Evidence-based retention: Where are

we now?
Simon J. Littlewood

Relapse is unpredictable. Retention is used at the end of orthodontic

treatment to resist tooth movements back toward the original malocclusion,
but it is also required to resist unwanted tooth movements and disruptions in
the occlusion that occur as a result of normal age changes. The approaches to
retention vary signicantly across the world. This article explores why we
need retention and our current understanding of the best evidence-based
approach to reducing relapse. There is a lack of high-quality evidence to
support several aspects of retention, so the implications for clinical practice
are discussed. (Semin Orthod 2017; 23:229236.) Crown Copyright & 2017
Published by Elsevier Inc. All rights reserved.

Introduction  Perhaps it does not matter, and there are a

etention is arguably the most important
R part of any orthodontic treatment plan.
Achieving stability after orthodontics continues
to be highly challenging and this article will
explore our current understanding of the best
evidence-based approach to reducing relapse.
Differing approaches to retention
worldwide
Surveys of orthodontic clinicians retention
practice demonstrate that there is a highly varied
approach to retention, which differs between
different geographical locations. Table 1
demonstrates that there is no agreement to the
best approach to retention.
This difference in clinical practice could be
due to a number of possibilities:
 Different population may have different types
of relapse and therefore require a different
approach to retention. While this is possible,
this seems unlikely, particularly with increas-
ingly mobile populations and globalization.
Orthodontics Department, St Lukes Hospital, Bradford, UK.
Address correspondence to Simon J. Littlewood, BDS, MDSc, FDS
(Orth) RCPS, M Orth RCS, FDSRCS, Orthodontics Department,
St Lukes Hospital, Little Horton Lane, Bradford BD5 0NA, UK.
E-mail: simonjlittlewood@aol.com
Crown Copyright & 2017 Published by Elsevier Inc. All rights
reserved.
1073-8746/17/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.12.010
range of different retainers that all successfully
reduce relapse.
 We do not yet have sufcient high-quality
scientic evidence to help us make informed
clinical decisions.
Why do we need retention?
Relapse is unpredictable.7 The classic retention
studies by Professor Bob Little and co-workers in
the 1980s and early 1990s highlighted the
unpredictability and high levels of relapse that
can occur once retainers are stopped.813 As a
result of these and other similar long-term ret-
rospective studies from this period,1416 there has
been a gradual change of practice from pre-
scribing retainers for 12 years to long-term
retention. The research shows that there are
some patients who, despite not wearing retainers
long-term, will remain stable. However, we are
unable to identify which patients will remain
stable, so we have to treat all patients as if they
have the potential to relapse long-term.
It is worth briey considering why teeth
relapse.17 Orthodontic relapse can occur as a
result of
 periodontal and gingival tissues,
 occlusal factors, and
 soft tissues pressures.
After orthodontic tooth movement, the
periodontal and gingival bers remodel to the
new tooth position. The majority of bers

Seminars in Orthodontics, Vol 23, No 2, 2017: pp 229236 229

230 Littlewood

Table 1. International Approaches to Retention.

Country Year of Summary of Survey Key Findings
Publication

Republic of 2013 82% Response rate from specialist
Ireland1 orthodontists to postal or electronic
questionnaire
USA2 2011 18% Response rate from members of
American Association of Orthodontics to
electronic questionnaire
USA3 2010 33% Response rate from members of
American Association of Orthodontics to
postal questionnaire
UK4 2009 80% Response rate from British Orthodontic
Society members related to a hypothetical
crowded Class II division 1 case
Netherlands5 2009 91% Response rate from orthodontists
in the country to a postal questionnaire
Australia and 2004 300 Randomly selected Australian and 70
New Zealand6 randomly selected New Zealand orthodontists
were sent postal questionnaires
Commonest types of retainers were upper
and lower vacuum-formed retainers
Hawleys and Vacuum-formed retainers were
preferred in the maxilla, and bonded were
preferred in the mandible
Hawleys were most popular in maxilla, and
bonded retainers most popular in mandible
Upper and lower vacuum-formed retainers were
the most popular in the national health service.
There was increased use of mandibular bonded
retainers in patients who paid for the treatment
themselves
Bonded retainers were most popular in both
arches. There were more removable retainers used
in cases of upper arch expansion or extractions,
and the most popular removable in these cases
was a Hawley retainer
Upper vacuum-formed and lower bonded
retainers were the most common

