GOOD MORNING

INSTITUTE OF DENTAL SCIENCES

DEPARTMENT OF ORTHODONTICS

SEMINAR ON

Retention & Relapse

Guided by :
Dr. P.S.Raju Dr. D.K. Agarwal Dr. Preeti Bhattacharya Dr. Abhishek Agarwal Dr.Ankur Gupta

Submitted by:
SHRIYA JAIN [80] VARNIKA [94]

INTRODUCTION DEFINITION OF RETENTION NEED FOR RETENTION DEFINITION OF RELAPSE CAUSES OF RELAPSE SCHOOL OF THOUGHTS RIEDELS THEOREM OF RETENTION LEGNTH OF RETENTION RETENTION PLANNING SPECIAL CONSIDERATION IN RETENTION OF CERTAIN MALOCCLUSION RETAINERS

Any treatment is failure until the results can be retained. In orthodontics, although the patient may feel that treatment is complete when appliances are removed, an important stage lies ahead, that is retention of orthodontically treated tooth & maintaining the results for the lifetime of patient.

DEFINITION: By Joondeph & Riedel The holding of teeth in idealistic & functional positions. By Moyer Maintaining newly moved teeth in position, long enough to aid in stabilizing their correction.

Orthodontically treatment results are potentially unstable as number of factors influence the results. Retention is planned to prevent the relapse from occurring.

It is the loss of any correction achieved by orthodontic treatment.

1. 2.

3. 4. 5. 6. 7. 8. 9. 10.

Failure to remove the cause of malocclusion Incorrect diagnosis & failure to properly plan treatment Lack of normal cuspal interdigitation. Arch expansion, laterally &/or anteriorly Incorrect arch size & harmony Incorrect axial inclinations Failure to manage rotations Improper contacts Tooth size disharmony Pressure exerted by erupting third molar

1. 2. 3. 4.

Present concepts of retention are based basically on four schools of thought as follows The Occlusion School The Apical Base School The Mandibular Incisor School The Musculature School

In 1880, Norman Kingsley suggested thatThe occlusion of teeth is the most important factor in determining the stability in a new position. Good interdigitation always aid in stability in a new position.

 1.

2.

3.

Hays Nance concluded that If a stable permanent result is to be obtained following orthodontic treatment, mandibular teeth must be positioned properly in relation to the basal bone. Arch length may be permanently increased only to a limited extent. Excessive lingual or labial tipping should be avoided.

It was proposed by Grieve & Tweed. For reasons of stability, the mandibular incisors must be placed upright or slightly retroclined over the basal bone.

It was introduced by Paul Roger. Establishing a proper muscle balance is necessary.

NOTE: All the four philosophies are

interrelated .

Riedel summarized all the different philosophies into ten theorems: Theorem 1 Teeth that have been moved tend to return to their former positions. Theorem 2 The elimination of the causes of a malocclusion should aid in the retention of its correction.

Theorem 3 Overcorrection of a malocclusion is a safety factor in retention because certain amount of relapse is to be expected after even the minutest of correction. Theorem 4 Occlusion is an important factor in retention. Interdigitation in post-treatment is important for stability. There should be occlusal balance & harmonious occlusal contact during functional movements like mastication.

Theorem 5
Bone & adjacent tissues must be allowed to recognize around of newly positioned teeth. The bone & soft tissue surrounding the recently moved teeth require time to reorganize themselves. The soft tissue surrounding the oral cavity takes longer time to orient itself to new position of teeth.

Theorem 6
Lower incisor must be placed upright over the basal bone. By this we achieve the most stable results.

Theorem 7 Corrections carried out during period of growth are less likely to relapse. Theorem 8 The farther teeth have been moved, the less the likelihood of relapse. (Controversial)

Theorem 9 Arch form, particularly in the mandibular arch, cannot be permanently altered by appliance therapy.

