READERS' FORUM
Letters to the editor*
Bonded lingual retainers
e read the article “Lingual retainers bonded
W without liquid resin: A 5-year follow-up study”
in the January 2013 issue of the AJO-DO with great
interest (Tang ATH, Forsberg CM, Andlin-Sobocki A,
Ekstrand J, H€agg U. Am J Orthod Dentofacial Orthop
2013;143:101-4). The authors are to be commended
for their work to evaluate the effect of excluding the
liquid resin component of a composite bonding product
that is based on bisphenol A diglycidylmethacrylate
when bonding lingual retainers. However, we have
2 concerns regarding this article.
First, why did the authors combine the mandibular
and maxillary retainers in their research? In clinical
work, we have noted that maxillary fixed retainers have
a greater tendency to fall off, perhaps as a result of
chewing movements, especially in patients with deep
overbite. We believe that it would be better to divide
the mandibular and maxillary retainers into 2 subgroups.
Table I showed 7 bonded maxillary retainers in the
test group and 9 in the control group, 13 bonded man-
dibular retainers in the test group, and 11 in the control
group. This means that 4 patients in the test group and 7
patients in the control group had only maxillary re-
tainers. Although the difference is small, with the rela-
tively small sample size, this small discrepancy could
make a significant difference.
Our second concern is that there were 20 retainers
in both groups, but the totals of tooth surfaces bonded
with a metal retainer were 74 in the test group and 110
in the control group. How did such a great difference
occur? Would it have some influence on the number
of debonded tooth surfaces and the loosened retainers
in the study period? And if the retainers in the control
group had a long span, there could have been frequent
bonding failures. We think that this should have been
taken into account during the analysis and discussion
of the results.
Lu Ye
Pu Yang
Chengdu, Sichuan, China
Am J Orthod Dentofacial Orthop 2013;143:596
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.03.003
*The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
596
Authors' response
T hank you for conveying these questions to us. We
believe that questions are the primary driving force
of scientific progress. Two concerns are related to
possible bias in our study design because of differences
in numbers between the maxillary and mandibular
retainers and between the bonding surfaces of the test
and control groups.
In our randomized, single-blind study, we randomly
selected patients for the test and control groups to
bond 2, 4, or 6 teeth according to the best benefit for
each patient by the best possible clinical judgments. In
small-scale clinical randomized studies, uneven num-
bers between the test and control groups in terms of
sex, number of bonded surfaces, maxillary vs mandibular
retainers, and so on are possible. In a larger randomized
study, these tend to level out. During the study, we were
aware of these issues as described. For evaluating our
control group, we resorted to comparisons with reported
results from larger studies: ie, references 15 and 16 in
our article. The outcome of such comparisons showed
that our control group's data were similar to those of
other studies with considerably larger patient groups.
This proved that our control group was randomized
enough. Since the test group was also randomized in
the same way, we can trust the results of the test group.
If the uneven numbers are purely due to random error,
statistical procedures will handle the uneven numbers
well.
Alternatively, a stratification study design might
overcome the problems described. It requires a consid-
erably larger patient group so that factors such as max-
illary and mandibular retainers, number of teeth
bonded, tooth type bonded, degree of overbite, dietary
roughness, type of malocclusion (maxillary retainer at
risk for Class II and vice versa in Class III), patients' eth-
nic origins, bonding material used, operator factors,
oral hygiene equipment used, and so on, can be con-
sidered. However, until it can be shown that bonding
lingual retainers without liquid resin is a viable tech-
nique, it does not seem reasonable to subject large
numbers of patients to a mode of treatment that might
not give satisfactory results. Furthermore, it is not easy
to ensure that all factors of interest have been identi-
fied and included in the sampling and stratification
of the study. It is also not easy to ensure consistency
of the factor studied; eg, patients in a soft-diet group
might not have a soft diet at every meal during the