POST-ORTHODONTIC TREATMENT RELAPSE DEPENDING ON DIFFERENT RETAINERS AND ITS RELATION TO LONG-TERM PATIENT SATISFACTION

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Sapir Argaman

5th Course, group 13

POST-ORTHODONTIC TREATMENT RELAPSE

DEPENDING ON DIFFERENT RETAINERS AND ITS

RELATION TO LONG-TERM PATIENT SATISFACTION

Master’s Thesis

Supervisor PhD, Arūnas Vasiliauskas

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY

FACULTYOFODONTOLOGY

THECLINICOFORTHODONTICS

POST-ORTHODONTIC TREATMENT RELAPSE DEPENDING ON DIFFERENT RETAINERS AND ITS RELATION TO LONG-TERM PATIENT SATISFACTION Master’s Thesis

The thesis was done

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EVALUATION TABLE OF CLINICAL–EXPERIMENTAL MASTER’S THESIS Evaluation:... Reviewer:... (scientific degree, name and surname)

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No. MT parts MT evaluation aspects

Compliance with MT requirements and evaluation Yes Partially No 1 Summary (0.5 point)

Is summary informative and in compliance with the

thesis content and requirements? 0.3 0.1 0

2 Are keywords in compliance with the thesis

essence? 0.2 0.1 0 3 Introduc- tion, aim and tasks (1 point)

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work justified in the introduction of the thesis? 0.4 0.2 0

4 Are the problem, hypothesis, aim and tasks formed

clearly and properly? 0.4 0.2 0

5 Are the aim and tasks interrelated? 0.2 0.1 0

6

Review of literature (1.5 points)

Is the author’s familiarization with the works of

other authors sufficient? 0.4 0.2 0

7

Have the most relevant researches of the scientists discussed properly and are the most important results and conclusions presented?

0.6 0.3 0

8 Is the reviewed scientific literature related enough to

the topic analysed in the thesis? 0.2 0.1 0

9 Is the author’s ability to analyse and systemize the

scientific literature sufficient? 0.3 0.1 0

10

Material and methods (2 points)

Is the research methodology explained

comprehensively? Is it suitable to achieve the set aim?

0.6 0.3 0

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Are the samples and groups of respondents formed and described properly? Were the selection criteria suitable?

0.6 0.3 0

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Are other research materials and tools

(questionnaires, drugs, reagents, equipment,etc.) described properly?

0.4 0.2 0

13

Are the statistical programmes used to analyse data, the formulas and criteria used to assess the level of statistical reliability described properly?

0.4 0.2 0

14

Results (2 points)

Do the research results answer to the set aim and

tasks comprehensively? 0.4 0.2 0

15 Does presentation of tables and pictures satisfy the

requirements? 0.4 0.2 0

16 Does information repeat in the tables, picture and

text? 0 0.2 0.4

17 Is the statistical significance of data indicated? 0.4 0.2 0

18 Has the statistical analysis of data been carried out

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19

Discussion (1.5

points)

Were the received results (their importance, drawbacks) and reliability of received results assessed properly?

0.4 0.2 0

20 Was the relation of the received results with the

latest data of other researchers assessed properly? 0.4 0.2 0

21 Does author present the interpretation of results? 0.4 0.2 0

22 Do the data presented in other sections (introduction,

review of literature, results) repeat? 0 0.2 0.3

23

Conclu- sions (0.5 points)

Do the conclusions reflect the topic, aim and tasks of

the Master’s thesis? 0.2 0.1 0

24 Are the conclusions based on the analysed material?

Do they correspond to the research results? 0.2 0.1 0

25 Are the conclusions clear and laconic? 0.1 0.1 0

26

References (1 point)

Is the references list formed according to the

requirements? 0.4 0.2 0

27 Are the links of the references to the text correct? Are the literature sources cited correctly and precisely?

0.2 0.1 0

28 Is the scientific level of references suitable for

Master’s thesis? 0.2 0.1 0

29

Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than 5 years – at least 40%?

0.2 0.1 0

Additional sections, which may increase the collected number of points 30 Annexes Do the presented annexes help to understand the

analysed topic? +0.2 +0.1 0

31

Practical recommen -dations

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are they related to the received results? +0.4 +0.2 0

General requirements, non-compliance with which reduce the number of points 32

Genera l require - ments

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15-20 pages (-2 points)

<15pages (-5points) 33 Is the thesis volume increased artificially? -2 points -1 point

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requirements of Master’s thesis? -1 point -2 points

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scientifically, logically andlaconically? -0.5 point -1 points

36 Are there any grammatical, styleor

computer literacy-relatedmistakes? -2 points -1 points 37 Is text consistent, integral, and are the

volumes of its structural parts balanced? -0.2 point -0.5

points

38 Amount of plagiarism in the thesis. >20%

not evaluated 39 Is the content (names of sections and sub-

sections and enumeration of pages) in -0.2 point -0.5

points compliance with the thesis structure and

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40

Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections distinguished logically and correctly?

-0.2 point -0.5 points

41 Was the permit of the Bioethical

Committee received (if necessary)? -1 point

42 Are there explanations of the key terms

and abbreviations (if needed)? -0.2 point -0.5

points 43

Is the quality of the thesis typography (quality of printing, visual aids, binding) good?

-0.2 point -0.5 points *In total (maximum 10 points):

*Remark: the amount of collected points may exceed 10 points.

Reviewer’s comments:

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1. SUMMARY

Objectives:

1) To evaluate the patient compliance with removable retainers and reasons for

non-compliance. 2) To evaluate the post-orthodontic treatment relapse depending on different retainers. 3) To assess the long-term satisfaction rate among post orthodontic patients in relation to the experience of relapse and type of retainer. 4) To compare the patient compliance with removable retainers and long-term patient satisfaction with orthodontic treatment in relation to gender. 5) To compare the knowledge regarding the influence of orthodontic treatment on general wellbeing, patient compliance with removable retainers and long-term patient satisfaction with orthodontic treatment among odontology and medical students.

Material and methods:

An anonymous self-administered questionnaire was distributed to

international students from both Odontology and Medical faculties at the Lithuanian University of Health Science. The selection criteria were: international odontology and medical students who have received fixed orthodontic treatment not less than 1 year ago. The questionnaire was organized into five sections with questions about sociodemographic status, orthodontic treatment results, retention period, relapse experienced and long-term patient satisfaction with the orthodontic treatment. Data were processed using MS Excel 2010 and analysed using IBM SPSS Statistics, version 20. The statistical significance level was set at p<0.05.

