orthodontic finishing and retention

Orthodontic Finishing and
Retention
www.indiandentalacademy.com

When is the patient ready for
finishing?
• Most active treatment is completed
• Canines are in Class I
• Alignment of the arches is relatively close
and coordinated
• Extraction spaces are closed
• Roots are reasonably parallel

Finishing Checklist
• Check for root parallelism on progress
panorex
• Check for marginal ridge height
discrepancies, incisal edge alignment, and
rotation corrections
• Check for proper pre-prosthetic spacing
• Check overjet, overbite, and midlines
• Check occlusal contacts

Root Parallelism
• Take a panorex 6 to 12 months prior to
anticipated finishing
• Uprighting roots can be achieved through bends
in the archwire or repositioning of the brackets

Mariginal ridges of the posterior
teeth should be level
• Easiest way to align marginal ridges is more
precise bracket placement at the start of
treatment
• Can be achieved by adding second order bends
to the archwire
• Ideal finishing archwires are flexible but able to
hold a bend ex. Beta-Titanium, multi-stranded
rectangular steel, round steel

Incisal edges should be even
• Incisal edges should line up unless
planning for post-ortho restorations
• Best achieved through bracket placement
• Repositioning late may extend the length
of treatment
• Bends in the wire can account for vertical
and in and out discrepancies caused by
different thickness of the teeth and bracket
depths

Pre-prosthetic spacing

Leveling Gingival Margins

Overjet, Overbite, and Midlines
• Ideally the overjet is 0 when measured
from the labial of the lower incisor to the
lingual of the upper incisor
• Overcorrection of anteroposterior may be
necessary especially in severe Class II
and III cases

Overjet

Overjet, Overbite, and Midlines
• The upper incisors should overlap 30-40%
the lower incisors
• Overcorrection should be considered in
deep bite and open bite situations.
• Midlines may not be coincident if there are
tooth size discrepancies
• The upper midline can be off as much as
4mm without notice

Overbite

Occlusion
• Check molar and canine relationships
• Use articulating paper to check contacts
• Evaluate incisal guidance and canine rise
• Interferences may need to be adjusted
• Settling may be necessary

Settling
• Usually use a light archwire that has any
finishing bends duplicated
• Common choices are multi-stranded
rectangular steel and round steel because
they allow for more individual movement
of the teeth
• Archwires can also be removed, and the
teeth can be laced together with a steel
ligature to prevent space opening

Settling
• Vertical elastics are used for
approximately 2 weeks to pull the teeth
together and increase contact
• The goal is to achieve a “socked in”
occlusion

Settling with Multi-Stranded Wire

Tooth Positioner Used for Settling

Positoners
• Impressions are made prior to debonding
• Teeth are set into ideal positions
• Positioner is made to the ideal set-up
• Useful in cases where there is a lot of
gingival hypertrophy
• Actively worn for about 4hrs./day
• Worn passively at night

Ideal Goal

Final Records
• Lateral Ceph, Panorex, Models, and
Photos optional AP ceph, PA x-rays
• Can be done immediately after debonding
or after allowing the gingiva to heal and
teeth to better settle
• Pre- and Post-treatment tracings should
be compared to evaluate the radiographic
results

Superimposition for Profile

Superimposition of Maxilla and
Mandible

Why Retention?
• Maintain the corrected alignment
• Allow time for the gingival and periodontal
tissues time to reorganize
• The teeth are inherently unstable
immediately after removal of fixed
appliances
• Counteract changes that may result from
growth

Retention is Essential for Three
Reasons
• the gingival and periodontal structures and
tissues affected by orthodontic tooth movement
require time for reorganization once appliances
are removed.
• the teeth may be in an inherently unstable
position and , therefore, susceptible to relapse
produced by the surrounding soft tissue
pressures.
• growth changes may modify the treatment
result.

The Influence of the Periodontal
Tissues on Stability and
Retention
• The periodontal ligament will reorganize
over a period of three to four months.
• The gingival tissues will remodel more
slowly over a longer period of time.
• Supracrestal fibers may take up to one
year to remodel.

