The need for retentionAn important

consideration
P. Emile Rossouw, and Robert W. Malloy Jr

Retention is a culmination of all our orthodontic knowledge. This is when we

have planned, treated, and now have to maintain what has been attained.
Moreover, we have to understand how we reached our goal and also be
respectful of those factors wanting to disrupt a successful correction of a
malocclusion. If we planned correctly and our treatment plan was executed
well then retention is merely a passive process of observation and minimal
adjustments. On the contrary, if the treatment did not go according to our
treatment plan albeit because of the nature of the difcult malocclusion,
patient compliance problems or aberrant growth interferences, it is
imperative to have an excellent retention protocol in place to actively pursue
our ultimate goal of a healthy and functional occlusion. This article will
enlighten the reader to important factors as to why planning retention is a
responsibility from the beginning of orthodontic treatment. (Semin Orthod
2017; 23:109122.) & 2017 Elsevier Inc. All rights reserved.

linicians who fully grasp the underlying
C principles of retention, who appreciate its
difculties and who are able and willing to devote
to it that high order of mechanical skills which
adequate retaining devices demand, will nd few
things in dentistry which bring quite the sat-
isfaction and permanent pleasure as the branch
they have chosen to practice (orthodontia)
Calvin Case (Retention in Dental Orthope-
dia, Principles of Retention, 1908)1
Retentionthe holding process
Retention of a tooth is the holding process of this
attained position, such as maintaining an esthetic
and functional occlusion which meets for example
the ideal requirements of the American Board of
Orthodontics2 or those of the keys of normal
occlusion of Andrews.3 However, when discussing
retention, one must distinguish between relapse,
Division of Orthodontics and Dentofacial Orthopedics, University
of Rochester Eastman Institute for Oral Health, Rochester, NY.
Address correspondence to P. Emile Rossouw, BSc, BChD, BChD
(Hons-Child Dent), MChD (Ortho), PhD, FRCD(C), Division of
Orthodontics and Dentofacial Orthopedics, University of Rochester
Eastman Institute for Oral Health, 625 Elmwood Ave, Rochester, NY
14620. E-mail: emile_rossouw@urmc.rochester.edu
& 2017 Elsevier Inc. All rights reserved.
1073-8746/17/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.12.002
physiologic recovery, and developmental changes.
The term relapse has been used, perhaps
erroneously, when referring to all post-treatment
changes.4 Relapse is usually associated with failure.
However, physiologic stability 5 is a term which
appears to encompass the acceptable changes a
clinician can expect; it also includes the normal
aging changes of the dentition, which take place
irrespective of treatment outcome. That is,
physiologic stability refers to inuencing events
such as growth and development, occlusal settling,
biological adaptation, physiologic inuences,
rebound effects as a result of the elasticity of the
tissues and the more difcult to control,
neuromuscular inuences.
Relapse occurs when the corrected maloc-
clusion slips back or falls back to a former con-
dition especially after improvement or seeming
improvement. Riedel and Brandt6 believed that
the word was too harsh a description of the
changes that follow orthodontic treatment, and
they preferred the term post-treatment adjust-
ment for these changes. However, poor clinical
treatment should not be conducted or condoned
under the designation of relapse or under the
auspices of one of the other terms noted as part
of the long-term stability problem. It is imperative
to be cognizant of the different descriptions of
long-term change to enable the clinician to
interpret stability of the nished result and also
provide adequate communication of possible

