Original Article

Patient perceptions and attitudes regarding post–orthodontic treatment

changes
Nurver Karslıa; Irmak Ocakb; Burak Gülnarc; Tamer Tüzünerd; Simon J. Littlewoode

ABSTRACT

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Objectives: To determine patient perceptions and attitudes regarding posttreatment changes at
least 2 years after completion of orthodontic treatment.
Materials and Methods: A total of 125 patients (75 females, 50 males, aged 22.93 6 2.98 years)
were enrolled at least 2 years after debonding. Participants had either vacuum-formed retainers
(VFRs) or bonded retainers (BRs). Posttreatment changes were evaluated digitally by comparing
tooth positions at debonding and at least 2 years after debonding. A questionnaire was used to
assess patient attitudes. Retainer usage, awareness of relapse, satisfaction with their current
occlusion, and whether posttreatment changes were severe enough for them to consider
retreatment were investigated.
Results: All patients showed some posttreatment changes in irregularity. Only 74% of patients
wearing VFRs and 47.1% of patients wearing BRs were aware of posttreatment changes. Patients
were more likely to notice posttreatment changes if there was an increase in mandibular irregularity
of 1–3 mm. Awareness of posttreatment changes in the upper arch was higher in both groups. The
majority of participants were satisfied with the results even if they noticed some minor
posttreatment changes (VFR, 69.4%; BR, 76.5%). Dissatisfaction with posttreatment changes
did not necessarily mean that a patient wanted retreatment.
Conclusions: A total of 26% of patients wearing VFRs and 52.9% of patients wearing BRs were
unaware of posttreatment changes. Approximately half of the patients who noticed posttreatment
changes were still satisfied with the result 2 years after debonding. Even patients dissatisfied with
the effect of posttreatment changes do not necessarily want retreatment. (Angle Orthod.
2023;93:440–446.)
KEY WORDS: Retention; Posttreatment changes; Vacuum-formed retainer; Bonded retainer;
Patient satisfaction; Satisfaction; Retreatment

INTRODUCTION
Posttreatment changes after orthodontic treatment
are a recognized risk of treatment. These changes can
be a true relapse or the return of the teeth to their
a
Assistant Professor, Department of Orthodontics, Faculty of
Dentistry, Karadeniz Teknik University, Trabzon, Turkey. pretreatment positions, or they can be a result of age
b
Assistant Professor, Department of Orthodontics, Faculty of changes, possibly attributed to late growth and
Dentistry, Ankara Medipol University, Ankara, Turkey. changes in soft tissue pressures around the denti-
c
Private Practice, Kayseri, Turkey. tion.1,2 Orthodontists try to mitigate against this by fitting
d
Professor, Department of Pedodontics, Faculty of Dentistry,
retainers, but unwanted changes can still occur as a
Karadeniz Teknik University, Trabzon, Turkey.
e
Consultant Orthodontist, Orthodontic Department, St Luke’s result of poor compliance with removable retainer
Hospital, Bradford, UK. wear, failed fixed retainers, or unwanted activity in fixed
Corresponding author: Dr Simon J. Littlewood, Orthodontic retainers while still in situ.3
Department, St Luke’s Hospital, Little Horton Lane, Bradford, Posttreatment changes are measured using a
BD5 0NA, UK
(e-mail: [email protected]) variety of approaches, including assessing irregularity
in each arch using Little’s Irregularity Index (LII) as well
Accepted: February 2023. Submitted: October 2022.
Published Online: March 22, 2023 as changes in arch form, for example, intercanine and
Ó 2023 by The EH Angle Education and Research Foundation, intermolar widths, and interarch relationships such as
Inc. overjet and overbite.4 Although there is no doubt that

