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The Practice Building BULLETINThe Practice Building BULLETINThe Practice Building BULLETIN VOLUME IVISSUE XXV

Serial Extractions with Appliance Therapy AfterwardsNon-Extraction Treatment with General SpacingLower Incisor ExtractionEarly Extractions vs. Late Extrac-tions Non-Extraction with Rapid Palatal Expansion TreatmentNon-Extraction TreatmentExtraction TreatmentExtraction vs. Non-Extraction Treatment

Many studies have been performed to ascertain if there is a better way to move teeth that will reduce post-orthodontic relapse. They have looked at every causative factor. I have included a table of topics that have been reviewed. For more de-tail please review Dr. Florman’s ar-ticle.

The truth is “Relapse happens”, and it may have very little to do with the dentist’s treatment mechanics or plan.

Despite recommended measures to decrease the chances of relapse, nothing definitive has been devel-oped. Permanent retention appears to be the only reliable way to keep the dental arches in a position simi-lar to that in which they were the day after the patient’s braces were removed However, prevention of dental relapse is possible if an in-terdisciplinary approach is devel-oped.---FLORMAN

» THE PROBLEM AND THE SOLUTION:

The problem is Orthodontic practic-es in this country are not geared to track patients for more than a year or

» PRACTICE POTENTIAL:

I have now been in practice for over twenty years. Over this period so many patients come through my of-fice that have had orthodontic care when they were younger and did not wear their retainers. Others have never had any orthodontic treatment but complain that their lower teeth are beginning to become crowded. They walk into the office and say doctor can’t you just fix this. This lower tooth never used to be this way.

It made me wonder what is being done to keep patients’ teeth straight after they finish orthodontic treat-ment? What should be done to keep patients’ teeth straight that have nev-er had orthodontic treatment? And whose responsibility is it to provide retention care to our patients?

» DESCRIPTION:(Relapse and Retention)

Factors that have been evaluated for their possible effect on Relapse

Development and AgingSkeletal ChangesSoft-Tissue ChangesDentoalveolar ChangesMuscle Balance/Soft-tissue Forces/HabitsThe position of the teeth. Occlusal Factors and ForcesPeriodontium

TABLE FORMATArch Length and WidthCurve of SpeeGenderSeverity of MalocclusionMandibular Incisor Dimensions and PositionSerial Extractions with No Appli-ance Therapy

two after treatment at best. The ma-jority of these practices are efficient at treating patients and getting them into retention but do not continue to monitor them over their lifetime. Most orthodontic patients graduate high school, move away to college, and lose touch with their orthodon-tist. The general dental practice is the only line of defense that exists to provide the retention services needed indefinitely. The orthodon-tist is usually not seen again until a problem returns, and this patient is being referred back for re-treatment. Therefore responsibility for evalu-ating a patient’s post-orthodontic occlusion should lie in the hands of the dentists and the hygienists who will care for them for the rest of their lives. Unfortunately most general dentists have been given so little orthodontic training that they follow the ”Don’t ask don’t tell” philosophy of treatment. That is to say the majority of dentists do not even ask their patients if they have previously had orthodontics done!

This is a huge disservice especially when patients spend thousands of dollars and years of their lives to get straight teeth. The least we could do is to become part of the process to help them maintain their beautiful smile.

» DISCUSSION

Treatment ProceduresEvaluate every patient thatAdd an Orthodontic screening form to your record packetEvaluate your new patients Evaluate your old patientsPatients who are no longer under the care of the orthodontistPatients who may still be under the

The Final Retainer

The Practice Building BULLETINThe Practice Building BULLETINb. Do you wear retainers?

c. Do you see your orthodontist to have them adjusted?

d. Do you know that indefinite re-tention is necessary?

An oral examination needs to be performed to evaluate the dentition for relapse, beginning with the low-er incisors.

5. Dental professionals need to be-gin offering retainers to their pa-tients, regardless of whether they have had braces or not. If patients need bruxing appliances, combina-tion splint-retainers can be fabricat-ed for the lower jaw.

The general dentist needs to take advantage of this opportunity to not only provide their patients with an invaluable service but to establish a new income stream for their prac-tice. We have committed our lives to the practice of dentistry and the principles of ethics, which were founded on the basis of non malefi-cence. We counsel our patients on brushing, flossing, smoking ces-sation, effects of tobacco and oral cancer, bruxing, and sleep disor-ders. Why has the importance of orthodontic relapse slipped through the cracks? We all must continue the campaign on educating our peers and patients to the importance of retention. I hope this article will be a catalyst for all dentists and hy-gienists as our profession continues to evolve.

