Relapse part 2

Inferior positioning of maxilla
www.indiandentalacademy.com

Stability of Le Fort I osteotomy in maxillary inferior positioning:
Review of the literature
Costa et al. IJAOOS 2000
 Fixation techniques
 Wire fixation and IMF
 Rigid fixation only
 Rigid fixation and bone grafting
 Rigid fixation and alloplastic materials (porous
block hydroxyapetite)

Stability of Le Fort I osteotomy in maxillary inferior positioning:
Review of the literature
Costa et al. IJAOOS 2000
 Wire/IMF – highest relapse – 50% overcorrection
 RIF – more stable upto 2 mm
 Rigid fixation with autogenous bone - stable, and predictable
 Rigid fixation with porous block hydroxyapetite showed
excellent stability.
 Greater relapse in the posterior part of the maxilla

The Le Fort I downsliding osteotomy: A study of
long-term hard tissue stability- Steve Wagner
IJAOOS2000
 Long-term skeletal changes in 13 patients who
underwent a Le Fort I downsliding
 9 single-jaw procedure
 4 bimaxillary procedure

The Le Fort I downsliding osteotomy: A study of
long-term hard tissue stability- Steve Wagner
IJAOOS2000
 Results
 RIF - enhance the horizontal stability of the maxilla
in patients with single-jaw surgery.
 Maxilla was more stable vertically in patients with
bimaxillary surgery with RIF, compared to isolated
maxillary surgery and RIF
 Conclusion: 2-mm relapse value may be useful in
planning the vertical amount of maxillary incisor
exposure.

Dental relapse
 Rotations
 Over correction
 Fibrotomy- Jacobson
 Lower anterior crowding
 Arch length decreases with age
 Permanent retention
 Archform- maintained as pretreatment

 Deepbite
 Retainer with anterior bite plate
 Openbite
 High pull HG + retainer
 Posterior bite blocks
 Openbite Activator/Bionator

Functional relapse
 Class II- Retainer only – if relapse seen- FA- 1-2yrs
1. HG (at night) + retainer- well motivated pts
2. Functional appliance (activator/bionator) + retainer
 Class III
 Continuing mandibular growth very likely
 Mild – retainer or FA
 Maxillary orthopedic protraction
 Chin cup therapy
 Moderate to severe- mand rotates downward
 Surgical correction after growth has expressed itself

Retainers

RETAINERS
Retainer- An appliance used to hold teeth in
position after orthodontic treatment.
Removable
Fixed
Active
Passive

Removable retainers
INDICATIONS
 Used in predictable cases of limited retention.
 Serve effectively against intraarch instability.
 In the form of modified functional appliances or part-
time headgear in patients with growth problems.
 Not indicated in cases requiring long-term retention.

Hawley retainer
 Designed by Charles Hawley in 1908
 Most frequently used retainer
 Short labial bow
 Adams Clasp on molars

Modifications :
 Long labial bow – Closing space distal to canine
 Labial bow soldered to bridge of Adams clasp –
avoids risk of space opening due to cross over wire
 Fitted labial bow – Offers excellent retention
 Anterior bite plane – To retain or correct deep bite
cases
 Expansion screw with split labial bow
 With tongue crib.
 With Z spring on second molars for lingual
movement of molars

High Labial Retainer
Harvey L. Lavitt JCO Jan1972
 Control over each tooth separately
 Springs for correction of rotation and uprighting
 Both active and retentive
 More esthetic

Begg’s Wraparound retainer
Popularized by P.R.Begg.
Bow extending till last erupted molar
 No crossover wire, eliminates risk of space
opening up

Habit Breaking/Restraining
 Tongue crib appliance
 Tongue crib anchored to oral cavity by clasps and
labial bow
 Used for interception of habits like tongue thrusting
and thumb sucking.