Results: The main reasons for non-compliance with orthodontist instructions were forgetfulness

(38.2%) and discomfort (20.6%). Patients who have received only removable retainers experienced significantly more noticeable changes in their teeth alignment (p=0.005). “Dissatisfied” patients mostly indicated to have noticeable changes in teeth alignment (p<0.001). “Satisfied” patients mostly indicated to have unnoticeable changes in teeth alignment (p<0.001). Dissatisfaction with current teeth alignment was associated more with females then males (p=0.018). Odontology students more commonly would like to repeat the orthodontic treatment if relapse is experienced comparing with the medical students (p=0.018). In addition, odontology students found to be more familiar with the influence of orthodontic treatment on general wellbeing than the medical students (p=0.038).

Conclusions:

The main reasons for non-compliance with orthodontist instructions were

forgetfulness and discomfort. Post-orthodontic treatment relapse is associated more with removable retainer than fixed retainer. Long-term patient satisfaction is strongly related to the experience of relapse. Female patients concerned more about their dental appearance than male patients.

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2 Odontology students concerned more about their dental appearance then medical students. In addition, odontology students have more knowledge than medical students regarding orthodontics and the awareness of the effects of occlusion on general wellbeing.

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3

2. INTRODUCTION

Maintaining the dental alignment stability after orthodontic treatment has been and continues to be a challenge to the orthodontic profession. The main goal of orthodontic treatment is to produce a normal, stable and well-functioning occlusion that is esthetically acceptable, in other words we can call it “ideal” occlusion [1]. Follow-up studies of many orthodontic cases have revealed that although “ideal” occlusion and dental alignment have been reached, after the orthodontic treatment there is a tendency for relapse toward the original malocclusion [2].

We can divide the period after the orthodontic treatment into two phases, a retention phase, and a post retention phase. The retention phase is the time during which the periodontium reorganized after the skeletal and dental changes correlated with orthodontic treatment. The components that form the periodontium such as periodontal ligament, gingival fibers and supra crestal fibers complete this process over different periods of time (from 3-8 months). This is the reason the retention phase is completed within a year after the orthodontic treatment is finished [3, 4].

The post retention phase continues for the rest of the patient’s life. During this phase, changes in teeth position may occur due to changes in the periodontium which are the result of continued skeletal growth and development. During this phase orthodontic retainers are used in order to compensate the effects of those growth changes and to avoid relapse [5]. Thus, retention is an essential and mandatory component of orthodontic treatment and it might be an important factor in determining the long term patient satisfaction with the orthodontic treatment [1].

A recent Cochrane Review done in 2016 assessed the available methods of retention and reported that “there is insufficient high quality evidence to make recommendations on retention procedures for stabilising tooth position after treatment with orthodontic braces” [6]. Thus, still nowadays, there is no evidence about which retention method can provide the best results and avoid post-orthodontic treatment relapse.

Since most orthodontic retainers are removable, patient compliance is a considerable factor in maintaining dental alignment stability and avoiding post-orthodontic treatment relapse [3]. There is not enough research on patient compliance with removable retainers. A research made in 2017 by Al-Moghrabi D et al. concluded that “further research is required to identify effective interventions and possible barriers in order to improve removable orthodontic appliance compliance” [7]. This lack of information, leaves the orthodontics speciality with many different opinions and practice protocols.

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4 The main hypothesis of this study was that long- term patient satisfaction is related to the experience of relapse after the orthodontic treatment. Another hypothesis is that odontology students have more knowledge regarding orthodontics and the awareness of the effects of occlusion on general wellbeing. In addition, we speculated that odontology students concern more about dental esthetic than laypersons, thus, we expected odontology students to be more cooperative with orthodontist instructions.

Concerning gender, our hypothesis was that females are more concerned with esthetic appearance than males.

The aim of this study was to evaluate the post-orthodontic treatment relapse depending on different retainers and its relation to long-term patient satisfaction among international students.

Our tasks were:

1. To evaluate the patient compliance with removable retainers and reasons for non-compliance. 2. To evaluate the post-orthodontic treatment relapse depending on different retainers.

3. To assess the long-term satisfaction rate among post orthodontic patients in relation to the experience of relapse and type of retainer.

4. To compare the patient compliance with removable retainers and long-term patient satisfaction with orthodontic treatment in relation to gender.

5. To compare the knowledge regarding the influence of orthodontic treatment on general wellbeing, patient compliance with removable retainers and long-term patient satisfaction with orthodontic treatment among odontology and medical students.

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5

3. REVIEW OF LITERATURE

Orthodontic treatment goal is to correct malocclusion and to produce a normal or so called "ideal" occlusion [1]. Once orthodontic treatment is completed, retention is necessary in order to resist the tendency of teeth to return into their original position [4]. Retaining the teeth in their corrected positions after treatment sometimes can be very challenging. Relapse can be considered as any unfavorable change in tooth position after orthodontic treatment away from the corrected malocclusion [8]. Clinicians involved in orthodontic treatment should have an understanding of the etiology of relapse and be familiar with different methods of reducing post-orthodontic treatment relapse.

3.1 Etiology of relapse

It has been suggested that teeth relapse for a variety of reasons such as periodontal or gingival factors, occlusal factors, soft tissue factors and normal facial growth and developmental factors [4, 8, 9]. Stability can only be achieved if the forces derived from these factors are in equilibrium [4].

3.1.1 Periodontal and gingival factors

During the orthodontic treatment, when teeth are moved, the tissues in the periodontal ligament and gingiva remodel to the new tooth position [8]. Remodeling of the periodontal ligament takes about 3-4 months. The gingival fibers remodeling takes 4 to 6 months, and the supra crestal fibers remodeling takes the longest period of time which is approximately 8 months [3, 4]. The clinical significance is that, if teeth are not held long enough in their new position to allow remodeling of the periodontium, the periodontal and gingival fibers will pull the teeth back towards their original position. [4, 5, 8, 9].

3.1.2 Occlusal factors

It has been suggested that well-adjusted dentition with equal occlusal contacts and proper occlusal loading on teeth, is more likely to be stable and may reduce the chance for relapse [9]. Accordingly, occlusal disturbances, improper tooth contacts and the abnormal loading of teeth may lead to increased mobility of the affected teeth which may contribute to relapse [8].

3.1.3 Pressure from orofacial soft tissues

The teeth are positioned in an area of balance between the tongue and the lips and cheeks. This area of balance is theoretically known as the neutral zone. Practically, in order to achieve dental stability, the teeth should be placed in this neutral zone at the end of the orthodontic treatment. Accordingly,

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6 it is likely that if teeth are positioned far from this ‘neutral’ zone, they will be unstable. Even though the forces from the tongue are stronger, healthy periodontium can resist the proclination of the teeth [9]. This is true especially for the lower incisors. If incisors are proclined or retroclined excessively, relapse is more likely to occur. Although the theory about placing the teeth in the neutral zone is useful, practically there are two major problems. First, currently, the exact position and dimensions of the neutral zone are unknown. Second, due to changes in muscle tone that occur with age, it is likely that the neutral zone may change as well [10].

