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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 56-63

Retention in fixed orthodontic treatment: An important aspect affecting success of treatment outcome – A questionnaire study


Department of Orthodontics, H.P. Government Dental College, Shimla, Himachal Pradesh, India

Date of Submission24-Feb-2020
Date of Decision01-Apr-2020
Date of Acceptance22-Apr-2020
Date of Web Publication20-Jun-2020

Correspondence Address:
Monika Mahajan
Department of Orthodontics, H. P. Government Dental College, Shimla - 171 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_17_20

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  Abstract 


Context: Postorthodontic treatment, retention is an important phase which can be decisive in determining the stability of the achieved result of functional occlusion and esthetic appearance of the patient. There are different types of retainers and different retention protocols followed among the orthodontists. Aims: The purpose of this study was to determine different factors which affect compliance of the patient with removable retainers. Materials and Methods: Thirty-eight patients, who had finished fixed orthodontic treatment and were in retention phase wearing Hawley removable retainers, were included in the study. They were given a questionnaire which dealt with factors affecting patient compliance with removable retainers and different reasons for not wearing removable retainers. Statistical Analysis Used: Categorical variables were reported as counts and percentages. Gender comparisons were made with the Chi-square test/Fisher's exact test. Conclusion: The most common reason for not wearing retainer was reported as patients forgetting to wear the retainer. The common reason for relapse may be associated with patients who think that responsibility of retention is only of orthodontist and not themselves or of both. Gender wise: it was found that the factors of level of satisfaction during the present retention phase, forgetting to wear it, and responsibility of retention showed statistically significant differences.

Keywords: Compliance, fixed orthodontic treatment, removable retainers


How to cite this article:
Mahajan M. Retention in fixed orthodontic treatment: An important aspect affecting success of treatment outcome – A questionnaire study. J Dent Res Rev 2020;7:56-63

How to cite this URL:
Mahajan M. Retention in fixed orthodontic treatment: An important aspect affecting success of treatment outcome – A questionnaire study. J Dent Res Rev [serial online] 2020 [cited 2020 Aug 7];7:56-63. Available from: http://www.jdrr.org/text.asp?2020/7/2/56/287331




  Introduction Top


Orthodontic treatment is able to bring about a change in the dentofacial features of an individual, thus improving his functional occlusion, physical appearance leading to enhancement of self-esteem, and behavior of the patient.[1] However, after orthodontic treatment, a retention phase is must in order to provide stability to the new position of the teeth attained, hence maintaining better esthetics and functional occlusion.[2]

The success of the orthodontic treatment outcome can be maintained only if the patient wears the said retention appliance. Several studies have shown relapse to occur in 70% of all cases after orthodontic treatment.[3] Relapse is usually caused by the recoil of the periodontal ligament fibers which are influenced by other factors such as continuous growth of an individual and forces of orofacial musculature. Reorganization of periodontal ligament fibers occurs over a period of 3–4 months. The gingival collagen fibers take 4–6 months to remodel and the supracrestal fibers remain deviated for more than 232 days.[4]

Various types of retainers can be given after orthodontic treatment such as removable Hawley retainers, fixed retainers, and vacuum-formed retainers. Routine removable retainer is still reported to be used by more than 50% of the orthodontists.[5] Different retention protocols are followed by different orthodontists. A survey suggested that orthodontists chose retention procedure according to their personal preference. Most of the orthodontists prescribe 6 month of full-time wear of removable retainer.[6]

There are less studies on retention protocol and factors associated with retainer compliance. Retention phase depends mostly on the patients' compliance as well as certain other factors such as age, gender, educational status, type of retainer, parental influence, and time since debonding.[7] Nanda and Kierl studied that the cooperation of patients toward retainer wear was to be determined by their attitudes toward treatment, need for approval, and need for achievement.[8] Patients' compliance toward any form of treatment was found to be influenced by psychological and sociodemographic traits.[9] Mehra et al. found that patient-related factors such as desire for treatment and relationship with parents as important factors for motivation of patients toward compliance.[10]

The noncompliance toward retainer wear is out of orthodontists control and may affect the outcome of the treatment in the long run. Fifty percent of patients did not wear retainers as instructed which according to Wong and Freer were due to discomfort and forgetfulness.[11]

In today's age, with increased awareness of general population toward orthodontic treatment, there is a need for the orthodontists, dentists, and patients to understand the importance of wearing retainers after orthodontic treatment for the successful outcome of the treatment.

