Review Article

Clear retainer

Priyakorn Chaimongkol, Abstract

Supanee Suntornlohanakul
A clear retainer is a removable retainer that is popular in the present day. Compared
Department of Preventive Dentistry,
with conventional fixed and removable orthodontic retainers, it is a more esthetic,
Faculty of Dentistry, Prince of
Songkla University, Songkla, comfortable, and inexpensive appliance. Although several studies have been published
Thailand about clear retainers, it could be difficult to interpret the results because of the variety
of study designs, sample sizes, and research methods. This article is intended to compile
the content from previous studies and discuss advantages, disadvantages, fabrication,
insertion, and adjustment. Moreover, the effectiveness in maintaining dental position,
occlusion, retention protocols, thickness, and survival rate of clear retainers is discussed.
Key words: Clear retainer, thermoplastic retainer, vacuum‑formed retainer

INTRODUCTION survival time, and wear of retainers. However, it could be

difficult to interpret the results and evidence presented
The retention phase is an important phase in keeping teeth in in these studies because of the variety of study designs,
a debonding position and inhibiting the teeth from returning sample sizes, and research methods. This review aims to
to their original position.[1] Both removable and fixed retainers compile the content from previous studies and discuss
can be used to provide retention. A clear retainer (Essix® advantages, disadvantages, fabrication, insertion, and
retainer, thermoplastic retainer, or vacuum‑formed retainer) adjustment. Moreover, the effectiveness in maintaining
is a removable retainer that was introduced in 1993 by dental position, occlusion, retention protocols, thickness,
Dr.  John Sheridan[2] as an esthetic, comfortable, and and survival rate of clear retainers are discussed in the
inexpensive appliance compared with conventional fixed discussion part.
and removable orthodontic retainers.[3] It is a transparent
and thin but strong vacuum‑formed appliance. Nowadays, Advantages
clear retainers are produced by many companies such as • More esthetic and less visible[3,4]
Essix®, which is a registered trademark of Raintree Essix, • Inexpensive[3,4]
Inc., Zendura®, which is produced by Bay materials LLC • Ease of fabrication[2]
and Vivera®, which is produced by Align Technology, Inc. • Ability to place on the day the fixed appliance is
debonded[2]
To date, several studies have been published about the • Decreased chair time[2]
effectiveness, retention protocols, occlusal contacts, • Capable of correcting minor tooth discrepancies[4] due
to flexibility and positioner effect[2]
• Provides better oral hygiene than fixed retainer[5]
Access this article online
• Serves as a temporary bridge or crown for missing
Quick Response Code:
Website: teeth[2]
www.apospublications.com • Acts as night guard for bruxism.[2]

DOI: This is an open access article distributed under the terms of the Creative
10.4103/2321-1407.199173 Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.

For reprints contact: [email protected]

Address for Correspondence:
Dr. Priyakorn Chaimongkol, PhD Candidate, Department of
Preventive Dentistry, Faculty of Dentistry, Prince of Songkla
University, Hatyai, Songkhla 90110, Songkla, Thailand. How to cite this article: Chaimongkol P, Suntornlohanakul S. Clear
E-mail: [email protected] retainer. APOS Trends Orthod 2017;7:54-60.

