Topics of the day:

1. Re: Relapse of lower incisor with bonded retainer
2. Re: Relapse of lower incisor with bonded retainer
3. Re: Bonded Retainer Relapse
4. Re: Bonded Retainer Relapse
5. Re: Relapse with dead-soft wire bonded retainer
6. Re: Relapse of lower incisors with a bonded lower retainer
7. Re: Relapse of lower incisors with a bonded lower retainer
8. RE: tongue thrust
9. RE: Coolpix 5400
10. Osteoporosis
12. ESCO - The Electronic Study Club for Orthodontics

Date: Thu, 4 Mar 2004 09:43:11 EST
Subject: Re: Relapse of lower incisor with bonded retainer

Dr. Castella,

First, kudos to you for posting a non ideal case on this discussion.  You may be one of the few orthodontists in the country willing to admit publicly in a national forum that every case is not perfect.  This type of problem and the discussion that will hopefully follow is exactly what a study club is for.

I think this case is a good one to globalize into a general discussion of the age old question of stability of the teeth following the removal of the appliances and specifically lower incisor stability. To have a tooth move with a wire bonded to it says to me that even though this case looks good as a finished case, the result was unstable enough to overpower a significant effort to hold those teeth in place.

I would suggest that there were multiple factors contributing to this instability and my approach to figuring out something like this is to consider what research and clinical experience seems to show will inhance stability and then see where this particular case might differ from those elements.

From every thing I have read and from my own experience, lower arch stability is influenced by 4 major diagonstic/treatment plan decisions related to solving any malocclusion and I think all of those factors come into play in this case.  I also see one other factor specific to this case but it is related to all of the general points.

In general I think stability comes from the following 4 factors pretty much in the order I have listed and I think that there is a pretty convincing body of literature spanning 60 years or so supporting these points. 

The 4 factors are:

1)  Resolution of the initial problem, which is usually a tooth size arch length discrepancy, i.e. crowding.  If the teeth are to large for the bone, you have to solve this problem first. Solving it usually means removing some tooth material or holding E space if that option exists.  Just aligning teeth by pushing them around into a different position with out addressing the fact that genetically they are to big for the bone they erupted into is not really solving the problem.

In this regard it would be helpful to see the initial photos of your case but I am willing to guess that that lateral was blocked out to the lingual and the lower midline was off to the left (it still looks slightly off to the left) and I would also guess that the canine erupted blocked out buccaly. In my practice this means remove some tooth material either by interproximal reduction or extraction(s), depending on the amount of crowding and tooth morphology etc. Since all of the teeth are there it is obvious that you did not extract, and from the shape of the teeth and the contacts it doesn't look like there was any interproximal reduction.  

I feel that broader contacts created by interproximal reduction as well as the reduction of tooth mass contributes a lot to incisor stability, especially when the case is going to be treated non extraction.  Lee Boese has written quite a bit about this subject and I am echoing his findings.

2)  Maintaining original arch form.
3)  Maintaining intercanine width.

Both of these are related of course and I wonder how your final arch form relates to your initial arch form.  Rick McLaughlin talks a lot about arch form in his books and in his lectures and has made it an important part of the MBT system he developed.  In the MBT system there are 3 basic arch forms and he chooses the one that best fits the initial arch from then uses that arch form through out treatment. There is still some customization of the arch form required but the 3 basic arch forms cover a vast majority of patients and for me is a much more sensible approach than having a "one size fits all" arch form. (disclaimer:  I use McLaughlins MBT system in my office and am a strong advocate of the principles it is based on.  I also do some lecturing on the MBT system of mechanics) 

Your finished arch form looks quite broad and while some advocate a "broad arch" for esthetics, I find that the best esthetics (and the one that the patients most want) are the good esthetics that come from teeth that stay straight so I like to choose my arch form based on what is going to give the teeth the best chance at staying aligned.  The gingivia around both canines looks thin and I see alot of clinical crown which also make me think that there was some expansion of the intercanine width.

4)  Keeping incisors upright over basal bone, i.e. not tipping them out to the buccal. The university of Washington studies show a pretty strong evidence that you will get more incisor relapse if incisors were moved forward during treatment.  Again, I look at the gingivia around the lower central incisors and it looks thin and those clinical crowns look long so I would think that the incisors have come forward during treatment. (Sorry about all of the gingivia talk, I went to Penn for ortho and besides Dr Vanarsdall talking a lot about gums, there was a periodontist in my class as well, so I was forced to look at gingivia and discuss it for 2 solid years and now I can't help myself...........:-)...)   

So those are the 4 general points that you can go back and evaluate on this case when trying to figure out if any or all were a factor in contributing to the movement of that incisor.  It would be great if you could post the initial photos and what you conclude after reading this and any other posts people send in.

