Download PBB25 Final Retainer

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VOLUME IV
ISSUE XXV
The Final Retainer
» PRACTICE POTENTIAL:
I have now been in practice for over
twenty years. Over this period so
many patients come through my office that have had orthodontic care
when they were younger and did
not wear their retainers. Others have
never had any orthodontic treatment
but complain that their lower teeth
are beginning to become crowded.
They walk into the office and say
doctor can’t you just fix this. This
lower tooth never used to be this
way.
It made me wonder what is being
done to keep patients’ teeth straight
after they finish orthodontic treatment? What should be done to keep
patients’ teeth straight that have never had orthodontic treatment? And
whose responsibility is it to provide
retention care to our patients?
» DESCRIPTION:
(Relapse and Retention)
Factors that have been evaluated for
their possible effect on Relapse
Development and Aging
Skeletal Changes
Soft-Tissue Changes
Dentoalveolar Changes
Muscle Balance/Soft-tissue Forces/
Habits
The position of the teeth.
Occlusal Factors and Forces
Periodontium
TABLE FORMAT
Arch Length and Width
Curve of Spee
Gender
Severity of Malocclusion
Mandibular Incisor Dimensions
and Position
Serial Extractions with No Appliance Therapy
Serial Extractions with Appliance
Therapy Afterwards
Non-Extraction Treatment with
General Spacing
Lower Incisor Extraction
Early Extractions vs. Late Extractions
Non-Extraction with Rapid Palatal
Expansion Treatment
Non-Extraction Treatment
Extraction Treatment
Extraction vs. Non-Extraction
Treatment
Many studies have been performed
to ascertain if there is a better way
to move teeth that will reduce postorthodontic relapse. They have
looked at every causative factor. I
have included a table of topics that
have been reviewed. For more detail please review Dr. Florman’s article.
The truth is “Relapse happens”, and
it may have very little to do with
the dentist’s treatment mechanics or
plan.
Despite recommended measures
to decrease the chances of relapse,
nothing definitive has been developed. Permanent retention appears
to be the only reliable way to keep
the dental arches in a position similar to that in which they were the
day after the patient’s braces were
removed However, prevention of
dental relapse is possible if an interdisciplinary approach is developed.---FLORMAN
» THE PROBLEM AND THE
SOLUTION:
The problem is Orthodontic practices in this country are not geared to
track patients for more than a year or
two after treatment at best. The majority of these practices are efficient
at treating patients and getting them
into retention but do not continue
to monitor them over their lifetime.
Most orthodontic patients graduate
high school, move away to college,
and lose touch with their orthodontist. The general dental practice is
the only line of defense that exists
to provide the retention services
needed indefinitely. The orthodontist is usually not seen again until a
problem returns, and this patient is
being referred back for re-treatment.
Therefore responsibility for evaluating a patient’s post-orthodontic
occlusion should lie in the hands
of the dentists and the hygienists
who will care for them for the rest
of their lives. Unfortunately most
general dentists have been given so
little orthodontic training that they
follow the ”Don’t ask don’t tell”
philosophy of treatment. That is to
say the majority of dentists do not
even ask their patients if they have
previously had orthodontics done!
This is a huge disservice especially
when patients spend thousands of
dollars and years of their lives to get
straight teeth. The least we could do
is to become part of the process to
help them maintain their beautiful
smile.
» DISCUSSION
Treatment Procedures
Evaluate every patient that
Add an Orthodontic screening
form to your record packet
Evaluate your new patients
Evaluate your old patients
Patients who are no longer under
the care of the orthodontist
Patients who may still be under the
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care of the orthodontist
Discussing options
Examination
Records
Diagnostic casts before records
should be kept
photos
Recall
Patient instructions
b. Do you wear retainers?
Discussing orthodontic retention
with patients should be no different
than discussing brushing and flossing regimens. Preventing relapse is
possible. I recommend the following:
5. Dental professionals need to begin offering retainers to their patients, regardless of whether they
have had braces or not. If patients
need bruxing appliances, combination splint-retainers can be fabricated for the lower jaw.
» TREATMENT
PROCEDURES:
1. Dentists, hygienists, and orthodontists need to inform patients
that retention should be indefinite
regardless of the pre-existing malocclusion, the treatment modality,
or length of time they were in treatment. Because we have no way of
determining who will develop lower
crowding relapse, the retainer will
act as insurance indefinitely.
2. Dental practitioners need to incorporate a statement regarding indefinite retention into their pretreatment informed consent documents
and remind patients at the end of
orthodontic treatment that indefinite retention is a must.
3. Dental practitioners need to develop a regular post-orthodontic
retention program. Fee structures
need to be developed to accommodate retention needs, including
a retainer exam fee, a retainer adjustment fee, a retainer replacement
fee, and, if needed, limited re-treatment fees.
4. Practitioners need to perform “retention relapse examinations” similar to providing their patients with
an oral cancer screening. This is
easily done at the regularly scheduled prophy exam. The exam can
begin with some simple questions:
a. Have you had orthodontic treatment?
c. Do you see your orthodontist to
have them adjusted?
d. Do you know that indefinite retention is necessary?
