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removable retainers
Evi E. Heier, DDS, a Aimd A. De Smit, DDS, PhD, a Ingrid A. Wijgaerts, D D S , b and
Patrick A. Adriaens, DDS, DMD, MScD, PhD b
Brussels, Belgium
Removable retainers have been used by clinicians since the early years of orthodontic practice.
During the last decades, an increasing number of cases are retained with bonded lingual retainers.
The current study was performed to evaluate whether significant differences in gingival conditions
exist between patients who wear removable or fixed retainers. Differences in build-up of plaque and
calculus were also investigated. Maxillary and mandibular measurements were taken at baseline
(just before debonding) and 1, 3, and 6 months later, from canine to canine on 36 patients. Among
these patients, 22 had fixed retainers, and 14 wore removable retainers. The gingival condition was
scored according to three parameters: Modified Gingival Index, bleeding on probing, and gingival
crevicular fluid flow. After staining with Diaplac, the Plaque Index was registered. The amount of
calculus was measured with a calibrated periodontal probe. Gingival inflammation decreased from
baseline throughout the entire period of retention. A comparable limited gingival inflammation was
found in the presence of both types of retainers. Slightly more plaque and calculus were present on
the lingual surfaces in the fixed retainer group. This did not result in more pronounced gingival
inflammation than in the removable retainer group, within the evaluated period. (Am J Orthod
Dentofac Orthop 1997;112:607-16.)
W h en removable retainers are used, clinicians have to rely on patients' discipline and
long-term compliance. Oral hygiene, however, will
not be complicated by this kind of appliance. The
introduction of bonding techniques enabled the
construction of permanent interdental wire connections as retention device. 16 As these retainers are
placed "invisibly" on the lingual tooth surfaces,
patients' acceptance is evident and compliance with
the orthodontic retention therapy is high. The continuing presence of the retention wires, however,
creates areas that are difficult to keep clean, thus
favoring plaque formation and food impaction. This
situation may lead to the development of carious
lesions, TM favor the formation of calculus, and induce gingival inflammation and periodontal disease. 9
Zacchrisson, 1 one of the pioneers in the field of
From the Faculty of Dentistry, Free University of Brussels.
aAssistant Professor, Department of Orthodontics.
aProfessor and Chairman, Department of Orthodontics, School of Dentistry.
bAssistant Professor, Department of Periodontology.
bProfessor and Chairman, Department of Periodontology, School of
Dentistry.
Reprint requests to: Dr. Aim~ A. De Smit, Department of Orthodontics,
School of Dentistry, Free University of Brussels, Laarbeeklaan 103, 1090
Brussels, Belgium.
Copyright 1997 by the American Association of Orthodontists.
0889-5406/97/$5.00 + 0 8/1/79813
608 Heier et aL
H e i e r e t al.
609
Table I. M e a n s of five o u t c o m e m e a s u r e s o n d i f f e r e n t l o c a t i o n s b y t r e a t m e n t g r o u p a n d t i m e o f f o l l o w - u p
Baseline measure
1-month follow-up
3-month follow-up
6-month follow-up
Index
Site
FR
RR
FR
RR
FR
RR
FR
RR
MGI
B
IB
IL
L
B
IB
IL
L
B
ID
L
B
L
B
L
0.71
1.71
1.42
0.79
0.25
0.36
0.50
0.32
24.57
46.91
15.29
2.86
2.78
0.01
0.20
0.74
1.40
1.26
0.80
0.40
0.57
0.70
0.34
25.56
55.27
15.70
2.56
2.78
0.01
0,05
0.44
1.01
1.03
1.12
0.18
0,23
0.37
0.56
11.I1
28.31
16.25
1,12
3.34
0.00
0.13
0.68
1.02
0.87
0.49
0.30
0.46
0.43
0.23
12.04
21.71
4.56
1.18
2.50
0.00
0.01
0.21
0.56
0.86
0.30
0.19
0.23
0.32
0.18
11.04
20.07
8.86
1,38
2.82
0.00
0.19
0.68
1.23
0.99
0.63
0.34
0.35
0.45
0.18
12.32
28.98
10.83
1.59
2.43
0.00
0.01
0.24
0.66
0.94
0.40
0.22
0.30
0.30
0.23
22.29
25.46
8.04
1.02
3.03
0.00
0.20
0,89
1,40
1,23
0,74
0,41
0.47
0.40
0.22
16.88
35.18
11.00
1.24
2.52
0.00
0.06
BOP
GCFF
PI
DCI
MGI: Modified Gingival Index; BOP." Bleeding On Probing; GCFF: Gingival Crevicular Fluid Flow; Ph Plaque Index; DCI: Dental Calculus Index.
