Retention management decisions:

A review of current evidence and

emerging trends
Wellington J. Rody Jr, and Timothy T. Wheeler

Retention protocols remain controversial despite the fact that long-term

stability is rarely observed in orthodontics. In this review article, we examine
current evidence and discuss emerging trends to managing retention which
may ultimately improve patient care. Our goal is to provide information that
may help overcome the gap between scientic evidence and clinical practice.
(Semin Orthod 2017; 23:221228.) & 2017 Elsevier Inc. All rights reserved.

Introduction overlooked by clinicians and should be consid-

A
ered when writing the patients treatment plan.
major concern driving orthodontic patient
The recommended length of time for wearing
dissatisfaction during retention is rooted in
a retainer varies from orthodontist to ortho-
the instability, which can be broadly dened as an
dontist and recent systematic reviews state that
excessive post-orthodontic displacement of tooth
there is insufcient evidence to make recom-
position accompanied by esthetics and/or
mendations on retention procedures.68 In
functional concerns. It is well known in the
addition, there is no consensus in the literature
orthodontic community that the periodontal and
regarding the retention protocol that will ensure
gingival bers need additional time to stabilize
more long-term stability and predictability.9 It is
around the teeth after active therapy; never-
beyond the scope of this article to describe
theless, the etiology of orthodontic relapse still
in detail all the retention devices available
remains unclear and controversial. Alignment
in orthodontics and readers are referred
instability varies widely within the population and
to Johnston and Littlewood10 or classic
may occur through various mechanisms, some of
orthodontic textbooks for further descriptions
which are beyond the clinicians control. Arch
about individual appliances. Instead, the goal of
expansion, rebound of periodontal bers,
this article is to elaborate on retention protocols,
alveolar bone remodeling, skeletal growth pat-
examine current evidence, and discuss emerging
tern, occlusal settling, mesial drift of posterior
trends to managing retention which ultimately
teeth, parafunctional habits, quality of nal
may improve patient care. Some of the topics
occlusion, and lack of patients compliance are
described below may seem obvious for many
but a few of the potential factors that may play a
orthodontists; however, for a variety of reasons
role in post-orthodontic relapse.1,2 Indeed, clas-
they are often ignored as we tend to practice
sic studies done by Little35 showed that long-
based on our individual training and experience,
term stability of the lower teeth alignment is
along with all the inherited bias that comes
rarely observed; thus, management decisions
with it.
regarding retention and the patients care after
active orthodontic therapy must not be
Current evidence about orthodontic
retention
Department of Orthodontics, College of Dentistry, University of
Florida, Gainesville, FL. There is an extensive orthodontic literature
Address correspondence to Wellington Rody Jr, DDS, MS, describing a variety of retention regimens and
Department of Orthodontics, University of Florida, Health Science
appliances; however, most of the studies lack a
Center, D7-19, Gainesville, FL 32610-0444. E-mail: wrody@dental.
u.edu high level of scientic precision. Randomized
& 2017 Elsevier Inc. All rights reserved.
controlled trials (RCTs) remain the gold stand-
1073-8746/17/1801-$30.00/0 ard of research and while the number of RCTs in
http://dx.doi.org/10.1053/j.sodo.2016.12.009 dentistry has increased dramatically in recent