Seminars in Orthodontics, Vol 23, No 2, 2017: pp 109122 109

110 Rossouw and Malloy Jr
post-treatment changes to prospective patients.
Thus, all orthodontic patients should be well-
informed of the expected long-term changes and
the need to conform to the retention protocol.
Retention regimens have become an essential
part of the present-day orthodontic treatment
plan. The ultimate success of the long-term
orthodontic treatment result depends on a
compilation of steps, including appropriate
planning, well-controlled treatment mechanics,
retention compliance and, in general, an
appreciation of the biological limits of tooth
movement.
Efforts to improve knowledge and treatment
methods have resulted in many excellent inves-
tigations into aspects of relapse.712 Despite these
important studies, many causes of orthodontic
relapse are not fully understood.13 Many pitfalls
that lead to treatment problems exist, and no
orthodontist is immune to them.14,15
Occlusal stability after orthodontic treatment
should be considered a primary goal for every
orthodontist.9 However, relapse may occur
unexpectedly and for no obvious reason.
Moreover, the fact that a malocclusion is
corrected, or for that matter left untreated, is
also no guarantee that no further changes will
occur as normal untreated occlusions show
longitudinal changes.
Stability theorems have been in the published
literature for a long time. Thus, if one refers to
Theorem 1:16 Teeth return to their original
positions; it is not strange to expect some
change as the dentition and occlusion mature.
Retention can be categorized as follows:
1. Passive retention, and
2. Active retention.
Passive retention
This occurs from the initiation of treatment
where the clinician not only pursues the best
and most stable position of the occlusion, but
also refrains from moving the teeth beyond the
physical limits of the periodontium and its
balance between the muscular curtains of the
craniofacial region. During this process the
potential of some interceptive treatment such as
planned or serial extraction or maxillary rapid
expansion may be used to place this develop-
ment in the correct direction on route to
attaining a healthy, functional, and stable
occlusion. If the so-called ideal occlusal rela-
tionships have been attained it should also be
merely a passive process to maintain the
occlusion. Passive retention thus occurs through
the equilibrium created by efcient treatment.
However, it is soon realized that this is a short-
lived practice and that a more realistic active
role of retention is essential.
Active retention
Active retention can be considered as another
phase of treatment. Some call it re-treatment,
revision, or an active regimen of post-treatment
minor to major intervention while the patient
wears either removable or xed retainers. This is
essential because:
1. The need for reorganization of the gingival
and periodontal bers following removal of
the conventional orthodontic appliances.
Thus, it is very important that the level and
alignment phase of initial treatment take this
rst phase of passive retention in consider-
ation. Should there be any tendency for a
space to open or a rotation to revert active
retention comes to the fore especially in the
post-treatment phase. The type of retainer
used and the duration of retention are highly
variable from one patient to another, mostly
depending on the orthodontists selec-
tion.15,17 However, it is an accepted theory
that the time of retention must be at least the
amount of time necessary for the periodontal
bers around the teeth to reorganize into
their new positions.18,19 Reitan made clini-
cians aware of the fact that this process can
occur over approximately 232 days in dogs.19
Unfortunately, even in patients who wear
retainers for at least a year, the long-term
post-retention stability has still been shown to
be poor, indicating relapse in approximately
half of the cases.8
2. Any growth during the post-treatment phase
impacts the stability of the occlusion (see
section below). It will also be made clear in the
Growth Study information to follow that as
long as we deal with a living being, changes will
occur which impact the post-retention