The Influence of Soft Tissue
Pressures on Retention and
Stability
• Without establishing or maintaining a
balance of the forces created by the
tongue, lips and cheeks during and after
treatment, soft tissues may produce a
relapse tendency

The Influence of Growth on
Retention and Stability
• most orthodontic treatment is initiated and
completed during the early permanent
dentition and is likely to be completed
during a time when the patient is still
growing.
• there is a lasting growth potential for the
orofacial complex

The Influence of Growth on
• A protracted period of growth is of
particular concern in patients whose
original malocclusion was an outcome of
their pattern of skeletal growth.
• Though it is often an aid in rectifying
many types of orthodontic problems,
growth may also be a cause of relapse in
treated individuals.

Planning for Growth

Planning for Stabilization and
Retention
• A strategy for the retention of a treated
orthodontic case should be considered at
the time of diagnosis and treatment
planning and should be reviewed at the
time the case is ready for
debonding/debanding

Procedures and Appliances
Utilized for Stabilization and
Retention
• Removable appliances
• Adjunctive Surgical Procedures to Help
Stabilization and Retention
• Fixed Appliances for Retention and
Stabilization

Maximizing Stability,
Minimizing Relapse
(modified from Joondeph, D.R and Reidel, R.A. 1994)
• Teeth that have been moved tend to
return to their original positions.
• Elimination of the cause of a malocclusion
will prevent relapse.
• Malocclusion should be overcorrected as
a safety factor.

Maximizing Stability, Minimizing
Relapse (cont’d)
• Proper occlusion is an important factor in
holding teeth in their corrected positions.
• Bone and adjacent tissues must be
allowed to organize around newly
positioned teeth.
• If mandibular incisors are placed upright
over basal bone, they are more disposed
to remain in good alignment.

Maximizing Stability, Minimizing
Relapse (cont’d)
• Corrections achieved during periods of
growth are less likely to relapse.
• The further teeth have been moved the,
the less likelihood there is of relapse.
• Arch form particularly in the lower arch,
can not be permanently altered by
appliance therapy

Retention Planning:
No Retention
• Corrected anterior crossbites with good overbite.
• Posterior crossbites with good torque and axial
inclinations of the corrected problem.
• Some serial extraction cases.

Retention Planning:
No Retention
• Cases where maxillary growth was
restrained and the patient has stopped
growing.
• In a dentition where teeth have been
separated to allow for the eruption of teeth
which had been blocked out.

Retention Planning:
Limited or Finite Retention
• Class I cases, treated non-extraction,
characterized by spacing and protrusion of
the maxillary incisors.
• Extraction cases, class I or II. Depending
on the original problem and the patient’s
adaptation to diminishing amounts of
retainer wear, it is difficult to predetermine
the time schedule for retention of these
cases.

Retention Planning:
• Corrected deep overbites which often
require retention in the vertical plane.
• Rotated teeth, corrected early (before root
formation completed), in the mandibular
incisor area. These cases may also be
helped by limited surgical procedures.

Retention Planning:
• Class II Division 2 cases may require an
extended period of retention to allow for
musculature adaptation.
• Cases where supernumerary were present
or ectopic eruptions have been corrected
may require extended periods of retention.

Retention Planning:
Permanent or Continuous Retention
• Cases where expansion accounts for a
significant portion of the correction, especially
mandibular arch expansion.
• Cases where considerable space between the
maxillary central incisors have been closed or
where considerable generalized spacing has
been corrected.
• Where severe rotations or labio-lingual
malpositions have been corrected (especially in
adults).

Four Major Indications for Fixed
Orthodontic Retention
• maintenance of lower incisor position
during late stages of growth.
• maintenance of diastema areas and other
areas where naturally occurring spaces
have been closed.
• maintenance of pontic spaces.
• maintenance of extraction areas where the
space has been closed.

