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Post-treatment Management of Orthodontic Patients Gerald Nelson, DDS

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by Gerald Nelson, DDS

What happens after the braces come off? Post-orthodontic stability is a bit of a mystery. Research to date has given us little to rely on other than indefinite retention. In this article, I will discuss the management and efficiency of this period of patient care. The information comes from having partnership practices with three remarkable orthodontist colleagues, Michael Meyer, Earl Johnson and Paul Kasrovi, and from decades of collaboration with Karen Moawad, orthodontic consultant.

When I came out of residency and entered practice with these UCSF colleagues, we provided an extraordinary amount of doctor time to our retention patients, seeing them four or five times in the first year, three the next and biannually after that. Current ideas on efficiency suggest that comprehensive treatment should involve less than 25 times, from the very first visit to the final retention visit. Before our efficiency makeover, we used 20 visits during retention alone.

It really changed when Mike and I decided we each needed a three-month sabbatical from the office. At the time we were each working four days per week in two office spaces. We preceded scheduling our sabbatical with a thorough analysis of our efficiency, figuring we could pare clinic time requirements to the point that one of us could manage for three months. We made many changes, and our retention protocol was radically revised.

Our current retention protocol looks something like this:

Hardware
Non-extraction patients – Maxillary pressure-formed (as opposed to vacuum-formed) slip-cover retainer, lower 3-3 lingual fixed retainer bar with bonded pads on the cuspids. Reasoning is this combination is ideal for a good finish that doesn't need any touching up with active springs on a Hawley. The slipcover holds spaces closed, and doesn't need any adjustments (no doctor time). If the patient is a bruxer, you can use 2mm of Biostar (Great Lakes Orthodontics) material, which is almost indestructible. We spot the occlusion so that there are some bilateral contacts in CR. The lower bonded retainer is more secure if you lay a thin coat of composite over the bonding pads to cover most of the lingual surface of the cuspid – more comfortable to the tongue as well. Prior to bonding, we might do some IPR to flatten the interpoximal surfaces. Patients can floss with this retainer by looping the floss around each individual incisor to floss all the way down to the sulcus.

We tell young patients with fixed retainers that they must keep the bonded retainer until they are out of college, at which time they can come to see us and discuss the pros/cons of keeping it in place. We tell adult patients that it should be considered a permanent fixture.

Extraction patients – Need to keep that extraction site closed. We usually place an upper Hawley and lower slipcover retainer. Both require almost no doctor time, and the lower slipcover can act as a night guard. At one time we tried upper and lower slipcover retainers. I don't recommend this, as the occlusion does not settle well. I learned the hard way as I tried to find my ABO cases.

Mixed dentition patients – This retainer will hold incisor alignment, arch length molar width and can be worn through transition without affecting the emerging buccal segments.

Retainer Wear Requirements

We ask patients to wear the retainer full time for four weeks and then just at night. Many practices use full-time retainers for a much longer period. I think this just adds to doctor time and to broken or lost appliances without any benefit to stability. After fixed appliances are removed, the circumferential fibers tighten up in response to mastication without the support of archwires. If the retainer is worn full time, this adaptation is delayed.

Retention Period Visits
Our basic plan is three to four visits after the deband/retainer delivery appointments. Retainers are delivered the same day as deband or the day after. You must have an in-house lab to do this, but it is pretty easy if the retainers are an upper slipcover and lower fixed.
  1. Eight weeks to check cooperation – at this point the patient has been using the removable retainers at night only for one month. Final records have been reviewed by the doctor, and copies of photos and radiograph were sent out to the dentist. The patient can be shown the beginning records at this visit, and a testimonial form completed.
  2. Four months later – confirm cooperation, follow up on referrals, e.g. third molars.
  3. Twelve months later – some patients will be dismissed at this visit, often those with fixed lower lingual bars.
  4. Twelve months – dismiss from practice. At this time we advise the referring dentist that the patient continues to use the retainer without visits in our office and has been told that he or she is welcome to come in if there are any concerns.

Minor Tooth Movement
If a patient has a need for some minor tooth movement after deband, such as closing a slight space or controlling a rotation tendency, we consider this an active phase, and see the patient every six weeks until our minor tooth movement goal is met. Then we start our normal retention protocol. Consequently, we try pretty hard to avoid any discrepancies at deband.

Retainer Loss
If a patient loses a removable retainer, or the fixed retainer becomes loose, and there has been some movement, our typical choice is to bracket the anterior teeth involved, align for two months and then replace the retainers. This choice uses much less doctor time than using an active spring retainer. We know this from experience.

Final Records
We use final records to plan the retention period, to evaluate interproximal bone, to look at the cortical bone layer of the condyles and verify the condition of the root forms. Because of a carefully crafted approach to obtaining them, we rarely have any resistance to final records. Here's the sequence: When the deband visit is put in the schedule, the computer trips a letter home and to the dentist explaining that treatment will end on (date) and that if there are any concerns about the finish, we should be notified. The letter explains the need for the X-rays, models and photos, which will be done at the deband appointment. Combining final records with this appointment makes the most sense to the patient family, who is typically quite agreeable to any procedures involved with removal of the braces. The excitement of the deband appointment is enhanced by the ceremony of taking photographs (copies of which are sent home) and radiographs (copied to the dentist). Naturally this works best if all records are taken in-office. If you delay final records to some other time, there will often be resistance.

Key Entries During the Retention Period
Each patient should have at least these four topics included in the treatment notes during the retention period:
  1. Retainer cooperation status – notes showing whether the patient is fully following instruction, that the dentition stability is/is not satisfactory, or any caveats that are observed, and advice given.
  2. TMJ status – notes should show that a TMJ screening was done, and the result; WNL, or any departure from that, and what advice was given, or referral made.
  3. Wisdom teeth – notes must show that the status of these teeth was observed using proper records, and that appropriate recommendations made.
  4. Periodontal status – any caveats noted in treatment planning, or during treatment, should have a follow-up note during retention. Especially note food impaction due to loose contacts and make recommendations. If all is well, a note should indicate that.
Final Thoughts
The retention period is an important responsibility of an orthodontist. The protocol above allows one to meet this responsibility efficiently, and will maintain the approval of your patient families and referring dentists.

Author’s Bio
Gerald D. Nelson, DDS, health sciences clinical professor, Orthodontic Division, Department of Orofacial Sciences, UCSF Dental School is a 1965 graduate of UCSF. He currently supervises treatment in the resident clinic, lectures on mixed dentition, skeletal anchorage and biomechanics. He is editor of the PCSO Bulletin. He is a PCSO board member and delegate in the AAO House, and serves on the editorial board of the AJO/DO.
Orthotown Magazine
September 2025
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