Patient Experience and Satisfaction of Orthodontic Retention after Treatment in Saudi Arabia

Background: Orthodontics treatment aimed to make patient satisfied about treatment result starting from appearance to the function. Orthodontic retention is consider as important stage to stabilize the result of orthodontic treatment and avoid relapse that caused by normal age changes. Methods: A cross-sectional study performed through patient questionnaires. A total of 450 patients were included in the study. The questionnaire included 19 questions. The questionnaire consisted of question about socio-demographic status of the respondents such as age, gender, also included question about the type of retainer fixed or removable retainers that were used, duration of wearing retainer and Retention protocol. Result: In our study majority of the participants were females (87.3%), and 55.3% belonged to the 20-25 years age group. The fixed orthodontic related history showed 59.8% had undergone the treatment for 1 to 3 years and 31.6% of the participants reported that they had removed the fixed braces for more than five years. Among these participants, 89.5% (n=34) reported that the fascia (space) closed between the upper frontal teeth after Frenectomy, and 65.8% (n=25) agreed that spaced between the two upper front teeth still closed after removing the retainer. Conclusion: The study findings showed that the majority of the participants were aware of the frequency and duration of wearing retainers but didn't completely adhere to the instructions given by the orthodontists and/or dentists. The major reason for not using retainers was difficulty in speaking or uncomfortableness.


Introduction
Orthodontics is the science that deals with the abnormalities of facial growth, dentition development and occlusion, with diagnosis, interception and treatment [1] . The main objective of orthodontic treatment is to achieve an esthetically appropriate natural, stable and well-functioning occlusion, in other words we may call it "ideal" occlusion [2] . Orthodontic retention is the final stage of orthodontic treatment and aims to maintain the teeth in their corrected positions after the completion of orthodontic tooth movement and the sound orthodontic treatment planning and the achievement of appropriate occlusal and soft tissue treatment goals can help to minimise orthodontic relapse [3] . Once active orthodontic treatment has been finished, teeth tend to return to their original positions. This phenomenon is called as Relapse [4] . The importance of maintaining the tooth alignment after orthodontic treatment was recognized as early as 1904 to avoid relapse [5] . Orthodontic relapse is a common finding after successful orthodontic treatment [6,7] . After finishing the active treatment, teeth tend to relapse toward the original positions due to pressures exerted by the surrounding tissues and the continued growth, [8,9] which makes the retention of the corrected positions a challenging phase for the orthodontist [10] . It has been reported that a varying degree of compensation in the lower dental arch occurred during the post-retention period in 70-90% of the orthodontically treated cases, whereas the observed changes in the upper arch were milder [11] . A number of variables were correlated with orthodontic relapse such as retention protocol, patient compliance, age and final occlusion after therapy [11] .
These variables are likely to behave in conjunction to cause a relapse in the large majority of patients [12] . However, there were also many variations in retention protocols concerning retainer type selection and retention length. For example, removable vacuum-formed retainers in the UK were most frequently used to retain the maxillary dental arch [13] . Australia and New Zealand [14] . While a fixed and removable retainer combination was widely used in Norway for maxillary dentition [15] . In addition, orthodontists operating in the same nation had significant distinctions [16] . Noted that "individual orthodontists used removable retainers very often or rarely" This was probably due to the reality that a retention method choice was mainly based on personal preference, experience and other non-scientific criteria [4] . Orthodontists came up with different methods, appliances and regimens for retention, but there is no consensus on how long retainers should be worn [17] .
While several studies have shown that fixed retainers are safe and effective over the long term for most patients [16,18] . Latest study found that the only predictive factors which significantly increase the risk of alignment instability are not using a fixed retainer and years without retention [19,20] . Therefore the primary aim of this study was to assess the satisfaction of patients and expectation about post-orthodontic retention. Patient satisfaction after orthodontic treatment often tends to be affected by a number of factors such as gender, age, duration of treatment, patient knowledge, compliance, doctor-patient relationship and dentofacial improvement also seem to contribute to the level of satisfaction [21,22] . Overall satisfaction of patients with their orthodontic experience is closely related to their expectations of stability [23] . Retention is an necessary and mandatory component of orthodontic treatment and could be an important factor in determining the long term patient satisfaction with the orthodontic treatment [2] .
Kaplan suggested that patients should be informed of the high chance that some relapse will occur after appliances are removed and the normal changes that occur over time. In this way, patients become an essential part of the decision-making process, besides the orthodontist, regarding the appropriate duration of retention procedures. Undoubtedly, successful preservation of orthodontic outcomes is most effective if patients accept responsibility for wearing and maintaining appropriate retention appliances [5] . Consequently, successful preservation of orthodontic outcomes can be accomplished if patients take responsibility for the maintenance and wearing the retainers [23] . Wong and Freer also reported that over 50% of patients admitted that they did not wear retainers as instructed, with the most common reasons being discomfort and forgetfulness [24] .

