IMPORTANCE OF RETAINERS AFTER ORTHODONTIC TREATMENT

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1

Obayda Halabi

Fifth year, group 16

IMPORTANCE OF RETAINERS AFTER

ORTHODONTIC TREATMENT

Master’s thesis

Supervisor

PhD, Arunas Vasilauskas

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2 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY FACULTY OF ODONTOLOGY DEPARTMENT OF ORTHODONTICS

IMPORTANCE OF RETAINERS AFTER ORTHODONTIC TREATMENT

Master’s Thesis

The thesis was done

by student ... Supervisor...

(signature) (signature)

... …... (name surname, year, group) (degree, name surname)

... 20…. ... 20….

(day/month) (day/month)

Kaunas, 2017

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3 TABLE OF CONTENTS SUMMARY...4 INTRODUCTION...5 OBJECTIVES………..………..………....6 1. LITTREATURE REVIEW……….………..7 1.1 Retainers………....8

MATERIALS AND METHODS……….………...13

RESULTS ……….……14 DISCUSSION………....26 ACKNOWLEDGMENTS...…….29 CONFLICT OF INTERESTS...29 CONCLUSIONS ……...29 PRACTICAL RECOMMENDATIONS……….…...29 REFRENCES……….……30

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Importance of retainers after orthodontic treatment

SUMMARY

Aim:

Retention is a very important procedure in orthodontics, which secures the long term outcome and satisfaction of orthodontic treatment results. The objective of this study is to show the importance of retainers after orthodontic treatment taking into consideration patients’ opinion, especially those who didn’t follow their treatment by orthodontic retainers.

Material and methods:

The survey questionnaire was developed and 148 questions were made for patients who had already done with their orthodontic treatment 1, 2 or more years ago. Fifty randomly selected Lebanese patients in Tripoli who had been prescribed dental retainers were included in this survey. Data collection referred to demographic studies, treatment satisfaction, retention protocols, compliance, stability and relapse, problems related with the chosen retainer: appearance, speech, oral hygiene, hygiene of the retainer itself, need for replacement and preferred retainer was performed. A statistical analysis was performed by collecting data and analyzing the software package SPSS 20. The data were expressed as a frequency and percentage. Significance between differences was evaluated by a chi-square test. The p-value of <0.05 was considered as statistically significant.

Results:

The overall response rate for survey was 83.33% Most of the patients (85%) were happy after debond, 75% of people that used retainers were happy after retainer removal. Those who didn’t use retainer at all 85% were unhappy now in upper jaw while 100% were unhappy in the lower jaw.

Conclusion:

 The use of retainers is very important in order to prevent teeth from relapsing.  Patient compliance is a must otherwise the treatment results will fail.

 Females seek orthodontic treatment more than males for esthetics and they are more cooperative.

 Hawley retainer was most preferable in upper jaw, bonded retainer best used in lower dental arch.

 Hawley retainer and clear vacuum-formed retainer affected the speech while bonded did not.  Bonded retainer affected the oral hygiene status while Hawley and clear did not

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5

INTRODUCTION

Malocclusion it’s not a disease by itself, it’s a morphological deviation from normal growth and development which might be or might not be associated with any pathological condition. [1]. Orthodontic treatment is recommended for all classes of malocclusion, in order to restore normal functions, improve jaws relation, and achieve the required aesthetic. Aesthetic nowadays is the most reason why people, especially adults, are seeking orthodontic treatments. In order to achieve patient’s goals, either for functional or aesthetic needs, treatment should be saved from failure.

With time, and after orthodontic appliance is removed, the occlusion might change again, teeth may move or rotate, and this will happen in very high percentage. To avoid all of these problems retainers must be used for a period of time to ensure satisfactory and valuable treatment. Retention is an important aspect of orthodontics, which may influence the long term outcome and satisfaction level of patients who undergo orthodontic treatment. Dr. Calvin Case in 1920 stated that “if there is one part of orthodontia more than another that is absolutely indispensable to the success of this specialty and its establishment upon a firm foundation as one of the arts and sciences, it is the permanent retention of regulated orthodontically moved teeth.”[2].

