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. 2016 Jan 29;2016(1):CD002283.
doi: 10.1002/14651858.CD002283.pub4.

Retention procedures for stabilising tooth position after treatment with orthodontic braces

Simon J Littlewood  1 , Declan T Millett, Bridget Doubleday, David R Bearn, Helen V Worthington
Affiliations

Retention procedures for stabilising tooth position after treatment with orthodontic braces

Simon J Littlewood et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Retention is the phase of orthodontic treatment that attempts to keep teeth in the corrected positions after treatment with orthodontic braces. Without a phase of retention, there is a tendency for teeth to return to their initial position (relapse). To prevent relapse, almost every person who has orthodontic treatment will require some type of retention.

Objectives: To evaluate the effects of different retention strategies used to stabilise tooth position after orthodontic braces.

Search methods: We searched the following databases: the Cochrane Oral Health Group's Trials Register (to 26 January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 12), MEDLINE via Ovid (1946 to 26 January 2016) and EMBASE via Ovid (1980 to 26 January 2016). We searched for ongoing trials in the US National Institutes of Health Trials Register (ClinicalTrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform. We applied no language or date restrictions in the searches of the electronic databases. We contacted authors of randomised controlled trials (RCTs) to help identify any unpublished trials.

Selection criteria: RCTs involving children and adults who had had retainers fitted or adjunctive procedures undertaken to prevent relapse following orthodontic treatment with braces.

Data collection and analysis: Two review authors independently screened eligible studies, assessed the risk of bias in the trials and extracted data. The outcomes of interest were: how well the teeth were stabilised, failure of retainers, adverse effects on oral health and participant satisfaction. We calculated mean differences (MD) with 95% confidence intervals (CI) for continuous data and risk ratios (RR) with 95% CI for dichotomous outcomes. We conducted meta-analyses when studies with similar methodology reported the same outcome. We prioritised reporting of Little's Irregularity Index to measure relapse.

Main results: We included 15 studies (1722 participants) in the review. There are also four ongoing studies and four studies await classification. The 15 included studies evaluated four comparisons: removable retainers versus fixed retainers (three studies); different types of fixed retainers (four studies); different types of removable retainers (eight studies); and one study compared a combination of upper thermoplastic and lower bonded versus upper thermoplastic with lower adjunctive procedures versus positioner. Four studies had a low risk of bias, four studies had an unclear risk of bias and seven studies had a high risk of bias. Removable versus fixed retainers Thermoplastic removable retainers provided slightly poorer stability in the lower arch than multistrand fixed retainers: MD (Little's Irregularity Index, 0 mm is stable) 0.6 mm (95% CI 0.17 to 1.03). This was based on one trial with 84 participants that was at high risk of bias; it was low quality evidence. Results on retainer failure were inconsistent. There was evidence of less gingival bleeding with removable retainers: RR 0.53 (95% CI 0.31 to 0.88; one trial, 84 participants, high risk of bias, low quality evidence), but participants found fixed retainers more acceptable to wear, with a mean difference on a visual analogue scale (VAS; 0 to 100; 100 being very satisfied) of -12.84 (95% CI -7.09 to -18.60). Fixed versus fixed retainersThe studies did not report stability, adverse effects or participant satisfaction. It was possible to pool the data on retention failure from three trials that compared polyethylene ribbon bonded retainer versus multistrand retainer in the lower arch with an RR of 1.10 (95% CI 0.77 to 1.57; moderate heterogeneity; three trials, 228 participants, low quality evidence). There was no evidence of a difference in failure rates. It was also possible to pool the data from two trials that compared the same types of upper fixed retainers, with a similar finding: RR 1.25 (95% CI 0.87 to 1.78; low heterogeneity; two trials, 174 participants, low quality evidence). Removable versus removable retainersOne study at low risk of bias comparing upper and lower part-time thermoplastic versus full-time thermoplastic retainer showed no evidence of a difference in relapse (graded moderate quality evidence). Another study, comparing part-time and full-time wear of lower Hawley retainers, found no evidence of any difference in relapse (low quality evidence). Two studies at high risk of bias suggested that stability was better in the lower arch for thermoplastic retainers versus Hawley, and for thermoplastic full-time versus Begg (full-time) (both low quality evidence).In one study, participants wearing Hawley retainers reported more embarrassment more often than participants wearing thermoplastic retainers: RR 2.42 (95% CI 1.30 to 4.49; one trial, 348 participants, high risk of bias, low quality evidence). They also found Hawley retainers harder to wear. There was conflicting evidence about survival rates of Hawley and thermoplastic retainers. Other retainer comparisonsAnother study with a low risk of bias looked at three different approaches to retention for people with crowding, but normal jaw relationships. The study found that there was no evidence of a difference in relapse between the combination of an upper thermoplastic and lower canine to canine bonded retainer and the combination of an upper thermoplastic retainer and lower interproximal stripping, without a lower retainer. Both these approaches are better than using a positioner as a retainer.

