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The ThePractice Practice Building Building BULLETIN BULLETIN 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 The Practice Building BULLETIN 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? The Practice 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: Building BULLETIN 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 Get copy from original Chapter 1 2. Round Contoured: 1616B Image The Practice Building BULLETIN Get copy from original Chapter 1 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. The Practice 10. Apron Spring Labial – (“Roberts Retraction Arch) Image 1616J Get copy from original Chapter 1 11. Wrap Around: Image 1616K Get copy from original Chapter 1 Building BULLETIN 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” The Practice Building BULLETIN 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 The Practice Building BULLETIN 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 The Practice buttons can then be polished for patient comfort with a composite diamond or disc. Building BULLETIN 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 The Practice 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 Building BULLETIN 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 The Practice 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 Building BULLETIN 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, Building BULLETIN 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. The Practice Building BULLETIN The Practice Building BULLETIN The Practice Building BULLETIN The Practice Building BULLETIN The Practice Building BULLETIN