Dental procedures are very expensive especially orthodontic treatment is one of the most expensive treatment in Lebanese clinics. Moreover the government does not support any of the dental treatment and consider it as an aesthetic procedure this makes Lebanese people, especially the poor, which are the majority in Tripoli to not visit regularly the dental offices until extraction is the only solution available. Tripoli is a city located in north of Lebanon and considered as the second capital, were 500,000 citizens are living within it. [3].

In Lebanon there is one dentist for each 900 person which is considered a big number according to the Lebanese dental council, but in Tripoli there is only 245 dentists practicing in 2017, which is equivalent to one dentist for more than 2000 patients, among these 245 dentists only 14 orthodontists. [4].

Some studies in Lebanon were done among children and adolescent stated that 75% of the sample tested had class I malocclusion, 25% had class II, and 5% had class III. [5] Other studies has different percentage were the class II malocclusion turned to be the highest by 49%, and females

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6 were the most. [1] Retention is a crucial procedure in orthodontics, which secure the long term outcome and satisfaction of orthodontic treatment.

Hypothesis:

Aim:

The aim of this study was to evaluate the importance of retainers after orthodontic treatments taking into consideration patients’ opinion, especially those who didn’t follow their treatment by retainers.

Objectives:

1) To find out importance of dental retainers for prevention of relapse after orthodontic treatment. 2) To evaluate patients compliance after prescription of orthodontic retainer.

3) To examine and compare any gender differences in compliance.

4) To investigate the most popular retention appliances prescribed by the orthodontists in Northern Lebanon.

5) To evaluate patients’ opinion about influence of orthodontic retainer on the speech. 6) To evaluate patients’ opinion about influence of orthodontic retainer on the status of oral hygiene.

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Literature review

Stabilization of the teeth in their new positions after orthodontic treatment is extremely challenging. After treatment, teeth have a tendency to move back to the original malocclusion due to many factors: gingival, occlusal, periodontal, and growth related factors. Also teeth movement can be due to age changes. Orthodontist cannot predict which patients are at risk to relapse, or which treatment will be stable, that’s why orthodontist should treat all his patients as they have a high tendency to relapse. Patient should be informed about all of this, and he should know that his treatment may fail if retainer is not used. There is no evidence which kind of retainers is the best, doctors can choose the type according to their experience, which kind will suit each patient. [6]

Cooperation and stability

Stability of the treatment is highly dependent on doctor and patient cooperation. Orthodontist role in finishing and detailing arches and occlusion is very important in stability of teeth in the new position. Also good cusp to fossa relationship, and planning the anchorage at the beginning of treatment is important to avoid mesial drift of the anchored molars. Moreover, orthodontist should be aware of some mistakes, for example placing teeth in an unstable position will lead to relapse. It is well known that rotated teeth and diastema have high tendency to relapse. [7]

Patient cooperation is not less important than the dentist work, rather he might make the treatment fail. Patient should believe that retainer must be worn most of the time especially in the first 3 to 6 months. After 3 months bone remodeling and reorganization of the periodontal ligaments will occur, so shifting of teeth is very common in this period. Also the gingival collagen fiber network takes 4-6 months to remodel. [8] Likewise wearing retainer during night is very important during the first year after deboning. [8] It was thought that retainers must be worn overnight for 5 years but new studies shows that till 1 year is enough. [8]

Doctor has to observe the patient closely and has to predict if he/she is cooperative or not. In case the patient shows a careless attitude the doctor should choose bonded retainer for him/her, and if the patient is highly cooperative the doctor can choose any kind of retainer either Hawley, clear, etc.… Patients’ will should be taken into consideration.

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Retainers

Retainers can be either bonded or removable. Depending on the situation of the patient or the patients’ will retainer can be chosen.

Fixed retainers:

Bonded retainer (Figure 1) is a fixed appliance, which is effective for long term stabilization. It was introduced in the United States in 1970s’, and it is widely used since that date. It is placed on the lingual side of the teeth bonded with light cured composite resin. Bonded retainer should be extended from canine to canine, and it has an esthetic characteristic compared with the removable retainers. It is more comfortable for the patients in speech and in swallowing and does not require their compliance. This type of retainers is also used when the periodontal support is decreased. [9]

Fig 1. Bonded retainer

Placement:

1. Make sure the wire is fitting properly

2. Clean the lingual surface with plain prophy paste 3. Etching with phosphoric acid for 20-30 seconds 4. Rinsing the etch with water

