Over the course of my training, I've been taught by many wonderful educators--gifted, giving individuals who piqued my curiosity, challenged my thinking, and most of all gave me a lifelong love of learning. One of the greatest influences in my professional career is Dr. J. Daniel Subtelny, who has been Chairman of the University of Rochester Eastman Dental Center's orthodontic program since he created it in 1955.
At the core of Dr. Subtelny's program when I was at Eastman were his intensely probing "Hot Seat" sessions. In each seminar, an orthodontic resident was assigned a patient and asked to present everything about that individual over the course of five or six weeks, every Wednesday from 8 a.m. to noon. Imagine 20-24 hours of case presentation on one patient! We started with embryogenesis and progressed through non-nutritive sucking patterns of the fetus, any and all parafunctional habits, nutritional considerations, and every phase of growth and development. The actual treatment plan would be proffered by the beaten and humbled resident around hour 15 or 16. In Dr. Subtelny's Socratic method, every question was answered by another question until utter exhaustion settled in. But guess what? We knew our stuff. Hundreds and hundreds of residents over the years have passed through his refiner's fire and come out better, wiser, and humbler.
That brings us to JCO's newest feature, The Hot Seat--named after Dr. Subtelny's program. Since my days of studying general surgery, I've continued to receive several professional journals from that field, all of which I still enjoy. One such publication, General Surgery News, has a department that I always look forward to reading, called "On the Spot". Using that model as an inspiration, The Hot Seat will feature some of the best clinicians and educators in our specialty. Each installment will be based on a single, often controversial topic and will have a new set of contributors. The challenge to each respondent is to be brief, sometimes pithy. And just as in the General Surgery News column, I'll add a few summary remarks at the bottom of each question. Your suggestions for future topics are welcome. And if you'd like to be considered as a contributor, please e-mail me at orthograham@gmail.com.
Similar articles from the archive:
- THE HOT SEAT Extractions August 2013
- THE HOT SEAT Temporary Anchorage Devices February 2014
- THE HOT SEAT Cone-Beam Computed Tomography August 2014
Fixed retention is:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Recommended on every mandibular arch, canine to canine.
S. Jay Bowman, DMD, MSD
Portage, MI
A necessary evil in some instances, but not an excuse to misrepresent stability-study findings.
Robert S. Haeger, DDS, MS
Kent, WA
The most dependable.
Neal Kravitz, DMD, MS
South Riding, VA
A major part of my practice. We regularly bond lower 3-3 with Ortho FlexTech and Transbond LR.
Elliott Moskowitz, DDS, MS
New York, NY
Predictably effective, requiring a minimum of patient cooperation, and certainly satisfies short-term retention goals.
W. Ronald Redmond, DDS, MS
San Clemente, CA
Necessary, though unfortunately patients think of “fixed” retention as “permanent” (lifetime), which isn’t healthy long-term.
John J. Sheridan, DDS, MSD
Jacksonville, FL
Very beneficial if it is esthetic without
the need for frequent or complex
monitoring.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
Great if the patient will clean well around the retainer wire.
Peter Sinclair, DDS, MSD
Los Angeles, CA
A pain in the butt to place.
Flavio Uribe, DDS, MDS
Farmington, CT
The best retention method to ensure acceptable long-term lower incisor alignment.
Commentary by Dr. Graham: I think we can all agree on this one.
Hawley retainers are:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Worn only at night in the maxillary arch. Reducing acrylic in the lingual embrasures frees the posterior teeth to settle.
S. Jay Bowman, DMD, MSD
Portage, MI
Effective and versatile, but lacking in esthetics.
Robert S. Haeger, DDS, MS
Kent, WA
Great to allow further settling of the occlusion.
Neal Kravitz, DMD, MS
South Riding, VA
Still a fantastic choice. We like to add a thin layer of clear acrylic to the labial bow to provide better control of the anterior teeth.
Elliott Moskowitz, DDS, MS
New York, NY
Limited in their ability to resolve retention issues, not worn, easily lost, and ineffective for mandibular incisor retention. They belong in the museum of orthodontic appliances of yesteryear.
W. Ronald Redmond, DDS, MS
San Clemente, CA
Better for long-term retention because they’re removable and facilitate good oral hygiene.
John J. Sheridan, DDS, MSD
Jacksonville, FL
Dependable, and have been so for the past 105 years. The labial bar is somewhat unesthetic, but this is of minor concern when the patient can wear them at night only.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
Long-lasting, but unesthetic.
Peter Sinclair, DDS, MSD
Los Angeles, CA
Very flexible.
Flavio Uribe, DDS, MDS
Farmington, CT
The best cleansable, long-lasting type of retainer.
Commentary by Dr. Graham: Moskowitz by a mile.
Long-term stability is:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Possible, and should always be a treatment goal.
S. Jay Bowman, DMD, MSD
Portage, MI
Still a goal worth striving for by appropriate treatment planning and execution.
