Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62:(1 Suppl): 51–57

doi: 10.1111/adj.12475

Retention and relapse in clinical practice

SJ Littlewood,*† S Kandasamy,‡§¶ G Huangk
*St Luke’s Hospital, Little Horton Lane, Bradford, BD5 0NA, United Kingdom.
†Leeds Dental Institute, University of Leeds, United Kingdom.
‡School of Dentistry, The University of Western Australia.
§Centre for Advanced Dental Education, Saint Louis University, MO, USA.
¶West Australian Orthodontics, Midland, WA, Australia.
kProfessor and Chair, University of Washington, Department of Orthodontics, Seattle, Washington, USA.

ABSTRACT
Maintaining teeth in their corrected positions following orthodontic treatment can be extremely challenging. Teeth have
a tendency to move back towards the original malocclusion as a result of periodontal, gingival, occlusal and growth
related factors. However, tooth movement can also occur as a result of normal age changes. Because orthodontics is
unable to predict which patients are at risk of relapse, those which will remain stable and the extent of relapse that will
occur in the long-term, clinicians need to treat all patients as if they have a high potential to relapse. To reduce this risk,
long term retention is advocated. This can be a significant commitment for patients, and so retention and the potential
for relapse must form a key part of the informed consent process prior to orthodontic treatment.It is vital that patients
are made fully aware of their responsibilities in committing to wear retainers as prescribed in order to reduce the chance
of relapse. If patients are unable or unwilling to comply as prescribed, they must be prepared to accept that there will be
tooth positional changes following treatment. There is currently insufficient high quality evidence regarding the best type
of retention or retention regimen, and so each clinician’s approach will be affected by their personal, clinical experience
and expertise, and guided by their patients’ expectations and circumstances.
Keywords: Fixed retainers, incisor crowding, relapse, removable retainers, retainers, retention, stability.
Abbreviations and acronyms: IPR = Interproximal reduction; SDB = Sleep disordered breathing.

