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Original Article
Orthodontic Retainers: Review Paper
Abdulfatah B. Khmaj1 *, Mofida R. Khmaj1, Zakaria A. Khmaj2
1. Zawia University, Faculty of Dentistry, Department of Prosthodontics and Dental Materials, Alzawiyah, Libya.
2. Belarusian Medical Academy of Postgraduate Education, Department of Orthodontics and Dentofacial Orthopedics ,
Minsk, Republic of Belarus.
*Correspondence: [email protected] or [email protected]
Abstract:
To ensure that the results of fixed orthodontic therapy are maintained and do not relapse, it is crucial to retain and
preserve the treatment outcomes. Retention is an essential aspect of orthodontics and can be viewed as the final stage of
treatment. It is necessary to maintain an optimal esthetic and functional occlusion following orthodontic therapy.
Aim : The objective of the article is to acknowledge the significance of maintaining the outcomes of orthodontic therapy
and to assess the various techniques used to fabricate fixed and removable appliances for retention.
Materials and Methods:
The present article evaluates the different protocols for lingual fixed retainers, as well as removable retentive appliances
such as Hawley, Begg, and vacuum-formed retainers (VFR). Removable appliances have been used for retentive
purposes for a long period of time. Bonded fixed retainers were introduced in the 1970s, and they have several
advantages over removable retentive appliances, such as better esthetics, the absence of patient cooperation, and
suitability for lifelong retention. Fixed retainers can be of conventional or digital type. Conventional fixed retainers can
be fabricated and attached directly or indirectly to the teeth using a transfer tray. Moreover, bonded retainers can now
be digitally manufactured using computer-aided design and computer-aided manufacturing (CAD-CAM).
Results: Effective retention and stability of orthodontic treatment results are highly dependent on various factors such
as the chosen retention technique, survival rate, and the individual patient's case. Therefore, a thorough diagnosis,
comprehensive treatment plan, and careful selection of a suitable retentive appliance play crucial roles in ensuring
optimal post-treatment stability.
Conclusion: Extensive study of literatures and previous publication suggests that there is a lack of sufficient evidence
to determine the superiority of any specific retention protocol. Therefore, there is a need for evidence-based studies and
controlled clinical trials to evaluate various orthodontic retentive appliances, determine the optimal duration of retention
period, and evaluate the success and failure rates of retention based on each specific technique
Key words: Tooth stability; Removable retainers; Fixed retainers; Dual retention; Life-long retention.
Citation. Khmaj1 Abdulfatah B , Orthodontic Retainers: Review Paper
https://doi.org/10.54361/ljmr.17-07
Received: 2/05/23accepted: 20/05/23; published: 30/06/23
Copyright ©Libyan Journal of Medical Research (LJMR) 2023. Open Access. Some rights reserved. This work is
available under the CC BY license https://creativecommons.org/licenses/by-nc-sa/3.0/ig
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Introduction:
The long-term stability of the treatment is the goal In 1973, Robert W. Kneirim introduced the
of every orthodontist. The concluding stage of application of fixed retainers after orthodontic
orthodontic treatment is retention. Many treatment for the first time (3). These retainers were
practitioners believe that, some degree of relapse bonded to the lingual surface of the teeth based on
will occur even with a retentive appliance. The the acid-etch technique. In 1977, Zachrisson
retention of the treatment result starts at the very presented the structural advantages of multi-
beginning of treatment, as retention depends stranded flexible wires, as he explained that
deeply on a correct diagnosis of the case and on a because of their flexibility, multi-stranded wires
sound treatment plan. Moreover, obtaining an did not restrict physiological tooth mobility (4).