Subjects and Methods
This is a cross-sectional observational study design conducted from March 10, 2020-May 20, 2021 to assess the satisfaction of patients and expectation about post-orthodontic retention in Saudi Arabia. The questionnaire is taken from previous questionnaire [25] . The questionnaire included 19 questions, mainly containing multiplechoice questions and was consisted seven sections which organized for orthodontic patients who had already done with orthodontic treatment. Inclusion criteria are as follows: patients aged between 15 years and 60 years, Female and Male, agree to participate, from Saudi Arabia. Any participants were younger than 15 years or older than 60, disagree to participate, outside of Saudi Arabia or not Saudi were excluded from our study.

Statistical analyses and sample size calculation
Data were represented in the form of frequencies (number of responders) and valid percentages for categorical variables. Mean (SD) and frequency and percentage were calculated. SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) was used to perform all statistical calculations, version 23 for Microsoft Windows. Considering a confidence level of 95%, a marginal error of 5%. A total of 450 eligible participants responded to the questionnaire and examination was done were included in the statistical analysis.

Ethical considerations
All participants written consents from their parents and willing to be interviewed and examined if they agree or not to take part in the study. Only those who agreed to participate were included. Before conducting any study-related procedures, ethical approval was obtained from Research Ethics Committee at Riyadh Elm University, Saudi Arabia.

Results
In our study majority of the participants were females (87.3%), and 55.3% belonged to the 20-25 years age group [ Table 1]. The fixed orthodontic related history showed 59.8% had undergone the treatment for 1 to 3 years and 31.6% of the participants reported that they had removed the fixed braces for more than five years. It was reported by 8.4% (n=38) that they had undergone Frenectomy before the initiation of fixed orthodontic treatment. Among these participants, 89.5% (n=34) reported that the fascia (space) closed between the upper frontal teeth after Frenectomy, and 65.8% (n=25) agreed that spaced between the two upper front teeth still closed after removing the retainer. There was no statistically significant association found between fixed orthodontic treatment history and the age of the participants (p<0.05) [ Table 2].  However, there was a statistically significant association seen between the gender of the participants and the duration of the fixed orthodontic treatment. It was found that females underwent the treatment for a longer duration (> 3 years) (90.9%) compared to males (9.1%) (p=0.020), and Frenectomy was performed significantly higher in females (60.5%) (p<0.001) [ Table 3]. It was reported by 10.9% that they didn't use a retainer after removing fixed braces, and 27.3% (n=123) used stainless steel bonded retainer for both upper and lower arch [ Figure 1].
When we assessed the relationship of practices related to retainer used, it was reported by 70.3% that their orthodontist advised them to use the retainer for the whole day (both day and night), and 49.5% reported that it was instructed to be used only during the night. The frequency of wearing retainer showed that 5% never used retainer and 49.4% used it every day as advised by the orthodontist. The most reported reason for not using retainer difficulty to speak or no comfortable to use, and 12.5% mentioned the reason as they lost or damaged it. It was found that 38.2% replaced the retainer at least one time since it was first made available, and the major reason for replacing it was 'losing it' (43.1%). Only 21.4% reported that they made a follow-up appointment after completing fixed orthodontic treatment or after placing a retainer. It was reported by 40.1% of the participants that found noticeable changes in the alignment of teeth from the corrected alignment (after removing fixed braces), and the changes were more seen during 7-12 months (39.1%). However, there was no statistically significant association seen between practices related to retainer and baseline characteristics of the participants (p>0.05) [ Table 4]. When we asked the participants how often they should wear a retainer, the majority of them (92.3%) agreed that it should be worn, which was significantly more reported by the participants of age group 20-25 years and 26-30 years (p=0.002). The most common reason that participants thought for seeing the changes in the alignment (relapse) after correction of the malocclusion was 'not earing the removable retainer as advised by the orthodontist, which was comparatively more reported by male than females (p=0.001) [ Table 5].