Seminars in Orthodontics, Vol 23, No 2, 2017: pp 221228 221

222 Rody Jr and Wheeler
years, very few RCTs have been done on ortho-
dontic retention,1114 which results in less reli-
able research guiding clinical practice. This
leaves the evidence open to criticism and pro-
vides challenges to clinicians in delivering reli-
able information to post-orthodontic patients.
These challenges will become increasingly
apparent as patients can now turn to the web to
obtain health information instead of consulting
with their own orthodontists. This raises con-
cerns, given that Doramac and Rossi-Fedele15
recently noted that the quality of the content
about retention on the internet is generally
questionable and a large discrepancy exists for
retention protocols between practices that offer
web resources. Thus, this section of the paper
provides a critical review of selected studies with
moderate to low risk of bias. A small selection
that highlights key points and important clinical
questions in retention will be reviewed here. This
approach will allow us to understand what
questions have already been answered by
current evidence and what conclusions are still
inuenced by anecdotal opinion.
(1) Hawley-type versus clear retainers: Currently
there is a trend toward the use of clear
retainers in orthodontics,1618 which are
vacuum-formed appliances made of a thin
sheet of thermoplastic material that adapts
closely to the teeth including the occlusal
surfaces. Although there is a plethora of
reasons for this trend, the most signicant
reasons lie in the excellent esthetic charac-
teristics, low cost and most importantly, easy
fabrication.19 In the quest for evidence-based
interventions important questions still
remain though: Is there enough evidence
to substantiate a transition from traditional
Hawleys to clear retainers? Are clear
retainers reliable over the long term? Is
reliability of clear retainers dependent on
the thermoplastic used? The controversy in
question was initially tested in 1998 by
Lindauer and Shroff20 using a non-
randomized prospective approach and the
authors could not detect any differences
between Hawley and clear retainers. More
recently, a systematic review by Mai et al.21
has reached the same conclusion and
suggested that further high-quality RCTs
are necessary to determine which retainer
is a better selection for orthodontists. Quite a
few RCTs were published in this area and in
spite of their limitations, have resulted in
important progress in the eld of orthodon-
tic retention. By using a large sample size of
397 individuals in a single-center RCT done
in Britain, Rowland et al.22 could not detect a
signicantly better clinical performance by
clear retainers during the rst 6 months after
debond. The clinical variables analyzed
in this RCT included tooth rotations,
irregularity index, inter-molar and inter-
canine widths. Subsequently, two other RCTs
added to this evidence and indicated that
clear retainers are as effective as Hawley
retainers in maintaining post-orthodontic
alignment and dental arch dimensions.23,24
Even though Hichens et al.19 specically
reported some advantages of clear retainers
over Hawley retainers including cost-
effectiveness, improved patient satisfaction
and less breakage, the latter was not further
supported by another RCT of 120 adolescent
patients where Sun et al.25 reported equal
brakeage rates between the two during a
1-year period. Reduced occlusal settling after
debond has also been reported as a potential
disadvantage of clear overlay retainers; how-
ever, the basis for this statement is largely
anecdotal and supported primarily from a
case control study done by Sauget et al.26 in
which 30 patients were followed up clinically
for 3 months after debond. The authors
concluded that the Hawley retainer allowed
for a signicant increase in the number of
posterior occlusal contacts whereas the clear
retainer did not allow the posterior teeth to
settle down as efciently. A similar result was
reported by Tsai27 in a randomized trial at St.
Louis University that evaluated short-term
occlusal contact changes in 40 post-
orthodontic patients who received either
clear or Hawley retainers. After 3 months,
a signicant difference in the quantity of
posterior contacts and near contact was
found between groups; thus, he concluded
that the Hawley retainer allowed for slightly
better settling. In summary, the literature
indicates that there is no strong evidence to
support the use of one retainer over another;
nevertheless, cost-effectiveness and patient
acceptability seem to be the driving forces
 Retention management decisions
behind the increased popularity of clear
retainers. The ability of Hawley retainers to
provide better occlusal settling warrants
further investigation in more controlled
RCTs that pay attention to a large sample
size and duration of follow-up.
(2) Part-time versus full-time wear: How long should
removable retainers be worn full time?
Perhaps this is the clinical question which
most commonly occurs to the orthodontist
from the patient at the end of active
orthodontic therapy. The good news is that
this question may have already been
answered by two RCTs. The study by Gill
et al.11 merits further discussion, as it was the
rst high level of evidence study to compare
part-time and full-time removable retainer
wear regimens. The results of their study
showed that part-time wear of clear retainers
is a successful retention regimen to prevent
relapse of the nal occlusion outcome. In
addition to measuring the Littles irregularity
index, they also analyzed three other impor-
tant aspects of the occlusion (arch width,
overjet, and overbite) and none of the
patients in the part-time group showed
signicant changes within 6 months after
debond. These results are similar to those in
Jderberg et als study,13 who compared the
alignment stability of dental arches receiving
full-time clear retainers for 3 months with
those wearing retainers full time only during
the rst week after debond. Their results
showed that both regimens are equally
effective to prevent unwanted relapse; thus,
the authors concluded that the clear retainer
is sufcient for maintaining the results after
orthodontic treatment and that night-time
wear is adequate. To the best of our knowl-
edge, no similar RCTs exist to date for other
types of removable retainers, leaving the
question open as to the attainable effectiveness
of part-time wear of Hawley retainers for the
rst six months after treatment is completed.
(3) Removable versus xed retainers: It is said that a
lot can happen in 7 days when it comes to
orthodontic retention. Unfortunately, this is a
fact and we know it is true. Perhaps that is why
a recent survey clearly shows a preference
towards the use of xed retention in modern
orthodontics.18 If a clinician wants to be on the
safe side and rule out the danger of relapse,
223
xed retention may be the obvious choice.
Nevertheless, this approach may bring long-
term harm if the appliance is left unsupervised.
Unwanted side-effects due to distorted xed
retainers are common and range from minor
rotations to bone fenestrations and excessive
displacement of the anchoring teeth.28,29
Moreover, the ability of xed retainers to
compromise oral hygiene practices cannot be
neglected. The literature is full of ambiguous
and contradictory ndings regarding the long-
term periodontal outcomes of xed retainers.
Some evidence suggests that xed retainers are
clinically safe to the periodontium as long as
they remain intact3032; however, increased
plaque accumulation, soft tissue changes and
detrimental effects in the alveolar bone have
been reported by other groups.3336 Thus, the
next question that comes to mind is: Are xed
retainers really necessary for long-term stabil-
ity? Although the obvious answer may be yes,
this is not in agreement with the results of a
study carried out by Edman Tynelius et al.,37
who demonstrated that retention protocols
without xed retention were equally efcient
in preventing post-orthodontic relapse for a
period of ve years. Certainly, this decision
making process between xed versus remov-
able retainer may be challenging in different
clinical scenarios, including the one where the
patient is unable to keep regular follow-up
retention appointments. At the University of
Florida, hybrid retention is a common practice
in these cases. By hybrid retention, we mean
that a clear overlay retainer is fabricated on top
of the bonded retainer and is worn nightly
(Fig. 1). In our anecdotal opinion the hybrid
approach has many advantages: (1) it reduces
Figure 1. Hybrid retention in the lower arch with a
clear overlay retainer on top of a xed retainer.
224 Rody Jr and Wheeler