will discuss the responsibilities of the patient and the

INTRODUCTION
Maintaining teeth in their corrected positions after
treatment is often the most challenging part of an
orthodontic treatment plan. Relapse following
orthodontic treatment is traditionally thought of as a
move back towards the original malocclusion. How-
ever, a return towards the initial malocclusion does
not always occur, and relapse could be considered as
any unfavourable change in tooth position after
orthodontic treatment away from a corrected maloc-
clusion. These changes may also be the result of nor-
mal age-related effects.
Clinicians involved in orthodontic treatment need
to have a thorough understanding of the aetiology of
relapse and be familiar with different methods of
reducing this relapse. This includes familiarity with
the advantages and disadvantages of various retainers,
as well as the ability to advise patients on how to
wear retainers effectively.
The present article will provide a contemporary
overview of retention and relapse in orthodontics, and
© 2017 Australian Dental Association
clinician in reducing relapse following treatment.
HISTORICAL PERSPECTIVE
In 1934, Oppenheim stated “Retention is one of the
most difficult problems in orthodontia; in fact, it is
the problem.”1 Eighty years later, clinicians continue
to struggle with the same issue. Over the decades,
many theories have been proposed regarding reten-
tion. For example, Kingsley felt that occlusion was
the key to stability.2 An alternative theory was that
the apical base had to be respected.3 Similarly, was
the idea that the mandibular incisors had to be placed
over basal bone in order to promote stability.4–6
Finally, Rogers proposed that proper function and
balance of the musculature was related to stability.7
These theories, as well as others, will be discussed in
more detail below. In reality, orthodontic relapse is
complicated and highly variable, and better data to
provide evidence-based recommendations to our
patients, is needed.
51
SJ Littlewood et al.
The best information currently available comes
from the long-term post-retention registry at the
University of Washington. Riedel and Little are cred-
ited with the collection of over 800 long-term post-
retention cases and discovered that relapse occurred
in a high percentage of patients but in an individual
patient, relapse was quite unpredictable.8,9 It was also
found that canine width expansion was unstable in
the long-term9, and Little stated that lifetime perma-
nent retention was the only reliable way to prevent
relapse.10
AETIOLOGY OF RELAPSE AND DURATION OF
RETENTION
Relapse after orthodontic treatment can be a result of
orthodontic factors and normal age changes.11,12
These orthodontic factors include periodontal and gin-
gival factors, occlusal factors and factors related to
soft tissue pressures and limits of the dentition.
Periodontal and gingival factors
When teeth are moved the tissues in the periodontal
ligament and gingivae remodel to the new tooth posi-
tion. Until these tissues have remodelled, they have a
tendency to manoeuvre the teeth back towards their
original position. The fibres that take the longest to
remodel are the elastic fibres around the neck of the
teeth, the dento-gingival and interdental fibres, which
can take 8 months or more to remodel.13 The teeth
therefore need to held in position for long enough for
these fibres to adjust. An alternative approach is to
use a simple surgical procedure called pericision that
severs these gingival fibres and this will be discussed
later.14
Occlusal factors
It is purported that a soundly interdigitated dentition,
with even occlusal contacts and correct occlusal load-
ing of teeth, is more likely to be stable; however, there