remodel after 34 months, but the elastic bers
around the neck of the teeth (dentogingival and
interdental bers) can take 8 months or more to
remodel.18 This means that teeth need to be held
in their corrected position until these bers are
remodeled. The alternative is to cut these bers
using pericision, the process which is discussed
later in the article.
The way teeth occlude at the end of treatment
may affect the stability of the teeth, so placing the
teeth in the correct occlusal relationships, with
well-interdigitated occlusion may help to reduce
relapse.1921
The teeth lie in an area of balance between
the tongue on one side and the lips and cheeks
on the other.22 This area of balance has been
referred to as the neutral zone; and the further
the teeth are moved out of this zone of stability,
the more unstable they are likely to be. The
challenge for the orthodontist is that it is not
possible to visualize this neutral zone and it is
possible this zone changes through life as a result
of age changes in the surrounding soft tissues.
While the clinician has a number of
approaches to reduce the periodontal, occlusal,
and soft tissue effects on relapse, there is a fourth
factor that is out of the control of the ortho-
dontist, i.e., growth. There are small, unpre-
dictable changes in facial growth throughout
life23 and these may have unwanted effects on the
occlusion. These changes should be regarded as
normal physiological age changes. These same
unpredictable changes in occlusion are even
seen in patients who have not had orthodontic
treatment.2426
It is important that we explain to patients
about the risk of these long-term, normal phys-
iological changes to occlusion. Patients need to
understand that they are normal age changes
and without long-term retention, unpredictable
amounts of relapse will occur. One solution to
resisting these long-term age changes is to advise
the patient to continue wearing their retainers
for as long as they want straight teeth.
Implications of long-term retention
It is true that not all patients show relapse, but the
amount and nature of orthodontic relapse is
unpredictable for all patients, and so we there-
fore need to assume that all patients have the
potential to show relapse.
If we accept that long-term retention may be
required, then there are responsibilities for both
the patient and the clinician. The clinician has a
responsibility to explain to the patient, as part of
the consent process before treatment is started,
about the unpredictable risk of relapse and the
need for long-term retention. This retention is to
reduce the chance of teeth moving back to their
 Evidence-based retention
original position following the orthodontic
treatment, but also to resist unwanted age
changes in the occlusion. The clinician also has
the responsibility to plan an evidence-based
approach to retention and explain to the
patient their role in this retention regimen,
including the compliance required, maintenance
of the retainers, and how to minimize unwanted
side effects as a result of the retainers.
The patient needs to take personal responsi-
bility for following this advice. If the patient is
unwilling, or unable, to commit to long-term
retention, including accepting the maintenance
and compliance needed, then orthodontic
treatment may not be appropriate.
Evidence-based retention: What do we
mean by evidence-based?
All health care should be evidence-based. It is
worth clarifying what we mean by evidence-
based medicine. Evidence-based medicine has
been described as the conscientious, explicit,
and judicious use of current best evidence in
making decisions about the care of individual
patients27 and involves considering the
following:
 best research evidence;
 clinical expertise; and
 patient values, expectations, and circum-
stances.
While this article will focus on the best
research evidence for retention, it is important to
remember that evidence-based care also involves
factors related to the clinicians expertise and
clinical experience and should be tailored to
each individual patient.
The higher the quality of research evidence,
the more condent we can be in the ndings.
Randomised controlled trials (RCTs) are
regarded as the highest quality study design for
individual trials. These type of trials have their
challenges and are not always appropriate for
answering all clinical questions, but they often
provide us with the best way of evaluating
the outcome of treatment interventions. The
majority of this article will, therefore, focus on
the results of RCTs into retention.
231
Cochrane Review into retention
Cochrane Reviews are systematic reviews of pri-
mary research in human health care and health
policy, and are internationally recognized as the
highest standard in evidence-based health care
resources.28
The updated Cochrane Review entitled
Retention procedures for stabilizing tooth
position after treatment with orthodontic bra-
ces29 concluded:
We did not nd 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 insufcient high-quality evi-
dence to make recommendations on reten-
tion procedures for stabilizing tooth position
after treatment with orthodontic braces. Fur-
ther high-quality RCTs are needed.
One of the criticisms of Cochrane Reviews is
that they often conclude there is insufcient
high-quality evidence to make recom-
mendations. This is because Cochrane Reviews
only make recommendations based on high
levels of evidence. This quality of evidence is
measured using a stringent quality assessment
approach called GRADE (Grading of Recom-
mendation, Assessment, Development, and
Evaluation).30 There are 4 possible gradings in
this quality assessment and these provide
implications about how condent we can be in
the results (Table 2).
Cochrane Reviews focus on RCTs, but the
quality of evidence can be downgraded due to a