Patients come into our offices trust-ing that we will give them a straight smile. They spend thousands of dol-lars and years of their lives await-ing straight teeth. We make them retainers, tell them to wear them, and send them on their way. The majority of these patients eventu-ally discontinue their retention and receive no guidance or support from the dental community. Although we blame the patients for not wearing their retainers after the fact, should we continue to pretend that is all their fault?

To that end I would like to make the following recommendations to help establish an ideal a system where patients are being evaluated for their retention needs:

1. Inform- Dentists, hygienists, and orthodontists need to inform pa-tients that retention should be indef-inite regardless of the pre-existing malocclusion, the treatment modal-ity, or length of time they were in treatment. Because we have no way of determining who will develop lower crowding relapse, the retainer will act as insurance indefinitely.

2. Informed Consent- Orthodon-tists need to incorporate a statement regarding indefinite retention into their pretreatment informed con-sent documents and remind patients at the end of orthodontic treatment that indefinite retention is a must even when they leave the orthodon-tists care and return to the care of their general dentist.

3. Retention program-Dental prac-titioners need to develop a regular post-orthodontic retention program. Fee structures need to be developed to accommodate retention needs, including a retainer exam fee, a re-tainer adjustment fee, a retainer re-placement fee, and, if needed, lim-ited re-treatment fees.

4. Examinations- Practitioners need to perform “retention relapse ex-aminations” similar to providing their patients with an oral cancer screening. This is easily done at the regularly scheduled prophy exam. Discussing orthodontic retention with patients should be no different than discussing brushing and floss-ing regimens. The exam can begin with some simple questions:

a. Have you had orthodontic treat-ment?

b. Do you wear retainers?

c. Do you see your orthodontist to have them adjusted?

care of the orthodontistDiscussing optionsExamination RecordsDiagnostic casts before records should be kept photosRecallPatient instructions

» TREATMENT PROCEDURES:

Discussing orthodontic retention with patients should be no different than discussing brushing and floss-ing regimens. Preventing relapse is possible. I recommend the follow-ing:

1. Dentists, hygienists, and ortho-dontists need to inform patients that retention should be indefinite regardless of the pre-existing mal-occlusion, the treatment modality, or length of time they were in treat-ment. Because we have no way of determining who will develop lower crowding relapse, the retainer will act as insurance indefinitely.

2. Dental practitioners need to in-corporate a statement regarding in-definite retention into their pretreat-ment informed consent documents and remind patients at the end of orthodontic treatment that indefi-nite retention is a must.

3. Dental practitioners need to de-velop a regular post-orthodontic retention program. Fee structures need to be developed to accom-modate retention needs, including a retainer exam fee, a retainer ad-justment fee, a retainer replacement fee, and, if needed, limited re-treat-ment fees.

4. Practitioners need to perform “re-tention relapse examinations” simi-lar to providing their patients with an oral cancer screening. This is easily done at the regularly sched-uled prophy exam. The exam can begin with some simple questions:

a. Have you had orthodontic treat-ment?

The Practice Building BULLETINThe Practice Building BULLETINd. Do you know that indefinite

retention is necessary?

5. Prevention- Dental professionals need to begin offering retainers to their patients, regardless of whether they have had braces or not when it is necessary. If patients need brux-ing appliances, a combination up-per splint and lower retainers can be fabricated.

» THE APPLIANCES:

Appliance therapy design worksheet - Describe how and why to use it

1115 Open Palate Retainer

This appliance is designed primari-ly as a final retainer to be used at the completion of any orthodontic ther-apy. The area over the hard palate has been left free of acrylic. Speech is left virtually unaffected and there is no danger of the patient develop-ing a deviated swallowing pattern as the tongue never loses its’ natu-ral contact wit the hard palate. The ribbon of acrylic that is contacting the lingual of the anteriors is re-en-forced with Kevlar in order reduce the possibility of fracture. Adams clasps are used because they stay retentive over time. Both the clasps and the labial bow must be designed to stay out of occlusion to prevent any unwanted tooth movement.

Note- Please always send both up-per and lower casts along with a bite relationship to the lab for fab-rication of this appliance.

1161 Maxillary Final Retainer

Whether you are actively doing or-thodontics or not, every dentist at

one time in there career has had to replace a patients retainer. There are many different appliance de-signs and variations but this is the basic retaining appliance. It fea-tures Adam’s clasps on the first mo-lars and a standard, tightly adapted “Hawley” type labial archwire run-ning from the distal of both cuspids. The acrylic should be well adapted to the palate and the lingual aspect of the teeth. Every effort should also

be made to keep it thin for comfort.