An oral examination needs to be
performed to evaluate the dentition
for relapse, beginning with the lower incisors.
The general dentist needs to take
advantage of this opportunity to not
only provide their patients with an
invaluable service but to establish a
new income stream for their practice. We have committed our lives
to the practice of dentistry and the
principles of ethics, which were
founded on the basis of non maleficence. We counsel our patients on
brushing, flossing, smoking cessation, effects of tobacco and oral
cancer, bruxing, and sleep disorders. Why has the importance of
orthodontic relapse slipped through
the cracks? We all must continue
the campaign on educating our
peers and patients to the importance
of retention. I hope this article will
be a catalyst for all dentists and hygienists as our profession continues
to evolve.
Patients come into our offices trusting that we will give them a straight
smile. They spend thousands of dollars and years of their lives awaiting straight teeth. We make them
retainers, tell them to wear them,
and send them on their way. The
majority of these patients eventually discontinue their retention and
receive no guidance or support from
the dental community. Although we
blame the patients for not wearing
their retainers after the fact, should
we continue to pretend that is all
their fault?
To that end I would like to make the
following recommendations to help
establish an ideal a system where
patients are being evaluated for
their retention needs:
1. Inform- Dentists, hygienists, and
orthodontists need to inform patients that retention should be indefinite regardless of the pre-existing
malocclusion, the treatment modality, or length of time they were in
treatment. Because we have no way
of determining who will develop
lower crowding relapse, the retainer
will act as insurance indefinitely.
2. Informed Consent- Orthodontists need to incorporate a statement
regarding indefinite retention into
their pretreatment informed consent documents and remind patients
at the end of orthodontic treatment
that indefinite retention is a must
even when they leave the orthodontists care and return to the care of
their general dentist.
3. Retention program-Dental practitioners need to develop a regular
post-orthodontic retention program.
Fee structures need to be developed
to accommodate retention needs,
including a retainer exam fee, a retainer adjustment fee, a retainer replacement fee, and, if needed, limited re-treatment fees.
4. Examinations- Practitioners need
to perform “retention relapse examinations” similar to providing
their patients with an oral cancer
screening. This is easily done at the
regularly scheduled prophy exam.
Discussing orthodontic retention
with patients should be no different
than discussing brushing and flossing regimens. The exam can begin
with some simple questions:
a. Have you had orthodontic treatment?
b. Do you wear retainers?
c. Do you see your orthodontist to
have them adjusted?
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d. Do you know that indefinite
retention is necessary?
5. Prevention- Dental professionals
need to begin offering retainers to
their patients, regardless of whether
they have had braces or not when it
is necessary. If patients need bruxing appliances, a combination upper splint and lower retainers can
be fabricated.
» THE APPLIANCES:
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one time in there career has had to
replace a patients retainer. There
are many different appliance designs and variations but this is the
basic retaining appliance. It features Adam’s clasps on the first molars and a standard, tightly adapted
“Hawley” type labial archwire running from the distal of both cuspids.
The acrylic should be well adapted
to the palate and the lingual aspect
of the teeth. Every effort should also
Note- Please always send both upper and lower casts along with a
bite relationship to the lab for fabrication of this appliance.
Labial Arch Wire Options:
Several different designs are available for the labial wire portion of
these retainers. Detailed description and applications of the most
common ones are listed here and
are described in greater detail in
Appliance therapy design worksheet
- Describe how and why to use it
1115 Open Palate Retainer
be made to keep it thin for comfort.
Note- Please always send both upper and lower casts along with a
bite relationship to the lab for fabrication of this appliance.
This appliance is designed primarily as a final retainer to be used at the
completion of any orthodontic therapy. The area over the hard palate
has been left free of acrylic. Speech
is left virtually unaffected and there
is no danger of the patient developing a deviated swallowing pattern
as the tongue never loses its’ natural contact wit the hard palate. The
ribbon of acrylic that is contacting
the lingual of the anteriors is re-enforced with Kevlar in order reduce
the possibility of fracture. Adams
clasps are used because they stay
retentive over time. Both the clasps
and the labial bow must be designed
to stay out of occlusion to prevent
any unwanted tooth movement.
Note- Please always send both upper and lower casts along with a
bite relationship to the lab for fabrication of this appliance.
1161 Maxillary Final Retainer
Whether you are actively doing orthodontics or not, every dentist at
1162 Simple Mandibular Retainer
Shown here is a basic lower appliance with standard a standard
“Hawley” type labial archwire. Molar rests are placed on the molars for
posterior stability and to keep the
appliance from over-seating into the
tissue. Clasps are optional, the most
commonly requested clasps are Adams Clasps as illustrated in the insert photo. Please be very specific
as to your design preferences when
requesting this appliance.
Chapter 1.
1. Standard Arch: Image 1616A
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2.
Round Contoured:
1616B
Image
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faces from possible abrasion from
the wire.
