ORIGINAL ARTICLE

Quantification of patient compliance with Hawley

retainers and removable functional appliances
during the retention phase
Timm Cornelius Schott,a Christoph Schlipf,b Bettina Glasl,c Christian L. Schwarzer,d Joachim Weber,e
and Bjo€ rn Ludwigf
T€
ubingen, Traben-Trarbach, Hameln, Ludwigsburg, and Homburg, Germany

Introduction: The success of retention with removable retainers is highly dependent on efficient patient compli-
ance. The aim of this study was to quantify patient compliance with removable retainers using microelectronic
wear-time documentation during the retention phase. Methods: One hundred patients, between 13 and 20 years
of age, were retained with removable Hawley retainers and functional appliance retainers after successful multi-
€bingen, Germany, and in 4 private practices in Germany. Micro-
bracket treatment at the University Hospital of Tu
sensors were incorporated into the orthodontic retainers by polymerization, and daily wear time was documented
in 15-minute intervals during the retention phase for up to 15 months. Patient compliance was quantified with
wear-time documentation. Additionally, the influences of age, sex, place of treatment, device type, and health
insurance status on compliance were determined and statistically evaluated. Results: Most study participants
complied with the prescribed wear time of 8 hours or more per day. Combined patient data indicated a median
wear time of 7.0 hours per day over the evaluation period. Wear-time documentation showed either regular or
irregular patterns of compliance. Initial compliance did not usually alter over the retention phase. Compliance
was not influenced by device type, but age, sex, place of treatment, and insurance status produced changes
in the median wear time of up to 50%. Conclusions: Electronic wear-time documentation of patients'
compliance is an easily comprehensible measurement that allows orthodontists to examine the patient's
contribution to the success of retention and personalize treatment accordingly. Place of treatment and health
insurance status are more closely associated with compliance than are basic patient demographics. (Am J
Orthod Dentofacial Orthop 2013;144:533-40)

T
he aim of orthodontic retention is to stabilize the
position of the teeth after orthodontic treatment
in optimal esthetic and functional positions.1 In
the retention phase, the final alignment of the dentition
is maintained because the associated soft tissues
a
Assistant professor, Department of Orthodontics and Orofacial Orthopedics,
Eberhard Karls University, T€ubingen, Germany.
b
Postgraduate student, Department of Orthodontics and Orofacial Orthopedics,
Eberhard Karls University, T€ubingen, Germany.
c
Private practice, Traben-Trarbach, Germany.
d
Private practice, Hameln, Germany.
e
Private practice, Ludwigsburg, Germany.
f
Adjunct professor, Department of Orthodontics, University of Saarland, Hom-
burg, Germany; private practice, Traben-Trarbach, Germany.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Reprint requests to: Timm Cornelius Schott, Department of Orthodontics and Or-
ofacial Orthopedics, University Hospital of Dentistry, Oral Medicine, and Maxil-
lofacial Surgery, Eberhard Karls University T€ubingen, Osianderstr 2-8, 72076
T€ ubingen, Germany; e-mail, timm.schott@med.uni-tuebingen.de.
Submitted, January 2013; revised and accepted, April 2013.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.04.020
remodel at a rate above the baseline,2 and the remodel-
ing process varies among different tissue types.3 Various
methods of retention are applied4,5; the main types are
the removable Hawley, vacuum-formed, and fixed re-
tainers in the United States.6 In 2010, Hawley retainers
were the most commonly used, as reported by active
members of the American Association of Orthodontists.7
However, their success is related to patients' compliance.
Lack of compliance can destroy the best treatment plan-
ning and the most promising treatment strategy.
The use of removable retainers means the responsi-
bility for retention lies with the patient. Compliance
with removable retainer usage is out of the control of
the orthodontist. This can lead to frustration for both
practitioners and patients.8 Opinions vary about how
many hours the removable retainers should be worn
per day.9 It has been reported that more than 50% of pa-
tients admitted that they did not wear their retainers as
instructed; the most common reasons were discomfort
and forgetfulness.10 There are wide variations in the
retention regimen used by orthodontists, varying from
533
534 Schott et al