occlusion. These factors include growth,
maturation, environmental inuences such
 The need for retention
as habits, allergies, airway inuences and
others or a combination of these with a
resultant return of tooth irregularity, deep
bite or open bite which emphasize the
implementation of active retention post-
treatment.
3. Treatment in itself may have pushed teeth in an
unstable position which may be a result of a
treatment philosophy, treatment occurred
too late and the clinician is forced to
make compromises, patient requests, non-
compliance with recommendations and thus
forces the clinician to compromise in order to
reach a reasonable outcome. Active treatment
in these instances often requires xed retention
or a very active protocol of retainer follow-up.
4. The impact of soft tissue albeit adenoids,
tonsils or another form of airway obstruction,
or incompetent lip function due to a protru-
sive dentition or vertical elongation of the face
during treatment. Moreover, such treatment
often requires a surgical component of treat-
ment to attain a successful outcome. In these
circumstances active retention is undoubtedly
very important to maintain the result.
Normal changes in the untreated
dentition
One of the most often cited treatment requests is
that of the correction of lower incisor crowding.
Needless to say, it is probably also the most
common complaint in respect to changes fol-
lowing orthodontic treatment; that of late lower
incisor irregularity. The focus of many studies has
been on the mandibular arch, the assumption
being that alignment of the lower arch serves as a
template around which the upper arch develops
and functions. The following questions Why is
retention necessary?; When can retainer use be
discontinued? and Will signicant change fol-
low? are answered in the most objective manner
by observing the long-term changes occurring as
a result of normal aging.
The impact of normal growth, development, and
maturation
Four published and well-referenced growth and
development studies, amongst others, will serve
as the basis for this clarication of the changes
normally occurring during the maturation process
and undoubtedly inuencing the craniofacial
111
environment with or without orthodontic treat-
ment. These include reports from the Belfast
Growth Study (Belfast, North Ireland)20; The
National Health and Nutrition Examination
Survey (NHANES, USA)21; Bolton Growth
study (Cleveland, USA)22 and the Burlington
Growth Study (Toronto, Canada).23
The Belfast Growth Study (Belfast, North
Ireland)
(a) Richardson and co-workers have studied the
normal changes in various age groups using
data from this growth study.2429 They
documented that between 7 and 15 years
there appears to be a decrease in crowding.
An average decrease of 0.91 mm occurred
between 7.75 and 10.85 years, and the
decrease continued by small and insignif-
icant amounts, 0.15 mm, between 10.85 and
15.5 years. However, crowding seemed to
increase after 15.5 years and at a time after
the eruption of the second permanent
molars (0.41 mm).25,29
(b) Furthermore, third molar development also
originated from this center, in particular its
effect on lower arch crowding. It was noted
that crowding increased signicantly and
the permanent rst molars showed mesial
drifting by a signicant measurement dur-
ing the time of third molar development
and eruption. Third molar impact on
crowding is controversial, however, it is
not the third molars per se that are
important here, but more the age when
these teeth erupt or not erupt/impact.
Thus, increase in crowding seems to match
increase in age.24,2729
(c) Similar measurements were noted in a study
looking at changes from 18 to 21 years.25
(d) A signicant average increase in lower
incisor arch crowding of 0.2 mm (range
0.21.4 mm) occurred from 21 to 28 years
and these changes continued as measured
from 28 to 50 years.29
(e) An interesting phenomenon was reported by
the Richardson group out of the Belfast
Study; they noted a decrease in crowding by
creating space for the teeth (second molar
extraction group showed a decrease in lower
crowding 0.75 mm and the lower rst molars
slightly distal movement) versus an increase
112 Rossouw and Malloy Jr

