Development of a clinical practice guideline for orthodontic retention

Development of a clinical practice guideline for orthodontic retention
Author: Cleo Wouters, Toon A. Lamberts, Anne Marie Kuijpers-Jagtman, Anne Marie Renkema
Citation: Wouters, C., Lamberts, A.A., Kuipers-Jagtman, A.M. and Renkema, M.A. (2019) Development of a clinical practice guideline for orthodontic retention. Orthod Craniofac Res 22:69-80

Purpose: To develop a clinical practice guideline (CPG) for orthodontic retention (OR).

Materials and Methods:

  • The CPG was developed according to the AGREE II (Appraisal of Guidelines for Research & Evaluation II) instrument and EBRO (Dutch methodology for evidence-based guideline development).
  • Reporting was done according the RIGHT statement.
  • A Task Force developed clinical questions regarding OR and a systematic lit search in PubMed and EMBASE was performed.
  • The risk of bias was assessed using Cochrane RoB tool and rated quality of evidence using GRADE.
  • The Task Force formulated considerations and recommendations after discussing the evidence. The concept CPG was sent for commentary to all relevant stakeholders.

Results

One systematic review—with 15 studies—met the inclusion criteria. 

In case of low evidence and lack of outcome measures, expert- based considerations were developed.

KEY RECOMMENDATIONS

Retention in the upper arch

  • Apply removable upper retainers in patients with a low risk of relapse.
  • Apply fixed upper retainers in patients with a moderate risk of relapse.
  • Apply dual upper retention in patients with a high risk of relapse.
  • Consider the use of upper HRs in patients with poor oral hygiene.

The choice for the upper retention modality is determined by several factors: initial malocclusion, treatment result, tx modality, OH, patients’ compliance, personal preferences and practitioners’ experience.

Retention in the lower arch

  • Apply fixed retainers for lower arch retention.
  • Apply dual lower retention in patients with high risk of relapse. 
  • Consider the use of lower HRs (Hawley Retainer) in patients with poor OH.

-In comparison with removable retainers, lower fixed retainers lead to more gingival bleeding, pockets and recessions.
-Since VFRs (Vacuum Formed Retainers) are contraindicated in patients with poor OH, HRs are indicated in these cases.
-An alternative is a retainer only bonded to the lower canines. For the patient and dental professional, the cleaning of this retainer type is easier. Patients should, however, be informed about the risk of changes in alignment when retainers are only bonded to the lower canines.
-When oral hygiene is sufficient, lower fixed retention should be the first choice.

Design and wire material for upper fixed retainers

  • Bond all upper six anteriors in case of initial rotations.
  • Use square or rectangular SS wire material for upper fixed retainers.
  • Consider the use of lateral-to-lateral fixed upper retainers in case of dual retention.

Design and wire material for lower fixed retainers

  • Bond retainers to all lower six anteriors in patients with high risk of relapse.
  • Use square or rectangular SS wire material for lower fixed retainers.
  • Consider the use of retainers only bonded to the lower canines in patients with low risk of relapse.
  • Consider the use of thick single-strand SS retainers only bonded to lower canines in patients with poor OH.
  • Inform patients about the risk of changes in alignment when retainers are only bonded to the lower canines.

Removable retainers

  • Choose based on own experience and patients’ preferences for a HR retainer or VFR
  • Select when anchorage for a HR is inadequate, a VFR
  • Consider, in case of solitary removable retention and depending on the initial situation and treatment modality, short-term full-time wearing of removable retainers.

Frequency of retention check-ups

  • Schedule the first retention check-up preferably within 3 months after insertion of the retainers.
  • Schedule 2-4 retention check-ups in a period of 1-2 years after insertion of the retainers, depending on the timing of transferring the patient to the dentist.
  • Communicate with the dentist regarding retention check-ups to guarantee effective retention aftercare.

Responsibilities orthodontist, dentist, patient

  • Provide patients with all necessary information regarding their OR (Orthodontic Retention)
  • Provide dentists with all necessary information regarding the OR of their patients
  • Refer the patient for aftercare to the dentist in a systematic and responsible manner

Conclusions:

  • This CPG offers practitioner recommendations for best practice procedures regarding OR and may reduce variation between practices and assists with patient aftercare. 
  • A carefully chosen retention procedure for individual patients, combined with clear in-formation and communication between orthodontist, dentist and patient will contribute to long-term maintenance of ortho tx results.

Limitations:

The paucity of evidence-based studies concerning OR leads to a CPG development mainly based on expert opinion and clinical evidence.

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