B: Buccal; IB: Interdental Buccal; IL: Interdental Lingual; L: Lingual; ID: Interdental.
FR: Fixed Retainer; RR: Removable Retainer.
Statistical Analysis
A univariate repeated measurement analysis of variance (ANOVA) model was used, containing one repeated
factor (time) and one between factor (code:distinguishing
the removable versus the fixed retainer group). Each
analysis resulted in three P values, one for each factor and
one as interaction term. Subsequently, a Scheff6 post hoc
analysis calculated the significance levels of the differences between pairs. Throughout the entire statistical
analysis, a significance level ofp <- 0.05 was maintained.
RESULTS
For each of the two study groups (fixed or
removable retainer), mean values at baseline, at
1-month, 3-month, and 6-month follow-up examinations are presented in Table I. The changes through
time are visualized in Figs. 2 through 6. Table II
shows the changes from baseline to 1-month followup, from 1- to 3-month follow-up, and from 1- to
6-month follow-up. The differences for the five
outcome measures between the group wearing fixed
retainers (FR) and the group with removable retainers (RR) can be seen in Table III.
At baseline, the mean MGI (Fig. 2) of both
retainer groups was below score 1 for the buccal and
lingual sites. The mean interdental values (Table I)
were slightly higher in the F R than in the R R group
(at the lingual aspect FRIL:l.42; RRIL:1.26 and at
the buccal aspect FRIB:I.71; RRIB:I.40). These
differences were only significant for the interdental
buccal region (p = 0.0163). The mean MGI after
wearing retainers for 1 month showed a tendency to
be lower than at baseline for all sites and for both
Heier et al.
610
F~G
- - c o ~ :
e
1.4
1.2
. . . . . .
2L
0f
1.4
/2
',,
J
jJJ
..... 2.Y'
.L
-1
i!i
D
Fig. 2. Modified gingival index. A, Buccal sites. B, Interdental buccal sites. C, Interdental
lingual sites. D, Lingual sites.
Heier et al.
611
B,45
f/1
~ f
....
i!i!I
C~E=
F~
....... i !
v
A
B L E ~ N ~ ON ~ROBZNG=X~OENT~L
~ I N ~ U ~ ~ZTE~
~.TS
o,75
~.SS
~.65
B,55
/
/'
--
-~
COOE=
i!
3
, Em~<months)
. . . . . . .
for the interdental sites: 35 in the removable retainer group and 25 with fixed retainers. The lowest
GCFF values were situated at the lingual sites: 11 in
the RR group, and 8 in the FR group.
Before debonding, comparable mean plaque indexes near 2.8 were found in the two groups on the
buccal and lingual surfaces (Fig. 5). The buccal
value had dropped significantly to about 1.2 on the
buccal surfaces at 1-month follow-up (Table I). It
remained at approximately the same level at 6
months, after a small but nonsignificant increase at
the 3-month follow-up (Table II). The mean lingual
PI in the removable retainer group was reduced to
2.5 after 1 month, 2.4 at month 3, and 2.5 at the
6-month follow-up. In the fixed retainer group, the
mean PI at the lingual sites climbed to 3.3 at
1-month, to end at 3.0 at 6 months (Table I). This
score was significantly higher than the score in the
removable retainer group (Table III).
On the buccal surfaces, the mean DCI (Fig. 6)
remained near zero throughout the evaluation period. The mean DCI on the lingual surface at
baseline was slightly above zero (0.2 ram) in the
group receiving a fixed retainer, whereas calculus
was almost absent (0.05 ram) in the other group.
One month 'later, the mean calculus level was
brought down further to 0.1 mm for the FR group
and to 0.01 mm for the RR group. At 6 months, the
mean lingual measurements had gone up to the
original values (Table I).
DISCUSSION
6"12
Heier et al.
~RE~ICU~R ~LU~
~ L O W : ~ C C ~ L SZ~E~
i!
.... COOE:
f~
~OE:
RR6
-?
:I
4~ r
-i
:I
L
C0~EZ
~0~E~
- -
-i
oa.:
t Jm~(~anths)
Fig. 4. Gingival crevicular fluid flow. A, Buccal sites. B, Interdental sites. C, Lingual sites.
l.e
H e i e r et al.
