Objective:

To discern patients' opinions regarding responsibility for orthodontic retention and to determine whether patient attitudes toward retention are related to perceptions of treatment success.

Materials and Methods:

Questionnaires regarding orthodontic retention were distributed to first-year undergraduate college students (n  =  158), first-year dental students (n  =  183), and retention patients at orthodontic offices (n  =  214). Items included treatment satisfaction, perceived responsibility for retention, type of retainer prescribed, reasons for discontinuing use of retainers, and relapse experienced.

Results:

Four hundred twenty-eight of 555 participants indicated that they had received orthodontic treatment. Most indicated they were either “satisfied” or “very satisfied” with their teeth, both at the end of treatment (96%) and currently (84%). There was a strong relationship between the perception of stability of tooth position and current satisfaction level (P < .0001). Most individuals (88%) indicated that they themselves were responsible for maintaining the alignment and fit of their teeth. Those who indicated that someone else was responsible were nearly twice as likely to be dissatisfied with their teeth (P  =  .0496). Patients who had been prescribed clear, invisible retainers were significantly more likely to be “very satisfied” currently (50%) compared to those with Hawley (35%) or permanently bonded (36%) retainers (P  =  .0002). Patients with Hawley retainers were significantly less likely to be wearing them currently as prescribed (45%) than those with invisible (65%) or bonded (68%) retainers (P < .0001).

Conclusions:

Satisfaction with orthodontic results after treatment is related to patient perceptions of responsibility for retention and perceived stability of tooth position. Patients should play a contributory role in formulating orthodontic retention plans.

Undesirable changes in the alignment of teeth following orthodontic treatment commonly occur unless some form of retention is employed.14 Kaplan5 suggested that patients should be informed of the high probability that some relapse will occur after appliances are removed and of the natural adaptations that take place over time. In this way, patients become an integral part of the decision-making process, along with the orthodontist, regarding the appropriate duration of retention procedures. Undoubtedly, successful preservation of orthodontic results is achieved most effectively if patients accept responsibility for wearing and maintaining appropriate retention appliances.

Blake and Bibby6 presented six basic treatment principles to which orthodontists should adhere to improve posttreatment stability of orthodontic alignment. Others710 advocated long-term retention for most patients because of the uncertainty involved in determining which patients will remain stable. Ideally, the choice of the type of retainer appropriate for each individual patient, whether fixed or removable, should be made by considering the unique circumstances involved.7,8 These include both the potential and expected changes that may occur over time and the patient's ability and willingness to comply with the retention plan. However, results from one survey11 suggested that orthodontists are more likely to choose retention procedures according to their own personal preferences.

The 2008 JCO Study of Orthodontic Diagnosis and Treatment Procedures12 demonstrated a continuing increase in the routine use of permanent bonded retainers by orthodontists. Studies7,8 have shown fixed retainers to be safe and effective for most patients over the long term. Others,13,14 however, have found them to be associated with an increased accumulation of calculus and point to them as a cause of gingival recession. Orthodontists acknowledge that permanent retention may be inappropriate for certain patients.8,9 Routine removable retainer use is still reported by more than 50% of orthodontists.12 Compliance with removable retainer wear is out of the control of the orthodontist and may lead to frustration for both practitioners and patients.9,15 Wong and Freer16 reported that more than 50% of patients admitted that they did not wear retainers as instructed, with the most common reasons being discomfort and forgetfulness.

Whereas several studies have investigated the attitudes and preferences of orthodontists toward various retention protocols, few have reported on the perceptions of patients regarding orthodontic retainers and stability.4,16,17 The purpose of the current study was to discern patients' opinions regarding responsibility for orthodontic retention and to determine associations between patient attitudes toward retention and perceptions of treatment success.

A survey was constructed for distribution to former orthodontic patients with questions regarding their retention experiences. Items included demographic information and questions pertaining to treatment satisfaction, perceived responsibility for retention, type of retainer prescribed, reasons for discontinuing use of retainers, and relapse experienced. Institutional review board approval was obtained and the survey was distributed to 555 individuals, including first-year undergraduate college students (n  =  158), first-year dental students (n  =  183), and retention patients at several local orthodontic offices (n  =  214). Participation was voluntary. College students and dental students were surveyed during class time and were requested to return the survey whether or not they had ever undergone orthodontic treatment. Differences among groups, and differences and associations among responses, were determined using Chi-square analysis or the Wilcoxon rank-sum test with a significance threshold of P < .05.