3.1.4 Normal facial growth and developmental factors

Any skeletal changes that occur following orthodontic treatment will influence the achieved dental relationships. The patient’s growth pattern is usually taken into account before and during the orthodontic treatment. However, little attention is given to skeletal growth changes that occur after the orthodontic treatment. For many years it was assumed that facial growth stops at the end of puberty [4]. Although, it is now known that facial growth continues throughout life such as minor changes in the relationship between the mandible and maxilla, and changes in the soft tissue pressures on the dentition. Therefore, the dentition is placed in a biological environment that is constantly changing. Thus, it is not surprising that changes in the alignment of teeth and occlusal relationships may occur throughout life [5, 8].

3.1.5 Third molars

Despite the prevailing opinion that third molar can lead to relapse (especially in the lower anterior segment), the extraction of mandibular third molars in order to prevent late lower incisor crowding remains a controversial topic and a common practice in dentistry. Multiple studies investigated the influence of third molars on crowding and assessed their effects on the lower dental midline and anterior crowding. The results found only a small (negligible clinical significance) or no effect with large standard deviations [9, 11].

Most studies indicate that it is difficult to point at a single etiological factor and that relapse is more likely to be a multi factorial problem [5]. The clinician’s responsibility is to explain the unpredictable nature of relapse, the factors known to be involved and advice on the reduction of the risks by the appropriate use of retainers. Thus, it is important for the patients to understand their responsibility and be aware of the fact that retention is designed to maintain the occlusal and dental stability following orthodontic treatment [12].

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7 3.2 Type of retainers

Retainers can be broadly classified as either fixed or removable.

3.2.1 Removable retainers

Removable retainers are most often used only part-time (for example, only at night) and can be removed on socially sensitive occasions and so are more acceptable for the patient. In addition, it is easier to maintain oral hygiene with removable retainers (as they can be removed for cleaning). Patient compliance is essential with removable retainers, non-compliance can result in relapse. Removable retainers placing direct responsibility on the patient in maintaining teeth alignment following orthodontic treatment. The most common removable retainers used nowadays are the Hawley-type retainers (plastic with metal wire across the front teeth) and vacuum formed retainer (made from clear plastic with no wires) [12-15].

3.2.2 Fixed retainers

Fixed retainers are permanently bonded to the palatal/lingual surfaces of the labial segments. The great advantage of fixed retainer over removable retainer is that it removes the need for patient compliance. A major disadvantage of fixed retainers is that they cannot be removed for cleaning, so plaque and calculus may accumulate in the area of the bonded retainer very easily. Comparing with the removable retainers, fixed retainers require maintenance and need to be checked regularly by the orthodontist to ensure that they are still bonded in place [8, 12].

Orthodontist often chooses to use a combination of fixed and removable retainers. This retention method is considered as “dual” retention. A fixed retainer is bonded to the patient's labial segment, and in addition, patients are provided with a removable retainer to wear at night [12]. A recent Cochrane Review which evaluated the methods of retention available nowadays reported that there was insufficient high-quality evidence on the best type of retainer or retention regimen [6, 16].

3.3 Patient compliance with removable retainers

Since most orthodontic retainers are removable, patient compliance is an important factor. However, little research has been published regarding retainer compliance. A survey of retainer compliance made by Wong and Freer reported that more than 50% of patients admitted that they did not wear their removable retainers as instructed. The most common reasons were discomfort and forgetfulness [3, 17, 18]. Thus, successful preservation of orthodontic results can be achieved if patients accept responsibility for maintaining and wearing the retainers [18].

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8 3.4 Patient long-term satisfaction with orthodontic treatment

Patient satisfaction has relatively limited coverage in the orthodontic literature [19]. A study made in 2010 by Maia NG and Normando D concluded that from a long-term perspective patient satisfaction is related to the stability of the orthodontic treatment results [20]. Thus, retention is an essential, even critical, component of orthodontic treatment and it might be an important factor in determining the long- term patient satisfaction with the orthodontic treatment.

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4. MATERIAL AND METHODS

A study evaluating the patient compliance with removable retainers, post-orthodontic treatment relapse depending on different retainers and long-term patient satisfaction with orthodontic treatment was carried out at the Lithuanian University of Health Science (LSMU) Medical academy (MA) in Kaunas, Lithuania. A self-administered structured anonymous questionnaire written in English was distributed to international students who have received fixed orthodontic treatment from Odontology faculty (OF) and Medical faculty (MF) during November 2018 to January 2019. Ethical approval (attached in Annex No. 1) was obtained from the bioethics department in LSMU (No. BEC-OF-02 ). Anonymity of the information was ensured by removing all personal identifiers.

4.1 Subjects

A total of 159 international odontology students and 688 international medical students studied at LSMU during the 2018/2019 study year. The selection criteria for this study were: international students from LSMU-MA-OF/ MF who have received fixed orthodontic treatment not less than 1 year ago.

As a part of this study, we made a comparison between the answers of OF and MF. Thus, it was important for us to achieve an equal number of participants from both faculties. From the OF only 33 students fulfilled the inclusion criteria, therefore, we had to achieve a similar number of participants from MF. Overall, from 80 questionnaires, a total of 68 international students from both faculties returned their questionnaire, OF (n=33) and MF (n=35). The response rate was 85%. The participants in the study were 38.2% males and 61.8% females, mostly 20-25 years old (60.3%). Participation was voluntary and anonymous; thus, the return of the completed questionnaire was considered as acceptance to participate.

4.2 The questionnaire

The questionnaire (attached in Annex No. 2) included 30 questions and was divided into 5 parts that inquired about sociodemographic information, questions pertaining to the results of orthodontic treatment, type of retainer prescribed, patient compliance with removable retainer, and reasons for discontinuing use of retainers, relapse experienced and the relation to long-term patient satisfaction with the orthodontic treatment.

4.2.1 Questions regarding sociodemographic characteristics

The first part of the questionnaire included questions regarding age, gender, faculty, academic year of study and nationality (Table 1). The question about the age included 4 possible choices: “Below

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10 20”, “20-25”, “26-30”, “Above 30”. These choices later grouped into 2 groups: “25 and below”, “26 and above”. The nationality of the majority of participant was Israeli, all the other nationalities (Swedish, German, Italian, British, Spanish, Cyprotic, Indian, French, Lebanese, South Korea, Norway, Barbadian and Brazilian) grouped into one group of “Other nationality”.

4.2.2 Questions regarding orthodontic treatment results

The second part of the questionnaire included questions about the orthodontic treatment duration and results- if the orthodontic treatment produced better smile, better chewing/biting ability, positive influence on speech abilities, positive influence on self-confidence and positive influence on final esthetic profile. In this part the participant had to choose 1 answer from 5 options, where 1 is “Absolutely not”, 2- “I don't think so”, 3- “Neutral”, 4- “Yes, I think so”, 5- “yes, absolutely”. Later for the coding procedure, these options grouped into 3 groups where 1 is “No”, 2- “Neutral” and 3- “Yes”.