54 © 2017 APOS Trends in Orthodontics | Published by Wolters Kluwer - Medknow

 Chaimongkol and Suntornlohanakul: Clear retainer

Disadvantages PROBLEMS DURING INSERTION AND USE

• Demands good compliance[6] OF ESSIX® APPLIANCES
• Nonsettling of occlusion due to occlusal surface
coverage of clear retainer[7,8] Looseness of appliance
• Prone to wear and needs replacement at least annually[4] During insertion, if appliance is too loose, it can be
• Easily lost due to transparency[4] tightened at chairside by using a Hilliard Undercut
• Looseness of retainer in case of gingival inflammation Enhancing Thermoplier #82510.[10]
or puffy gum.[4]
Too tight appliance
A clear retainer should be flexible when passing through the
FABRICATION undercuts. If excessive force is needed to insert or remove
the retainer, it is mostly because of plastic adaptation into
Steel trays with multiple retention holes and polyvinyl
undercuts gingival to contact points. The way to prevent
siloxane are recommended for impression to prevent
this problem is blocking out excessive undercuts on the
distortion, and polyvinyl siloxane has excellent elastic
cast prior to thermoforming. Otherwise, these undercuts
recovery so the impression does not distort. It remains
have to be cut‑off by using a blade and that will consume
dimensionally stable for 6 months and can be repoured
chairside time.[10]
again without distortion. Moreover, it is easy to work
with and can register interproximal morpholog y Gingival compression
precisely. It comprises light and heavy bodies; a light If a clear retainer presses on surrounding tissue, it leads to
body provides excellent detail of interproximal space a pale tissue color at the border of the appliance. Excessive
whereas a heavy body ensures the stability of the gingival retainer height can be reduced with curved Mayo
impression. Alginate is not the material of choice for scissors #18001. Nevertheless, the border of the appliance
Essix® impressions because it is not dimensionally stable should not be trimmed until it conforms to the cervical
and accurate enough to provide precise anatomic detail line because that will reduce plastic adaptation in retentive
of retentive undercuts below the contact points. Die undercuts.[10]
stone is recommended because it has high compression
strength and minimal expansion. After obtaining a dental Minor relapse
cast, interproximal areas and gingival borders should be Failure to wear the retainer leads to the retainer losing
distinct and excessive undercut should be blocked out its fit during the retention period. However, slightly
with compound filling to enable the patient to remove malaligned teeth can be realigned using the same clear
it more easily. Then, plastic thermoforming machines retainer without fixed appliances or another clear retainer.
will be used for Essix® retainer construction.[4] A clear Since a clear retainer is semi‑elastic and has resiliency and
retainer must fit on the model and adjustment is not shape‑memory, a minor relapse can be corrected until
usually needed. However, the area of muscle attachment the teeth return to their debonded position. The patient
must be reduced.[9] has to wear the retainer full‑time until it passively fits and
malaligned teeth are realigned. After that, a night‑time
INSERTION AND ADJUSTMENT appliance is prescribed.[2,11] In addition, adjusting a retainer
with Hilliard thermopliers can realign teeth and the
A clear retainer can be inserted by seating the retainer retainer should be worn full‑time. Then, a new retainer is
with finger pressure. Normally, the retainer should constructed and can be worn at night.
not slip easily over the teeth but should be inserted
Repair
with a reasonable amount of pressure to press it over
If the appliance has wear, crack, separation, or split areas, it
interproximal undercuts gingival to the contact points.
is preferable to make a new appliance instead of repairing.
If it does not seat properly, it is usually because of
However, heat guns can be used to repair the appliance if
interproximal ridges that have not been adequately
necessary.[9]
reduced. This area can be reduced and smoothed at
chairside using a blade. During the first insertion, the
patient might feel tight during the use of the retainer MAINTENANCE
but the warmth in the mouth will make this sensation
disappear.[2] After that, occlusion should be equilibrated The care after receiving an Essix® retainer is important.
using double‑sided articulating paper and grinding the Appliances should be worn full‑time except during eating
high spot with a trimmer bur.[4] to allow natural consumption and to avoid crushing of

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 Chaimongkol and Suntornlohanakul: Clear retainer

