THE EDITOR'S CORNER

Many orthodontists accept an obligation for retention of their treatment results far beyond what is reasonable or what should be normally expected. They say, "I want to continue to see my cases as long as they are willing to come back and see me, so that I can learn from them what the longer range effects of orthodontic treatment and retention are. " They also say, " I want to see my patients until their third molar problem is solved; until the third molars have either erupted properly into the arch or have been extracted."

Let's examine these reasons. The first one--that you will learn something from studying your treatment results long range--may be valid for certain orthodontists. For the great majority, it is a most difficult way to attempt to learn something. The experience of the last half-century should tell us something about this approach to learning. I am not aware that we know much more about retention than when we started. It is misleading to encourage especially the young men in the thought that this is a valid approach to the management of retention.

The second reason is even more obscure than the first. There is no substantial evidence that third molars are related to the stability of an orthodontic result. Many orthodontists, who will tell you that they do not believe that third molars have anything to do with the stability of an orthodontic result, paradoxically keep seeing patients in retention and post-retention until the "third molar problem" is solved to their satisfaction.

I sometimes wonder how much of this is caused by a reluctance to dismiss a case. Most orthodontists do not want to put their imprimatur on a case that is less than perfect. Yet, there are cases that never do get completed to the orthodontist's satisfaction. Also, less often, there are cases that never do get completed to the patient's satisfaction. But, if you never dismiss a case, you never have bad results.

It is time to put our retention house in order by facing the realities of orthodontic practice and establishing a rationale of retention which deals with the retention problem and not with the orthodontist's problem.

One of the easiest ways of slipping into this routine of open-end retention is to take cases into retention which are not yet through with active appliance therapy, to attempt to use a retainer as a finishing appliance for more than minor band space closure. You may never reach a point where the case is completed to anybody's satisfaction. Another way is to accept too much responsibility for the stability of a treatment result or to promise the patient and/or yourself more stability than you have a right to expect in light of orthodontic experience with stability. Another way is to take on cases with irregularities that are only minor and that have a high potential for instability. When such cases relapse, you have accomplished next to nothing. Another way of getting into prolonged retention is to take on patients whom you know to be reluctant and expect to be uncooperative. If you are doing any or all of these things, are you also telling yourself that you want to see your patients as long as possible on retention in order to learn something, or that you want to see them until their "third molar problem" is solved?

If the basis for prolonged retention visits is largely a delusion and if the true reasons are identifiable, it should not be difficult to arrive at a rationale of retention which is suited to the present state of the art and our knowledge about it.

Good treatment is a basis of retention and we must each examine our treatment system to maximize the number of cases which reach the end of active appliance therapy in a reasonable amount of time, completed to a point where minimal closure of band spaces and settling of the cuspation is what remains. How each of us reaches that state may vary. Some are doing it now; some may be well-advised to change their treatment system; some may not be systematized at all and need to install a treatment system; some may be trying to treat too many cases, to see too many patients in a day.

We must acknowledge that teeth change position following orthodontic correction. While some corrections will enhance stability, inherent instability can change even the finest result that the modern orthodontist is able to effect. We should not dream impossible dreams, nor cause our patients to do so. Treatment should be undertaken if it can be justified in spite of a possible loss of a percentage of correction. Patients should have a realistic view of what the odds are, even if they don't always remember what you tell them or what you write to them. Documentation should not be aimed so much at the orthodontist's protection as at the education of the patient to the realities of orthodontic treatment.

The orthodontist and the patient should have the option of deciding about retention together, which may be a decision on a realistic basis between permanent retention and frequent instability. Of the two, I am not sure that permanent retention does not often make more sense. Semi-permanent retention with permanent part-time wear of retainers may contribute an unhealthful jiggling to the teeth. Permitting the teeth to become irregular after spending a great deal of skill, time, effort and money to make them straight, may defy logic to some extent. However, with the retention appliances that we presently have, it is not realistic to think that many patients would persist with permanent retention. Therefore, it may be reasonable to trade a slight irregularity for semi-permanent retention, unless some other retaining device can be developed which will be permanent, invisible, not require continuous attention, and not interfere with the occlusion or with periodontal health.

Whether patients are on long retention--even permanent retention--or not, a way should be found to let loose of a great majority of our retention cases. The image of the individual orthodontist and of the specialty are not enhanced by keeping private practice patients ostensibly for six, eight, or ten years or longer. This is not a cradle to the grave proposition. If it were not for the grace of a substantial attrition, many orthodontic offices would be overrun with retention patients.

One additional way of slipping into open-end retention is to include the retention fee in the overall treatment fee. If the impression is created that the orthodontic fee covers retention and the amount of retention is not specified, some patients will keep coming for years because the case is "unfinished". Either the contract should spell out how much retention time is included or, better still, the retention fee should be a separate fee on some appliance and per-visit basis. If the orthodontist is not making a charge for retention visits, he is giving away time that is largely non-productive. If he is charging for these visits, there should be some justification other than his learning something or his overseeing the solution to the "third molar problem".