Original Article

Wear resistance of four types of vacuum-formed retainer materials:

A laboratory study
Taiyub A. Rajaa; Simon J. Littlewoodb; Theresa Munyombwec; Nigel L. Bubbd

ABSTRACT

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Objective: To investigate the resistance to wear of four different vacuum-formed retainer (VFR)
materials: Essix C+, Essix ACE, Duran, and Tru-Tain. Essix C+ is a polypropylene polymer; the
other materials are polyethylene co-polymers.
Materials and Methods: The study was undertaken at the Leeds Dental Institute, Leeds, UK, with
26 samples in each group. The specimens were vacuum-formed according to the manufacturers’
guidelines, and a custom-made wear-simulation machine was used to conduct the test. Each
specimen was subjected to 1000 cycles of the wear simulation, with steatite balls as the antagonist
material. The resistance to wear of the VFR materials was evaluated by measuring the maximum
wear depth using noncontact, three-dimensional surface profilometry. The wear depth was given in
micrometers.
Results: The median wear depth was 63.20 mm for the Essix C+ group, 7.88 mm for the Essix ACE
group, 9.75 mm for the Duran group, and 12.08 mm for the Tru-Tain group. The Kruskal-Wallis test
to compare the four VFR materials detected a statistically significant difference between the groups
(P , .001). Comparisons of the groups using the Mann-Whitney U-test demonstrated that the
Essix C+ group had significantly greater wear than the other three groups (P , .001). There was no
statistically significant difference in median wear depth between the two groups with the least
amount of wear—the Essix ACE and Duran groups.
Conclusions: Under the standardized conditions of this laboratory study, the three polyethylene
co-polymer materials—Essix ACE, Duran, and Tru-Tain—exhibited significantly less wear than the
polypropylene material, Essix C+. (Angle Orthod. 2014;84:656–664.)
KEY WORDS: VFR; Vacuum-formed retainer; Wear resistance; Wear test

INTRODUCTION
Relapse is considered to be any change in tooth
position or arch relationship that occurs during the
initial posttreatment period.1 The exact causes of
relapse are difficult to identify, but there are thought
to be four factors that are responsible for its
occurrence: the elastic recoil of the periodontal tissues,
a
Specialist Orthodontist, St Luke’s Hospital, Bradford, UK.
b
Consultant Orthodontist, St Luke’s Hospital, Bradford, UK.
c
Lecturer in Biostatistics, Centre for Epidemiology & Biosta-
tistics, University of Leeds, Leeks, UK.
d
Lecturer in Dental Materials, Leeds Dental Institute, Faculty
of Medicine and Health, University of Leeds, Leeds, UK.
Corresponding author: Dr Taiyub Raja, Department of
Orthodontics, St Luke’s Hospital, Little Horton Ln, Bradford,
BD5 0NA, UK
(e-mail: taiyub_raja@hotmail.com)
Accepted: October 2013. Submitted: June 2013.
Published Online: December 23, 2013
G 2014 by The EH Angle Education and Research Foundation,
Inc.
the pressures exerted from the facial and oral soft
tissues, occlusal forces, and posttreatment facial
growth and development.2 Clinicians have little or no
control over the influence of growth and soft tissue
factors on relapse, which adds to the difficulty of
managing the problem.
Over the past 30 years, several studies have
evaluated long-term dental stability following different
orthodontic treatment modalities.3–7 All of these studies
have had a minimum follow-up period of 10 years,
extending to 20 years. Most of the treatment modal-
ities—which included non-extraction, first premolar
extraction, second premolar extraction, serial extrac-
tion, and expansion treatment—showed long-term
relapse rates of up to 70%.
Vacuum-formed retainers (VFRs) are removable,
clear, thermoplastic retainers. Ponitz8 first described
their use for the purpose of orthodontic retention in
1971. Since being introduced into the UK National
Health Service fee structure in 1996, the rate of
increase in the use of VFRs has been approximately