in crowding comparing to a nonextraction an effort by Prof. T. Wingate Todd and his

group (maintenance of second molars in a associates to examine normal human mental and
nonextraction group which showed an physical growth and development. The Bolton
increase in lower crowding 2.0 mm with Study, concentrating on growth and develop-
lower rst molars mesial movement).26 ment of the face and teeth, was initiated in 1929
by B. Holly Broadbent, Sr. The radiograph was
NHANES Study (Centers for Disease the primary study tool used. There were over
Control and Prevention, USA) 6000 research subjects with over 2800 of those
subjects participating in both studies.
The NHANES is a program of studies designed
From the extensive longitudinal growth data
to assess the health and nutritional status of
collected in the 1930s and 1940s Behrents34
adults and children in the United States.
evaluated 163 cases spanning ages 1783 years
Moreover, NHANES is a major program of the
which resulted in two volumes of his landmark
National Center for Health Statistics (NCHS).
doctoral thesis evaluating the longitudinal
NCHS is part of the Centers for Disease Control
changes of the Bolton subjects. A summary of
and Prevention (CDC) and has the responsi-
the data was compiled as two monographs from
bility for producing data essential for living and
the well-known Center for Human Growth and
health for the Nation. The NHANES program
Development, University of Michigan at Ann
began in the early 1960s and conducted surveys
Arbor in 1985.35,36
that provided data focusing on different pop-
From these studies Behrents3436 concluded
ulation groups or health topics. In 1999, the
that:
survey became a continuous program collecting
yearly data that has a changing focus on a
1. Considerable craniofacial changes occur
variety of health and nutrition measurements to
beyond 17 years in males and females.
meet emerging needs. A nationally repre-
2. Craniofacial changes continue into the oldest
sentative sample of about 5000 persons is sur-
age spans (83 years) in an apparently adaptive
veyed each year. Researchers have accessed this
but decelerating manner.
information and two examples are herewith
3. Sexual dimorphism was noted.
shown to illustrate the effect of growth on the
4. Vertical changes were common in adulthood;
dentition.30,31
in general, more vertical in females (Fig. 4)
It is interesting to note that only 54.5% of
and more horizontal in males (Fig. 5).
children aged 811 possess well-aligned lower
5. Soft tissue changes were greater than skeletal
incisors.30,31 The irregularity appears to increases
changes, especially elongation of the nose,
with age.31 On average the difference between
attening of the lips and augmentation of the
clinically acceptable (03.5 mm), moderate (3.5
chin. It is obvious that these changes not only
5.5 mm), and severe (45.5 mm) lower incisor
affect the long-term soft tissue prole out-
irregularity was dened by Little (1975)
come with and without treatment, but should
(Fig. 1).32 Fig. 2 portrays the distribution of
be taken in consideration at the treatment
the categories across the population. Buschang
planning stage.
and Shulman31 made an interesting comparison
among studies describing long-term lower incisor
irregularity changes in mm/yr (Fig. 3). Note Burlington Growth Center study
change during late 2nd decade and onwards as (University of Toronto, Toronto, Canada)
shown up to 42 years, practically decreased to
The Burlington Growth Center at the University
zero increase per year.
of Toronto was initiated by Dr. Robert Moyers in
1952. Burlington, Ontario was a town with a
Bolton Growth Study (Western Reserve
population of 9000 situated approximately 30
University, Cleveland, USA)
miles from Toronto. The region at that time
The Bolton-Brush Growth Study Center research comprised 40% of the national population.23,37,38
collection comprises one of the worlds most The predominant racial group was Caucasian
extensive sources of longitudinal human growth and mostly Anglo Saxon. The Burlington
data. The Brush Inquiry was initiated in 1926 as Growth Study was managed by Dr. Frank
 The need for retention
Figure 1. Irregularity index.32 The aggregate of the
millimeter measurements of the discrepancy of the
contact points (A B C D E) provides the score
of the index. Less than 3.5 mm is clinically acceptable,
3.55.5 mm indicates moderate irregularity, and
greater than 5.5 mm indicates severe irregularity.
Popovich, Professor, and Past Director of
Burlington Growth Center from 1961 to 1989.23
He completed the collection of this
longitudinal growth data and soon realized
that he had accumulated one of the most
signicant databases for craniofacial growth in
the world.
The specied ages selected for the study were
3, 6, 8, 10, and 12. Records were obtained
annually on the 3-year-old children; at ages 9,
12, 14, 16, and 20 years on the original 6-year-
old children and at 12 and 20 years on the
original 12-year-old children. This resulted in
an original sample of 1258 children repre-
senting approximately 90% of the Burlington
children in these age groups. Complete ortho-
dontic records were obtained for all children
and included cephalometric radiographs; hand-
wrist radiographs; dental models; photographs
and other general health and background
information.
In order to ascertain changes beyond 20 years a
study was conducted in which the sample was
extended to 40 years for the original 3-year-old
sample and to 70 years for the original parent
sample. The sample is thus, one of the worlds most
important collections of longitudinal craniofacial
and occlusal, growth, and development data.
Eslambolchi et al.39 used the latter sample to assess
the aging characteristics of the sample. They
reported the following:
Mean changes were recorded in Children at
time 1 (T1), 13.0 years; time 2 (T2), 19.6 years;
113
and time 3 (T3), 42.4 years. The changes were as
follows:
(a) Decrease in intercanine width; inter-rst
premolar width; arch length; anterior space;
and total space (T1T3).
(b) Increase in Little irregularity index (1975)
(T1T3).
(c) An important observation of rates of change:
slower changes seen from T2 to T3 as
compared from T1 to T2.
Mean changes recorded in Parents from 36.1
to 69.4 years were as follows:
a) Decrease in intercanine width; inter-rst
premolar width; arch length; anterior space;
and total space.
b) Increase in the Littles irregularity index.8,32
c) Very important observation of rates of
change: Little irregularity index and anterior
space analysis increased slower compared to
children from T2 to T3.
Thus, the latter data39 provides clinical
applicable retention duration information.
Conclusions from this Burlington study39:
a) Late developmental crowding is a process
which continues throughout life.
b) The rate of increase in crowding or irregu-
larity of the lower incisors seems to decrease
with increasing age (440 years).
Clinical signicance of this Burlington Growth
center data39:
The retention phase should continue at least
into the third-fourth decades and ideally longer if
possible on a limited basis.
It is important to emphasize that all the noted
examples of growth center material provided
similar data; that is, craniofacial changes con-
tinue throughout life and it appears that it slows
down in early adulthood.
Other factors which signicantly inuence the
retention decision
Overbite, overjet, and other dental changes
Overbite and overjet increase signicantly from
the mixed to the permanent dentition. During
the maturation of the permanent dentition
114 Rossouw and Malloy Jr

