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A Comparison between Hawley and Acrylic-Free Retainers (A clinical trial)

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Akram Faisal Alhuwaizi

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Journal of the College of Dentistry _____ Vol. 12, 2002 _______ A comparison between Hawley…

A Comparison between Hawley and

Acrylic-Free Retainers (A clinical trial)

Dr. Akram Faisal Alhuwaizi B.D.S., M.Sc., Ph.D.

Lecturer at the POP Department
College of Dentistry, University of Baghdad

Abstract
A new type of orthodontic retainer (Sarhan acrylic-free type) was compared to the
conventional Hawley retainer. Fixed appliance treatment using metal brackets was
completed for thirty orthodontic patients. Then each patient wore each type of retainer for
one month and the patient’s and orthodontist’s remarks were noted and analyzed.
Seventy percent of the patients were more comfortable with retainers than their previous
fixed appliances especially those who wore the acrylic-free retainers. The main reason for
their comfort was improved esthetics (85.7%).
Generally, the patients were more comfortable with the acrylic-free retainer than the
Hawley type because it caused less interference with speech and less soft tissue
impingement and was easier to clean. However, the acrylic-free retainer had a number of
limitations including interference in deep bite cases and difficult construction procedure. (J
Coll Dentistry 2002; 12: 115-21)

Introduction 2. Sturdy enough to withstand long-term

After active treatment, retention of the
achieved results makes wearing an
appliance necessary, although the patient
may feel that treatment has apparently
been completed. It is therefore the duty of
the clinician to make the retention period
as trauma free and pleasant as possible
(Sarhan and Fones, 1993).
A good retaining device should hold
each tooth in the desired position, and
allow functional activity to act freely. In
addition, the appliance should be self-
cleansing and inconspicuous (Graber,
1977). The retainer that meets all these
requirements and also allows for the
gradual reduction of wearing time, by
definition, has to be a removable
appliance.
Removable, fixed, passive and active
retainers have been described (Proffit,
1993). There are several types of
removable orthodontic retainers: Hawley,
Begg, positioner, oral screen, Essix …etc
(Sheridan et al., 1993). The ideal
removable retainer should be:
1. Able to allow functional occlusion.
use.
3. Convenient for the orthodontist to provide
and maintain.
4. Patient-friendly in both comfort and wear
routine (Collett, 1998).
The Hawley retainer consisting of two
Adams clasps, a labial bow, and acrylic
base plate is the most commonly used
appliance. However, if not properly cleaned,
the base plate could become unhygienic,
may cause allergic reactions in some
patients, and can cause speech problems,
at least initially, because of its bulk. As a
result, it may not be tolerated by some
patients (Sarhan and Fones, 1993).
The earlier acrylic-free, tooth-borne metal
retainers were the Jackson Crib
(Weinberger, 1926) and that of Sicher
(1923). Unfortunately, both these designs
proved difficult to adjust, however this was
overcome in the Sarhan-type appliance by
using a more flexible design.
Sarhan and Fones (1993) stated that by
providing the patient-with a light, totally
mucosa-free retention appliance, patient
cooperation and comfort can usually be
enhanced.