immediate night-only wear of retainers to 3 to 6 months

Table I. Fifteen randomly selected subjects demon-
of full-time wear followed by night-only wear. Hawley
strate the different monthly wear times during treat-
retainers worn only at night were shown to be equally
ment with removable retainers
effective at reducing relapse as were the same retainers
worn full time for 6 months and only nightly there- Treatment months
after.11 1-3 4-6 7-9 10-12
Patient
The results of previously published studies about
wear time and compliance were based only on self- Subject Sex Age (y) Median wear time (h)
reporting of compliance with questionnaires and not 47 F 18.1 9.0 9.2 9.0 9.2
33 F 15.3 5.9 6.9 8.1
objective experimentally determined wear times.12,13 In 17 F 18.1 7.7 8.3 9.0 9.2
practice, most orthodontists develop their own 75 M 15.7 2.6 4.4
retention protocol based on either what they were 80 M 16.1 3.2 4.0
taught in residency or their clinical experience. With 65 M 15.7 2.1 2.6
no method of objectively determining whether patients 25 M 16.7 11.2 10.8
43 M 17.5 12.1 11.8
follow the prescribed wear time, orthodontists cannot 36 F 14.9 4.0 7.0 5.8 5.1
assess whether unsatisfactory changes in tooth 11 M 14.5 6.7 8.6 7.2 8.1
position are caused by poor compliance or by an 18 F 18.2 8.5 8.2 6.5 6.7
ineffective retainer. 41 F 15.2 9.0 9.1 9.8
New technologies for the objective measurement of 7 F 13.2 9.0 9.4 10.0 9.1
13 M 13.5 8.7 9.7 9.2 9.1
wear time using microsensors incorporated into remov- 31 M 13.6 8.7 10.0 10.1 8.4
able retainers now make experimental quantification of
patient compliance possible.14,15 Wear-time measure- F, Female; M, male.
ment and documentation can be performed simply and
routinely by staff in an orthodontic office.16,17 The Table I. Twenty-six patients were treated at the Depart-
overarching purposes of this study were to quantify ment of Orthodontics at the University Hospital of
removable retainer compliance during the first T€ubingen, and 74 patients were treated in independent
retention phase and to evaluate the potential specialist practices in Germany. There were no signifi-
association of compliance with several demographic, cant differences in age and sex of the patient groups
clinical, and social variables such as age, sex, retainer from the different locations. However, the health insur-
type, place of treatment, and type of health insurance. ance status was different among the patients. Statutory
A further aim was to determine how much patient health insurance in Germany through sickness funds is
compliance can realistically be expected during compulsory for workers whose gross income does not
treatment with removable retainers. exceed a certain threshold, for unemployed persons,
and for certain other population groups. Employees
MATERIAL AND METHODS with incomes above the threshold can opt into a volun-
One hundred patients (52 male, 48 female) recruited tary sickness fund (private health insurance), which is
between January 2011 and June 2012 participated in more expensive but offers additional benefits. About
the study, based on the following inclusion criteria: 88% of the subjects were covered by the statutory health
age between 13 and 20 years, no syndromic illnesses, insurance (74% obligatory, 14% voluntarily).18 No pa-
completed active orthodontic treatment with an indica- tient was excluded from the study during the treatment
tion for use of a removable retainer with a microsensor period. Written patient consent and that of the parent or
completely incorporated by polymerization, wear time legal guardian when necessary was obtained for the
of 3 or more months after the introduction of the device, incorporation of the wear-time sensor and subsequent
and checkup appointments at least every 100 days. The data evaluation. The study was approved by the ethics
mean patient age at the start of treatment was 15.46 commission of the University of T€ubingen (project num-
years (range, 13-20 years). Wear-time documentation ber 339/2012B01). The influences of the following pa-
and follow-up were variable, depending on when the pa- rameters on wear times were evaluated: age, sex, type
tients were recruited to the study; however, all patients of retention device (Hawley retainer or functional appli-
had at least 90 days of wear-time documentation. ance retainer), place of treatment (university hospital or
Representative compliance measured by the wearing private orthodontic practice), and health insurance
times of 15 randomly selected patients with different status (statutory health insurance or private health
periods of long-duration therapy are documented in insurance).