5. Apply bonding

6. Light cure for 20 seconds

7. Placing the wire and adding composite resin 8. Light cure for 30 seconds

9. Cover sharp metal edges with composites 10. Finishing and polishing. [10]

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9 Advantages of bonded retainer:

- It is indicated for the most changeable area, which is in area of lower front teeth. - Patient compliance is not required

- Best esthetic among all retainers - Can be placed for the whole life. [12] Disadvantages of bonded retainers: - Plaque accumulation

- Difficulty to maintain oral hygiene

- Bonding may break occasionally and teeth may shift - Cannot be used in the posterior segment

- If it is in maxilla it should be more gingival to avoid problems in occlusion, which could be difficult in some cases to achieve. [12]

Removable retainers: Hawley retainer:

Hawley retainer (figure 2) is a removable retainer made up of acrylic base and a stainless steel buccal arch. It extends from the distal surfaces of the canines contouring the anterior teeth. Additional retention on the posterior side such as Adams’ clasps, or circumferential clasps engage the molars. It provide better intercuspation for posterior teeth, and may generate small tooth movement. With Hawley retainer it is easy to maintain good oral hygiene, also it has a low cost which makes it affordable for all patients. [9]

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10 It is broadly noticed that Hawley retainer affects the speech and this is mentioned in almost all articles prescribing it. Hawley retainer affects the articulatory movements in consonant–vowel combinations. [11]

Advantages of Hawley retainer:

-Easy to fabricate.

- Fabricated in lab, reduced chair time.

- Can be removed for cleaning it, teeth brushing, flossing and social occasions. - Acrylic palate is rigid: significant anchorage, hold transverse expansion. - Adjustable: easily modified, and can be adjusted for finishing of treatments. - Durable: can last for several years. [12]

Disadvantages of Hawley retainer:

- Poor esthetic

- affect speech especially in maxilla. [12]

Clear retainer (Vacuum-formed):

Clear retainer (Figure 3) is a removable retainer used originally for esthetic reasons. It is made up from clear acrylic wafer, vacuum or pressure formed on cast. A pressure or vacuum machine can be used in dental office to fabricate clear retainer, night guards, sports mouth guards, bleaching trays, occlusal splints. It is very useful for people who needs a long term retainer wear and at the time they are seeking esthetic view. Another use for the clear retainer is when we have a congenital missing tooth/teeth for example; a pontic is embedded into the retainer keeping the space until the patient is ready for implant. Durability of this retainer can be increased be making the plastic more thick, especially for patients who have severe bruxism they must use Essix C+ plastic. New technologies such as Drufomat is a vacuum machine and Vivera which offers a digital scanner for impression are very useful and recently the best to make the clear retainer. [12]

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Fig 3. Clear retainer

Advantages of clear retainers: - Transparency and esthetic

- Very good for long term retainer - Good use during day time - Does not affect speech

Disadvantages of clear retainer:

- Short durability, should be changed every 24 months

- Posterior covering affect settling when it is worn all the time. [12]

Patients’ satisfaction

Satisfaction of the orthodontic treatment is very important for the doctor and the patient at the same time, the doctor will win the challenge and the patient will reach his/her desired goal. Patients should show a high responsibility and cooperation with the doctor by wearing the retainer for the prescribed time otherwise the results will be affected and both of them won’t be satisfied. [13] Some authors do not agree with this concept and depending on a study done in Amsterdam stated that if the retainer is prescribed for a long period of time patient compliance won’t affect the treatment very significantly. [14] Also another study were made, to test if the motivation and expectation are related with satisfaction, usually people with high expectation got disappointed with the results, while motivated people are getting high satisfaction rates. [15] Orthodontic treatment is a way to fix the dental and skeletal problems, it is not prosthodontics, some people expects everything from braces, which is a misunderstanding view, treatment will help the patient to get

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12 into normal range of rules made by historical scientists such as Angle. Patients usually seek esthetic, but esthetic view differs between doctors and patients. Doctor consider esthetic as Angle class I but for patients the most important is their teeth color and brightness. [16]