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Journal of the College of Dentistry _____ Vol. 12, 2002 _______ A comparison between Hawley…
Previous clinical trials have compared
Essix and Hawley retainers assessing
occlusal contacts, irregularity index,
overbite and overjet changes (Sauget et
al., 1997; Lindauer and Shoff, 1998). No
previous study has assessed the patient
comfort and cooperation of this new
retainer as compared to the Hawley
retainer, and hence this study was carried
out.
Materials and Method
After completing the active orthodontic
treatment with fixed orthodontic appliance
using metal brackets for 30 patients, two
sets of alginate impressions were made
for each patient. Two types of orthodontic
retainers were constructed:
1. Hawley retainer
It is composed of two Adams clasps on
the first molars (0.7mm wire), a Hawley
arch (0.7mm wire) with its distal ends
soldered to the bridges of the Adam clasps
with two small U-loops located bilaterally
in the area of the posterior teeth (Fig. 1),
and an acrylic base plate usually 2-3mm in
thickness (Witt et al., 1988) as shown in
figure 2.
2. Acrylic-free retainer
It is composed of labial and lingual
bows made of 0.9mm round stainless steel
wires soldered to an Adams clasp (0.8mm
wire) both buccally and palatally. The
labial bow incorporates small U loops to
allow activation of the clasp and
realignment of the bow (Fig. 3). The
internal bow must maintain contact with all
the lingual surfaces and the soldered joint
between the lingual bow and the clasp
must fit tightly to the tooth to provide the
reciprocal force for the Adams clasp (Fig.
4). For the upper retainer, the level of the
internal bow must be carefully placed to
avoid interference with the lower teeth
during occlusion (Sarhan and Fones,
1993).
Each patient was randomly assessed to
one of two groups:
1. Group 1: includes 15 patients who
received the acrylic-free retainer first
and the Hawley retainer after one
month.
2. Group 2: includes 15 patients who
received the Hawley retainer first and
the acrylic-free retainer after one month.
At the end of the first month of retention,
the patient was asked questions regarding
the difference between his removable
retainer and his previous fixed appliance.
The removable retainer was taken from the
patient and the other type of retainer was
inserted. At the end of another month, the
patient was asked another set of questions
regarding the difference between the two
types of removable retainers.
Checkup appointments were scheduled
every two weeks to adjust the retainers.
Patients were instructed to wear the
appliance full-time only removed during
meals and brushing minimizing time of
removal as much as possible in accordance
with Houston and Isaacson (1980) and
Collett (1998). Oral hygiene and hygiene of
the appliance was also stressed.
The questions asked at the end of the
first month
1. Which appliance was more comfortable
the removable retainer or the previous
fixed appliance?
a. Retainer certainly more comfortable
b. Retainer slightly more comfortable
c. Don’t know
d. Fixed slightly more comfortable
e. Fixed certainly more comfortable
2. If you are more comfortable with the
removable appliance, please note why?
3. If you were more comfortable with the
fixed appliance, please note why?
The answers of these questions were
analyzed separately for the 2 groups.
The questions asked at the end of the
second month
1. Which retainer was more comfortable?
2. Which retainer has better esthetics?
3. Which retainer is easier to clean?
4. Which retainer has better odor?
5. Which retainer caused less pain?
6. Which retainer interferes with speech?
7. Which retainer cause soft tissue
impingement?
8. Which retainer cause occlusal
interference?
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Journal of the College of Dentistry _____ Vol. 12, 2002 _______ A comparison between Hawley…

Figure 1: The distal end of the Hawley arch forms small adjustment loops and
terminates soldered to the Adams clasp.

(a) (b)
Figure 2: Maxillary (a) and mandibular (b) Hawley retainer.

Figure 3: Buccal view of the acrylic-free retainer.

(a) Maxillary (b) Mandibular

Figure 4: Occlusal view of the acrylic-free retainer.

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Journal of the College of Dentistry _____ Vol. 12, 2002 _______ A comparison between Hawley…
Also, the orthodontist’s remarks were
noted regarding:
1. Which retainer caused allergic
reaction?
2. Which retainer was associated with
skipped visits?
3. Which retainer was associated with
discontinued treatment?
The answers of these questions were
analyzed together for both groups.
The statistical analysis of the study
included Chi square tests. Yates correction
was used in contingency tables. A
probability level of 5% was regarded as
significant. The sensitivity of Chi square in
clinical trials were the numbers of the
sample are small is low, and hence the
comparisons will also be referred to as
more or less irrespective of statistical
significance.
Results and Discussion
After the first month of retention, the
satisfaction of the patient with the newly
inserted removable retainer was assessed
by comparing his impression of the retainer
to that of the fixed appliance as shown in
table 1. About 80% of those who wore the
acrylic-free retainer (group 1) thought that it
was more comfortable than their previous
fixed appliance, whereas only 60% of those
who wore the Hawley retainer (group 2)
thought that it was more comfortable than
their previous fixed appliance. This clearly
shows that group 1 were more satisfied
with their retainers than group 2. However,
these differences were statistically
insignificant (X2=1.429, d.f.=2, N.S.).
For those who found their retainers
more comfortable than their fixed
appliances, the most common reason for
their comfort with the retainers was better
esthetics (85.7%), whereas improved
hygiene accounted to 42.9% and
mastication was reported to a lesser
degree (4.8%). On the other hand, 19.0%
of them preferred retainers because they
presented a change from the fixed
appliance (Table 2). Concerning the
reasons for comfort with retainers, the
differences between group 1 and 2 were
statistically insignificant for all the reasons
as shown in table 2. This may be because
of the low sensitivity of Chi square test in
small samples.
Only 6 patients (20% of the total
sample) found their retainers less
comfortable than their fixed appliances
(Table 1). The reasons for their discomfort
with the retainers were soft tissue
impingement, occlusal interference of the
Adams clasp, and need to remove the
appliance during eating. Concerning the
difference between group 1 and 2
regarding the reasons for discomfort with
retainers, only soft tissue impingement was
reported by Hawley retainer wearers more
than acrylic-free retainer wearers (Table 3).
However, statistical analysis is not possible
because of the low number of patients
dissatisfied with their retainers.
During this phase the researcher noted
a remark that patients who ended their
fixed appliance treatment with an archwire
with closing loops were more satisfied with
the change to removable retainers than
those who ended with a straight archwire.
After the second month of retention,
meaning after finishing one month with
each appliance several observations were
made by the patient and the orthodontist.
Firstly, concerning the orthodontist
remarks only one case of what seemed to
be an allergic reaction to the acrylic base
plate was seen associated with the Hawley
retainers. Although previous reports have
shown allergic reactions to soldered joints
and have suggested the use of wrap
around labial bow to eliminate soldered
joints (Bishara, 1995), no such allergies
were found in our 30 patients which may be
because of the relatively short period of
wearing each appliance. The statistical
difference between the two types of
retainers was insignificant (Table 4)
During the experiment which lasted 2
months (one month for each retainer), visits
were scheduled biweekly meaning a total
of 4 visits. During wearing the acrylic-free
retainers 5 patients (16.7%) did not attend
one of their appointments and during
wearing the Hawley retainers 7 patients
(23.3%) did not attend one of their
appointments. The statistical difference
between the two types of retainers was
insignificant (Table 4).
Only two of the 30 patients did not
attend at the end of the second month and
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Journal of the College of Dentistry _____ Vol. 12, 2002 _______ A comparison between Hawley…

