10.59987/ads/2014.3.81-86
The aim of the study is to evaluate the long term results of ribbond retainer after orthodontic treatment. One hundred and thirty patients who were orthodontically treated satisfied the inclusion criteria of having received a semipermanent retention were treated with FRC lingual retainers (Ribbond ®). It was performed a follow up evaluation after 2 years average from the retainer application and any complication or failure was recorded. Data from 119 remaining patients that met the inclusion criteria were analyzed and no instances of loosening were observed. It may be concluded that orthodontic canine-to-canine FRC retainers provide aneffective means of retaining realigned anterior teeth for at least two years
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Annali di stomatologia
movement of relapsing
Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study
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Original Article
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movement of relapsing
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Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study
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                                                                                                         Original article



    Survival of post-treatment canine-to-canine lingual
    retainers with fiber-reinforced composite resin: a
    retrospective study




                                                                                                           i
                                                                                                         al
                                                                                                      on
    Davide Farronato, DDS, PhD1                                   ly understood, but relates to a number of factors, includ-
    Roberto Briguglio, MD, DDS2                                   ing periodontal and occlusal factors, soft tissue pres-
    Francesco Mangano, DDS1                                       sures and growth (1). This has led many orthodontists to
    Lorenzo Azzi, DDS3                                            conclude that permanent retention may be the only reli-
    Giovanni Battista Grossi, MD, DDS3                            able way to keep ideal alignment after treatment (2-9).




                                                                                             zi
    Francesco Briguglio, DDS, PhD2                                Many appliance types have been used for the reten-
                                                                  tion of posttreatment tooth position, both fixed (10)
                                                                  and removable (11). In order for retainers to be ac-




                                                                               na
    1 Department of Morphologic and Surgical Sciences,            ceptable they must maintain the teeth in position
      Insubria University, Varese, Italy                          without compromising oral health. They must also be
    2 Department of Experimental Sciences and Dentistry           acceptable to patients and be reliable (12).
      Specialist Medical-Surgical, University of Messina,         At the present, two types of fixed retainers are in use:
      Italy




                                                                    er
                                                                  a heavier wire bonded only on the canines and a
    3 Department of Biomedical, Surgical and Dentistry            lighter wire, usually multi-stranded, bonded to both
      Science, University of Milan, Italy                         the incisors and the canines (13-15).
                                                                  As an alternative to multistrand wire, the use of fiber-re-



                                                            t     inforced composite (FRC) retainers has been devel-
    Corresponding author:
    Francesco Briguglio
                                                         In       oped (16-20). These FRC are available in varying
                                                                  widths and forms, including braided polyethylene fibers
    Department of Experimental Sciences and Dentistry             (Connect®, Kerr Inc, Orange, CA, USA), woven poly-
    Specialist Medical-Surgical, University of Messina            ethylene fibers (Ribbond®, Ribbond Inc., Seattle WA,
    Viale Gazzi                                                   USA) as well as other fiber types and forms. The clini-
                                                ni
    98100 Messina, Italy                                          cians may use strips of reinforcing fiber bundles that al-
    E-mail: fra.briguglio@alice.it                                ready have been impregnated with resin in a prior con-
                                                                  trolled manufacturing process or may incorporate a low-
                                     io

                                                                  viscosity dental resin into the reinforcement at chair-
    Summary                                                       side. Whether the FRC is prepared by the dentist or
                                                                  purchased already impregnated, it is usually applied in
    The aim of the study is to evaluate the long term             conjunction with a restorative composite in the fabrica-
                           iz



    results of ribbond retainer after orthodontic treat-          tion of a two component fixed splint. The FRC material
    ment. One hundred and thirty patients who were                is used as a substructure to provide increased strength
    orthodontically treated satisfied the inclusion cri-          and rigidity beneath an outer layer of particulate com-
           Ed




    teria of having received a semipermanent reten-               posite, which provides an aesthetic appearance and
    tion were treated with FRC lingual retainers (Rib-            better wear resistance (21).
    bond®). It was performed a follow up evaluation               Several studies have assessed the effectiveness of dif-
    after 2 years average from the retainer application           ferent types of bonded wire retainers (22-30), showing
    and any complication or failure was recorded.                 a large range in failure rates. Unfortunately, limited
    Data from 119 remaining patients that met the in-             clinical information is available concerning the reliabili-
IC