Most of the patients that are seeking changes in smile are females, they are always trying to be beautiful and attractive, that’s why fulfilling their expectation is really challenging. Their expectation are really high and satisfaction is much less than males. [17] This is normal because females in general are more accurate and they look for details, and the doctor job is to make them feel happy and satisfied as much as he can. Many studies shows that females are more interested in keeping their oral cavity healthy and clean so they have better oral hygiene than males. [18]

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Materials and methods

Survey

This survey is made up of 148 questions, distributed on 19 A4 pages, the first four questions asking about personal information of the patient including name, age and sex. Next section is about patients’ satisfaction with their teeth in 3 stages: before treatment, after braces were removed and at the moment; asking about the upper jaw, then the lower jaw, later about occlusal bite. Six photos of retainers were added to clarify for the participants which kind of retainers they have used, in case they did, and the period of time they wore it, total period, and how many hours per day also whether they were wearing it during night. Furthermore, the participant were asked if they were obliged to replace their retainer and the cause of its replacement, and if they were preferring another kind of retainers and why. Then the participants were asked to rate their appearance with the retainer used whether it was poor or esthetic, and if it was easy or difficult to maintain good oral hygiene, or to keep their retainer clean. Same questions were asked for upper jaw then for lower jaw separately. The survey was designed with a skip option which allow the participant to skip any section which is not related to his case, to avoid annoyance and useless informations.

The survey was distributed to 60 people, in Tripoli- Lebanon, 50 out of them answer it back. Then the data were collected and transferred to an Excel sheet with all coding system used in the questionnaire. After transferring the data, a statistical analysis was performed by the software package SPSS 20. The data were expressed as a frequency and percentage. Significance between differences was evaluated by a chi-square test. The p-value of <0.05 was considered as statistically significant.

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Results

The overall response rate for survey was 83.33%

Table 1. Demographic distribution.

Codes Frequency (N) Percentage (%)

age (years) 13-17 1 7 14

18-43 2 43 86

gender male 1 18 36

female 2 32 64

people with retainers 1 43 86

people without retainers 2 7 14

Table 1. Represents the demographic distribution, in age, gender and patients who used retainers or did not. In the first category, which is age the most prevalent group is patients who are older than 18 years and are 43(86%). The rest of the patients which are 7(14%) are adolescent were their age vary between 13 and 17 years old. The second category, which is related to gender shows that more than half 32(64%) of the participants were females, and 18(36%) were males. Third category shows those patients who used retainer and who did not. 43(86%) of them wore it and 7(14%) did not use it.

Table 2. Distribution of retainers.

maxillary N (percentage) mandibular N (percentage) P value Hawley 22 44% 8 21% 0.001 Clear 14 28% 3 8% Bonded 14 28% 27 71% total 50 100% 38 100% χ2 = Chi-Square test; P<0.001

Table 2. and Figure 4. shows retainers distribution, in upper and lower jaw separately, in upper jaw the total number was 50 retainers, 22 of them (44%) were Hawley retainers, 14 (28%) were clear retainers, and 14 (28%) were upper bonded retainers. In the mandible the total number was 38 lower retainers, 8 of them (21%) were Hawley retainers, 3 (8%) were clear retainers, 27 (71%) were bonded retainers. The chi square value here was: p< 0.001.

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15 Fig. 4. Distribution of retainers.

Table 3.Patient satisfaction in upper jaw immediately after debond.

Crosstab

Satisfaction upper Total P value

neglect happy Unhappy

gender

male

Count 1 16 1 18

0.249

% within gender 5.6% 88.9% 5.6% 100.0%

% within satisfaction upper 100.0% 37.2% 16.7% 36.0%

female

Count 0 27 5 32

% within gender 0.0% 84.4% 15.6% 100.0%

Total

Count 1 43 6 50

% within gender 2.0% 86.0% 12.0% 100.0%

χ2 = Chi-Square test; p= 0.249

In Table 3: 16 males (88.9 %) were happy with the results, and only 1 (5.6%) was unhappy. For females 27 (84%) were happy while 5 (15%) were unhappy.

0 5 10 15 20 25 30 maxillary N (percentage) mandibular N (percentage)

Chart Title

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Table 4. Satisfaction in lower jaw immediately after debond.