Angle Orthodontist, Vol 93, No 4, 2023 440 DOI: 10.2319/100222-677.1

PATIENT PERCEPTIONS OF POSTTREATMENT CHANGES 441

these changes are easily measured, what is less clear

is whether these changes are relevant to patients,
whether they notice these changes, whether they
cause dissatisfaction, and whether they would prompt
them to seek retreatment.
Previous research attempted to identify factors that
may affect patient satisfaction with posttreatment
changes. However, changes were artificially created
on mandibular study models.5
It would therefore be interesting to explore patient

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perceptions to posttreatment changes that have
occurred. The aims of this study were to determine
patient perceptions of and attitudes to posttreatment
changes.
The null hypotheses were the following:

1. Patients would not recognize posttreatment chang-

es of increased irregularity of upper and lower teeth,
overjet, or overbite change.
2. There would be no effect on patient satisfaction
caused by an increase in the irregularity of upper
teeth, increase in the irregularity of lower teeth,
overjet change, or overbite change.
3. Patients would not be concerned enough to
undergo retreatment if they noticed posttreatment
changes in the irregularity of upper and lower teeth
and changes of overjet and overbite.

MATERIALS AND METHODS

All patients in the orthodontic department who Figure 1. Questionnaire to measure patient perception.
completed orthodontic treatment with a fixed appliance
between 2018 and 2019 with digital scans available
The inclusion criteria were the following: (1) no
from debonding were invited to participate. The study
craniofacial syndrome, (2) cervical vertebral maturation
received ethical approval by the Karadeniz Teknik
at cervical stage 5 or cervical stage 6, and (3)
University in May 2021 (2021/172), and informed
completion of treatment with only fixed appliance
consent was obtained from all participants.
therapy.
Although patients were treated by multiple orthodon-
tists, all were fitted with standard bonded retainers The exclusion criteria were (1) no digital scan data
(BRs) or removable vacuum-formed retainers (VFRs). after debonding, (2) any impacted or missing tooth at
For the BR group, a 0.0195-inch flattened 6-coaxial the start of treatment, (3) different retainers in the upper
stranded wire (Stranded Retention Wire, Ortho Classic and lower arches, and (4) history of orthognathic
Inc., McMinnville, Ore) was bonded directly lateral-to- surgery.
lateral in the maxilla and canine-to-canine in the A questionnaire was designed to obtain information
mandible. It was recommended to continue wearing about the patients’ experiences and opinions regarding
the BR indefinitely. For patients in the VFR group, a set the retention period. A pilot study was completed with a
of alginate impressions was taken at the end of the group of patients to check the intelligibility and
debonding appointment, and a 0.40-inch VFR (Dents- answerability of the questions. The final questionnaire
ply Raintree Essix, Sarasota, Fla, USA) was construct- is shown in Figure 1. Dr Karslı accompanied patients
ed in the laboratory and delivered on the same day. All as they answered the questionnaire to avoid problems
patients were instructed to wear their retainers full-time with responsiveness.
for a year and then at night only for 6 months. After this, The questionnaires determined whether:
they were able to switch to alternate night wear. The
same type of retention appliance was used in both 1. Patients recognized relapse and, if so, which
arches in all patients. aspects of relapse they recognized.

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442 KARSLI, OCAK, GÜLNAR, TÜZÜNER, LITTLEWOOD

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Figure 2. (A) Little’s irregularity index. (B) Intercanine width. (C) Overjet and overbite.