The aim of our study is to identify different clinical and social variables affecting compliance of the patient in wearing removable retainers after orthodontic treatment, hence enabling us in identifying the reasons for patients in not wearing removable retainers.


  Materials and Methods Top


Thirty-eight of patients who had finished fixed orthodontic treatment in the department of orthodontics and dentofacial orthopedics were included in the sample with males 14 in number and females 24 in number. Each patient after debonding was advised to wear removable retainer throughout the day except during eating and brushing. They were advised to come for monthly follow-up. The patients included in the study were present in the retention phase for more than 3 months. The questionnaire was given to all the patients coming for follow-up after debonding and wearing removable retainers in order to identify perception and attitude of the patient toward removable retainer. The questionnaire which consisted of 4 subgroups with 21 questions [Appendix 1][7],[12],[13] required to record the responses as simple yes or no.



Subgroup I had six questions which collected the data regarding the patients' education level, the time since debonding, their satisfaction at the time of debonding as well as during the present retention phase. Subgroup II consisted of six questions, observing different reasons of having difficulty with wearing of removable retainers. Subgroup III had five questions which assessed the reason for not wearing removable retainer. Subgroup IV had five questions which evaluated reasons for relapse of orthodontic treatment.

Categorical variables were reported as counts and percentages. Gender comparisons were made with the Chi-square test/Fisher's exact test. Normality of quantitative data was checked by measures of Kolmogorov–Smirnov tests of normality. As our continuous data (age, duration, etc.) were skewed, so was given as mean ± standard deviation, median, and interquartile range, for skewed data comparisons for two groups were made by Mann–Whitney test. P < 0.05 was considered statistically significant. Analysis was conducted using SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA).


  Results Top


The sample consisted of 38 patients which included 14 (36.8%) males and 24 (63.2%) females who had finished fixed orthodontic treatment and were presently wearing Hawley removable retainers. The recordings were made by counting the number of patients who said yes or no and accordingly calculating the percentage.

Subgroup I

The mean age of the patients was 19.24 years, treatment duration was 2.54 years, time since debonding was 7.81 months, time into retention period was 7.89 months, and duration of retainer wear was 20.11 h [Table 1].
Table 1: Descriptive statistics showing demographics of subjects

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The percentage of young patients (<18 years) was 60.5% and of adult patients (>18 years) was 39.5%. Most of the patients were persuading their education and hence were at undergraduate level which was 84.2%, whereas 13.2% of the patients were graduate and only 2.6% were postgraduate which correlated as the number of adult patients was less. 78.9% of the patients reported with treatment satisfaction at the time of debonding, whereas 21.1% of the patients were not satisfied. This changed to 76.3% still reporting satisfaction during the present retention phase and 23.7% not being satisfied, and in both cases, it was statistically significant [Table 2].
Table 2: Descriptive statistics showing percentage of responses to different questions in all subgroups

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Subgroup II

The factors affecting patient compliance were found to be in the following decreasing order, with 39.5% of the total patients finding it bothersome to insert and remove, 28.9% each finding it not good in appearance along with not a good fit, 26.3% reporting difficulty in speech with the retainers along with the problem of breaking frequently, and finally, 13.2% having gagging with the retainers, but none was statistically more significant than the other [Table 2].

Subgroup III

The most common reason for not wearing retainer was reported as 47.4% of the patients forgetting to wear the retainer, followed by 31.6% of them figured that they have worn it too long, 23.7% of them thought that it was not important to wear, and 5.3% of the patients had lost it or some dentists had told them to stop wearing it. The results showed that the parameter of forgetting to wear was significantly higher statistically than those who have lost it or where some dentists have told them to stop wearing it [Table 2].

Subgroup IV

The most common reason for relapse may be associated with irregular follow-up found in 65.8% of the total patients. Furthermore, 65.8% of the patients thought that responsibility of retention was of both orthodontist and themselves in comparison to 28.9% who thought that it was of themselves and 5.3% thought that only orthodontists are responsible for retention, and this difference was statistically significant. 44.7% of the patients showed compliance by wearing removable retainer 24 h a day, followed by 42.1% wearing for 18 h, 7.9% wearing for 12 h, and 5.3% wearing for 16 h, which was again statistically significant [Table 2].

Gender wise

The findings were also evaluated for males and females separately statistically to know the gender difference in any of the perception and attitude of the patient toward removable retainer.