61:3
,,
. . . .
CODE*
FRE
-~
"-'-k
-'k
. .....
""-..
.......
1.B=
1.4 I
L.e
0,6
.... ~E,
0,4 ~
0,2
e~E~
0
Z
B
Fig, 5. Plaque index. A, Buccal sites. B, Lingual sites.
kinds of retainers. Some of the mean indices were a
little lower in the fixed retainer group, some a little
higher than in the removable retainer group, but
these small differences were not statistically significant. On this basis, it can be concluded that, in the
scored patient groups who wore fixed lingual retainers during a 1-month period, this did not lead to a
gingival condition, which was more unfavorable than
that in the group wearing removable appliances.
Our assessments of MGI, BOP, and G C F F at
3-month recall appeared to bring all mean values of
the group with fixed retainers at a lower level than
those with the removable retainers worn only during
the night. As the differences were seldom statistically significant, we cannot state that oral hygiene
conditions were more favorable in the group with
fixed retainers. Moreover, there is even less reason
to accept that they had worse gingival conditions.
Going to 6-month recall, a tendency toward
higher indices was noticed in both groups. How-
ever, these increases were not statistically significant. In general, the m e a n MGI, BOP, and G C F F
in the fixed retainer group remained below the
indices for the removable retainer group. A striking difference between the two groups concerning
gingival health could not be observed. The trend
toward increased values at 6 months for both
groups could be interpreted as an indication for
the need for r e p e a t e d motivation and oral hygiene
instructions at least on a 6-month interval basis.
Further investigation could test the validity of this
interval on a long-term basis.
In both groups, the mean buccal PI before
debonding was found to be very close to the lingual
values. The mean value near 2.8 shows that, at the
end of the orthodontic treatment, the patients did
not succeed in reaching a high standard of oral
hygiene. The mean MGI, BOP, and GCFF values
discussed previously suggest that, in those regions
with a buccal and lingual presence of at least a
614 Heier et aL
~. tv
^
~.tB
o.13
~.ee
%-
RR~
7
e . 24
e.e3
0,22
0.21
g.l.9
e,iB
. ,. 1.7.
0
....
....
i/'
B.14
B. ia
B.ll
e.o9
............
o.e8
0.07
.. .3. .'
............
.
---
z.m ~
-B.eI
- -
CODE=
FRG
CODE=
RRG
B
Fig. 6. Dental calculus index. A, Buccal sites. B, Lingual sites.
615
Heier et al.
T a b l e II. Mean differences a n d p levels from baseline to 1 month follow-up, from 1 to 3 month follow-up, and from 1 to 6 month
follow-up, for five outcome measures on different locations by treatment groups
Site
MGI
B
IB
IL
L
B
IB
IL
L
B
ID
L
BOP
GCFF
PI
DCI
L
B
L
X
-0.27
-0.70
-0.39
+0.33
-0.07
-0.13
-0.13
+0.24
-13.46
-18.60
+0.96
- 1,74
+0.56
-0.01
-0.07
1- to 3-month follow-up
RR
P
0.0540*
0.0000"
0.0004*
0.9436
0.8420
0.2364
0.1980
0.8963
0.1933
0.1398
0.9994
0.0000"
0.0009*
0.2472
0.1272
-0.06
-0.38
-0.39
-0.31
-0.10
-0.11
-0.27
-0.11
-13.52
-33.56
-11.14
- 1.38
-0.28
-0.01
-0.04
FR
P
0.9519
0.0013"
0.0005*
0.9567
0.6177
0.3140
0.0006*
0.9896
0.2350
0.0021"
0.5851
0.0000"
0.2553
0.9854
0.7354
-0.23
-0.45
-0.17
-0.82
+0.01
0.00
-0.05
-0.38
-0.07
-8.24
-7.39
+0.26
-0.52
0.00
+0.06
1- to 6-month follow-up
RR
P
0.1474
0.0000"
0.3137
0.4913
0.9999
1.0000
0,8996
0.6653
1.0000
0.7808
0.7904
0.3915
0.0023*
0.1102
0.1903
FR
0.00
+0.21
+0.12
+0.14
+0.04
-0.11
+0.02
-0.05
+0.28
+7.27
+6.27
+0.41
-0.07
0.00
0.00
P
0.9999
0.1832
0.6343
0.9954
0.9594
0.3621
0.9944
0.9990
0.9999
0.8724
0.8927
0.0814
0.9684
0.9999
1.0000
X
-0.20
-0.35
-0.09
-0.72
+0.04
+0.07
-0.07
-0.33
+11.18
-2.85
-8.21
0.10
-0.31
0.00
+0.07
RR
P
0,2717
0.0027*
0.8064
0.6077
0.9763
0.7124
0.7370
0.7662
0.3518
0.9880
0.7318
0.9209
0.1590
0.1253
0.1976
+0.21
+0.38
+0.36
+0.25
+0.11
+0.01
-0,03
-0.01
+4.84
+13.47
+6.44
+0.06
+0.02
0.00
+0.05
0.2420
0.0016"
0.0015"
0.9748
0.5257
0.9963
0.9815"
0.9999
0.9073
0.4921
0.8846
0.9858*
0.9995
0.9999
0.5194
MGI: Modified Gingival Index; BOP: Bleeding On Probing; GCFF: Gingival Crevicular Fluid Flow; PI: Plaque Index; DCI: Dental Calculus Index.