3. Flat Hawley: Image 1616C
6. Acrylic Arch:
A Flat wire is used to contact the
labial surface of the anterior teeth
and is soldered to the adjustment
loops at the cuspids. The Flat Wire
is contoured back to the distal of the
cuspids and affords added retention
to stabilize the cuspids after movement.
4. Flat “Contoured” Hawley: Image 1616D
Similar to the Flat Hawley, this wire
is individually contoured to the entire labial and interproximal surfaces of the incisors.
5. Plastic “Coated” Hawley: Image 1616E
This wire gains superior anterior
retention through the use of clear
acrylic that tightly conforms to the
labial and interproximal surfaces of
the incisors. This prohibits movement, and particularly rotation, of
the incisors and is often used on
“Wrap Around” labial wires to aid
stability.
7. Reverse Hawley:
1616G
9. Witzig Double Loop:
1616I
Image
Image
The Reverse Hawley is fabricated
with the adjustment loop running
from the distal to the mesial. This
labial wire is excellent when you do
not want any wire on the distal of
the cuspids. A typically scenario requiring this design is when positive
cuspid control is needed, particularly if the cuspid has been rotated
significantly during orthodontic
therapy.
8. Ricketts Arch:
This Labial wire is preferred on retainers when the anterior teeth are
restored with veneers. The Plastic
coating protects the porcelain sur-
Image 1616F
“U” Loops are placed on the laterals
and the distal recurved arms are contoured to the cuspids. These distal
recurves can be used to increase retention as well as help stabilize cuspids that may have required rotation
during active treatment. If carefully
activated, they can be used to effect
minor lingual rotation of the cuspids, unilaterally or bilaterally.
Image 1616H
The Ricketts Arch, like the Reverse Hawley, crosses the dentition
through the embrasures interproximal to the laterals and cuspids. The
This design is a modification of the
Ricketts arch using a narrow vertical loop. This design is excellent
for final stability of the anterior segment but only allows for very minor
adjustments during retention. It is
typically used only when a removable final retainer is preferred after
completion of orthodontic therapy.
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10. Apron Spring Labial – (“Roberts
Retraction Arch) Image 1616J
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11. Wrap Around: Image 1616K
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Note- Please always send both upper and lower casts along with a
bite relationship to the lab for fabrication of this appliance.
1169A Wrap-Around Retainer
– with labial acrylic support
1165 The San Antonio Retainer
length.
Before fabricating the appliance,
the lab will separate the rotated and
crowded anteriors from the stone
cast and reset them in an ideal alignment. The appliance is then fabricated to this corrected anterior position
and sent back to you for delivery.
On the day of delivery complete the
necessary interproximal recontouring, then place the appliance. When
worn, the spring action of the cuspid wires will direct a light labiallingual force to align the teeth.
Once the teeth are straight the appliance can continue to be worn as
a final retainer.
Named for the Texas Study Club
that first described it, this retainer
has many special features worthy of
consideration.
The labial arch wire extends from
molar to molar for excellent retention and control of the entire arch.
Since it does not pass over the occlusal surface, there is no occlusal
interference to prevent proper function. To stabilize the labial, two
small interproximal support wires
pass from the acrylic and wrap
around the arch wire between the
cuspids and the laterals. Also note
the extended arms to the cuspids to
provide support and prevent rotation.
Usually “C” clasps are used distal
of the 12-year molar for retention of
the appliance. These are preferred
in order to prevent any occlusal interference. If retention is a problem
due to buccal crown contour it is
advisable to place a small composite ledge on the molars to create a
retentive undercut for the clasp.
Finally, a thin, heat-cured acrylic
base is used for strength and comfort. During finishing, extra care
must be taken to be sure that the
acrylic is in contact with the entire
lingual surface of each tooth.
Often, due to the long span of the labial archwire in the “wrap-around”
design, the labial wire has a great
deal of flex and can come out of adjustment if the appliance is handled
roughly. To help alleviate this problem, and to add stability and retention to the anteriors, clear acrylic is
processed tightly against the labial
surface of the incisors as illustrated.
This feature adds superior retention
to the overall appliance and eliminates the need for a small interproximal support wire distal to the
lateral incisors as seen in the San
Antonio design.
Note – Since tooth movement is in
a labial-lingual direction, adequate
vertical dimension is essential. If
the patient has a closed vertical and
the upper and lower anteriors are
already in contact tooth movement
will not occur.
AA- show the basic set up that the
lab does and the inter-proximal recontouring that the doctor needs to
accomplish
1331 Modified Spring Retainer
U/L
1065 The Spring Hawley Retainer
This appliance is useful in correcting minor rotations and crowding
up to 1-1/2mm from cuspid to cuspid in the lower anteriors. The space
necessary to correct this crowding
is gained by judicious interproximal recontouring in the anterior region only, as the appliance is NOT
designed to gain any arch width or
This design is useful for correcting
minor rotations of the upper anterior teeth. The teeth are set-up in the
corrected position on the model and
then the appliance is constructed.