Authors' conclusions: We did not find any evidence that wearing thermoplastic retainers full-time provides greater stability than wearing them part-time, but this was assessed in only a small number of participants.Overall, there is insufficient high quality evidence to make recommendations on retention procedures for stabilising tooth position after treatment with orthodontic braces. Further high quality RCTs are needed.

PubMed Disclaimer

Conflict of interest statement

Simon J Littlewood: I have previously given educational orthodontic lectures for 3M Unitek. This in no way compromises the integrity of his involvement in this review, but is disclosed for complete transparency. Declan T Millett: none known. Bridget Doubleday: none known. David R Bearn: I received fees from Ormco Europe for lectures not directly related to this review topic. Helen V Worthington: none known.

Four of the review authors (SL, DM, BD and DB) have an interest or have been involved in studies investigating retention procedures, but this has in no way influenced the quality or objectivity of this review.

Two of the review authors (DM and BD) are co‐authors of included studies (Millett 2007; Rohaya 2006), so these review authors did not undertake the analysis of these studies during the review process.

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 1 Stability ‐ Little's Irregularity Index.
1.2
1.2. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 2 Failure of retainers in lower.
1.3
1.3. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 3 Adverse effects on health: evidence of caries.
1.4
1.4. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 4 Adverse effects on health: evidence of gingival bleeding.
1.5
1.5. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 5 Adverse effects on health: evidence of periodontal pocketing.
1.6
1.6. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 6 Patient satisfaction: how acceptable was the retainer to wear?.
1.7
1.7. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 7 Patient satisfaction: how easy was retainer to keep clean?.
1.8
1.8. Analysis
Comparison 1 Removable versus fixed retainers, Outcome 8 Patient satisfaction: how happy are you with appearance of teeth after 1 year of retention.
2.1
2.1. Analysis
Comparison 2 Fixed versus fixed retainers, Outcome 1 Failure of retainers.
3.1
3.1. Analysis
Comparison 3 Removable versus removable retainers, Outcome 1 Stability ‐ Little's Irregularity Index ‐ upper labial segment ‐ 1 year.
3.2
3.2. Analysis
Comparison 3 Removable versus removable retainers, Outcome 2 Stability ‐ Little's Irregularity Index ‐ lower labial segment ‐ 1 year.
3.3
3.3. Analysis
Comparison 3 Removable versus removable retainers, Outcome 3 Stability ‐ crowding upper labial segment ‐ 1 year.
3.4
3.4. Analysis
Comparison 3 Removable versus removable retainers, Outcome 4 Stability ‐ crowding lower labial segment ‐ 1 year.
3.5
3.5. Analysis
Comparison 3 Removable versus removable retainers, Outcome 5 Stability: lower intercanine width.
3.6
3.6. Analysis
Comparison 3 Removable versus removable retainers, Outcome 6 Stability: lower intermolar width.
3.7
3.7. Analysis
Comparison 3 Removable versus removable retainers, Outcome 7 Stability: upper intercanine width.
3.8
3.8. Analysis
Comparison 3 Removable versus removable retainers, Outcome 8 Stability: upper intermolar width.
3.9
3.9. Analysis
Comparison 3 Removable versus removable retainers, Outcome 9 Stability: overjet.
3.10
3.10. Analysis
Comparison 3 Removable versus removable retainers, Outcome 10 Stability: overbite.
3.11
3.11. Analysis
Comparison 3 Removable versus removable retainers, Outcome 11 Stability: settling with increased posterior contacts.
3.12
3.12. Analysis
Comparison 3 Removable versus removable retainers, Outcome 12 Stability: settling with increased anterior contacts.
3.13
3.13. Analysis
Comparison 3 Removable versus removable retainers, Outcome 13 Stability: maintaining corrected rotations in the upper.
3.14
3.14. Analysis
Comparison 3 Removable versus removable retainers, Outcome 14 Stability: maintaining quality of finish (PAR).
3.15
3.15. Analysis
Comparison 3 Removable versus removable retainers, Outcome 15 Survival of retainers: how many broke in total.
3.16
3.16. Analysis
Comparison 3 Removable versus removable retainers, Outcome 16 Survival of retainers: how many were lost in total.
3.17
3.17. Analysis
Comparison 3 Removable versus removable retainers, Outcome 17 Survival of retainers: upper.
3.18
3.18. Analysis
Comparison 3 Removable versus removable retainers, Outcome 18 Survival of retainers: lower.
3.19
3.19. Analysis
Comparison 3 Removable versus removable retainers, Outcome 19 Patient satisfaction: able to wear retainer as instructed?.
3.20
3.20. Analysis