Crosstab

Satisfaction lower Total P value

happy unhappy Gender male Count 15 3 18 0.609 % within gender 83.3% 16.7% 100.0%

% within satisfaction lower 35.7% 37.5% 36.0%

female

Count 27 5 32

% within gender 84.4% 15.6% 100.0%

Total

Count 42 8 50

% within gender 84.0% 16.0% 100.0%

χ2 = Chi-Square test; p= 0.609

In Table 4: 15 males (83%) were happy and only 3 (16%) were unhappy. 27 female (84.4%) were happy while 5 (15.6%) were unhappy.

Table 5. Satisfaction now after removing of retainers in upper jaw.

Upper mix satisfaction upper now Cross tabulation

Satisfaction upper now

Total

P value

unhappy happy

Upper mix bonded Count 3 11 14

0.01

% within upper mix 21.4% 78.6% 100.0%

% within satisfaction upper now 17.6% 34.4% 28.6%

% of Total 6.1% 22.4% 28.6%

removable Count 8 20 28

% within upper mix 28.6% 71.4% 100.0%

% of Total 16.3% 40.8% 57.1%

without Count 6 1 7

% within upper mix 85.7% 14.3% 100.0%

% of Total 12.2% 2.0% 14.3%

Total Count 17 32 49

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% of Total 34.7% 65.3% 100.0%

χ2 = Chi-Square test; P< 0.01 statistically significant.

In Table 5 and Figure 5 upper bonded retainer: 3 (21.4%) patients are unhappy and 11 (78.6%) are happy. Upper removable: 8 (28.6%) are unhappy, 20 (71.4%) are happy. Without retainer: 6 (85%) are unhappy, and 1 (14.3%) is happy.

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Table 6. Gender and satisfaction about results in upper jaw.

gender * satisfaction upper now Cross tabulation

Satisfaction upper now

Total

P value

unhappy happy

gender male Count 6 11 17

0.6

% within gender 35.3% 64.7% 100.0%

% within satisfaction upper now

35.3% 34.4% 34.7%

% of Total 12.2% 22.4% 34.7%

female Count 11 21 32

% within gender 34.4% 65.6% 100.0%

64.7% 65.6% 65.3%

% of Total 22.4% 42.9% 65.3%

Total Count 17 32 49

% within gender 34.7% 65.3% 100.0%

100.0% 100.0% 100.0%

% of Total 34.7% 65.3% 100.0%

χ2 = Chi-Square test; P= 0.6

Cross tabulation data about satisfaction in upper jaw between genders presented in Table 6 also as in Figure 6

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Table 7. Lower mix retainers / satisfaction.

Satisfaction lower now lower mix Cross tabulation

Lower mix Total

P value

lower bonded lower

removable without lower Satisfaction lower now no Count 3 6 7 16 0.01 % within satisfaction lower now 18.8% 37.5% 43.8% 100.0%

% within lower mix 11.1% 37.5% 100.0% 32.0%

yes

Count 24 10 0 34

% within satisfaction

lower now 70.6% 29.4% 0.0% 100.0%

% within lower mix 88.9% 62.5% 0.0% 68.0%

Total

Count 27 16 7 50

% within satisfaction

lower now 54.0% 32.0% 14.0% 100.0%

% within lower mix 100.0% 100.0% 100.0% 100.0%

χ2 = Chi-Square test; P< 0.01 statistically significant.

11.1 % were unhappy with lower bonded while 88.9% were happy. Lower removable 37%were unhappy while 62.5% were happy. People without retainers 100% unhappy. (Table 7), (Figure 7)

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Table 8. Gender and satisfaction in lower jaw.

gender * satisfaction lower now Cross tabulation

Satisfaction lower now Total P value

no yes gender male Count 7 11 18 0.318 % within gender 38.9% 61.1% 100.0%

% within satisfaction lower

now 43.8% 32.4% 36.0%

female

Count 9 23 32

% within gender 28.1% 71.9% 100.0%

now 56.2% 67.6% 64.0%

Total

Count 16 34 50

% within gender 32.0% 68.0% 100.0%

now 100.0% 100.0% 100.0%

In Table 8: 7 patients (38.9%) are unhappy, 11 (61.1%) are happy. 9 females (28.1%) are unhappy, and 23 (71.9%) are happy. (Figure 8)

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Table 9. Time of wearing retainer versus satisfaction in the upper jaw.