the appliance. Regular cleaning of removable dental lengthened to mesiobuccal grooves of first molars or a
appliances promotes good hygiene but toothpaste is not full coverage retainer should be used.
allowed because it can dull the plastic and may crack the
appliance. If the retainer becomes loose and the patient The border of the appliance should extend gingivally
can use their tongue to remove the appliance, they should 3–4  mm on both facial and lingual sides.[4] The gingival
discontinue wearing it and call their doctor immediately. edge should be notched in the area of labial and lingual
Moreover, chewing gum while wearing the retainer is not frenums.[4]
allowed.[10]
An Essix ® retainer is U‑shaped and does not cover
the palate, so if expanded arch stabilization is needed,
CONTRAINDICATION OF CLEAR RETAINER U‑shaped 0.030‑inch wire should be bent to conform to the
shape of the palate and placed 2–3 mm from the cervical
Swollen interproximal tissue margins of the teeth.[4]
The appearance of interproximal tissue affects the
retention of the appliance. In this situation, a Hawley Sometimes, a canine to canine retainer is difficult to remove.
retainer or fixed retainer should be used until the patient A modification of a fingernail purchase tool can be added
has normal morphology of interproximal tissue.[4] to help the patient remove the appliance more easily. The
appliance remover tool is a helping tool for removing a
Severe pretreatment dental rotation clear retainer by using it from the cheek side and from the
In cases of severe dental rotation, especially of the incisors, tongue side and can provide comfort, especially for men
a fiberotomy is recommended before the retention phase. with large fingers.[4]
Moreover, a fixed retainer should be used combined with
an Essix® retainer.[10] Another design is a clear retainer with a bite plane. There
are two‑ways to create a bite plane on an Essix® retainer,
Use as bleaching tray using acrylic or Hilliard thermoplaster.[10]
A vacuum‑formed retainer should not be used as a
bleaching tray because it has a different design to a A patient with pretreatment anterior open bite can also use
bleaching tray, for example in the area of the bleaching gel a clear retainer with an amplified retention system, which
reservoir and gingival margin. Moreover, bleaching trays consists of cuspid to cuspid bonded lingual retainers,
are thinner and softer.[12,13] lingual caplin hooks, and intraoral elastics. It was fabricated
with the instruction to use vertical elastic at night to
Dental arch expansion maintain overbite. Vertical elastics are placed at the lingual
For patients who had constricted arches at the beginning side with slight force (100 g). With the use of elastic, the
of treatment and were treated by dental arch expansion, a patient has no difficulty while sleeping [Figure 1].[10]
Hawley retainer is recommended, whereas a vacuum‑formed
retainer is not advised because it may not be rigid enough For a patient who lost teeth, a clear retainer with a crown or
in this situation.[14] denture teeth can be constructed [Figure 2].[19] One useful
application of a clear retainer is to fabricate a temporary
Patient with anterior open bite bridge to replace missing anterior teeth. It is challenging
A canine to canine clear retainer should not be used in for orthodontists and implantologists to provide both
patients with an anterior open bite tendency,[3] whereas function and esthetics during the period that a patient is
a full posterior occlusal coverage design should be used waiting for final single tooth restoration.[20] This design of
in these patients to prevent posterior teeth eruption and a clear retainer can be used to restore edentulous areas in
recurrence of anterior open bite.[8,15]

DESIGNS
The extension of clear retainers varies from canine to
canine[2,3] to all teeth in both maxillary and mandibular
arches.[8,16] However, a full posterior occlusal coverage
design has been commonly chosen[8] because it can reduce
the risk of posterior teeth eruption during retention.[15]
Moreover, Wang[17] and Sheridan et  al.[18] recommended
that in cases of extraction, the distal margin should be Figure 1: Amplified retention system

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 Chaimongkol and Suntornlohanakul: Clear retainer