is no substantial agreement or evidence to support this
claim. It must be recognised that gross occlusal inter-
ferences, displacing tooth contacts and the abnormal
loading of teeth may predispose the affected teeth to
mobility which may contribute to relapse.
Soft tissue pressures and limits of the dentition
It is preferable, where possible, to position teeth
within an area of soft tissue balance between the ton-
gue on the lingual and the lips and cheeks on the
labial aspect. This is an area of balance that is
prosthodontically referred to as the neutral zone.
Although the forces from the tongue are stronger, the
52
activity of a healthy periodontium will resist proclina-
tion of the teeth.15 The farther teeth are moved out of
this ‘neutral’ zone, the more unstable they are likely
to be. This is particularly true for the lower labial seg-
ment and if incisors are proclined or retroclined exces-
sively, relapse is more likely. It is also believed that
significant changes in the arch form, in particular the
lower intercanine width, make relapse due to soft tis-
sue pressures more likely. There are, of course, situa-
tions in which it is necessary to alter lower incisor
position or intercanine width, for example, to improve
aesthetics, but, in these cases, the clinician needs to
plan an appropriate retention strategy to resist the
increased relapse potential.16–18
Physiological relapse
It has been shown that there are potential subtle facial
growth or age-related changes that occur throughout
life19 including minor changes in the relationship
between the mandible and maxilla, and changes in the
soft tissue pressures on the dentition. The dentition is
therefore within a biological environment that is con-
stantly changing, and so it is not surprising that there
is the potential for changes to occur in the alignment
of teeth and occlusal relationships throughout life.
These changes in alignment and occlusal relationships
should perhaps be regarded as normal age changes.
INFORMED CONSENT
Whilst relapse does not happen in every patient, clini-
cally it is difficult to predict which patients will
undergo post-treatment change and so it is critical
that all patients are treated as if they have the poten-
tial for relapse. As a result, many clinicians now rec-
ommend life-long retention. When a patient asks
“How long should I wear my retainers”, the answer
is “For as long as you want straight teeth”. An impor-
tant aspect of informed consent for orthodontic treat-
ment is the need for the patient to fully understand
the long-term risk of relapse, and appreciate the pro-
cedures to minimise the risk. There are important
responsibilities for the clinician and the patient.
The clinician’s responsibility is to explain the unpre-
dictable nature of relapse, the factors known to be
involved and advise on the reduction of risk by the
appropriate use of retainers. The clinician needs to
explain the commitment that is required, including
any possible long-term financial costs associated with
repairing and replacing retainers, costs associated with
addressing any relapse that occurs following failure to
comply with retention, and provide information about
retainer care. The long-term care of retainers is vital
to ensure that they fulfil their maintenance role in the
long-term, without compromising oral health. This
© 2017 Australian Dental Association
 Relapse and retention in orthodontics

advice should include a retainer review program to (a)

assess the need for repair or replacement.
It is also important that patients understand their
responsibility and involvement in reducing relapse.
Before the commencement of treatment, patients
should be fully informed about the retainer commit-
ment required.

