CLINICIAN’S CORNER C

Nickel-titanium mandibular bonded lingual 3-3

retainer: For permanent retention and solving
relapse of mandibular anterior crowding
Eric J. W. Liou, DDS, MS,a Louise I. J. Chen, DDS,b and C. Shing Huang, DDS, PhDc
Taipei, Taiwan

An innovative technique that involves a nickel-titanium mandibular bonded lingual 3-3 retainer was used to
treat relapse of mandibular anterior crowding. The purpose of this study was to demonstrate clinical
procedures and to study the effects of a new mandibular bonded lingual 3-3 retainer on the mandibular dental
arch. In 18 patients, changes in the irregularity index and in arch dimensions (intercanine width, arch length,
and arch depth) were measured against the patients’ mandibular dental casts, which were obtained at
completion of the previous orthodontic treatment (T0). These measurements were taken at the beginning of
retreatment (T1), and 2 (T2), 4 (T3), and 6 (T4) months after initiation of retreatment. During the period of
relapse (T0-T1), the irregularity index increased from 1.3 to 3.5 mm and the mandibular arch dimensions
decreased. Four months after a segment of .018-in nickel-titanium archwire was bonded lingually from canine
to canine, the irregularity index decreased from 3.5 to 1.0 mm and the arch dimensions increased and
recovered their original posttreatment dimensions. The nickel-titanium archwire was left in place for permanent
retention after the period of retreatment. This simple technique effectively solved relapse of mandibular
anterior crowding in 4 months. This mandibular bonded lingual 3-3 retainer could be used both actively, to re-
treat mandibular anterior crowding without the use of lingual brackets, and passively, for maintenance as a
bonded lingual retainer. (Am J Orthod Dentofacial Orthop 2001;119:443-9)

T
he relapse of mandibular anterior crowding after
orthodontic treatment is common and remains a
challenging problem to solve. Several possibili-
ties are associated with relapse, such as reorganization of
the periodontal tissues,1,2 decrease of the crestal alveolar
bone level,3 overexpansion of the arch dimensions,4-6
and occlusal changes due to mandibular growth.7-10
The most effective way to re-treat mandibular anterior
crowding after retention requires the use of brackets and
archwires. However, patients are often reluctant to wear
braces again for the purpose of aligning the affected
teeth. Several active removable or fixed appliances and
retainers with lingual spurs or finger springs have also
been used for realigning the mandibular teeth.11-18
Bonding a segment of archwire to the lingual sur-
faces of the mandibular anterior teeth from canine to
From Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan.
aHead, Department of Orthodontics and Craniofacial Dentistry.
bResident, Department of Orthodontics and Craniofacial Dentistry.
cChairman and Professor, Faculty of Dentistry.
Reprint requests to: Eric J. W. Liou, Department of Orthodontics and Craniofa-
cial Dentistry, Chang Gung Memorial Hospital, 199 Tung-Hwa North Rd,
Taipei, 105, Taiwan; e-mail, lioueric@ms19.hinet.net.
Submitted, June 2000; revised and accepted, August 2000.
Copyright © 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/1/111397
doi:10.1067/mod.2001.111397
canine was originally proposed to improve the long-
term stability of orthodontic treatment results.19-25 In
the construction of bonded lingual retainers, stainless
steel archwire was used almost exclusively in both
rigid and flexible forms, including different diameters,
shapes, and plain or multi-stranded archwires.19-26 The
first-generation mandibular bonded lingual 3-3 retainer
was a plain round .032- to .036-in blue Elgiloy (Elgiloy
Limited Partnership, Elgin, Ill) wire with a loop at each
end. The second generation was a twisted, 3-stranded
.032-in wire. The third generation was a plain round
.030- to .032-in wire with both ends sandblasted with
50- to 90-µm aluminum oxide particles to increase the
micromechanical retention.27 As an alternative to stain-
less steel archwire, resin fiberglass strips were devel-
oped to reduce the bulk of the bonded lingual
retainer.28,29 The fiberglass strips are soaked in com-
posite resin and bonded to acid-etched enamel. Their
rigidity, however, limits physiologic and possible
orthodontic tooth movement.
