Jaz’s Introduction: 
Imagine you’ve hired some builders to create a building view maybe let’s say you’re building a new dental practice okay? So these builders come and they start building the foundation and then they build the building upwards for your new dental practice. And while they’re doing this maybe they put some scaffolding everywhere to support the structures as they’re sort of building everything up and making everything join up. Now imagine the building is now complete, it’s all done but as the builders are leaving you say to the builders, wait what about all the scaffolding you know you need to get rid of the scaffolding right? It looks ugly it’s done you know take off the scaffolding and the builders say to “No if we take the scaffolding away the entire building would collapse you.” You’d freak out, you’d be like what the hell is this? What kind of building is this, that’s not stable.

Well someone once explained orthodontics to me in this way we’re using that analogy and they said to me that orthodontics like what is that about? Like they get everything straight, they get everything aligned but unless you wear your retainers everything will just collapse and go crooked again and that’s when they told me this building analogy. They said orthodontists are like these people who are leaving this scaffolding behind because without the scaffolding, the building will collapse.

Well our understanding of retention has changed a lot over the years. I know back in the day it’s probably the reason why we see so many relapse cases is that back in the day we thought or rather orthodontists thought that if you put everything in a stable position and everything is class one and you get the correct inter incisal angle et cetera, that everything will remain stable and retention is not really needed long term and we all know that this is completely false and that retention now the thinking is, is that retention is for lifetime.

Welcome, Protruserati. I’m Jaz Gulati to this episode all about retention with Dr Angela Auluck. I mean this is a mammoth, this is a huge topic in orthodontics and in general dentistry because if they’re going to an orthodontist guess who they’re coming back? To their general dentist to maintain their fixed retainer or their attention. So I think as general dentists even if you’re not doing like orthodontics we need to be well versed in retention because this is something that affects so many of our patients.

In this episode we’re going to talk about the very nitty gritty details of placing a fixed retainer about which is the most superior retainer, removable versus fixed or do you always have to do both. So I know this will be very impactful episode for those who are interested in learning more about retention protocols.

Protrusive Dental pearl
The Protrusive Dental pearl I have for you is a communication one. Very often our patients will blame their lower incisor crowding on wisdom teeth they will say when my wisdom teeth came through I started to get crowding, so is this true? Well you should tell your patients, NO it’s not true because it was proven in a study by Harridine. Now in the group of Harridine et al what they did is they did a randomized controlled trial. They took people with extraction of wisdom teeth and they took people without extraction of wisdom teeth who had orthodontics and they followed them up. And they found no statistical difference in terms of the relapse that they had. So this is something that we need to explain to our patients. Now if you’re wondering if I also know a study to help disprove the lady that says that the her children sucked all the calcium out of our teeth, I don’t have that study at hand but you know what when a lady just says that to me I just ignore it I nod and we move on because what are you going to gain from arguing right? I mean what can you possibly gain from arguing in that piece of history. Just suck it up buttercup and move on is my advice anyway. Let’s crack on with this episode with Angela Auluck all about retention protocols.

Main Episode:
Angela Auluck, welcome to the Protrusive Dental podcast. How are you?

[Angela]
I’m very good. Thank you, Jaz. I’m very excited to be on your show. I listen to you a lot. It didn’t come up on my Spotify 2020 but you will in 2021. I discovered you quite late.

[Jaz]
We talked, we gossip about almost like GDPs versus Orthodontists and when is it okay to compromise. And that was a very controversial episode no one’s heard it and by the time this comes out people will have heard it but you know what there’s so much controversy and the same thing I said to goss is I’m going to say to you as well that when I as a GDP I started doing my diploma. In orthodontics I thought that in restorative there were different camps different opinions but the world of orthodontics is just polarized in a way there’s so many different camps and different ways to skin a rabbit and I realized that more and more when I did orthodontist. Do you feel that when you got into orthodontics that was the case as well?

[Angela]
I think when you’re, when you go through your orthodontic training, you actually leave there with very indoctrinated views about how you should be treating something. So I trained at the Eastman so I do things the Eastman way and you come out very confident and you’re right as soon as you come out in the big wide world. It’s almost a revelation because you then realize that actually all the orthodontists around you are all doing lots of different things and sometimes can lead to a little bit of sort of loss of confidence or questioning yourself but I think that’s a great thing. We should always be questioning ourselves, questioning what other people are doing around us. But it should always be in a collaborative manner. It should be okay well you do it like that, why do you do it like that? Is that a better way? Should I be doing it like that? So there’s nothing wrong with everyone doing things differently but I think as long as our results are good and of a certain standard, you’re right. There’s in orthodontics there’s many different ways.