4.2.3 Questions regarding the retention period

The third part of the questionnaire included questions regarding the time in retention and type of retainer prescribed (Hawley, vacuum retainer, fixed upper, fixed lower). In this question the participants were instructed to choose all answers applied. Later the answers grouped into 4 groups- no retainer, removable retainer, fixed retainer, removable+ fixed retainers. In this part, the participants who did not use removable retainer were instructed to skip to the next part of the questionnaire. The participants who used removable retainer were asked about how often they were instructed to wear the removable retainer at night, how often they wear or wearing currently the retainer and what are the reasons for non-compliance with orthodontist instructions.

4.2.4 Questions regarding the experience of relapse

The fourth part of the questionnaire focused on the experience of relapse after the orthodontic treatment. The participants were asked if they have recognized any changes in teeth alignment after the orthodontic treatment, for this question 5 possible choices were given: “No changes at all”, “might be”, “some small unnoticeable changes”, “noticeable changes” and “many noticeable changes”. These choices later grouped into 3: “No changes at all”, “Unnoticeable changes”, “Noticeable changes”. Question about how long after the orthodontic treatment the relapse appeared was given as an open question and the answers later grouped into 6 groups based on the most common answers: “I didn't have any changes”, ”After a month”, “After 6 month or less”, “After a year”, “After 3 years or less”, “More than 3 years”. In addition, the participants were asked if the

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11 relapse bothers them, if they had any follow up appointment and what is the reason (in their opinion) for the relapse.

4.2.5 Questions regarding patient long-term satisfaction with orthodontic treatment

The fifth part of the questionnaire included questions about patient satisfaction with current teeth alignment and if they would like to repeat the orthodontic treatment. For the question about satisfaction with the current teeth alignment, the participant had to choose 1 answer from 5 options, where 1 was “Very dissatisfied”, 2- “Dissatisfied”, 3- “Neutral”, 4- “Satisfied”, 5- “Very satisfied”. Later for the coding procedure, the answers grouped into 3 groups where 1 was “Dissatisfied”, 2- “Neutral”, 3- “Satisfied”.

The last question of the questionnaire was- “Would you like to repeat the orthodontic treatment?” the participant had to choose 1 answer from 5 options, where 1 was “Absolutely not”, 2- “I don't think so”, 3- “Neutral”, 4- “Yes, I think so”, 5- “yes, absolutely”. Later the answers grouped into 3 groups where 1 was “No”, 2- “Neutral”, 3- “Yes”.

4.3 Data analysis

Data were processed using MS Excel 2010 and analysed using IBM SPSS Statistics, version 20. The descriptive analysis included the calculation of the prevalence: categorical data were presented as percentages (%) and frequencies (n). Comparisons were done using the Chi-Square Test and Fisher's exact test. The statistical significance level was set at 95% (p<0.05).

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5. RESULTS

The results are presented according to the five parts of the questionnaire and the study tasks. All the 68 participants are international students from LSMU-MA-OF/MF who have received fixed orthodontic treatment not less than 1 year ago. Sociodemographic characteristics of the participants are shown in Table 1.

Table 1. The main sociodemographic characteristics of the study sample.

Characteristic n % Age 25 and below 41 60.3 26 and above 27 39.7 Sex Female 42 61.8 Male 26 38.2 Faculty Odontology 33 48.5 Medicine 35 51.5 Year of study 1 st year 8 11.8 2 nd year 11 16.2 3 rd year 8 11.8 4 th year 4 5.9 5 th year 23 33.8 6 th year 14 20.6 Nationality Israeli 41 60.3 Other nationality 27 39.7

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13 Table 2. Answers to questions regarding orthodontic treatment results

According to the answers presented in Table 2, most of the participants (83.8%; n=57) indicated that the orthodontic treatment produced better smile for them, 79.4% (n=54) indicated that the orthodontic correction had a positive influence on their self-confidence, 77.9% (n=53) indicated that they are satisfied about final esthetic profile. In the questions about the functional benefits of orthodontic treatment (improve chewing/biting/ speech abilities), most commonly, the participant choose “No” or “Neutral” as an answer. When we compared the answers with faculty, there was statistically significant difference (p=0.038) between the answers of medical and odontology students when they were asked if the orthodontic treatment improved their chewing/biting ability, when 51.5% (n=17) of odontology students and only 25.7% (n=9) of medical students answered "Yes".

The third part of the questionnaire is presented in Table 3.

Table 3. Answers to questions regarding retention period and type of retainer.

Question Responses N %

How many years ago were your braces removed? Between 1-5 16 37 15

23.5

Between 6-10 54.4

Between 11-15 22.1

Type of retainer prescribed No retainer

Removable retainer Fixed retainer Removable+fixed 1 18 11 38 1.5 26.5 16.2 55.9 Question Responses N %

Did the orthodontic treatment produced a better smile for you? No 6 5 57

8.8

Neutral 7.4

Yes 83.8

Did you feel that the orthodontic treatment has improve your chewing/biting ability? No Neutral Yes 16 26 26 28 25 15 11 3 54 9 6 53 23.5 38.2 38.2 Has the result of orthodontic treatment had a positive influence on your

speech ability?

Has the orthodontic correction of your teeth had a positive influence on your self-confidence?

How satisfied are you with your final esthetic profile?

No Neutral Yes No Neutral Yes Dissatisfied Neutral Satisfied 2 41. 36.8 22.1 16.2 4.4 79.4 13.2 8.8 77.9

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14 Most of the participants 54.4 % (n=37) removed their braces 6-10 years ago and received removable + fixed retainer 55.9 % (n=38). Eighteen (26.5%) of the participants received only removable retainer and 11 (16.2%) received only fixed (upper, lower or both).

It means that from 68 participants, 56 received removable retainer and were able to answer the questions regarding the compliance with orthodontist instructions (Table 4). The first task of this study was to evaluate the patient compliance with removable retainer and reasons for non-compliance.

Table 4. Answers to questions regarding patient compliance with orthodontist instruction

How often were you instructed to wear your retainer(s) at night? I don't remember Once a week Every other day

Every day My orthodontist told me I don't need

to wear it/them anymore 5 2 6 42 1 22 9 4 6 12 3 7.4 2.9 8.8 61.8 1.5

How often do you wear your retainer(s) at night? Never Once a month

Once a week Every other day

Every day My orthodontist told me I don’t have to wear it/them anymore 32.4 13.2 5.9 8.8 17.6 4.4

The answers show that most of the participants were instructed to wear their retainer(s) every night 61.8% (n=42) and that large number of the participants 32.4% (n=22) are not using their removable retainer any more. When we compared the results in relation to faculty and gender, we got no statistically significant results.