2. Patients were satisfied with the teeth and, if not, square tests were used for comparisons. The intra-
which aspects of their relapse most concerned class correlation coefficient was used to calculate the
them. reproducibility and reliability. A P value less than .05
3. Patients were concerned about their relapse was considered statistically significant.
enough to want retreatment. Multinomial logistic regression and binary logistic
Digital scans were used to assess posttreatment models were also used. To use the logistic regression,
changes. For this, 3Shape Ortho Analyzer (3Shape A/ the variables were divided into distinct categories as
S, Copenhagen, Denmark) software was used. Mea- follows:
surements were performed at two different time points:  LII: 0–1 mm/1–3 mm/.3 mm
T1, immediately after debonding; and T2, at least 2  Change in overjet (T2–T1): ,1 mm/1–3 mm/.3 mm
years after debonding (postretention). The following  Change in overbite (T2–T1): ,1 mm/1–3 mm/.3 mm
measurements were performed by the same author (Dr  Sex: male/female
Karslı) (Figure 2):  Age: 18–24 years (young adult)/25–35 years (older
 LII: the summed labiolingual displacement of the adult)
linear distances from one anatomical contact point to
the adjacent contact point of the anterior teeth. RESULTS
 Overbite: the mean vertical overlap of the maxillary to
the mandibular central incisors. Total Number of Patients Included
 Overjet: the distance parallel to the occlusal plane
A total of 143 individuals who completed orthodon-
from the incisal edge of the most labial maxillary
tic treatment between 2018 and 2019 were invited,
central incisor to the most labial mandibular central
and a total of 125 patients (85.4%), 75 females and 50
incisor.
males, volunteered to participate in the research. The
Three weeks later, the same author randomly mean age was 22.93 6 2.98 years, with a range of
selected 20 models and performed the measurements 18.25–34.50 years. Tables 1 and 2 show descriptive
again to calculate the intraclass correlation to assess statistics in relation to retainer type; sex; and whether
reproducibility and reliability. The intraclass correlation the patient was still complying with retainer wear,
coefficient was in the range of 0.999–1.000, showing a aware of posttreatment changes, dissatisfied with
high level of reproducibility. posttreatment changes, and so unhappy with the
posttreatment changes that the patient would request
Statistical Analysis retreatment.
Statistical analyses were performed with SPSS for
Windows 17.0 (SPSS Inc., Chicago, Ill). The normality Table 1. Age and Duration After Debonding of Patients According
of data was tested with Kolmogorov-Smirnov or to Retainer Typea
Shapiro-Wilk tests when needed. Descriptive values VFR BR
were given as mean and standard deviations (for Age, y, mean 6 SD 23.0 6 2.93 22.5 6 3.34
normal data), median and 95% confidence intervals Duration after debonding, y, 3.44 6 1.20 2.82 6 0.93
(for nonparametric data), and percentages for categor- mean 6 SD
ical and nominal variables. Time-dependent changes a
BR indicates bonded retainer; SD, standard deviation; and VFR,
were tested with the Wilcoxon signed-rank test. Chi- vacuum-formed retainer.

Angle Orthodontist, Vol 93, No 4, 2023

PATIENT PERCEPTIONS OF POSTTREATMENT CHANGES 443

Table 2. Sex, Compliance With Retainer, Awareness of Table 4. Distribution of Awareness vs Little’s Irregularity Index
Posttreatment Changes, Dissatisfaction With Posttreatment
Little’s Irregularity Index, n (%)
Changes, and Request for Treatment Data According to Retainer
Typea Awareness ,1 mm 1–3 mm .3 mm
VFR (n ¼ 108) BR (n ¼ 17) Yes, upper arch 4 (80) 13 (27) 17 (24)
Yes, lower arch – 4 (8) 18 (25)
n % n %
Yes, both arches – 9 (19) 23 (32)
Sex No 1 (20) 22 (46) 14 (19)
Female 63 58.3 12 70.6
Male 45 41.7 5 29.4
Continued retainer use irregularity of their upper and/or lower labial segments
Yes 37 34.3 10 58.8 (Table 3). In the VFR group, there were statistically