[Jaz]
Absolutely. And just like in restorative I found that my mindset improved and I like what you said there and I’m saying that my mindset improved and I became a happier dentist once I accept it. It’s a beautiful thing in our profession, that there are so many different ways to do it. And we if we see the beauty of that rather than see the frustration then I think we can be much happier with ourselves. So definitely when I learned more about orthodontics I was like oh my goodness, I thought restorative had polarized opinions, different occlusion camp stuff but now I learned about orthodontics, I was like oh my goodness this is so varied but it’s in a beautiful way.

But just a little bit about yourself Angela and just setting the scene. Tell us a little about where you practice? How long you’ve been a specialist orthodontist? For a little bit about you Angela.

[Angela]
So I carried out my undergraduate training at King’s and whenever I do these kinds of things I love mentioning sort of where I studied because I find it gives me a connection to other alumni so you know hopefully after people have watched this somebody might connect and say oh I went to Kings too and there’s another friend on Instagram so my undergrad training was at King’s and they were the best years I think of my life. I had such a great time there made great friends and my mentors I would still say are from there. And that’s where I was inspired to learn how to move teeth, that’s where I decided I want to be an orthodontist.

After that my post-grad training was at the Eastman. I’d always known that all I wanted to do was walk through that archway for three years of my life and so I did everything I needed to do possibly do to sort of get my place for orthodontic training there. And so I’ve been an orthodontist now for 15 years and I own a practice with my husband in Wimbledon village called the Dental Rooms. It’s a specialist referral practice so we have all the specialties in one under one roof. It’s my second home, my team is my second family and all my time effort everything goes into that place and it’s the fruits of our labor, that place and I thoroughly enjoy seeing my patients there. It’s a perfect platform for me to be able to do what I really want to do which is multi-disciplinary, being part of a multi-disciplinary team, helping the others achieve what they need to achieve with their work to.

[Jaz]
It’s so great to be able to work as a team and you working alongside restorative dentists. What percentage of your patients are adults and what percentage of these adults that you’re treating are actually part of a bigger picture that actually after your orthodontic intervention they’re going to need a rehabilitation implants or significant restorative work? Can you just give us an idea of that?

[Angela]
Yes so my practice is a completely private practice and kind of leads to being seeing more adults than children. And I would say about 80% of my patients are adults and of those I would say probably about 30 to 40 percent of them are referred by one of the other specialists in the practice or are referred by somebody external to the practice but requires input from either the periodontist or the prosthodontist endodontist. But a lot of prosthodontic and also cases come together I find in our practice. It’s quite nice of the patients, Jaz I was going to say that they can sometimes end up with two or three specialists in the surgery with them. It just helps to make decisions faster and it was the patience.

[Jaz]
I had George Cardozo on the podcast who said very similar thing to you. He’s a prosthodontist and he just opened my eyes to the fact that I actually myself need to work more with specialists as a multi-disciplinary team because you get to have more fun as a team. But there are a few little downsides to that as well I guess. So I’m going to ask you what’s your pet peeve? What’s the thing that annoys you the most about working with restorative dentists, of prosthodontist? What’s the annoying request that you get that actually this is completely unreasonable or this is really annoying, anything you could share in that light?

[Angela]
So it’s always when me as an orthodontist with my orthodontist hat on thinks okay I’ve done it I’m finished I’ve got the teeth to exactly where he said he wanted them. And then they come in with their mirror or their shim stock, I hate shim stock, and they come in with their shim stock and they’re like but can you make this contact like a little bit lighter? And you’re like really? What are you talking about? It’s going to settle. Leave it, it’ll settle. And so we sometimes have that kind of banter going on in the practice but you have to respect each other’s philosophies and provide for them what they want. So yes we don’t have any arm twisting going on in the staff saying you have to say that case is finished when we see that patient together I never do that.

[Jaz]
I really like that example you gave because essentially the prosthodontists ask you to intrude by eight microns but it’s hilarious actually. I quite like that one. So I mean let’s dive into the massive, massive, topic of retention. So this episode is for everyone orthodontists, GDPs, students, whoever you are because retention is huge it affects everyone. So I want to start with bit of contextualizing it going back in time because you probably get the same and please tell me if you don’t, the orthodontics that I do as a GDP and yes I have a special interest got a diploma. A lot of the patients come to me most of the patients come to me and a lot of them have relapses so they’ve had relapses and I’m treating them as a second intervention of orthodontics and they all have the same kind of story like oh you know what it wasn’t emphasized enough to me or my orthodontist didn’t really encourage me enough or I didn’t know or my dog ate them and I didn’t realize I needed to wear them. Do you think there has been a generational shift in terms of what orthodontists are saying 30 years ago to what they’re saying now regarding the view on retention or are our patients lying to us?