The reasons for non-compliance are demonstrated in the diagram below (Figure 1). In this question the participants were instructed to choose all the reasons applied for non-compliance with orthodontist instructions.

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15 Fig 1. The reasons for non-compliance with orthodontist instructions.

The most common reasons are “I forgot to wear it” (38.2%), “it is a hassle to wear”, “It makes it hard to talk” (20.6%) and “I don't like the way it feels” (19.1%).

The fourth part of the questionnaire focused on the experience of post-orthodontic treatment relapse (Table 5).

Table 5. Answers to questions regarding the experience of relapse.

There were any changes in the alignment of your teeth after the orthodontic treatment? No changes at all Small unnoticeable changes Noticeable changes 3 30 35 3 5 26 13 14 26 6 36 43 25 4.4 44.1 51.5

If there were changes, how long after your braces removed you recognized the changes in teeth alignment?

Did the changes in the alignment of your teeth bother you?

Did you have any follow up appointment after your braces removed?

After a month After 6 month or less

After a year After 3 years or less

More than 3 years

No Neutral Yes Yes No 4.4 7.4 38.2 19.1 20.6 38.2 8.8 52.9 63.2 36.8 4.4 19.1 38.2 20.6 11.8 12 20.6 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 I don't like the way it looks I don't like the way it feels I forgot to wear it It's just a hassle I lost my retainer My retainer doesn't fit anymore It makes it hard to talk p e r c e n tage Complaint

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16 Thirty five (51.5%) of the participants indicated that there were noticeable changes in teeth alignment after the braces were removed. Twenty six (38.2%) of participants who experience relapse, indicated that the relapse occurred a year after the braces removed.

The diagram (Figure 2) demonstrates the possible reasons (in patient's opinion) for the relapse. In this question the participant were instructed to choose all answers applied.

Fig 2. The possible reasons for relapse (in patient's opinion).

Many respondents indicated that possible reason for the relapse can be that they didn't wear the removable retainer as the orthodontist instructed 39.7% (n=27). Nineteen (27.9%) indicated that they have some habits that might have led to the relapse and 26.5% (n=18) thinks that the reason might be because the orthodontist didn't put fixed retainers for them. When we made a comparison between this question and the question about changes experienced in teeth alignment, we found that among the 27 participant who indicated that they didn't wear the removable retainer as the orthodontist instructed, 19 (70.3%) indicated that there were noticeable changes in teeth alignment. This relation was statistically significant (p=0.022). Among the 18 participant who thinks that the reason might be because the orthodontist didn't put fixed retainers for them, 15 (83.3%) indicated that there were noticeable changes in their teeth alignment, we found this relation to be statistically significant as well (p=0.005).

In order to evaluate the post-orthodontic treatment relapse depending on different retainers, we compared the type of retainer prescribed with the changes experienced in teeth alignment. The results are shown in Table 6.

39.7 26.5 27.9 5.9 0.0 10.0 20.0 30.0 40.0 50.0 I didn't wear my removable retainers as the orthodontist instructed me

The orthodontist didn't put fixed retainers

I have some habits that might be the cause of

the movement of my teeth

Problems with fixed retainer - fell off, not

properly put P e r c e n tage Possible reasons

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17 Table 6. Post-orthodontic treatment relapse depending on different retainers

Do you think that there were any changes in

the alignment of your teeth after the orthodontic treatment? Total No changes at all Small unnoticeable changes Noticeable changes

Type of retainer I didn't have any retainer n 0 1 0 1

% 0.0% 3.3% 0.0% 1.5% Removable retainer n 0 3 15 18 % 0.0% 10.0% 42.9% 26.5% Fixed retainer n 1 7 3 11 % 33.3% 23.3% 8.6% 16.2% Removable+Fixed n 2 19 17 38 % 66.7% 63.3% 48.6% 55.9% Total Count 3 30 35 68 % 100.0% 100.0% 100.0% 100.0%

From the 18 patients who received only removable retainer, 83.3% (n=15) reported to have noticeable changes in teeth alignment, this difference is statistically significant (p=0.005). From the 11 patients who received fixed retainer, only 3 (27.2%) reported to have noticeable changes. From the 38 patients who received both removable and fixed retainers, Nineteen (50%) reported to have small unnoticeable changes and 44.7% (n=17) reported to have noticeable changes.

The answers regarding patients satisfaction with teeth alignment and if they would like to repeat the orthodontic treatment are presented in Table 7.

Table 7. Patient long-term satisfaction with teeth alignment.

Most of the participants indicated that they are satisfied with current teeth alignment (51.5%; n=35) and do not want to repeat orthodontic treatment (54.4%; n=37).

In order to assess the long-term satisfaction rate among post orthodontic patients in relation to the experience of relapse and type of retainer, we made a comparison between the question about

Are you satisfied with your current teeth alignment?

Would you like to repeat the orthodontic treatment?

Dissatisfied Neutral Satisfied No Neutral Yes 19 14 35 37 3 28 27.9 20.6 51.5 54.4 4.4 41.2

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18 patient satisfaction with current teeth alignment and the question regarding the post-orthodontic treatment changes in teeth alignment. The results are presented in Table 8.

Table 8. The influence of relapse on long-term patient satisfaction.

Are you satisfy with the alignment of

your teeth?

Total

Dissatisfied Neutral Satisfied

Do you think that there were any changes in the alignment of your teeth after the orthodontic

treatment? No changes at all n 0 0 3 3 % 0.0% 0.0% 8.6% 4.4% Small unnoticeable changes n 2 4 24 30 % 10.5% 28.6% 68.6% 44.1% Noticeable changes n 17 10 8 35 % 89.5% 71.4% 22.9% 51.5% Total n 19 14 35 68 % 100.0% 100.0% 100.0% 100.0%

In the table we can see that from the 19 patients who are "Dissatisfied" with their current teeth alignment, 17 (89.5%) indicated that they have noticeable changes in teeth alignment (p<0.001). From the 35 patients who are "Satisfied" with their current teeth alignment, 24 (68.6%) indicated that they have unnoticeable changes in teeth alignment (p<0.001).

When we compared the type of retainer used to current patient satisfaction with teeth alignment (Table 9) we got statistically significant results.

Table 9. Comparison between type of retainer and patient long term satisfaction

Are you satisfy with the alignment of your teeth?

