acific Coast Society of Orthodontists Bulletin Summer 2018 - 46

Retention
Special Section

RETENTION

Post-Treatment Management
of Orthodontic Patients
What happens after the braces come off? Postorthodontic stability is a bit of a mystery. To date,
research has given us little to rely on other than
indefinite retention.

Dr. Gerald Nelson
Former Editor-in-Chief
PCSO Bulletin

This article will discuss the management and
efficiency of this period of patient care. The information comes from my partnership practices
with three remarkable orthodontist colleagues -
Michael "Mike" Meyer, Earl Johnson, and Paul
Kasrovi - and from decades of collaboration with
orthodontic consultant Karen Moawad.
When I came out of residency and entered
practice with these University of California, San
Francisco, (UCSF) colleagues, we provided an
extraordinary amount of doctor time to our
retention patients, seeing them four to five times
in the first year, three times during the next, and
biannually after that. Current ideas on efficiency
suggest that comprehensive treatment should
involve less than 25 visits from the very first to
the final retention visit. Before our efficiency
makeover, we used up 20 visits during retention
alone.
It really changed when Mike and I decided we
each needed a three-month sabbatical from the
office. At the time, we were each working four
days per week in two office spaces. We preceded
scheduling our sabbaticals with a thorough
analysis of our efficiency, figuring we could pare
clinic time requirements to the point that one of
us could manage for three months. We made
many changes and radically revised our retention
protocol.
Our current retention protocol looks something
like this.
Hardware
Non-Extraction Patients
Pressure-formed (as opposed to vacuum-formed)
slip cover retainer, lower 3-3 lingual fixed retainer
bar with bonded pads on the cuspids. This combination is ideal for a good finish that needs no
touching up with active springs on a Hawley. The

slipcover holds spaces closed and needs no
adjustments (i.e., no doctor time). If the patient is
a bruxer, you can use 2 mm biocryl material,
which is almost indestructible. We spot the
occlusion so that there are some bilateral contacts in centric relation (CR). The lower bonded
retainer is more secure if you lay a thin coat of
composite over the bonding pads to cover most
of the lingual surface of the cuspid; this is more
comfortable for the tongue as well. Prior to bonding, we may do some interproximal reduction
(IPR) to flatten the interproximal surfaces.
Patients with this retainer can floss by looping
the floss around each individual incisor to floss
all the way down to the sulcus.

We tell young patients with fixed retainers that
they must keep the bonded retainer until they
are college-graduation age, at which time they
can come to see us and discuss the pros and cons
of keeping it in place.
We tell adult patients that it should be considered a permanent fixture.
Extraction Patients
It is crucial to keep the extraction site closed. We
usually place an upper Hawley and lower slipcover retainer. Both require almost no doctor
time, and the lower slipcover can act as a night
guard. At one time we tried upper and lower slipcover retainers. I don't recommend this, as the
occlusion does not settle well. I learned this the
hard way as I tried to find my ABO cases.

PCSO Bulletin  Summer 2018

Table of Contents for the Digital Edition of acific Coast Society of Orthodontists Bulletin Summer 2018