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Orthodontic retention protocols: an evidence-based overview

Article in British dental journal official journal of the British Dental Association: BDJ online · June 2021
DOI: 10.1038/s41415-021-2954-7

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 Orthodontic retention
GENERAL

Orthodontic retention protocols: an evidence-based

overview
Dalya Al-Moghrabi,*1,2 Simon J. Littlewood3 and Padhraig S. Fleming2

Key points
Prescription of prolonged
retention following orthodontics is
essentially routine, with part-time
wear of removable retainers as
effective as full-time wear.
Little or no detrimental change to the
periodontal health is observed with
orthodontic retainers in the short-
term or the long-term, except in rare
circumstances where inherent activity
in the bonded retainer in situ can lead
to unwanted tooth movement.
Fixed and removable retainers show
similar effectiveness in maintaining
stability outcomes in the short term;
however, superior preservation of
alignment may be observed with the
former in the longer term.
The combined use of both fixed
and removable retainers is widely
prescribed; however, little is known
about the additional benefit over
the use of either type in isolation.

Abstract
In view of the diversity of orthodontic presentations, a single optimal retention protocol does not exist, with
approaches tailored based on pre-treatment characteristics, treatment-induced changes and general patient
characteristics. However, orthodontic practitioners should be responsive to the best available evidence to formulate
optimal retention protocols in terms of appliance type, design and regimen, in particular. Based on a comprehensive
search strategy, we discuss fundamental aspects concerning orthodontic retention of particular interest both to
orthodontists and general dentists. These include stability and periodontal outcomes, cost-effectiveness, patient
experiences, survival and failure rates of retainers, and the duration of retention.

Introduction
Evidence-based practice relies on the utilisation
of the best available evidence, clinical expertise,
and consideration of patient preferences
and values to formulate appropriate clinical
decisions. Reference to the literature concerning
orthodontic retention is paramount given the
range of possible retention protocols and the
existence of conflicting research findings.
Challenges associated with retention-based
research chiefly relate to the need for prolonged
periods of retention and the complexity
around predicting patient compliance over
this protracted period (Box 1). Despite the
increasing awareness of evidence-based
approaches, less than one-third of practising
orthodontists in the United States (US) refer to
the literature to deal with clinical uncertainties.1
We aim to provide an evidence-based overview
1
Department of Preventive Dental Sciences, College of
Dentistry, Princess Nourah bint Abdulrahman University,
Riyadh, Saudi Arabia; 2Barts and the London School of
Medicine and Dentistry, Queen Mary University of London,
London, UK; 3Orthodontic Department, St Luke’s Hospital,
Bradford, UK.
*Correspondence to: Dalya Al-Moghrabi
Email address: dhalmoghrabi@pnu.edu.sa
Refereed Paper.
Accepted 6 January 2021
https://doi.org/10.1038/s41415-021-2954-7
concerning the optimal use of orthodontic example, prescription of both maxillary fixed
retention with particular focus on the selection and removable retainers and mandibular fixed
of the appropriate retainer and design as well as retainer alone is the most commonly used
wear regimens, with an emphasis on both risks regimen in Norway and The Netherlands.2,3 In
and benefits, and accounting for operator and Switzerland, a combination of two retainers is
patient preference. frequently used in maxillary extraction and
expansion cases.4 In the UK, a combination
Which retention regime is most prevalent of fixed and removable retention, particularly
regionally? in the mandibular arch, is more common in
There is a significant amount of geographic private practice in comparison to NHS and
variation in relation to the prescription of hospital-based services.5 In the US,6 Saudi
retention protocols, although both fixed and Arabia7 and Australia,8 maxillary removable
removable regimens are in vogue globally. For retainers and mandibular fixed retainers are
Box 1 Challenges and limitations associated with research on orthodontic
retention
• The inability to differentiate between physiological maturational changes and true relapse
• Limited prospective research with prolonged follow-up of orthodontic patients in retention
• High dropout rates, especially for longer follow-up studies, therefore risking potential attrition bias.
This issue of dropouts may also result from lack of incentive for patients to return as active treatment
is no longer being provided
• Lack of standardised outcomes for retention-related research
• The preponderance of research has been conducted in university hospitals in which orthodontic
treatment is usually subsidised
• Failure to quantify patient compliance objectively
• Shortage of proven approaches targeting patient compliance
• Limited number of studies focused on patient experiences during retention
• Lack of standardisation of recommended wear protocols
• Failure to understand whether post-treatment change is acceptable to patients and, if so, to what extent.