Complete the necessary interproximal recontouring on the day of delivery. When in place, the resulting
labial-lingual force will align the
teeth. The helical coil in the labial
wire portion, and the “mushroom”
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helical coil spring design of the active lingual component, make this
appliance very effective for quickly
aligning the incisors.
sentially a finishing retainer and no
significant rotations, or mesial/distal movements should be attempted
with this design.
Adequate space for alignment of the
anteriors is essential and this design
will NOT gain arch width or length.
The appliance may also be used as a
final positioning retainer but is not
recommended for closing spaces.
1164 RAM Retainer (designed by
Dr. Robert A. Meese)
1332 Modified Adaptor™
The Modified Adaptortm appliance
is used for minor tooth rotations
and alignments of both the posterior and anterior teeth. It works like
the spring retainer in that the teeth
on the working model are carefully
placed in their ideal position prior
to fabricating the appliance.
This unique design features a solid
lingual acrylic base that is tightly
contoured to all of the lingual surfaces. The buccal posterior segments
are joined to the lingual via stainless steel wires and the labial portion covering the six anterior teeth
is joined to the posterior segments
via stainless steel Omega Loops in
the cuspid/bicuspid region.
Once seated, this highly flexible
appliance gently settles the teeth
in the correct alignment. Since the
Modified Adaptor™ allows for full
occlusal contact of the posterior
teeth, natural function aids in a rapid and secure settling in of the buccal segments. Unlike a Positioner, it
is extremely comfortable, virtually
undetectable, and can be worn full
time, except while eating.
Please note however, that it is es-
The RAM final retainer adds a twist
to the wrap around designs seen in
other final retainers. First there are
no clasps or support wires crossing the occlusion. Then by using a
sliding labial bow a small amount
of space closure and retraction can
be accomplished. The sliding labial
consists of a .010 X .022 wire that
runs through tubes placed buccal to
the first bicuspid region. Bilateral
elastics are then placed from hooks
at the distal end of the labial wire to
hooks in the molar region that are
on the distal support wires.
gent in wearing their final retainers.
When this happens patients often
prefer to have this corrected without having to wear brackets again.
The Bloore Aligner is excellent for
this purpose. Springs called eyelet
arms are placed lingual to each incisor and individually activated to
move the teeth into alignment. As
needed interproximal reductions
and incisal re-contouring are utilized to gain room and provide an
esthetic result.
Note - When used on the lower arch,
it is important to make sure that the
incisors are not coupling with the
lingual of the uppers prior to initiating treatment as vertical and AP
clearance are required in order to
successfully correct the lower anteriors. Once the anteriors are realigned, it is recommended to consider using a fixed lingual retainer
for final retention.
AA – Activating the eyelet arms
1116 The “Invisible” Retainer
Note - A positive overjet is necessary if lingual retraction is required
for the space closure.
1076F Bloore Aligner
U/L
After completing orthodontic therapy it is not uncommon for patients
to experience a small amount of
relapse crowding in their upper or
lower incisors. This is especially
true when they have not been dili-
Here is popular retainer design
for the extremely appearance conscious patient. It is fabricated from
a thin sheet of clear acrylic that is
vacuum-formed to the occlusal and
incisal surfaces of the entire arch.
The completed appliance typically
extends over the buccal and labial
surfaces, and is typically finished
just short of the gingival margins
on the labial and buccal surfaces.
On the upper appliance, the palate
is horseshoed for patient comfort.
Note- These retainers are quite thin
and are contra-indicated for anyone
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who bruxes their teeth. Also, the patient needs to be instructed on the
gentle care required for this appliance.
tach them to the prescription slip.
We will reseat your bands on the
model and guarantee you a better
fit.
2164 Three to Three Fixed Banded Retainer
AA – Cementation.
maintain anteriors after orthodontic
treatment, it is no longer considered
2166 – Banded 4x4 Retainer U/L
adequate. Recent research shows
that it is necessary to bond each
tooth individually to maintain them
in their corrected position.
Shown here is a cuspid to cuspid,
stainless steel banded, lingual retainer which can be made either
from your preformed bands or from
our own custom fit bands. The lingual wire is carefully adapted to be
in direct contact with the lingual
surfaces of each anterior tooth and
is typically placed 2mm below the
incisal edge.
Important note- Although this is
one of the most common designs
used to maintain lower anteriors
after orthodontic treatment, it is no
longer considered adequate. Recent
research shows that it is necessary
to bond each tooth individually to
maintain them in their corrected position.
AA- On all fixed banded appliances
Space Maintainers will fabricate
custom bands unless you prefer to
use your own preformed bands.
When sending your own bands,
please do not pour them up in the
impression. Take the impression
without the bands in place and at-
Many clinicians recommend including the first bicuspids in all fixed retainers. This is especially true when
significant orthodontic movements
have been necessary to achieve the
desired final results. The lingual
wire is carefully adapted to be in
direct contact with the lingual surfaces of each anterior tooth and is
typically placed 2mm below the incisal edge.
Important note- Recent research
shows that it is necessary to bond
each tooth individually to maintain
them in their corrected position.
Individual anterior teeth can be secured to the lingual wire by simply
adding composite over the lingual
wire.