[Angela]
They can’t be lying to us so the studies are actually showing us that 70% of adult patients are coming to us because they have had orthodontic relapse. Not age related changes but orthodontic relapse. 70% that’s a lot. That’s like a huge failure on the part of whoever carry is carrying out those treatments and yes I would say because they’re adults and they are mostly patients who have had their orthodontic treatment in their teen years. There has now I think been a change. Do I think historically even when I was doing my training we were taught if you place the teeth in a certain position in terms of the occlusion, in terms of the soft tissues and the periodontal tissues that it will remain stable and it was all almost sort of a hierarchical thing you were only a really good orthodontist if you could keep, if the teeth stay stable after you treated them without retainers like what madness is that now when we think about it. So there was definitely a problem in that in the way that orthodontists were taught but that those were real beliefs that that we as orthodontists as a group that we had. But I think now there is a real big realization there, the research now is so much better. We have controlled randomized, controlled trials to show us that teeth don’t stay straight so there’s a lot more research and I think less head in the clouds so yes there has been a generational change and I think actually probably a really big realization that teeth don’t stay straight, they don’t.

[Jaz]
Awesome. I wasn’t expecting what you’d say to that maybe I thought you would say that actually we were doing all along but no it’s good of you to say that actually there has been a change in thinking changing the evidence and that’s what we’re seeing and you’re totally right I mean so many of these patients that I’m treating with orthodontics are relapse cases adults and it’s always just the same stories you have. So I’m going to jump on to the next question and someone say if you had to have I mean have you had orthodontics Angela?

[Angela]
No ,well I’ve had extraction orthodontics so I have no canines.

[Jaz]
Okay.

[Angela]
No low premolars but that was it. No never a brace.

[Jaz]
Do you wear a retention? Do you have retention?

[Angela]
I don’t have a retainer. I’ve never had orthodontic treatment. I don’t have a retainer but my teeth are moving and I am on the verge of having some aligner treatment.

[Jaz]
Okay so let’s hypothetically speak now and let’s say you’ve had that aligner treatment for yourself, for your own mouth what would be your retention protocol and why?

[Angela]
Okay. So I would go for a lower fixed retainer because whenever I place a lower fixed retainer for my patients they always the reaction is always like oh that’s okay, it’s comfortable, it’s not invasive and there’s always a very positive reaction. However when I place the upper no one ever is, patients generally you can tell if you read their sort of emotions or read them the initial very first reaction it’s not comfortable or it doesn’t feel as good as the lower one. And that’s obviously to do with the occlusion and also the anatomy of the upper incisors so for the uppers I would go for a removable retainer to be worn on a part-time basis. And I think that’s also to do with the fact with the amount of risk in in which teeth are more likely to move. So in my case, my lower incisors I’ve got one that’s beginning to rotate that’s going to be more unstable I better hold that one. Also age-related changes, I’m still quite young just and I’m going to grow older and my teeth are going to move in terms of age-related changes we know it’s the lower incisors that are going to lose their alignment so why not hold those. So I would go for lower fixed and upper removable.

[Jaz]
Brilliant and I think I totally agree with the my patient’s perception after an upper fixed retainer and also in terms of if I was to count up all the retail fix retainer failures I’ve seen, I’ve seen disproportionately more upper fix retained fixed retainers fail than lowers even though you’d imagine that there have been more lower fixed chain is placed so it could just go to show that is there any evidence to say the failure rate of upper fixed trainers is higher than lower fixed retainers? So as far as you know I mean I don’t expect you to be an academic in any way I know you’re very wet fingered but as far as you know because that’s a difficult thing to study anyway.

[Angela]
Yeah it’s a difficult thing to study and in terms of retainer research I think a lot of the things that we as clinicians do when it comes to retention because there’s not that much research is it’s mostly based on our clinical experience, what works in our hands and what doesn’t so and also individual patient preference right?

[Jaz]
According to the evidence which is better?

[Angela]
In terms of fixed versus removal?

[Jaz]
Yes absolutely fixed versus removal which is which is the ultimate evidence-based formal retention that you would recommend or the evidence would recommend? Is there one that’s more superior significantly than the other?