Satisfaction upper now * mix upper time Cross tabulation

Mix upper time Total P

neglect Hawley yes Hawley

no clear yes clear no value Satisfaction upper now unhapp y Count 8 2 5 1 1 17 0.165 Expected Count 5.6 4.5 3.5 1.0 2.4 17.0 % within satisfaction upper now 47.1% 11.8% 29.4% 5.9% 5.9% 100.0% % within mix upper time 50.0% 15.4% 50.0% 33.3% 14.3% 34.7% happy Count 8 11 5 2 6 32 Expected Count 10.4 8.5 6.5 2.0 4.6 32.0 % within satisfaction upper now 25.0% 34.4% 15.6% 6.2% 18.8% 100.0% % within mix upper time 50.0% 84.6% 50.0% 66.7% 85.7% 65.3% Total Count 16 13 10 3 7 49 Expected Count 16.0 13.0 10.0 3.0 7.0 49.0 % within satisfaction upper now 32.7% 26.5% 20.4% 6.1% 14.3% 100.0% % within mix upper time 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% χ2 = Chi-Square test; p= 0.165

In Table 9: unhappy patients: 2 wore Hawley more than 20 hours, and 5 didn’t wear for more than 20 hours. 1 patient wore the clear retainer for more than 20 hours and 1 patient didn’t do.

Happy patients: 11 patients wore the Hawley retainer more than 20 hours, and 5 didn’t wear. 2 patients wore the clear retainer for more than 20 hours were happy and 6 didn’t wear and were happy.

Hawley appliance wear 84.6% happy, 15.4% unhappy; Hawley didn’t wear 50% happy, 50% unhappy

Clear appliance wear 66.7% happy, 33.3% unhappy; clear didn’t wear 85.7% happy, 14.3% unhappy. (Figure 9)

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Fig 9. Time of wearing retainer versus satisfaction in the upper jaw. Table 10. Time of wearing retainer versus satisfaction in the lower jaw.

Lower satisfaction mix * mix lower time Cross tabulation

Mix lower time Total P value

Hawley yes Hawley no clear no

Lower satisfaction mix happy Count 2 2 0 4 0.1 % within lower satisfaction mix 50.0% 50.0% 0.0% 100.0%

% within mix lower

time 33.3% 100.0% 0.0% 40.0%

unhappy

Count 4 0 2 6

% within lower

satisfaction mix 66.7% 0.0% 33.3% 100.0%

% within mix lower

time 66.7% 0.0% 100.0% 60.0%

Total

Count 6 2 2 10

% within lower

satisfaction mix 60.0% 20.0% 20.0% 100.0%

% within mix lower

time 100.0% 100.0% 100.0% 100.0%

In Table 10: patients that used Hawley retainer for more than 20 hours per day 33.3% were happy while 66.7% were unhappy. No patients wore the clear retainer for more than 20 hours and all 100% were unhappy

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Table 11. Gender versus appearance with retainers:

gender * appearance mix Cross tabulation

Appearance mix Total

P value

Hawley like Hawley

unlike

clear like clear

unlike bonded like gender male Count 2 7 2 1 2 14 0.33 % within gender 14.3% 50.0% 14.3% 7.1% 14.3% 100.0% % within appearance mix 50.0% 38.9% 28.6% 100.0% 15.4% 32.6% female Count 2 11 5 0 11 29 % within gender 6.9% 37.9% 17.2% 0.0% 37.9% 100.0% % within appearance mix 50.0% 61.1% 71.4% 0.0% 84.6% 67.4% Total Count 4 18 7 1 13 43 % within gender 9.3% 41.9% 16.3% 2.3% 30.2% 100.0% % within appearance mix 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% χ2 = Chi-Square test; P= 0.33

In Table 11: Males: 22% liked the appearance with Hawley retainers while 78% didn’t like. 66.7% liked the appearance with clear retainers, while 33.3% didn’t like. 100% liked the appearance with the bonded retainers.

Females: 15% liked the appearance with Hawley retainer, while 85% didn’t like it. 100% liked the appearance with the clear retainer. Also 100% liked the appearance with bonded retainer.