number of factors that may affect how condent
we can be in the ndings:
 Risk of bias (limitations in design and execu-
tion of study).
 Indirectness (whether the study measures
what we are interested in).
 Inconsistent results (conicting results from
different studies).
 Imprecise results (wide condence intervals).
 Probability of publication bias.
To put this in the context of the Cochrane
Review on retention,29 there is moderate quality
232
Table 2. Explanation of GRADE Quality Rating.
GRADE Quality Denition
Rating
High We are very condent that the true effect Further research is very unlikely to change our condence
is close to the estimate of the effect
Moderate We are moderately condent in the
effect estimate
Low Our condence in the effect estimate
is limited
Very low We have little condence in this estimate Any estimate of effect is very uncertain
of evidence from research looking at whether
thermoplastic retainers should be worn full-time
or part-time. All other evidences were rated as
low or very low using the GRADE quality rating.
How does this Cochrane Review help? In
addition to providing moderate quality of evi-
dence on part-time wear of thermoplastic
retainers, this Cochrane Review also identies
weaknesses in existing research and suggests how
this can be overcome in the future.29
Beyond the conclusions, the review identies
15 RCTs into orthodontic retention29; but due to
quality issues, we can only have limited
condence in their ndings. It is, therefore,
very likely that future high-quality research in this
area could change the estimate of the effect
reported in these studies. This leaves the con-
temporary clinician in a difcult position. Is it
better to ignore all the other research as we
cannot be condent in the ndings? Or is it
better to look at the results of the best available
research, accepting that it is not perfect, but draw
some tentative conclusions to inform our clinical
practice until higher-quality evidence becomes
available?
For the remaining part of this article, I will
discuss some of the lower-quality evidence that
was identied from the RCTs in the Cochrane
Review,29 but it is very important that this should
be read and interpreted in the context of the
lower quality of evidence we have discussed.
How often to wear removable retainers?
There have been studies looking at whether
removable retainers should be worn full-time or
part-time.3133 We have already discussed that
there is no evidence to suggest that there is any
difference in relapse between patients who wear
Littlewood
Implications
in the estimate of effect
Further research is likely to have an important impact on
our condence in the estimate of effect and may change the
estimate
Further research is very likely to have an important impact
on our condence in the estimate of effect and is likely to change
the estimate
thermoplastic retainers full-time or part-time.3132
There is also low-quality evidence that there is no
difference in relapse between patients who wear
Hawley retainers full-time or part-time.33 We do
not have any information as to whether this part-
time wear needs to be every day or not. We also do
not have information about the effect of this part-
time wear over several years.
Which types of bonded retainers are best?
The Cochrane Review29 identied 3 RCTs that
compared polyethylene ribbon-xed retainer
and multistrand bonded retainers.3436 The
materials and methodology in these 3 studies
were similar, so the data from these 3 studies
were pooled.29 The studies showed contrasting
results, but overall the pooled data showed no
difference in failure rates of the 2 retainer types.
The studies did not investigate how successful
these different bonded retainers were in
reducing relapse.
Which types of removable retainers are
best?
There is limited evidence that after 6 months,
thermoplastic retainers are slightly better at
reducing relapse in the mandibular arch than
Hawley retainers. In the maxillary arch, both are
equally successful.37 The amount of relapse with
both retainers was minimal, so it could be argued
that both types of retainers are successful at
reducing relapse, and other factors may be more
important in determining the choice of retainers.
In the same study, there was limited evidence
that patients showed a greater level of satisfaction
with the thermoplastic retainers than Hawley
retainers.38 Patients reported less embarrassment
 Evidence-based retention
when wearing thermoplastic retainers and
found them easier to wear. Patient satisfaction
with removable retainers is particularly
important as this may affect compliance, which
ultimately is likely to affect long-term stability.
The thermoplastic retainer was also found to be
more cost effective over the study period of
6 months.38
Another RCT with a lower quality of evidence,
also comparing thermoplastic and Hawley
retainers, suggested upper thermoplastic retain-
ers retained rotated teeth better than Hawley
retainers.39 There is also limited evidence to
suggest that thermoplastic retainers retain the
quality of result better than Begg retainers.40
Fixed or removable retainers: Which are
best?
At the time of the 2016 Cochrane Review, there
was only one study, published as abstracts,
reporting an RCT comparing xed and remov-
able retainers was identied.4143 This study
compared thermoplastic retainers with bonded
multistrand retainers in the lower arch. Bonded
retainers were found to be slightly better at
reducing irregularity in the lower arch than
thermoplastic retainers. However, patients with
bonded retainers seemed to show an increase in
gingival bleeding. From this study, there is also
limited evidence to suggest that patients pre-
ferred bonded retainers, nding them more
acceptable to wear than thermoplastic retainers.
There are ongoing RCTs comparing removable