[Angela]
Yeah so i mean there are a lot of factors when you’re looking at what’s more superior and what’s not right okay. So firstly you’re looking at how stable do the teeth remain over a period of time with either a fixed retainer or with a removable retainer. So the clinical outcome essentially so that’s one thing that you’re looking at in terms of comparing the two and the other thing you’re looking at is how is it for the patient. What is the patient preference? What is their experience? What are they more likely to get on with? So if we were actually looking at the research I’d say probably the best research that we have so far is a randomized controlled trial that’s come out of the royal London by Al Margari and all that orthodontic team they collaborated with a periodontist there and they compared stability and periodontal health with fixed and with removable retainers over a period of four years. And they did that quite recently so that paper came out in 2018, it’s a randomized control trial and they did everything perfectly. And what they found was that actually over four years the fixed retainer is better clinically in terms of holding your alignment so the clinical outcome. And in terms of periodontal health because a lot of concerns with fixed retainers is that we may be compromising the periodontal health in terms of patients aren’t able to clean properly right? But there was no difference. So the periodontal health was not great actually in both groups. So I think it goes to show that it’s important to educate our patients even in terms of oral hygiene after they’ve completed their oral orthodontic treatment but from that, and from my clinical experience I would say fixed retainers if you want to really ensure that you’re going to hold the teeth and you’re not putting it in the hands of the patients, fixed retainers.

[Jaz]
Brilliant. So that’s really useful to know. And actually from the periodontal literature we know that just because someone has crowding that it doesn’t necessarily mean that their periodontal health will be not as good as someone without crowding and it’s down to the patient who an actually bother so if you’re a good brusher you’re a good cleaner routinely that’s going to be true whether you’ve got crowded teeth or not. Ao the fact that you said that hang on even if they’ve got a fixed retainer or they don’t have a fixed trainer their periodontal outcomes are similar it just shows this is the it’s actually the patient themselves that need to take it upon them to do the hard work. So this leads very nicely to a clinical question. Now is if you can just because most people are listening at the moment to this while they’re chopping the onions, gardening washing dishes or whatever let’s talk about one of the most difficult things I found is when you’re newly starting to do it is a very fiddly fixed retainer that you’re placing now. I’ve tried various methods including lab made on an acrylic jig and that is really quick and easy actually but for those who have got the wires and those that sometimes you need to bend and those like the flex set ones that you don’t need to bend can you just run through which you use? And talk us through your clinical technique to placing successful fixed retainers on the lower arch?

[Angela]
Okay so I’m glad you said lower arch because that’s probably it’s the easiest so you don’t have the occlusion to think about right? So what I use usually well what I always use is lab made stainless steel twist flex multi-strand wire and what I asked my lab to do is to produce me a molded wire so they bent it by hand and it’s customized with a jig and it but it’s not an acrylic jig where it’s held on both sides with the canine, on the canines it’s basically a memosil jig you know? The soft memosil? So they basically make the retainer and then they position it with this memosil that hangs just over the incisal edges of the centrals yeah? So I can then basically take that off the model and then hang it exactly the same way on the lower incisors in my patient and then it is just sitting there very passively and that’s the most important thing for me is that the retainer is passive. I’m not having to push it or hold it down when I’m bonding it to the teeth okay?

So now I’ve got teeth that have are prepared so I clean them I use a sandblaster after that they’ve been cleaned. Love my RONDOflex I actually have so many of those that they’re my favorite thing we have them all over the practice so I clean the teeth and then we go ahead and we bond it but I do not hold it down anywhere so I’m very particular with our lab that it should be made well.

[Jaz]
And just to make it really tangible and very like so we can visualize it once you’ve got the memosil on with the fix retainer in place, essentially?

[Angela]
Should I do next steps? Because you want to know exactly like what do I do then right? Okay so now imagine I’ve got clean teeth so I’ve tried this retainer on, I’ve checked that it’s fitting nicely I basically hold it against each tooth and make sure that it’s not having to displace, to be sitting on that tooth okay? Then I remove it we etch the teeth, on the teeth I then hang this retainer back on intraorally and I start to bond so I use light flow composite and I just start with the so if I start with the most distal tooth so if it’s canine usually you’d go lower three to three right? So I just I place some bond on that canine and my nurse cures it that’s it done. Then we do the lateral. Then I remove the memosil jig and then I just go around all the teeth centrals and then the other side. And that way you’re just really ensuring that it is passive and it’s comfortable for the patient and the teeth aren’t going to move.