TYPES OF RETAINERS

Removable Retainers
Removable retainers have the advantages of being
easier to maintain oral hygiene (as they can be
removed for cleaning), and may only need to be worn
part-time. It has been shown that in many cases,
removable retainers need only be worn at night to
maintain dental stability.20–22 Good patient compli-
ance is essential with removable retainers, and if con- (b)
sistent wear is overlooked, relapse occurs. This
method of retention places full responsibility directly
on the patient in maintaining tooth alignment follow-
ing orthodontic treatment.
The most common examples of removable retainers
used worldwide are the Hawley-type retainers (with
an acrylic baseplate and usually a wire labial bow,
Figure 1) and thermoplastic retainers (made from
clear plastic, Figure 2). There is some evidence to sug-
gest that, at least in the short-term, patients prefer the
appearance and comfort of thermoplastic retainers
which are more cost-effective and slightly more effec-
tive in maintaining stability, particularly in the lower
Fig. 1 (a) Upper Hawley style removable retainer. (b) Lower Hawley
arch.23,24 There is no high quality, long-term research style removable retainer.
to indicate whether these advantages are maintained
long-term.

Fixed retainers
Fixed retainers offer the advantage of being in place
permanently which removes the need for patient com-
pliance with retainer wear (Figure 3, the retainers are
typically bonded to the palatal/lingual surfaces of the
labial segments. As they cannot be removed for clean-
ing, they are more prone to plaque and calculus accu-
mulation.25 It is therefore vital that patients are
provided with clear instructions on oral hygiene mea-
sures associated with their bonded retainers. The
retainers also need to be checked regularly to ensure
that they are still bonded in place. In addition, there
are reports of occasional, severe, unwanted tooth
movements caused by different types of failed/faulty Fig. 2 Upper and lower clear thermoplastic removable retainers.
fixed retainers as a result of the bonding of some or
all teeth within the span of the fixed retainer.26–28
This method of retention makes the clinician responsi- are made aware that if appliance maintenance is not
ble for the maintenance of the fixed retainer. It is crit- performed by either their orthodontist or general den-
ical during the informed consent process that patients tist, they are at risk of tooth relapse.
© 2017 Australian Dental Association 53
SJ Littlewood et al.
(a)
(b)
Fig. 3 (a) Lower fixed retainer; Bonded only at teeth 33 and 43.
(b) Lower fixed retainer; Bonded at all the lower incisor teeth.
Studies which have compared the merits of fixed
and removable retainers suggest that both appear to
reduce relapse in routine cases. However, there are
situations in which full-time retention is required, and
so a fixed retainer may be preferred. The main exam-
ples of higher-risk relapse cases are listed in Table 1.
Clinicians may often choose to use a combination
of fixed and removable retainers in a process referred
to as ‘dual’ retention. The patient is fitted with a fixed
retainer, and is provided with a removable retainer to
wear at night as a back-up.
A recent Cochrane Review which assessed the meth-
ods of retention reported that there was insufficient
Table 1. Cases where fixed retention may be
preferred
• Following closure of a spaced dentition (including a marked
median diastema)
• Following creation of space prior to prosthodontic
management
• Reduced periodontal support
• Following correction of severe rotations
• For patients who cannot tolerate even minor changes in
occlusion
• Following correction of severely impacted teeth
• In cleft lip and palate patients with evidence of severe post-
surgical scarring that may predispose to relapse after
orthodontics
• In compromised cases in which the aims of treatment may be
more limited, and focus is geared more towards achieving a
good aesthetic result without aiming for a fully corrected
malocclusion with ideal occlusion
54
high-quality evidence on the best type of retainer or
retention regimen.29 As a result, each clinician’s
approach to retention will be strongly influenced by
their clinical experience and expertise with different
retainers, as well as the patient’s values, expectations
and circumstances.
ADJUNCTIVE PROCEDURES
Adjunctive procedures are techniques that alter the
hard or soft tissues in an attempt to reduce relapse.
Examples include pericision and interproximal reduc-
tion.
Pericision
Pericision is a simple soft tissue surgical technique
aimed at severing the periodontal fibres around the
neck of the teeth (dento-gingival and interdental
fibres) and is sometimes referred to as supracrestal cir-
cumferential fiberotomy. The procedure is performed
under local anaesthetic and there is weak evidence to
suggest that it reduces relapse of rotated teeth, partic-
ularly in the maxilla.14,30 The procedure should only
be undertaken in cases in which there is a good gingi-
val biotype and cortical bone support, minimal or no
recession and the patient has excellent oral hygiene.
As it is a surgical procedure, it is usually reserved for
severely rotated teeth.
Interproximal reduction
Interproximal reduction (IPR) is a hard tissue proce-
dure aimed at removing small amounts of enamel
interdentally. It is not fully understood how this may
reduce relapse, but it has been suggested that it may
flatten the interdental contacts between incisors and
therefore increase stability. It is suggested that IPR
may compensate for the normally occurring reduction
in inter-canine width which occurs during adoles-
cence.31
A recent randomised controlled trial compared the
use of interproximal reduction with other methods of
retention for Class I crowded cases treated with
extractions and fixed appliances.32–34 It was shown
that using IPR alone in the lower arch (without a
retainer) was equally successful at reducing relapse as
using a lower bonded retainer or a positioner. This
raises the interesting possibility of the use of inter-
proximal reduction as an alternative or in conjunction
with retainers. The results need to be interpreted with
caution before deciding on universally applying this
procedure on all patients. Consideration needs to be
given to the data which refers to patients who were
followed for 5 years as it is possible that relapse
might occur after this observation period.
© 2017 Australian Dental Association