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Table 12. Gender versus retainer affecting speech:

gender * speech Cross tabulation

Speech Total Hawley affected Hawley did not affect clear affected clear did not affect bonded affected bonded did not affect P value gend er male Count 9 0 3 0 0 2 14 0.475 % within gender 64.3% 0.0% 21.4% 0.0% 0.0% 14.3% 100.0% % within speech 42.9% 0.0% 37.5% 0.0% 0.0% 28.6% 32.6% female Count 12 4 5 2 1 5 29 % within gender 41.4% 13.8% 17.2% 6.9% 3.4% 17.2% 100.0% % within speech 57.1% 100.0% 62.5% 100.0% 100.0% 71.4% 67.4% Total Count 21 4 8 2 1 7 43 % within gender 48.8% 9.3% 18.6% 4.7% 2.3% 16.3% 100.0% % within speech 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% χ2 = Chi-Square test; P= 0.475

In Table 12: Males: 100% found that Hawley retainer affected the speech. 100% found that clear retainer affected the speech. 100% found that bonded retainer did not affect the speech.

Females: 75% said that Hawley retainer affected the speech while 25% said it did not affect. 71% said that clear retainer affects the speech while 29% said that clear retainer did not affect speech. 16% said that bonded retainer affects the speech, 84% said it did not affect.

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Table 13. Capability of keeping oral hygiene with retainers versus gender:

gender * hygiene Cross tabulation

hygiene Total P value

Hawley easy Hawley difficult clear easy clear difficult bonded easy bonded difficult gender male Count 6 2 3 0 0 3 14 0.69 % within gender 42.9% 14.3% 21.4% 0.0% 0.0% 21.4% 100.0% % within hygiene 37.5% 28.6% 42.9% 0.0% 0.0% 37.5% 32.6% female Count 10 5 4 3 2 5 29 % within gender 34.5% 17.2% 13.8% 10.3% 6.9% 17.2% 100.0% % within hygiene 62.5% 71.4% 57.1% 100.0% 100.0% 62.5% 67.4% Total Count 16 7 7 3 2 8 43 % within gender 37.2% 16.3% 16.3% 7.0% 4.7% 18.6% 100.0% % within hygiene 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% χ2 = Chi-Square test; P= 0.69

In Table 13: Males: Hawley: 75% said it’s easy to maintain oral hygiene, 25% said it’s difficult. Clear: all males 100% said it is easy to maintain oral hygiene. Bonded: 100% said it is difficult. Females: Hawley: 66.7% said it’s easy, 33.3% said it is difficult. Clear: 57% said it is easy, and 43% said it is difficult. Bonded: 28% said it is easy to maintain oral hygiene, and 72% said it’s hard.

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Discussion

In this study, patients who had already done with their orthodontic treatment were selected to find the differences between people who followed their treatment by a retainer for a certain period of time and people who didn’t use retainers. Patients’ opinions were taken, regarding their satisfaction with the treatment. 50 patients were asked, results were calculated and analyzed.

Demographic

The results in the demographic table (Table 1) shown that the number of females were almost double the number of males in this study, 32 females vs. 18 males. To know the reason of this, answer can be found easily, females are more motivated to do orthodontic treatment in order to look more pretty and confident. [19] Females have 4 reasons why they want to do orthodontic treatment: first they focus on their self-perception of their appearance, second they are easily influenced by others’ opinion, third reason is aesthetic and forth is confidence plus to avoid negative thought caused by their teeth. [19] A Chinese study done in china on Chinese and foreigners shows that Chinese women are seeking orthodontic treatment much more than foreigners females and much more than Chinese males for esthetic reasons. [20]

In addition the results in Table1 shows that adults seeking treatment are much more than adolescent patients and this agree with the same studies done. [19, 20].

For retainers (Table 2) we got the most used retainer in upper jaw, which is the Hawley retainer while for bonded and clear they were equal. For the lower jaw the most used was bonded then Hawley then very small amount of clear. These stats are compatible with the researches done before where scientists found that Hawley retainer is very good to be used in upper jaw because it gives very good stability while in the lower jaw it may cause injury in the soft tissue that’s why bonded is the best used in the lower jaw. [21] Nevertheless, studies about clear retainer showed that it is the least used due to many factors that will be listed later. [21]

Satisfaction

After debond immediately most of the patient are usually happy with the result, here we got in our results in table 3 about upper jaw that almost 85% of patients were happy immediately after debond, comparing with the results of table 5 which gives results of satisfaction after 2 or more years after removing of retainer or those who didn’t even used retainer, we found that almost 75% of people that used retainers were happy while approximately 25% were unhappy. The big problem was with those who didn’t use retainer at all were 85% are unhappy now. This was expected due to the