October 2013  Vol 144  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Schott et al
Fig 1. Retention devices with integrated TheraMon-
sensor: A, Hawley retainer; B, functional appliance
retainer.
Hawley retainers in both jaws were used in 71 pa-
tients, and functional appliance retainers in 29 patients
(Fig 1). The devices were made with Orthocryl (Dentau-
rum, Ispringen, Germany) according to standard proce-
dures. It was advised that the device should be worn
by the patient for a minimum of 8 hours a day. The pa-
tients were informed that longer daily wear times were
favorable because they could positively influence the
outcome of the retention phase.
The TheraMon-Sensor (Handelsagentur Gschladt,
Hargelsberg, Austria, or Forestadent, Pforzheim, Ger-
many) was used in this study because it offers significant
advantages compared with the Smart Retainer, as
described by Schott and G€ oz.15 The microsensor was
completely embedded in the polymer matrix of the
maxillary removable Hawley retainer and the functional
appliance retainers without difficulty (Fig 1).19 The
nondetachable sensors did not affect the comfort of
the retainer. During the entire treatment, the ambient
temperature was measured by the sensor every 15 mi-
nutes and saved in its integral memory, together with
the time and the date. At regular checkup appointments,
the recorded data were transmitted outside the oral
cavity to a computer within seconds via the TheraMon
reading station using radio-frequency identification
technology and processed with the proprietary
American Journal of Orthodontics and Dentofacial Orthopedics
535
TheraMon software (version 2.1.0.13).14 The actual
measured temperature of the oral cavity was trans-
formed by the software to wear times, distinguishing
wear times from nonwearing times. The software identi-
fied possible temperature manipulations by the patients
as abnormal, with conspicuous measurement values
highlighted with the built-in detailed analysis. Data pro-
cessed by the dental staff were displayed as wear-time
graphics (Figs 2-4).
Statistical analysis
Statistical analysis of the data was performed with
SPSS for Windows (version 20; IBM SPSS, Chicago, Ill).
The data distribution was tested for normality using
the Shapiro-Wilks t test. Because the mean wear times
were mostly not normally distributed, minimum, 25th
percentile, median, 75th percentile, and maximum
values were used as statistical indexes, and nonpara-
metric tests were used for data analysis. The mean
monthly wear times of each group are shown in boxplots
(Fig 5), and the summarized mean wear times over a 3-
month period are presented in Table II. The Mann-
Whitney U test was used to investigate the differences
in wear times between the groups. The alpha level was
set at 0.05. Thus, P #0.05 was considered significant.
RESULTS
The median monthly wear time was only 7.0 hours in
all patient groups.
Two sets of wear-time documentation presented in
Figure 2 show characteristic patterns of wearing
behavior. Figure 2, A, shows that a patient wore a Haw-
ley retention device for a mean of 7.7 hours daily over
the entire 15-month retention phase, but with mean
monthly wear times ranging between 4.9 and 10.4
hours. In contrast to patients with high but fluctuating
mean compliance, other patients had high and regular
compliance. Figure 2, B, illustrates 12 months of wear
times for another patient in this group who wore a Haw-
ley device regularly over the retention period for a mean
of 9.0 hours (8.8-9.9) daily.
Low monthly wear times usually resulted from the re-
tainer's not being worn for several days or being worn
for only a few hours each day, as illustrated in
Figure 3. In this example, the sum of the daily hours
from which the mean wear time was calculated for the
third month was only 4.9 hours (see Fig 2, A). The
graphic shows that the retainer was not worn on 11
days, was only worn for less than 3.5 hours on 4 days,
and was worn for 9 to 10 hours daily on only 9 days.
An evaluation of the wear-time documentation from
all study participants over the first 3 months
October 2013  Vol 144  Issue 4
536 Schott et al

Fig 2. Characteristic median wear times (hours): A, fluctuating over 15 months; B, regularly over 12
months.

Fig 3. An illustration of the sum of the daily hours from which a mean wear time for the third month with
only 4.9 hours median wear time (red dots) was calculated in Figure 2, A. Daily wear time is indicated by
the purple line, and prescribed wear time by the horizontal blue bar.

demonstrated that 60% of patients wore the retainer for from the data set using a randomization list to illustrate
a mean of less than 8 hours daily, 25% wore it between 8 the characteristic patterns of wear. The patterns show
and 10 hours daily, and 15% wore it for more than 10 that participants usually maintained the same wear
hours daily. The 15 patients listed in Table I were chosen behavior demonstrated during the first 3 months for