    clusion criteria were analyzed and no instances of            ty of FRC retainers for long term retention of mandibu-
    loosening were observed. It may be concluded                  lar and maxillary anterior segment from canine-to-ca-
    that orthodontic canine-to-canine FRC retainers               nine after orthodontic treatment (12, 31, 32).
    provide aneffective means of retaining realigned              Therefore, the aims of this study were to retrospec-
C




    anterior teeth for at least two years.                        tively evaluate the clinical survival rate of FRC lingual
                                                                  retainers by means of a historic cohort study, and to
    Key words: retention, ribbond, orthodontic treat-             investigate the influence of gender, patient age and
    ment, FRC, movement of relapsing.                             retainer location on survival.
©




    Introduction                                                  Materials and methods

    Retention is the phase of orthodontic treatment that at-      Sample
    tempts to maintain teeth in their corrected positions after
    active tooth movement. The etiology of relapse is not ful-    The records of individuals participating in this study

    Annali di Stomatologia 2014; V (3): 81-86                                                                             81
    D. Farronato et al.


    were selected from a larger pool of patients treated at    mined by closely adapting a piece of tinfoil to the lin-
    the practice of the first author (D.F.).                   gual festooning of the teeth (Fig. 2). The required
    One hundred and thirty patients who were orthodonti-       length of Ribbond was cut with a special scissors
    cally treated satisfied the inclusion criteria of having   (Ribbond fiber cutter, Ribbond Inc., Seattle WA, USA)
    received a semipermanent retention between January         supplied by the manufacturer to prevent unraveling.




                                                                                                         i
    2004 and July 2006. All identical type of FRC lingual      The fiber ribbon was saturated with a few drops of




                                                                                                       al
    retainers (2 mm woven polyethylene ribbon-rein-            bonding agent (Clearfil Se Bond, Kuraray America,
    forced; Ribbond ® , Ribbond Inc, Seattle WA, USA)          Inc. New York, NY, USA) and embedded with flow
    (Fig. 1) were bonded from canine to canine in the          (Enamel Plus HFO Flow, Micerium, Avegno GE Italy).




                                                                                                    on
    maxilla, mandible or in both arches, using the same        Care was taken to keep the wet ribbon away from light
    procedures with the same materials, by a single oper-      to prevent initial polymerization, which would interfere
    ator. Periodontally unhealthy teeth were excluded as       with its manipulation. The wetted Ribbond was placed
    fmps and fmbs was not lower than 20% or if any tooth       and the flosses were bent in an upward direction to
    was mobile or prosthetically restored. Composite           position the FRC just above the interproximal areas.




                                                                                           zi
    restorations were accepted in inclusion criteria but in    The Ribbond was closely adapted into the interproxi-
    those cases sandblasting was performed under dam           mal contacts against the teeth by the help of instru-
    to increase the retainer adhesion.                         ments and light cured for 40 seconds from lingual and




                                                                             na
                                                               proximal directions. Then, flosses were removed and
                                                               fibers were coated approximately 0,5 mm with another
    Application of retainers                                   layer of light-cured composite (Enamel plus HFO,
                                                               Micerium, Avegno GE Italy) and the embrasures were




                                                                 er
    Routine adhesive removal and polishing were per-           shaped in order to facilitate good oral hygiene, paying
    formed (33) and instruction in oral hygiene were care-     attention not to have any part of the fiber exposed
    fully carried out before FRC retainers were inserted.      (Fig. 3). Excess resin was removed and a thin applica-
    The technique for placing the FRC retainer included        tion of glycerin was placed on all the retainer to pre-



