Sometimes while I am surfing the web, I will check what is “floating around” the internet regarding orthodontic topics. I talk to my patients often about retainer options when their braces are removed, and I was surprised to see the amount of information and discussions out there regarding bonded retainers – small wires that are bonded to the back side of front teeth (usually lowers) – after braces have been removed. Like most topics, there is a large amount of credible information available, and an equally large amount of…how shall I put this…baloney? If you are wondering about if bonded retainers are right for you, here is my take on the subject.

First a little about my overall orthodontic philosophy. There are many ways to treat patients orthodontically. There are many MANY appliances, manufactures of braces, wires, instruments, elastics, etc… that all claim to be the best.  There are a large number of “systems” that practitioners can choose to follow exclusively, and there are different types of retainers and retention protocols that orthodontists can choose to offer to their patients. Personally, I choose to be educated and aware of all the options that are available to my patients (both cutting edge and traditional tried-and-true), and do my best to make decisions whenever possible according to evidence based practices (from scholarly peer reviewed journals of our profession) mixed with years of clinical experience. Borrowing from Dr. William Proffit’s article about using research to guide clinical decisions:

An orthodontist, like all health care providers, wants to know three things about the treatment he or she is providing: its

1. effectiveness (how well it works, i.e., how effective it is in dealing with the patient’s problems, taking into account possible negative side effects),
2. efficiency (how cost-effective it is, with cost in its broader sense to include time and effort for the provider and impact on the patient), and
3. predictability (the amount of variation in patient response).

Lets look at bonded retainers in light of these three factors.

1. Are bonded retainers effective?  Meaning, do they work well? Bonded retainers can work extremely well, and I have found there are two main factors that will determine how well they work. Fist, the patient must be determined to be an excellent candidate for the responsibility to have a bonded retainer. After carefully observing the patient’s habits (oral hygiene, their tendency to keep braces intact or to break them often, and overall compliance and responsibility with treatment), I usually have a good idea if a bonded retainer will work well for them. If a patient does not have excellent hygiene practices, I personally will not recommend a bonded retainer until they prove otherwise. Poor hygiene around bonded retainers is asking for failure, with periodontal health risk. On the other hand, excellent awareness and hygiene usually leads to favorable long term prognosis. The second factor is how well the bonded retainer is applied to the teeth by the orthodontic office. I think properly bonding a retainer is one of the most technique sensitive things that I do day to day, and therefore I exclusively place all bonded retainers in my practice. I know this is not the norm, and not efficient for my practice in the short (see #2!)term, but I have found massive gains in effectiveness since I started doing the bonding myself.
2. What about efficiency? As stated above, I spend A LOT of time making sure bonded retainers are placed just right. This not cost efficient for my practice short term, but have found that long term the increase in effectiveness and predictability (see #3!) make this overall very efficient. Much fewer re-treating with braces, much fewer failures, and much happier patients!
3. Are bonded retainers predictable? In other words, how much variation is expected in how patients respond to the bonded retainers? This is obviously very dependent on the factors that I described above. I find that if I am selective with who are proper candidates for bonded retainers,and treat each patient on an individual basis, bonded retainers are very predictable. Having said that, I can predict that at some point they will fail (break) and will need maintenance. Just like a car, your furnace, or your roof, a retainer needs proper care, maintenance, and sometimes replacement to work properly. Some people will need to wear the bonded retainers for life to maintain aligned teeth, while others may wish to have them removed at some point in favor of removable retainers. It is all individual, and each individual should be treated according to their unique lifestyle, habits, and wishes.

I hear often from patients who come to see me for re-treatment (their teeth have shifted after orthodontic treatment in the past), ” My previous orthodontist never offered me bonded retainers! Why not?” Honestly, I cannot answer that question. Maybe they found that in their practice they were not effective, efficient, or predictable, and never offered then to anyone. Why? Maybe in the past their staff members placed the retainers and they failed often (By the way, some staff members in practices I know are great at placing bonded retainers!). Maybe they did not choose wisely in who are and are not good candidates for bonded retainers, and they failed often. Maybe they did offer bonded retainers in their practice, but choose not to offer one to you based on your hygiene or compliance issues. Or maybe they just liked removable retainers better to avoid the possible negative side effects that some patients can experience with hygiene, maintenance, etc…The important thing is for me to consult with you in the present, and to engage in an honest discussion about the pros and cons of bonded retainers (and the pros and cons of removable retainers), and then determine if they will be effective, efficient, and predictable for you.