Total

Dissatisfied Neutral Satisfied

Type of retainer No retainer n 0 0 1 1 % 0.0% 0.0% 2.9% 1.5% Removable retainer n 9 5 4 18 % 47.4% 35.7% 11.4% 26.5% Fixed retainer n 3 0 8 11 % 15.8% 0.0% 22.9% 16.2% Removable+Fixed n 7 9 22 38 % 36.8% 64.3% 62.9% 55.9% Total n 19 14 35 68 % 100.0% 100.0% 100.0% 100.0%

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19 From the 18 participants who received removable retainer, 9 (50%) are "Dissatisfied" with current teeth alignment and only 4 (22%) chose "Satisfied"(p=0.012). From the 11 participant who received fixed retainer, 8 (72%) are "Satisfied" and only 3 (28%) are "Dissatisfied". From the 38 participants who received both fixed and removable retainers, 22 (58%) are "Satisfied" with current teeth alignment.

In addition, we compared this part of the questionnaire in relation to faculty and gender. When we compared these two questions with faculty, we found statistically significant difference in the question about the will to repeat the orthodontic treatment (Table 10).

Table 10. The will to repeat the orthodontic treatment- comparison with faculty.

Faculty Total

Odontology Medicine

Would you like to repeat the orthodontic treatment? No n 13 24 37 % 39.4% 68.6% 54.4% Neutral n 3 0 3 % 9.1% 0.0% 4.4% Yes n 17 11 28 % 51.5% 31.4% 41.2% Total n 33 35 68 % 100.0% 100.0% 100.0%

From the 33 odontology students, 17 (51.5%) would like to repeat the orthodontic treatment and from the 35 medical students only 11 (31.4%) would like to repeat the orthodontic treatment. This relation found to be statistically significant (p=0.018). The question about satisfaction with current teeth alignment found to be statistically insignificant when compared with faculty.

When we compared this two questions with gender, we found that from the 19 patient who are dissatisfied with teeth alignment, 16 (84.2%) were females and only 3 (15.8%) are males (p=0.018). The question about the will to repeat the orthodontic treatment found to be statistically insignificant when compared with gender.

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20

6. DISCUSSION

This study surveyed the opinions of 68 medical and odontology students who had completed fixed orthodontic treatment mostly 6-10 years ago. No attempt was made to determine the characteristics of the original malocclusions or any other treatment factors involved.

The first task of our study was to evaluate the patient compliance with removable retainer and reasons for non-compliance. While evaluating this task, we found some limitations, since most of the patient completed the orthodontic treatment 6-10 years ago, they did not use their removable retainer anymore. We believe that this is the reason why large number of the participant chose “Never” when asked about how often they are wearing their removable retainer. The main reasons for non-compliance with orthodontist instructions were forgetfulness and that it is hard to talk with the retainer. Other studies have found that the major reasons for non-compliance are discomfort (especially regarding Hawley retainer) and that the retainer does not fit anymore [3, 17].

The second task of the study was to evaluate the post-orthodontic treatment relapse depending on different retainers. We found statistically significant difference between the type of retainer prescribed and the experience of orthodontic relapse. Fifty percent of patients who received both fixed and removable retainers, reported to have small unnoticeable changes in teeth alignment and 44.7% reported to have noticeable changes, this high percentage can be related with the fact that when we grouped the answers, we didn’t pay attention if the fixed retainer is on both jaws. In most cases the patient received upper removable retainer and lower fixed. However, some recent studies shows that undesirable changes in tooth position have been reported even with fixed retainers in place [21-23]. Recent study by M. Wolf et al. [21] recommends a removable retainer in addition to a fixed retainer, especially in cases exhibiting transverse expansion of the mandible and pronounced overjet correction. Noticeable changes found to be related (p=0.005) with patients who received only removable retainer. Recent study found that not wearing a fixed retainer and years without retention are the only predictive factors that significantly increase the risk of alignment instability [24-25].

The third task of this study was to assess the long-term satisfaction rate among post orthodontic patients in relation to the experience of relapse and type of retainer. In order to evaluate it, we compared the patient satisfaction with current teeth alignment to the experience of relapse. Patients who indicated to have noticeable changes in teeth alignment were significantly more likely to be dissatisfied with teeth alignment in the long-term (p<0.001), accordingly, patients who indicated to

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21 have unnoticeable changes in teeth alignment were significantly more likely to be satisfied with teeth alignment in the long term (p<0.001). Similar studies concluded that from a long-term perspective, patient satisfaction is related to the stability of the orthodontic treatment results [18, 20]. This finding supports our claim that long-term patient satisfaction is related to the experience of relapse. When comparing patient satisfaction with type of retainer prescribed, we found that patient who received removable retainer are more likely to be dissatisfied with teeth alignment in the long-term (p=0.012) and patient who received both fixed and removable mostly showed satisfaction with teeth alignment (58%). Similar study [18] found that current satisfaction was highest for patients who received clear, invisible retainers (vacuum formed retainer). In our opinion, there is no single approach which is appropriate for all patients and that orthodontic retention decisions should be made with consideration of differences among individuals.

As a part of this study, we evaluated what in the patient's opinion can be the reasons for the changes in teeth alignment. Twenty seven (39.7%) indicated that possible reason for the relapse can be that they didn't wear their removable retainer as the orthodontist instructed. Among those 27 participant, 70.3% (n=19) indicated to have noticeable changes in teeth alignment. This difference was statistically significant (p=0.022). Nikolay et al. [18] presented similar findings; most of the patients who experience changes in teeth alignment following the orthodontic treatment referred those changes to factors under their own control such as not wearing the removable retainer. Patients who are incapable or unwilling to wear their retainers as prescribed must be prepared to accept that there will be relapse following orthodontic treatment.

The fourth task of our study was to compare the patient compliance with removable retainer and long-term patient satisfaction with orthodontic treatment in relation to gender. In our study sample the male-to-female ratio was almost 1:3. No statistically significant difference in compliance was observed between male and female subjects. However, there was statistically significant difference in the rate of satisfaction with current teeth alignment. From the 19 patient who are dissatisfied with teeth alignment, 16 are females and only 3 are males (p=0.018). Our assumption was that females are more concerned with esthetic appearance then males and our results matched the expectations. Accordingly, recent studies reported that women tend to be more interested in their smile esthetics than men, and female patients have been reported to be more critical with their dental appearance than male patients [26, 27].

The fifth task of our study was to compare the knowledge regarding the influence of orthodontic treatment on general wellbeing, the patient compliance with removable retainers and long-term patient satisfaction with orthodontic treatment among odontology and medical students. In our

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22 study sample, the odontology-to-medicine student's ratio was almost 1:1. There were statistically significant differences in the rate at which odontology students answered “Yes” when they asked if the orthodontic treatment improved their chewing/biting ability (p=0.038). There was 51.5% (n=17) of odontology student and only 25.7% (n=9) of medicine answered “Yes”. In our opinion, this results is related to the fact that odontology students have more knowledge regarding orthodontics and the awareness of the effects of occlusion on general wellbeing. Adegbite, et al. [28] made a study aiming to assess the knowledge of orthodontics and the awareness of the effects of malocclusion on the general wellbeing, among medical students. They concluded that medical students have limited knowledge of orthodontics as a specialty.