1162 Simple Mandibular Retain-er

Shown here is a basic lower ap-pliance with standard a standard “Hawley” type labial archwire. Mo-lar rests are placed on the molars for posterior stability and to keep the appliance from over-seating into the tissue. Clasps are optional, the most commonly requested clasps are Ad-ams Clasps as illustrated in the in-sert photo. Please be very specific as to your design preferences when requesting this appliance.


Labial Arch Wire Options:

Several different designs are avail-able for the labial wire portion of these retainers. Detailed descrip-tion and applications of the most common ones are listed here and are described in greater detail in

Chapter 1.

1. Standard Arch: Image 1616A

Get copy from original Chapter 1

2. Round Contoured: Image 1616B

The Practice Building BULLETINThe Practice Building BULLETINGet copy from original Chapter 1

3. Flat Hawley: Image 1616C

A Flat wire is used to contact the labial surface of the anterior teeth and is soldered to the adjustment loops at the cuspids. The Flat Wire is contoured back to the distal of the cuspids and affords added retention to stabilize the cuspids after move-ment.

4. Flat “Contoured” Hawley: Im-age 1616D

Similar to the Flat Hawley, this wire is individually contoured to the en-tire labial and interproximal surfac-es of the incisors.

5. Plastic “Coated” Hawley: Im-age 1616E

This Labial wire is preferred on re-tainers when the anterior teeth are restored with veneers. The Plastic coating protects the porcelain sur-

faces from possible abrasion from the wire.

6. Acrylic Arch: Image 1616F

This wire gains superior anterior retention through the use of clear acrylic that tightly conforms to the labial and interproximal surfaces of the incisors. This prohibits move-ment, and particularly rotation, of the incisors and is often used on “Wrap Around” labial wires to aid stability.

7. Reverse Hawley: Image 1616G

The Reverse Hawley is fabricated with the adjustment loop running from the distal to the mesial. This labial wire is excellent when you do not want any wire on the distal of the cuspids. A typically scenario re-quiring this design is when positive cuspid control is needed, particu-larly if the cuspid has been rotated significantly during orthodontic therapy.

8. Ricketts Arch: Image 1616H

The Ricketts Arch, like the Re-verse Hawley, crosses the dentition through the embrasures interproxi-mal to the laterals and cuspids. The

“U” Loops are placed on the laterals and the distal recurved arms are con-toured to the cuspids. These distal recurves can be used to increase re-tention as well as help stabilize cus-pids that may have required rotation during active treatment. If carefully activated, they can be used to effect minor lingual rotation of the cus-pids, unilaterally or bilaterally.

9. Witzig Double Loop: Image 1616I

This design is a modification of the Ricketts arch using a narrow verti-cal loop. This design is excellent for final stability of the anterior seg-ment but only allows for very minor adjustments during retention. It is typically used only when a remov-able final retainer is preferred after completion of orthodontic therapy.

The Practice Building BULLETINThe Practice Building BULLETIN10. Apron Spring Labial – (“Roberts Retraction Arch) Image 1616J


11. Wrap Around: Image 1616K


1165 The San Antonio Retainer

Named for the Texas Study Club that first described it, this retainer has many special features worthy of consideration.

The labial arch wire extends from molar to molar for excellent reten-tion and control of the entire arch. Since it does not pass over the oc-clusal surface, there is no occlusal interference to prevent proper func-tion. To stabilize the labial, two small interproximal support wires pass from the acrylic and wrap around the arch wire between the cuspids and the laterals. Also note the extended arms to the cuspids to provide support and prevent rota-tion.

Usually “C” clasps are used distal of the 12-year molar for retention of the appliance. These are preferred in order to prevent any occlusal in-terference. If retention is a problem due to buccal crown contour it is advisable to place a small compos-ite ledge on the molars to create a retentive undercut for the clasp.

Finally, a thin, heat-cured acrylic base is used for strength and com-fort. During finishing, extra care must be taken to be sure that the acrylic is in contact with the entire lingual surface of each tooth.


1169A Wrap-Around Retainer – with labial acrylic support

Often, due to the long span of the la-bial archwire in the “wrap-around” design, the labial wire has a great deal of flex and can come out of ad-justment if the appliance is handled roughly. To help alleviate this prob-lem, and to add stability and reten-tion to the anteriors, clear acrylic is processed tightly against the labial surface of the incisors as illustrated. This feature adds superior retention to the overall appliance and elimi-nates the need for a small inter-proximal support wire distal to the lateral incisors as seen in the San Antonio design.