770 BRITISH DENTAL JOURNAL | VOLUME 230 NO. 11 | June 11 2021

© The Author(s), under exclusive licence to British Dental Association 2021

commonly prescribed. In the majority of
studies, vacuum-formed retainers are the
preferred type of removable retainer.2,3,5,6
In terms of the duration of wear, indefinite
retention is prescribed by less than 20% of
the orthodontists in Norway,2 52% in Saudi
Arabia,7 approximately 80% in Australia,8 the
US6 and the UK,5 and 90% in The Netherlands.3
This variation in preferences and protocols
underscores the importance of a clear
appreciation of the relative merits of each
alternative.
Orthodontic retention protocols
Based on a comprehensive literature search of
studies published until September 2020 with
no language restriction applied (see online
supplementary information), the evidence
concerning numerous clinical outcomes
relevant to orthodontic retention were assessed,
including the stability of alignment, adverse
effects on oral health and patient experiences,
survival and failure rates, cost-effectiveness
and duration of retention (Fig. 1). These
outcomes are considered drawing on findings
from high-quality studies, chiefly randomised
controlled trials (RCTs), controlled clinical
trials and prospective studies, where possible.
For how long should retainers be worn?
The prescription of prolonged retention
has become ubiquitous in clinical practice
following the work of Little et al. (1988)9 in
which mandibular incisor malalignment
was observed in up to 90% of orthodontic
Fig. 1 Outcomes related to orthodontic retention
Emergency
appointments
Cost-effectiveness
Chairside time
Duration of retention
Frequency of follow-up appointments
Adherence requirements
BRITISH DENTAL JOURNAL | VOLUME 230 NO. 11 | June 11 2021
© The Author(s), under exclusive licence to British Dental Association 2021
patients at 20-year follow-up. This body of
research was retrospective in nature with a
short period of retention, meaning that much
of the observed change was likely related to
maturation rather than relapse.9,10 However,
it addressed an important research question
and shed clarity on the nature and extent of
age-related, physiological effects as well as true
orthodontic relapse.
Maintenance of orthodontic treatment
outcomes involving prolonged retention
places an onus on the durability of retainers,
the associated adverse effects on oral health
and the levels of adherence to removable
retainer wear. Unfortunately, poor adherence
with removable retainer wear is commonplace,
with cessation of wear already observed in 67%
of orthodontic patients after the second year in
retention in one study.11
According to the most recent Cochrane
review, there is a lack of clear evidence
concerning the superiority of full- over part-
time wear regimens.12 Within this review, two
RCTs comparing the effectiveness of part-
and full- time wear of clear retainers were
included,13,14 with a further study involving
Hawley retainers.15 Similar incisor irregularity
index scores 13,14,15 and transverse arch
measurements13,14 were observed, indicating a
lack of added benefit of full-time wear. However,
in two of these studies,14,15 participants in the
full-time group were only instructed to wear
retainers full-time for the initial phase (the first
three months14 and six months),15 followed by
part-time wear for the remaining year of the
study, making it difficult to distinguish the true
Horizontal
Stability Transverse
Vertical
Outcomes related to
orthodontic retention Oral health
Patient experiences
Survival and failure rates
GENERAL
effects of full-time wear protocols. In contrast,
Gill et al. (2007),13 involved a single regimen
throughout the study; however, the period
of follow-up was restricted to six months.
Therefore, the prescription of either prolonged
fixed retention or part-time wear of removable
retainers on a long-term basis is recommended.
Which removable retainer is best?
Hawley and clear retainers are commonly
prescribed and have been compared in a
number of RCTs (Table 1). Although numerous
outcomes were evaluated, these studies did not
exceed one year of follow-up.
In one study, clear retainers showed superior
preservation of alignment of the incisors when
compared to Hawley retainers;17 however, no
significant differences were found in terms
of transverse measurements,17 even when
clear retainers had palatal coverage.27 Vertical
settling measured by the number of posterior
occlusal contacts was superior in patients
wearing Hawley retainers when compared
to clear retainers at three-month follow-up,
despite full-time prescription of the former.28
However, a recent RCT with longer follow-up
found similar levels of contact of occlusal
surfaces at one-year review with Hawley
and clear retainers.26 Clear retainers were
also associated with less embarrassment and
were more acceptable to patients than Hawley
retainers.18,21,23 This was reflected in the better
short-term adherence to clear retainer wear.25
Furthermore, clear retainers were found to be
more cost-effective than Hawley retainers over
the initial six months post-debond.18
Plaque scores
Calculus scores
Gingival inflammation
Periodontal
Gingival recession
outcomes
Bleeding on probing
Probing depth
Clinical attachment level
White spot lesions
Dentition
Caries
Speech
Discomfort
Aesthetics
Breakage
Detachment
Loss
771
 GENERAL