2165 Direct Bond Fixed Retainer
This appliance is bonded to the lingual of the cuspids by the use of
custom contoured, direct bond pads.
These pads have a metal-mesh backing for superior retention. The lingual wire is carefully contoured and
routinely placed 2mm below the
incisal edges unless prescribed otherwise. Additionally, many choose
to add the first bicuspids into the
retentive unit as illustrated in the
inserted photo.
Important note- Although this is one
of the most common designs used to
AA- bonding the retainer into place
2212 E-Z Bond Lingual Retainer
The E-Z Bond Retainer is a multistrand, dead soft, wire that is carefully contoured to the lingual of the
six anterior teeth and is light-cured
with composite to each of the six
anterior teeth.
The key advantage to this appliance is use of a laboratory fabricated transfer tray that makes correct
placement of the wire easy with a
minimum of chair time.
The transfer tray has small reservoirs at each bonding site with an
excess material escape channel directly lingual to each of the anterior
teeth. This assures a complete wrap
of bonding cement around the lingual wire.
To place the appliance, the reservoirs are filled with composite by
use of a syringe. The tray is then
gently seated by finger pressure,
allowing any excess composite to
flow out of the escape channels.
Then it is light cured.
After curing the material, any excess
cement is removed from the tray
with a high speed hand piece and
a diamond. Then the tray is slowly
and carefully lifted off of the teeth.
The top of the individual composite
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buttons can then be polished for patient comfort with a composite diamond or disc.
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5511 The Positioner
Complete, step by step, chairside
instructions are provided with your
first E-Z Bond Retainer.
NOTE: When requesting an E-Z
Bond Retainer for the maxillary
anteriors, it is important to send
an opposing model and a wax bite.
Sufficient overbite and overjet is essential to provide clearance for the
maxillary E-Z Bond Retainer.
AA- Show step by step, how to
bond this appliance in place
2166M – Bonded
Bonded
Fixed Lingual Retainers
Long-term, post-orthodontic treatment studies suggest that some degree of relapse is inevitable. The
most recent research shows that it
is necessary to bond each tooth individually to maintain them in their
corrected position. This is hard to
accomplish without making it more
difficult for the patient to maintain
their hygiene. Typically patients
who have lingual bonded retainers
have to use floss threaders to clean
interproximally.
The lingual bonded retainer shown
here is designed to allow the patient
to floss normally making much easier for them to maintain a healthy
oral condition. Using Australian
wire, loops are placed between all
the teeth except in the lower incisor region where the interproximal
distances are to close. These loops
avoid the interproximal areas allowing the patient to floss. A Floss
Threader is recommended for use
between the lower incisors.
AA – Adjustment of the acrylic
AA – Checking for sore spots and
high spots
AA- show the basic set up that the
lab does and the inter-proximal recontouring that the doctor needs to
accomplish
» CARE FOR THE
APPLIANCES:
The Positioner is mainly used to help
settle in the occlusion at the end of
a full fixed bracket and band case.
This retaining appliance is fabricated from flexible plastic (silicone or
rubber) and is typically made into
a slightly over treated Class I relationship.
The appliance is fabricated after the
individual teeth are cut from a current set of models and reset into an
ideal relationship. Impressions for
this appliance can be taken with
brackets still in place. This will allow you to deliver the appliance
immediately on the same day that
you plan to remove your bands and
brackets. Upon delivery the patient
is instructed to clench their teeth
into the Positioner on a scheduled
basis. This action not only allows
for a gentle settling-in of the individual teeth into their correct positions, but it also has a functional
element of establishing a correct interarch relationship. Various colors,
as well as the standard clear material, are available for this appliance.
Note: A specific “Set-up and Positioner Prescription” form is available upon request.
Both fixed and removable appliances need special care. Some of
the most common problems are addressed below:
1. Fixed orthodontic appliances will
demand special oral hygiene care.
We highly recommend the use of
fluoride to help prevent caries activity.
2. It is often a good idea to give your
patient some Brace Relief (a medicated orthodontic wax) to protect
their tissues from being irritated by
the brackets and wires.
3. Never allow a removable appliance near high temperatures or allow it to dehydrate for more than 24
hours.
4. All appliances should be kept
moist when not in use. A retainer
case works nicely. The patient
should simply place the appliance
in the case with a small piece of wet
paper towel.
5. All appliances should be cleaned
every day. A soft brush and toothpaste, or soaking in denture cleaner,
is all that is needed.
AA – Always check the casts in occlusion to help you select the proper
clasps and their
placement
6. Removal of the appliance is best
accomplished by using equal pressure on both sides of the mouth.
This will minimize the chance of
damage to the resilient portion of
the appliance.