Figure 2. Mandibular incisor irregularity in untreated US subjects, 1550 years of age. The subjects who showed
moderate to severe irregularity were 39.5%. Using the irregularity index from Little32 the various categories of
irregularities for the sample is shown. (Modied with permission from Buschang and Shulman31 and Rossouw.33)

(1320 years), these changes were reversed, and
decreases in overbite and overjet were observed
by Barrow and White,40 Bjrk,41 Moorrees,42 and
Sinclair and Little.43
Intermolar width remains relatively stable in
untreated individuals.39,4245 Arch length
decreases over time.3945 Moreover, longitudinal
data show that changes in arch dimensions, as
well as lower incisor crowding occur as part of the
normal aging process.3436,3945
Maintenance of the natural space for
lower incisor alignment
After eruption of the lower permanent incisors, it
appears that there is little or no skeletal growth in
the anterior part of the lower jaw at this time (see
Passive retention section).35,42,4648 An important
means of creating space for incisor alignment is
the fact that the lower incisors procline relative to
the mandibular plane by an average of 131
between 5 and 11 years.49 This gain in space is
enhanced by an increase in arch width across the
canines caused by alveolar growth, just before
and during the eruption of the permanent
incisors.8,50,51
In addition, Leeway space or ultimately the
E-space provides space for the larger permanent
incisors; that is, the excess space by which the
primary molars and canine is larger compared to
their permanent successors.42,45,5261 This natu-
ral occurring space should be utilized where
needed as it becomes difcult to regain this space
and often space is subsequently gained by sur-
passing the biological limits. Any disturbance in
establishing the development of the normal
occlusion as described could have a detrimental
impact on the alignment of the lower incisors.

Figure 3. Rates of crowding (mm/yr)comparison of Longitudinal Studies. (Modied with permission from
Buschang and Shulman31 and Rossouw.33)
 The need for retention 115