Theorem 10: many treated malocclusions require permanent retaining devices given by Moyer

RALEIGH WILLIAMS proposed six treatment keys during finishing to enhance stability of most unstable part of dental arch i.e lower anterior segment.

The incisal 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 lower incisor stability

It also creates optimum balance of soft tissues (within the normal range) in the lower third of the face for all the variations in apical base differences

The lower incisor apices should be spread distally to the crowns more than is generally considered appropriate (parallel roots) and the apices of the lower lateral incisors must be spread more than those of the central incisors.

The apex of the lower cuspid should be positioned distal to the crown.

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

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

The lower incisors should be slenderized as needed after treatment. Lower incisors without proximal wear have round and small contact points which are accentuated if the apices have been spread for stability.

Consequently, the slightest amount of continuous mesial pressure can cause various degrees of collapse in the lower incisor segment. Flattening lower incisior contact points create flat surface that help resist labiolingual crown displacement.

The time table for soft tissue recovery from orthodontic treatment outlines the principle of retention against intra-arch instability.

A. Teeth require essentially full time retention after comprehensive orthodontic treatment for the first 3 to 4 months after a fixed orthodontic appliance is removed. For this a removable appliance can be given which is to be worn full time except during meals or a fixed appliance that is not too rigid.

B. Because of the slow response of the gingival fibres, retention should be continued for at least 12 months if the teeth were quite irregular initially but can be reduced to part time after 3 to 4 months.

After approximately 12 months, teeth should be stable & it should be possible to discontinue the retention in non growing patient.

In some patients who are not growing will require permanent retention to maintain the teeth which may be unstable due to lip, cheek & tongue pressure .

Reidel has grouped malocclusion which require : 1. No

Retention 2. Limited Retention 3. Permanent or Semi permanent Retention

A.

Cross bite

Anterior : When adequate overbite has been achieved. Posterior : When axial inclination of teeth remain reasonable after correction. B. Dentition treated with serial extractions C. Correction achieved by retardation of maxillary growth once the patient has completed growth

2. Limited Retention
A. Class I non-extraction cases with spacing & protrusion of maxillary incisor (until normal lip & tongue function has been achieved) B. Class I & II extraction cases C. Early correction of rotated teeth to their normal position before root completion D. Cases involving ectopic eruption or the presence of supernumerary teeth E. Corrected deep bites F. Class II division 2 cases : Extended retention to allow for muscle adaptation

3. Permanent or Semi permanent Retention

A.

B. C. D.

In many cases, to maintain existing esthetics extraction may not be done. The only way to create space in such cases is through expansion. These cases, especially in mandibular arch require permanent or semipermanent retention. Cases of considerable generalized spacing Severe rotation or severe labiolingual malposition Spacing between maxillary central incisors with an otherwise normal occlusion

Relapse toward a skeletal class II relationship must result from combination of tooth movement (forward in upper arch, backward in lower arch or both) & differential jaw growth of maxilla relative to the mandible.

Tooth movement which may occur due to local periodontal & gingival factors, could be a short term problem.

Whereas differential jaw growth is a more important long term problem

In such cases over correction of the occlusal relationship can be done. If more than 2mm of the forward repositioning of the lower incisor has occurred during treatment , permanent retention will be required.

The relapse tendency after class II correction can be controlled by two ways : First is to continue headgear to restrict maxillary growth in conjunction with a retainer to hold the teeth in alignment.

Other method is to use a functional appliance of activator bionator type to hold teeth & occlusal relationship.

Retention is often needed for 12 to 24 months or more in patients who had a severe skeletal problem initially.

Chincap may be used to counter the continued growth tendency of mandible. But the use of chincap is believed to increase the vertical growth of the mandible. Mild class III cases are best retained using class III functional appliance such as reverse activator, FR 3 or class III bionator. Severe class III cases that relapse from mandibular growth after treatment requires surgical correction after growth ceases.