1065 The Spring Hawley Retain-er

This appliance is useful in correct-ing minor rotations and crowding up to 1-1/2mm from cuspid to cus-pid in the lower anteriors. The space necessary to correct this crowding is gained by judicious interproxi-mal recontouring in the anterior re-gion only, as the appliance is NOT designed to gain any arch width or

length.

Before fabricating the appliance, the lab will separate the rotated and crowded anteriors from the stone cast and reset them in an ideal align-ment. The appliance is then fabricat-ed to this corrected anterior position and sent back to you for delivery. On the day of delivery complete the necessary interproximal recontour-ing, then place the appliance. When worn, the spring action of the cus-pid wires will direct a light labial-lingual force to align the teeth.

Once the teeth are straight the ap-pliance can continue to be worn as a final retainer.

Note – Since tooth movement is in a labial-lingual direction, adequate vertical dimension is essential. If the patient has a closed vertical and the upper and lower anteriors are already in contact tooth movement will not occur.

AA- show the basic set up that the lab does and the inter-proximal re-contouring that the doctor needs to accomplish

1331 Modified Spring Retainer U/L

This design is useful for correcting minor rotations of the upper anteri-or teeth. The teeth are set-up in the corrected position on the model and then the appliance is constructed. Complete the necessary interproxi-mal recontouring on the day of de-livery. When in place, the resulting labial-lingual force will align the teeth. The helical coil in the labial wire portion, and the “mushroom”

The Practice Building BULLETINThe Practice Building BULLETINhelical coil spring design of the ac-tive lingual component, make this appliance very effective for quickly aligning the incisors.

Adequate space for alignment of the anteriors is essential and this design will NOT gain arch width or length. The appliance may also be used as a final positioning retainer but is not recommended for closing spaces.

1332 Modified Adaptor™

The Modified Adaptortm appliance is used for minor tooth rotations and alignments of both the poste-rior and anterior teeth. It works like the spring retainer in that the teeth on the working model are carefully placed in their ideal position prior to fabricating the appliance.

This unique design features a solid lingual acrylic base that is tightly contoured to all of the lingual sur-faces. The buccal posterior segments are joined to the lingual via stain-less steel wires and the labial por-tion covering the six anterior teeth is joined to the posterior segments via stainless steel Omega Loops in the cuspid/bicuspid region.

Once seated, this highly flexible appliance gently settles the teeth in the correct alignment. Since the Modified Adaptor™ allows for full occlusal contact of the posterior teeth, natural function aids in a rap-id and secure settling in of the buc-cal segments. Unlike a Positioner, it is extremely comfortable, virtually undetectable, and can be worn full time, except while eating.

Please note however, that it is es-

sentially a finishing retainer and no significant rotations, or mesial/dis-tal movements should be attempted with this design.

1164 RAM Retainer (designed by Dr. Robert A. Meese)

The RAM final retainer adds a twist to the wrap around designs seen in other final retainers. First there are no clasps or support wires cross-ing the occlusion. Then by using a sliding labial bow a small amount of space closure and retraction can be accomplished. The sliding labial consists of a .010 X .022 wire that runs through tubes placed buccal to the first bicuspid region. Bilateral elastics are then placed from hooks at the distal end of the labial wire to hooks in the molar region that are on the distal support wires.

Note - A positive overjet is neces-sary if lingual retraction is required for the space closure.

1076F Bloore Aligner U/L

After completing orthodontic thera-py it is not uncommon for patients to experience a small amount of relapse crowding in their upper or lower incisors. This is especially true when they have not been dili-

gent in wearing their final retainers. When this happens patients often prefer to have this corrected with-out having to wear brackets again. The Bloore Aligner is excellent for this purpose. Springs called eyelet arms are placed lingual to each in-cisor and individually activated to move the teeth into alignment. As needed interproximal reductions and incisal re-contouring are uti-lized to gain room and provide an esthetic result.

Note - When used on the lower arch, it is important to make sure that the incisors are not coupling with the lingual of the uppers prior to initi-ating treatment as vertical and AP clearance are required in order to successfully correct the lower an-teriors. Once the anteriors are re-aligned, it is recommended to con-sider using a fixed lingual retainer for final retention.