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27 relapsing of teeth which is common in almost all studies done showing the importance of retainers

in order to save teeth after orthodontic treatment. [22]. Results in tables 4 and 7 showing satisfaction in lower jaw, and we found that immediately after

debond approximately 85% of the patients were happy while 15% only were unhappy. After removing of retainer 89% of those who used fixed retainer were happy while only 62.5% of those who used removable lower retainer were happy. This is also observed in previous studies that lower bonded retainers are much effective that lower removable ones. [23]. Patients who didn’t use lower retainer were 100% unhappy this was surprising result with a P < 0.05 which was strongly significant. There was no difference between female and males regarding satisfaction, people who did not satisfied had very high expectation while they should know before what limitation this treatment can achieve. [24] Moreover the success of the treatment is dependent on the compliance of the patient with the orthodontist [25] this can be seen clearly with the results in tables 9 and 10 where 85% of patients who wore the Hawley retainer for more than 20 hours per day were happy, while those who didn’t wear % of them were unhappy; And 66.7% of those who used clear retainer for more than 20 hours per day were happy. In the lower jaw no patients wore the lower clear retainer for more than 20 hours and 100% were unhappy, also those who wore the Hawley retainer in the lower jaw for more than 20 hours per day 66.7% were unhappy this will confirm that the best choice for lower jaw in bonded retainer. [23]

Appearance

In Table 11 we are discussing how the patient are rating their appearance with the retainers used, 78% of males and 85% of females didn’t like the appearance with the Hawley retainer, this is one of the most common disadvantages of the Hawley retainer, so for patient who are seeking aesthetic view they could use another kind of retainers in depend on the patient choice and request. [26, 27] Patients with clear retainers 66.7% of males liked it while 100% of females liked it, this kind of retainer is done for aesthetic purposes. [27]. All patients females and males liked the appearance with the bonded retainer.

Retainers affecting speech

Table 12 is done to find which retainers are affecting speech, all males said that Hawley and clear retainers affect speech while bonded did not affect speech. Female were more accurate 75% said that Hawley retainer affect speech, 71% said that clear retainer affect speech while 84% said that

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28 bonded retainer doesn’t affect speech. These results are compatible with the studies done before, that Hawley retainers are mostly affecting speech. [11, 28]

Retainers affecting oral hygiene

In Table 13 results show which retainers are affecting the oral hygiene and this was found: 75% of males and 67% of females said that it’s easy to maintain oral hygiene with Hawley retainers, 100% of males and 57% of females said that it’s easy to maintain oral hygiene with clear retainers, 100% of males and 72% of females said it’s hard with bonded retainer. It’s well known that with bonded retainer patient cannot keep his/her month clean [29], because of accumulation of plaque around and below the wire which make it difficult to remove. With Hawley retainer is very easy to clean your mouth just remove it and brush and floss, also its easy to keep the retainer itself clean. [30].

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Acknowledgment:

I would like to thank all family members and friends who helped me to find the desired participants that suit my study, never forget Doctor Suzanne Ayoubi specialist in orthodontics who helped me find the majority of the samples, I really appreciate her help.

Conflict of interests

Obayda Halabi has not encountered any conflict of interests, 60 copies of the survey was printed and distributed either manually or by the help of specialized orthodontist Dr. Suzanne Ayoubi who helped by offering her own patients.

Conclusion

 The use of retainers is very important in order to prevent teeth from relapsing.  Patient compliance is a must otherwise the treatment results will fail.

 Females seek orthodontic treatment more than males for esthetics and they are more cooperative.

 Hawley retainer was most preferable in upper jaw, bonded retainer best used in lower dental arch.

 Hawley retainer and clear vacuum-formed retainer affected the speech while bonded did not.  Bonded retainer affected the oral hygiene status while Hawley and clear did not

Practical recommendations

Compliance is one of the most important factors for the success of treatment, that’s why doctors should find a way to convince their patients to wear their retainers as prescribed. This can be achieved by showing pictures of old failed cases, which did not use retainer or by showing live cases if possible, this will help a lot in convincing patients and enhancing cooperation with the orthodontist.

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