REPEAL AND RESTRAINT

REPEAL AND RESTRAINT

Relapse in orthodontics is the more or less significant reappearance of the initial malocclusion and dental malpositions after active treatment.

It must be differentiated from the “normal” physiological maturation of the dental arches.

It still remains, in the opinion of all authors, the most difficult problem to solve in orthodontics.

Retention, which is an integral part of orthodontic treatment, is the means of preventing this relapse.

1. DEFINITIONS:
   1.  Recidivism :

🞂​ In medical terms, recurrence refers to the recurrence of a disease occurring after the subject has regained health.

🞂​ In orthodontics, it is the recurrence of malpositions or malocclusions that had been corrected by treatment. It can be total or partial.

1.2 Contention:

Retention in orthodontics corresponds to the stage immediately following the active treatment period, its purpose is to maintain the results obtained by the latter. We can therefore bring together under this term all the procedures which contribute to preventing relapse from occurring.

2. THE REPEATED OFFENSE:
   1.  Causes of recurrence:

The origin of orthodontic relapse is multifactorial. These causes can be classified into three factors:

• General factors.
• Local factors.
• Neuromuscular factors.
• ​

1. General factors:

 a. General causes:

• Endocrine disorders (thyroid, hormonal changes due to menopause or puberty, etc.)
• Nutrition, the psyche too.

Dr. MEGHERBI February 28, 2024

2.  Genetic causes:

Research is focused on one or more genes explaining the appearance of mandibular retrognathia and dolichomandibularis after treatment of significant Class II and III defects before the end of growth.

3.  Patient and family cooperation:

Cooperation is important during all phases of treatment: wearing active devices and then retention devices.

4.  Normal and pathological post-orthodontic growth:

Remember that the growth of the mandible continues longer than that of the maxilla. This phenomenon is favorable to retention in Class II cases, and unfavorable in Class III cases.

2. Local factors:
3. The shape of the teeth:

Some authors, notably H.Peck and S.Peck, believe that the recurrence of rotations is strongly linked to the morphology of the roots; a tooth with an oval-shaped root is less likely to rotate than a tooth with a circular-shaped root.

2. The meshing:

The shorter the cusps, the less deep the meshing and the less the tooth is connected to its antagonists .

3. The orientation of the occlusal plane :

Some authors believe that any therapeutic tilting of the occlusal plane is bound to relapse. PLANAS believes that an occlusal plane inclined downwards and forwards directs the chewing forces obliquely in a way that could push the mandible backwards, the maxilla forwards, and thus promote the relapse of a Class II malocclusion.

Therefore, the occlusal plane should be oriented upwards and forwards for Class IIs, downwards and forwards for Class IIIs.

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4. The occlusal function:

Balanced functional occlusion is an occlusion without posterior contacts in the propulsion movement (immediate posterior disocclusion) and without contact on the non-working side during diduction movements.

Poor occlusal function can cause relapse.

5. The evolution of wisdom teeth:

• For some authors, the 3rd upper molar would be the origin of a mesial force leading to instability of the occlusion ( CHATEAU ).
• In the mandible, when this tooth develops intraosseously, due to the proximity of the ascending branch, some authors believe that a mesial thrust is created causing incisal crowding ( SCHULHOF, THEUVENY ).
• Others believe that this push is ineffective, if it exists ( BROADBENT, BISHARA and ANDREASEN, LITTLE and RIEDEL, VAN DER LINDEN ).

There is no scientifically established data to recommend or contraindicate their removal for orthodontic reasons […] these removals are the subject of controversy, but seem to be accepted in clinical practice.

In conclusion, germectomies should be reserved:

1. in cases where the risk of congestion occurring due to insufficient space is high (DDM treated without extractions with appreciable lip pressure);
2. in cases where an inflammatory accident is foreseeable, taking into account the space for the teeth.
3. Dental disharmony:

DDD can be a factor in relapse, due to the difference in mesiodistal diameters of the teeth of one arch compared to the other, because the occlusion is not locked.