A flexible bonded lingual retainer has not been used
to solve the problem of relapse in mandibular anterior
crowding. Theoretically, however, the resilient nickel-
titanium (NiTi) archwire is an excellent alternative to
stainless steel multi-stranded or plain archwire for use
as a bonded lingual retainer or as an active appliance
443
444 Liou, Chen, and Huang American Journal of Orthodontics and Dentofacial Orthopedics
April 2001

Fig 1. This mandibular bonded lingual 3-3 retainer is a

segment of .018-in NiTi mandibular archwire. Both ends
are sandblasted and bent to adjust intercanine width.
A
for solving relapse of mandibular anterior crowding
without brackets.
A new technique that uses the NiTi mandibular
bonded lingual 3-3 retainer has been developed. This
technique involves bonding a segment of mandibular
NiTi archwire lingually canine to canine to solve
relapse of mandibular anterior crowding and to serve as
a posttreatment bonded lingual retainer. The purpose of
this study was to demonstrate the clinical procedures
and to study the effects of the NiTi mandibular bonded
lingual 3-3 retainer on the mandibular dental arch.
B
MATERIAL AND METHODS
Eighteen patients (11 females and 7 males) who had
various amounts of relapse of mandibular anterior crowd-
ing and who needed orthodontic retreatment were studied.
Their ages ranged from 14 to 25 years old at the beginning
of the retreatment. The period between completion of the
previous orthodontic treatment and the beginning of
retreatment ranged from 2 years to 5 years 7 months.
Medium-force .018-in NiTi mandibular archwires
(Sentalloy; GAC International, Islandia, NY) were used
to re-treat the mandibular anterior crowding. These wires
are manufactured in 3 forms—the accu-form, standard, C
and ideal arch forms. The NiTi wires were bonded with
Fig 2. Bonding procedures of NiTi mandibular bonded lin-
light-cured resin (Enlite; Ormco, Glendora, Calif) onto
gual 3-3 retainer to re-treat mandibular anterior crowding.
the lingual surfaces of the canines at a position along the
A, NiTi archwire is first held loosely by ligature wires; B,
contact points of the mandibular anterior teeth. left-side end is then bonded to left canine (arrow), and
archwire is tightly tied to fit each incisor, one by one,
Clinical procedures
toward right side. C, Right-side end (arrow) is then
Archwire selection and adjustment. The NiTi arch- bonded to right canine. NiTi archwire is bonded along the
wire was first coordinated for the lingual curvature and position of contact points.
arch form along the contact points of the mandibular
incisors on the dental cast obtained at completion of the
previous orthodontic treatment. A best-fit arch form NiTi archwire was loosely ligated to the mandibular
was selected. The selected NiTi archwire was then bent incisors with several .010-in ligature wires through the
and adjusted for the intercanine width with a 3-prong embrasures (Fig 2, A). While it was held loosely by the
plier (Fig 1). Both ends of the NiTi archwire were then ligature wires, the NiTi archwire was oriented horizon-
cut to adjust the canine-to-canine arch perimeter and tally along the contact points, and either the right or the
were microetched with sandblast before bonding.27 left end was first fitted and bonded onto the lingual
Bonding procedures. The lingual surfaces of the surface of the canine on that side (Fig 2, B). The arch-
mandibular canines were cleaned with pumice, and the wire was then tightly tied to fit each incisor, one by
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 119, Number 4
A
B 2 (T2), 4 (T3), and 6 (T4) months after the initiation of
C depth in the period of relapse (T1 vs T0) or retreatment
Fig 3. Schematic illustrations of measurements.
one, toward the other canine (Fig 2, B). Finally, the
other end of the archwire was bonded to the opposite
canine (Fig 2, C). The ligature wires remained in situ to
Liou, Chen, and Huang 445
Fig 4. Changes of irregularity index. Asterisks, P < .001,
significantly greater than 1 mm.
control the orthodontic tooth movement. The patients
were seen once a month, and the ligature wires were
retied, changed, or removed as needed. After comple-
tion of the retreatment, the ligature wires were
removed and the NiTi archwires were left in situ for
permanent retention.