Angle Orthodontist, Vol 84, No 4, 2014 656 DOI: 10.2319/061313-448.1

WEAR RESISTANCE OF FOUR VACUUM-FORMED RETAINERS
nine times greater than that of Hawley retainers.9 A
vacuum machine adapts heat-softened plastic by
negative pressure, creating a vacuum, and pulls the
plastic onto a working study cast. The two most
common materials used for VFRs are polyethylene co-
polymers and polypropylene polymers.
Polyethylene polymers have the advantage of
allowing acrylic to be bonded to the material and,
thus, are the plastic of choice when bite planes need to
be incorporated into the appliance. The material is also
considered more esthetic because it is virtually
transparent. Polypropylene polymers are considered
to be more durable and flexible, but esthetically they
are inferior to polyethylene because the material is
translucent. Acrylic cannot be added to the plastic.
The advantages of VFRs include low cost, ease of
fabrication, and patient acceptability due to minimal
bulk and thickness.10 One randomized controlled trial
has concluded that VFRs hold corrections of lower
anterior teeth better and are more cost-effective than
Hawley retainers. The majority of patients appear to
prefer VFRs over Hawley retainers, and VFRs are less
likely to be broken.9,11
However, recent studies have found that there
appear to be some problems with the physical
properties of VFRs, in particular their resistance to
wear. Campbell et al.12 looked into the reasons for
replacement of VFRs over a 1-year period. For 38% of
the retainers that needed replacing (13 out of 34), the
reason was because the retainer had worn away
excessively. Lindauer and Shoff13 noted that a number
of Essix retainers became perforated and cracked in
the 6–18 months following placement.
As it is vital for VFRs to continue to be effective for
many years because of the risk of relapse, there is a
need to investigate which VFR materials available
commercially have the best resistance to wear. Wear
is defined as the removal of material from solid
surfaces as a result of mechanical interaction between
two or more relatively moving surfaces.14 Clinical wear
is a complex process and involves several mecha-
nisms interacting at once.
At the time of writing, the authors are only aware of
one published study that has investigated the wear
properties of VFRs. In that study, Gardner et al.15
assessed three different VFR products for their
resistance to wear: two of the materials were polypro-
pylene polymers, whereas the third was a polyethylene
polymer. The samples underwent 1000 cycles of wear
under a load of 25 kg using an Instron machine, with
steatite balls as the antagonist material. The authors
found that the polyethylene material had significantly
less wear than the two polypropylene materials. There
was no statistically significant difference found be-
tween the means of the two polypropylene products.
657
The material used as an antagonist has also been
the subject of much debate in the literature. A broad
variety of antagonist materials, such as human
enamel, stainless steel, steatite, and dental porcelain,
have been used, yet there appears to be no consensus
on which of these materials is the most appropriate for
use during wear testing.16–19
The aim of this study was to investigate the
resistance to wear of four different commercially
available VFR materials—Essix C+, Essix ACE,
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Duran, and Tru-Tain. Resistance to wear of the
materials was evaluated by measuring the maximum
wear depth of the samples using noncontact, three-
dimensional surface profilometry. The wear depth was
given in micrometers.
The null hypothesis for this study was that there is
no difference in maximum wear depth between the four
VFR materials after the materials have been subjected
to a standardized wear test.
MATERIALS AND METHODS
The study was a controlled laboratory study that did not
involve patients; hence, ethical approval was not needed.
Samples were prepared at St Luke’s Hospital, Bradford,
UK, and the wear test and analysis of specimens were
done at the Leeds Dental Institute, Leeds, UK.
Four well-known materials were chosen for inclusion
in the study: Essix C+, Essix ACE, Duran, and Tru-
Tain (Table 1). The methodology was standardized for
all the specimens, and each material was used as
supplied by the manufacturers. The specimens were
all 1.0 mm thick (0.040 inches) and had dimensions of
125 mm 3 125 mm before vacuum forming. The
manufacturer’s instructions for each product were
followed in detail when vacuum forming.
Sample Size
Estimates for sample size determination were
obtained from the paper by Gardner et al.15 To detect
a minimum clinical difference of two units with a
standard deviation of 2.4, assuming a significance
level of 5% (a 5 .05) and 80% power, the study
needed to have 26 specimens per group.
Wear Testing
An acrylic template block was manufactured to be
used in the Pro-Form vacuum forming machine for the
creation of the samples (Figure 1). The final speci-
mens were flat and rectangular in shape and placed in
the custom-made sample holder prior to wear testing
(Figure 2).