The one specific point regarding this case (and it ties in with all of the above) is that it looks like you needed some buccal root torque on that lateral to get the root under the crown.  When I look at the full arch finished photo, it looks like the incisal edges are lined up but if you look at the lingual surface of the lateral right at the gingival margin, it looks displaced to the lingual relative to the other teeth.  I look for when checking my own cases prior to debond.  When I see that, I almost always have to go in and put some torque in a wire and bring the root buccal under the crown.  Your relapse in this case is the crown moving to the lingual and it looks to me like it is up-righting over the root.  Jim Boley talks a lot about proper lower incisor torque and stability in his lectures and I agree with him on this point (and on most others as well).

Again Paul, thanks for posting the picture and opening up this discussion.  My response is a long answer to a short question but I don't think there are any easy answers to things like what you showed.  I will be interested to read others comments and I hope you put your own analysis after digesting everyone's comments.

John McDonald
Salem, OR

In my cases, I find this problem a lot when I try to force the incisors in to alignment with just nitinol wire without first opening adequate space to easily bring the tooth into the arch.  When I try to force it in, the root stays lingual and I have to drop back and open the space to allow the torqued wire to work. 

So to tie it all together it gets into the treatment decision of where are you going to get the space to bring the tooth (teeth) into proper alignment, torque and all.  Do you have to reduce the amount of tooth material to create the space (point #1) or are you going to "expand" or push the teeth around which then forces you to consider what your limits are in regard to points 2, 3, and 4 and how that is going to affect the long term stability of the case. 

We all know that eruption, mesial drift, occusal forces, growth and adaptive biology in general are all working against long term lower incisor stability.  Given that understanding, I feel that if I am going to have any chance at all at giving my patients teeth a decent chance to remain straight, I need to pay attention to all the details.

From: "Charles J. Ruff" <>
To: "The Electronic Study Club for Orthodontics" <ESCO@LISTSERV.UIC.EDU>
Subject: Re: Relapse of lower incisor with bonded retainer
Date: Wed, 3 Mar 2004 10:43:46 -0500

Dear Paul,

As someone who is committed to the idea of fixed retention, let me offer some advice.

1. just thinking out loud on this first comment-thin attachment on 6, 22, 24 &25. Did you push the limits of non x tx? Since there were no original records, I wonder. I have no idea if "pushing the limits" even assuming you did that would make much of a difference to retnetion.

2. The lower right lateral also is turned a little but obviously no where near as much as the left

3. I have used different forms of fixed lower retainers but generally have found dead soft wires of one type of another to be problems waiting to happen. I know a dead soft wire is easy to form and saves chair time but they tend to break or even it seems stretch. That may have been the problem here.

4. The only dead soft product that I like is Flextech from Reliance, a product developed by the legendary Dave Musich (:-). this does not seem to have many problems assoicated with it.

5. I would prefer to use a 0.032 bar bonded just to the 3's whenever possible. This is rigid there is published materail by Bjorn Z on long term efficacy. In cases of lower incisor extraction, severe rotations, or pre tx spacing, I will use a gold plated 0.0195 twist but this requires lab work to fit it.

6. did you do any stripping prior to removing the braces. Knowing that there is a loss of arch length with age, I always look for excuses to IPR (using wheels) especially in non x cases just to "take the pressure off."

7. how do you plan on straightening these teeth. I would remove the retainer and use a pressure formed clear retainer (full coverage essix) ala Keith Hilliard reather than a spring type Halwey.

Good luck

Charlie Ruff


Date: Wed, 3 Mar 2004 13:04:08 EST
Subject: Re:Bonded Retainer Relapse

It is always very difficult to evaluate & give possible reasons of relapse looking only at intraoral photos. I will take a chance & offer the following thougths:
1. My first thought is that this might have been better to treat as an extraction case. I base this thought on the lower 7's-not erupted completely, still with tissue over the distal occlusal. Upper 7's erupting in a buccal inclination & hanging lingual cusps. The tissue on labial of lower incisors is very thin.
2. The finished result the lower laterals have broken contacts. There does not appear to be an even distal axial root inclination of the incisors.
3. The upper cuspids are too upright & incisal tips are in the embrassure instead of slight mesial inclination to relate with lower cuspids for good guidance.
4. There is a lack of overbite-thus lack of disclusion.
5. I doubt if the upper & lower second molars were banded. This almost always results in balancing interferences & fulcrums that cause a mesial deflection of the mandible which shows first in lower incisor relapse. Look closely at the left second molars and you see a buccal inclination & the upper lingual cusp  is hanging "down". A big balancing interference & premature centric.
Of course, complete records would give much more info to answer more accurately but these are thoughts based only on the intraoral records.

Bob Williams-Los Altos, CA. ( Dick being from CA am I too outspoken?)


Date: Wed, 3 Mar 2004 19:48:37 EST
Subject: Re: Bonded Retainer Relapse

Dr. Castella,

I use a lower fixed retainer that is bonded to every tooth (3 to 3). I have been told by my colleagues that is an over kill but I rarely have any problems. I used to use a flex wire but proved to be too soft and broke too easy. I use 018 or 020 ss wire and have been very happy with it. The problem with the rotation may be a coincident. I would go back and look at the original records to see how rotated these teeth used to be. With the type I use even if one of the pads comes loose it still keeps the tooth straight since the pad is touching it.

Good luck

Tony Togrye


Date: Sun, 7 Mar 2004 22:21:13 +0100 (CET)
From: "Jérôme Wanono" <>
Subject: Re: Relapse with dead-soft wire bonded retainer

Dear Dr Castella,

Since one year, my wife, Dr Telegat, has bonded about 80 patients with the same wire that you have used : Respond Dead Soft Ormco 0195. She experienced also 4 or 5 cases of relapse identical than yours and one was worse.

Her conclusions are: the wire is too soft and allows small overlapping by sliding of the contact points. This could maybe be avoided, by - stripping lightly the contact points to obtain plane contact surfaces and- by covering with composite  all the wire, from the mesial to the distal . This means that a very small amount of wire will be free of composite between the teeth, reducing its flexibility.

Anyway, she is now using a rigid coaxial wire and gave up the use of dead-soft wires for retention except for cases with small amounts of crowding at the beginning of treatment.

Hope this will help.

Jerôme Wanono

Date: Wed, 3 Mar 2004 07:35:27 EST
Subject: Re: Relapse of lower incisors with a bonded lower retainer

Dear Dr. Castella,

In almost all cases in which a bonded lingual retainer has been properly placed (with light or heavy wire), and relapse occurs similar to your photo, look for a distortion in the wire caused by the patient improperly masticating on foods that they were told not to eat. 

Elliott Moskowitz

Date: Friday, March 05, 2004 9:17 PM
Subject: Re: Relapse of lower incisors with a bonded lower retainer

Bent twist wire?  I recently received a transfer patient  where the mandibular right canine was moved out of bone with gingival stripping labially so severe it needed to be extracted. Complicating factors included very poor oral oral hygiene.

Richard Jacobson

Pacific Palisades CA  or


From: "Paul Thomas" <>
Subject: RE: tongue thrust
Date: Wed, 3 Mar 2004 16:30:13 -0000

I'm pleased to see that I haven't been hung out to dry on the tongue thrust issue.  It's amazing how this theory continues to surface despite considerable strain gauge research on soft tissue pressures, etc.

In reference to Charlie's question regarding the signature block and for those whom I know electronically.  What can I say??  I met a beautiful, brainy (PhD in molecular biology) consultant orthodontist when lecturing in England several years back. I sold my practice, my home and we were married last July (see attached) In October, I started half-time at the Eastman in London.  My appointment is as "senior research fellow", but I'm doing a bit of everything including orthognathic surgery and implant surgery, diadactic instruction with the grads, research, etc.  I'm there every other week and have enjoyed working with Nigel Hunt, Sue Cunningham, Tim Lloyd (mxfx surgeon).  So far, a very nice way to wind-down a career.  I'm still back in the US one week out of every two months to work in my old surgery practice (the restrictive covenant doesn't allow ortho)......and of course, it's nice to keep up with the US scene via the list serve.

Best to All,

Paul M Thomas, DMD, MS
Senior Research Fellow:
Eastman Dental Institute
for Oral Healthcare Sciences
London, England


From: "JM" <>
To: "The Electronic Study Club for Orthodontics" <ESCO@LISTSERV.UIC.EDU>
Subject: RE: Coolpix 5400
Date: Wed, 3 Mar 2004 20:36:46 +1100

Hi Brett,

Regarding the focus with the Coolpix - I would have assumed that you were using the manual focus with your 990 (as I did with my Coolpix 995 ). So I would use the same method with the 5400 - I find these cameras spend a lot of time "hunting" for auto focus intra-orally. Incidentally, I now use a FujiS1 with a ring flash and haven't looked back.

The Nikon D70 below AUD$2000 is another brilliant choice for dental use.

John Mamutil

Baulkham Hills


Date: Thu, 4 Mar 2004 12:10:24 +1300
From: "Craig Sharp" <>
To: "ESCO" <>
Subject: Osteoporosis

Hello Group,

I have a mid- fifties female patient who would like treatment (probably upper and lower
fixed appliances with upper premolar extrns) but has just been diagnosed with
osteporosis.  Medication has been started.

Do you know of any contra-indications to Ortho. Tx in cases of oseoporosis ?  Is resorption
more of a problem ?  Should the Ortho. be delayed until the calcium levels have been normalised ?

Any advice\recommendations would be appreciated.

Craig Sharp

From: "Charles J. Ruff" <>
To: "The Electronic Study Club for Orthodontics" <ESCO@LISTSERV.UIC.EDU>
Subject: IMTEC
Date: Wed, 3 Mar 2004 18:31:31 -0500

Some of you may have noticed ads in the AJODO for IMTEC ortho implants. They are offering four CE programs around the country and I am thinking of taking the program in NY on April 10th. On the web site for IMTEC, the only info they provide is a place to pay with my credit card. No other info about the course of the concept. I am familier with the AbsoAnchor microscrews and I am wondering if this course is worth the money.

Someone from Baylor where ever that is ( :-) is teaching it. Even that is not on the web site.

Can anyone provide additional info?


Charlie Ruff

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