Model analysis
Serial mandibular dental casts were obtained for
each patient at the beginning of retreatment (T1), and at
retreatment. The dental casts obtained at completion of
the previous orthodontic treatment were labeled T0. The
mandibular irregularity index,30 intercanine width,31
arch length,31 and arch depth5 of each dental cast were
measured to 0.1 mm with a sliding caliper (Fig 3).
Statistical analyses
The irregularity index was set at 1 mm as the target
for solving the relapse of mandibular anterior crowd-
ing. The irregularity indexes, at T1, T2, T3, and T4, were
compared with the target value of 1 mm with the use of
a 1-sample t test (P < .05).
The period of relapse was from T0 to T1, and the
period of retreatment was from T1 to T4. The measure-
ments of the intercanine width, arch length, and arch
(T4 vs T1) were analyzed with a paired t test (P < .05).
The changes in the period of relapse (T1-T0) were com-
pared with the changes in the period of retreatment
(T4- T1), also with a paired t test (P < .05). The changes
in intercanine width were compared with the changes
in arch depth during the period of relapse and retreat-
ment with an analysis of variance (P < .05).
446 Liou, Chen, and Huang
Table I. Changes of the mandibular arch dimensions
Changes of arch dimensions
Relapse Retreatment
T1-T0 T4-T1 T1-T0
Intercanine
Width -1.2 ± 0.8 1.6 ± 1.0 ***
Arch length -0.7 ± 1.4 0.6 ± 1.3 NS
Arch depth -0.3 ± 1.0 0.4 ± 0.9 NS
*P < .05; ***P < .001; NS, not significant.
RESULTS
During the period of relapse, the average irregular-
ity index increased from 1.3 to 3.5 mm (Fig 4). All arch
dimensions decreased in this period, from 29.5 to 28.2
mm (P < .001) for intercanine width, from 19.5 to 19.2
mm (P > .05) for arch depth, and from 55.4 to 54.7 mm
(P > .05) for arch length (Fig 5, Table I). The decrease
in intercanine width was significantly greater (P < .05)
than was the decrease in arch depth during the period
of relapse (Table I).
None of the 18 patients had an irregularity index that
was less than 1 mm at the beginning of retreatment.
After 2 months (T2) of retreatment, the irregularity index
decreased rapidly, from 3.5 to 1.6 mm; the index reached
1 mm after 4 months (T3), and improved to 0.8 mm after
6 months (T4) (Fig 4). The irregularity index was signif-
icantly greater than the target value of 1 mm at T1 and
was not significantly different from the original goal of
1 mm at T2, T3, and T4. The completion of retreatment
and resolution of the mandibular crowding was achieved
in 2 to 4 months of additional treatment.
As the irregularity index decreased, the mandibular
arch dimensions increased to pre-relapse values. The
increase during retreatment was not significantly dif-
ferent from the decrease in the period of relapse (Table
I). The increase was 28.2 to 29.8 mm (P < .001) for
intercanine width, 19.5 to 19.6 mm (P > .05) for arch
depth, and 54.7 to 55.3 mm (P > 0.05) for arch length
(Fig 5, Table I). The increase in intercanine width dur-
ing retreatment was significantly greater (P < .001)
than the increase in arch depth (Table I).
DISCUSSION
Mandibular arch dimensions, both arch length and
intercanine width, typically decrease following reten-
tion as the anterior crowding increases, whether or not
the orthodontic treatment maintains, expands, or con-
American Journal of Orthodontics and Dentofacial Orthopedics
April 2001
Statistics
Paired t test ANOVA
T1-T0 Intercanine width
T4-T1 vs T4-T1 vs arch depth
T1-T0 T4-T1
*** NS * ***
NS NS — —
NS NS — —
stricts the initial mandibular arch dimensions.32 Total
arch length is a combined measurement of the trans-
verse and sagittal arch dimensions. The decrease in arch
length could be due to the transverse decrease in inter-
canine width and the sagittal decrease in arch depth.
The strategy for solving relapse of mandibular ante-
rior crowding in this study was to recover the
decreased arch dimensions. The recovery could be an
increase of intercanine width in the transverse dimen-
sion or an increase of arch depth in the sagittal dimen-
sion. In this study, intercanine width decreased signifi-
cantly, by 1.2 mm, whereas arch depth decreased
insignificantly, by 0.3 mm, in the period of relapse. The
major decrease in arch dimension was due to interca-
nine width rather than arch depth. Therefore, the strat-
egy was to recover intercanine width rather than to tip
the mandibular incisors forward to increase arch depth.