[Jaz]
So you’re attacking and you’re putting the flowable composite on the canines first and then removing the-

[Angela]
I don’t do, this canine and then this canine because you can then introduce flexion in your fixed retainer so I go canine-lateral-central-central-lateral-canine I go round like that. You’re not going to start to then introduce flexion forces yeah?

[Jaz]
That is a real gem right there that is a real clinical pearl right there.

[Angela]
Then hold the wire there then you start to then hold it here it could lift up in the middle right? Then you’re going to have to push it down onto your central it’s not good. Go around.

[Jaz]
Well as you’re bonding it on one canine and let’s say your lower right canine and then the lateral just before you put the composite on the lateral, are you gently pushing the wire up against the teeth with the flat plastic or not at all?

[Angela]
No I just, at that point I would just hold the memosil jig and just make sure it’s not lifting up as in coming up but no. Don’t need to push it if it’s made well and this is where you’ve got to really get to know your technician and speak to your technician and once sometimes I send them back so they know that she’s fussy. I’m not actually, my therapist doesn’t put my fixed retainers on for me I do them myself, I’m that fussy about it. So I think it’s just really making sure that your technician knows what you’re expecting and you’re expecting a well-adapted passive fit.

[Jaz]
Amazing. Thanks so much for that description. Now here’s a little curveball, you’ve got your fixed retainers and you’ve beautifully described how we’re going to place it and I’ve learned something that actually just be careful not to bond the canine then the canine, it’s a great point you raised there but what about people who have had expansion because we know expansion can relapse but your fixed retainer is not going to protect from that if it’s canines canine, So what would you do, adjunctively, for these patients who’ve had expansion?


[Angela]
Okay so I’ll tell you what I do, right? Because there is actually no fixed or correct way, there’s just probably so many ways but I use dual retention for all my patients. So what I recommend to my patients is let’s have a fixed retainer especially if you’ve expanded everything and nothing’s going to be stable really so a fixed retainer followed by wearing a vacuum foam retainer at night time on a part-time basis so I say okay “So you’ve got your fixed retainers but we need to support the posterior teeth.” It’s all about sort of explaining to them why you’re doing and why you’re asking them to do so much. So the fixed retainer is on and they then for four months wear a nighttime retainer every night, they will then be, I’ll review them and then based on sort of their experiences because usually they haven’t worn it every night, they may have skipped tonight and they will then explain to you how tight it felt the night after they skipped tonight and you can kind of gauge by questioning them how much stability there is and then if I feel comfortable I’ll ask them to reduce the wear to alternate nights for the next four months and then eventually by the end of 12 months because I review my patients for forever almost but at the end of 12 months I would be hoping that we could get them down to one or two nights a week but it’s really, really, customized, Jaz, it’s so different for every patient because of so many factors as you know.

[Jaz]
Well i appreciate you giving us a like a guideline answer because that’s really helpful but then you totally raise a great point, retention should be specific for that individual patient because certain movements are always going to be less stable severe rotations and stuff you got to so that’s covered. That really nicely I appreciate that when would you, do you ever use a Hawley retainer or is that something that’s really quite old-school and there’s no place for it? Sorry if that’s a bit controversial. If you describe also for those listeners who don’t know what a Hawley retainer is as well.

[Angela]
Yeah good idea okay. So a Hawley retainer is a removable retainer that’s made of acrylic as the base plate and then there are stainless steel wires that are molded as cribs to hold it in for retention. So on the sixes, on the fours or the fives and then essentially there’s a stainless steel wire which is called the labial bow that runs from three to three and so you know that is traditionally what retainers were made of before we came across these vacuum formed Essex type retainers and there is still a place for them I think. I think if you’ve got a patient who has a number of teeth missing and they’re going to have a time before their prosthodontic work then Hawley retainers are quite a nice way to add context pontics to it to maintain and hold spaces you can like use little wire spurs on either side of the gentler spaces to really make sure that you don’t get closing in of the teeth into that space so retaining spaces it’s really good. It’s also really good for, if you need settling because your teeth, posterior teeth can still sort of move I would say those are probably the most times that we would use it but actually I don’t because patients who have gone to length to have treatment that’s invisible or unnoticeable or discreet and not going to thank you for giving them a Hawley retainer and you have to actually really be sure that your patients are going to wear their retainers right? I mean you’re relying on them and I just feel that in terms of aesthetics and comfort and speech dysfunction, they’re not popular.