Dr. Dan Rejman is the owner of Meadows Orthodontics in Castle Rock, CO. He has been board certified by the American Board of Orthodontics since 2007, and is in his third year serving as the councilman representing the Rocky Mountain and Southwest Orthodontic Societies for the College of Diplomates of the American Board of Orthodontics.

A questions that I am often asked by patients and their parents is, “What works best to keep teeth clean while wearing braces?”  My reply is “whatever works best for you as an individual”.  Many patients do really well with traditional toothbrushes, while others respond really well with to electric brushes. There are also many adjunct devices that help clean between teeth and reach spaces that may be hard for brushes to contact (especially with braces on). With so many choices available when you walk through the dental section of supermarkets and drug stores, here is a guide to help find what will work best for you.

Traditional manual toothbrushes:  As I stated, many orthodontic patients do a fantastic job of keeping healthy teeth and gums using traditional toothbrushes. After braces are placed, our assistants at Meadows Orthodontics review brushing techniques one on one with our patients, as braces add an additional challenge to the brush reaching the surfaces that need plaque removal. I stress to my patients that the most commonly missed areas are where the teeth and gums meet, both below the braces of the lower teeth, and above the braces on the upper teeth. wire. Try to allocate more time to these areas, starting at the back teeth, then working around the mouth one tooth at a time, making sure not to skip any, until you reach the back teeth of the other side. I describe this to kids as “driving around the race track”, as this ensures no areas are missed. Likewise, try to avoid random movements that jump from one part of the mouth to the other- people often get into patterns where some areas are cleaned really well, while other areas are totally skipped over. What about circular motions vs. up and down, vs. side to side? Just like washing a car, as long as all surfaces are cleaned, I tell my patients that they can use whatever motion is the most effective for them! If you want to use trapezoid movements and are good at it… fine!

Use a toothbrush with soft bristles, and avoid stiff  bristles. This will help reduce the chance of brushing causing gingival recession (where the gum recedes to expose the roots of the teeth). As far as all the different bristle shapes, designs, colors, etc…use what is comfortable for you! The one that you use well, consistently and with the correct technique is the best one. At each return visit to have braces or Invisalign checked and adjusted, we will grade your oral hygiene, and give you tips and encouragement if needed.

Electric toothbrushes:  Having said all the above about manual toothbrushes, electric toothbrushes are also a great option. Two of my own kids were not doing well on their own with traditional manual toothbrushes (my third one does amazing with a manual brush), so I got them an electric model. Bingo! they love to use it, and their was a big difference in keeping their teeth clean. A large part of it for them is using something technological and fun, which they responded to immediately.

The biggest difference with a high quality electric brush is that the “scrubbing” movement is taken care of by the brush itself. Children and the elderly especially may lack the coordination for these fine movements, and electric brushes area great option for them. Patients, especially kids, need to be aware that the bristle head still needs to be placed in the correct locations to get the teeth cleaned. Reaching these places is just as described above for the manual brushes. Which brand should you purchase? I recommend both Oral-B and Sonicare brushes. They each claim the superiority of their product, but they are both amazing and your teeth will be happy with either brand. Also, each brand has several levels of brushes. The mechanism and effectiveness is the same for each model, but the more expensive ones have more gadgets built in such as timers, bluetooth tracking for parents, etc… choose the model that has the extras that interest you the most.

Plastic pics, floss, interdental microbrushes, etc.. : The dental aisle usually has many accessories that can be very helpful in cleaning your teeth )I like plastic dental pics, and use them while I am watching TV). Again, choose what you like and what you are comfortable with. They are usually very inexpensive, can be purchased in bulk, and help to clean in areas that brushes cannot reach (in between teeth, under and around braces if food becomes trapped). Flossing will require the use of “floss threaders”. We review how to use these with every patient after braces have been placed.

Waterpiks:  Waterpiks are a great option to use in conjunction with brushes, as the bursts of water are great for flushing out debris and plaque from hard to reach areas, and from around devices such as expanders. You cant go wrong with the Waterpik brand, which is very popular with my patients.

I hope these suggestions help, and if you ever have questions, feel free to ask me, or call Meadows Orthodontics at 303-660-0112.

Dan Rejman, D.D.S., M.S. is the owner of Meadows Orthodontics. There are two locations in Castle Rock, CO for local families: One in the Meadows, and one in the Founders and Terrain area.