compared with the increase in crowding and

Figure 4. Female long-term changes. Note the vertical
changes occurring from 17 to 57 years of age.
(Adapted with permission from Behrents.35)
Anterior component of force resulting in
mesial migration of teetha retention
nightmare
The cause of increased crowding in the intact
lower arch is not fully understood. It is obviously
multifactorial, and for this reason, it is difcult to
show a cause and effect relationship. Mesial
migration of human teeth has been recognized
since the late eighteenth century, when it was
described by Hunter,62 and is shown by the
forward movement of the posterior teeth during
adolescence. There is evidence to support the
view that it is largely responsible for the increase
in crowding during the teenage years. Mesial
migration may be caused by physiological mesial
drift, by the anterior component of the force of
occlusion on mesially inclined teeth, by the
mesial vectors of muscular contraction or by
the contraction of the transseptal bers of the
periodontal ligament.45,46,5463
mesial movement of rst molars in nonextraction
subjects provide convincing evidence of the
effects of developing third molars on the anterior
part of the arch.68,69 Other studies on patients
treated by extraction of second molars6774
reported similar results. It is a mistaken
impression that it is only impacted third molars
that cause the problem. A third molar that erupts
is likely to exert more pressure on the dental arch
than one that remains impacted, and some
impacted third molars may exert more pressure
than others.7173 Decisions relative to the timing
of third molar extraction should be made on the
basis of potential development of pathosis,
technical considerations of the surgical proce-
dure and long-term periodontal implications
rather than potential impact on mandibular
incisor crowding.75 Although erupting
mandibular third molars probably exert some
force on the dentition,67,7478 most of the sci-
entic studies69,7982 have found no signicant
correlation between the presence or absence of
mandibular third molars and developmental
incisor crowding. The effect of mandibular third
molars on the dentition, particularly the lower
incisors, remains unclear according to Bishara
and Andreasen.82
Irrespective of the impact of all the latter
factors, be aware that as a group they all have a
minor or major impact on occlusal changes.
Thus, to ensure that a treatment result is main-
tained retention compliance remains an imper-
ative part of the orthodontic treatment regimen.

Role of third molars in the development

of mandibular incisor crowdingthe easy
answer, but so controversial
Third molar agenesis and extraction studies6167
suggest that mesial migration is greater in the
presence of a developing third molar. This sug-
gestion is strongly reinforced by second molar
extraction studies.68,69 Removal of the second
molar effectively isolates the third molar from the
rest of the arch. The reduction in crowding and Figure 5. Male long-term changes. Note the horizon-
the distal movement of rst molars in patients tal changes occurring from 17 to 59 years of age.
whose second molars have been extracted (Adapted with permission from Behrents.35)
116 Rossouw and Malloy Jr

adolescence (Fig. 6, Buschang et al.86).

Crowding of the mandibular incisors was
observed in vertical growers as a result of
chronic airway obstruction.87,88
If one observes one part and one dimension of
the craniofacial environment, the mandible, and
look at how it changes from 4 years to 21 years
the realization quickly underlines the fact that
there is limited space for the development of the
dentition and occlusion. Basal transverse
dimension in the anterior part of the mandible
increases minimally after the age of 4 years and
even less from 10 years to adulthood.89,90
Need it be said that this fact emphasizes the
need to start planning retention at the outset of
treatment.
It is thus obvious that such statements as:
Wrinkling of the teeth represents a true com-
parison of similar changes occurring for the
other structures of the body; that is, the teeth and
periodontium undergo the same changes as for
example the skin, hence, wrinkling of the skin.
Moreover, as portrayed in this section of
untreated changes, late mandibular incisor
crowding may be unrelated to any previous
orthodontic treatment. There is no doubt that
normal untreated occlusions provide valuable
insight into longitudinal changes and thus
management of tooth alignment.

Changes in treated dentitions

Numerous long-term treatment results or stabil-
ity studies have been published. The reader is
referred to a previous edition of Seminars in
Orthodontics, Stability and Long-term change,
Volume 5, number 3, 1999. Equivalent changes,
albeit more or less as shown for the untreated
Figure 6. (A) Craniofacial growth maturity gradient:
males 416 years.86 Note the late vertical maturation of
Ar-Go. (B) Craniofacial growth maturity gradient:
females 416 years.86 Note the late vertical
maturation of Ar-Go.