7. Tensions of desmodontal fibers: The relapse movements most affected by desmodontal factors are rotations and reopening of spaces.
8. Tissue compression following closure of extraction space:

2.1.3 Neuromuscular factors:

All authors agree that removing the causes of

Malocclusion due to the muscular and functional environment is essential in the search for stability.

Dr. MEGHERBI February 28, 2024

2.  Most recurring anomalies
   1.  Class I malocclusions:
      1. Anterior infraclusions
      2. Mandibular incisal crowding.
      3. Transverse expansion.
      4. The rotations.
      5. Diastemas:
   2.  Class II malocclusions:

Class II/1: As far as molar relationships are concerned, the relapse is only very slight.

Class II/2: The problem with this malocclusion concerns the overbite, which all authors consider to be particularly exposed to relapse.

a.2.3 Class III malocclusions:

Mandibular growth, which often continues very late in boys, is the main cause of relapse. Another factor is the volume and activity of the tongue. The tongue will therefore cause an early relapse.

3.  Prevention of recurrence and methods of stabilizing treatment effects :

The onset of recurrence can be immediate, as soon as the device is removed, or delayed and progressive, generally more pronounced around the age of thirty. Each practitioner develops, based on their professional experience, a certain number of reference criteria on which they rely to try to counter this phenomenon.

1 Establishing Andrews occlusion:

Andrews ‘ six keys to ideal occlusion (CL I canine and molar, mesial angulation of the teeth, torque, absence of rotation, absence of diastema, a flat or weak curve of spee) represent a fundamental therapeutic objective. The first key, in particular, ensures posterior locking, which appears to be one of the pillars of a stable occlusion.

2. choice of extractions:

In cases where extractions are necessary, extraction today still

almost systematic of the first premolars, is a probable factor of instability.

Dr. MEGHERBI February 28, 2024

3.  Functional environment control:

Mastery of the neuro-muscular environment remains the Achilles heel of our profession (functional rehabilitation).

4.  Assessment of the growth pattern.
5.  Overcorrection.
6.  Coronary arteries:
   • Mandibular incisor plastic surgery:
   • Maxillary incisor plastic surgery:
7.  Fibrotomy.
8.  Gingivoplasty.
9.  Frenectomy.
10. THE CONTENTION:
    1.  Objective :

Retention corresponds to the final phase of orthodontic treatment and begins after active treatment.

Its objectives are:

1. Stabilize teeth during tissue reorganization
2. Promote the establishment of good occlusion
3. Limit the effects of a new or existing pathogenesis.
4.  Principles:

The choice of the type of restraint must be guided by certain principles; A good restraint must be:

• immediate:
• intelligent: A restraint is said to be intelligent when it specifically and individually counters the risks of recurrence presented by the patient.

Dr. MEGHERBI February 28, 2024

• Fixed: Not all retention systems can be fixed, but whenever possible, fixed appliances should be preferred and removable appliances avoided.
• Extended.

3.  Restraint devices:

1 Unimaxillary devices:

• Removable unimaxillary devices:
  1. Hawley’s plate: It can be hollowed out at the palatal level, in cases of agenesis, a facet can be added.
  2.  The SVED plaque:

This is a palatal plate with a return of

Resin surrounding the free edge of the maxillary incisors.

3. The lower removable plate. d) The nocturnal lingual envelope.

e)The thermoformed gutter:

It is a gutter made with a rigid transparent thermoplastic material (approximately 1mm thick)

heated and vacuum-formed onto the end-of-treatment plaster cast.