Comparison 3 Removable versus removable retainers, Outcome 20 Patient satisfaction: able to wear retainers away from home?.
3.21
3.21. Analysis
Comparison 3 Removable versus removable retainers, Outcome 21 Patient satisfaction: embarrassed to wear retainer?.
3.22
3.22. Analysis
Comparison 3 Removable versus removable retainers, Outcome 22 Patient satisfaction: amount of discomfort ‐ never or only on occasion.
3.23
3.23. Analysis
Comparison 3 Removable versus removable retainers, Outcome 23 Patient satisfaction: worse or much worse than wearing fixed appliances?.
4.1
4.1. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 1 Irregularity change of upper labial segment (V‐CTC vs. V‐S).
4.2
4.2. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 2 Intercanine change in upper (V‐CTC vs. V‐S).
4.3
4.3. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 3 Intermolar width change in upper (V‐CTC vs. V‐S).
4.4
4.4. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 4 Arch length change in upper (V‐CTC vs. V‐S).
4.5
4.5. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 5 Irregularity change in lower labial segment (V‐CTC vs. V‐S).
4.6
4.6. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 6 Intercanine width change in lower (V‐CTC vs. V‐S).
4.7
4.7. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 7 Intermolar width change in the lower (V‐CTC vs. V‐S).
4.8
4.8. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 8 Arch length change in lower (V‐CTC vs. V‐S).
4.9
4.9. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 9 Overjet change (V‐CTC vs. V‐S).
4.10
4.10. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 10 Overbite change (V‐CTC vs. V‐S).
4.11
4.11. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 11 Final irregularity in upper after more than 5 years (V‐CTC vs. V‐S).
4.12
4.12. Analysis
Comparison 4 Upper removable and lower fixed retainer versus upper removable and lower adjunctive procedure, Outcome 12 Final irregularity in lower after more than 5 years (V‐CTC vs. V‐S).
5.1
5.1. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 1 Irregularity change in upper labial segment (V‐CTC vs. P).
5.2
5.2. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 2 Intercanine width change in upper (V‐CTC vs. P).
5.3
5.3. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 3 Intermolar width change in upper (V‐CTC vs. P).
5.4
5.4. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 4 Arch length change in upper (V‐CTC vs. P).
5.5
5.5. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 5 Irregularity change in lower labial segment (V‐CTC vs. P).
5.6
5.6. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 6 Intercanine width change in lower (V‐CTC vs. P).
5.7
5.7. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 7 Intermolar width change in lower (V‐CTC vs. P).
5.8
5.8. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 8 Arch length change in lower (V‐CTC vs. P).
5.9
5.9. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 9 Overjet change (V‐CTC vs. P).
5.10
5.10. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 10 Overbite change (V‐CTC vs. P).
5.11
5.11. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 11 Final irregularity in upper after more than 5 years (V‐CTC vs. P).
5.12
5.12. Analysis
Comparison 5 Upper removable retainer and lower fixed retainer versus positioner, Outcome 12 Final irregularity in lower after more than 5 years (V‐CTC vs. P).
6.1
6.1. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 1 Irregularity change in upper labial segment (V‐S vs. P).
6.2
6.2. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 2 Intercanine width change in upper (V‐S vs. P).
6.3
6.3. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 3 Intermolar width change in upper (V‐S vs. P).
6.4
6.4. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 4 Arch length change in upper (V‐S vs. P).
6.5
6.5. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 5 Irregularity change in lower labial segment (V‐S vs. P).
6.6
6.6. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 6 Intercanine width change in lower (V‐S vs. P).
6.7
6.7. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 7 Intermolar width change in lower (V‐S vs. P).
6.8
6.8. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 8 Arch length change in lower (V‐S vs. P).
6.9
6.9. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 9 Overjet change (V‐S vs. P).
6.10
6.10. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 10 Overbite change (V‐S vs. P).
6.11
6.11. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 11 Final irregularity in upper after more than 5 years (V‐S vs. P).
6.12
6.12. Analysis
Comparison 6 Upper removable retainer and lower adjunctive procedure versus positioner (P), Outcome 12 Final irregularity in lower after more than 5 years (V‐S vs. P).
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