Removable wraparound retainers
 Wire enforced plastic bar along the labial and
lingual surfaces of the teeth.
 3 to 3
 6 to 6
 Firmly holds each tooth into position

Wraparound cantilever retainer
Timonthy J. Tremont JCO Feb- 2003
 Ideal for a well finished case
 Cantilever arm- middle of first bicuspid soldered to
labial bow
 Bow adjusted by giving a slight bend in the cantilever
arm

Van der Linden Retainer
JCO May2003

Kesling’s Tooth positioner
Described by H.D.Kesling in 1945
Made of thermoplastic rubber like material
Spans interocclusal space and covers clinical
crowns and a small portion of gingiva
 No activation needed
 Difficulty in speech
 Risk of TMJ problems

Essix Retainers- Fabrication and supervision for
permanent retention
John. J. Sheridan et al JCO Jan 1993
 Fixed retainers must be systematically monitored for
displacement and hygiene problems .
 Removable appliances become loose, the mechanical
constraints are lessened and the teeth can shift.
 Essix thermoplastic copolyester retainers are a
thinner, but stronger, cuspid-to-cuspid version of the
full-arch, vacuum-formed devices.

permanent retention

permanent retention
 Advantages :
 The ability to supervise without office visits.
 Absolute stability of the anterior teeth.
 Durability and ease of cleaning.
 Low cost and ease of fabrication.
 Minimal bulk and thickness (.015").
 The appliance can serve as a night guard against bruxism.
 Alternative to spring retainers in correcting minor tooth
movements.
 Can be used to reduce occlusal forces from the opposing arch
when moving posterior teeth.

Osamu Active Retainer for Correction of Mild
Relapse- Sanchez et al JCO Jan 1998
 Developed by Dr Osamu Yoshii- Tokyo, Japan
 Transparent removable appliance that can correct
individual tooth positions during the retention phase

 2 superimposed layers.
 Inner layer- 1.5mm ethylene vinyl acetate
copolymer (Bioplast) adapts to the interproximal
areas and covers the palatal and lingual aspects of
the teeth.
 The outer layer- of .75mm hard elastic
polycarbonate, covers the occlusal aspects of the
teeth and makes the retainer elastic and stable

All wire retainer
 The Clip-On system creates a “bonding mound” on
the clasp of the premolar, and clips the clasp to the
mound. This provides sturdy support for the All-Wire
Retainer.

Fixed retainers
 Indications :
 Maintenance of lower incisor position during late
growth.
 Diastema maintenance
 Maintenance of pontic or implant space.
 Keeping extraction spaces closed in adults.

Fixed retainers
 Newman 1965 introduced direct bonding of
orthodontic attachments
 Kneirim 1973 published the first report of the use of
this technique to construct bonded fixed retainers.
 Zachrisson 1977 introduced direct bonded lingual 3-3
retainers
 Årtun and Zachrisson 1982 first described the clinical
technique for the use of a multistrand wire canine-to-
canine bonded fixed retainer.
 Zachrisson 1983- fixed retainer bonded to all the
teeth in the labial segement

INDICATIONS FOR BONDED
RETAINERS
Lee BJO 1981
Bonded canine-to-canine retainer:
1. Severe pretreatment lower incisor crowding or rotation
2. Planned alteration in the lower intercanine width
3. After advancement of the lower incisors during active
treatment
4. After nonextraction treatment in mildly crowded cases
5. After correction of deep overbite.

INDICATIONS FOR BONDED RETAINERS
Zachrisson JCO 1983
Flexible wire retainer
 Closed median diastemas
 Spaced anterior teeth
 Adult cases with potential postorthodontic tooth
migration
 Accidental loss of maxillary incisors, requiring
closure, and retention of large anterior spaces
 Spacing reopening, after mandibular incisor
extractions
 Severely rotated maxillary incisors
 Palatally impacted canines

Bonded retainers

Third-Generation Mandibular Bonded Lingual 3-3
Retainer
BJORN U. ZACHRISSON JCO Jan 1995
First Generation Second Generation Third Generation

Retainer
 Fabrication

Retainer

Resin Fiberglass Bonded Retainer
MICHAEL DIAMOND JCO 1987
 3 major problems with bonded cuspid-to-cuspid
retainers:
 Holding the lingual arch in position during
bonding.
 Adapting the arch to the contours of the teeth
 Repairing a broken arch in the mouth.