Demographic characteristics of the groups surveyed are shown in Table 1. Of the 555 surveys distributed, 428 individuals reported a history of orthodontic treatment, and their characteristics are shown in Table 2. While nearly all of the patients surveyed in orthodontic offices had a history of wearing braces, there was no significant difference in the proportion of dental (66%) and college (61%) students who reported previous treatment (P > .05). Among college students, Asians (45%), Blacks (41%), and Hispanics (50%) were significantly less likely to have undergone orthodontic treatment than Whites (72%) (P < .0001). Participants without a history of wearing braces were asked to return the survey without answering the remaining questions. Not all respondents answered all questions, and some indicated multiple answers to questions that sought only one answer. Answers given to the various questions by those with a history of orthodontic treatment are reported in Tables 3 through 5.

Table 1

Demographic Characteristics of the Groups Surveyed

Demographic Characteristics of the Groups Surveyed
Demographic Characteristics of the Groups Surveyed
Table 2

Demographic Characteristics of the Participants Reporting a History of Wearing Braces

Demographic Characteristics of the Participants Reporting a History of Wearing Braces
Demographic Characteristics of the Participants Reporting a History of Wearing Braces
Table 3

Answers to Questions Regarding Treatment Satisfaction and Stability

Answers to Questions Regarding Treatment Satisfaction and Stability
Answers to Questions Regarding Treatment Satisfaction and Stability
Table 4

Answers to Questions Regarding Responsibility for Retention

Answers to Questions Regarding Responsibility for Retention
Answers to Questions Regarding Responsibility for Retention
Table 5

Answers to Questions Regarding Retainer Type and Duration of Retention

Answers to Questions Regarding Retainer Type and Duration of Retention
Answers to Questions Regarding Retainer Type and Duration of Retention

Most respondents indicated that they were either “satisfied” or “very satisfied” with the alignment and fit of their teeth, both at the end of treatment (96%) and currently (84%) (Table 3). Of the 422 subjects who indicated their level of satisfaction at both times, 40% (n  =  170) reported a decrease in satisfaction since the end of treatment, and only 2% (n  =  8) reported greater satisfaction currently. The remaining 58% (n  =  244) indicated the same level of satisfaction at both time points. There was a strong relationship between the perception of stability of tooth position since treatment concluded and the current level of satisfaction (P < .0001). Of those who reported that their teeth had not moved, 82% said they were very satisfied with the current straightness and fit of their teeth, compared to 39% overall. Only 2% of those who perceived no posttreatment tooth movement said they were not satisfied currently, compared to 18% of those who perceived a little movement and 55% of those who perceived a lot of movement.

Regarding responsibility for orthodontic retention, most (88%) individuals perceived that they themselves were responsible for maintaining the alignment of their teeth after treatment (Table 4). However, some indicated that the orthodontist (n  =  45), the general dentist (n  =  7), parents (n  =  6), or others (n  =  4) were responsible. Those who reported that anyone other than themselves was responsible for orthodontic retention were nearly twice as likely to report dissatisfaction with the current straightness and fit of their teeth, versus those who claimed responsibility themselves (29% vs 15%; P  =  .0496).

Most of the patients said that they received a removable mandibular retainer after treatment, either with (48%) or without (32%) wires (Table 5). Only 17% said they had a bonded or banded mandibular retainer, and the remainder (4%) received no mandibular retainer. Of those receiving retainers, 26% reported that their retainer had broken or needed repair or replacement at least once. There were no statistically significant differences among the patients with Hawley (27%), invisible (clear) (21%), or bonded (35%) retainers with past breakage, repair, or replacement reported (P > .05). However, there was a relationship between the type of retainer prescribed and current satisfaction with treatment. Patients with invisible retainers were significantly more likely to report that they were “very satisfied” currently (50%) compared to those with Hawley (35%) or permanently bonded (36%) retainers (P  =  .0002). There were no differences in the number of individuals who reported that they were not satisfied with the alignment and fit of their teeth currently among the various retainer types (P > .05). Patients given no retainer were significantly more likely to report that they were currently “not satisfied” (53%; P  =  .0002).

Of the patients who reported that they received mandibular retainers, 45% said that they had stopped wearing them regularly. Discontinuation of retainer use was significantly related to the type of retainer prescribed (P < .0001), with only 45% of those with Hawley retainers claiming to still wear them compared to 65% of those with invisible retainers and 68% of those with bonded retainers. However, bonded retainers had been in place, on average, for a significantly longer period of time (7.8 years) than Hawley (3.5 years) or invisible (1.8 years) retainers (P < .0001). When only those patients out of treatment for more than 1 year were considered (n  =  354), 66% of those with bonded retainers said they were still in place, compared to 54% wearing invisible retainers and 39% wearing Hawley retainers (P < .0001). Reasons given for discontinuing retainer use were significantly different depending on the type of retainer prescribed (P  =  .0002). For removable retainers (Hawley or invisible), the most common reason for stopping wear was “I just stopped wearing it eventually” (n  =  52; 33%). Those with bonded retainers most often said the retainer was removed by an orthodontist or dentist (n  =  8; 42%) or that it was lost or broken (n  =  5; 26%).