Discussion
In fixed orthodontic treatment [FOT], retention is crucial for preventing relapse of the final occlusal outcome. However, some degrees of relapse are unavoidable until appropriate retention protocol is followed after removing the active appliances [1] . Evidence shows that patient compliance decreases as FOT progress, and poor compliance to orthodontist's instructions related to the use of retainers can often compromise the achieved orthodontic outcomes [2] . There is a lack of information regarding the use of retainers and patients' satisfaction and expectation following FOT in the KSA. Hence this study aimed to assess patients' satisfaction and expectation about post-orthodontic retention. The study findings showed that approximately 60% of participants reported that they underwent FOT for duration of 1-3 years. There is no consensus about the actual treatment duration of using active fixed appliances for correction of malocclusion in literature. However, a meta-analysis has reported that the mean duration of orthodontic treatment to be 19.9 months [3] . Several factors could influence FOT's duration, including gender, type of malocclusion (overbite, crowding, etc.), pre-treatment ANB value, extractions, patient compliance, the time between appointments, and oral hygiene status, and other sociodemographic characteristics [4,7] . Among these factors, patients' compliance with orthodontist's instructions regarding the use of retainers is crucial in the stability after FOT. The presence of maxillary and/or mandibular midline diastema due to high frenal attachment may compromise the closure of the space between the frontal teeth [8] . Frenectomy is indicated in such patients to facilitate closure of the midline diastema in the course FOT, which can be performed before, during, and after the closure of the space depending on the individual case [9] . In our study, only 8.4% had undergone frenectomy, and among this, approximately 66% reported that space between was closed. Our study findings showed that the majority of the participants reported that they were instructed to wear retainer full time and nearly half of the participants. After removing active appliances, the application of retainer would minimize the changes caused by growth and enables reorganization of the tissue, thus allowing neuromuscular adaptation to the corrected tooth position [10] . A study conducted by Ren et al. reported that a longer duration of retainer use was found to be a protective factor for relapse [11] . Orthodontists use a different form of retainers that includes both fixed (bonded) and removable (acrylic), vacuum formed, and spring retainers [12] . An orthodontist commonly prefers fixed bonder retainers (FBR) as they have better esthetics, lifelong retention, good patient acceptance [13] . In our study, the majority of the participants used FBR, and nearly half of them reported that they used it every day. When asked about the reasons for not wearing retainers, the major reason was difficult to speak or uncomfortableness. The stability of orthodontic treatment is hugely dependent on patient satisfaction and compliance to instructions given by orthodontists [14] . Our study findings showed that 78.6% didn't attend follow-up appointments, and 82.3% noticed some changes in the alignment from the corrected tooth position. Adhering to the use of retainers is often challenging for the patients especially if they are removable retainers and for this reason, the majority of the orthodontist suggests extended wear of bonded retainers as they will minimize the changes in the alignment after orthodontic correction [15] . A survey done in Saudi Arabia among orthodontists reported that the majority of them preferred Hawley's retainers for maxillary arch and bonded lingual retainers for mandibular arch [16] . Removable retainers for the maxillary arch will help the orthodontists involve the patient in taking responsibility for maintaining the treatment outcomes. Regardless of the type, retainers should not cause any pain or discomfort and should be acceptable for people to wear. Any harm or discomfort caused by the retainer would make patients not use it and thus compromising the maintenance of achieved outcomes from FOT, leading to relapse. However, the duration and frequency of retainer wear are still controversial topics among orthodontists. Majority of the orthodontist has the view that optimal time interval for the first retention period should be one year [17,18] . According to Parker, retention of at least 232 days is essential for the fibers surrounding the tooth's root area to regenerate and provide stability after removing active orthodontic appliances [19] . The study findings highlight that majority of the participants were instructed to use retainers by their orthodontists and thus signifies the importance of communication between the patient and dentist or orthodontists regarding orthodontic retention (OR). The patient should be educated about the importance of OR in the maintenance of the orthodontic treatment outcomes and its relationship with relapse. Furthermore, the compliance of the patient is wearing removable retainers, and the drawbacks of fixed retainers make it essential to plan to follow up after treatment. Thus, patients should be instructed for appropriate aftercare and follow up systematically and responsibly with dentists or orthodontists.

Conclusion
The study findings showed that the majority of the participants were aware of the frequency and duration of wearing retainers but didn't completely adhere to the instructions given by the orthodontists and/or dentists. The major reason for not using retainers was difficulty in speaking or uncomfortableness. More than three-fourths of the participants agreed that they didn't attend a follow-up appointment after the retainer application.
Orthodontists and/or dentists should give sufficient information related to orthodontic retention and provide appropriate instructions regarding the use and maintenance of retainers to patients in order to increase compliance.

Ethics approval
Institutional research ethics board approval was acquired before conducting any study-related procedures. A statement was included at the beginning of the questionnaire clarifying that the participation in this study is voluntary and that collected data will be anonymous and will only be used for this study.