The wear machine used in this study has previously
been described in detail by Harrison and Lewis,20 with
Angle Orthodontist, Vol 84, No 4, 2014
658
Table 1. VFR Materials Investigated in This Studya
Product Manufacturer
Essix C+ Dentsply Raintree Essix, Bradenton, Fla
Essix ACE Dentsply Raintree Essix, Bradenton, Fla
Duran SCHEU-Dental GmbH, Iserlohn, Germany
Tru-Tain Tru-Tain, Rochester, Minn
a
VFR indicates vacuum-formed retainer.
b
Composition confirmed after consultation with manufacturers.
some minor modifications made for this study. The
sample holder is secured to the base-plate, which is
moved horizontally by the electrical motor. Above this
are 10 steel rods that hold the antagonist/abrader
material—steatite balls 8 mm in diameter (PE Hines &
Sons Ltd, Staffordshire, UK). At the superior end of the
rods are weights that apply a load of 460 g as the
steatite antagonist contacts the VFR specimen.
In this study, a cycle was defined as the horizontal
cycle of the base plate, which moves 16 mm horizon-
tally to the right and then 16 mm to the left, back to its
start position. A complete horizontal cycle takes
47 seconds. Simultaneously, the steel rods that secure
the antagonist have a vertical drop of 3 mm that results
in contact of the steatite balls with the VFR sample.
The duration of contact is 0.2 seconds before the steel
rods move upward again. Figure 3 is a diagram that
describes the major component parts of the wear
machine and the movements caused by the camshaft.
Figure 1. The heating element of the vacuum-forming machine
acting on the VFR sheet. The acrylic template is in place over the
vacuum area.
Angle Orthodontist, Vol 84, No 4, 2014
RAJA, LITTLEWOOD, MUNYOMBWE, BUBB
Compositionb
Polypropylene
Co-polyester (of polyethylene terephthalate)
Polyethylene terephthalate glycol (PETG)
Polyethylene terephthalate glycol (PETG)
Each specimen was abraded for 1000 cycles of the
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wear machine, which took 13 hours and 4 minutes to
complete. A linear wear trough was clearly created in
the samples during this process. When the next set of
specimens was tested, the wear machine was cleaned
and lubricated and new abraders were used.
The specimens were thoroughly cleaned with
distilled water and dried with air from a 3-in-1 dental
air compressor to remove and clear any debris prior to
scanning. The profilometer used for the analysis of
samples was the Proscan 2000 (Scantron, Taunton,
UK), which is a noncontact, three-dimensional surface
profilometer that uses confocal multiplex sensors. The
S5/03 sensor used to scan all the samples has a
resolution of 0.01 mm and a spot size of 4 mm, thereby
allowing detailed analysis. The central 4 mm of the
wear trough was the area determined for analysis.
The software affiliated with the Proscan 2000
produced a series of two- and three-dimensional
images. An example of a scan from the Essix C+ group
is shown in Figure 4. The wear depth of the trough was
measured using a three-area wear-depth analysis. The
deepest area of the wear trough was compared against
the average depth of the two ‘‘normal height’’ areas on
either side. The output measure was drop in height (in
micrometers). The analysis was repeated, and an
average of the two readings was taken to be the wear
depth of the trough for that sample.
Statistical Analysis
Data analysis was carried out using SPSS version
16.0 (SPSS Inc, Chicago, Ill). The wear depth was
summarized using medians, interquartile range,
means, and standard deviations. The data in each
group were checked for Normality using a Shapiro-
Wilk test. The data violated the assumptions of
Normality and constant-variance required for analysis
of variance (P , .00); hence, nonparametric tests were
used in this study. The Kruskal-Wallis test was used to
investigate whether differences existed between the
groups; where significance was found, further com-
parisons of groups were conducted using the Mann-
Whitney U-test for unpaired data.
A P value of .05 was considered to be statistically
significant. A Bonferroni correction was applied to the
WEAR RESISTANCE OF FOUR VACUUM-FORMED RETAINERS
Figure 2. The sample holder and loaded VFR samples.
P value to take into account the multiple comparisons
that were to be made. As six comparisons were
required in total, the new P value was calculated by
dividing .05 (the old P value) by 6 (the number of
comparisons conducted).21 Thus, the P value used to
indicate significance in the Mann-Whitney U-test was
.01 (rounded up to two decimal places).
To ensure consistency of the results, all the wear-
depth measurements were repeated 2 weeks after they
Figure 3. The major components and workings of the wear machine.
659
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were originally done. A Bland-Altman plot was used to
assess intrarater agreement between the two read-
ings.22 In addition to the Bland-Altman plot, bias
estimates and 95% limits of agreement were calculated.
RESULTS
Table 2 shows the descriptive statistics for the wear
depth in the four treatment groups. The median wear
Angle Orthodontist, Vol 84, No 4, 2014
660 RAJA, LITTLEWOOD, MUNYOMBWE, BUBB