Table 1 Summary of randomised controlled trials involving a comparison between Hawley and clear retainers

In favour of
Follow-up
Study Outcomes
period Hawley Clear No
retainers retainers difference
Rohaya et al. (2006)16 Prevention of rotational relapse 9 months ✓

Stability of anterior alignment ✓

Rowland et al. (2007)17 ICW, IMW, OJ, OB and tooth rotation ✓

and Hichens et al. 6 months
(2007)18 Cost-effectiveness ✓

Patient satisfaction ✓

Sun et al. (2011)19 Survival and failure rates 1 year ✓

Atik et al. (2017)20 Articulatory movements 3 months ✓

Saleh et al. (2017) 21

Patient acceptability 6 months ✓

Wan et al. (2017) 22

Changes in articulation 3 months ✓

Plaque and calculus scores ✓

Gingival inflammation and bleeding on probing ✓

Plaque and calculus accumulated on removable retainers ✓

Manzon et al. (2018)23 6 months
Breakage ✓

Subjective compliance ✓

Patient acceptability ✓

Stability outcomes based on American Board of Orthodontics objective grading system ✓

Moslemzadeh et al.
6 months
(2018)24 ✓
Gingival index

Vagdouti et al. (2019)25 Objectively assessed wear 3 months ✓

Alkan et al. (2020)26 Occlusal force distribution, individual tooth force and occlusal surface area 1 year ✓

Xian et al.* (2020) 27

ICW, IPW and IMW 6 months ✓
Key:
* = clear retainer with palatal coverage
ICW = intercanine width; IPW = interpremolar width; IMW = intermolar width; OB = overbite; OJ = overjet.

In terms of periodontal outcomes, in one
study, significantly higher plaque and calculus
scores were found in patients wearing
clear retainers than those wearing Hawley
retainers, with no significant difference in
terms of gingival inflammation and bleeding
on probing at six-month follow-up. 23
Clear retainers of 0.75 mm thickness were
associated with higher failure rates than
Hawley retainers at one-year follow-up;
however, the difference was not statistically
significant.19 When clear retainers of 0.75
mm and 1 mm thickness were compared,
the former was associated with significantly
higher breakage at one-year follow-up. 29
Nevertheless, similar levels of stability were
observed at six months with clear retainers
(1 mm and 1.5 mm) and Hawley retainers.24
Differences in wear resistance and thinning
rate with clear retainers have been illustrated
in a number of laboratory-based studies based
on the material used and manufacturing
technique (Table 2).
Begg retainers, although not commonly used,
may be associated with less difficulty in eating
when compared to clear retainers, although clear
retainers are typically removed for eating.34 Begg
retainers were considered to be less comfortable
overall and less aesthetic.34 Furthermore, little
difference in Peer Assessment Rating scores
and anterior segment irregularity were found
with Begg and clear retainers at six-month
follow-up.34 In a further study, no significant
difference in terms of posterior occlusal contact
was observed between Hawley retainers and
modified positioners combined with mandibular
spring aligners at two-month follow-up, despite
full-time prescription of Hawley retainers.35
Overall, therefore, a single removable
retainer suited to all patients and presentations
does not appear to exist. This is reflected in
the conclusion from the most recent Cochrane
review that there is insufficient evidence to
support the use of one removable retainer
over another in terms of stability and patient
satisfaction.12 As such, the selection of the
appropriate removable retainer should be
tailored and underpinned by an appreciation
of the relative merits of each of the alternatives.
Which fixed retainer design is most
effective?
A range of fixed retainer designs exist, being
bonded to all six lower anterior teeth (canine to
canine) or attached to the canines, in isolation
(canine and canine), with many proprietary
and other variants differing in dimension,
morphology and material constituents. Despite
the widespread use of fixed retention, there
is limited data regarding the comparative
effectiveness of the various alternatives.12
In one study, higher levels of irregularity were
observed with fixed retainers bonded to canines