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Kumar 2011 {published and unpublished data}
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References to studies excluded from this review

ACTRN12612000670875 {unpublished data only}
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Pandis 2007 {published data only}
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Pandis 2013 {published data only}
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Taner 2000 {published and unpublished data}
    1. Taner T, Haydar B, Kavuklu I, Korkmaz A. Short‐term effects of fiberotomy on relapse of anterior crowding. American Journal of Orthodontics and Dentofacial Orthopedics 2000;118(6):617‐23. - PubMed
Vecere 1983 {published and unpublished data}
    1. Vecere JW. Extraction space closure stability following canine retraction and periodontal surgery. American Journal of Orthodontics 1983;84(1):89‐90.

References to studies awaiting assessment

References to ongoing studies

ChiCTR‐TRC‐07000055 {unpublished data only}
    1. Hawley's retainer and transparent retainer for the oral cavity hygiene in orthodontic patients. Ongoing study Registered 2007.
ChiCTR‐TRC‐07000454 {unpublished data only}
    1. The impact of the Hawley's removable retainer and clear overlay removable retainer on orthodontic patients' oral hygiene. Ongoing study Registered 2007.
Forde 2015 {unpublished data only}
    1. Removable versus fixed orthodontic retention: a prospective randomised controlled trial. Ongoing study 2011.
IRCT2013113015598N1 {unpublished data only}
    1. Comparision of the effect of three different approaches of retention on reopening of extraction space of fixed orthodontic patients in three different retention phases. Ongoing study 2013.

Additional references

Aasen 2005
    1. Aasen T, Espeland L. An approach to maintain orthodontic alignment of lower incisors without the use of retainers. European Journal of Orthodontics 2005;27:209‐14. - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Little 1981
    1. Little RM, Wallen TR, Riedel RA. Stability and relapse of mandibular anterior alignment ‐ first premolar extraction cases treated by traditional edgewise orthodontics. American Journal of Orthodontics 1981;80(4):349‐65. - PubMed
Little 1988
    1. Little RM, Riedel RA, Årtun J. An evaluation of changes in mandibular anterior alignment from 10 to 20 years postretention. American Journal of Orthodontics and Dentofacial Orthopedics 1988;93(5):423‐8. - PubMed
Mai 2014
    1. Mai W, He J, Meng H, Jiang Y, Huang C, Li M, et al. Comparison of vacuum‐formed and Hawley retainers: a systematic review. American Journal of Orthodontics and Dentofacial Orthopedics 2014;145(6):720‐7. - PubMed
Melrose 1998
    1. Melrose C, Millett DT. Toward a perspective on orthodontic retention?. American Journal of Orthodontics and Dentofacial Orthopedics 1998;113(5):507‐14. - PubMed
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012.
Richmond 1992
    1. Richmond S, Shaw WC, O'Brien KD, Buchanan IB, Jones R, Stephens CD, et al. The development of the PAR Index (Peer Assessment Rating): reliability and validity. European Journal of Orthodontics 1992;14(2):125‐39. - PubMed
Worthington 2015
    1. Worthington H, Clarkson J, Weldon J. Priority oral health research identification for clinical decision‐making. Evidence‐based Dentistry 2015;16(3):69‐71. - PubMed

References to other published versions of this review

Littlewood 2004
    1. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures for stabilising tooth position after treatment with orthodontic braces. Cochrane Database of Systematic Reviews 2004, Issue 1. [DOI: 10.1002/14651858.CD002283] - DOI - PubMed
Littlewood 2006
    1. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures for stabilising tooth position after treatment with orthodontic braces. Cochrane Database of Systematic Reviews 2006, Issue 1. [DOI: 10.1002/14651858.CD002283.pub3] - DOI - PubMed

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