                                                         t
    placement of the dental dam extending to the first pre-
                                                      In
    molars bilaterally. Tooth surfaces from canine to ca-
    nine were etched with a 37% orthophosphoric acid gel
    for 30 seconds, then rinsed with an oil-free air-water
    spray for 40 seconds and left slightly moist for the wet
    bonding technique. An adhesive system (Clearfil Se
                                          ni
    Bond, Kuraray America, Inc. New York, NY, USA) was
    applied following the manufacturer’s instructions, us-
    ing a disposable brush and including the interproximal
                                 io

    surfaces and facial areas. The resin was not light
    cured at this time. Five 30-cm pieces of dental floss
    (Crest Glide, Procter & Gamble, Cincinnati, Ohio
    USA) were cut and tied all together at one end. Keep-
                          iz



    ing the knot on the facial side, the free ends of the
    floss were threaded into inter-canine interproximal
    spaces and pulled lingually. A thin layer of flowable
          Ed




    composite (Enamel Plus HFO Flow, Micerium, Avegno          Figure 2. Placing flosses into inter-canine interproximal
    GE Italy) was placed onto the lingual surface from ca-     spaces and determination of the required length of ribbon
    nine-to-canine and light cured for 20 seconds. The         by adapting a piece of tinfoil to the lingual surface of the
    dental arch length from canine to canine was deter-        teeth.
IC
C
©




    Figure 1. Two mm wide Ribbond® used as orthodontic lin-
    gual retainer.                                             Figure 3. The lower FRC retainer in place.

    82                                                                              Annali di Stomatologia 2014; V (3): 81-86
    Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study


    vent the formation of an oxygen-inhibiting layer on the           Statistical analysis
    resin. The FRC retainer was subsequently polymer-
    ized from all aspects (e.g. facial, incisal, lingual, proxi-      Statistical analysis was performed using the Statisti-
    mal) for 60 seconds, respectively. Finally, after re-             cal Package for Social Sciences (version 18.0, SPSS
    moval of the rubber-dam, the occlusion was checked                Inc., Chicago, Illinois, USA). Descriptive statistics and




                                                                                                                  i
    with the use of a 32-µm articulation paper and adjust-            Kaplan-Meier curves were calculated.




                                                                                                                al
    ed if necessary.                                                  Survival was defined at two levels: functional survival
    Every patient was clearly informed of the importance              (endpoints: absolute failures) and overall survival
    of oral hygiene by giving more attention to plaque                (endpoints: both absolute and relative failures). Ob-




                                                                                                             on
    control and was instructed to use dental floss for                servations with no event in the respective analysis
    proper interproximal oral hygiene.                                were censored at the end of the individual observa-
                                                                      tion period. Kaplan-Meier survival analyses were
                                                                      done for the complete group of FRC retainers and
    Follow-up and definition of clinical events                       discriminated according to gender, age of the groups




                                                                                                   zi
                                                                      and retainer location.
    Average follow up was 39.9 months (median 40.7
    months, IQR 14.9, months, SD 13.3 months). After




                                                                                    na
    bonding, the patients were recalled for clinical ex-              Results
    aminations every 6 months, or when the patients re-
    ported a failure. During the follow-up period all inter-          Of 130 patients, eleven were not able or willing to be
    ventions were recorded, such as polishing and fin-                clinically evaluated. Therefore, data from 119 remain-




                                                                         er
    ishing after chipping of small fragments of the resin             ing patients that met the inclusion criteria were in-
    composite, repair of small delaminations with                     cluded in the analysis. Of these, 15 patients had FRC
    restorative resin composite, or rebonding of FRC re-              retainers in both arches, so that a total of 134 FCR
    tainer after loosening.                                           retainers were studied.
    If the FRC retainers debonded were lost during the


                                                              t       The maximum follow-up period was 61.4 months (me-
    follow-up period, they were registered as “absolute
    failure”. When less severe clinical events occurred,
                                                           In         dian 40.7 months, IQR 14.9, mean 39.9 months, SD
                                                                      13.3). Most of the patients were adults, with a median
    such as fracture or delamination of the composite                 age of 32.5 years at the time of follow-up examination.
    without loosening of the bond between composite                   No instances of loosening were observed, therefore the
    and the teeth bonded, the FRC retainers were re-                  functional survival rate was 100%. Table 1 shows a
                                                ni
    paired and the event was registered as “relative fail-            summary of the demographic characteristics of the pa-
    ure” (Fig. 4a, b).                                                tient population and the effect of confounding factors on
    The wearing time was measured in months and was                   the overall survival rate. In total, relative failure (fracture
                                     io

    calculated as the time between bonding and any clini-             or delamination of the composite) was recorded in 25
    cal event recorded as failure. Only the first failures            FRC retainers, corresponding to 18.7% of the 134 re-
    were counted and a reported failure in the maxilla or             tainers bonded. Conversely, the present study shows
    in the mandible was counted as a separate incidence.              that the FRC location exerted a significant influence on
                           iz