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Figure 4. Proscan-produced cross-sectional and three-dimensional views of sample 20 from the Essix C+ group.

depth for the Essix C+ group was 63.20 mm, much
higher than the median wear depth in the other groups.
The median wear depth was 7.88 mm in the Essix ACE
group, 9.75 mm in the Duran group, and 12.08 mm in
the Tru-Tain group.
The box-and-whisker plot in Figure 5 shows that
Essix C+ had a much greater median wear depth
and more variation than the other three materials.
The box plot demonstrates that the data was
skewed.

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WEAR RESISTANCE OF FOUR VACUUM-FORMED RETAINERS 661

Table 2. Median Wear Depth and Other Numerical Descriptive Statistics of the Groupsa
95% CI for Mean
Group Median, mm IQR Range Mean (SD) Lower Limit Upper Limit
Essix C+ 63.20 14.41 22.47 65.50 (7.66) 62.41 68.59
Essix ACE 7.88 5.09 15.25 9.80 (4.51) 7.98 11.62
Duran 9.75 3.67 11.70 10.26 (3.10) 9.01 11.51
Tru-Tain 12.08 11.41 19.60 14.03 (5.99) 11.62 16.45
a
n 5 26 per group. IQR indicates interquartile range; SD, standard deviation; CI, confidence interval.

The intrarater agreement was good, as demonstrat- The Kruskal-Wallis test showed that there were

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ed by the Bland-Altman plot (Figure 6). The mean of significant differences in the median wear depths
the differences (bias estimate) was 0.02 mm, and no between the four groups (P , .001). The results of
measurements were outside the 95% limits of agree- the group-wise comparisons using the Mann-Whitney
ment (0.31, 20.27). U-test are shown in Table 3. These results confirmed

Figure 5. Box-and-whisker plot comparing the VFR groups.

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662 RAJA, LITTLEWOOD, MUNYOMBWE, BUBB

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Figure 6. Bland-Altman plot—level of intrarater agreement between wear readings.

