Managing a Patient with a Lost Retainer or Completely Debonded Appliance

Lost Retainer/Completely Debonded Appliance

• The majority of lost retainers are passive in nature. They may be used at the end of a first phase of orthodontic treatment (following maxillary expansion for example) or at the end of a complete course of orthodontic treatment to retain the obtained result while the elastic fibres reorganize.
• Patients often lose or misplace a removable retainer that they have been asked to wear at all times.
• Patients may completely debond appliances when they don’t follow the orthodontist’s instructions (e.g., contact sports without a mouthguard fitted to the appliance, inappropriate food, improper oral hygiene). Completely debonded appliances can be re-cemented, if recently debonded (unless they are broken or distorted, in which case they need to be remade). The most commonly debonded appliance is the bonded lingual appliance, while rapid palatal expanders (RPEs) may occasionally debond. 

Presentation

Population

Patients undergoing active orthodontic treatment or having finished a course of orthodontic treatment

Signs

• Absence of retainer or retaining wire, or patient reports loss of retainer
• Patient arrives with appliance or bracket in hand
• Presence of cement or composite around the teeth supporting the appliance

Symptoms

Concomitant dental or facial injuries, if debonding occurs secondary to trauma

Investigation

Lost Retainer or Broken or Partially/Fully Debonded Retaining Wire

• Ask the patient the following questions:
• When can the patient next be seen by their orthodontist?
• When was the retainer lost? The urgency of the patient’s condition is directly related to the length of time it’s been lost (the longer the period, the less urgent to replace immediately).
• When was the orthodontic treatment finished? If the active treatment was finished recently, relapse potential is at its highest.
• Perform an intraoral examination of the debonded appliance as well as tooth alignment and occlusion (Fig. 1).

Completely Debonded Appliance or Bracket

• Ask the patient the following questions:
• When can the patient next be seen by their orthodontist?
• When was the retainer lost? The urgency of the patient’s condition is directly related to the length of time it’s been lost (the longer the period, the less urgent to replace immediately).
• When was the orthodontic treatment finished? If the active treatment was finished recently, relapse potential is at its highest.
• Perform an examination of the debonded appliance as well as tooth alignment and occlusion.
• Try in the debonded appliance to see if it fits to the current tooth position.  

Diagnosis

Based on clinical examination and history of complaint, a diagnosis of lost retainer or completely debonded appliance is determined.

Lost Retainer (removable or retaining wire)

• Patient history

Completely Debonded Appliance (RPE or bracket)

• Patient history
• Examination
• Concomitant facial and or dental injuries
• Evaluation of the fit of the appliance

Treatment

Common Initial Treatments

Lost Retainer (removable or retaining wire)

General Practitioner

If the patient can be seen within a few days, refer back to their treating orthodontist.

The goal is to maintain the tooth alignment in cases where the patient has lost a retainer soon after a comprehensive orthodontic treatment has been completed, and to retain the transverse dimension in cases where the retention appliance placed immediately after palatal expansion (Fig. 2) is lost.

• In cases where the loss of the retainer is recent and the tooth alignment is adequate: take an impression to make an in-house vacuum-formed retainer (VFR – e.g., Essix® retainer) or send it to a laboratory for construction. 
• It is recommended that the occlusion (plastic of the appliance) be adjusted to obtain even occlusal contacts on as many teeth as possible in order to increase patient comfort. Adjust the VFR with care as they can easily be perforated.

Orthodontist

• Remaking a retainer for a patient who has just finished an active phase of treatment is almost always necessary.
• Usually, teeth relapse quickly when the retainer is not worn for the required time. In cases where rapid palatal expansion has been carried out, the transverse dimension must be retained for a period of 3–6 months.  
• Often, the patient does not notice the relapse, unless it is in the anterior region or when it is significant.
• When the relapse occurs, and the patient and/or orthodontist are not satisfied with the result, the orthodontist can prescribe an active removable appliance to correct the minor relapse.
• In cases where the relapse is significant, a re-treatment period with fixed appliances may be necessary.

Completely Debonded Appliance (banded RPE with 4 bands, or RPE with resin-bite opening blocks or brackets)

General Practitioner

If the patient can be seen within a few days, refer back to their treating orthodontist.

• When an appliance is completely debonded and the patient brings it with them, it is important to examine the appliance thoroughly first, then the patient’s mouth. 
• The general practitioner can try to re-fit the appliance after removing any cement off the appliance and teeth. The appliance can be used as a removable appliance until the treating orthodontist can be seen for cementation of appliance.
• In the case of a completely debonded expansion appliance, the general practitioner may have to deactivate the appliance in order for it to be reseated (turning the screw the opposite direction indicated on the appliance for 1 to 3 turns will usually allow a better fit).

Orthodontist

Try to re-fit the expansion appliance after removing any cement off the appliance and teeth.

If the debonded appliance cannot be inserted, this usually means that severe relapse has occurred and the construction of a new appliance is necessary, with the need for new, current impressions.

Advice

• Call the treating orthodontist; most have an emergency contact number.
• Treatment depends on the time it will take for the patient to be seen by their treating orthodontist; the longer the wait, the more important it is to intervene and prevent further relapse. It is recommended to refer the patient back to their treating orthodontist.

THE AUTHORS

	Dr. Papadakis is an associate professor in oral health, faculty of dentistry, University of Montreal, Montreal.
	Dr El-Khatib is an associate professor in oral health, faculty of dentistry, University of Montreal, Montreal.
	Dr Montpetit is an assistant professor in oral health, faculty of dentistry, University of Montreal, Montreal.

Correspondence to: Dr. Papadakis, faculty of dentistry, University of Montreal, 3525 Queen Mary Road, Montreal, QC  H3V 1H9. Email: athena.papadakis@umontreal.ca

The authors have no declared financial interests.

This article has been peer reviewed.