Another hypothesis of this study was that odontology students concern more about dental esthetic then laypersons. The only evidence we found to confirm our hypothesis is that from the 33 odontology students, 17 (51.5%) would like to repeat the orthodontic treatment and from the 35 medicine students only 11 (31.4%) would like to repeat the orthodontic treatment. This difference found to be statistically significant (p=0.018). Other studies compared the perception of smile aesthetics between dental and non-dental students and found that dental students are generally more receptive to smile alterations [29]. When evaluating the patient compliance with removable retainer we expected to get more compliance with orthodontist instructions among the odontology student but we got no statistically significant results.

This study has several limitations that need to be taken into account when interpreting its results. First, our questionnaire evaluated the relapse depending on different retention methods according to the patient opinion. Use of other instruments and objective clinical examinations would have created a better opportunity to understand which retention methods would have the lowest risk for relapse and provide long term patient satisfaction. Another limitation is that our sample was relatively small, this is the reason we had to group some answers to larger groups such as the retainer type which we grouped into removable, fixed, removable+ fixed. Future studies should evaluate the specific retainer type (Hawley, vacuum form and upper/ lower fixed) influence on dental alignment changes after the orthodontic treatment.

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23

7. CONCLUSIONS

 The main reasons for non-compliance with orthodontist instructions were forgetfulness and discomfort.

 Post-orthodontic treatment relapse is associated more with removable retainer than fixed retainer.

 Long-term patient satisfaction is strongly related to the experience of relapse. In addition, patients who have received only removable retainer are more likely to be dissatisfied with teeth alignment in the long term.

 Female patients are more concerned about their dental appearance then male patients.

 Odontology students concerned more about their dental appearance then medical students. In addition, odontology students have more knowledge than medical students regarding orthodontics and the awareness of the effects of occlusion on general wellbeing.

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24

8. PRACTICAL RECOMMENDATIONS

 We believe that the best way to achieve long-term patient satisfaction is to provide an appropriate retention plan with agreement from both the orthodontist and the patient so that the patient is informed of the options available and is motivated to cooperate with orthodontist instructions and to share responsibility. This informed consent process should be done prior to orthodontic treatment. As part of the informed consent, patients need to be fully aware of their responsibility to wear their removable retainers in order to reduce the chance of relapse. It is the clinician’s responsibility to ensure that patients are well instructed regarding the use and the care of their retainers. If patients are incapable or unwilling to cooperate with orthodontist instructions, they must be prepared to accept that there will be relapse following treatment.

 In light of the findings in this study, we concluded that medical students would benefit from basic introduction to the dental sub-specialties, especially in orthodontics. This should improve their ability to refer and manage patients appropriately.

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25

9. REFERENCES

1. Bondemark L, Holm A-K, Hansen K, Axelsson S, Mohlin B, Brattstrom V. Long-term Stability of Orthodontic Treatment and Patient Satisfaction. Angle Orthod. 2007;77(1).

2. Al Yami EA, Kuijpers-Jagtman AM, van’t Hof MA. Stability of orthodontic treatment outcome: follow-up until 10 years postretention. Am J Orthod Dentofacial Orthop. 1999;115: 300–304. 3. Pratt MC1, Kluemper GT, Lindstrom AF.Patient compliance with orthodontic retainers in the

postretention phase. Am J Orthod Dentofacial Orthop. 2011;140:196-201

4. Melrose C, Millett DT. Toward a perspective on orthodontic retention? Am J Orthod Dentofacial Orthop 1998;113:507-14.

5. Thilander B. Orthodontic relapse versus natural development. Am J Orthod Dentofacial Orthop, 2000;117:562-3.

6. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures

for stabilising tooth position after treatment with orthodontic braces. Cochrane Database Syst Rev 2016; (1).

7. Al-Moghrabi D, Salazar FC, Pandis N, Fleming PS. Compliance with removable orthodontic appliances and adjuncts: A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2017; 152: 17-32. doi: 10.1016/j.ajodo.2017.03.019.

8. Littlewood SJ, Kandasamy S, Huangk G. Retention and relapse in clinical practice. Aust Dent J. 2017; 62: 51–57

9. Littlewood SJ, Russell JS, Spencer RS. Why do orthodontic cases relapse? Orthod Updat. 2009;2:43–49.

10. De La Cruz A, Little RM, Sampson P, _Artun J, Shapiro PA. Long-term changes in arch form after orthodontic treatment and retention. Am J Orthod Dentofac Orthop 1995;107:518–530. 11. Stanaitytė R, Trakinienė G, Gervickas A. Do wisdom teeth induce lower anterior teeth

crowding ? Stomatologija, Baltic Dent Maxillofac J. 2014;16(1):15–8.

12. Johnston CD, Littlewood SJ. Retention in orthodontics. Br Dent J. 2015;218(3):119–22.

13. Mai W, He J, Meng H, Jiang Y, Huang C, Li M, Yuan K, Kang N. Comparison of vacuum-formed and Hawley retainers: a systematic review. Am J Orthod Dentofacial Orthop 2014; 145: 720–727.

14. Shawesh M, Bhatti B, Usmani T, Mandall N. Hawley retainers full or part time? A randomized clinical trial. Eur J Orthod 2010;32:165–170.

15. Thickett E, Power S. A randomized clinical trial of thermoplastic retainer wear. Eur J Orthod 2010;32:1–5.

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26 16. Singh P, Grammati S, Kirschen R. Orthodontic retention patterns in the United Kingdom. J

Orthod. 2009;36(2):115–21.

17. Wong P, Freer TJ. Patients’ attitudes towards compliance with retainer wear. Aust Orthod J 2005;21:45-53.

18. Mollov ND, Lindauer SJ, Best AM, Shroff B, Tufekci E. Patient attitudes toward retention and perceptions of treatment success. Angle Orthod. 2010;80(4):468–73

19. Pachêco-Pereira C, Pereira JR, Dick BD, Perez A, Flores-Mir C. Factors associated with patient and parent satisfaction after orthodontic treatment: A systematic review. Am J Orthod Dentofac Orthop. 2015;148(4):652–9.

20. Maia NG, Normando D, Maia FA, Ferreira MA, do Socorro Costa Feitosa Alves M. Factors associated with long-term patient satisfaction. Angle Orthod 2010;80:1155-8.

21. Wolf M, Schulte U, Küpper K, Bourauel C, Keilig L, Papageorgiou SN, et al. Post-treatment changes in permanent retention . J Orofac Orthop 2016;77(6):446–53.

22. Atack N, Harradine N, Sandy JR, Ireland AJ. Which way forward? Fixed or removable lower retainers. Angle Orthod. 2007;77(6):954–9.