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Table 2 Summary of main laboratory-based studies related to clear retainer material characteristics
Study Materials
C+ (Raintree Essix, New Orleans, La)
Gardner et Invisacryl C (Great Lakes
al. (2003)30 Orthodontics, Towanda, NY)
0.040-in TR sheet material (Bay
Dental Direct, Bay City, Mich)
Essix C+ (Dentsply Raintree Essix,
Bradenton, Fla)
Essix ACE (Dentsply Raintree Essix,
Raja et al. Bradenton, Fla)
(2014)31
Duran (SCHEU-Dental GmbH,
Iserlohn, Germany)
Tru-Tain (Tru-Tain, Rochester, Minn)
Polyethylenterephthalat-glycol
co-polyester
Doğramacı
et al.
(2018)32 Polypropylene
Essix ACE (Dentsply Raintree Essix,
USA)
Materiale Biocompatibile
Bratu et al. Termoformabile (Leone, Italy)
(2019)33
Erkodur (clear) (Erkodur, Germany)
Crystal (Bio-Art, Brazil)
only in comparison to six anterior teeth at two-
year follow-up.36 In another trial, significantly
better stability outcomes were observed with
0.0175” multi-strand stainless steel fixed
retainers when compared to 0.0195” dead-
soft coaxial wire at one-year follow-up.37 The
difference was attributed to the unique physical
properties of the material used.37 Furthermore,
no additional benefit of CAD/CAM nickel-
titanium fixed retainers over conventional
fixed retainers at six-month38 and one-year 39
follow-up has been shown in individual trials.
The majority of RCTs involving a comparative
assessment of metal and aesthetic (fibre-
reinforced composite resin) fixed retainers have
demonstrated no difference in terms of failure
rate, although less failures with the metal fixed
retainer were observed in some of these (Table 3).
In terms of the bonding technique used, fixed
retainers bonded with an unfilled bonding resin
and composite adhesive were associated with less
failures than retainers bonded with adhesive alone
at two-year follow-up.49 However, no difference
in failure between fixed retainers bonded using
direct and indirect bonding techniques,50 or with
chemically and light-cured adhesives,51 at two-
year follow-up has been demonstrated.
BRITISH DENTAL JOURNAL | VOLUME 230 NO. 11 | June 11 2021
© The Author(s), under exclusive licence to British Dental Association 2021
Thickness Results
Mean wear: 5.9 microns
1 mm Mean wear: 6.1 microns
Mean wear: 1.6 microns
Median wear depth: 63.20 μm
Median wear depth: 7.88 μm
1 mm
Median wear depth: 9.75 μm
Median wear depth: 12.08 μm
After thermoforming the
original blank thins between
19% and 65%
1–1.5 mm Difference in thinning rate
between the group when
pressure-formed: 0.11 mm
Mean net mass loss: 0.53
milligrams
Mean net mass loss: 0.51
milligrams
1 mm
Mean net mass loss: 0.55
milligrams
Mean net mass loss: 0.6
milligrams
What effect do fixed retainers have on
periodontal health?
In terms of periodontal outcomes, retrospective
research with prolonged follow-up of patients
in fixed retention has not shown detrimental
periodontal effects.52,53 Higher calculus scores,
marginal gingival recession and probing depth
were noted in patients who had fixed retainers for
over 9–11 years in comparison to shorter periods
(up to six months).53 Comparative studies of
fixed retainers reported inconsistent findings in
terms of periodontal outcomes associated with
metal and aesthetic fixed retainers (Table 3).
Furthermore, less calculus accumulation was
found with fixed retainers bonded with an
unfilled bonding resin and composite adhesive
compared with retainers bonded with adhesive
alone after two years.49 However, fixed retainers
are still reserved for patients exhibiting
meticulous oral hygiene. Furthermore, long-
term follow-up of patients in fixed retention
has shown that up to 1% of patients54 may show
unexpected changes in terms of the development
of inadvertent torque expression with flexible
spiral fixed retainers, which may risk periodontal
breakdown including loss of attachment and
gingival recession.55
GENERAL
Summary of findings
TR sheet material showed significantly greater resistance to
wear in comparison to the other groups
Essix C+ group showed significantly greater wear in
comparison to the other three groups
After thermoforming of retainers, the thickness of the final
retainer varies throughout the dentition, being thinnest over
the mid-labial surface of the lower incisors
When both types were pressure-thermoformed,
polyethylenterephthalat-glycol co-polyester retainers were
significantly thinner than polypropylene
Polypropylene retainers were significantly thicker when
pressure-thermoformed in comparison to vacuum-formed
No significant difference between the groups in terms of net
mass loss
Are fixed or removable retention regimes
more effective?
Fixed and removable retention regimes place an
onus on adherence and follow-up in differing
ways. Three main RCTs involving a comparative
assessment of fixed and vacuum-formed
retention have been published (Table 4). In one
study, similar levels of lower incisor stability
were observed between fixed and vacuum-
formed retainers at 18-month follow-up;56
however, the difference became statistically
significant and more apparent at four-year
follow-up with improved outcomes noted for
fixed retention, suggesting that the benefit of
fixed retention may become more apparent
over time.11 In terms of posterior occluding
surface area, no significant difference was found
between the fixed, Hawley and clear retainers
at six-month follow-up, although settling was
more efficient in the fixed retainer group.61
In a further study, fixed retainers,
prefabricated positioners and interproximal
enamel reduction of mandibular anterior teeth
did not lead to a clinically significant difference
in terms of stability outcomes at five-year
follow-up.62 However, the fixed retainers were
the least cost-effective two years post-debond.63
773
 GENERAL