Mandibular growth and its effect on late

mandibular incisor crowding
Changes in mandibular growth direction and
rotation during the post-treatment and post-
retention periods have also been implicated in
the etiology of late incisor crowding.8385
In addition, the vertical development of Figure 7. Little32 irregularity changes from the pre-
the mandibular ramus continues until late treatment (T1) to the post-retention observation (T3).
 The need for retention
Figure 8. Mean overbite changes.
dentitions, have been recorded for treated
dentitions. Herewith, three examples to show
these changes.
Two classic follow-up long-term studies using the
same sample, but providing data at different time
points
The rst project portrayed occlusal changes
following mechanotherapy subsequent to
extractions91 and it was published 10 years post-
retention. Treatment was completed with Edge-
wise xed appliances and the following obser-
vations were recorded by Little and co-workers.
(a) T1: The subjects showed 70% moderate to
severe irregularity, 23% moderate, and 54%
severe.
(b) T3: The subjects still showed 70% moderate
to severe irregularity; but now the reverse was
measured, 56% moderate; and 16% severe.
(c) The important observation is that the treated
occlusions for this sample appeared to have
returned to the same percentage of irregu-
larity prior to the start of treatment, 70%.
This same sample was recalled after 20 years
post-retention; that is, 20 years following ortho-
dontic mechanotherapy subsequent to extrac-
tions.92 Again Little and co-workers observed
interesting changes.
a) 30% of the 10-year group showed clinically
acceptable incisor alignment. According to 32
the irregularity index should measure
between 0 and 3.5 mm.
b) 10% of the 20-year group showed clinically
acceptable incisor alignment.
c) Needless to say, one can criticize the proto-
cols of the studies as compared to others
117
that have shown apparent greater stability,
treated by one clinician utilizing one philos-
ophy and other reasons, however, the results
are still clinically concerning especially
with these signicant post-retention changes.
Thus, retention protocols must be strictly
enforced to ensure acceptable long-term
outcomes.
d) In addition, the changes recorded followed
similar patterns to untreated dentitions.
Serial extraction without treatment matched to
untreated and treated samples from a Growth
Center
Post-retention mandibular incisor stability was
recorded after premolar serial extraction.93 The
experimental sample of 22 subjects included 12
males and 10 females. Serial extraction was used to
correct tooth size arch length discrepancy, but not
followed by comprehensive appliance therapy.
This experimental sample was matched to an
untreated control group to form pairs (5 years
post-retention); all obtained from the Burlington
Growth Center, University of Toronto. Incisor
irregularity was measured according to the Little32
protocol at T2 and T3 (Not at T1 due to
unerupted canines). These untreated samples
were compared with an extraction followed by
an orthodontic appliance treated group similar to
that of the treated extraction groups noted above
by Little et al.91 The conclusions of the Woodside
et al.93 study are as follows:
a) No differences were measured between serial
extraction and untreated matched groups at
(T3) (p 4 0.05).
Figure 9. Mean overjet changes.
118 Rossouw and Malloy Jr

c) No long-term stability predictors of clinical

value were identied.
d) No gender differences existed at T3.
e) Mechanotherapy was the only distinctive
difference between the groups and it could
be speculated that the impact of tooth move-
ment through the orthodontic treatment
possibly inuenced the outcome.

The latter results make one referred back to

Figure 10. Mean intercanine width changes.
Lower incisor irregularity follows the normal
b)
growth pattern and was independent of serial
extractions.
an old, but the information still match that of any
contemporary report regarding the skills of the
clinician94:
(i) The number of mechanical aids has
increased.