statistically significant difference was found.[3] Moreover,

Demir et  al.[21] also investigated the clinical effectiveness
of clear and Hawley retainers at 1 and 2 years after the
treatment phase and showed that clear retainers were more
effective for mandibular anterior teeth retention. Thus, they
concluded that both types of retainer were successful but
the vacuum‑formed retainer is more effective at holding
the correction of incisors on both arches, especially in the
mandible.[3,16,21] In addition, patients were more compliant
with vacuum‑formed retainers than Hawley retainers[22]
and they have semi‑elasticity and shape‑memory so
minor relapses can be corrected.[2] These factors might
be related to irregularity on both arches. Although clear
Figure 2: Clear retainer with maxillary right canine denture tooth retainer is effective at maintaining the position of incisors,
in the case of a patient with severe pretreatment dental
patients who have had an emergency extraction, and a new rotation, especially in the lower incisors, a fixed retainer
prosthesis is unavailable. However, it should be used in the was suggested to used combined with an Essix® retainer.[10]
short term when waiting for hard or soft tissue grafting and
implant. Moreover, it is inappropriate for occlusal function With the use of thermoplastic retainers, intercanine and
restoration and use in patients with a high lip line who are intermolar width was maintained[16,21] and no statistically
aware of esthetics.[19] significant differences were found at any time interval
between part‑time and full‑time wear groups.[23] However,
The advantages of a clear retainer with a prosthesis are its in patients with an expanded arch, the Hawley retainer is
low cost, abutment teeth conservation, short fabrication the retainer of choice due to its sufficient rigidity.[14]
time and the provision of good retention. Moreover, it can
be used immediately for tooth replacement after dental
extraction and it does not impede wound healing if it is OCCLUSION
relieved around the area of the dental socket. However, it
presents a slight compromise in terms of esthetics and it Achieving occlusal stability is a goal of retention. Occlusal
has poor color stability in the long‑term, thus it should be contacts or centric stops are one of the important
used temporarily.[19] factors that have an effect on occlusal stability. Moreover,
increasing occlusal contacts in centric occlusion can
Loss of clear retainers is one of the problems that often reduce the force distributed on the teeth.[24] Good occlusal
occurs. The technique for preventing this problem is to add contacts and intercuspation are important factors for stable
a colored stripe along the lingual border of the retainer to orthodontic results.[25] Therefore, the ideal retainer should
make it visible.[4] enable occlusal settling.[4]

A previous study determined the change of occlusal contact

EFFECTIVENESS IN MAINTAINING DENTAL in centric occlusion during retention with a full‑coverage
POSITION Essix® retainer at 9 months and 2.5 years. Regimens for
using retainers are 6 months full‑time use and 3 months
Rowland et  al.[16] compared the effectiveness of using a night‑time use. The results showed that no significant
Hawley retainer and a clear retainer for 6 months and found change was found in the number of posterior teeth occlusal
that no statistically significant differences in tooth rotation, contacts at 9 months whereas posterior occlusal contact
intercanine width and intermolar width were found in either significantly increased at 2.5  years. They concluded that
maxillary or mandibular arches. However, the results found occlusal contacts did not increase because Essix® retainers
significant changes in the irregularity of incisors with a covered occlusal surfaces of the teeth. In addition, after
Hawley retainer and the mandibular labial segment has Essix® retainer removal, teeth continued mobility and
greater irregularity than the maxillary labial segment. In occluded each other.[8] Moreover, another study also
addition, there was no clinically significant difference unless showed that after 3  months of using clear retainers,
single‑tooth displacement is located in the mandibular posterior occlusal settling was significantly less likely to
arch. Another study also showed more irregularity in both occur than with Hawley retainers. The regimen for using
maxillary and mandibular arches in the Hawley group than a Hawley retainer was 3 months’ full‑time use while the
in the vacuum‑formed retainer group, even though no clear retainer was 3 days’ use and nightly thereafter. Thus,

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 Chaimongkol and Suntornlohanakul: Clear retainer