    In addition, multiple failure sites in one retainer were          the failure rate. In fact, the incidence of relative failures
    counted as one failure. All data were recorded by be-             was remarkably lower for the mandibular than for the
    ing typed directly into an anonymized database.                   maxillary FRC retainers.
           Ed
IC
C




     a                                                                     b
©




    Figure 4. (a) FRC retainer’s relative failure at 60 months’ follow-up. (b) Higher magnification of the retainer, showing inter-
    proximal delamination and fracture of the composite (arrows). Is possible to notice plaque accumulation in correspondence
    to the gap, the interproximal wire can’t pass between teeth and demonstrate the fiber integrity. In this condition fiber keepon
    helding the fractured parts together avoiding teeth migration (Pekka K. Vallittu: Ultra-high-modulus polyethylene ribbon as
    reinforcement for denture polymethyl methacrylate: A short communication, Dent Mater 13:381-382, November,1997), but
    there could be high risk of infiltrating caries in the interproximal area and unaesthetic discoloration.

    Annali di Stomatologia 2014; V (3): 81-86                                                                                     83
    D. Farronato et al.


    Figure 5 shows that the cumulative overall survival       passive at the time of bonding, the teeth may move.
    rate for the FRC retainers was 81.3%. Kaplan-Meier        Another technique-related problem is frequent bond
    overall survival rates at 5 years were higher for         failure, either in the wire/composite interface if too lit-
    mandibular retainers (86.3%) compared to maxillary        tle composite is added, or in the adhesive/enamel in-
    retainers (65.6%). These differences in survival per-     terface in situations with moisture contamination or




                                                                                                        i
    centages were statistically different (Fig. 6, log rank   retainer movement during the bonding procedure




                                                                                                      al
    test, P=0.007).                                           (34). In addition to bond failure, stress fracture of the
                                                              interdental wire segments was reported (22). Some
                                                              clinical studies have shown that there is a relatively




                                                                                                   on
    Discussion                                                high failure rate ranging between 10.3 to 47%, de-
                                                              pending on the technique used and follow-up obser-
    Orthodontic canine-to-canine retainers are frequently     vation period (22, 27-29, 35).
    used to avoid relapse and secondary crowding of in-       Recently, FRC materials have been introduced for
    cisors. Such retainers may either be fixed or remov-      the fabrication of fixed dental prostheses, root posts




                                                                                          zi
    able. Fixed lingual retainers were introduced in the      and periodontal splints and much research is current-
    1970s (10) and are often made of stainless steel          ly being conducted for these clinical applications (36-
    wires. The major advantage of bonded canine-to-ca-        43). Conversely, very few studies have focused on




                                                                            na
    nine retainers relative to removable is that they are     the use of FRCs as orthodontic retainers (31, 44, 45).
    compliance free. However, if the retainer wire is not     A main advantage of a FRC retainer compared with the
                                                              classic twist-flex retainer is its high transparency, result-
                                                              ing in an almost invisible retainer (Fig. 7a-c). The re-




                                                                er
                                                              tainer can thus be placed close to incisal edge. This is
                                                              an advantage from both biological and biomechanical
                                                              points of view (44). One major disadvantage of the
                                                              FRC retainer is that the placement procedure is time



                                                        t     consuming and technique sensitive. Moreover, it is
                                                     In       more expensive than other types of bonded retainers.
                                                              To the best of our knowledge, this is the first large
                                                              investigation to have analyzed the clinical survival
                                                              rate of FRC lingual retainers for a long follow-up pe-
                                                              riod. Of the 134 orthodontic retainers being followed
                                         ni
                                                              none have exhibited debonding and the only kind of
                                                              failure was fracture or delamination of the interproxi-
                                                              mal composite (18.7%) without loosening of the bond
                                  io

                                                              between composite and the 804 teeth bonded.
                                                              Therefore, 100% of the retainers were still in place
                                                              after 5 years.
                                                              These results are substantially different from those
                          iz