appropriate functional occlusion that fits well with Discussion:
the patient’s facial features and muscular The long-term age changes of the skeletal and soft
structures will aid tremendously in maintaining tissue predict that relapse of the teeth after
stable post treatment results. orthodontic treatment is highly possible. As a
In the 19th century, occlusion was believed to be result, every treated case should be considered as a
the most important factor for stability of teeth after potential lifelong retention to maintain the stability
orthodontic treatment. In the 20th century of the treatment outcomes. In the case of removable
Lundstrom supported the idea that the most retentive appliances, the patient is allowed to
important factor for stability is the apical base, remove them from the mouth to maintain oral
whereas Mcauley insisted on the importance of hygiene, but the success of their application
canines and molar relationship (1). On the other depends on the patient’s compliance. The Hawley
hand, Tweed claimed that the inclination of removable retainer is fabricated with acrylic resin,
incisors plays a role, and that upright incisors help which covers the palatal or lingual soft tissue. This
in occlusion stability (2). acrylic resin is connected to a stainless steel
Removable appliances such as the vacuum formed vestibular bow that extends from the distal surface
retainer (VFR), Begg and Hawley retainers are of the canines. In addition, the Hawley appliance
among the most common removable retentive has Adams or circumferential clasps. The Hawley
appliances. The Begg and Hawley retainer have an appliance can be applied to both the upper and
advantage over other types of retainers as its lower jaw. Moreover, the Begg retainer, which is
possible to activate the loop or the clasp to slightly mainly applied to the upper jaw, is also fabricated
adjust or re-straighten teeth if necessary. Also, with acrylic resin that covers the palate, but the
removable retentive appliances are more practical stainless steel vestibular arch begins on the distal
in maintaining the achieved arch expansion after surfaces of the second molars contouring the
orthodontic treatment. vestibular surface of the posterior and anterior
As more studies of long-term teeth stability were teeth without the need for retentive clasps. In some
introduced, the idea of fixed retention developed. cases, retentive clasps can be added to stabilize the
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appliance (5). Both the Hawley and Begg surface of the canines only (16). The tip ends of this
removable retentive appliances have good generation of retainers are sandblasted with
durability (5), promote intercuspation of molars (6) aluminum oxide to improve mechanic retention
and can be used to provide force on a tooth or teeth (16). The fourth generation of retainers is made of
to re-straighten them if necessary (7). five-stranded wires with a 0.032-inch diameter and
In many literatures, the term Vacuum Formed could be bonded to all anterior teeth (16). The fifth
Retainer (VFR), thermoplastic retainer, or invisible and last generation of retainers is blue elgiloy wires
retainer (clear) is used interchangeably. In 1971, with a 0.032-inch diameter and is sandblasted at
Ponitz first introduced the thermoplastic retainer the end, as they are bonded strictly to the lingual
(9) and it was further developed by Sheridan (10). surface of the canines (16). Zachrisson, in his
The VFR is the most commonly chosen removable studies, bonded triple-stranded wires to all
retainer by orthodontists in the Republic of Ireland anterior teeth. However, in his paper where he
(11), Australia (12), and in the National Health shared a 20-year experience with fixed bonded
Service (NHS) and hospital practices in the United retainers, he reported that a five-stranded wire
Kingdom (13). The VFR has good durability and with a 0.0215-inch diameter provided better
esthetic appearance, and it also proposes patient retention results based on failure rates observed in
comfort and acceptability (14). follow-up sessions of his patients (20).
Fixed retainers are the retainers of choice for many Fiber reinforced composite materials were
orthodontists, especially for stabilizing the introduced as an alternative to fixed wire retainers
treatment result of the lower jaw. Zachrisson in (17). Resin fiberglass is more aesthetic and smaller
1977 demonstrated the advantages of using multi- in size; however, their high long-term failure rates
stranded metallic wires as fixed retainers (18). In and inability to maintain the physiological
1982, Artun and Zachrisson introduced the mobility of teeth decreased their demand among
bonding of multi-stranded wires to the lingual orthodontists (17).