Robert S. Haeger, DDS, MS
Kent, WA
A balance between lip pressure, tongue pressure, and occlusal forces, which are not constant.
Neal Kravitz, DMD, MS
South Riding, VA
A fish story!
Elliott Moskowitz, DDS, MS
New York, NY
Something that begins in diagnosis and treatment planning and needs to be more completely explained to the patients and parents prior to treatment.
W. Ronald Redmond, DDS, MS
San Clemente, CA
A myth—I don’t think it exists.
John J. Sheridan, DDS, MSD
Jacksonville, FL
Highly improbable without long-term monitoring by a qualified professional. Our teeth tend to move toward their pretreatment positions, in addition to the changes due to aging.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
A great goal, though bones are not cement and teeth will move over time.
Peter Sinclair, DDS, MSD
Los Angeles, CA
The Problem in orthodontics.
Flavio Uribe, DDS, MDS
Farmington, CT
More predictable if the retainers are maintaining alignment rather than the correction of an anterior open bite.
Commentary by Dr. Graham: The bane of our existence, but Kravitz and Redmond say it best.
Retention should:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Be simple and predictable if long-term stability goals are achieved during active treatment.
S. Jay Bowman, DMD, MSD
Portage, MI
Be as effective and as unobtrusive as possible.
Robert S. Haeger, DDS, MS
Kent, WA
Be understood in coordination with natural dental changes.
Neal Kravitz, DMD, MS
South Riding, VA
Be decided upon from the very beginning and sought to the very end of treatment.
Elliott Moskowitz, DDS, MS
New York, NY
Not be a forgotten phase of orthodontic treatment. It should be taught more seriously in postgraduate residency programs and be based upon realistic patient expectations.
W. Ronald Redmond, DDS, MS
San Clemente, CA
Be prescribed as a lifetime need, just as prescription glasses are a lifetime need.
John J. Sheridan, DDS, MSD
Jacksonville, FL
Be minimally invasive, efficient, esthetic, and as comfortable as possible.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
Keep the teeth in reasonable alignment as long as the patient uses the retaining device.
Peter Sinclair, DDS, MSD
Los Angeles, CA
Only be removed by the mortician.
Flavio Uribe, DDS, MDS
Farmington, CT
Be easier to ensure.
Commentary by Dr. Graham: Well stated, Peter!
My nightmare retention case is:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
A non-cooperating, high-angle, open-bite, non-growing tongue thruster!
S. Jay Bowman, DMD, MSD
Portage, MI
When retainers are never worn and the patient never returns as prescribed—until now.
Robert S. Haeger, DDS, MS
Kent, WA
An open bite or late mandibular growth.
Neal Kravitz, DMD, MS
South Riding, VA
A surgical open-bite case with adenoid facies, hypotonic muscles, mouthbreathing, and poor oral hygiene. In the mouth, the muscle always wins.
Elliott Moskowitz, DDS, MS
New York, NY
A patient with a robust forward tongue position that is unresolved, or significant pretreatment incisor rotations in a patient who rejects fixed retention.
W. Ronald Redmond, DDS, MS
San Clemente, CA
Inherently unstable teeth due to excessive perioral musculature imbalance.
John J. Sheridan, DDS, MSD
Jacksonville, FL
The skeletal open bite on a non-growing patient who is blatantly exhibiting the ravages of poor hygiene.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
An anterior open bite that continues to creep open.
Peter Sinclair, DDS, MSD
Los Angeles, CA
A male, Class II division 2 crowded, nonextraction case who finished well at age 16. Grew from 5'2" to 6'8" in 18 months—teeth moved a mile! True story.
Flavio Uribe, DDS, MDS
Farmington, CT
A Board-quality outcome of a patient who was corrected in all dimensions and returned with relapse in all dimensions.
Commentary by Dr. Graham: Every case described here keeps me up at night—thanks a lot!
Clear, slip-cover retainers are:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Temporary; they prevent “vertical” driftodontics or settling (which is something we need!).
S. Jay Bowman, DMD, MSD
Portage, MI
Esthetic and effective if fabricated from thin, fully conforming and comfortable plastic.
Robert S. Haeger, DDS, MS
Kent, WA
Great for replacements or totally socked-in occlusions.
Neal Kravitz, DMD, MS
South Riding, VA
Acceptable. We like having our patients wear these retainers during the day and Hawley-type retainers at night.
Elliott Moskowitz, DDS, MS
New York, NY
An important part of modern removable retention protocols, often not designed or prescribed thoughtfully because they involve more skill than just taking an impression and fabricating a thermoplastic retainer.
W. Ronald Redmond, DDS, MS
San Clemente, CA
Effective if properly fabricated.
John J. Sheridan, DDS, MSD
Jacksonville, FL
Appreciated by the patient due to their outstanding esthetic qualities. They hold all teeth in the absolute positions where they were when braces were removed, but need to be replaced more frequently.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
Cheap, esthetic, and usually worn by patients, but unfortunately don’t last very long.