[Jaz]
I agree and no one will ever thank you for giving you one of those. So I’m glad you agree with me with my views on Hawley as well. Angela, you’ve covered my main questions and I’m going to take a couple of questions from the Protrusive Dental community Facebook group. Actually some really cracking questions have been sent in. Zak, my buddy Zak, who’s done some great episodes on comprehensive care, he wants to know about he said well I’m going to actually read it out because what Zak is very wordy English you know, okay? “Can you ask about the psychological aspects of retainer wear?” I’d say he thinks it’s a grossing neglecting problem I never thought about this before, “so I rather give my patients three sets of removable retainers okay?” Design dependent on biomechanics than a fixed retainer because what he’s found, what’s Zak saying is that for fixed retainer wearers they think that oh that’s my retention done and then five years later if you get arch form collapse and then they’re relapsing all over the show that’s his own words there what could you say to Zak as an interesting sort of debate or a discussion about his viewpoint on the psychological aspects of having a fix retainer and the patient thinking that’s everything but then you can get an arch form collapse what would you say to that?

[Angela]
Okay I think it’s all about patient education. So the way that I handle retention is from the very first day that patient comes to my into my surgery, I talk about retention a lot at consultation probably half of my chat is about retention and it’s the first part of their treatment plan that I explained to them that okay if we move your teeth this is what we are then going to have to do in terms of maintenance, are you happy for that to happen? Are you prepared for that to happen? Because if it’s a no that conversation may either need to stop or you need to then change tactic and explain to the patient well that your teeth are going to move because there’s no other ways of guaranteeing it.

So it’s a lot to do with patient education, you’ve got to consent them for moving their teeth and knowing that the risks are that their teeth will relapse if they don’t play ball with the retention part of the treatment but we’re still as orthodontists we’re still responsible for their retention I don’t think we can just put the fixed retainer on and expect them to see them in five years and think that everything’s going to be fine. So yes that’s right, they will still sometimes you can see a patient with a fixed retainer but really walked arch form because the teeth have been firstly moved in very unstable positions and then fixed retainers can also fail along the way. So for me I think the best way is to give them the fixed retainers, give them the removable retainers and then ensure that they are coming in for regular maintenance. So in my practice I have an orthodontic plan that patients join, it’s included in their package in the first year and then following that they sign up to a plan and therefore I then know that they have committed to maintaining their retention and then I do everything I can to ensure that their teeth then stay straight so they come in I check their fixed retainers I replace them if they need to be replaced we check their removable retainers and we keep re-educating them at every point. So the psyche of my patients is not that same psyche that they think they’re getting their teeth are going to stay straight once they’ve been straightened ,they are absolutely freaked out that their teeth are going to move if they don’t carry on with their retainers so I think it’s a lot to do with how we educate our patients but that’s a lot to do with how we educate ourselves and what we understand about retention and I think that’s probably one of the biggest problems at the moment but we’re all learning how to move teeth but there’s very little emphasis placed on retention. It’s actually the most important part of the plan if those teeth don’t stay straight you’re just going to keep getting patients coming back to you it’s just highly frustrating. So that’s probably you know the way to do it joint responsibility.

[Jaz]
Amazing. Education, joint responsibility and not just relying just on a fixed retainer there’s also that removable component to help with the arch form. Richard Mckindo actually on the group also has a different mentality and we have to respect different mentalities. Richard’s mentality as a GDP and a very good one that, Hello Richard, I know you’re listening buddy, he provides his patients with I assume it’s vivera he said three sets of removable retainers. So let’s go, let’s just talk about viveras okay? He gives his patients viveras because he feels safe in knowing that should there be a failure of retention it’s easy to then point the finger at the patient for compliance right because he feels as though if a fixed retainer fails silently then he feels that the patient will be able to point the finger at the dentist, it’s an interesting viewpoint as well. What would you say about that?

[Angela]
So I don’t think there should, I don’t think one should feel that that somebody’s blaming somebody else there is a solution for this. So if when you give a fixed retainer to a patient when you place that if you give them then a removable retainer that is their secure blanket okay and this is how I explain it to the patient that your fixed retainer can fail so when we get to the point where you’re only wearing your nighttime retainer one night a week, you’re doing that so that you’re actually checking your fixed retainer you’re putting it in and if it feels comfortable that’s fine your fixed retainer is doing what it needs to be doing if it feels tight you need to pick up the phone and you need to organize to come and see me because there’s something wrong your teeth are moving and it’s probably your fixed retainer’s broken and they get that in writing too. So I would say that is the way to deal with it otherwise yeah you can just put it all on the patient and give the member for their own retainers but think about it from your shoes, if I when I finish my treatment I’m not going to want to wear vivera retainers 24 hours a day for six months and then every night for the rest of my life because that is actually how they’re designed to be, retaining the teeth. I don’t think my patients would thank me for making them wear their aligners like that it’s not what I would want for myself.