At the completion of orthodontic treatment

3 years later of orthodontic treatment

A removable upper retainer is made with bite plate, which lower incisor will contact behind the maxillary anteriors if the bite begins to deepen. The retainer does not separate the posterior teeth. Retainer may be required for several years after fixed appliance, until the growth ceases.

Relapse following correction of open bite is usually a result of molar extrusion or incisor intrusion. Incisor intrusion may occur due to continued indulgence in habits such as thumb sucking or tongue thrusting. Thus elimination of the associated etiologic factors would help in long term stability.

Excessive vertical growth tendencies & continued eruption of posterior may pose the risk of relapse. In such cases corrected open bite is best maintained by high pull headgears to upper molar or Use of posterior bite plane that stretches the musculature & produces an intrusive force on the dentition.

Retainers

Passive Orthodontic Appliances that help in maintaining and stabilizing the position of a single tooth or group of teeth to permit reorganization of the supporting structures.

According to Graber a retaining appliance:

Should restrain each tooth in its direction of relapse. Should permit the forces associated with functional activity to act freely on the teeth. Should be self cleansing as possible and should easy to maintain oral hygiene.

Should be as inconspicuous as possible i.e. esthetic

Should be strong enough for day to day usage.

Classified as

Removable

Fixed

Serve effectively for :

Retention against intraarch instability

Retainers in patients with Growth Problems

I. II. III. IV. V.

Hawleys Retainers.

Beggs Retainer.
Removable Wraparound Retainers.

Keslings Tooth Positioners.

Osamus Invisible Retainers

Most common removable retainer.

Designed in the 1920s as an active removable appliance.

Components:

Clasps on Molar teeth

Labial Bow (from Canine to Canine)

Palatal part : Automatically provides a

potential bite plane to control overbite.

Labial Bow : Excellent control of the incisors.

After the Extraction of First Premolars Standard Design of Hawleys Retainer can not be used as :
It cannot Keep the extraction space closed It can WEDGE the premolar extraction space open (as labial bow extends till there)

Lower Standard Hawley Retainer is fragile.

Also difficult to insert due to UNDERCUTS in the molar and premolar region.

To overcome this :

Labial Bow Soldered to the buccal section of the Adams Clasps on the first molars bow. Wrap Labial Bow around the entire arch, using C-clasps on second molars for retention. Bring Labial wire from the baseplate between the lateral incisor and canine to solder a wire extension distally to control the canines.

Hawleys Retainer With Long Labial Bow

Hawleys Retainer with labial bow crossing distal to lateral incisor

Hawleys Retainer with continuous Labial Bow soldered to clasps

Hawley's retainer labial Bow attached to c-clasps on molars.

Also known as :-

Clip on Retainer

Full arch wrap around retainer keeps every tooth in position. This can be a disadvantage >>> as retainer should allow tooth movement individually,

stimulating reorganization of the

PERIODONTAL LIGAMENT

INDICATED IN :

Periodontal breakdown which requires splinting the teeth together

A wrap around retainer of lower arch showing wire reinforcement of plastic material

More esthetic as compared to Hawleys Retainer.

Less comfortable than Hawleys Retainer.

VARIANT:

Canine to Canine Clip on Retainer

Widely used in lower anterior region. Can be used to realign irregular incisors if mild crowding has developed after treatment.

For Lower extraction case..

Extend the wraparound wire distally on the lingual only to the central groove of the first molar.

It provides control of the second premolar and the extraction site.

Given by P.R. Begg . Labial bow Extends distally posterior to the

last erupted molar to be embedded in the

acrylic base plate.

No clasp is used. Ideal for cases where settling of occlusion is required.

Can be used as a -:

Removable retainer Continued as a retainer after serving initially as a finishing device.

It maintains the occlusal relationships as intraarch tooth positions.

Positioners do not retain incisor irregularities and rotations as well as standard retainers.

Because of its bulk, patients often have difficulty in wearing a positioner full time or nearly so.