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No 71 65.7 7 41.2
significant changes for all parameters (increase in LII of
Awareness of relapse
Yes, upper arch 29 26.9 5 29.4 the maxilla and the mandible, overjet, and overbite). In
Yes, lower arch 21 19.4 1 5.9 the BR group, the LII of the maxilla increased
Yes, both arches 30 27.8 2 11.8 statistically significantly.
No 28 25.9 9 52.9
Dissatisfaction from relapse
Yes, upper arch 20 18.5 3 17.6
Awareness of Posttreatment Changes
Yes, lower arch 6 5.6 1 5.9 A total of 74% of patients wearing VFRs and 47.1%
Yes, both arches 7 6.5 0 0
No 75 69.4 13 76.5 of patients wearing BRs were aware of posttreatment
Request for retreatment changes (Tables 2 and 4). There was no statistically
Yes 32 29.6 4 23.5 significant difference in the awareness of treatment
No 76 70.4 13 76.5 changes between those patients who continued to
a
BR indicates bonded retainer; VFR, vacuum-formed retainer. wear their VFRs and those who had discontinued their
use (Table 5). In contrast, those patients whose BRs
Continued Use of Retainers More Than 2 Years failed were aware of the changes (Table 5).
After Debond
Dissatisfaction With Posttreatment Changes
At 2 years after debond, 34.3% of the patients in the
VFR group continued to use their retainers at night, A total of 30.6% of patients wearing VFRs and
whereas 58.8% of patients still had the BRs in place 2 23.5% of patients wearing BRs were dissatisfied with
years after debond (Table 2). The patients whose BRs the posttreatment changes (Tables 2 and 6). It was
had failed chose not to have them replaced, so they more common to be unhappy with changes in the
were left with no retainers. For the patients whose BRs upper arch than the lower arch. There was no
failed, the average survival time was 5.1 months. It was difference in dissatisfaction with the posttreatment
not possible to know accurately at what stage patients changes between those patients that were still wearing
who stopped wearing the removable retainers decided retainers and those who had discontinued their use
to stop wearing them. (Table 7).

Posttreatment Changes Request for Retreatment

All 125 patients showed some degree of posttreat- A total of 29.6% of patients wearing VFRs and
ment change as measured by changes in the 23.5% of patients wearing BRs were dissatisfied

Table 3. Results of Dental Arch Measurements According to Retainer Typea

VFR BR
T1 T2 T1 T2
Median 95% CI Median 95% CI P Median 95% CI Median 95% CI P
Maxillary LII 1.23 1.20–1.54 3.06 3.02–3.75 *** 1.47 1.08–2.94 2.70 2.38–4.40 ***
Maxillary intercanine width 34.99 34.54–35.22 34.15 33.82–34.53 *** 35.06 33.67–35.25 34.15 33.66–34.99
Mandibular LII 1.21 1.14–1.48 3.36 3.45–4.17 *** 0.79 0.64–1.41 1.35 1.29–2.76 **
Mandibular intercanine width 26.59 26.36–26.92 25.80 25.33–25.86 *** 25.93 25.23–26.67 25.61 24.76–26.38 **
Overjet 2.64 2.53–2.80 2.99 2.84–3.20 *** 2.83 2.47–2.96 2.97 2.59–3.40
Overbite 1.62 1.47–1.76 1.89 1.85–2.28 ** 1.48 1.19–1.82 1.55 0.92–2.25
a
BR indicates bonded retainer; CI, confidence interval; LII, Little’s Irregularity Index; T1, immediately after debonding; T2, at least 2 years after
debonding (postretention); and VFR, vacuum-formed retainer.
* P , .05; ** P , .01; *** P , .001.

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444 KARSLI, OCAK, GÜLNAR, TÜZÜNER, LITTLEWOOD

Table 5. Effect of Retainer Type on Discontinued Use and Awareness of Changesa

VFR BR
Awareness Continued, n (%) Discontinued, n (%) P Continued, n (%) Discontinued, n (%) P
Yes, upper arch 11 (29.7) 18 (25.4) .167 2 (20) 3 (42.9) .039*
Yes, lower arch 11 (29.7) 10 (14.1) 0 (0) 1 (14.3)
Yes, both arches 8 (21.6) 22 (31) 0 (0) 2 (28.6)
No 7 (18.9) 21 (29.6) 8 (80) 1 (14.3)
a
BR indicates bonded retainer; VFR, vacuum-formed retainer.
* P , .05, v2 test.