October 2013  Vol 144  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Schott et al
Fig 4. Detailed analysis of 1 day of the wear time in Figure 3, showing the measured temperature over time.
the entire treatment period. The mean monthly wear
times altered during the retention phase by up to 1.7
hours. Most patients' compliance improved slightly,
and it worsened in only a few. Only a few participants
showed mean monthly wear time fluctuations of more
than 1.7 hours.
These data representations can be used by dental
staff for high-resolution insight into patient behavior.
For instance, using the wear-time graphic in Figure 3
and the detailed analysis (Fig 4), they could determine
that on October 19, 2011, the patient had a documented
wear time of 14 of 24 hours, and that the retainer was
worn from 18:45 to 5:45 (11 hours) continuously, dur-
ing the day from 14:15 to 14:45 (0.5 hour), and from
16:15 to 17:45 (1.5 hours), providing an additional 2
hours of daytime wear.
To better understand the factors influencing compli-
ance, we evaluated how age, sex, place of treatment, de-
vice type, and health insurance status were associated
with compliance in 100 study participants during the
first 3 months of the retention phase. The type of device
(Hawley retainer or functional appliance retainer) was
not associated with compliance, as shown in the box-
plots in Figure 5, A. The remaining parameters clinically,
but not statistically, influenced the participants' compli-
ance to a greater or lesser extent. Female patients wore
the retainer daily for a median of 7.2 hours; this was
0.8 hour longer than the male participants (6.4 hours)
(P 5 0.486) (Table II; Fig 5, B). The wear time of patients
between 13 and 15 years of age was 1.4 hours longer
than that of older patients (16-20 years) (P 5 0.206)
(Table II; Fig 5, C). The wear time of 6.0 hours for pa-
tients who were treated at the university hospital was
1.2 hours shorter than that of those from private prac-
tices (7.2 hours) (P 5 0.188) (Table II; Fig 5, D). Compli-
ance was most closely associated with the type of health
American Journal of Orthodontics and Dentofacial Orthopedics
537
insurance company. Privately insured participants wore
the retention device for a median of 3.4 hours less
than patients with statutory health insurance during
the first 3 months of the retention phase (P 5 0.066)
(Table II; Fig 5, E)
DISCUSSION
Here we present for the first time the association be-
tween clinical and social parameters and wear time of
removable retainers with incorporated microelectronic
sensors. Asked directly, most study participants said
that the installation of a sensor had positively influenced
their compliance. This opinion agrees with the results of
a previous study in which the patients who were aware of
the ability to measure their compliance wore the retainer
longer than those who were unaware of the control and
monitoring.20
The high reliability of the TheraMon measurement
system is of note. Over the evaluated time period of up
to 15 months and when the retainer was worn, compli-
ance was registered daily at 15-minute intervals for all
100 study participants, representing exceptional perfor-
mance of the device. The overall median wear time of 7.0
hours was close to the recommended wear time of about
8 hours for removable retention devices, was accepted by
most patients, and was usually adhered to for several
months. Although the patients were told that longer
daily wear times were favorable because they would
positively influence the retention phase, only a few fol-
lowed these recommendations. The relatively small per-
centage of patients (20%) who wore their retainer for
only a mean of about 3 hours a day throughout the first
3 months of their retention phase were not usually suc-
cessfully pointed toward better compliance in later
stages of treatment. In these instances, the use of a
removable retainer was not promising over the whole
October 2013  Vol 144  Issue 4
538 Schott et al

Fig 5. Association of median monthly wear time (hours)

with other parameters: A, device type: functional appliance
retainer (n 5 29) or Hawley retainer (n 5 71); B, sex (48
female, 52 male); C, age category (13-15 years, n 5 58,
or $16 years, n 5 42); D, place of treatment (university hos-
pital, n 5 26, or private practices, n 5 74); E, health insur-
ance status (statutory, n 5 87, or private, n 5 13).

retention phase. Another study should clarify the wear

times if the prescribed wear time is 24 hours.
The use of microsensors for monitoring wear was not
a source of conflict between orthodontists and patients,
but a documented measurable that provided added
value for both persons. Most patients maintained their
compliance without significant change throughout the
retention phase. Constant compliance possibly resulted
because all patients in this study were already familiar
with active removable devices (eg, functional appliances)
before they had their fixed appliances.
It was not possible to determine how regularly a Fig 5. (continued)
patient wore the retainer during the retention phase
from the established mean monthly daily wear times. with high compliance fluctuation, it remains unknown
This information could only be obtained by analyzing whether a mean high but irregular fluctuating daily
the measured daily wear times, which documented the wear time during the retention phase is as effective as
variability in behavior of the participants. In a patient a mean high but regular wear time. The interesting,