AA – Adjustment of Adams clasps
Contraindications and Concerns
AA - Adjustment of the labial bow
Circumfrential Supracrestal Fiberotomy (CSF) is one of the only
Adjustment Tips
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successful post-orthodontic treatments to show any long-term
success in preventing rotational
relapse. CSF is performed immediately after removal of the orthodontic appliances. By releasing
the soft-tissue tension and allowing
the reattachment of periodontal fibers, moderate long-term success
has been shown in preventing rotational relapses. This treatment has
been well studied. After CSF, little
or no attachment loss has been described in any significance, nor any
other negative sequelae. It is highly
recommended that patients with
moderate to severe pre-orthodontic
rotations in the
lower anterior undergo CSF.
» LAB REQUIREMENTS:
Space Maintainer’s goal is to give
you the best service possible. To
help us get your lab work back to
you on time, we need the following:
1. A detailed prescription. If you are
having a problem designing an appliance have a look at our Practice
Building Bulletin called The Appliance Therapy Worksheet. After
a few go throughs with this sheet
you’ll be have no problem designing an appliance.
2. Always give us the date wanted
and when appropriate the patients’
appointment date. If there is a problem in meeting the due date the lab
will call.
3. Accurate casts poured in stone
that capture all the teeth and land
areas . Air bubbles or holes on tooth
surfaces are unacceptable as they
can negatively effect the fit of the
appliance.
4. Provide a carefully taken construction bite that represents the
exact vertical and AP position that
you desire in the finished appliance.
This is the single most important
step to successful treatment after
making the correct diagnosis.10 IT
IS IMPORTANT TO CHECK THE
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COMPLETED CONSTRUCTION
BITE BY PLACING IT BACK ON
THE WORKING MODELS. Then
carefully wrap the bite separately
for shipment.
» SUPPLY LIST:
Whether you have been practicing
for one month or forty years you
will find that you already have almost everything on this supply list.
Be sure to take a moment and review
it. Is there a favorite instrument that
you use that I have left out?
Appliance Design Worksheet*
Kromopan Impression Material*
Fluoride Releasing Band Cement*
Regular or Light Cure
Wet Field Bonding Adhesive*
White Utility Comfort Wax Or
Brace Relief*
Interproximal Stripping Tool*
Vinyl Mixing Bowl*
Wide Blade Spatula*
Distilled Water
Impression Trays* (We Recommend A Rim Lock Design)
Impression Tray Tree
Acrylic Burs*
Acrylic Polishing Burs*
Acrylic Repair Kit*
Pressure Pot*
139 Bird Beak Pliers*
Three Prong Pliers*
Stiff Robinson Brush*
Etchant*
Retainer Brite*
Sonic Appliance Cleaner*
Patient Appliance Care CD*
Patient Calendar Booklets*
Colored Retainer Cases*
ing dentistry since 1991. He is highly respected as both an orthodontist
and an educator. He has authored
over forty scientific publications
in the field of dentistry and medicine. Dr. Florman is the Executive
Program Director for the Academy
of Dental Therapeutics and Stomatology, a national dental continuing
education organization. He is also
an active clinical advisor to many
pharmaceutical and dental companies. He is a member of the American Dental Association, California
Dental Association, and the American Association of Orthodontists.
His hobbies include golf, running,
hiking, bicycling, photography, and
computer graphic design.
» REFERENCES
1. Vaden, J.L., Harris, E.F., Gardner, R.L. “Relapse revisited.”Am
J. Orthod Dentofacial Orthop. 17
May;111(5):543-53.
2. Little, R.M. “Stability and relapse
of dental arch alignment.” Br J Orthod. 1990 Aug;17(3):235-41.
3. Bjork, A., Hlem, S. “Prediction
of the age of maximum pubertal
growth in body height.” Angle Orthod 1967 37:134
4. Akgul, A.A., Toygar, T.U. “Natural craniofacial changes in the third
decade of life: a longitudinal study.”
Am J Orthod Dentofacial Orthop.
2002 Nov;122(5):512-22.
* available from Success
Essentials call 800-423-3270.
5. Bishara, S.E., Treder, J.E., Jakobsen, J.R. “Facial and dental
changes in adulthood.” Am J Orthod Dentofacial Orthop. 1994
Aug;106(2):175-86.
Michael Florman, DDS
6. Moorreess, C.F.A. “The dentition
of the growing child.” Cabridge:
Harvard University Press;1959.
» AUTHOR PROFILE
Dr. Florman received his dental degree from the Ohio State University and completed his post graduate training in Orthodontics at New
York University. Dr. Florman is a
Diplomate of the American Board of
Orthodontics, and has been practic-
7. Sinclair, P., Little, R. “Maturation
of untreated normal occlusions.”
Am J Orthod Dentofacial Orthop
136:83;114-23
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8. Blake, M., Bibby, K. “Retention
and stability: a review of the literature.” Am J Orthod Dentofacial Orthop. 122 Sep;114(3):299-306.
9. Sinclair, P., Little, R. “Dentofacial maturation of untreated normals.” Am J Orthod Dentofacial
Orthop 134;88:146-156
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19. Acar, A., Alcan, T., Erverdi, N.
“Evaluation of the relationship between the anterior component of
occlusal force and postretention
crowding.” Am J Orthod Dentofacial Orthop. 2002 Oct;122(4):36670.
