Orthodontic retention

CLINICAL

Orthodontic treatment planning: can we plan for

stability?
Padhraig S. Fleming1

Key points
There is a key interplay between often A novel hierarchy of orthodontic stability This hierarchy will be subject to adaptation but
competing occlusal, functional and aesthetic accounting for contemporary approaches to should underpin our understanding of the merits
goals during orthodontics. retention is proposed. of orthodontic intervention, allied to the burden
of retention, and therefore could be integral both
to planning decisions and decision-making.

Abstract
Careful orthodontic treatment planning should involve the delineation of clear treatment objectives within each dental
arch. Treatment planning decisions are underpinned by aesthetic goals, dental health considerations and the prospect
of stability, with these factors often competing. There is also a near-universal acceptance of the requirement for some
form of retention. A novel hierarchy of orthodontic stability is proposed. As further evidence emerges and technical
refinement continues, it is likely that this will undergo further adaptation. Ultimately, however, this knowledge will
ensure that our understanding of the merits of orthodontic intervention, allied to the burden of retention, can be clearly
presented to prospective orthodontic patients.

Introduction planning centred on the position of the lower experiences, including teasing and bullying,
anterior teeth, with significant advancement with possible related effects in terms of self-
Orthodontics has undergone seemingly held to be unstable and rarely justifiable.4,5 confidence and social wellbeing.8 Moreover,
relentless growth and refinement in recent This philosophy appears to have less traction orthodontic intervention has proven effective
years. The last two decades, in particular, have nowadays, with a diminishing emphasis on the in mitigating these adverse effects in these
been marked by an emphasis on refinement positioning of the lower anteriors. more salient malocclusions, particularly
of appliances, to improve both experience Consequently, planned tooth movements those characterised by visible impairment
and aesthetics; a drive to reduce treatment may involve a trade-off between aesthetic including excessive overjet, overbite and
times, with use of surgical and non-surgical objectives, including both facial and dental anterior spacing. 9 The inter-relationship
adjuncts; and continued efforts to circumvent aesthetic goals, and the prospect of long-term between stability and aesthetics is pertinent to
suboptimal compliance and to reduce the need stability. This interplay is further influenced by the management of a range of malocclusions.
for extractions.1,2 the effects of tooth movement on dental health, The achievement of a Class I incisor
Notwithstanding this, the health benefits allied to the effects of ageing and the relative relationship is typically a central treatment
of treatment remain uncertain; conversely, stability of various tooth movements. The latter objective. This relates to the increased
the aesthetic benefits of orthodontics are is known to be influenced by maturational prospect of stability and optimal aesthetics.
undeniable. The latter stem from predictable change and, therefore, is almost inevitable Stability may stem from the combination
improvement in both dental and smile without recourse to some form of retention.6 of a normal overjet and overbite, with the
aesthetics, and have prompted a paradigm shift Notwithstanding this, planning decisions may maxillary incisors resting on the tips of the
in treatment planning with increasing focus on influence the likelihood of producing more mandibular incisors, while the lower anteriors
the anteroposterior and vertical positioning of stable outcomes. may in turn be stabilised with a fixed lingual
the maxillary anteriors.3 Historically, treatment retainer.10 Correction of excessive overjet
Orthodontic planning and involves a judgement as to whether to reduce
1
Barts and The London School of Medicine and Dentistry, aesthetics this by means of retraction of the maxillary
Orthodontics, Institute of Dentistry, Queen Mary University
of London, London, E1 2AD, UK.
incisors, advancement of the mandibular
Correspondence to: Padhraig Fleming Aesthetic improvement associated with incisors or a combination of these movements.
Email address: [Link]@[Link]
orthodontic treatment may translate into Specifically, in the presence of significantly
Refereed Paper. improved oral health-related quality of life.7 procumbent maxillary incisors and a
Accepted 1 October 2020 There is also agreement that more marked protrusive upper lip and soft tissue pattern,
[Link]
malocclusions predispose to negative social retraction of the maxillary incisors may be