[Jaz]
I appreciate that and also I think the answer to or not an answer but just a good valid point to this question and the last one is a belt and braces approach right? You want your fixed tension and your removal and they do their tasks together and it gets amplified and the whole patient education. So that’s all wrapped within that as a package. So last question out from rob-

[Angela]
One more when it comes to sort of orthodontists and GDPs it kind of feels like sometimes fixed retainers are the bane of our lives right like so patients are coming in. It’s broken again and you know then you’re having to fix it but I tell you what, if you put them on this if you have some sort of a plan where you know that you are being renumerated for fixing their retainers and they know that they’re not paying every time for an emergency appointment the psyche of psychological feeling about fixed retainers it really changes and it just becomes about okay we’re all in this together and we’re going to look after it together and you’ll get the odd patient who has come in a number of times but then you also have the odd patients who can maintain a fixed retainer for three years and nothing happens. So I think the psyche about fixed retainers has to change and it’s actually about the amount of time that we have to spend in our diaries looking after them and how we’re enumerated so I think everyone should really think about a plan, it really changes everything.

[Jaz]
When you said it about to seven eight minutes ago you mentioned the autonomy plan I was like oh my god this is amazing and I got sidetracked but you’re right, this plan so that there’s joint responsibility and the patient doesn’t feel like they’re paying a suddenly like a higher fee when they’re coming in when it’s broken and they sort of feel protected it’s like an insurance policy for them and it also means that you as a dentist, orthodontist are remunerated as well along the way so then it doesn’t feel like sometimes you come in and maybe it’s been seven months since you’ve placed a fixed chain and then you feel like okay I can’t possibly charge this patient because it’s been so soon but I think there’s something in it for both the dentist and the patient to have an orthodontic plan. So that is a real gem so if you guys out there are doing a fair amount of orthodontics as Angela says consider having a plan component because that will really get rid of those issues I guess.

[Angela]
Yeah and making sure that your patients know nothing’s for life they don’t go and have their hair colored and think they’re going to do it once and then that’s it, it’s done they need to understand there’s maintenance involved. It’s an aesthetic treatment always going to need maintenance.

[Jaz]
It’s the same with a composite polishing, it’s the same with teeth whitening, so it’s the same with that so I appreciate that. Last question now is for saying from Rob Arden. Hi Rob thanks for listening buddy, “does everyone have a good rule of thumb for upper anterior bonded retainers?” See Angela we couldn’t go the whole episode without discussing this very annoying thing about upper fixed retainers he says especially when occlusion means space is limited so he knows that Tif on courses and he’s just been a great guest on the podcast before and we’ve sort of discussed this a similar topic about using restorative composites. So like your nano hybrid or something like that instead of flowable and DAHLing the patients in. So Dahl as in Dahl chap who came up with the concept of bonding things in high at the front and letting the posterior settle intrusion at the front. So please refer back to episodes 16 and 17 I think it was if you guys want to listen to more about a Dahl but essentially it’s sometimes difficult because you want to make the patient as comfortable as possible so you want to actually shave that composite down so it’s not too proud but at the same time you want to have the strength but I’ve been thinking in my diploma we never discussed this technique and I’ve got a feeling that orthodontists don’t routine routinely dahl upper anterior techniques and my thinking is because and that’s actually goss as well to thank because when he came on as a guest is because part of the objectives of comprehensive orthodontics is to get the overbite correct enough so that you actually have your space right?

[Angela]
Yeah that’s you’ve just hit the nail on the head. It’s a great question Rob because it is like something that bothers every clinician at some point in their working time but as orthodontists when we’re training we never get really taught about short-term orthodontics or every patient is treated comprehensively which means that we are finishing them to the ideal overbite and the ideal overjet. So essentially you should always have enough space to put on a fixed retainer without it affecting the occlusion okay but in real life now we know that there are patients who are only going to who are going to request anterior alignment only maybe only upper arch treatment and firstly I think the most important thing is to know from the outset how you’re going to be finishing the inclusion and to let the patient know don’t promise them a fixed retainer when then afterwards you can’t put one on that’s really important but if are hell-bent on putting on that fixed retainer or the patient is really convinced that’s the only way they want to retain their teeth and you don’t have the space occlusally to do it then I don’t see a problem with carrying out the Dahl technique I work very very closely with prosthodontists and so I see a lot of restorative stuff going on in the practice and I see the Dahl concept it works amazingly.Sso I have no problems, sometimes for my patients when I’ve had problems with the occlusion the prosthodontist has just put on canine ramps with composite so palatally building up the palatal surfaces of the upper canines so then that that opens up the bite a little allows me space to put on the fixed retainers and then there’s a little bit of that dahling going on and again it’s just making sure that your patients understand that they’re going to have a little bit of tiny open bite at the back and that it’s going to take months for that to resolve.