10. Sinclair, P.M., Little, R.M.
“Maturation of untreated normal
occlusions.” Am J Orthod. 136
Feb;83(2):114-23.
20. Southard, T.E., Southard, K.A.,
Tolley, E.A. “Periodontal force: a
potential cause of relapse.” Am J
Orthod Dentofacial Orthop. 1992
Mar;101(3):221-7.
11. Carter, G.A., McNamara, J.A. Jr.
“Longitudinal dental arch changes
in adults.” Am J Orthod Dentofacial
Orthop. 122 Jul;114(1):88-99.
21. Bishara, S.E., Jakobsen, J.R.,
Treder, J., Nowak, A. “Arch width
changes from 6 weeks to 45 years
of age.” Am J Orthod Dentofacial
Orthop. 17 Apr;111(4):401-9.
12. Melrose, C, Millett, D.T. “Toward a perspective on orthodontic
retention?” Am J Orthod Dentofacial Orthop. 122 May;113(5):50714. Review.
13. Reitan, K. “Tissue rearrangement during retention of orthodontically rotated teeth.” Angle Orthod
1959;29:105-13
14. Burzin, J, Nanda, R. “The stability of deep overbite correction in
retention and stability.” Orthodontics. 1993:61-79
15. Beyron, H.L. “Occlusal changes
in adult dentition.” J Am Dent Assoc. 1954 Jun;48(6):674-86. No abstract available.
16. Southard, T.E., Behrents, R.G.,
Tolley, E.A. “The anterior component of occlusal force. Part 1. Measurement and distribution.” Am J
Orthod Dentofacial Orthop. 123
Dec; 96(6):493-500.
17. Southard, T.E., Behrents, R.G.,
Tolley, E.A. “The anterior component of occlusal force. Part 2. Relationship with dental malalignment.”
Am J Orthod Dentofacial Orthop.
1990 Jan; 97(1):41-4.
18. Okeson, J.P. “Management of
Tempromandibular Disorders and
Occlusion.” Mosby 5th edition.
pgs.109-148
22. De Kock, W. “Dental arch depth
and width studies longitudinally 12
years of age to adulthood.” Am J
Orthod 1972;62:56-66
23. Moussa, R., O’Reilly, M.T.,
Close, J.M. “Long-term stability
of rapid palatal expander treatment
and edgewise mechanotherapy.”
Am J Orthod Dentofacial Orthop.
1995 Nov;108(5):478-88.
24. De La Cruz, A., Sampson, P.,
Little, R.M., Artun, J., Shapiro, P.A.
“Long-term changes in arch form
after orthodontic treatment and retention.” Am J Orthod Dentofacial
Orthop. 1995 May;107(5):518-30.
25. Rossouw, P.E., Preston, C.B.,
Lombard, C.J., Truter, J.W. “A longitudinal evaluation of the anterior border of the dentition.” Am J
Orthod Dentofacial Orthop. 1993
Aug;104(2):146-52.
26. Shannon, K.R., Nanda, R.S.
“Changes in the curve of Spee with
treatment and at 2 years post treatment.” Am J Orthod Dentofacial
Orthop. 2004 May;125(5):589-96.
27. Ormiston, J.P., Huang, G.J.,
Little, R., Decker, J.D., Seuk, G.D.
“Retrospective analysis of longterm stable and unstable orthodontic
treatment outcomes.” Am J Orthod
Dentofacial Orthop. 2005 Nov;
128(5):575-582.
28. Shields TE, Little RM, Chapko
MK. Stability and relapse of mandibular anterior alignment: a cephalometric appraisal of first-premolar-extraction cases treated by
traditional edgewise orthodontics.
Am J Orthod. 1985 Jan;87(1):2738.
29. Houston WJ. Incisor edgecentroid relationships and overbite depth. Eur J Orthod. 1989
May;11(2):139-43.
30. Peck, S., Peck, H. “Crown dimensions and mandibular incisor alignment.” Angle Orthod
1972:42;148-153
31. Shah, A.A., Elcock, C., Brook,
A.H. “Incisor crown shape and
crowding.” Am J Orthod Dentofacial Orthop. 2003 May;123(5):5627.
32. Mills, L.F. “Arch width, arch
length and tooth size in young adult
males.” Angle Orthod 1964:34:1249
33. Keane, A., Engle, G. “The mandibular dental arch. pat IV. Prediction and prevention of lower
anterior relapse.” Angle Orthod
137;49:173-80
34. Smith, R.J., Davidson, W.M.,
Gipe, G.P. “Incisor shape and incisor crowding; a re-evaluaion of the
Peck and Peck ratio.” Am J Orthod
130;82:3-5
35. Puneky, P.J., Sadowsky, C., Begole, E.A. “Tooth morphology and
lower incisor alignment many years
after orthodontic therapy.” Am J
Orthod 135;86:299-305
36. Glynn, G., Sinclair, P.M., Alexander, G. “Nonextraction orthodonitc therapy: posttreatment dental
and skeletal stability.” Am J Orthod
Dentofacial Orthop 132;92:321-8
37. Strang, R. “The fallacy of den-
The Practice
ture expansion as a treatment procedure.” Angle Orthod. 1959; 19:1222
38. Weinstein, S., Haack, D.C.,
Morris, L.Y., Snyder, B.B., Attaway,
H.E. “On an equilibrium theory of
tooth position.” 1963:33;1-26.