both of them wore the Hawley retainer last
(Table 4). This may be because of
dissatisfaction with the second retainer
(Hawley) or may be due to personal
reasons. Contacting those patients was not
possible and therefore the following results
of patient remarks and complaints were
made for only the 28 patients who
completed the full experiment.
Questions asked to the patient included
an option of ‘Don’t know’ because some
patients were uncertain or they have
forgotten the first appliance worn one
month ago. In such cases they were urged
to select ‘Don’t know’ rather than guessing
an answer (Table 5).
Concerning the patient’s remarks on the
difference between acrylic-free retainers
and Hawley retainers the following points
can be drawn:
1. Acrylic-free retainers are more
comfortable, easier to clean and have a
better odor (Table 5) because of the
absence of the acrylic base plate.
2. Acrylic-free retainers cause less speech
interference (Table 5) and soft tissue
impingement (Table 6) because of the
absence of the acrylic base plate.
3. Hawley retainers have better esthetics
(Table 6) because their labial bow is
made of 0.7mm wire while that of the
acrylic-free retainer is made of 0.9mm
wire.
4. Hawley retainers cause less occlusal
interference (Table 6) because their
Adams clasp is made of 0.7mm wire
while that of the acrylic-free retainer is
made of 0.8mm wire. Also, the Adams
clasps of the acrylic-free retainers are
much more difficult to adjust because it
is entirely made of a wire frame.

Table 1: Responses of the patients to comfort with removable and fixed

appliances.

Group 1 Group 2
Total
Acrylic-free Hawley type
Retainer certainly more comfortable 8 (53.3%) 6 (40.0%) 14 (46.7%)
Retainer slightly more comfortable 4 (26.7%) 3 (20.0%) 7 (23.3%)
Don’t know 1 (6.7%) 2 (13.3%) 3 (10.0%)
Fixed slightly more comfortable 2 (13.3%) 3 (20.0%) 5 (16.7%)
Fixed certainly more comfortable 0 (0.0%) 1 (6.7%) 1 (3.3%)
Total 15 (100%) 15 (100%) 30 (100%)
* X2=1.429, d.f.=2, N.S.

Table 2: Reasons of comfort with removable retainers.

Group 1 Group 2
* Total Significance
Acrylic-free Hawley type
Better esthetics 11 (83.3%) 7 (77.8%) 18 (85.7%) X2=0.073, d.f.=1, N.S.
Easier hygiene 5 (41.7%) 4 (44.4%) 9 (42.9%) X2=0.101, d.f.=1, N.S.
Easier mastication 0 (0.0%) 1 (11.1%) 1 (4.8%) X2=0.022, d.f.=1, N.S.
A change 2 (16.7%) 2 (22.2%) 4 (19.0%) X2=0.058, d.f.=1, N.S.
Total 12 (100%) 9 (100%) 21 (100%)
* Percentages add to more than 100% because some patients reported more than one
answer.

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Journal of the College of Dentistry _____ Vol. 12, 2002 _______ A comparison between Hawley…

Table 3: Reasons of discomfort with removable retainers.