In Subgroup I, the mean values were higher for males in parameters of age, treatment duration, time since debonding, and time into retention but were higher for females in duration of retainer wear, though the Mann–Whitney test showed no statistically significant difference between them [Table 3].
Table 3: Mann-Whitney test showing results gender wise

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The females were more satisfied (87.5%) than males (64.3%) at the time of debonding, which was statistically not significant. Furthermore, the satisfaction in the present retention phase was more in females (79.2%) in comparison to males (71.4%), though this was statistically significant [Table 4].
Table 4: Descriptive statistics showing percentage of responses in Subgroup I and IV gender wise

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In Subgroup II, in evaluating the factors affecting patient compliance, it was observed that the percentage of male sample was more in reporting with difficulty in speech (28.6) in comparison to females (25%), bothersome to insert and remove the retainers (57.1%) than females (29.2%), and with the problem that the retainer breaks frequently (28.6%) in comparison to females (25%), but the difference was nonsignificant statistically. On the other hand, the percentage of females was more in reporting for the problem of gagging (16.7%) in comparison to males (7.1%), not finding it good in appearance (35.7%) in comparison to males (25%), and not having a good fit (33.3%) in comparison to males (21.4%), though none was statistically significant [Table 5].
Table 5: Descriptive statistics showing percentage of responses to different questions in Subgroup II and III gender wise

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In Subgroup III, on comparing the result according to gender for the most common reason for not wearing retainer, it was observed that the percentage of male sample was more for those who lost it (7.1%) in comparison to females (4.2%), different dentist told them to stop wearing it (7.1%) in comparison to 4.2% of the females, figured that had worn it too long (50%) in comparison to 20.8% of the females, and forgot to wear it (85.7%) in comparison to females (25%), but the difference was significant statistically only in the reason of forgetting to wear the retainer. On the other hand, the percentage of females was more for the reason that they do not think it was important (29.2%) in comparison to 14.3% of the males, though not statistically significant [Table 5].

In Subgroup IV, on comparing the result according to gender for the most common reason for relapse, it was concluded by Mann–Whitney test that there was no statistically significant difference in mean values of the time into retention wear which was 8.14 months for males and 7.75 months for females and also the duration of retainer wear which was 18.86 h for males and 20.83 h for females was seen [Table 3]. On comparing the result for the responsibility of retention, it was observed that the percentage of male sample was more for holding the orthodontist responsible (14.3%) and also those who considered themselves responsible (42.9%) for retention in comparison to female (20.8%). On the other hand, the percentage of females was more (79.2%) who thought that it was the responsibility of both orthodontist and the patient for the retention in comparison to the male (42.9%), and this difference was statistically significant [Table 4].

Overall, when comparison was made, gender wise: it was found that the factors of level of satisfaction during the present retention phase, forgetting to wear it, and responsibility of retention showed statistically significant differences.


  Discussion Top


Different studies have shown that patients with removable retainers showed greater compliance 2 years postdebonding in comparison to vacuum-formed retainers, as the former does not cover occlusal surface making them less prone to wear off with time, also allowing better occlusal settling along with taking less time to clean in comparison to vacuum-formed retainers.[7] Hence, we based our study on removable retainers only.

Subgroup I

It has been shown that younger patients are more retainer compliant initially than adults but reverse with time, hence decreasing overall compliance with time.[7] Allan and Hodgson showed that best co-operators were 14-year-old children.[14] Another study showed a similar finding which may be associated with the fact that younger patients are more receptive, obedient, and influenced toward parents.[15] Similarly, our study showed that as most of our patients were young (60.5%), they responded with increased mean duration of retainer wear which was 20.11 h.

Anderson et al. reported that posttreatment satisfaction with orthodontic treatment was positively correlated with pretreatment motivational levels of the patients.[16] Another study showed a strong correlation between patients' perception of stability of tooth position since treatment finished and the current level of satisfaction.[13] In our study, the patients satisfied at the time of debonding decreased from 78.9% to 76.3%, but this difference was statistically not significant.

Subgroup II

A study showed that only 5% of the noncompliant participants reported esthetics as the reason for not wearing either removable retainers or vacuum-formed retainers.[7] In our study, the factors affecting patient compliance were in the following decreasing order as finding it bothersome to insert and remove, finding it not good in appearance along with not a good fit, difficulty in speech with the retainers along with the problem of retainer breaking frequently, and finally, having gagging with the retainers, but none was statistically more significant than the other.