AA – Activating the eyelet arms

1116 The “Invisible” Retainer

Here is popular retainer design for the extremely appearance con-scious patient. It is fabricated from a thin sheet of clear acrylic that is vacuum-formed to the occlusal and incisal surfaces of the entire arch. The completed appliance typically extends over the buccal and labial surfaces, and is typically finished just short of the gingival margins on the labial and buccal surfaces. On the upper appliance, the palate is horseshoed for patient comfort.

Note- These retainers are quite thin and are contra-indicated for anyone

The Practice Building BULLETINThe Practice Building BULLETINwho bruxes their teeth. Also, the pa-tient needs to be instructed on the gentle care required for this appli-ance.

2164 Three to Three Fixed Band-ed Retainer

Shown here is a cuspid to cuspid, stainless steel banded, lingual re-tainer which can be made either from your preformed bands or from our own custom fit bands. The lin-gual wire is carefully adapted to be in direct contact with the lingual surfaces of each anterior tooth and is typically placed 2mm below the incisal edge. Important note- Although this is one of the most common designs used to maintain lower anteriors after orthodontic treatment, it is no longer considered adequate. Recent research shows that it is necessary to bond each tooth individually to maintain them in their corrected po-sition.

AA- On all fixed banded appliances Space Maintainers will fabricate custom bands unless you prefer to use your own preformed bands. When sending your own bands, please do not pour them up in the impression. Take the impression

without the bands in place and at-

tach them to the prescription slip. We will reseat your bands on the model and guarantee you a better fit.

AA – Cementation.

2166 – Banded 4x4 Retainer U/L

Many clinicians recommend includ-ing the first bicuspids in all fixed re-tainers. This is especially true when significant orthodontic movements have been necessary to achieve the desired final results. The lingual wire is carefully adapted to be in direct contact with the lingual sur-faces of each anterior tooth and is typically placed 2mm below the in-cisal edge.

Important note- Recent research shows that it is necessary to bond each tooth individually to maintain them in their corrected position. Individual anterior teeth can be se-cured to the lingual wire by simply adding composite over the lingual wire.

2165 Direct Bond Fixed Retain-er

This appliance is bonded to the lin-gual of the cuspids by the use of custom contoured, direct bond pads. These pads have a metal-mesh back-ing for superior retention. The lin-gual wire is carefully contoured and routinely placed 2mm below the incisal edges unless prescribed oth-erwise. Additionally, many choose to add the first bicuspids into the retentive unit as illustrated in the inserted photo.

Important note- Although this is one of the most common designs used to

maintain anteriors after orthodontic treatment, it is no longer considered

adequate. Recent research shows that it is necessary to bond each tooth individually to maintain them in their corrected position.

AA- bonding the retainer into place

2212 E-Z Bond Lingual Retainer

The E-Z Bond Retainer is a multi-strand, dead soft, wire that is care-fully contoured to the lingual of the six anterior teeth and is light-cured with composite to each of the six anterior teeth.

The key advantage to this appli-ance is use of a laboratory fabricat-ed transfer tray that makes correct placement of the wire easy with a minimum of chair time.

The transfer tray has small reser-voirs at each bonding site with an excess material escape channel di-rectly lingual to each of the anterior teeth. This assures a complete wrap of bonding cement around the lin-gual wire.

To place the appliance, the reser-voirs are filled with composite by use of a syringe. The tray is then gently seated by finger pressure, allowing any excess composite to flow out of the escape channels. Then it is light cured.

After curing the material, any excess cement is removed from the tray with a high speed hand piece and a diamond. Then the tray is slowly and carefully lifted off of the teeth. The top of the individual composite

The Practice Building BULLETINThe Practice Building BULLETINbuttons can then be polished for pa-tient comfort with a composite dia-mond or disc.

Complete, step by step, chairside instructions are provided with your first E-Z Bond Retainer.

NOTE: When requesting an E-Z Bond Retainer for the maxillary anteriors, it is important to send an opposing model and a wax bite. Sufficient overbite and overjet is es-sential to provide clearance for the maxillary E-Z Bond Retainer.

AA- Show step by step, how to bond this appliance in place

2166M – Bonded Bonded Fixed Lingual Retainers

Long-term, post-orthodontic treat-ment studies suggest that some de-gree of relapse is inevitable. The most recent research shows that it is necessary to bond each tooth in-dividually to maintain them in their corrected position. This is hard to accomplish without making it more difficult for the patient to maintain their hygiene. Typically patients who have lingual bonded retainers have to use floss threaders to clean interproximally.