The clinical procedures for this study were designed
to recover rather than to overexpand arch dimensions and
arch form. As the irregularity index decreased from 3.5 to
0.8 mm in the 6 months of retreatment, the mandibular
arch dimensions recovered by 1.6 mm in intercanine
width, 0.4 mm in arch depth, and 0.6 mm in arch length.
The increases in the period of retreatment were not sig-
nificantly different from the decreases in the period of
relapse (1.6 vs 1.2 mm, 0.4 vs 0.3 mm, 0.6 vs 0.7 mm).
An alternative strategy to recover from posttreat-
ment crowding of the mandibular anterior teeth is to
narrow the mesiodistal width of the mandibular
incisors by interproximal stripping of the enamel struc-
ture. In this way, the mandibular anterior teeth can be
realigned without changing arch dimensions. However,
the procedure of stripping results in a loss of tooth
structure and does not ensure long-term stability of the
mandibular anterior teeth.33
Postretention mandibular anterior crowding is a phe-
nomenon that continues in patients through their 20s,
into their 40s, and likely beyond.32 Nothing seems use-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 119, Number 4
C
Fig 5. Changes of A, the intercanine width; B, arch length;
C, arch depth.
ful in predicting the long-term result, neither variables in
clinical findings, dental casts, cephalometric radiographs
before or after treatment, nor any combination of these
variables.32 In such a situation, permanent retention may
be required to maintain arch dimensions and to prevent
Liou, Chen, and Huang 447
D
Fig 6. Clinical application of NiTi mandibular bonded lin-
gual 3-3 retainer to re-treat mandibular anterior crowding
in a 12-year-old girl. A, Immediately after placement of
NiTi archwire; B, 2 months; C, 4 months; D, 6 months after
placement of NiTi archwire.
448 Liou, Chen, and Huang
A A
B B
C
D increases in strain.34,35 Strain that accumulates in the
Fig 7. Clinical application of NiTi mandibular bonded lin-
gual 3-3 retainer to treat mandibular anterior crowding in
a 19-year-old male. A, Immediately after placement of
NiTi archwire; B, 2 months; C, 4 months; D, 6 months
after placement of NiTi archwire.
American Journal of Orthodontics and Dentofacial Orthopedics
April 2001
Fig 8. Clinical application of NiTi mandibular bonded lin-
gual 3-3 retainer as a passive bonded retainer immedi-
ately after orthodontic treatment in a 12-year-old girl. A,
Placement of NiTi archwire before debonding; B, six
months after debonding.
the posttreatment relapse of the mandibular anterior
incisors. The bonded lingual NiTi archwires were there-
fore kept in place for permanent retention after the
period of retreatment. Until now, stainless steel wire,
either plain or multistranded, has been used to construct
mandibular bonded lingual 3-3 retainers. This article is
the first report on the use of NiTi archwire for a
mandibular bonded lingual 3-3 retainer.
The bonded lingual NiTi archwire was bent to adjust
the intercanine width in some of the cases. However,
bending of a NiTi archwire might result in unwanted
strain and cause unpredictable movement of the canines
and lateral incisors. Bending stress causes volumetric
changes in the crystal structure and induces phase trans-
formation from austenite to martensite that significantly
NiTi archwire could be lessened by heat treatment35 or,
more practically, by embedding the sites of wire-bend-
ing inside the bonded resin.
CONCLUSIONS
The NiTi mandibular bonded lingual 3-3 retainer is
an effective tool for solving relapse of mandibular ante-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 119, Number 4
rior crowding rapidly and without patient compliance
or the use of brackets. It solves the relapse in 2 to 4
months by recovering intercanine width to its pre-
relapsed dimension. The NiTi mandibular bonded lin-
gual 3-3 retainer can serve multiple purposes. It can be
used as an active lingual orthodontic appliance for re-
treating (Fig 6) or treating (Fig 7) mandibular anterior
crowding without lingual brackets, or as a passive
bonded lingual retainer after a period of active ortho-
dontic treatment (Fig 8).
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