surface of canines only (19). The wires used in Computer-aided design and manufacturing
manufacturing fixed retainers were characterized technology are very commonly used in oral and
into several generations since their introduction to dental science to provide stable and efficient
orthodontics (15). The first generation of fixed treatment. Fixed lingual retainers have not
retainers is blue elgiloy or stainless steel round changed over the years until more recently, as
wire with a diameter of 0.025-0.036 inches. The first bonded fixed retainers can now be manufactured
generation had a terminal loop that was bonded using computer-aided design and manufacturing
only to the lingual surface of the right and left (CAD/CAM) technology. This digital method
canines (16). The second generation of fixed could offer stable post-treatment results for simple
retainers is a triple-stranded wire with a diameter and severe orthodontic cases. Techniques and
of 0.032 inches and is bonded to the lingual surface types of wires to manufacture a bonded fixed
of all anterior teeth (16). The multi-stranded wires retainer using CAD/CAM vary. The SureSmile
replaced the stainless steel round wire as they have technology was designed to deliver high-quality
higher elasticity that helps maintain the care with a minimal amount of patient discomfort,
physiological mobility of the retained teeth (16). as well as reduce errors in treatment results (21).
The third-generation retainer can either be a round SureSmile technology provides precise retentive
0.032-inch stainless steel or a rounded 0.030-inch appliances that can help orthodontists deliver truly
gold-coated plain wire, bonded to the lingual customized care (21). SureSmile uses the technique
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of bending prefabricated copper-nickel-titanium polyester and ethylene co-polymer, with a
wire by the handle of a machine to manufacture the thickness ranging from 0.6 to 2.0 mm, is used to
retainer (21). The Memotain retainers are manufacture the retainer (14). Co-polyester is more
manufactured using a different technique, which aesthetic but tends to fracture easily, while
includes carving out a block of nickel-titanium ethylene co-polymer is much more resilient but
wire of 0.014x0.014 inch thickness (31). less retentive (14). The VFR is fabricated using a
Methods of Manufacture: plastic thermoforming pressure machine, which
Removable retentive appliances, such as Hawley, adapts the heat-softened plastic over the dental
Begg, and Vacuum-formed retainers, are cast with the help of positive pressure or by using
fabricated in the dental laboratory. For Hawley a vacuum machine, which adapts the softened
and Begg removable retainers, the lab technician plastic blank to the dental cast by negative pressure
prepares the working model by applying a small (14).
amount of liquid separator foil (22). This separator Conventional fixed retainers can be bonded to the
is applied everywhere except along the areas lingual surface of anterior teeth from the canine to
where the wires (bow, loop, and clasps) will be the canine directly or indirectly. First and foremost,
waxed in place. Next, the technician adapts the the practitioner should perform professional oral
wire for the bow and clasps to the dental cast using hygiene and treat the lingual surface with a
hot baseplate wax on the facial surface (22). sandblaster using a 50 micro alumina silicate,
Further, the technician adds the acrylic polymer in which is removed using high-volume suction (32).
layers and gradually builds up the baseplate to the The sandblaster has been shown to increase the
desired dimension. The acrylic retainer is cured shear bond strength of the lingual retainer (32). A
under pressure to ensure that the acrylic is fully suitable prefabricated multi-stranded stainless
hardened (22). The following step is the trimming steel retainer wire is chosen, and the orthodontist
procedure, divided into two categories: cut- fixes the retainer using the acid etch technique.