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 CLINICAL

appropriate in order to maximise the aesthetic

benefit of treatment. Moreover, retraction
of the maxillary incisors may promote the
achievement of lip competence, which may
reduce the propensity to relapse in the overjet.
Similarly, by limiting advancement of the
mandibular incisors, there may be less risk
of lower anterior irregularity reappearing and
of recurrence of the overjet. Conversely, in
the presence of retrusive soft tissue patterns
with relatively thin soft tissues and limited
upper lip support, the scope to undertake
retraction of the maxillary incisors may be
limited or absent.11 As such, a decision may be
made to address the overjet by advancement
of the mandibular incisors, in isolation or in
conjunction with minimal maxillary incisor
retraction. This approach will help to optimise
both facial and dental aesthetics, but does
increase the risk of relapse associated with
re-uprighting of the mandibular incisors
in the post-treatment phase. The latter may
ultimately translate both into mandibular
incisor irregularity and increased overjet.
Alternatively, a decision may be made to
accept a residual overjet in the presence of a
skeletal II discrepancy or retrusive soft tissue
profile, where orthognathic surgery is not
considered appropriate. Permanent bonded
retention may be mandatory in these cases.
Similar logic can be applied to Class I
malocclusion, with anteroposterior change
of the dentition often not indicated in the
presence of acceptable facial and soft tissue
support. Meanwhile, protrusive soft tissues
in conjunction with excessive proclination
of the incisors may dictate retraction of the
dentition with space creation to reduce the
degree of dental and associated soft tissue
protrusion. While this approach may lead to
aesthetic improvement, significant retraction Fig. 1 a, b) Class I malocclusion with bimaxillary proclination. c) There was crowding of both
may place increasing onus on diligent use arches with proclination of the maxillary and mandibular incisors with protrusive soft tissues
of removable and fixed retention (Fig. 1). and a procumbent lower lip. d, e) A decision was made to treat this on an extraction basis with
loss of four premolars in order to relieve the upper and lower crowding, aligning the arches,
Finally, advancement of the dentition could
but f) also to facilitate retraction of the lower lip
be considered in class I (or indeed class II
division 2) cases with retrusive soft tissue
profile in order to enhance soft tissue objectives should be tailored but should include Orthodontic planning and dental
support. 11 Again, this improvement in aesthetic considerations. In particular, the health
aesthetics is counterbalanced by increasing inclination of the maxillary incisor is central
instability and a higher premium on diligent, to dental aesthetics, with excessive proclination While the aesthetic benefit of orthodontics
prolonged retention (Fig. 2). being unaesthetic while also predisposing to a is clear, the health impacts are less proven,
Finally, a similar thought process may apply reduction in the overbite12 as well as non-axial particularly in milder malocclusions.
to class III cases, with correction of the incisor loading on the incisor, which may rarely lead Notwithstanding this, orthodontic treatment
relationship necessitating either retraction to fremitus. A positive overbite is thought to does entail potential deleterious effects, chiefly
of the mandibular incisors, proclination of contribute to stability of class III correction; related to the integrity of the roots, periodontal
the maxillary incisors or a combination of as such, retraction of the mandibular incisors problems, and indeed demineralisation and
these movements (Fig. 3). Again, the specific is often key to class III correction. even caries in susceptible individuals. As such,

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A proposed hierarchy of stability

Since the post-retention studies carried out

in the University of Washington from the
1980s onwards, it has become accepted that
post-treatment change is highly likely but
unpredictable.16 The inevitability of tooth
movement following orthodontics relates
to maturational change, with characteristic
effects including a reduction in the mandibular
intercanine width and increased irregularity of
the mandibular anteriors, in particular.6 The
latter may well predispose to an increase in the
overbite. Unquestionably, these physiological
changes predispose to deterioration in the
alignment of the teeth. Consequently, we are
now in an era where retention is accepted and
considered indispensable in the majority of
cases, certainly if indefinite occlusal perfection
Fig. 2 A class II division 2 malocclusion treated on a non-extraction basis with a combination is targeted.
of fixed and removable appliances. Non-extraction treatment in the mandibular arch, in Notwithstanding this, a number of adjuncts
particular, is of mechanical benefit in terms of overbite reduction, allowing advancement of
and alternatives to the indefinite use of retention
the anterior dentition. This approach may, however, place an additional premium on stability,
have been proposed. These include the use
with lower fixed retention, in particular, advisable with significant advancement of the
mandibular incisors of surgical adjuncts including frenectomy
and supracrestal circumferential fiberotomy
to mitigate against specific issues, namely
there is a balance to strike between aesthetic undermining of the existing support and are maxillary median diastema and significant
benefit and potential deleterious effect. particularly likely in the presence of a thin rotation. The merits of these approaches
This interaction comes into sharper focus gingival phenotype, characterised clinically are unclear and neither are regarded as a
when planning significant anteroposterior and by pre-existing recession. The latter may be standalone solution.17 An alternative which
transverse change, in particular, but also to an associated with fenestration and dehiscence of has shown some promise is the use of selective,
extent during the alleviation of crowding, which the root surfaces.14,15 It may be inappropriate incremental inter-proximal reduction during
may necessitate significant arch dimensional to attempt significant intra-alveolar tooth the post-treatment period. Acceptable levels of
change. Clearly, there are safe limits to the movement in these cases, instead either stability were demonstrated with this approach
magnitude of tooth movement governed by considering transverse change through sutural up to three years post-treatment, although up
constraints related to the alveolar housing, expansion or generating space conservatively to 5 mm of enamel reduction was necessary in
cortical plates and the soft tissue envelope.13 in an effort to limit the onus on significant the lower intercanine region.18
Specifically, movement is restricted by the tooth movement. Moreover, incomplete The requirement for a retention regime
absence of sufficient alveolar bone, with attempts correction leading to a degree of aesthetic (currently mechanical rather than biological)
to overcome this risking root resorption, improvement may be appropriate in order is, almost universally accepted, with ongoing
instability and periodontal problems. to safeguard dental health. The latter may refinement to improve predictability and
Periodontal problems associated with occasionally increase the onus on prolonged acceptability.19 Notwithstanding this, there
orthodontic tooth movement relate to retention. has been little discourse in relation to the