Removable Appliances for
• Positioners
• Hawley retainers
• Clear overlay
retainers
• Spring realigners
• Functional appliances

Hawley Retainer
• Advantages:
• Can be used in most cases
• Hygiene not an issue
• Can add different adjuncts

Hawley Retainer
• Common Adjuncts:
• Long labial bow
• Springs for minor tooth movement
• Bite Plate
• Acrylic teeth
• Acrylic on the labial bow

Hawley Retainer
• Disadvantages:
• Requires patient compliance.
• Visible labial bow.
• Interproximal wire may case opening of spaces.
• High incidence of breakage and loss.

Positioner

Positioner
• Advantages:
• Teeth re-set in
laboratory to ideal
position.
• Final adjustments can
be made without fixed
appliances.
• Disadvantage:
• Difficult to wear- thus
not good as a long
term retainer.
• Not good for rotations

Spring Re-aligner
• Advantages:
• Teeth re-set in laboratory to ideal position.
• Can correct minor relapse of crowding of
anterior teeth.
• Can be used as passive retainer once
correction is obtained.
• Disadvantages:
• For minor corrections only.

Spring Re-aligner

Fixed Retainers
• Indications:
• Maintenance of lower incisor position during late stages
of growth
• Maintenance of space closure of naturally occuring
spaces or extraction spaces
• Maintenance of pontic space.

Fixed Retainers
• Types:
• Bonded flexible wire(i.e. Respond, Wildcat)
• Lingual bar with pads bonded to canines
• Traditional or Maryland Bridge
• Lingual wire soldered to bands

Fixed Retainers
• Advantages:
• Does not require patient
compliance.
• Permanent retention.
• Disadvantages:
• Difficult to maintain
hygiene.
• Poor patient acceptance.
• Orthodontist assumes
responsibility for relapse.
• Potential for becoming
de-bonded.

Fixed Retainers

Clear Overlay Retainers
Advantages:
• Patient Acceptance.
• Inexpensive.
• Can be delivered on
same day as de-bond.
Disadvantages:
• Rapidly worn.
• Teeth without occlusal
coverage may become
super-erupted.

Comparison of Retainers
Tibbets, AJO, 1994, 106:671
• Comparison of 3 different types of retainers:
Positioner plus lower bonded 3-3 retainer, Essix
retainer, and Hawley retainer.
• Evaluated 30 cases 6 months after de-bond.
• Evaluated the following criteria: Angle
classification, overjet, overbite, maxillary
intercuspid width, maxillary intermolar width,
mandibular intercanine width, mandibular
intermolar width, maxillary arch length, and
mandibular arch length.

Comparison of Retainers
“The results of this investigation indicate
there is no statistically significant between
treatment type, nor retainer types, with
regard to changes in the criteria above,
during the six month retention period
studied. In general, the changes which
occurred during active treatment remained
relatively stable after treatment during the
period observed.”

Maxillary Frenum
• An abnormal maxillary frenum requires
special consideration in planning
retention.
• Apart from transseptal and
dentoperiosteal fibers of the gingiva, the
fibrils connecting heavy maxillary frenulum
attachments to the alveolar process need
a very long period of remodeling.
(Thilander, Semin Orthod 2000)

Maxillary Frenum

Maxillary Frenum
Retention Strategies
Shapiro, Kokich, Dent Clin, 1981
“A properly designed Hawley retainer can
effectively maintain a closed diastema if
worn conscientiously. A multi-stranded,
flexible wire bonded to the lingual surfaces
of the incisors is an effective method of
fixed retention. In extreme situations, cast
gold restorations can be used to splint the
incisors.”

Adjunctive Surgical Procedures
to Help Stabilization and
Retention
• circumferencial supracrestal fibrotomy (CSF)
• removal of gingival papillae

How long is retention needed ?
• For some patients, lifetime retention will
be necessary.
• For almost all patients some retention will
be necessary.
• Removal of third molars in growing
patients may or may not affect long term
retention

When Instability is Apparent and
Relapse Occurs
• retreatment with limited or full fixed appliances
• placing a mandibular lingual arch
• modifying the patient’s current retainer(s)
• designing and fabricating new retainers
• equilibration
• myofunctional therapy
• accepting minimal relapse and not treating
further

Myofunctional Therapy

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orthodontic finishing and retention

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