Subgroup III

A study showed that 33% of the patients with removable retainers just stopped wearing it eventually and 26% said that it was lost or broken.[7] Another study showed that 51% of the patients regularly forget to wear the retainers.[12] Schott and Ludwig showed that majority of young patients had a discontinuous wear behavior with a pattern of not wearing the device on some days and then trying to compensate for this by wearing the device for more on other days.[17] Similarly, our study showed the following reasons in descending order for not wearing retainer as forgetting to wear the retainer, figured that they have worn it too long, thought it was not important to wear, and finally, patients have lost it or some dentists had told them to stop wearing it. In our study 47.4% of the patients forgot to wear the removable retainers and this parameter of forgetting to wear was significantly higher statistically than those who have lost it or where some dentists have told them to stop wearing it.

Subgroup IV

A study showed that the frequency of follow-up visit which was once every 4 weeks allowed for better assessment of retainer wear, check for possible breakages, and evaluation for fit of retainer, hence proving to be an important factor to affect patient compliance and less chances of relapse.[15] In our study, the most common reason for relapse may be associated with irregular follow-up found in 65.8% of the total patients.

Parker reported that at least 232 days of retention are needed for regeneration of fibers surrounding the apical, middle, and marginal areas of the root in order to provide stability after orthodontic treatment.[18] Destang and Kerr reported a better stability of the maxillary arch with 1-year retention in comparison to 6-month retention.[19] However, certain studies have recommended lifetime wearing of retainers for stability of orthodontic results.[20]

Mollov et al. showed that patients have certain responsibility during retention phase and that satisfaction with orthodontic results after treatment is related to patient perception of responsibility for retention and attained stability of tooth position. It showed greater satisfaction levels for patients who held themselves responsible for maintaining posttreatment outcome.[13] Our study showed 65.8% of the patients thought that responsibility of retention is of both orthodontist and themselves. Sinha et al. also showed that positive attitude of orthodontist resulted in an increase in level of compliance by the patient.[21] Another study showed that general dentists feel that orthodontists and patients should carry the responsibility for retainers for the first 6 months to be overtaken by dentists gradually but in collaboration with the orthodontists.[22] Similarly, another study showed that 88% of the patients perceived that retention after treatment was their responsibility and 11% thought orthodontists to be responsible.[13]

A study showed that relapse in orthodontic treatment was due to certain factors which were under their control by observing that 41% of the patients were not wearing retainer enough, 22% stopped wearing retainer too soon, 4% did not follow-up with the scheduled appointments, and 7% of them blamed the orthodontists for not following up long enough.[13] In our study, 44.7% of the patients showed compliance by wearing removable retainer 24 h a day, followed by 42.1% wearing for 18 h, 7.9% wearing for 12 h, and 5.3% wearing for 16 h.

Gender wise – A study showed that females are more likely to wear retainers than males, whereas another study by Schott et al. showed that there is no significant statistical difference in retainer wearing gender wise although females wear retainers for a longer period than males.[2],[15] In our study of all different questions, a significant difference was found in males forgetting to wear the retainers in comparison to females. Furthermore, females were more satisfied in the present retention phase in comparison to males, which was statistically significant, and females thought that responsibility of retention was of both orthodontists and themselves in comparison to males, which was again statistically significant.

As each individual is different, hence a fixed single approach cannot be made in all patients regarding treatment as well as retention postorthodontic treatment. There is a need for the orthodontist to evaluate the patient as an individual who will respond differently to orthodontic treatment and which further will affect the retention phase accordingly. The treatment compliance and retainer wear are multifactorial in orthodontic treatment. We should improve patient education about retention in orthodontics and consequences of not wearing retainers in order to help stabilize the treatment outcome.


  Conclusion Top


  1. The factors affecting patient compliance were found to be in the following decreasing order, finding it bothersome to insert and remove, finding it not good in appearance along with not a good fit, difficulty in speech with the retainers along with the problem of breaking frequently, and finally, having gagging with the retainers
  2. The most common reason for not wearing retainer was reported as patients forgetting to wear the retainer, followed by figuring that they have worn it too long, thought that it was not important to wear, and having lost it or some dentist had told them to stop wearing it
  3. The most common reason for relapse may be associated with irregular follow-up of patients along with patients who think that responsibility of retention is of only orthodontist
  4. Overall when comparison was made gender wise it was found that the factors of level of satisfaction during the present retention phase, forgetting to wear it and responsibility of retention showed statistically significant differences.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Feu D, de Oliveria BH, Almeida MA, Kiyak HA, Miguel JA. Oral health – Related quality of life and orthodontic treatment seeking. Am J Orthod Dentofacial Orthop 2010;138:152-9.  Back to cited text no. 1
    