The lingual bonded retainer shown here is designed to allow the patient to floss normally making much eas-ier for them to maintain a healthy oral condition. Using Australian wire, loops are placed between all the teeth except in the lower inci-sor region where the interproximal distances are to close. These loops avoid the interproximal areas al-lowing the patient to floss. A Floss Threader is recommended for use between the lower incisors.

5511 The Positioner

The Positioner is mainly used to help settle in the occlusion at the end of a full fixed bracket and band case. This retaining appliance is fabricat-ed from flexible plastic (silicone or rubber) and is typically made into a slightly over treated Class I rela-tionship.

The appliance is fabricated after the individual teeth are cut from a cur-rent set of models and reset into an ideal relationship. Impressions for this appliance can be taken with brackets still in place. This will al-low you to deliver the appliance immediately on the same day that you plan to remove your bands and brackets. Upon delivery the patient is instructed to clench their teeth into the Positioner on a scheduled basis. This action not only allows for a gentle settling-in of the indi-vidual teeth into their correct po-sitions, but it also has a functional element of establishing a correct in-terarch relationship. Various colors, as well as the standard clear materi-al, are available for this appliance.

Note: A specific “Set-up and Posi-tioner Prescription” form is avail-able upon request.

Adjustment Tips

AA – Always check the casts in oc-clusion to help you select the proper clasps and their placement

AA – Adjustment of Adams clasps

AA - Adjustment of the labial bow

AA – Adjustment of the acrylic

AA – Checking for sore spots and high spots

AA- show the basic set up that the lab does and the inter-proximal re-contouring that the doctor needs to accomplish

» CARE FOR THE APPLIANCES:

Both fixed and removable appli-ances need special care. Some of the most common problems are ad-dressed below:

1. Fixed orthodontic appliances will demand special oral hygiene care. We highly recommend the use of fluoride to help prevent caries ac-tivity.

2. It is often a good idea to give your patient some Brace Relief (a medi-cated orthodontic wax) to protect their tissues from being irritated by the brackets and wires.

3. Never allow a removable appli-ance near high temperatures or al-low it to dehydrate for more than 24 hours.

4. All appliances should be kept moist when not in use. A retainer case works nicely. The patient should simply place the appliance in the case with a small piece of wet paper towel.

5. All appliances should be cleaned every day. A soft brush and tooth-paste, or soaking in denture cleaner, is all that is needed.

6. Removal of the appliance is best accomplished by using equal pres-sure on both sides of the mouth. This will minimize the chance of damage to the resilient portion of the appliance.

Contraindications and Concerns

Circumfrential Supracrestal Fi-berotomy (CSF) is one of the only

The Practice Building BULLETINThe Practice Building BULLETINsuccessful post-orthodontic treat-ments to show any long-term success in preventing rotational relapse. CSF is performed imme-diately after removal of the orth-odontic appliances. By releasing the soft-tissue tension and allowing the reattachment of periodontal fi-bers, moderate long-term success has been shown in preventing rota-tional relapses. This treatment has been well studied. After CSF, little or no attachment loss has been de-scribed in any significance, nor any other negative sequelae. It is highly recommended that patients with moderate to severe pre-orthodontic rotations in the

lower anterior undergo CSF.

» LAB REQUIREMENTS:

Space Maintainer’s goal is to give you the best service possible. To help us get your lab work back to you on time, we need the follow-ing:

1. A detailed prescription. If you are having a problem designing an ap-pliance have a look at our Practice Building Bulletin called The Ap-pliance Therapy Worksheet. After a few go throughs with this sheet you’ll be have no problem design-ing an appliance.

2. Always give us the date wanted and when appropriate the patients’ appointment date. If there is a prob-lem in meeting the due date the lab will call.

3. Accurate casts poured in stone that capture all the teeth and land areas . Air bubbles or holes on tooth surfaces are unacceptable as they can negatively effect the fit of the appliance.

4. Provide a carefully taken con-struction bite that represents the exact vertical and AP position that you desire in the finished appliance. This is the single most important step to successful treatment after making the correct diagnosis.10 IT IS IMPORTANT TO CHECK THE

COMPLETED CONSTRUCTION BITE BY PLACING IT BACK ON THE WORKING MODELS. Then carefully wrap the bite separately for shipment.

» SUPPLY LIST:

Whether you have been practicing for one month or forty years you will find that you already have al-most everything on this supply list. Be sure to take a moment and review it. Is there a favorite instrument that you use that I have left out?