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enough with their retainers to request retreatment 52.9% of BR patients were unaware of these changes.
(Tables 2 and 8). This demonstrated that the measurements that ortho-
dontists use to assess posttreatment changes are
Factors Affecting Awareness of Posttreatment possibly more sensitive than what patients are actually
Changes and Requests for Treatment aware of. On average, 1–3 mm increases in irregularity
The only predictor for awareness of posttreatment in the mandibular labial segment are required before
changes using the regression model was a change in patients become aware of posttreatment changes.
mandibular irregularity as measured by an increase in Although the best predictor for awareness of change
LII of 1–3 mm (Table 9). was an increase in mandibular irregularity, patients
Dissatisfaction with the result and an increase in were more likely to be dissatisfied with changes in the
overbite 1–3 mm were found to be predictors for upper arch. This suggested that patients are less likely
patients requesting retreatment (Table 9). Neither age to notice changes in the upper arch, but when they do,
nor sex was found to be a predictor for awareness of they are a cause for greater dissatisfaction. Neither
posttreatment changes or request for retreatment. age nor sex appeared to affect awareness of post-
treatment changes or attitudes to retreatment.
DISCUSSION Further investigation into patient satisfaction with
their teeth position at least 2 years after debond
Main Findings showed that even if patients were aware of posttreat-
All patients who fulfilled the inclusion criteria showed ment changes, this did not necessarily mean that they
some degree of posttreatment changes 2 years after were dissatisfied with the result. Only 30.6% of patients
debonding, even with VFRs or BRs in place, as wearing VFRs and 23.5% of patients wearing BRs
measured by LII. This showed that retainers could were dissatisfied with the posttreatment changes,
reduce but could not completely prevent posttreatment despite a much higher percentage being aware of the
changes. The changes were larger in the patients changes.
wearing VFRs, with statistically significant changes in One of the possible implications of patients being
the LII in the maxilla and mandible in addition to dissatisfied with their results is that they may wish to
statistically significant changes in overjet and overbite. have retreatment. However, the results of this study
This could have been because many of the patients showed that even if patients were dissatisfied with their
with VFRs stopped wearing them. Interestingly, pa- results, only a minority disliked it enough to justify them
tients who were fitted with BRs only showed statisti- seeking retreatment: only 29.6% of patients wearing
cally significant posttreatment changes in the maxillary VFRs and 23.5% of those patients wearing BRs said
LII. Further long-term randomized controlled trials they would want retreatment. Presumably, the choice
would be advisable to compare the effectiveness of as to whether a further course of treatment is
BRs and VFRs. requested is also affected by other factors, such as
Although all patients showed some degree of willingness to undergo appliance treatment again,
posttreatment changes, 26% of VFR patients and including the ability to fund this treatment. Certainly,
dissatisfaction with treatment was identified as a
Table 6. Distribution of Request for Retreatment vs Satisfaction possible predictive factor influencing the desire for
Satisfaction Level, n (%) more treatment. A change in overbite of 1–3 mm was
Request for 0–20 21–40 41–60 61–80 81–100 also identified as a factor that may influence a request
retreatment for retreatment, but it was not possible from this study
Yes – 6 (100) 7 (88.5) 13 (41) 10 (13) to identify whether this was related to functional or
No 1 (100) – 1 (12.5) 19 (59) 68 (87)
esthetic reasons.