Peter Sinclair, DDS, MSD
Los Angeles, CA
Good for obsessive-compulsive adults, who will wear them 48 hours a day.
Flavio Uribe, DDS, MDS
Farmington, CT
A good approach for debonding and delivering retainers on the same patient visit.
Commentary by Dr. Graham: Great points by all, especially about proper fit.
I tell patients that retention:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Is part of their treatment—that retainers are “pajamas” for their teeth.
S. Jay Bowman, DMD, MSD
Portage, MI
Is a lifetime commitment to periodic wear of retention devices.
Robert S. Haeger, DDS, MS
Kent, WA
Is dependent on how picky they want to be about their teeth. The pickier you are, the longer and more often you need to wear your retainers.
Neal Kravitz, DMD, MS
South Riding, VA
Is critical to ensuring your beautiful smile.
Elliott Moskowitz, DDS, MS
New York, NY
Is an important aspect of orthodontic treatment that requires long-term patient understanding, cooperation, and realistic expectations.
W. Ronald Redmond, DDS, MS
San Clemente, CA
Will involve lifetime wearing of retainers while sleeping.
John J. Sheridan, DDS, MSD
Jacksonville, FL
Is required to hold the function and esthetics that the patient and I worked so hard to achieve, and will require constant professional monitoring.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
Is for life—you wear your retainer as long as you want your teeth to stay straight.
Peter Sinclair, DDS, MSD
Los Angeles, CA
Should stop when they turn 100.
Flavio Uribe, DDS, MDS
Farmington, CT
Is for as long as they want to keep their teeth straight.
Commentary by Dr. Graham: Shoaf and Uribe are compelling; Sinclair adds a nice twist, yet I think Alexander says it best.
Our most common retainer problem is:
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Adhesive breakage on the mandibular 3 × 3.
S. Jay Bowman, DMD, MSD
Portage, MI
Compliance.
Robert S. Haeger, DDS, MS
Kent, WA
Lower incisor relapse. End of discussion.
Neal Kravitz, DMD, MS
South Riding, VA
Non-compliance with Hawley-type retainers after interceptive Phase I treatment, or broken fixed maxillary retainers spanning to the canines or premolars.
Elliott Moskowitz, DDS, MS
New York, NY
Either lost retainers or retainers that are simply not worn consistently by the patient. Everything else is commentary.
W. Ronald Redmond, DDS, MS
San Clemente, CA
The patient not wearing the retainers as directed.
John J. Sheridan, DDS, MSD
Jacksonville, FL
Non-compliance with retention directives.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
Patients losing them and not wanting to pay for replacements.
Peter Sinclair, DDS, MSD
Los Angeles, CA
Dogs.
Flavio Uribe, DDS, MDS
Farmington, CT
Non-compliance with wear.
Commentary by Dr. Graham: Haeger and I must have the same patients!
The future of retention?
R.G. "Wick" Alexander, DDS, MSD
Arlington, TX
Interproximal enamel reduction on all patients and circumferential supracrestal fibrotomy on adults with severe rotations will improve the chances for long-term stability!
S. Jay Bowman, DMD, MSD
Portage, MI
Solid research is desperately needed to demonstrate the most effective and esthetic methods, along with appropriate timing and techniques to retain results.
Robert S. Haeger, DDS, MS
Kent, WA
How to better understand the balance of soft-tissue forces and mesial molar pressure on the teeth.
Neal Kravitz, DMD, MS
South Riding, VA
More orthodontists may consider fixed retention as luting agents improve, but removable retainers will always be part of orthodontic retention.
Elliott Moskowitz, DDS, MS
New York, NY
We should ensure that orthodontic forces are consistent with the directions and magnitude of tooth movements, consider extraction therapy more rather than less, and educate patients in developing realistic expectations about retention.
W. Ronald Redmond, DDS, MS
San Clemente, CA
Nanotechnology that monitors tooth position and, when needed, activates the periodontal ligament to inhibit relapse.
John J. Sheridan, DDS, MSD
Jacksonville, FL
It will depend on our progress in biological knowledge directed at decreasing the level and severity of relapse, while minimizing the dental and occlusal changes that accompany aging.
Sarah Shoaf, DDS, MEd, MS
Winston-Salem, NC
It depends on new materials that are more durable, esthetic, and effective.
Peter Sinclair, DDS, MSD
Los Angeles, CA
Using a local cream to ankylose the teeth forever!
Flavio Uribe, DDS, MDS
Farmington, CT
Biological!
Commentary by Dr. Graham: No real consensus here, but biology seems to be the theme.
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DR. GRAHAM
Dr. Graham is a Contributing Editor of the Journal of Clinical Orthodontics and an Adjunct Associate Professor for Clinical Orthodontics, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, and Department of Orthodontics, University of Rochester School of Medicine and Dentistry, Rochester, NY. He is in the private practice of orthodontics in Litchfield Park, AZ, and Salt Lake City; e-mail: orthograham@gmail.com.