it was concluded that the Hawley retainer enables settling use, night‑time use was recommended for both groups. The
of occlusion whereas the clear retainer holds teeth in a study found that the 1‑week full‑time group had higher
debonding position.[7] Thus, before using a clear retainer for irregularity but there was no significant difference between
retention, good posterior intercuspation has to be created the groups. In addition, no significant differences in overjet
when debonding. and overbite were found over a 6‑month observation
period. Thus, night‑time wear after 1  week of full‑time
Many studies found that a clear retainer created anterior wear was sufficient for stabilization after orthodontic
open bite. Jäderberg et al.[26] found no significant change in treatment.[26]
overbite during the use of a clear retainer for a 6‑month
observation phase, which is in line with Lindauer and Although many previous studies have investigated the
Shoff.[3] However, Sheridan et  al.[2] reported that slight effectiveness and stability of using an Essix® retainer
bite opening was detected by clinicians in 2.3% of their after orthodontic treatment with full‑time use, 6 months
patients, but the amount of bite opening was very small so is a short observation period when studying. However,
the patients did not notice the change. Furthermore, many it coincides with the reorganization period, which takes
clinicians reported that individual cases of anterior open around 200  days. [26] It would be more interesting if
bite after using an Essix® retainer are probably because longitudinal studies with a 1–5‑year follow‑up period or
of disclusion of posterior teeth while anterior teeth are longer were constructed to evaluate the effectiveness of
in contact with the Essix® retainer.[3] Moreover, canine to retention regimens.
canine Essix® retainers was used on the mandibular arch
in the studies of Sheridan et  al.[2] and Jäderberg et  al.[26] THICKNESS
Therefore, a theoretical risk of anterior open bite does
exist due to the eruption of posterior teeth. Nowadays, there are various thicknesses of plastic
sheet on the market. However, thicknesses ranging
RETENTION REGIMEN from 0.63 to 2.0  mm have been used in previous
studies[2,7,16,29] and vacuum‑formed retainer sheet thicknesses
Although removable retainers have many advantages, of 1.0 mm (68%) and 0.75 mm (16%) were most commonly
a long period of full‑time use is required and that is an recommended by orthodontists.[30] Moreover, one study
obstacle for many young patients.[27] Immediate full‑time showed that Essix® retainers that had <0.35 mm thickness
use of an Essix® retainer after debonding is suggested were capable of maintaining dental irregularity, overjet, and
but there are many opinions about the length of time. overbite. Therefore, the thickness of a clear retainer is not
Although periodontal fibers take a minimum of 232 days prone to be a factor for maintaining dental position.[26]
for reorganization,[28] previous studies recommended
different durations of full‑time use. For example, Rowland In a previous study, 0.75 mm‑thick thermoplastic sheets
were used and it was found that they broke at the
et al.[16] suggested 1 week whereas Wang[17] recommended
midline.[31] However, bruxism was not investigated in this
2 months and Lindauer and Shoff[3] showed that 3 months
study. Bruxism could be the cause of breakage because
of full‑time use is effective.
vacuum‑formed retainers cover occlusal surfaces, and
A previous study compared full‑time and part‑time use they can be broken under the stresses from functional
of an Essix® retainer by measuring the irregularity index, and parafunctional activities.[22] Thus, this condition of a
intercanine width, intermolar width, arch length, overbite patient is an important factor that should be evaluated to
and overjet at 6 months and 1 year after debonding. The make a decision on choosing the thickness of plastic sheets.
For a patient who has bruxism, thicker sheets should be
regimen for the full‑time group was 3 months’ full‑time
used. Moreover, the property of the plastic sheets should
use and 10 h/day of part‑time use. The results showed no
be considered in terms of durability, wear, and impact
statistically significant differences in the irregularity index,
resistance. In addition, these patients should wear a clear
intercanine width, intermolar width, arch length and overjet
retainer during the day instead of at night to lengthen the
whereas overbite increased statistically significantly in the
lifetime of the clear retainer.
part‑time group. However, the difference was 0.6 mm and
it may not be clinically significantly noticeable. Therefore,
part‑time wearing of an Essix® retainer was suggested.[23] SURVIVAL RATE
Another study evaluated and compared the stability of A previous study compared the survival time of a Hawley
Essix® retainer use after 6  months between 3  months’ retainer and a clear retainer for 1  year and found no
full‑time wear and 1 week of full‑time wear. After full‑time statistically significant difference between the groups in

58 APOS Trends in Orthodontics | January - February 2017 | Vol 7 | Issue 1

 Chaimongkol and Suntornlohanakul: Clear retainer

either the maxillary or mandibular arch.[31] However, the Financial support and sponsorship
duration of use for both types of retainer is different. The Nil.
Hawley retainer was prescribed for longer periods, i.e., 3
and 6 months’ full‑time wear, whereas patients receiving Conflicts of interest
clear retainers were instructed to wear retainers full‑time There are no conflicts of interest.
but for  <3  months. Moreover, patient compliance was
not presented. Other recent prospective randomized trial
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