Resin Fiberglass Bonded Retainer
MICHAEL DIAMOND JCO 1987
 Glass fibers (Fiberbond) separated into 6" strips,
sterilized with dry heat
 Measure and cut fibre glass thread
 Soak in light-cure bonding resin

Bonded orthodontic retainers: A review David
Russell Bearn AJO Aug 1995

Bonded orthodontic retainers: A review -
David Russell Bearn AJO Aug 1995
 The reported overall failure rates of bonded retainers
ranges from 10.3% to 47.0%.
 In the maxilla there is a 48% to 50% failure rate for
retainers with a 15% to 20% failure rate for individual
attachments.
 In the mandible there is a 12% to 20% failure rate for
retainers with a 4.4% failure rate for individual
attachments. (role of occlusal factors )

 Dahl and Zachrisson (JCO 1991)
 Concise composite resin and 0.0215-inch diameter
Penta One wire,
 Reported lower failure rates :
 10.1% failure rate for maxillary retainers with
2.9% failure rate for maxillary attachments
 5.9% failure rate for mandibular retainers with
4.0% failure rate for mandibular attachments.
 There is a wide range of observation periods (38 - 72
months) www.indiandentalacademy.com

 Failure type
 Detachment at the wire/composite interface- most
commonly observed.
 Placement of insufficient adhesive
 Material loss due to abrasion (62%)
 The abrasion of mandibular retainers - mechanical
forces such as toothbrushing and chewing.
 Composites with greater abrasion resistance -
decreased observed failure rate.www.indiandentalacademy.com

 Hygiene status and bonded retainers
 5 studies have reported on the hygiene effects of bonded
fixed retainer
 The observation periods of vary considerably (4 - 103
months)
 No increased periodontal disease or enamel decalcification
in relation to lingual bonded retainers.
 No difference b/w Multistranded and round wire.

Banded mandibular retainer

Banded Mandibular Adjustable Retainer
JACK BALENSEIFEN JCO 1991
 (B-MAR) combines
 Fixed retainer's
advantages - cooperation
and hygiene
 Ability to adjust the
appliance one to three
months after insertion.

Banded Mandibular Adjustable Retainer
JACK BALENSEIFEN JCO 1991

MOLAR-TO-MOLAR MANDIBULAR RETAINER
THOMAS E. CHRISTIE JCO July 1985
 Allows the mandibular
canines and molars to settle
naturally.
 Mandibular arch can be
expanded or contracted.
 Rotations can be corrected
by ligating the teeth to the
lingual arch.
 Advantages over a Hawley or a cuspid-to-cuspid retainer :

MOLAR-TO-MOLAR MANDIBULAR RETAINER
THOMAS E. CHRISTIE JCO July 1985
Incisors can be advanced, retracted, intruded or
extruded by ligating them to the lingual arch.
Spurs added in incisor region - tongue thrust
Second and third molar eruption can be facilitated
with auxiliary springs.
Class II elastics can be used in retreatment.

12 keys to stability- Gorman
1. Whenever possible, allow lower incisors to align
themselves either thro’ serial extraction or use of lip
bumper in early mixed dentition
2. Overcorrect lower rotation as early in treatment as
possible
3. Reproximation of incisors early in Rx and again at
retention enhances stability
4. Avoid increasing the intercanine width during active
treatment.

5. Extract bicuspids where mand arch discrepancy is
4mm or greater, except where facial esthetics
dictates otherwise
6. Recognize that more a tooth is moved, more likely
it is to relapse, overcorrect accordingly
7. Upright lower incisors to atleast 90o whenever the
profile permits
8. Create a flat occlusal plane during Rx and
overcorrect the overbite.

9. Prescribe supracrestal fibrotomy for severely
rotated teeth
10. Retain the lower arch until all growth is complete
11. Place retainers the same day appliance is remove
12. Recognize that compromise often necessary in the
interest of facial esthetics and that sometimes
lifetime retention is necessary

Recovery after relapse
1. Re-treatment- interested & cooperative patients.
Rebanding, extraction- crowding, eliminate factors
contributing to relapse
2. Crowding- light pressure against mandibular anteriors.
3. Springs and clasps to Hawley’s retainer.
4. Class II- Kloehn type HG
5. Habits- removable appliance
6. Equilibration
7. Patient accept minimal relapse than continue with
prolonged Rx or retention

stability
 Begins with clinical examination
 Treatment goals designed with stability in
mind
 Appropriate treatment mechanics
 Retention is a part of stability

Relapse part 2

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Relapse part 2