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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 remodel at a rate above the baseline,2 and the remodel-
position of the teeth after orthodontic treatment ing process varies among different tissue types.3 Various
in optimal esthetic and functional positions.1 In methods of retention are applied4,5; the main types are
the retention phase, the final alignment of the dentition the removable Hawley, vacuum-formed, and fixed re-
is maintained because the associated soft tissues 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
a
Assistant professor, Department of Orthodontics and Orofacial Orthopedics, However, their success is related to patients' compliance.
Eberhard Karls University, T€ubingen, Germany.
b
Postgraduate student, Department of Orthodontics and Orofacial Orthopedics, Lack of compliance can destroy the best treatment plan-
Eberhard Karls University, T€ubingen, Germany. ning and the most promising treatment strategy.
c
Private practice, Traben-Trarbach, Germany.
d
Private practice, Hameln, Germany. The use of removable retainers means the responsi-
e
Private practice, Ludwigsburg, Germany. bility for retention lies with the patient. Compliance
f
Adjunct professor, Department of Orthodontics, University of Saarland, Hom- with removable retainer usage is out of the control of
burg, Germany; private practice, Traben-Trarbach, Germany.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- the orthodontist. This can lead to frustration for both
tential Conflicts of Interest, and none were reported. practitioners and patients.8 Opinions vary about how
Reprint requests to: Timm Cornelius Schott, Department of Orthodontics and Or- many hours the removable retainers should be worn
ofacial Orthopedics, University Hospital of Dentistry, Oral Medicine, and Maxil-
lofacial Surgery, Eberhard Karls University T€ubingen, Osianderstr 2-8, 72076 per day.9 It has been reported that more than 50% of pa-
T€ ubingen, Germany; e-mail, timm.schott@med.uni-tuebingen.de. tients admitted that they did not wear their retainers as
Submitted, January 2013; revised and accepted, April 2013. instructed; the most common reasons were discomfort
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists. and forgetfulness.10 There are wide variations in the
http://dx.doi.org/10.1016/j.ajodo.2013.04.020 retention regimen used by orthodontists, varying from
533
534 Schott et al
October 2013 Vol 144 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Schott et al 535
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-
Fig 1. Retention devices with integrated TheraMon- Whitney U test was used to investigate the differences
sensor: A, Hawley retainer; B, functional appliance in wear times between the groups. The alpha level was
retainer. set at 0.05. Thus, P #0.05 was considered significant.
American Journal of Orthodontics and Dentofacial Orthopedics 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 537
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 insurance company. Privately insured participants wore
times altered during the retention phase by up to 1.7 the retention device for a median of 3.4 hours less
hours. Most patients' compliance improved slightly, than patients with statutory health insurance during
and it worsened in only a few. Only a few participants the first 3 months of the retention phase (P 5 0.066)
showed mean monthly wear time fluctuations of more (Table II; Fig 5, E)
than 1.7 hours.
These data representations can be used by dental DISCUSSION
staff for high-resolution insight into patient behavior. Here we present for the first time the association be-
For instance, using the wear-time graphic in Figure 3 tween clinical and social parameters and wear time of
and the detailed analysis (Fig 4), they could determine removable retainers with incorporated microelectronic
that on October 19, 2011, the patient had a documented sensors. Asked directly, most study participants said
wear time of 14 of 24 hours, and that the retainer was that the installation of a sensor had positively influenced
worn from 18:45 to 5:45 (11 hours) continuously, dur- their compliance. This opinion agrees with the results of
ing the day from 14:15 to 14:45 (0.5 hour), and from a previous study in which the patients who were aware of
16:15 to 17:45 (1.5 hours), providing an additional 2 the ability to measure their compliance wore the retainer
hours of daytime wear. longer than those who were unaware of the control and
To better understand the factors influencing compli- monitoring.20
ance, we evaluated how age, sex, place of treatment, de- The high reliability of the TheraMon measurement
vice type, and health insurance status were associated system is of note. Over the evaluated time period of up
with compliance in 100 study participants during the to 15 months and when the retainer was worn, compli-
first 3 months of the retention phase. The type of device ance was registered daily at 15-minute intervals for all
(Hawley retainer or functional appliance retainer) was 100 study participants, representing exceptional perfor-
not associated with compliance, as shown in the box- mance of the device. The overall median wear time of 7.0
plots in Figure 5, A. The remaining parameters clinically, hours was close to the recommended wear time of about
but not statistically, influenced the participants' compli- 8 hours for removable retention devices, was accepted by
ance to a greater or lesser extent. Female patients wore most patients, and was usually adhered to for several
the retainer daily for a median of 7.2 hours; this was months. Although the patients were told that longer
0.8 hour longer than the male participants (6.4 hours) daily wear times were favorable because they would