Table 3 Summary of randomised controlled trial findings involving comparisons of metal and aesthetic fixed retainers

In favour of
Follow-up
Study Comparisons Outcomes
period No
Metal FR Aesthetic FR
difference
0.0175” multi-strand SS FR
Rose et al. (2002)40 and 1 mm polyethylene woven 2 years Survival rate ✓
ribbon FR
0.9 mm multi-strand SS FR
Liu (2010)41 and 0.75 mm fibre-reinforced 1 year Bleeding scores and pocket depth ✓
composite FR
Failure rate ✓
0.0215” coaxial FR and glass Modified gingival index and bleeding
Tacken et al. (2010)42 2 years ✓
fibre-reinforced FR on probing
Plaque index ✓
0.0175” multi-strand SS FR Failure rate ✓
Scribante et al.
and polyethylene fibre- 1 year
(2011)43 Patient satisfaction ✓
reinforced resin composite FR
0.0175” multi-strand SS FR
Bolla et al. (2012)44 6 years Failure rate ✓
and glass fibre-reinforced FR
0.0175” multi-strand SS FR
Salehi et al. (2013)45 and polyethylene woven 18 months Failure rate ✓
ribbon FR
0.0175” multi-strand SS FR
Sfondrini et al. and 0.5 mm silanised-treated,
1 year Failure rate ✓
(2014)46 glass fibres-reinforced
composite resin FR

0.0175” multi-strand SS FR Plaque scores and gingival index ✓

Torkan et al. (2014)47
Sobouti et al. (2016) 48
Key:
FR = fixed retainer; SS = stainless steel
and fibre-reinforced resin 6 months Calculus index, bleeding on probing
composite FR ✓
and width of periodontal ligament
0.0175” flexible spiral wire FR,
0.0009” dead-soft twisted
2 years Survival and failure rates ✓
wires FR and fibre-reinforced
composite FR