Appliance Design Worksheet*Kromopan Impression Material*Fluoride Releasing Band Cement* Regular or Light CureWet Field Bonding Adhesive*White Utility Comfort Wax Or Brace Relief*Interproximal Stripping Tool*Vinyl Mixing Bowl*Wide Blade Spatula*Distilled WaterImpression Trays* (We Recom-mend A Rim Lock Design)Impression Tray TreeAcrylic Burs*Acrylic Polishing Burs*Acrylic Repair Kit*Pressure Pot*139 Bird Beak Pliers*Three Prong Pliers*Stiff Robinson Brush*Etchant*Retainer Brite*Sonic Appliance Cleaner*Patient Appliance Care CD*Patient Calendar Booklets*Colored Retainer Cases*

* available from Success Essentials call 800-423-3270.

» AUTHOR PROFILE

Michael Florman, DDS

Dr. Florman received his dental de-gree from the Ohio State Univer-sity and completed his post gradu-ate training in Orthodontics at New York University. Dr. Florman is a Diplomate of the American Board of Orthodontics, and has been practic-

ing dentistry since 1991. He is high-ly respected as both an orthodontist and an educator. He has authored over forty scientific publications in the field of dentistry and medi-cine. Dr. Florman is the Executive Program Director for the Academy of Dental Therapeutics and Stoma-tology, a national dental continuing education organization. He is also an active clinical advisor to many pharmaceutical and dental compa-nies. He is a member of the Ameri-can Dental Association, California Dental Association, and the Ameri-can Association of Orthodontists. His hobbies include golf, running, hiking, bicycling, photography, and computer graphic design.

» REFERENCES

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2. Little, R.M. “Stability and relapse of dental arch alignment.” Br J Or-thod. 1990 Aug;17(3):235-41.

3. Bjork, A., Hlem, S. “Prediction of the age of maximum pubertal growth in body height.” Angle Or-thod 1967 37:134

4. Akgul, A.A., Toygar, T.U. “Natu-ral craniofacial changes in the third decade of life: a longitudinal study.” Am J Orthod Dentofacial Orthop. 2002 Nov;122(5):512-22.

5. Bishara, S.E., Treder, J.E., Ja-kobsen, J.R. “Facial and dental changes in adulthood.” Am J Or-thod Dentofacial Orthop. 1994 Aug;106(2):175-86.

6. Moorreess, C.F.A. “The dentition of the growing child.” Cabridge: Harvard University Press;1959.

7. Sinclair, P., Little, R. “Maturation of untreated normal occlusions.” Am J Orthod Dentofacial Orthop 136:83;114-23

The Practice Building BULLETINThe Practice Building BULLETIN8. Blake, M., Bibby, K. “Retention and stability: a review of the litera-ture.” Am J Orthod Dentofacial Or-thop. 122 Sep;114(3):299-306.

9. Sinclair, P., Little, R. “Dentofa-cial maturation of untreated nor-mals.” Am J Orthod Dentofacial Orthop 134;88:146-156

10. Sinclair, P.M., Little, R.M. “Maturation of untreated normal occlusions.” Am J Orthod. 136 Feb;83(2):114-23.

11. Carter, G.A., McNamara, J.A. Jr. “Longitudinal dental arch changes in adults.” Am J Orthod Dentofacial Orthop. 122 Jul;114(1):88-99.

12. Melrose, C, Millett, D.T. “To-ward a perspective on orthodontic retention?” Am J Orthod Dentofa-cial Orthop. 122 May;113(5):507-14. Review.

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14. Burzin, J, Nanda, R. “The sta-bility of deep overbite correction in retention and stability.” Orthodon-tics. 1993:61-79

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16. Southard, T.E., Behrents, R.G., Tolley, E.A. “The anterior compo-nent of occlusal force. Part 1. Mea-surement and distribution.” Am J Orthod Dentofacial Orthop. 123 Dec; 96(6):493-500.

17. Southard, T.E., Behrents, R.G., Tolley, E.A. “The anterior compo-nent of occlusal force. Part 2. Rela-tionship with dental malalignment.” Am J Orthod Dentofacial Orthop. 1990 Jan; 97(1):41-4.

18. Okeson, J.P. “Management of Tempromandibular Disorders and Occlusion.” Mosby 5th edition. pgs.109-148

Dentofacial Orthop. 2005 Nov; 128(5):575-582.

28. Shields TE, Little RM, Chapko MK. Stability and relapse of man-dibular anterior alignment: a ceph-alometric appraisal of first-pre-molar-extraction cases treated by traditional edgewise orthodontics. Am J Orthod. 1985 Jan;87(1):27-38.