October 2013  Vol 144  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Schott et al 539

Table II. Median monthly wear times in the first 3 months of the retention period for various parameters
Wear time (h)

Parameter n Median Minimum 25th percentile 75th percentile Maximum P value*

Sex
Female 48 7.2 0.2 4.2 9.0 15.4 0.486
Male 52 6.4 0.1 2.8 9.1 18.6
Age (y)
13-15 58 7.5 0.2 4.1 9.3 15.2 0.206
16-20 42 6.1 0.0 3.2 8.3 18.6
Retainer type
Functional 0.624
Appliance 29 6.8 0.2 3.1 8.7 12.9
Hawley 71 7.0 0.0 3.5 9.2 18.6
Place of treatment
University hospital 26 6.0 0.1 1.9 8.6 15.1 0.188
Private practice 74 7.2 0.2 3.8 9.3 18.6
Health insurance status
Statutory 87 7.1 0.0 4.1 9.3 18.6 0.066
Private 13 3.7 0.5 2.0 7.3 10.0

*Mann-Whitney U test; level of significance, P #0.05.

clinically relevant, and still unresolved problem of “what
is the optimal wear time for a successful treatment
result” should form part of the investigations in further
studies.
The experimental quantification of compliance indi-
rectly corroborated established results in the literature to
date.21 Accordingly, female and younger patients were
more likely to wear their retainer longer than male and
older patients. This study is novel in showing that loca-
tion of treatment (university hospital or independent
private practice) had a greater influence on patient
compliance than did age or sex. The clinically relevant
better compliance of patients who were treated in a pri-
vate practice compared with patients treated in a univer-
sity hospital is probably multifactorial and should be
clarified in future studies. Health insurance status, which
had the most pronounced influence on patient compli-
ance, was unexpected and has not been described in
the literature until now. Although statistical significance
was not reached in our study population, possibly
because of sample size, this is an interesting and socially
relevant variable worthy of further investigation.
The precise measurement of levels of patient compli-
ance has previously been extremely difficult. Compliance
is multifaceted and difficult to predict.22 The patients'
various parameters and personal circumstances,
including social lives, activities, personal preferences,
and possible dissatisfactions regarding treatment, result
in highly individual and dissimilar compliance character-
istics, which require individualized retention protocols.
Therefore, uniform and mandatory wear protocols for
all patients are unlikely to be favorable for success in
the retention phase. By using accurate, objective wear-
time documentation, orthodontists can initially deter-
mine which wear times are acceptable and complement
this with longer follow-ups or patient counseling. For
instance, based on compliance in the first few months
of the retention phase, orthodontists can devise an
appropriate retention protocol with both their own
and the patient's input. Getting patients involved in
treatment decisions and making them aware of their
own responsibility for successful retention are important
for maintaining high levels of compliance.23 There is no
doubt that orthodontists, through both effective
communication based on wear-time documentation
and clinical skill, hold the key to optimizing and person-
alizing the treatment.
CONCLUSIONS
1. Through electronic wear-time documentation,
compliance times of orthodontic patients became
a comprehensible measurement for the first time.
Orthodontists can recall the wear times for the
whole retention phase at any time and assess their
effect on retention-phase efficiency. The retention
protocol can be altered if necessary, the patient
can be encouraged, and therapy plans can be adapt-
ed in good time.
2. Quantification of compliance showed to what
extent the patients contributed to the success of
retention and whether possible changes to the
retention protocol or treatment plans were neces-
sary.