and bonded retainers, which should increase our
knowledge in this key area in the future.
Evidence for adjunctive techniques for
reducing relapse
Adjunctive techniques are hard or soft tissue
modications designed to enhance stability at the
end of treatment: interproximal reduction and
pericision, respectively.
Interproximal enamel reduction (IPR)
It has been suggested that IPR may reduce
relapse either by reducing the amount of excess
tooth tissue or perhaps by providing a atter,
more stable interdental contact.44 A high-quality
233
RCT4548 that investigated this compared the
following 3 groups:
 upper thermoplastic retainer, and lower xed
retainer bonded only to the canine teeth;
 upper thermoplastic retainer, and lower arch
treated with IPR, but no retainers; and
 positioner.
They followed up the patients for 1 year45 and
then 2 years,46 and found all 3 approaches were
equally effective at reducing relapse. In addition
to the stability results, they also found that
bonded retainers were the least cost effective
of the 3 retention regimens tested.47
After 2 years, they stopped the retainers and
followed up the patients at least 5 years out of
retention. There was minimal relapse in all 3
groups, and no signicant difference between
the 3 retention regimens.48
This study raises the interesting possibility of
using IPR, but no retainer in the lower arch.
When interpreting the results of the study, it is
important to note that the patients were all Class
I crowding cases treated with premolar extrac-
tions and had essentially normal skeletal rela-
tionships. Clinicians will need to decide whether
these ndings are generalizable to their own
patients. It is also unclear whether age changes
will adversely affect the alignment in patients who
are not wearing retainers long-term.
Pericision
This is also known as supracrestal circumferential
berotomy and is a simple surgical procedure
used to section the interdental and dentogingival
bers around the neck of the teeth. There are no
RCTs investigating this technique. The best-
quality evidence is a prospective clinical trial
with controls.48 This study seemed to suggest that
rotational relapse of teeth could be reduced in
the maxilla by up to 30%. However, the lack of
appropriate randomization and large dropouts
means we must interpret the results with caution.
Dangers of retainers
One of the secondary outcomes of the Cochrane
Review into retention29 was adverse effects on
oral health, including caries and periodontal
234 Littlewood
problems, but there was only limited information
identied from the RCTs in the review, with
limited long-term follow-up.
RCTs are expensive and time consuming to
run, and long-term follow-up of patients in these
trials over many years is very difcult to achieve.
We should, however, be aware that there are case
reports of health problems with retainers, par-
ticularly xed retainers. Examples of problems
include increased plaque, gingival bleeding, and
calculus, and even unwanted tooth movement
leading to compromised periodontal support
with bonded retainers that are still in situ.4951 It
is, therefore, important that all patients who are
wearing retainers long-term, should be reviewed
regularly by a competent clinician, such as a
general dental practitioner or orthodontist. This
is to ensure that the retainer is not only fullling
its role of maintaining stability, but also not
causing any harm. It is the clinicians responsi-
bility to advise the patient on the importance of
this long-term maintenance and how best to do
this. It is the patients responsibility to follow this
advice.
Lack of high-quality evidence
While the updated Cochrane Review into
retention29 provides some information to inform
an evidence-based approach to orthodontic
retention, there are clearly still many unanswered
questions. At the time of writing, there was
limited high-quality evidence from research
on which to base our clinical practice of
retention.
This means, there may be a greater emphasis
on making clinical decisions based on our per-
sonal clinical experience and patients values,
expectations, and circumstances. This may
include our own clinical experience with differ-
ent types of retainers, for example, failure rates
of bonded retainers or how successful we are in
motivating our patients to wear removable
retainers. It is, therefore, important to audit the
results of our own clinical work as well as being
aware of the results of high-quality research. It is
also important that the treatment plan is fully
customized to the patient and meets their desires
and expectations. There may be many different
factors that relate to a specic patient, which may
affect the retention plan. This may include the
patients attitude to relapse, their ability or desire
to clean around xed retainers, nancial impli-
cations of different retainer regimens, or will-
ingness to remember to wear their removable
retainers as instructed.
Conclusions
1. Approaches to retention differ signicantly in
different parts of the world.
2. Relapse is unpredictable and is a result of post-
orthodontic changes in the occlusion, but also
normal age changes. The use of long-term
retention may be the best approach to
reducing this relapse. The patient needs to
continue wearing retainers for as long as they
want to keep their teeth straight.
3. A recently updated Cochrane Review looking
at the best research evidence into retention
provides some information to allow a more
evidence-based approach to retention.
4. There is a lack of high-quality evidence
from research about retention, so our
approach to retention will be strongly
inuenced by our own clinical experience
and expertise with different retainers, as
well as the patients values, expectations,
and circumstances.
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