(P 5 0.486) (Table II; Fig 5, B). The wear time of patients positively influence the retention phase, only a few fol-
between 13 and 15 years of age was 1.4 hours longer lowed these recommendations. The relatively small per-
than that of older patients (16-20 years) (P 5 0.206) centage of patients (20%) who wore their retainer for
(Table II; Fig 5, C). The wear time of 6.0 hours for pa- only a mean of about 3 hours a day throughout the first
tients who were treated at the university hospital was 3 months of their retention phase were not usually suc-
1.2 hours shorter than that of those from private prac- cessfully pointed toward better compliance in later
tices (7.2 hours) (P 5 0.188) (Table II; Fig 5, D). Compli- stages of treatment. In these instances, the use of a
ance was most closely associated with the type of health removable retainer was not promising over the whole
American Journal of Orthodontics and Dentofacial Orthopedics October 2013 Vol 144 Issue 4
538 Schott et al
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)
clinically relevant, and still unresolved problem of “what the retention phase. By using accurate, objective wear-
is the optimal wear time for a successful treatment time documentation, orthodontists can initially deter-
result” should form part of the investigations in further mine which wear times are acceptable and complement
studies. this with longer follow-ups or patient counseling. For
The experimental quantification of compliance indi- instance, based on compliance in the first few months
rectly corroborated established results in the literature to of the retention phase, orthodontists can devise an
date.21 Accordingly, female and younger patients were appropriate retention protocol with both their own
more likely to wear their retainer longer than male and and the patient's input. Getting patients involved in
older patients. This study is novel in showing that loca- treatment decisions and making them aware of their
tion of treatment (university hospital or independent own responsibility for successful retention are important
private practice) had a greater influence on patient for maintaining high levels of compliance.23 There is no
compliance than did age or sex. The clinically relevant doubt that orthodontists, through both effective
better compliance of patients who were treated in a pri- communication based on wear-time documentation
vate practice compared with patients treated in a univer- and clinical skill, hold the key to optimizing and person-
sity hospital is probably multifactorial and should be alizing the treatment.
clarified in future studies. Health insurance status, which
had the most pronounced influence on patient compli- CONCLUSIONS
ance, was unexpected and has not been described in
the literature until now. Although statistical significance 1. Through electronic wear-time documentation,
was not reached in our study population, possibly compliance times of orthodontic patients became
because of sample size, this is an interesting and socially a comprehensible measurement for the first time.
relevant variable worthy of further investigation. Orthodontists can recall the wear times for the
The precise measurement of levels of patient compli- whole retention phase at any time and assess their
ance has previously been extremely difficult. Compliance effect on retention-phase efficiency. The retention
is multifaceted and difficult to predict.22 The patients' protocol can be altered if necessary, the patient
various parameters and personal circumstances, can be encouraged, and therapy plans can be adapt-
including social lives, activities, personal preferences, ed in good time.
and possible dissatisfactions regarding treatment, result 2. Quantification of compliance showed to what
in highly individual and dissimilar compliance character- extent the patients contributed to the success of
istics, which require individualized retention protocols. retention and whether possible changes to the
Therefore, uniform and mandatory wear protocols for retention protocol or treatment plans were neces-
all patients are unlikely to be favorable for success in sary.
American Journal of Orthodontics and Dentofacial Orthopedics October 2013 Vol 144 Issue 4
540 Schott et al
3. The median wear time during the retention period 10. Wong P, Freer TJ. Patients' attitudes towards compliance with
of several months showed that a wear time of about retainer wear. Aust Orthod J 2005;21:45-53.
11. Shawesh M, Bhatti B, Usmani T, Mandall N. Hawley retainers full- or
8 hours for removable retention devices was part-time? A randomized clinical trial. Eur J Orthod 2010;32:165-70.
accepted by most patients and was usually adhered 12. Kacer KA, Valiathan M, Narendran S, Hans MG. Retainer wear and
to for several months during the retention phase. compliance in the first 2 years after active orthodontic treatment.
4. The place of treatment and the health insurance sta- Am J Orthod Dentofacial Orthop 2010;138:592-8.
tus influenced compliance more than did the stan- 13. Pratt MC, Kluemper GT, Lindstrom AF. Patient compliance with
orthodontic retainers in the postretention phase. Am J Orthod
dard demographics such as age and sex. Dentofacial Orthop 2011;140:196-201.
5. Unknown compliance, the commonly cited argument 14. Ackerman MB, McRae MS, Longley WH. Microsensor technology
against removable retainers, does not apply to to help monitor removable appliance wear. Am J Orthod Dentofa-
removable retainers with built-in wear-time sensors. cial Orthop 2009;135:549-51.
15. Schott TC, G€ oz G. Applicative characteristics of new microelec-
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October 2013 Vol 144 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics