SHORT COMMUNICATION

Unexpected complications of bonded

mandibular lingual retainers
Christos Katsaros,a Christos Livas,b and Anne-Marie Renkemac
Nijmegen, the Netherlands

Introduction: The flexible spiral wire (FSW) retainer is the most frequently used type of fixed retainer bonded
on all 6 anterior teeth. Our aim in this article was to demonstrate unexpected posttreatment changes in the
labiolingual position of the mandibular anterior teeth associated with the use of FSW retainers. Methods:
During a 3-year period, patients attending the postgraduate orthodontic clinic of the Department of
Orthodontics and Oral Biology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands,
for regular, posttreatment follow-up appointments were screened for unexpected posttreatment changes in
the mandibular anterior region. Results: Twenty-one patients with FSW retainers bonded on all 6 mandibular
anterior teeth presented unexpected posttreatment changes in that region. Almost half of these patients were
assessed as needing retreatment. Two patients are presented to illustrate the 2 distinct patterns of
posttreatment changes: torque difference between 2 adjacent mandibular incisors and increased buccal
inclination and movement of one mandibular canine. Conclusions: FSW retainers bonded on the 6
mandibular anterior teeth might cause unexpected movements of anterior teeth to such an extent that
retreatment is necessary. Clinicians should consider this possibility when planning the retention strategy. (Am
J Orthod Dentofacial Orthop 2007;132:838-41)

T
he stability of the treatment result is an impor-
tant issue in orthodontics. Studies evaluating
longitudinal posttreatment records have shown
remarkable relapses in several occlusal traits, especially
the alignment of the mandibular anterior teeth.1-9
To avoid relapse in the mandibular anterior region,
various types of removable or fixed retainers are used
either for an extended period of time or permanently.
Two types of fixed retainers are mainly used: retainers
bonded only on the lingual surfaces of the canines (3-3
retainers) and retainers bonded on all 6 anterior
teeth.10-12 The most frequently used type of fixed
retainer bonded on all 6 anterior mandibular teeth is the
flexible spiral wire (FSW) retainer.
Several advantages and disadvantages of fixed re-
tainers have been described in the literature (see the
article by Zachrisson and Buyukyilmaz13 for a review).
However, we have noticed over the years that FSW
From the Department of Orthodontics and Oral Biology, Radboud University
Nijmegen Medical Center, Nijmegen, the Netherlands.
a
Professor.
b
Postgraduate student; staff, Department of Orthodontics, 251 Hellenic Air
Force and Veterans General Hospital, Athens, Greece.
c
Faculty orthodontist.
Reprint requests to: Christos Katsaros, Department of Orthodontics and Oral
Biology, Radboud University Nijmegen Medical Center, 309 Tandheelkunde,
PO Box 9101, 6500 HB Nijmegen, the Netherlands; e-mail, C.Katsaros@
dent.umcn.nl.
Submitted, April 2007; revised and accepted, July 2007.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.07.011
838
retainers in the mandible are sometimes related to
unexpected posttreatment changes in the labiolingual
inclination or position of mandibular anterior teeth; to
our knowledge, this has not been discussed until now.
Our aims in this article are to show these unex-
pected posttreatment changes in the labiolingual posi-
tion of mandibular anterior teeth associated with FSW
retainers and to discuss aspects that should be consid-
ered in the planning of orthodontic retention.
CASE PRESENTATIONS
The postgraduate orthodontic clinic of the Depart-
ment of Orthodontics and Oral Biology, Radboud
University Nijmegen Medical Center, Nijmegen, The
Netherlands, schedules regular follow-ups at 1, 2, 5,
and 10 years after treatment. During the follow-up
visits of the last 3 years, 21 patients were identified
with unexpected posttreatment changes in the mandib-
ular anterior region, although after treatment all these
patients had received FSW retainers bonded on the 6
mandibular anterior teeth. Almost half of these patients
needed retreatment.
Two distinct patterns of posttreatment changes were
recognized in these 21 patients: torque difference be-
tween 2 adjacent mandibular incisors (18 patients) and
increased buccal inclination and movement of 1 man-
dibular canine (3 patients). One patient from each
group is presented to illustrate these patterns of post-
treatment changes.
American Journal of Orthodontics and Dentofacial Orthopedics Katsaros, Livas, and Renkema 839
Volume 132, Number 6

Fig 1. Records of patient 1: A-C, intraoral photographs 2 years posttreatment; D and E,

pretreatment study models; F and G, posttreatment study models.

Torque difference between 2 adjacent mandibular
incisors (patient 1)
This male patient, who was treated with fixed
appliances in both jaws because of crowding, visited
our clinic at the age of 16.8 years for his regular
2-years posttreatment follow-up. During the clinical
examination, marked differences in labiolingual in-
clination were seen in the mandibular central inci-
sors; the left central incisor had excessive lingual
root torque, and the right central incisor had buccal
root torque. These tooth movements took place even
though the bonded retainer of .0195-in 3-strand
heat-treated twist flex wire (Wildcat; GAC Interna-
tional, Bohemia, NY) was still in place (Fig 1, A-C).
This difference in labiolingual inclination, also ex-
pressed as a difference in the height of the clinical
crowns (Fig 1, C), was not present either before (Fig
1, D and E) or after treatment (Fig 1, F and G).
840 Katsaros, Livas, and Renkema
Fig 2. Records of patient 2: A and B, 1 year posttreatment; C and D, pretreatment records; E and
F, end of treatment.
Increased buccal inclination and movement
of a mandibular canine (patient 2)
This 13.5 year-old female patient, treated with fixed
appliances in both jaws because of palatally erupting
canines, had a notable change in the position of the
mandibular left canine at her 1-year posttreatment visit.
This canine, buccally inclined and distobuccally ro-
tated, could not occlude properly with its antagonists
(Fig 2, A and B); the retainer of .0195-in 3-strand
heat-treated twist flex wire (Wildcat; GAC Interna-
tional) was still in place. This unfavorable canine
position was not evident either before (Fig 2, C and D)
or after treatment (Fig 2, E and F).
DISCUSSION
These 2 patients demonstrate that the use of FSW
retainers in the mandible is sometimes associated with
unexpected posttreatment changes in the mandibular
American Journal of Orthodontics and Dentofacial Orthopedics
December 2007
anterior teeth. They represent 21 patients with problems
who were identified during regular follow-up visits in a
3-year period. We estimate that about 5% of the
patients who received this type of retainer have 1 of
these complications.
Of the 2 clinical situations in our patient group, the
difference in torque between 2 adjacent mandibular
incisors appears to be the most common. Pizarro and
Jones14 presented 2 cases with FSW retainers in the
maxilla, with relapse in crown inclination recorded
during the posttreatment period. In both patients, the
relapse was toward the pretreatment inclination. How-
ever, the striking finding in our patients is that the
torque difference between the 2 adjacent incisors was
not present either before or at the end of orthodontic
treatment. Thus, this posttreatment torque change can-
not be characterized as relapse. Although the retainer
was always adapted on a working dental cast to be
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 132, Number 6
entirely passive, it cannot be excluded that the operator
might have induced elastic deflection of the wire during
the bonding technique. Furthermore, mechanical defor-
mation of the wire during the posttreatment period,
caused by biting on hard food, cannot be excluded.
The clinical pattern in which the inclination and
position of a canine changes during the retention period
resembles the posttreatment changes in the maxillary
central incisors presented by Brenchley,15 who used a
1-1 FSW retainer. In his 3 patients, Brenchley also
observed unexpected movement of 1 of the 2 central
incisors in the distolabial direction. This movement was
attributed to active straightening of the short piece of
wire during function. To overcome this problem, an
extension of the retainer to incorporate all 4 incisors
was suggested.15 In our patients, however, all 6 anterior
teeth were fixed with the retainer, and the interdental
distances between the mandibular anterior teeth are
generally rather small. Moreover, these posttreatment
changes cannot be considered relapse of the orthodontic
treatment, since the canine was not in such an unfavor-
able position either before or after treatment. The
possible etiological factors described above for the
torque difference between 2 adjacent mandibular inci-
sors— eg, an active component of the wire, elastic
deflection caused by the clinician, and mechanical
deformation of the wire—might also hold true for the
changes in canine inclination and position.
In both patterns, the answer might be hidden in the
mechanical properties that the multi-stranded wires
acquired as a result of the fabrication process. Further
research on this is required.
Interestingly, none of these posttreatment compli-
cations was observed in 235 patients examined at 5
years posttreatment, when thick stainless steel retainers
bonded only on the mandibular canines and not on the
incisors were used.17 Although such a retainer might be
a good alternative,12 there is evidence that a relatively
high percentage of patients have a slight to moderate
increase in posttreatment irregularity of the mandibular
incisors with it.16 For this reason, in patients who
require perfect control of the alignment of the mandib-
ular incisors, we now use .016 ⫻ .022-in stainless steel
retainers bonded on all 6 anterior teeth with the .022-in
side in contact with the tooth surface. Both the teeth
and the wire surface are prepared by sandblasting the
area of fixation. Whether this type of retainer is
superior to the other forms of lingual retainers in the
long term is not yet known.
The fact that these posttreatment changes needed
retreatment in so many patients stresses the importance
Katsaros, Livas, and Renkema 841
of early detection. Patients and general dentists should
be informed about the possibility of such complications
and should be instructed in how to detect them, if
possible, at an early stage.
CONCLUSIONS
FSW retainers bonded on all 6 mandibular anterior
teeth might induce unexpected movement of anterior
teeth to such an extent that retreatment is necessary.
Clinicians should consider this possibility when plan-
ning their retention strategy.
REFERENCES
1. Al Yami EA, Kuijpers-Jagtman AM, van’t Hof MA. Stability of
orthodontic treatment outcome: follow-up until 10 years postre-
tention. Am J Orthod Dentofacial Orthop 1999;115:300-4.
2. Little RM, Wallen TR, Riedel RA. Stability and relapse of
mandibular anterior alignment—first premolar extraction cases
treated by traditional edgewise orthodontics. Am J Orthod
1981;80:349-65.
3. Little RM, Riedel RA, Årtun J. An evaluation of changes in
mandibular anterior alignment from 10 to 20 years postretention.
Am J Orthod Dentofacial Orthop 1988;93:423-8.
4. Little RM, Riedel RA. Postretention evaluation of stability and
relapse—mandibular arches with generalized spacing. Am J
Orthod Dentofacial Orthop 1989;95:37-41.
5. Sadowsky C, Sakols EI. Long-term assessment of orthodontic
relapse. Am J Orthod 1982;82:456-63.
6. Uhde MD, Sadowsky C, BeGole EA. Long-term stability of
dental relationships after orthodontic treatment. Angle Orthod
1983;53:240-52.
7. Sadowsky C, Schneider BJ, BeGole EA, Tahir E. Long-term
stability after orthodontic treatment: nonextraction with pro-
longed retention. Am J Orthod Dentofacial Orthop 1994;106:
243-9.
8. Riedel RA, Little RM, Bui TD. Mandibular incisor extraction—
postretention evaluation of stability and relapse. Angle Orthod
1992;62:103-16.
9. Little RM, Riedel RA, Stein A. Mandibular arch length increase
during the mixed dentition: postretention evaluation of stability
and relapse. Am J Orthod Dentofacial Orthop 1990;97:393-404.
10. Zachrisson BU. Clinical experience with direct-bonded orth-
odontic retainers. Am J Orthod 1977;71:440-8.
11. Zachrisson BU. The bonded lingual retainer and multiple spacing
of anterior teeth. Swed Dent J Suppl 1982;15:247-55.
12. Zachrisson BU. Third-generation mandibular bonded lingual 3-3
retainer. J Clin Orthod 1995;29:39-48.
13. Zachrisson BU, Buyukyilmaz T. Bonding in orthodontics. In:
Graber TM, Vanarsdall RL Jr, Vig KW, editors. Orthodontics:
current principles and techniques. 4th ed. St Louis: Elsevier
Mosby; 2005. p. 621-44.
14. Pizzaro K, Jones ML. Crown inclination relapse with multiflex
retainers. J Clin Orthod 1992;26:780-2.
15. Brenchley ML. A cautionary tale of simplified retention. Br J
Orthod 1997;24:113-5.
16. Renkema AM, Katsaros C. Unpublished data.
17. Renkema AM, Al Assad S, Katsaros C. Effectiveness of bonded
lingual retainers in controlling relapse of the lower incisors. Eur
J Orthod 2003;25:439.