Group 1 Group 2
* Total
Acrylic-free Hawley type
Soft tissue impingement 0 (0.0%) 3 (75.0%) 3 (50.0%)
Occlusal interference 1 (50.0%) 1 (25.0%) 2 (33.3%)
Needs to be removed when eating 1 (50.0%) 1 (25.0%) 2 (33.3%)
Total 2 (100%) 4 (100%) 6 (100%)
* Percentages add to more than 100% because some patients reported more than one
answer.

Table 4: Orthodontist’s remarks on both types of retainers at the end of the

second month.

Acrylic-free Hawley type

Cases associated with … Significance *
(n-30) (n=30)
allergies? 0 (0.0%) 1 (3.3%) X2=0.073, N.S.
skipped visits? 5 (16.7%) 7 (23.3%) X2=0.058, N.S.
discontinued treatment? 0 (0.0%) 2 (6.7%) X2=0.022, N.S.
* d.f.=1

Table 5: Patient’s remarks on both types of retainers at the end of the second
month.

Chosen retainer (n=28)

Which retainer … Acrylic Hawley The Don’t
free type same know
was more comfortable? 15 (53.6%) 6 (21.4%) 5 (17.9%) 2 (7.1%)
has better esthetics? 5 (17.9%) 8 (28.6%) 9 (32.1%) 6 (21.4%)
is easier to clean? 18 (64.3%) 2 (7.1%) 7 (25.0%) 1 (3.6%)
has better odor? 5 (17.9%) 0 (0.0%) 12 (42.9%) 11 (39.3%)
caused less pain? 7 (25.0%) 6 (21.4%) 13 (46.4%) 2 (7.1%)

Table 6: Patient’s complaints on both types of retainers at the end of the

second month.

Acrylic-free Hawley type

Which retainer …
(n=28) (n=28)
interferes with speech? 3 (10.7%) 11 (39.3%)
cause soft tissue impingement? 0 (0.0%) 12 (42.9%)
cause occlusal interference? 6 (21.4%) 3 (10.7%)

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 Journal of the College of Dentistry _____ Vol. 12, 2002 _______ A comparison between Hawley…
Conclusion
Acrylic-free retainers were better
tolerated by the patients, and they have the
following advantages:
1. Hygienic
2. Does not interfere with speech and
swallowing
3. More acceptable to the patient
4. Can be heat sterilized after receiving
from the lab.
However, they have the following
limitations:
1. May cause interference in deep bite
cases.
2. Does not retain rotated teeth especially
lower incisors.
3. Considerable wire bending experience is
required for optimal accuracy.
4. Difficult to repair if bent (Alhuwaizi,
1997).
References
Alhuwaizi AF. (1997): Acrylic-free retainers.
Iraqi Annual Dental Conference,
(Abstract).
Bishara SE. (1995): Oral lesions caused by
an orthodontic retainer: a case report.
Am J Orthod Dentofacial Orthop;
108(2): 115-7.
Collett T. (1998): A rationale for removable
retainers. J Clin Orthod; 32(11): 667-9.
Graber TM, Neumann B. (1977):
Removable orthodontic appliances.
Philadelphia: WB Saunders.
View publication stats
Houston WJB, Isaacson KG. (1980):
Orthodontic treatment with removable
appliances. 2nd ed. Bristol: John Wright
& Sons Ltd., 123.
Lindauer SJ, Shoff RC. (1998):
Comparison of Essix and Hawley
retainers. J Clin Orthod; 32(2): 95-7.
Proffit WR. (1993): Retention. In:
Contemporary orthodontics. 2nd ed. St.
Louis: Mosby-Year Book, 534-5.
Sarhan OA, Fones TE. (1993): A simple
removable acrylic-free retainer (the
Sarhan type). Am J Orthod Dentofacial
Orthop; 103(1): 74-6.
Sauget E, Covell DAJr, Boero RP, Lieber
WS. (1998): Comparison of occlusal
contacts with use of Hawley and clear
overlay retainers. Angle Orthod; 67(3):
223-30.
Sheridan JJ, LeDoux W, McMinn R. (1993):
Essix retainer: fabrication and
supervision for permanent retention. J
Clin Orthod; 27: 37-45.
Sicher H. (1923): Bau unt funktion dis
fixationsaparets. Zeitshrift F Stomatol;
21: 580-94.
Weinberger BW. (1926): Orthodontics: an
historic review of its origin and
evolution. St. Louis: CV Mosby.
Witt E, Gehrke ME, Shaye R. (1988):
Removable appliance fabrication.
Quintessence Publishing. Chicago.
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