out/rough trim and the final trim (22). Cut- Placing a fixed retainer with a direct bonding
out/rough trim involves cutting out the basic shape (chair-side) technique requires a lot of skill and
of the retainer, followed by thinning and accuracy from the orthodontist. Various materials
smoothing excessive bulkiness. In the final trim, and methods are used to deliver the wire in place
the anterior acrylic is rounded down to the prior to bonding, including dental floss, elastics,
interdental papilla to maintain palatal tooth ligature wire, and/or finger pressure (32). Also, it
contact and not interfere with the antagonist teeth. must be stressed that good moisture control is a
Finally, the acrylic retainer is sanded and requirement for the successful bonding of the
smoothed along the previously trimmed areas (22). retainer via direct technique and this is achieved
The Vacuum-Formed Retainer (VFR) can be using cotton rolls, a field retractor, and dental
fabricated in the dental laboratory or in the dental saliva suction. Further, the retainer wire should be
office if the necessary materials and vacuum annealed to reduce the stiffness of the wire and to
machine are available, as the process of place it according to the shape of the frontal
manufacture is much faster than other removable segment of the arch (23). Next, the lingual surface
retentive appliances. Its fabrication requires taking of the teeth is etched with 37% orthophosphoric
a dental impression after debonding of the bracket acid for 15 to 30 seconds (23). After carefully
system and preparing a working model. A rinsing and drying the teeth, an etched appearance
rectangular or round blank of materials such as co- will appear on the lingual surface of the anterior
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teeth. A foam sponge is then used to place the proposed favorable clinical results (26,27). On the
liquid bonding resin (the adhesive) onto the other hand, Renkema et al. assessed the long-term
recently etched surface, and it is briefly success of canine-to-canine lingual retainers in
polymerized with a light reaction (23). A small maintaining the alignment of the mandibular
amount of low-viscosity composite material is anterior teeth post orthodontic treatment in 221
applied to the lingual surface of the 6 frontal teeth. patients (28). Five years post orthodontic
The foam sponge is used to adjust the composite treatment, the alignment of the mandibular
over the wire, and then each tooth is cured for 40 anterior teeth was maintained in 200 patients
seconds. The amount of composite should be (90.5%) (28). Moreover, the most common problem
enough to cover the wire only in the middle of the related to fixed retainers is bond failure. In a
crown and not all the way along the lingual crown randomized clinical trial, Pandis et al. evaluated
surface (23). the survival of fixed mandibular lingual retainers
In the case of the indirect bonding (laboratory) with chemical or photo polymerization over a
technique for fixed retainers, the treatment period of 2 years (30). The results showed the
protocol closely resembles that of the chair-side absence of a particular difference between the
technique. The procedure includes taking a dental survival of mandibular fixed lingual retainers
impression, preparing a plaster model, passively using chemical or light-cured adhesives, as the
adapting a stainless steel multi-stranded wire to overall failure rate was 46.4%.
the lingual surface of the anterior teeth on the The Duration of the Retention Period:
model, applying a separation liquid to the lingual A Cochrane review published in 2016 showed that
surface of the frontal teeth, bonding the retainer there is insufficient evidence to favor a particular
with a low viscosity composite, and polymerizing retention duration period or a retention protocol
it. A transfer tray is fabricated using a vacuum (29). Many practitioners agree on providing long-
machine and a thermoplastic plate. The tray is then term or indefinite retention using a combination of
placed in the patient's mouth, and the retainer is fixed and removable retention, a term widely
bonded using the etch-rinse adhesive bonding known as dual retention. In case the bonded fixed
technique. Finally, the transfer tray is carefully retainer fails, the removable retainer prevents the
removed, the fixed retainer is examined, and oral relapse of teeth. This is especially common for the
hygiene instructions are provided. mandibular arch as it possesses a high tendency to
In a randomized clinical survey, Bovail et al. relapse.
compared the direct and indirect fixation of the Conclusion:
retainer in terms of time efficiency. They It is important to give thorough consideration to
concluded that indirect fixation was 20% faster the type of retainer, the method of fabrication, and
than direct (24). the retention plan to ensure that the treatment
Effectiveness and Survival Rates of Retainers: outcomes remain stable over time. Although there
In a randomized clinical trial, Tynelius et al. is no clear evidence to support any particular
compared various retention strategies to maintain retention technique, additional randomized
the results of orthodontic treatment of the upper clinical trials of high quality are necessary to assess
and lower jaw (26). Tynelius et al. used vacuum- the effectiveness of various orthodontic retentive
formed retainers and bonded canine-to-canine appliances and techniques.
retainers on both arches. They concluded that the
VFR and the bonded canine-to-canine retainer both
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Figure 1: Vacuum Formed Retainer (VFR) and Lingual Fixed Retainer (3-3) on the upper arch.
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