the likelihood of relapse if the composite gets

detached from the wire or teeth, (2) it will
prevent unwanted tooth movement and its
deleterious effects on the periodontium if the
xed retainer gets distorted, and (3) the
patient does not need to rush to his/her
emergency appointment given that the clear
overlay works as a backup retainer and thus will
give the patient some extra-time to seek
orthodontic care.
Emerging trends to managing retention
The relationship between orthodontic proce-
dures and periodontal health is considered
challenging because some appliances can alter
the oral microbiota and induce periodontal
disease.38 To date, radiographs and cone beam
computed tomography (CBCT) scans are the
best imaging methods to monitor periodontal
conditions; nevertheless, radiation exposure and
expense preclude routine use. In addition, these
methods do not indicate if the process of
periodontal destruction is ongoing or
historical. For more than a decade, dental
researchers have been exploring alternative
options to identify individuals at increased risk
for periodontal disease, such as the emerging
eld of biomarker discovery in oral uids. The
analysis of specic constituents in saliva and/or
gingival crevicular uid (GCF) may provide
quantitative biochemical indicators for
evaluation of the level of inammation and the
status of bone turnover in the presence of
periodontal disease39,40; thus, growth in this
eld of research tends to be steep. GCF has been
found to contain large amounts of serum-derived
proteins, inammatory mediators, host-response
modiers and products of tissue breakdown.
Because GCF is more site-specic than saliva,
Figure 2. Gingival crevicular uid collection with a
paper strip (Periopaper, Oraow Inc.).
research in the area has been heavily geared
towards this body uid and a lot of data has been
published. GCF collection with paper strips is by
far the most popular method and it is considered
a non-invasive procedure since the lter paper is
inserted only 12 mm into the gingival sulcus
(Fig. 2). The natural sulcus in a healthy
individual has a depth of 13 mm; thus, the
paper strip would go as deep as a regular dental
oss during oral hygiene procedures.
There are only few published studies that use
GCF samples to compare the periodontal effects
of different retainer types34,41; thus, pioneering
this type of research can lead to clinical
improvement and biochemical control of reten-
tion regimens. More recently, our group made use
of cutting-edge platforms to investigate expression
of protein biomarkers related to periodontal
disease in the GCF of patients wearing ortho-
dontic retainers and interest patterns were
observed.39 We have grouped the biomarkers in
four categories based on their underlying
biological role in periodontal disease (Table).
In our initial investigation,34 we compared
biomarker proles in the GCF samples of