                                                              obtained in the clinical trial by Rose et al. (36), in
    Figure 5. Kaplan-Meier survival curve showing a 81.3%
                                                              which a total of 20 patients were assigned to receive
    success rate for the FRC retainers over a 61.4 month
                                                              Ribbond® fiber or multistranded wire canine-to-canine
          Ed




    period.
                                                              retainers. In terms of survival time, the results report-
                                                              ed by Rose would suggest that the multistranded wire
                                                              is significantly superior to the FRC retainer. It should,
                                                              however, be noted that their sample size was only 10
                                                              for each group and no sample size calculation were
                                                              reported. Moreover, the protocol described in the
IC




                                                              Rose’s article would be counter to the protocols used
                                                              for the construction of any fiber-reinforced structure
                                                              (44, 46-48). In fact, the authors polymerized the com-
                                                              posite before applying the fiber and did not adapt the
C




                                                              fiber closely against the teeth. Conversely, in the cur-
                                                              rent study the manufacturer’s instructions were fol-
                                                              lowed (14). In order for fiber to work, the resin com-
                                                              posite was not cured until after the fiber was closely
©




                                                              adapted against the tooth surface. In fact, placing the
                                                              fiber against the surface minimizes the bond line
                                                              thickness between the teeth and the fiber and, just
                                                              like orthodontic brackets, the thinner the layer of
                                                              bonding resin composite between the teeth and the
                                                              laminate, the better the results. Whichever reinforce-
    Figure 6. Survival percentages.                           ment technique is used, it is critical that manufactur-

    84                                                                             Annali di Stomatologia 2014; V (3): 81-86
    Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study


                                                                    explanation for this could be that all FRC retainers were
                                                                    applied by only one operator in our study, using the
                                                                    same materials and the same bonding techniques un-
                                                                    der rubber dam isolation. In fact, the bonding proce-
                                                                    dures are technique sensitive and factors such as




                                                                                                                   i
                                                                    minute movements of the retainer during the setting




                                                                                                                 al
                                                                    process of the adhesive or a lack of moisture control
                                                                    (49) could impair ideal adhesion. Dahl and Zachrisson’s
                                                                    (14, 15) reported the lower failure rates (9.8% of loos-




                                                                                                              on
                                                                    ening and wire fracture over a 38-month-observation
                                                                    period) with the use of the five-stranded spiral wire re-
                                                                    tainers (Penta-One), bonded by the same orthodontist.
                                                                    In a long-term clinical study where the retainers were
     a
                                                                    bonded by 15 different operators Foek et al. (23) re-




                                                                                                    zi
                                                                    ported a failure rate of 37.9%. Interestingly, however,
                                                                    they found that neither different operators nor experi-
                                                                    ence played a significant role in failure rate.




                                                                                    na
                                                                    Finally, our data showed no significant differences in
                                                                    failure rates between genders and age, in agreement
                                                                    with the findings of previous studies (23, 24). More-
                                                                    over, in keeping with other studies (22, 24, 50, 51),




                                                                       er
                                                                    there is clear evidence that FRC retainers in the up-
                                                                    per arch are much more likely to fail than in the lower
                                                                    arch, and this may reflect the role of occlusal factors
                                                                    in the failure of these retainers (29).



                                                            t
     b
                                                         In         Conclusions

                                                                    It may be concluded that orthodontic canine-to-canine
                                                                    FRC retainers provide an effective means of retaining
                                                ni
                                                                    realigned anterior teeth for at least five years.
                                                                    Careful preparation and adaptation of the Ribbond®
                                                                    fiber along with strict moisture control are the critical
                                     io

                                                                    steps for success in the FRC retainers.
                                                                    Nevertheless, there is a need for further controlled
                                                                    studies, both in vitro and in vivo, to validate the find-
                                                                    ings of this investigation.
                           iz



                                                                    References
           Ed




                                                            c
    Figure 7. (a) Mandibular FRC retainerat five-year follow-up       1. Melrose C, Millett DT. Toward a perspective on orthodontic
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IC




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                                                                               er
        Am J Orthod Dentofacial Orthop. 2001;120:648-653.                   39. Piovesan EM, Demarco FF, Cenci MS, Pereira-Cenci T. Sur-
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