B: Buccal; IB: Interdental Buccal; IL: Interdental Lingual; L: Lingual; ID: Interdental.
FR: Fixed Retainer; RR: Removable Retainer.
*Significant atp -< 0.05.
Ill. Mean differences and p levels between wearing fixed and removable retainers for five outcome measures on different
locations by time of follow-up
Table
Baseline
1-month
Index
Site
MGI
B
IB
IL
L
B
IB
IL
L
B
ID
L
B
L
B
L
-0.03
0.31
0.16
-0.01
-0.15
-0.21
-0.20
-0.02
-0.99
-8.36
-0.41
0.30
0.00
0.00
0.15
0.9950
0,0163"
0.4032
1.0000
0.2615
0.0051"
0.0242*
0.9999
0.9990
0.7977
0.9999
0.2762
0.9999
0.8592
0.0012"
-0.24
-0.01
0.16
0.63
-0.12
-0.23
-0.06
0.33
-0.93
6.60
11.69
-0.06
0.84
0.00
0.12
BOP
GCFF
PI
DCI
3-month
6-month
0.1261
0.9999
0.3597
0.7108
0.5010
0.0035*
0.8250
0.7708
0.9991
0.8887
0.5042
0.9830
0.0000*
0.0214"
0.0242*
-0.47
-0.67
-0.13
-0.33
-0.15
-0.12
-0.13
0.00
- 1,28
-8.91
- 1.97
-0.21
0.39
0.00
0.18
0.0000"
0.0000"
0.5858
0.9436
0.2525
0.3196
0.2679
0.9999
0.9978
0.7648
0.9955
0.6134
0.0533*
0.8582
0.0000*
-0.65
-0.74
-0.29
-0.34
-0.19
-0.17
-0.10
0.01
5.41
-9.72
-2.96
-0.22
0.51
0.00
0.14
P
0.0000"
0.0000"
0.0185"
0.9403
0.0789
0.0517
0.4466
0.9999
0.8667
0,7126
0.9850
0,5321
0.0040*
0.9900
0.0101"
MGI: Modified Gingival Index; BOP." Bleeding On Probing; GCFF: Gingival Crevicular Fluid Flow; PI: Plaque Index; DCI: Dental Calculus Index.
B: Buccal; IB: Interdental Buccal; IL: Interdental Lingual; L: Lingual; [19: Interdental.
FR: Fixed Retainer; RR." Removable Retainer.
*Significant atp -< 0.05.
f o r m a t i o n a r o u n d fixed r e t a i n e r s w a s c o n f i r m e d . H o w ever, this difference w a s a l r e a d y p r e s e n t b e f o r e t h e place-
m e n t o f t h e fixed r e t a i n e r , I f a p r o f e s s i o n a l p l a q u e a n d
A s s i s t a n t P r o f e s s o r in A p p l i e d Statistics, D e p a r t m e n t o f
calculus r e m o v a l
and oral hygiene
is likely t h a t t h e
p r o m i s e d by t h e
a c c o m p a n i e d by a s e s s i o n o n m o t i v a t i o n
i n s t r u c t i o n is r e p e a t e d every 6 m o n t h s , it
periodontal health should not be comp r e s e n c e o f b o n d e d lingual wires.
W e e x p r e s s o u r t h a n k s to K a t h y Goeffers, D D S ,
A s s i s t a n t P r o f e s s o r , D e p a r t m e n t of O r t h o d o n t i c s , F r e e
REFERENCES