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PATIENT PERCEPTIONS OF POSTTREATMENT CHANGES 445

Table 7. Effect of Retainer Type on Discontinued Use and Dissatisfaction With Changesa
VFR BR
Dissatisfaction Continued, n (%) Discontinued, n (%) P b
Continued, n (%) Discontinued, n (%) Pb
Yes, upper arch 7 (18.9) 13 (18.3) .220 1 (10) 2 (28.6) .245
Yes, lower arch 3 (8.1) 3 (4.2) 0 (0) 1 (14.3)
Yes, both arches 0 (0) 7 (9.9) 0 (0) 0 (0)
No 27 (73) 48 (67.6) 9 (90) 4 (57.1)
a
BR indicates bonded retainer; VFR, vacuum-formed retainer.
b
v2 test.

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How Do Findings Compare With Previous Limitations of the Study
Research?
The study was based on all the patients who had
It was previously shown that orthodontists are more completed fixed appliance treatment more than 2 years
critical than general dentists and laypeople about the ago during the 2018–2019 time period. This was, by its
irregularity of teeth,6–8 and this study showed that the nature, retrospective, so there may have been selec-
measurements orthodontists use to assess posttreat- tion bias for patients who were prepared to come back
ment changes are more sensitive than what patients to be part of the research.
can notice. The sample size may also not have been large
Previous research demonstrated that patients enough to show a significant effect of predictive factors
when using the regression analysis. However, the data
were most likely to recognize significant horizontal
for this study could be used to calculate appropriate
movements of the lower incisors and least likely to
sample sizes for future studies.
notice rotational movements of mandibular incisors
The feedback was based on a piloted questionnaire,
and the inclination of the lower canines5; however,
which meant that the questions and topics asked were
this work was undertaken on study models with determined by the research team. An alternative
artificially created occlusal studies. In this real-life approach would be to use focus groups or individual
study, patients assessing their own posttreatment interviews using qualitative research.9,10 The advan-
changes were more likely to notice changes in the tage of qualitative research is that it allows patients to
mandibular irregularity index of 1–3 mm, so this present their own ideas, motivations, and opinions;
study provides a valuable figure to gauge the addresses the power imbalance between researcher
average amount of relapse that is likely to concern and patient; and recognizes that each patient has an
a patient. individual approach to care.
The desire to undergo retreatment is complex and
is related to more factors than just the amount of Clinical Implications
posttreatment change, with previous qualitative re-
This study demonstrated that, when taking into
search suggesting that financial considerations and account patient perceptions of posttreatment changes,
treatment time also play an essential role.5 In the patients are likely to be considerably less critical than
same study on artificially created discrepancy on orthodontists. This in turn may lead to less dissatis-
study models, the authors suggested that a horizontal faction with posttreatment changes than might be
discrepancy of greater than 5 mm between lower expected, with patient tolerance to small changes
incisors would be a motivation for treatment, but this being higher than may be predicted. Even if the patient
seems to be a rather extreme measurement to use. is dissatisfied with the effects of posttreatment chang-
This study showed that patient dissatisfaction and a es, this may not, on its own, lead to a request for
change in overbite of 1–3 mm were factors most likely retreatment, a decision that is likely influenced by other
to drive a request for retreatment. factors.

Table 8. Distribution of Request for Retreatment vs Dissatisfaction With Result

Dissatisfaction, n (%)
Request for retreatment Yes, upper arch Yes, lower arch Yes, both arches No
Yes 13 (56.5) 3 (43) 6 (86) 14 (16)
No 10 (43.5) 4 (57) 1 (14) 74 (84)

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446 KARSLI, OCAK, GÜLNAR, TÜZÜNER, LITTLEWOOD

Table 9. Regression Model Analyses

Dependent Variable Predictor Factor Data Coefficient, b P 95% CI Lower–Upper Bounda
Awareness Mandibular Little’s Irregularity Index (1–3 mm) 0.249 **b
0.090–0.691
Retreatment Satisfaction level 4.131 ***c 2.251–7.582
Retreatment Dissatisfaction (both maxilla and mandibula) 1.907 ***c 1.381–2.633
a
CI indicates confidence interval.
b
Multinomial logistic regression.
c
Binary logistic regression.
* P , .05; ** P , .01; *** P , .001.

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