• Fixed unimaxillary devices: (bonded retention):
  1. Wire: Polished wire with a round section of diameter .030” (0.7mm) or .032” (0.8mm) is recommended .
  2. glued grids: ribbons applied to the lingual surfaces can sometimes be used in plastic ( Kevlar ). This process is most often used in periodontics.
  3. Synthetic fibers or glass fibers
  4. Prefabricated metal splints

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5. Bonded cast splints: metal splints are generally not made by the orthodontist, but by the specialist in fixed prosthetics, they represent the best retention for adults.

Noticed :

To conclude with unimaxillary fixed devices, it should be noted that the bonded retention can sometimes be temporary, even before the eruption of all the permanent teeth.

2 Bimaxillary devices:

• Removable bimaxillary devices:

1. The positioners:

The positioner, made of rubber or elastic elastomeric material, is a one-piece device consisting of two splints, one maxillary and one mandibular, secured together. These splints are made according to a

dental alignment and optimal arch relationships. It therefore acts as an active finishing device initially, and then, subsequently, as a retention device.

• The tooth positioner: (developed by KESLING in 1945)
• prefabricated positioners or “FINISHERS”:

2. The activators:

Initially designed for the correction of Class II skeletal discrepancies, they can also be used in retention. Constructed with very light propulsion and worn at night.

3. Intermaxillary elastics on removable plate:

Two removable plates can be connected by

intermaxillary elastics, either class II or class III type.

Dr. MEGHERBI February 28, 2024

2 Bimaxillary devices:

• Fixed bimaxillary devices:

1. The cingulate stops:

Cingulate stops are small masses of composite placed on the cingula of the maxillary incisors and often canines, intended to prevent recurrence of the overbite.

2. The anterior night elastic:

In reality, the anterior night elastic is a mixed device, with a fixed part and another removable part, most often made of an elastic.

• It is indicated for the containment of class II division 1 treatments.

3.4 Restraint in adults: 3.4.1. Particularities of adults:

1.  Psychology and motivation: The adult requests treatment

short and effective, there are often compromises and the restraint must be long-term or even permanent.

2.  Lack of growth: Skeletal discrepancies are compensated for by orthognathic surgery.
3.  Periodontal aging
4.  Joint context:

The orthodontist must know how to detect patients at risk so as not to aggravate or trigger joint problems.

3.4.2 Type of restraint:

Restraint in adults must be fixed, and will be of a nature;

• Glued braided threads
• Intracoronary wires included in composite
• Glued cast splints
• Metal containment grids

Dr. MEGHERBI February 28, 2024

• Bridges

In cases of multiple edentulousness, these systems can be supplemented by a removable, low-profile prosthesis.

3.5 Duration of restraint:

• -IZARD and CHATEAU recommend restraint day and night for a few weeks; after this period, restraint is only at night to allow the new joint to be broken in.
• THEUVENY, THEVENIN, MAGILL, stop the restraint after one year.
• SCHUDY, BONNOT, continue the retention until the end of growth and the development of the 3rd molar.
• OPPENHEIM, when discussing the duration of the restraint, is credited with the following answer: “until marriage for girls!”
  • 1919 – HAWLEY. “Twelve or fifteen years ago, a good friend of mine, who had been dealing with the difficulties of restraint for several years, said to me, ‘If anyone would take my cases when they are finished, restrain them, and be responsible for them afterward, I would be glad to give him half the fee.’”
• Hawley explains the advantages of the removable plate that now bears his name. He specifies that the plate should rise on the lingual surfaces up to the occlusal edge, as long as it does not interfere with the occlusion.

• There is no fixed and well-defined duration for restraint, but the following principles can reasonably be adopted:
• As long as the recidivism factors persist, it is essential to maintain restraint.

Conclusion :

At the end of this work we can say that recurrence exists and that it is therefore absurd to deny it and thereby promise the impossible. On the contrary, the practitioner is obliged to provide information to the patient before treatment , emphasizing the importance of the containment phase and the risks of possible recurrence, and implementing procedures designed to limit it.

REPEAL AND RESTRAINT

  Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.

REPEAL AND RESTRAINT