This study surveyed the opinions of 428 patients who had completed fixed orthodontic treatment an average of 5.3 years previously. No attempt was made to determine characteristics of the original malocclusions or any other treatment factors involved. Additionally, there was a large amount of variation among patients in the time since appliances had been removed, with 84% reporting completion of active treatment at least 1 year previously. However, the primary purpose of the study was to determine whether there were associations between patients' attitudes toward orthodontic retention and perceptions of treatment success.

The overwhelming majority of those surveyed perceived that orthodontic retention was their own responsibility (88%), with only 11% reporting that the orthodontist was primarily responsible. Those who considered anyone other than themselves to have primary responsibility for the stability of their treatment results were about twice as likely to report that they were not satisfied with the current alignment and fit of their teeth. This is consistent with other fields of medicine, in which shared responsibility for treatment has also been found to be an important component of treatment success.1820 It also suggests that getting patients involved in treatment decisions and making them aware of their own responsibility for retention regimens is important for maintaining high levels of satisfaction. This may also help to improve patient cooperation.

Although recent surveys8,12,21 suggest that the routine placement of bonded permanent retainers is becoming more common among orthodontists, only 17% of the patients in this study reported receiving one. Of the patients with bonded retainers, 35% reported that they had previously broken or needed repair or replacement, which was not significantly different from the failure rate reported for other types of retainers. This failure rate was consistent with that found by Booth et al.10 but was substantially higher than the approximately 5% rate reported by Zachrisson.7 

Patients with bonded and invisible retainers were more likely to be wearing them regularly at the time of the survey than those who were prescribed Hawley retainers. For those patients who had completed treatment at least 1 year prior to the present study, compliance with removable retainer wear, for invisible and especially Hawley types, was significantly lower than for bonded retainers. About two-thirds of bonded retainers were still in place after 1 year, whereas fewer than half of the patients with Hawley retainers reported that they were still wearing them as prescribed. Wong and Freer16 also found that fewer than 50% of patients wore removable mandibular retainers as instructed, although they did not differentiate between Hawley and invisible retainer types.

Most of the patients in this study who perceived movement of their teeth following treatment attributed those changes to factors under their own control: not wearing their retainer enough (41%), stopping retainer wear too soon (22%), or not following up with appointments (4%). Others considered posttreatment movement to be a natural phenomenon (14%) or a result of eruption of third molars (6%). Only 7% blamed the orthodontist for not following up long enough or for performing inadequate treatment.

Perception of stability of tooth alignment and fit was strongly related to current satisfaction with the orthodontic treatment outcome. The literature suggests that some form of retention is required to maintain tooth alignment in the long term. Invisible retainers have been shown to maintain individual tooth positions as well as or better than traditional Hawley retainers.22,23 However, Hawley retainers allow more beneficial settling of the occlusion after treatment than clear, full-coverage retainers.24 A recent study25 found that the greatest increase in posterior tooth contacts occurred when bonded retainers were used for retention. Although bonding permanent retainers seems to be the most predictable way to prevent unwanted tooth movements and encourage posterior settling, undesirable changes in tooth position have been reported even with bonded retainers in place.26 

Psychological traits of individual patients may affect their satisfaction with orthodontic treatment outcomes.27 Anderson et al.28 found that posttreatment satisfaction was positively correlated with pretreatment motivation levels. In the present study, satisfaction was greater for patients who claimed responsibility for maintaining posttreatment outcomes. However, the perception that alignment and fit of the teeth remained stable over time was also an important factor. Current satisfaction was highest for the patients who received clear, invisible retainers. It is apparent that no single approach is appropriate for all patients and that orthodontic retention decisions should be made with consideration of differences among individuals. Most likely, the best way to achieve long-term patient satisfaction is to devise an appropriate retention plan with input from both the orthodontist and the patient so that the patient is informed of the options available and is motivated to share responsibility for maintaining the outcome.

  • Most respondents indicated that they were either “satisfied” or “very satisfied” with the alignment and fit of their teeth, both at the end of treatment (96%) and currently (84%), at an average of 5.3 years posttreatment.

  • There was a strong relationship between the perception of stability of tooth position after treatment and current satisfaction (P < .0001).

  • Most individuals (88%) perceived that they themselves were primarily responsible for maintaining the alignment of their teeth after treatment. Those who believed that anyone else was responsible for retention were about twice as likely to feel dissatisfied with their teeth currently (P  =  .0496).

This study was supported in part by an A. D. Williams Summer Research Fellowship from Virginia Commonwealth University and by the Medical College of Virginia Orthodontic Education and Research Foundation.

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