29. Houston WJ. Incisor edge-centroid relationships and over-bite depth. Eur J Orthod. 1989 May;11(2):139-43.

30. Peck, S., Peck, H. “Crown di-mensions and mandibular inci-sor alignment.” Angle Orthod 1972:42;148-153

31. Shah, A.A., Elcock, C., Brook, A.H. “Incisor crown shape and crowding.” Am J Orthod Dentofa-cial Orthop. 2003 May;123(5):562-7.

32. Mills, L.F. “Arch width, arch length and tooth size in young adult males.” Angle Orthod 1964:34:124-9

33. Keane, A., Engle, G. “The man-dibular dental arch. pat IV. Pre-diction and prevention of lower anterior relapse.” Angle Orthod 137;49:173-80

34. Smith, R.J., Davidson, W.M., Gipe, G.P. “Incisor shape and inci-sor crowding; a re-evaluaion of the Peck and Peck ratio.” Am J Orthod 130;82:3-5

35. Puneky, P.J., Sadowsky, C., Be-gole, E.A. “Tooth morphology and lower incisor alignment many years after orthodontic therapy.” Am J Orthod 135;86:299-305

36. Glynn, G., Sinclair, P.M., Alex-ander, G. “Nonextraction orthodo-nitc therapy: posttreatment dental and skeletal stability.” Am J Orthod Dentofacial Orthop 132;92:321-8

37. Strang, R. “The fallacy of den-

19. Acar, A., Alcan, T., Erverdi, N. “Evaluation of the relationship be-tween the anterior component of occlusal force and postretention crowding.” Am J Orthod Dentofa-cial Orthop. 2002 Oct;122(4):366-70.

20. Southard, T.E., Southard, K.A., Tolley, E.A. “Periodontal force: a potential cause of relapse.” Am J Orthod Dentofacial Orthop. 1992 Mar;101(3):221-7.

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23. Moussa, R., O’Reilly, M.T., Close, J.M. “Long-term stability of rapid palatal expander treatment and edgewise mechanotherapy.” Am J Orthod Dentofacial Orthop. 1995 Nov;108(5):478-88.

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27. Ormiston, J.P., Huang, G.J., Little, R., Decker, J.D., Seuk, G.D. “Retrospective analysis of long-term stable and unstable orthodontic treatment outcomes.” Am J Orthod

The Practice Building BULLETINThe Practice Building BULLETINture expansion as a treatment proce-dure.” Angle Orthod. 1959; 19:12-22

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41. Little, R.M., Riedel, R.A. “Postretention evaluation of stabil-ity and relapse-mandibular arches with generalized spacing.” Am J Orthod Dentofacial Orthop. 123 Jan; 95(1):37-41.

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45. Little, R.M., Riedel, R.A., Stein, A. “Mandibular arch length increase during the mixed dentition: postre-tention evaluation of stability and relapse.” Am J Orthod Dentofacial Orthop. 1990 May;97(5):393-404.

46. Artun, J., Garol, J.D., Little, R.M. “Long-term stability of man-dibular incisors following success-ful treatment of Class II, Division 1,

malocclusions.” Angle Orthod. 19; 66(3):229-38.

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Post-orthodontic retention is need-ed to allow for periodontal and

gingival reorganization, minimize changes of growth, permit neuro-muscular changes and adaptation to the new tooth positions, and main-tain unstable tooth positions which may have been established to meet treatment goals and esthetic consid-erations.8

Orthodontic stability begins with the mandibular arch, especially the mandibular anterior teeth. The maxillary arch wraps around the mandibular arch, and changes that occur in the upper arch follow the lower teeth.48

Nanda discussed retention con-cerns in young patients undergoing puberty or in some stage of active growth.53 He stated that different retention devices based on facial morphology and severity of the malocclusion should be considered. For example, Class II individuals who may still need upper retraction force to prevent the maxilla from continuing to grow forward when the mandible has stopped growing. Patients with short face syndrome may need bite-plate type retainers until maxillomandibular growth has completed. Conversely, patients who have long face syndrome may require a high-pull face bow head-gear to hold the position of the mo-lars and to prevent further down-ward and backward growth of the mandible.

Indefinite retention is the only so-lution we have today to keep teeth aligned over time. It is hard to ar-gue the fact that without indefinite retention the dental arches will change, starting with the lower an-terior teeth. In many individuals, these changes will result in vary-ing degrees of collapse of the dental arches.

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