39. Reitan, K. “Principles of retention and avoidance of posttreatment relapse.” Am J Orthod. 1969
Jun;55(6):776-90. Review. No abstract available.
40. Little, R.M., Riedel, R.A., Stein,
A. “Mandibular arch length increase
during the mixed dentition: postretention evaluation of stability and
relapse.” Am J Orthod Dentofacial
Orthop. 1990 May;97(5):393-404.
41. Little, R.M., Riedel, R.A.
“Postretention evaluation of stability and relapse-mandibular arches
with generalized spacing.” Am J
Orthod Dentofacial Orthop. 123
Jan; 95(1):37-41.
42. Riedel, R.A., Little, R.M., Bui,
T.D. “Mandibular incisor extraction--postretention evaluation of
stability and relapse.” Angle Orthod. 1992 Summer;62(2):103-16.
43. McReynolds, D.C., Little, R.M.
“Mandibular second premolar extraction--postretention evaluation
of stability and relapse.” Angle Orthod. 144 Summer;61(2):133-44.
44. Amott, R.D. “A serial study
of dental arch measurments on
orthodonitc subjects: 55 cases at
least 4 years postretention [MSD
Thesis].” Chicago: Northwestern
University Dental School; 1962
45. Little, R.M., Riedel, R.A., Stein,
A. “Mandibular arch length increase
during the mixed dentition: postretention evaluation of stability and
relapse.” Am J Orthod Dentofacial
Orthop. 1990 May;97(5):393-404.
46. Artun, J., Garol, J.D., Little,
R.M. “Long-term stability of mandibular incisors following successful treatment of Class II, Division 1,
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malocclusions.” Angle Orthod. 19;
66(3):229-38.
47. Elms, T.N, Buschang, P.H, Alexander, R.G. “Long-term stability of
Class II, Division 1, nonextraction
cervical face-bow therapy: I. Model
analysis.” Am J Orthod Dentofacial
Orthop. 19 Mar;109(3):271-6.
48. Shah AA. Postretention changes
in mandibular crowding: a review of
the literature. Am J Orthod Dentofacial Orthop. 2003 Sep;124(3):298308.
49. Sadowsky, C., Schneider, B.J.,
BeGole, E.A., Tahir, E. “Long-term
stability after orthodontic treatment:
nonextraction with prolonged retention.” Am J Orthod Dentofacial Orthop. 1994 Sep;106(3):243-9.
50. Luppanapornlarp, S., Johnston,
L.E. Jr. “The effects of premolar
extraction: a long-term comparison of outcomes in “clear-cut” extraction and nonextraction Class II
patients.” Angle Orthod. 1993 Winter;63(4):257-72.
51. Little, R.M., Wallen, T.R., Riedel, R.A. “Stability and relapse of
mandibular anterior alignment-first
premolar extraction cases treated by
traditional edgewise orthodontics.”
Am J Orthod. 128 Oct;80(4):34965.
52. Graber, T.M., Vanarsdall, R.L.
“Orthodontics. Current Principles
and Techniques.” St. Louis: Mosby,
2002:34-1012.
53. Nanda, R.S., Nanda, S.K. “Considerations of dentofacial growth in
long-term retention and stability:
is active retention needed?” Am J
Orthod Dentofacial Orthop. 1992
Apr;101(4):297-302.
54. Little, R.M. “The irregularity
index: a quantitative score of mandibular anterior alignment.” Am J
Orthod. 1975 Nov;68(5):554-63.
Post-orthodontic retention is needed to allow for periodontal and
gingival reorganization, minimize
changes of growth, permit neuromuscular changes and adaptation to
the new tooth positions, and maintain unstable tooth positions which
may have been established to meet
treatment goals and esthetic considerations.8
Orthodontic stability begins with
the mandibular arch, especially
the mandibular anterior teeth. The
maxillary arch wraps around the
mandibular arch, and changes that
occur in the upper arch follow the
lower teeth.48
Nanda discussed retention concerns in young patients undergoing
puberty or in some stage of active
growth.53 He stated that different
retention devices based on facial
morphology and severity of the
malocclusion should be considered.
For example, Class II individuals
who may still need upper retraction
force to prevent the maxilla from
continuing to grow forward when
the mandible has stopped growing.
Patients with short face syndrome
may need bite-plate type retainers
until maxillomandibular growth
has completed. Conversely, patients
who have long face syndrome may
require a high-pull face bow headgear to hold the position of the molars and to prevent further downward and backward growth of the
mandible.
Indefinite retention is the only solution we have today to keep teeth
aligned over time. It is hard to argue the fact that without indefinite
retention the dental arches will
change, starting with the lower anterior teeth. In many individuals,
these changes will result in varying degrees of collapse of the dental
arches.
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