American Journal of Orthodontics and Dentofacial Orthopedics October 2013  Vol 144  Issue 4
540
3. The median wear time during the retention period
of several months showed that a wear time of about
8 hours for removable retention devices was
accepted by most patients and was usually adhered
to for several months during the retention phase.
4. The place of treatment and the health insurance sta-
tus influenced compliance more than did the stan-
dard demographics such as age and sex.
5. Unknown compliance, the commonly cited argument
against removable retainers, does not apply to
removable retainers with built-in wear-time sensors.
REFERENCES
1. Littlewood SJ, Millett DT, Doubleday B, Bearn DR,
Worthington HV. Retention procedures for stabilising tooth posi-
tion after treatment with orthodontic braces. Cochrane Database
Syst Rev 2006;CD002283.
2. Thilander B. Orthodontic relapse versus natural development. Am J
Orthod Dentofacial Orthop 2000;117:562-3.
3. Melrose C, Millett DT. Toward a perspective on orthodontic reten-
tion? Am J Orthod Dentofacial Orthop 1998;113:507-14.
4. J€aderberg S, Feldmann I, Engstrom C. Removable thermoplastic
appliances as orthodontic retainers—a prospective study of
different wear regimens. Eur J Orthod 2012;34:475-9.
5. Singh P, Grammati S, Kirschen R. Orthodontic retention patterns in
the United Kingdom. J Orthod 2009;36:115-21.
6. Keim RG, Gottlieb EL, Nelson AH, Vogels DS 3rd. 2008 JCO study
of orthodontic diagnosis and treatment procedures, part 1: results
and trends. J Clin Orthod 2008;42:625-40.
7. Valiathan M, Hughes E. Results of a survey-based study to identify
common retention practices in the United States. Am J Orthod
Dentofacial Orthop 2010;137:170-7.
8. Cerny R, Lloyd D. Dentists' opinions on orthodontic retention ap-
pliances. J Clin Orthod 2008;42:415-9.
9. Renkema AM, Sips ET, Bronkhorst E, Kuijpers-Jagtman AM. A sur-
vey on orthodontic retention procedures in The Netherlands. Eur J
Orthod 2009;31:432-7.
October 2013  Vol 144  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Schott et al
10. Wong P, Freer TJ. Patients' attitudes towards compliance with
retainer wear. Aust Orthod J 2005;21:45-53.
11. Shawesh M, Bhatti B, Usmani T, Mandall N. Hawley retainers full- or
part-time? A randomized clinical trial. Eur J Orthod 2010;32:165-70.
12. Kacer KA, Valiathan M, Narendran S, Hans MG. Retainer wear and
compliance in the first 2 years after active orthodontic treatment.
Am J Orthod Dentofacial Orthop 2010;138:592-8.
13. Pratt MC, Kluemper GT, Lindstrom AF. Patient compliance with
orthodontic retainers in the postretention phase. Am J Orthod
Dentofacial Orthop 2011;140:196-201.
14. Ackerman MB, McRae MS, Longley WH. Microsensor technology
to help monitor removable appliance wear. Am J Orthod Dentofa-
cial Orthop 2009;135:549-51.
15. Schott TC, G€ oz G. Applicative characteristics of new microelec-
tronic sensors Smart RetainerÒ and TheraMonÒ for measuring
wear time. J Orofac Orthop 2010;71:339-47.
16. Schott TC, G€ oz G. Wearing times of orthodontic devices as
measured by the TheraMonÒ microsensor. J Orofac Orthop
2011;72:103-10.
17. Schott TC, Ludwig B, Glasl BA, Lisson JA. A microsensor for
monitoring removable-appliance wear. J Clin Orthod 2011;45:
518-20.
18. Busse R. Disease management programs in Germany's statutory
health insurance system. Health Aff (Millwood) 2004;23:56-67.
19. Schott TC. Einbau eines mikrosensors in herausnehmbare kieferor-
thop€adische ger€ate. Quintessenz Zahntech 2011;37:898-904.
20. Ackerman MB, Thornton B. Posttreatment compliance with
removable maxillary retention in a teenage population: a
short-term randomized clinical trial. Orthodontics (Chic.) 2011;
12:22-7.
21. Pratt MC, Kluemper GT, Hartsfield JK Jr, Fardo D, Nash DA. Eval-
uation of retention protocols among members of the American As-
sociation of Orthodontists in the United States. Am J Orthod
Dentofacial Orthop 2011;140:520-6.
22. Fleming PS, Scott P, DiBiase AT. Compliance: getting the most
from your orthodontic patients. Dent Update 2007;34:565-6:
569-70, 572.
23. Mollov ND, Lindauer SJ, Best AM, Shroff B, Tufekci E. Patient at-
titudes toward retention and perceptions of treatment success.
Angle Orthod 2010;80:468-73.