Figure 11. The authors favorite retainers from the sagittal (A and B), frontal (C), maxillary occlusal (D), and
mandibular occlusal (E) views. These removable modied Hawley retainers allow proper hygiene, adjustments
when needed, and appropriate settling of the occlusion. The rigid design also allows for long-term part-time use.
 The need for retention
(ii) Few have been successful, many failed.
(iii) Success depends much on the manipulative
skills of the clinician.
A long-term stability study from a clinical practice
(approximately 11 years post-retention), one
clinician and one treatment philosophy.7,95
The following acceptable post-treatment changes
were observed:
1. Total arch crowding was completely corrected,
actually some band spaces were present;
however, crowding returned, but not to the
same extent and clinically very acceptable at
T3. Fig. 7 portrays the irregularity index
showing the post-treatment alignment with a
practically zero measurement, but with sig-
nicant changes at T1 and T3. However, T3 is
still after the post-retention period well within
the Little32 clinically acceptable range of
03.5 mm.
2. Overcorrection appeared to have played a role
in the eventual physiologic stable result; over-
bite and overjet were overcorrected and
expected changes as for untreated occlusion
occurred, but the outcome at T3 was within
the acceptable norms (Figs. 8 and 9).
Figure 12. An example of a long-term post-retention result showing a class I, well-aligned, healthy, esthetic,
functional, and stable occlusion; preferably without fulltime retention.
119
3. Intercanine width was slightly, but insignif-
icantly expanded during treatment (T1T2).
Post-treatment as measured at the post-
retention interval (T3) a signicant decrease
occurred and this although small, went
beyond the original measurement (Fig. 10).
4. As noted before; these changes indicate that
retention is an important treatment adjunct
process (Fig. 11).
Retention Protocol
Taken into consideration that change in the
occlusal contacts will occur in the long term, the
following example of a retention protocol is
recommended.33
1. Wear the removable retainers during the rst
month as much as possible.
2. Drink water to adapt, but remove the retainers
when eating.
3. A dental hygiene regimen should be followed
without the retainers in place. Moreover,
proper hygiene measures must also be in
place for the retainers.
4. After the rst month, the retainers only have
to be worn at home and at night. This is a
practical schedule as retainers are then kept at
120 Rossouw and Malloy Jr
home and misplacement elsewhere will be at a
minimum.
5. Retention visits are initially scheduled at 6
weeks; 3 months; 6 months; 1 year and then
annually.
6. As a rule of thumb, the retainer should be in
place at least for the same duration as the
treatment time; however, keep in mind that
depending on the age at T2, the physiologic
changes may be rapid or leveled off.29,31,39
Retainer wear should be determined
accordingly.
7. A classic regimen also is to wear the retainers
full time for half of the treatment time. Then
divide the remainder of the treatment time
in two periods; the rst period is for at home
wear and the second period is for night-time
wear; thereafter the retainers can be main-
tained for night-time wear or can be weaned
away by alternate night wear until it is worn
only to test for a good t. If there is any
difculty in the t, then an adjustment or at
least night-time wear be maintained.
8. The ultimate goal is no retainers.51,96 The
wean away process as described is thus
important. Some patients prefer to maintain
night-time retainer wear, and with no adverse
evidence shown for this exercise, it is recom-
mended to maintain night wear until the long-
term changes have minimal effect.29,31,39
Conclusion
1. To truly understand something is to under-
stand how it changes over time.
2. Untreated and treated changes in the denti-
tion do occur; unpredictably at times.
3. Retention, irrespective of the chosen appli-
ance to fulll this action, is an important
process and often underestimated in todays
clinical practice.
4. It is imperative to be cognizant of the different
descriptions of long-term change to enable the
clinician to interpret stability of the nished
result and also provide adequate communication
of possible post-treatment changes to prospective
patients. Thus, all orthodontic patients should be
well-informed of the expected long-term changes
and the need to conform to retention protocol.
5. The retention process can thus be seen as
another phase of orthodontic carea phase
where the occlusion is observed as it accom-
modates to a new environmentin addition,
minor adjustments can be made in order to
facilitate this settling and wean the patient
away from the retaining devices as maturity
of the adolescent is attained or when the
desired outcome goals have been established.
However, some occlusions may necessitate
permanent retention either to maintain a
patients objective or to negate the inuences
of aberrant neuromuscular inuences.
6. The nalization process should include active
stabilization and passive guidance procedures,
rather than rigid xation of teeth, which after
treatment could be in non-physiologic positions.
7. The purist orthodontist or the true occlusion-
ist endeavors to produce a healthy, func-
tional, esthetic, and physiologic stable
occlusion that will last for the patients lifetime
(Fig. 12).
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