23. Andriekute A, Vasiliauskas A, Sidlauskas A. A survey of protocols and trends in orthodontic retention. Prog Orthod. 2017;18:31.

24. De Bernabé PGG, Montiel-Company JM, Paredes-Gallardo V, Gandía-Franco JL, Bellot-Arcís C. Orthodontic treatment stability predictors: A retrospective longitudinal study. Angle Orthod. 2017;87(2):223–229.

25. Bjering R, Birkeland K, Vandevska-Radunovic V. Anterior tooth alignment: A comparison of orthodontic retention regimens 5 years posttreatment. Angle Orthod. 2015;85(3):353–9.

26. Tin-Oo MM, Saddki N, Hassan N. Factors influencing patient satisfaction with dental appearance and treatments they desire to improve aesthetics. BMC Oral Health. 2011;11:6.

27. Armalaite J, Jarutiene M, Vasiliauskas A, Sidlauskas A, Svalkauskiene V. Smile aesthetics as perceived by dental students : a cross-sectional study. BMC Oral Health. 2018; 18: 225.

28. Adegbite KO, Ogunbanjo BO, Ajisafe OA, Adeniyi AA. Knowledge of orthodontics as a dental specialty:A preliminary survey among LASUCOM students. Ann Med Health Sci Res 2012;2:14-8.

29. Omar H, Tai YT. Perception of smile esthetics among dental and non-dental students. J Educ Ethics Dent 2014;4:54-60.

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10. ANNEXES

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28 Annex 2: The questionnaire

My name is Sapir Argaman, I am a 5th year student of odontology faculty in LSMU and I am performing a

study evaluating the patient compliance with removable retainers, post orthodontic treatment relapse depending on different retainers and patient satisfaction with orthodontic treatment. This questionnaire is anonymous and meant only for patients who have received orthodontic treatment. I reassure, that answers and collected data is confidential, used exclusively for the purpose of this study.

Please answer these questions by putting a tick (X) in the appropriate box for each question. For example- 1. Age:  Below 20  20-25  26-30  30 and above 2. Sex:  Female  Male 3. Faculty:  Odontology  Medicine 4. Year of Study:  1st_year  2nd_year  3rd year  4th year  5th year  6th year 5. Nationality: ___________

6. How many years did you wear orthodontic appliances? ( tick the box that best match)

 4 years  3.5 years  3 years  2.5 years  2 years  1.5 years  1 year  6 month  3 month  1 month  Don't know

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29 In each case, you will be asked to choose the box that best describes your feeling or opinion.

For example-

1

No, absolutely not

2

No, I don't think so

3 Neutral 4 Yes, I think so 5 Yes, absolutely

7. Did the orthodontic treatment straighten your teeth?

1

No, absolutely not

2

8. Did the orthodontic treatment produced a better smile for you?

1

No, absolutely not

2

9. Did you feel that the orthodontic treatment has improved your chewing/biting ability?

1

No, absolutely not

2

10. Has the result of orthodontic treatment had a positive influence on your speech ability?

1

No, absolutely not

2

11. Has the result of orthodontic treatment had a positive influence on finding mate and/or career?

1

No, absolutely not

2

12. Has the result of orthodontic treatment had a positive influence on the performance of your work or school?

1

No, absolutely not

2

13. Has the orthodontic correction of your teeth had a positive influence on your self-confidence?

1

No, absolutely not

2

14. How satisfied are you with your final esthetic profile?

15. If you are not satisfied with your final esthetic profile, what is the reason?

 I have a protruded maxilla

 I have a retruded mandibulla

 Both

 I have a facial asymmetry

 Esthetic position of my lips is not satisfactory

 Other

16. How satisfied are you with your final smile esthetic?

1 Very dissatisfied 2 Dissatisfied 3 Neutral 4 Satisfied 5 Very satisfied

17. How satisfied are you with your general facial appearance?

1 Very dissatisfied 2 Dissatisfied 3 Neutral 4 Satisfied 5 Very satisfied 1 Very dissatisfied 2 Dissatisfied 3 Neutral 4 Satisfied 5 Very satisfied

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18. How many years ago were your braces removed? (Approximate if you cannot remember):___________ 19. Type of retainer prescribed (choose all that apply):

 Plastic with metal wire across the front teeth

 All, clear plastic with no wires

 Lower fixed retainers

 Upper fixed retainers

If you didn't have any removable retainer, you can skip to question 23

20. How often were you instructed to wear your retainer(s) at night? (Choose all that apply)

 I don't remember

 My orthodontist never told me how often to wear it

 Once a month

 Once a week

 Every other day

 Every Day

 My orthodontists told me I don't have to wear it/them anymore

 Other________________________

21. How often do you wear your retainer(s) at night?

 Never If so, how long ago did you quit wearing it/ them? ________

 Once a month

 Once a week

 Every other day

 Every day

 My orthodontists told me I don't have to wear it/them anymore

 Other________________

22. If you are not wearing your retainers as often as you were instructed, which of the following reasons contribute to this difference? (Choose all apply)

 I don't like the way it looks

 I don't like the way it feels

 I forgot to wear it

 It's just a hassle to wear

 I lost my retainer

 My retainer doesn't fit anymore

 It makes it hard to talk

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31

23. There were any changes in the alignment of your teeth after the orthodontic treatment?

1 No changes at all 2 Might be 3 Some small unnoticeable changes 4 Noticeable changes 5 Many noticeable changes

If there were changes, how long after your braces removed you recognized the changes in teeth alignment? (Approximately if you don't remember)___________________________

24. Did the changes in the alignment of your teeth bother you?

1

No, absolutely not

2

25. Did you go to your orthodontist and tell him/her about the changes in teeth position after you recognized the changes?

 YES

 NO

If no, why?

 I didn't have time

 I didn't want to wear brackets again

 Financial considerations

 Other____________________________________________________________________

26. Did you have any follow up appointment after your braces removed?

 YES

 NO

27. In your opinion, what was the reason for the changes in teeth arrangement? (Choose all apply)

 I didn’t wear my removable retainers as the orthodontist instructed me

 The orthodontist didn't put fixed retainers (splints)

 I have some habits that might be the cause of the movement of my teeth (tongue trusting, mouth breathing, finger sucking)

 Others_____________________________________________________________________

28. Are you satisfied with your current teeth alignment?

1 Very dissatisfied 2 Dissatisfied 3 Neutral 4 Satisfied 5 Very satisfied

29. Do you think that you need to repeat the orthodontic treatment?

1

No, absolutely not

2

3 Neutral 4 Yes, I think so 5 Yes, absolutely 30. Would you like to repeat the orthodontic treatment?

1

No, absolutely not

2

POST-ORTHODONTIC TREATMENT RELAPSE DEPENDING ON DIFFERENT RETAINERS AND ITS RELATION TO LONG-TERM PATIENT SATISFACTION

Sapir Argaman