Fig. 3 A class III case involving retraction of the mandibular incisors. a, b) This approach was planned to maintain the maxillary incisor
inclination for aesthetic reasons, while c) retroclination of the mandibular incisors led to increase in the overbite. The latter was facilitated
by use of pre-existing spacing in the mandibular arch. Establishment of a positive overbite is thought to increase the potential for stability of
correction of the incisor relationship

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predictability of stability of specific occlusal

Fig. 4 A tentative hierarchy for orthodontic stability based on existing approaches to
features. The latter is further complicated retention. This hierarchy has been inferred on the basis of best available prospective
in this era of prolonged retention against a evidence. The prospect of stability appears to be best for anteroposterior correction (both
backdrop of the aforementioned conflicting class II and class III), with retention often having relatively limited bearing on this. The
aesthetic and stability goals. long-term preservation of correction of spacing and malalignment may be good but is
The majority of orthodontic patients present highly reliant on successful retention. Overbite reduction may be linked to preservation
with more than a single occlusal anomaly. For of alignment. Transverse correction (particularly expansion) is unstable and contingent
on diligent wear of retainers, with rigidity of retainer material also important. Finally,
example, overjet and overbite often coexist in
correction of anterior open bite is often highly unstable, with passive approaches to
class II cases; moreover, perfect alignment of retention often unable to mitigate relapse
both arches is a rarity, particularly in adults.6
Equally, transverse issues commonly present in
conjunction with vertical and anteroposterior Hierarchy of stability
problems. Specific occlusal features may well
be more stable than others and the stability of • Vertical change: AOB Worst prognosis
the outcome is undeniably influenced by the • Transverse change Poor prognosis
provision of retainers. • Alignment: irregularity and spacing
It would be valuable from an informed • Vertical change: deep overbite Moderate prognosis
consent perspective to be able to speculate as to • Antero-posterior change
the prospect of stability of correction of a range Best prognosis
of occlusal features, and to have an appreciation
of the effect of retention in mitigating relapse. *Based on best available evidence involving consideration of
Indeed, Proffit et al. (2007)20 developed a retention procedures (fixed and/or removable)
hierarchy for stability of surgical orthodontic
procedures. The latter was underpinned largely
by prospective research; study of the likelihood
of orthodontic stability is also complicated by
the widespread acceptance of retention as
well as the range of approaches taken to this.
However, on the basis of an increasing body of
evidence, a tentative hierarchy of stability (Fig.
4) can be proposed.
Based on observational research, it appears
that anteroposterior correction is the most
Fig. 5 a) The stability of overbite reduction may be better than that alluded to in research
stable form of orthodontic movement.21,22 studies. This propensity to overstate the potential for relapse in overbite is linked to the
In particular, both class III and class II relationship between lower anterior alignment and overbite. Specifically, with perfect lower
correction appear to be relatively stable at the alignment in the presence of class I incisors significant, overeruption of the lower anteriors is
molar, canine and incisor level, particularly impeded by occlusal contact with the cingulum plateau of the maxillary incisors. b) However,
in skeletally mature individuals. On the basis lower anterior malalignment often leads to lingual movement of one or more lower incisors.
of prospective research, relapse of more than These teeth are then free to extrude, leading to a local increase in overbite. The latter is
therefore contingent on loss of alignment
1 mm of severe class II cases arose in less
than 25% at 12 months post-treatment.21 In a
retrospective 32-year follow-up involving 14 to be an important contributor to stable post-retention overbite. However, based on
participants, class II correction was generally outcomes. Again, the use of retainers appears an allied study involving participants who had
stable, although changes in both overbite and to have little influence on stability in this a longer period of retention, mean relapse of
lower anterior alignment were observed.22 spatial plane.23 just 0.8 mm arose over a follow-up period in
Parameters affecting stability of class II Increased overbite is generally regarded as excess of eight years.25 Establishing a corrected
correction are largely unclear, with Pancherz relatively unstable. However, on the basis of incisor relationship is a prerequisite permitting
et al. (2014)21 citing the importance of optimal long-term follow-up, it would be reasonable a centric stop for the lower incisors on the
buccal segment interdigitation, although this to conclude that this contention is influenced cingulum plateau on the maxillary central
has not been confirmed in allied research.21 It by successful retention to a much more incisors. It is important to note that change in
would also be intuitive to expect that reduction meaningful degree than is the case with position of the lower anteriors may influence
in lip incompetence would assist in promoting anteroposterior change. Based on the post- overbite depth, with lingual movement of
stability. Retention regime appears to have retention studies involving Little’s group,24 one or more incisors predisposing to their
relatively little bearing on the stability of class stability of overbite reduction was found to overeruption and subsequent increase in
II correction, however. Similarly, class III be problematic, with instability more likely overbite (Fig. 5). As such, diligent retention
correction is thought to be stable in skeletally with retroclined incisors at the outset with may assist in retaining overbite reduction in
mature individuals, with the overbite thought a positive correlation between initial and the longer term.

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