In terms of patients’ experiences, levels of
discomfort were higher with clear plastic
retainers in comparison to fixed retainers.57,60
None of the reported studies included an
objective measure of removable retainer wear.
In a recent cross-sectional study involving 309
patients, the median survival time for Hawley
and fixed retainers exceeded four years;
however, survival of clear plastic retainers did
not exceed a median of four months.64
Intra-arch stability outcomes assessed in the
identified RCTs are largely confined outcomes
affecting groups of teeth, including Little’s
Irregularity Index,65 arch length, intercanine and
intermolar widths, and extraction space opening
(Table 4). However, the precise nature of changes
related to specific features which are known to be
particularly prone to relapse, such as correction
of rotations and closure of diastema, are typically
overlooked. The shortage of evidence in this
respect limits our ability to predict the extent and
nature of relapse following treatment, while also
limiting our ability to provide evidence-based
underpinning for optimal retention of key
features of malocclusion.
Significant safety issues with both removable
and fixed retainers are thankfully rare and
information about them is often commonly
reported in isolated case reports, and not
necessarily within controlled prospective trials
with sample sizes calculated to identify the main
outcomes. More information about safety issues
is provided in other papers in this issue.66,67
Are fixed retainers more likely to be
associated with periodontal breakdown?
Better periodontal outcomes were observed with
clear plastic retainers compared to fixed retainers
at one-year follow-up.58 However, no significant
difference was observed in periodontal outcomes
in a study with more prolonged follow-up.11
Moreover, it appears that higher levels of plaque
and calculus are often seen with fixed retention,
although this rarely translates into periodontal
destruction.11,58 Clearly, however, this may be
contingent upon careful case selection.
Should a combination of fixed and
removable retainers be recommended?
There is limited data on the additional benefit of
the combined use of fixed and removable retainers
compared to the use of either in isolation. No
significant difference was found between the
use of a lingual fixed retainer combined with
a nights-only Hawley retainer and clear plastic
retainers only, in terms of alignment of the
lower incisors at one-year follow-up.68 However,
higher calculus index scores were noted in the
combination group.68 In a retrospective study,
the prescription of maxillary removable retainer
wear alone, or a combination of fixed and
removable, did not lead to significant difference
in terms of Peer Assessment Rating scores three
years post-treatment.69
Conclusions
Adoption of orthodontic retention protocols
should be underpinned by the best available
evidence while being responsive to patient

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 GENERAL

Table 4 Summary of randomised controlled trials involving comparative assessment of fixed and vacuum-formed retainers

In favour of
Follow-up
Study Outcomes
period No
FR VFR
difference
O’Rourke et al. (2016)56 Little’s Irregularity Index, arch length, ICW, IMW and extraction space opening 18 months ✓

Little’s Irregularity Index ✓

Al-Moghrabi et al. (2018)11 Arch length, ICW, IMW and extraction space opening 4 years ✓

Gingival inflammation, calculus and plaque levels, clinical attachment level and
✓
bleeding on probing
Little’s Irregularity Index and arch length ✓

ICW, IMW, overjet, overbite and extraction space opening ✓

Plaque and calculus scores and gingival inflammation ✓

Forde et al. (2018)57 and
1 year
Storey et al. (2018)58 ✓
Discomfort and interference with speech

Easiness to clean ✓

Survival rate ✓

Little’s Irregularity Index, arch length, ICW, IMW, overjet and overbite ✓
Krämer et al. (2019)59 and
18 months
Krämer et al. (2020)60 ✓
Discomfort and concerns about relapse

Little’s Irregularity Index, ICW, IMW and arch length ✓

Alrawas et al. (2020)38 6 months
Plaque index, gingival index, bleeding on probing and pocket depth ✓
Key:
FR = fixed retainer; ICW = intercanine width; IMW = intermolar width; VFR = vacuum-formed retainer.

preferences and tailored on an individual basis,
in particular due to the initial presentation.
Evidence concerning retention is accumulating,
with firm evidence to suggest that prescription
of night-time wear of removable retainers is
as effective as full-time wear over a short
period. There is also emerging evidence of the
superiority of fixed retainers over removable
alternatives over more prolonged periods of
follow-up. Notwithstanding this, optimal
adherence with removable regimens may help
in enhancing long-term outcomes.
Conflict of interest
The authors have no conflicts of interest to declare.
Acknowledgements
This research was funded by the Deanship of Scientific
Research at Princess Nourah bint Abdulrahman
University through the Fast-track Research Funding
Program.
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