[Jaz]
That’s fantastic and I think you raised two good points there many of many good points but the two highlight I want to highlight is a patient communication sometimes from the outset as a GDP we do compromise treatment just look on instagram right and you know that you’re not going to fully correct his overbite without committing to a comprehensive route of treatment which I think we should all open our eyes to it’s really good to do that but if you know and the patient knows that you’re compromising and then they’ve had a specialist consultation and they know what they’re getting themselves into then you know from the outset that you probably won’t have enough space so then A) communication and recognizing that and then B) you actually mentioned a really good tip about adding a composite on the canines there but if anyone’s going to do it make sure you design it in a way that the load is transmitted into the canines along the long axis which should actually help and again patient communication so that they understand what it’s going to feel like in terms of at the front and how long it’s going to settle, there are review protocols that be sort of arranged with that and a bit of contingency planning what happens if it doesn’t happen and we know it’s quite predictable but you have the odd patient where it might not happen so just have all that upfront in a really good conversation with the patient is key. Angela you’ve been absolutely fantastic I knew this would be brilliant and it has been about retention I think we’ve really covered. I’m sorry I threw some curveballs out there..

[Angela]
There’s so much to talk about with retainers right?

[Jaz]
Easily go on, we can easily go on right because we can talk more about technique at the top we can talk about when I’ve seen some case before where the twist flexes that started to talk the teeth some years from now and stuff like that but we’re running out of time but I just want to say thank you so much for coming on to sharing all these gems. If there are some people who want to learn more from you what, where can they find out more about you’ve done quite a few lectures on tubules and whatnot do you offer any educational programs, any study clubs for dentists?

[Angela]
So we have the dental rooms academy and that’s part of our practice and we regularly carry out lectures there we have an in-house training facility and so we quite often once a month with pre-occupied times once a month, we were doing case discussions with every time there’s two specialists. So quite often I’m there but that’s my favorite place, my other favorite place is tubules. I love speaking on that we’ve just started an aligner panel there we’re going to be called the a-team and we’ll be talking a lot about and with Goss and a few other great clinicians so those are probably the main channels for me. So through the dental rooms academy and through tubules.

[Jaz]
And your instagram handle, please tell us your instagram handle.

[Angela]
Dr Angela Auluck so please please message me. I love that platform, it’s my favorite thing at the moment.

[Jaz]
And one of the reasons I also want to get you one is because you like me are a big cricket fan.

[Angela]
Yes I love cricket. I love cricket so it’s my children.

[Jaz]
I need yes I remember so I know you you’re a king’s 11 punjab fan and the ipl but your children and I think your family are Mumbai Indian fans.

[Angela]
They are indeed. They are indeed so they took it this time but that sort of helped keep the peace but Jaz we’re getting there that kings 11. I feel like next time is going to be our time.

[Jaz]
I feel like Liverpool fell for like 30 years next year is our season you know so but I’m hoping it will come true and next year it will be our season in the ipl. So Angela thanks so much once again really appreciate you coming on the show.

[Angela]
Thank you so much, Jaz.

Jaz’s Outro: I hoped you enjoyed that with Angela. Thank you so much for listening all the way to the end. If you’re not already part of it, do join the Protrusive Dental community Facebook group where we’ve got such a a thriving community. It hasn’t got like thousands of thousands dentists, it’s got a small group but it’s all the Protruserati who enjoy the podcast and I just feel the love and the connection and the chemistry between everyone I think we’re all so helpful in this group because I think it’s like a safe little place because we’re kind of like-minded like if you listen to this you are similar to someone else who listens to Protrusive Dental podcast so if you want to find that community do join the Protrusive Dental community Facebook group I look forward to seeing you there anyway I’ll catch you in the next episode which is all about elastics in Invisalign. The do’s and don’ts of elastics and I’ll catch you same time. Same place next week. See ya!