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ART Estabilidad 2
ART Estabilidad 2
doi: 10.1111/adj.12475
ABSTRACT
Maintaining teeth in their corrected positions following orthodontic treatment can be extremely challenging. Teeth have
a tendency to move back towards the original malocclusion as a result of periodontal, gingival, occlusal and growth
related factors. However, tooth movement can also occur as a result of normal age changes. Because orthodontics is
unable to predict which patients are at risk of relapse, those which will remain stable and the extent of relapse that will
occur in the long-term, clinicians need to treat all patients as if they have a high potential to relapse. To reduce this risk,
long term retention is advocated. This can be a significant commitment for patients, and so retention and the potential
for relapse must form a key part of the informed consent process prior to orthodontic treatment.It is vital that patients
are made fully aware of their responsibilities in committing to wear retainers as prescribed in order to reduce the chance
of relapse. If patients are unable or unwilling to comply as prescribed, they must be prepared to accept that there will be
tooth positional changes following treatment. There is currently insufficient high quality evidence regarding the best type
of retention or retention regimen, and so each clinician’s approach will be affected by their personal, clinical experience
and expertise, and guided by their patients’ expectations and circumstances.
Keywords: Fixed retainers, incisor crowding, relapse, removable retainers, retainers, retention, stability.
Abbreviations and acronyms: IPR = Interproximal reduction; SDB = Sleep disordered breathing.
The best information currently available comes activity of a healthy periodontium will resist proclina-
from the long-term post-retention registry at the tion of the teeth.15 The farther teeth are moved out of
University of Washington. Riedel and Little are cred- this ‘neutral’ zone, the more unstable they are likely
ited with the collection of over 800 long-term post- to be. This is particularly true for the lower labial seg-
retention cases and discovered that relapse occurred ment and if incisors are proclined or retroclined exces-
in a high percentage of patients but in an individual sively, relapse is more likely. It is also believed that
patient, relapse was quite unpredictable.8,9 It was also significant changes in the arch form, in particular the
found that canine width expansion was unstable in lower intercanine width, make relapse due to soft tis-
the long-term9, and Little stated that lifetime perma- sue pressures more likely. There are, of course, situa-
nent retention was the only reliable way to prevent tions in which it is necessary to alter lower incisor
relapse.10 position or intercanine width, for example, to improve
aesthetics, but, in these cases, the clinician needs to
plan an appropriate retention strategy to resist the
AETIOLOGY OF RELAPSE AND DURATION OF
increased relapse potential.16–18
RETENTION
Relapse after orthodontic treatment can be a result of
Physiological relapse
orthodontic factors and normal age changes.11,12
These orthodontic factors include periodontal and gin- It has been shown that there are potential subtle facial
gival factors, occlusal factors and factors related to growth or age-related changes that occur throughout
soft tissue pressures and limits of the dentition. life19 including minor changes in the relationship
between the mandible and maxilla, and changes in the
soft tissue pressures on the dentition. The dentition is
Periodontal and gingival factors
therefore within a biological environment that is con-
When teeth are moved the tissues in the periodontal stantly changing, and so it is not surprising that there
ligament and gingivae remodel to the new tooth posi- is the potential for changes to occur in the alignment
tion. Until these tissues have remodelled, they have a of teeth and occlusal relationships throughout life.
tendency to manoeuvre the teeth back towards their These changes in alignment and occlusal relationships
original position. The fibres that take the longest to should perhaps be regarded as normal age changes.
remodel are the elastic fibres around the neck of the
teeth, the dento-gingival and interdental fibres, which
INFORMED CONSENT
can take 8 months or more to remodel.13 The teeth
therefore need to held in position for long enough for Whilst relapse does not happen in every patient, clini-
these fibres to adjust. An alternative approach is to cally it is difficult to predict which patients will
use a simple surgical procedure called pericision that undergo post-treatment change and so it is critical
severs these gingival fibres and this will be discussed that all patients are treated as if they have the poten-
later.14 tial for relapse. As a result, many clinicians now rec-
ommend life-long retention. When a patient asks
“How long should I wear my retainers”, the answer
Occlusal factors
is “For as long as you want straight teeth”. An impor-
It is purported that a soundly interdigitated dentition, tant aspect of informed consent for orthodontic treat-
with even occlusal contacts and correct occlusal load- ment is the need for the patient to fully understand
ing of teeth, is more likely to be stable; however, there the long-term risk of relapse, and appreciate the pro-
is no substantial agreement or evidence to support this cedures to minimise the risk. There are important
claim. It must be recognised that gross occlusal inter- responsibilities for the clinician and the patient.
ferences, displacing tooth contacts and the abnormal The clinician’s responsibility is to explain the unpre-
loading of teeth may predispose the affected teeth to dictable nature of relapse, the factors known to be
mobility which may contribute to relapse. involved and advise on the reduction of risk by the
appropriate use of retainers. The clinician needs to
explain the commitment that is required, including
Soft tissue pressures and limits of the dentition
any possible long-term financial costs associated with
It is preferable, where possible, to position teeth repairing and replacing retainers, costs associated with
within an area of soft tissue balance between the ton- addressing any relapse that occurs following failure to
gue on the lingual and the lips and cheeks on the comply with retention, and provide information about
labial aspect. This is an area of balance that is retainer care. The long-term care of retainers is vital
prosthodontically referred to as the neutral zone. to ensure that they fulfil their maintenance role in the
Although the forces from the tongue are stronger, the long-term, without compromising oral health. This
52 © 2017 Australian Dental Association
Relapse and retention in orthodontics
TYPES OF RETAINERS
Removable Retainers
Removable retainers have the advantages of being
easier to maintain oral hygiene (as they can be
removed for cleaning), and may only need to be worn
part-time. It has been shown that in many cases,
removable retainers need only be worn at night to
maintain dental stability.20–22 Good patient compli-
ance is essential with removable retainers, and if con- (b)
sistent wear is overlooked, relapse occurs. This
method of retention places full responsibility directly
on the patient in maintaining tooth alignment follow-
ing orthodontic treatment.
