985

KEY 1
Incisal edge of lower incisor should be placed on
A-P line or 1mm in front of it. optimum
Angulation not relavent

KEY 1

KEY 2
The lower incisor apices
should be spread distally
to the crowns
The apices of lateral

incisors incisors should be

spread more than those of
the central incisors

KEY 3
The apex of the lower cuspid should be
positioned distal to the crown.
Occlusal plane- positioning guide

KEY 4
All four lower incisor apices must be in the same
labiolingual plane
Contact point moves upward
Provision for additional space
Use of uprighting springs

KEY 5
The lower cuspid root apex must be positioned
slightly buccal to the crown apex.

KEY 6
The lower incisors should be slenderized as
needed after treatment
2 sources of post Tx pressure
1. Molars
2. Tooth-jaw discrepancy

Theorem - 7
Corrections carried out during
periods of growth are less likely to
relapse.
Early treatment
Importance of diagnosis and Rx planning.
Interception prior to compensations.
To attain proper muscle balance

Theorem - 8
The further teeth have been moved,
the less likelihood there is of relapse.
Questionable

and not proven.

Guidance of eruption preferable.

Theorem - 9
Arch form, particularly in the
mandibular arch, cannot be
permanently altered by appliance
therapy.
Mc Cauley Since molar width and canine width
are of such an uncompromising nature, one
might establish them as fixed quantities and
build the arches around them

RELAPSE

Dental

Skeletal

Functional

Surgical

 Trabecular and cortical bone as risk factors for orthodontic

relapse. Lothe et al AJO 2006

to evaluate whether the amount or the structure of mandibular
bone affects the potential for postorthodontic mandibular incisor
relapse
postretention database at the University of Washington, 10 years
postretention
Sixty relapse and 263 stable subjects were identified. Mandibular
cortical thickness measured on both panoramic and lateral
cephalometric radiographs was used to assess the amount of
mandibular bone
These results indicate that patients with thinner mandibular
cortices are at increased risk for dental relapse.

Mx forward
Mx asymetry

Mx up+mn forward

Mx frward
Mn back

Mn back

Mn down

 Pancherz (1981) Europ J ortho although

Herbst appliance resulted in good growth of Mb

during treat period.
Long term no difference b/w grp treated with
Herbst appliance & untreated controls.
Review of literature of Chun Meta Analysis
No advantage of functional app. on long term
Angles Dogma:
Alignment of teeth - Expansion of dental arches
Use of elastics bring teeth into occlusion
Extraction was not necessary for stability & esthetics
Calvin Case argued that neither stability nor
esthetics would be satisfactory in the long term for
many patients after alignment from expansion.

 controversy within the extraction of second molars

Samir E. Bishara and Paul S. Burkey, AJO-DO 1986 May

Prevention of "late" incisor imbrication

Present understanding

Non extraction treat.:

Fuller profile & less stability
Extraction treat.:
Flattening of profile & more stability

 Untreated normal:
Bishara et al (1989AJO and 1996 AO):
Evaluated changes in lower incisor between 12 and 25 years and

again at 45 years findings indicated :

Increase in tooth size arch length discrepancy with age
consistent decrease in arch length.
Average changes 2.7mm in males; 3.5mm in females.

Similar findings by
Lundstrom (1968)
Sinclair and Little (1983 AJO):Little et al (1981AJO)
observed that 90% of extraction cases that were well
treated orthodontically ended up with an unacceptable
lower incisor crowding.

RETAINERS
Retainer- An appliance used to hold teeth in
position after orthodontic treatment.

 Principles of retention in Orthodontia. Calvin Case.

AJO Nov 1920.

Logic of modern retention procedures. Kaplan. AJO
April 1988
Changes in mandibular anterior alignment 10 to
20yrs post retention. Little, Riedel, Artun. AJO May
1988
Class II relapse after Herbst treatment. AJO 1991
Pancherz
Trabecular and cortical bone as risk factors for
orthodontic relapse. Lothe et al AJO 2006