that the Essix C+ group showed significantly more polyethylene copolymer, TR. Essix C+ was, therefore,
wear than the other three groups. The only other tested in both studies.
statistically significant difference was between the Gardner et al.15 reported that the mean wear in the
Essix ACE and Tru-Tain groups, with Essix ACE Essix C+ group was 5.9 mm, in the Invisacryl C group it
material shown to have less wear. was 6.1 mm, and in the TR group it was 1.6 mm. The
TR group (polyethylene copolymer) demonstrated
DISCUSSION significantly less wear than the two polypropylene
groups. The results in that study indicated that the
The laboratory study by Gardner et al.15 described in
polypropylene materials had 3.7 to 3.8 times greater
the introduction is the only published study the authors
wear than the polyethylene material under their
have found investigating the wear properties of VFRs.
standardized wear trial.
In that study, the authors tested three different VFR
The current study tested one polypropylene materi-
products, two of which were polypropylene polymers—
al, Essix C+, and three polyethylene copolymer based
Essix C+ and Invisacryl C—while the third was a
materials, Essix ACE, Duran, and Tru-Tain. The
Table 3. Summary of the Results Obtained Using the MWU Test to
median was used to report the findings, as the data
Compare VFR Groupsa were found to be nonparametric. The difference in
median wear depth between the Essix C+ group and
Comparison MWU P Value Result
the other three groups was statistically significant.
1. Essix C+ vs Essix ACE .001 Significant difference
Median wear depth in the Essix C+ group was eight
2. Essix C+ vs Duran .001 Significant difference
3. Essix C+ vs Tru-Tain .001 Significant difference times greater than that in the Essix ACE group, 6.4
4. Essix ACE vs Duran .170 No difference times greater than that in the Duran group, and 4.7
5. Essix ACE vs Tru-Tain .002 Significant difference times greater than that in the Tru-Tain group.
6. Duran vs Tru-Tain .028 No difference Though both studies used different summary mea-
a
MWU indicates Mann-Whitney U; VFR, vacuum-formed retainer. sures, the results show a similar, statistically significant

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WEAR RESISTANCE OF FOUR VACUUM-FORMED RETAINERS
trend. The findings of this study and the study by
Gardner et al.15 indicate that the polyethylene-based
materials are at least 3.7 times more wear resistant
than the polypropylene materials. In total, both
studies have looked at six different widely available
VFR materials. Sheridan et al.10 stated that Essix C+
was extremely resistant to wear without providing
supporting evidence. However, two laboratory stud-
ies have now found that polyethylene copolymers are
more resistant to wear than polypropylene materials
like Essix C+.
It is noted that there is a big difference between the
wear depths of the samples achieved between this
study and those of the Gardner et al.15 study. Both
trials used different wear-simulating machines. Their
study had a load of 25 kg, whereas our study had a
much lighter load of 460 g. Both trials had an
experimental run of 1000 cycles and used the same
material for the antagonist, but the mean wear depth
achieved for Essix C+ in their study was 5.9 mm, and in
our study it was 65.50 mm.
It may be reasonable to suggest that the greater
load in the Gardner et al.15 study would have resulted
in more wear of the VFR samples, but the opposite has
been found. The effect of the wear simulation is,
therefore, unpredictable, and different machines may
produce different wear rates. However, it must be
remembered that the general trend between polypro-
pylene and polyethylene polymers is consistent be-
tween the two studies.
Wear is the net result of a number of fundamental
processes: abrasion, adhesive effects of the contact-
ing surfaces, fatigue, and corrosive effects, which act
in various combinations depending upon the physical
properties of the contacting surfaces and materials.
Thus, due to the complex nature of clinical wear, any
laboratory study designed to study wear is subject to
criticism.
CONCLUSIONS
N The three polyethylene copolymer materials—Essix
ACE, Duran and Tru-Tain—exhibited significantly
less wear than the polypropylene material, Essix
C+.
N Essix ACE had the lowest median wear depth of the
three polyethylene copolymer materials, followed by
the Duran group and then the Tru-Tain group.
N There was no statistically significant difference in
median wear depth between the Essix ACE and
Duran groups.
N Essix ACE had significantly less wear than the Tru-
Tain group, but the difference between the Duran
and Tru-Tain groups was not statistically significant.
663
N An appropriately designed, randomized, controlled
clinical trial may be helpful to determine whether
these findings are replicated in vivo.
ACKNOWLEDGMENTS
The VFR materials used in this study were kindly provided by
Ortho-Care, Bradford, UK (Essix C+ and Essix ACE); Euro-
dontic, Sheffield, UK (Duran); and Archform, Sheffield, UK
(Tru-Tain). Our thanks also go to Nigel Jacques, Elizabeth
Hepburn, Michael Pullan, and Rashid Mian for their technical
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expertise.
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