The Three Keys of Retention
Retention has been described as the most exasperating phase of orthodontics. The story has even been told of a practitioner who would gladly give half the fee to anyone who would supervise retention. Send those patients to me; I will be a content and wealthy clinician.
In reality, retention should be the least troublesome aspect of orthodontics because there is simply not much to do. Provide retainers that fit and then check them periodically. That's it. But the universal distress associated with retention has little to do with the efficiency of our retention devices; in the main, they work just fine. It is a reluctance to delegate responsibility, coupled with a failure to provide for retention contingencies, that generates dismay. I have devised the three keys of retention to alter this environment.
The first key is delegation of responsibility. When retention commences, my work is over. Given the circumstances, I have done my best, and now it's up to the patient to maintain the final result. I am the creator, not the guarantor, of the finished orthodontic product. I recognize my patients' right to discontinue retention, but they, not I, must live with and accept responsibility for their actions. I am, of course, disappointed when the results of my best efforts collapse, but this is not a problem unique to orthodontists among health-care professionals. I will not, and should not, assume any responsibility for the aftermath of non-retention.
The second key of retention is duration. My duty is to inform the patients of how they can best maintain their post-treatment results, and that's permanent retention. Kaplan's exhaustive review clearly indicates the miserable outcome of limited retention schedules.
My retention indoctrination begins during the pretreatment consultation. The patient is told that when the appliances are removed, my job is finished and theirs is about to begin. I phrase this explanation in terms that are difficult to misinterpret--the teeth will move unless retainers are worn consistently. I make no exceptions; no hazy promises of a blissful, retainer-free future; no allusions to a gradual decrease in retainer wear. Retention is forever: each night, every night. I want the patient's compliance on this point before I start. When treatment is complete, I remind patients of their pretreatment commitment and direct them to wear their retainers all the time for three months, and thereafter every single night. Compared to other bodily maintenance ceremonies, bedtime insertion of retainers is no heroic burden.
The third key of retention is duplication. Backup systems are used in many situations to prevent emergencies--that's why those of us who wear glasses have more than one pair, why Detroit puts a spare tire in the trunk, and why we have more than one set of house keys. Without a backup system to prevent the disruptions that arise from lost, broken, or worn-out retainers, the concept of constant retention is meaningless. It takes time to produce a replacement, and that's the flaw in most systems.
Typical case in point: The patient reports a lost or broken retainer (usually after the teeth have shifted and the patient is getting a bit panicky). An appointment is made for a new impression, the lab constructs a new appliance, an appointment is made for delivery, and finally the replacement retainer is fitted. Meanwhile, for a period of weeks (or even longer if the patient or orthodontist is out of town), the teeth have been fancy free. So much for retention.
When I deliver retainers, my briefing goes something like this: "I am giving you two retainers for each arch because if one is lost or broken, it is imperative that you have an immediate replacement. Otherwise, your teeth will shift. If that happens, the only way to recover would be through retreatment and additional expense. This can be avoided simply by doing what you have said you will do--wearing your retainers on an inflexible schedule. If either of your retainers is lost or damaged, it is your responsibility to contact us for a replacement."
This presentation covers a lot of retention territory: the purpose and importance of the backup retainer, the patient's responsibility for post-treatment stability, the consequences of non-compliance, and the fact that retreatment will not be on the house. A letter reinforcing these comments also provides medicolegal protection. No one could then doubt the emphasis placed on the constancy of retention, and the reserve retainer is a de facto stone wall against any allegations to the contrary.
The downside of backup retainers is not extra impressions, since impressions can be double-poured, but the additional lab bill for each case. This cost could be passed on to the patient, but I don't do it. The eradication of retention emergencies, the reduction in routine retention visits from twice to once a year, and the alleviation of my retention phobias have more than compensated for the additional expense.
Duplicate retention can be achieved with any combination of removable retainers. I prefer the clear slipover types, but I occasionally provide a standard Hawley or a positioner as a backup. Reserve retainers should be identical in function, but not necessarily in form.
I have shied away from banded or bonded retainers. They are fixed devices, and therefore I would have to monitor their maintenance. I don't want to replace the patient on the post-treatment responsibility hook. I might end up having to manage such problems as complete or partial retainer failure, calculus build-up, and hygiene difficulties. Also, you can't make a backup for a bonded retainer. Sooner or later, a fixed retainer must be removed and constant retention terminated. At that time, I would suggest calling up the reserves and going to a removable backup system. If you are going to end up in reserve retention, why not start there?
A final point: in my office, a retainer is a stabilization device, not a fashion statement. It is difficult to conceive of a patient taking retention seriously when there is a likeness of Daffy Duck waving an American flag embedded in the acrylic.
The three keys of retention have organized my philosophies into a logical progression. I have delegated the responsibility for dental stability to the patient, where it belongs. I have established the imperative of permanent duration, and I have enabled the patient, with duplicate retainers, to comply.