OTHER CONSIDERATIONS AFFECTING RELAPSE
Third molars
The extraction of mandibular third molars to prevent
late lower incisor crowding remains a controversial
topic and a common practice in dentistry. From an
orthodontic perspective, third molars have essentially
little to do with lower incisor crowding. Multiple
studies have investigated the influence of third molars
on crowding and assessed their effects on the lower
dental midline, anterior crowding and cases of bilat-
eral and unilateral third molar agenesis.35–39 The
results found only a small (negligible clinical signifi-
cance) or no effect with large standard deviations.
The large standard deviations indicated that, in some
cases, the crowding was greater in patients without
third molars present. Late incisor crowding is multi-
factorial in nature and factors other than third molars
play an important role. The removal of third molars
on the sole basis of preventing lower incisor crowding
is unsubstantiated and not evidence based.40
Growth considerations
There is no doubt that any skeletal changes that occur
following orhodontic treatment will influence the
achieved dental relationships. The patient’s growth
pattern is usually taken into consideration before and
during treatment; however, little consideration is usu-
ally given to post treatment skeletal growth changes
on the final outcome.41–45 Important skeletal changes
that require consideration and patient education are
extremes in vertical facial patterns, deep bites and
anterior open bites, late growth in long-face and Class
III patients and skeletal changes related to post-
orthognathic surgical patients including condylar
resorption.
Maxillary and mandibular expansion
Longitudinal studies about dental arch dimensions in
untreated subjects have shown that there is an
increase in intercanine and intermolar widths until the
complete eruption of the permanent dentition follow-
ing which a decrease in dental widths, more in the
intercanine than intermolar widths, occurs. The width
reduction continues for many decades even up to the
eighth decade of life.46–49 Therefore, any orthodontic
dental expansion beyond the original pre-treatment
status will increase the relapse potential post-treat-
ment and hence justify the need for life-time reten-
tion.
Skeletal maxillary expansion is generally carried out
as part of an orthodontic treatment plan to primarily
address an insufficient maxillary width and resulting
© 2017 Australian Dental Association
Relapse and retention in orthodontics
transverse discrepancy between the maxillary and
mandibular arches. There is a current trend towards
treatment planning around expanding the maxillary
arch (even when there is no transverse discrepancy)
with the aim of treating malocclusions ‘non-extrac-
tion’ or, at least, without premolar teeth extrac-
tions.50 As any expansion (especially in the
intercanine region) of the mandibular arch is essen-
tially unstable, the mandibular arch is considered the
best guide for gauging the success of expansion.
Expansion of the maxillary arch, especially when
there is no buccal crossbite present will require the
mandibular arch to be expanded accordingly, which is
inherently an unstable procedure.51
Although there is a lack of strong evidence regard-
ing the long-term stability of maxillary expansion,
one must be mindful of the limits the dentition when
carrying out expansion in either arch.52–54 Expansion
carried out in the maxillary arch should only result in
minimal expansion in the lower arch to provide the
patient with the best chance of long term stability.
Expansion and Sleep Disordered Breathing
A narrow maxilla has been suggested as a predispos-
ing craniofacial morphological risk factor related to
sleep disordered breathing (SDB). While studies have
shown improvement in airway dimensions and a
reduction in nasal resistance following maxillary
expansion55–57 most have shown some relapse to pre-
expansion values at review.58–60 Many of the studies
unfortunately have methodological flaws, primarily
related to the lack of long-term follow up, the use of
small heterogenous samples without a control group,
differences in the amount of expansion in each subject
and the large individual variability observed which
has over-exaggerated the effects of expansion on the
airway.
Recent studies have shown a significant improve-
ment in apnoea-hyponoea index scores in children
with sleep apnoea following rapid maxillary expan-
sion.61,62 As a result, rapid maxillary expansion was
advocated before adenotonsillectomy in children as
there was the prospect of a reduced need for surgery
following expansion in a large proportion of cases.
According to the inclusion criteria, it appeared that
maxillary expansion may have been carried out with-
out the presence of a posterior crossbite and based on
the presence of a high palatal vault; narrow maxillary
arch related to the restriction of the upper jaw at its
base.61,62 Clearly, advocating maxillary expansion pri-
marily to address airway issues or SDB when there is
no obvious posterior crossbite, is not evidence based
or justified as this would lead to significant bite open-
ing, posterior scissor bites and unfavourable den-
toalveolar compensations.
55
SJ Littlewood et al.
CONCLUSIONS
Maintaining teeth in their corrected positions follow-
ing orthodontic treatment can be extremely challeng-
ing. Relapse after orthodontic treatment is the result
of teeth moving back towards the original malocclu-
sion, but changes in tooth position may also occur as
a normal part of the growth and aging process.
Relapse is also unpredictable, and so it should be pre-
sumed that every patient has the potential for long-
term changes. As part of the informed consent process
for orthodontic treatment, patients need to be fully
aware of their commitment to wear retainers for as
long as they want to keep their teeth in their corrected
positions. It is the clinician’s responsibility to ensure
that patients are appropriately instructed regarding
the care of their retainers and provided advice about
the timing of retainer review and by whom. When
using fixed retainers, as part of the treatment consent
process, patients must be informed of the importance
of maintaining the integrity of the fixed retainer and
who will be taking this long-term responsibility. There
is currently insufficient high quality evidence on the
best type of retention or retention regimen, so each
clinician’s approach to retention will be affected by
personal clinical experience and expertise with differ-
ent retainers, and also the patients’ expectations and
circumstances. Patients who are unable or unwilling
to wear their retainers as prescribed must be prepared
to accept that there will be relapse following
orthodontic treatment. The extent of the relapse is
unpredictable.
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Address for correspondence:
Clinical Associate Professor Sanjivan Kandasamy
Department of Orthodontics
School of Dentistry
The University of Western Australia
17, Monash Ave
Nedlands 6009
Western Australia
Australia
Email: sanj@kandasamy.com.au
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