Table. Categories of biomarkers in gingival crevicular uid (GCF) and their relevance in periodontal disease.
Category Biomarker Biological relevance

Osteoclastogenesis-related factors
Pro-inammatory cytokines
Enzymes of extracellular matrix
degradation
Chemoattractant for monocytes
Receptor activator of nuclear factor
kappa-B ligand (RANKL)
Osteoprotegerin (OPG)
Interleukin 1 beta (IL-1)
Interleukin 8 (IL-8)
Matrix metalloproteinase 9 (MMP-9)
Matrix metalloproteinase 3 (MMP-3)
Monocyte chemoattractant protein 1
(MCP-1)
Monitoring of bone remodeling and
osteoclast activity
Recruitment of cells to infection sites
Promotion of bone resorption
Destruction of periodontal tissues
Recruitment of inammatory and
immune cells to periodontal sites
 Retention management decisions 225

Figure 3. Microarray images showing a higher intensity of the uorescent signal that comes from the line (arrow)
that represents the biomarker matrix metalloproteinase 9 (MMP-9) in a patient wearing xed retainer. Notice that
each antibody droplet, together with the positive (pos) and negative (neg) control, is printed in quadruplicate.
GCF samples were collected from the lingual surfaces of the lower incisors. (Reprinted from Rody et al.39 with
permission from Dr. James McNamara Jr., editor of of the Craniofacial Growth Series, University of Michigan).