2.
Schott TC, Schilpf C, Glasl B, Schwarzer CL, Weber J, Ludwig B. Quantification of patient compliance with Hawleys retainers and removable functional appliances during the retention phase. Am J Orthod Dentofacial Orthop 2013;144:533-40.  Back to cited text no. 2
    
3.
Sadowsky C, Sakols EI. Long-term assessment of orthodontic relapse. Am J Orthod 1982;82:456-63.  Back to cited text no. 3
    
4.
van Leeuwen EJ, Maltha JC, Kuijpers-Jagtman AM, van't Hof MA. The effect of retention on orthodontic relapse after the use of small continuous or discontinuous forces. An experimental study in beagle dogs. Eur J Oral Sci 2003;111:111-6.  Back to cited text no. 4
    
5.
Keim RG, Gotillieb EL, Nelson AH, Vogels DS 3rd. Study of orthodontic diagnosis and treatment procedures, Part 1: Results and trends. J Clin Orthod 2008;42:625-40.  Back to cited text no. 5
    
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Valiathan M, Hughes E. Result of a survey based study to identify the most common retention practices in the United States. Am J Orthod Dentofacial Orthop 2010;137:170-7.  Back to cited text no. 6
    
7.
Pratt MC, Kluemper GT, Lindstrom AF. Patient compliance with orthodontic retainers in post retention phase. Am J Orthod Dentofacial Orthop 2011;140:196-201.  Back to cited text no. 7
    
8.
Nanda RS, Kierl MJ. Prediction of cooperation in orthodontic treatment. Am J Orthod Dentofacial Orthop 1992;102:15-21.  Back to cited text no. 8
    
9.
Taylor GH, Wilson SL, Sharp J. Medical, psychological, sociodemographic factors associated with adherence to cardiac rehabilitation programs: A systemic review. J Cardiovasc Nurs 2011;26:202-9.  Back to cited text no. 9
    
10.
Mehra T, Nanda RS, Sinha PK. Orthodontists' assessment and management of patient compliance. Angle Orthod 1998;68:115-22.  Back to cited text no. 10
    
11.
Wong PM, Freer TJ. A comprehensive survey of retention procedures in Australia and New Zealand. Aust Orthod J 2004;20:99-106.  Back to cited text no. 11
    
12.
Lin F, Sun H, Ni Z, Zheng M, Yao L. A feasible method to improve adherence of Hawleys retainer in adolescent orthodontic patients: A randomized controlled clinical trial. Patient Prefer Adherence 2015;9:1525-30.  Back to cited text no. 12
    
13.
Mollov ND, Lindaeur SJ, Best AM, Tufekci SB. Patients attitudes toward retention and perceptions of treatment success. Angle Orthod 2010;80:468-73.  Back to cited text no. 13
    
14.
Allan TK, Hodgson EW. The use of personality measurements as a determinant of patient cooperation in an orthodontic practice. Am J Orthod 1968;54:433-40.  Back to cited text no. 14
    
15.
Behnam M, Sazzad S, Reza S, Samaneh S. Assesment of factors affecting adolescent patients' compliance with Hawleys and vacuum formed retainers. J Clin Diagn Res 2016;10:24-7.  Back to cited text no. 15
    
16.
Anderson LE, Arruda A, Inglehart MR. Adolescent patients' treatment motivation and satisfaction with orthodontic treatment. Do possible selves matter? Angle Orthod 2009;79:821-7.  Back to cited text no. 16
    
17.
Schott TC, Ludwig B. Microelectronic wear time documentation of removable orthodontic devices detects heterogenous wear behaviour and individualizes treatment planning. Am J Orthod Dentofacial Orthop 2014;84:208-13.  Back to cited text no. 17
    
18.
Parker GR. Transseptal fibers and relapse following bodily retraction of teeth, a histological study. Am J Orthod 1972;61:331-44.  Back to cited text no. 18
    
19.
Destang DL, Kerr WJ. Maxillary retention: Is longer better? Eur J Orthod 2003;25:65-9.  Back to cited text no. 19
    
20.
Morais JF, Freitas MR, Freitas KM, Janson G, Castello BN. Post retention stability after orthodontic closure of maxillary interincisal diastemas. J Appl Oral Sci 2014;22:409-15.  Back to cited text no. 20
    
21.
Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviours that predict patient satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic treatment. Am J Orthod Dentifacial Orthop 1996;110:370-7.  Back to cited text no. 21
    
22.
Habegger M, Renkema AM, Bronkhorst E, Fudalej PS, Katsaros C. A survey of general dentists regarding orthodontic retention procedures. Eur J Orthod 2017;39:69-75.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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