The most common examples of removable retainers
used worldwide are the Hawley-type retainers (with
an acrylic baseplate and usually a wire labial bow,
Figure 1) and thermoplastic retainers (made from
clear plastic, Figure 2). There is some evidence to sug-
gest that, at least in the short-term, patients prefer the
appearance and comfort of thermoplastic retainers
which are more cost-effective and slightly more effec-
tive in maintaining stability, particularly in the lower
Fig. 1 (a) Upper Hawley style removable retainer. (b) Lower Hawley
arch.23,24 There is no high quality, long-term research style removable retainer.
to indicate whether these advantages are maintained
long-term.
Fixed retainers
Fixed retainers offer the advantage of being in place
permanently which removes the need for patient com-
pliance with retainer wear (Figure 3, the retainers are
typically bonded to the palatal/lingual surfaces of the
labial segments. As they cannot be removed for clean-
ing, they are more prone to plaque and calculus accu-
mulation.25 It is therefore vital that patients are
provided with clear instructions on oral hygiene mea-
sures associated with their bonded retainers. The
retainers also need to be checked regularly to ensure
that they are still bonded in place. In addition, there
are reports of occasional, severe, unwanted tooth
movements caused by different types of failed/faulty Fig. 2 Upper and lower clear thermoplastic removable retainers.
fixed retainers as a result of the bonding of some or
all teeth within the span of the fixed retainer.26–28
This method of retention makes the clinician responsi- are made aware that if appliance maintenance is not
ble for the maintenance of the fixed retainer. It is crit- performed by either their orthodontist or general den-
ical during the informed consent process that patients tist, they are at risk of tooth relapse.
© 2017 Australian Dental Association 53
SJ Littlewood et al.
ADJUNCTIVE PROCEDURES
Adjunctive procedures are techniques that alter the
hard or soft tissues in an attempt to reduce relapse.
(b) Examples include pericision and interproximal reduc-
tion.
Pericision
Pericision is a simple soft tissue surgical technique
aimed at severing the periodontal fibres around the
neck of the teeth (dento-gingival and interdental
fibres) and is sometimes referred to as supracrestal cir-
cumferential fiberotomy. The procedure is performed
under local anaesthetic and there is weak evidence to
Fig. 3 (a) Lower fixed retainer; Bonded only at teeth 33 and 43.
(b) Lower fixed retainer; Bonded at all the lower incisor teeth.
suggest that it reduces relapse of rotated teeth, partic-
ularly in the maxilla.14,30 The procedure should only
be undertaken in cases in which there is a good gingi-
Studies which have compared the merits of fixed val biotype and cortical bone support, minimal or no
and removable retainers suggest that both appear to recession and the patient has excellent oral hygiene.
reduce relapse in routine cases. However, there are As it is a surgical procedure, it is usually reserved for
situations in which full-time retention is required, and severely rotated teeth.
so a fixed retainer may be preferred. The main exam-
ples of higher-risk relapse cases are listed in Table 1.
Interproximal reduction
Clinicians may often choose to use a combination
of fixed and removable retainers in a process referred Interproximal reduction (IPR) is a hard tissue proce-
to as ‘dual’ retention. The patient is fitted with a fixed dure aimed at removing small amounts of enamel
retainer, and is provided with a removable retainer to interdentally. It is not fully understood how this may
wear at night as a back-up. reduce relapse, but it has been suggested that it may
A recent Cochrane Review which assessed the meth- flatten the interdental contacts between incisors and
ods of retention reported that there was insufficient therefore increase stability. It is suggested that IPR
may compensate for the normally occurring reduction
in inter-canine width which occurs during adoles-
Table 1. Cases where fixed retention may be cence.31
preferred A recent randomised controlled trial compared the
use of interproximal reduction with other methods of
• Following closure of a spaced dentition (including a marked retention for Class I crowded cases treated with
median diastema) extractions and fixed appliances.32–34 It was shown
• Following creation of space prior to prosthodontic
that using IPR alone in the lower arch (without a
management
• Reduced periodontal support retainer) was equally successful at reducing relapse as
• Following correction of severe rotations using a lower bonded retainer or a positioner. This
• For patients who cannot tolerate even minor changes in
raises the interesting possibility of the use of inter-
occlusion
• Following correction of severely impacted teeth proximal reduction as an alternative or in conjunction
• In cleft lip and palate patients with evidence of severe post- with retainers. The results need to be interpreted with
surgical scarring that may predispose to relapse after
orthodontics
caution before deciding on universally applying this
• In compromised cases in which the aims of treatment may be procedure on all patients. Consideration needs to be
more limited, and focus is geared more towards achieving a given to the data which refers to patients who were
good aesthetic result without aiming for a fully corrected
malocclusion with ideal occlusion
followed for 5 years as it is possible that relapse
might occur after this observation period.
54 © 2017 Australian Dental Association
Relapse and retention in orthodontics
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