patients wearing xed retainers bonded only to
canines and Hawley-type removable retainers
using microarray chips. In this technique, small
droplets of antibodies are xed in an orderly
pattern onto a glass surface and are used as
capture molecules to detect biomarkers in oral
uids. Our results showed a distinct pattern in
patients with xed retainers made of a large
diameter round stainless steel wire bonded only to
canines. In particular, the biomarker matrix
metalloproteinase 9 (MMP-9) was detected in
higher levels in patients with xed retainers
(Fig. 3), who also showed higher plaque levels in
the incisor region. MMP-9 is a key enzyme for
degradation of extracellular matrix that can be
generated by different cell types in response to
pro-inammatory cytokines stimulation such as
intereleukin 1beta (IL-1). Higher GCF levels of
this biomarker had been previously correlated
with gingivitis, bleeding on probing, and attach-
ment loss by other groups.4246
The result of this initial study compelled us to
further investigate the impact of different xed
retainer designs on the periodontal status of post-
orthodontic patients. We have recently nished a
second study47 that aimed to analyze GCF
biomarker levels and clinical periodontal
parameters in patients wearing retainers
constructed of braided wires bonded to all six
lower anterior teeth. This design of xed retainer
was initially introduced by Zachrisson48 and it is
becoming popular worldwide as the braided wire
can be easily delivered at debond appointment
without the need of alginate impressions or extra
visits to the ofce. Nevertheless, the detrimental
effect on periodontal health of this type of retainer
is clinically obvious in patients with poor oral
hygiene. Our study47 results conrmed those of the
initial study, that higher loads of MMP-9 is found in
GCF of patients wearing xed retainers compared
with the other groups. Thus, further research is
necessary to establish whether GCF MMP-9 may be
used as a prognostic marker of periodontal disease
in the presence of xed retention. In addition, we
found positive correlations between plaque build-
up and GCF levels of MMP-9 and IL-1, as well as a
negative correlation between interleukin-6 (IL-6)
and probing depths. While no individual bio-
marker candidate is already successful for early
detection of periodontal disease, we hypothesize
that a combination of GCF biomarkers could
increase diagnosis or prognosis efciency and
might predict underlying periodontal changes in
the presence of xed retention. Future longi-
tudinal studies are needed to determine the use-
fulness of these markers as monitors for
periodontal disease.
Another trend that has recently appeared in
the orthodontic literature is that vibration may
enhance alignment stability following ortho-
dontic treatment. This hypothesis was put for-
ward by Zhang et al.49,50 based on the premise
that low-magnitude high-frequency mechanical
vibration stimulates osteoblast proliferation and
thus have an anabolic effect on bone. More
recently, the work of Yadav et al.51 gives this
hypothesis further ground by showing that
vibration applied at 30 Hz for 15 min on a
daily basis seem to increase tissue density and
collagen integrity in the mouse molar
periodontium. Moreover, the authors report a
decrease in osteoclast number and osteoclast
surface area in the vibration group, which is also
a strong indication of the bone anabolic effect of
226 Rody Jr and Wheeler
vibration in the periodontium of rodents. If this
also proves to be true in humans, we may see a
shift in the clinical application of vibration
devices in our specialty. In the past decade,
vibration therapy has been introduced in
\orthodontics as a means of accelerating tooth
movement and alveolar bone resorption. This is
indeed quite surprising due to the fact that
vibration therapy in the medical eld has always
been used in an opposite fashion as a means of
improving bone formation in patients with
osteoporosis. The uniqueness of the alveolar
bone may help to explain the discrepancy
between medical and dental clinical applications.
In a comprehensive review, Sodek and McKee52
highlights that the alveolar bone undergoes what
they call asynchronous remodeling in response to
functional demands imposed by the dentition. By
and large, research results have been mixed in
relation to whether or not vibration therapy is
capable of accelerating tooth movement and
increase osteoclast activity. While the works of
Nishimura et al.53 and Pavlin et al.54 reassert the
usefulness of vibration devices in accelerating tooth
movement, the literature is still growing in this eld
and a randomized trial published by Woodhouse
et al.55 seems to contradict previous ndings
showing that vibrational force did not
signicantly increase the rate of initial tooth
movement when xed appliances were used. Our
group at the University of Florida has recently
nished a single-center randomized controlled
crossover trial to test the efciency of vibration
therapy in accelerating tooth movement with clear
aligners56,57 and neither the rate of tooth move-
ment nor the expression of biomarkers in GCF
was found to be inuenced by vibratory forces.
Our biomarker panel in this study encompassed
molecules related to bone resorption and osteo-
clast activity and none of them were differentially
expressed in GCF due to vibration stress. As a
future direction, research may consider focusing
on GCF markers of osteoblast activity to explore
the potential anabolic effect of vibration devices in
the alveolar bone which may be promising as a
clinical tool to reduce relapse according to this
new trend.
Conclusion
The etiology of alignment instability following
orthodontic treatment is still enigmatic and
largely inuenced by individual factors and dif-
ferent retention protocols. Given the high inci-
dence of orthodontic relapse, clinicians should
be familiar with relevant studies and develop-
ments that can impact retention management
decisions. In this article, we have described some
of the key areas where gaps of knowledge exist
and where further research is warranted. Insights
into new areas of research that may impact
retention protocols in the future were also
discussed.
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