H.D. Kesling in 1945.

Made up of thermoplastic rubber material.

Covers the upper and lower clinical crowns

and part of the adjacent gingiva.

Made of thin thermoplastic sheets.

Relatively inconspicuous.

Well accepted by all patients.

Provide retention by : material fully covers the

clinical crown and extends to adjacent gingiva.

Spring retainer

It was designed to be used in the lower anterior segments. It is capable of aligning as well as retaining the corrected alignment of these teeth.

INDICATED where:

Intra-arch instability is anticipated

Maintenance of lower incisor position during late growth

Diastema maintenance

& Generalised Spacing

Maintenance of Pontic/ Implant Space

Keeping extraction spaces closed in adults

They are cemented or bonded to the teeth. Gaining popularity due to their relative invisibility and reduced dependence on the patient for wearing. Of two types :

1. Temporary Fixed Intracoronal Retainers

2. Temporary Fixed Extra Coronal Retentive appliances

Materials used :
Combinations of Amalgam and/ or wire and acrylic or composite restorative material.

These are not usually used in day to day

practice.

Loss of healthy tooth material. Tends to discolor. Potential sights of sensitivity and caries. Maintenance of oral hygiene might get compromised.

Employs :
Direct contact splinting. Flexible Spiral Wire Retainer.

Mesh Pad Retainers.

Adjacent teeth are bonded together at contact points using composite resins. Disadvantages:
Breakage of adhesive.

less hygienic. difficult to remove.

They can be banded or bonded. Banded 0.036/0.04 wire. Bonded 0.036 + mesh on canine Bonded is preferred over Banded retainers.

Bonded retainers are:

Completely invisible from the front.

Reduced Caries risk, as complete adhesion to the

tooth surface.

No time gap between removal of fixed appliance and bonding of retainer.

Reduced need for long term patient cooperation.

Can be bonded directly or indirectly.

Two dimensions of the wire are used :

THICK WIRE -0.032

THIN WIRE- 0.02

Thin wires are more frequently used. Thin wire is used in retainers in which all teeth in a segment are bonded.

Economical. Twists in the wire provide adequate retention. Allow slight movement of teeth (functional movements only). Generally thin (hence do not interfere with occlusion). Can be used with other removable retainers/ appliances.

Mandatory : Good Oral Hygiene. Movement of teeth may occur if wire is not passive.

Can interfere with occlusion in deep bite cases.

Wire mesh pad directly bonded to lingual/ palatal aspect of teeth.

Functional Appliance as an active retainer can be used in teenagers but not in adults. This is because simulating skeletal growth with a device does not happen in adults especially to a clinical useful extent. An activator can be used as an active retainer. Not indicated if more than 3mm of occlusal correction is sought(over this distance, tooth movement as a means of correction is a possibility)

An activator corrects teeth by restraining the eruption of maxillary teeth posteriorly and directing the erupting mandibular teeth anteriorly.

The more the flexible removable appliances are the more they become less suited for the retention part of active retention.
Hence an activator or bionator with an acrylic framework that contacts most teeth can be used.

Retainer Used Class II Malocclusion Fixed Appliance-->>>> Activator

Class III Malocclusion (Mild Cases)

Deep Bite Open Bite

Chin Cap, Reverse Activator, Fr3, Class III Bionator

Removable Upper Retainers High Pull Headgear to Upper Molars; Bite Block Appliance s/a Posterior Bite Plane Spring Retainers (esp. lower anteriors) Fixed Lingual Retainers Bonded Lingual Retainer Anteriorly-->Bonded Bridges using segments of braided wire to attach the pontic to the abutment tooth. Posteriorly-->Heavy Intracoronal Wire Bonded Retainers

Realignment Of Irregular Incisors Severe Rotations Diastema Maintenance Maintenance of Pontic/Implant Space

Closed Extraction Spaces(In adults)