Most of the patients undergo retreatment to address their aesthetic demands. These may include improvement in skeletal, dental or soft tissue problems that were not addressed in the initial orthodontic treatment.

Aesthetic issues can arise from untreated skeletal malocclusion in the sagittal dimension, such as class II and III malocclusions. These conditions typically result in insufficient patient facial profile improvement, resulting in convexity or concavity.

Aesthetic issues can arise from skeletal problems in the transverse dimension, which may present as a posterior crossbite with significant gaps during a smile. Transverse issues, such as crossbites and scissor bites, can also result in mandibular shifts due to occlusal interferences, leading to facial asymmetry and negatively affecting facial aesthetics.

Problems of excess in vertical dimension could manifest as a long face, gummy smile and retrognathic mandible. Deficiency in the vertical dimension could be expressed as reduced facial height and reduced teeth visibility during speech and smiling.

Persisting cants in the occlusal plane and asymmetry of the face developing due to it may be other reasons for patients seeking orthodontic retreat

Common dental problems requiring retreatment are malaligned teeth, proclination and persisting overjet post-treatment. These can lead to compromised smile aesthetics and soft tissue problems like convexity of profile, procumbent lips and lip trap.

Patients may opt for orthodontic retreatment to correct persisting soft tissue problems like excessive lip strain and lip thickness, acute or obtuse nasolabial angle, deep or shallow mentolabial sulcus, excessive or reduced gingival display on a smile, facial asymmetry arising from soft tissue or discrepancy in vertical and anteroposterior chin projection.

Soft tissue problems may also be expressed as dished-in profile, thinning of lips with excessive chin prominence, often a consequence of extraction protocols of treatment and over-retraction of incisors. Correction of such problems may require orthodontic retreatment which may be associated with aesthetic surgical procedures or even inter-disciplinary management like prosthetic rehabilitation. ^,

Some of the patients may require retreatment due to functional reasons like the inability to chew food efficiently or pain associated with mastication. An improper occlusion, such as a persisting crossbite, a scissors bite or a deep bite at the end of the treatment, leads to multiple occlusal interferences in centric and eccentric contacts. This may cause poor masticatory efficiency with clicking and pain in the TM joint.

In the long term, it may cause trauma from occlusion, periodontal break down, mobility of the interfering teeth and predispose the patient to a definite TM joint disorder. ^,

Too much retraction of incisors may lead to encroachment of tongue space with associated speech difficulties, although rarely associated with reduction of airway. In such cases, relapse or re-opening of extraction spaces is inevitable unless long-term permanent retention protocols are followed.

One of the main aims of orthodontic treatment is to address long-term oral health goals, such as increasing the longevity of dentition by creating a better environment for oral hygiene maintenance. Well-aligned teeth in good occlusion tend to be minimally prone to dental caries and periodontal disease.

Improperly aligned teeth may also predispose a patient to dental caries due to the inability to maintain oral hygiene.

If the treatment is completed without adequately closing the spaces, it can lead to serious oral health issues. This may occur due to the patient’s inability to maintain periodontal health because of existing gaps between teeth or open extraction sites and trauma from occlusion.

Therefore, long-term dental health maintenance should be considered the most important factor for determining the need for orthodontic retreatment.

One of the main reasons for suboptimal aesthetic and functional outcome is improper diagnosis and treatment planning. There could be innumerable clinical situations where multiple treatment options may be considered to address similar problems. Such variability in treatment planning may be due to different schools of thought followed by individual clinicians. The commonest being the extraction vs non-extraction controversy and the hard tissue vs soft tissue paradigm. Considering varied opinions in treatment planning among clinicians and paradigm shifts that the science of orthodontics has undergone over the past century, it is difficult to mark a treatment plan as right or wrong in the truest sense. As long as the plan is supported by scientific justification and norms, addresses the chief concern of the patient and looks into the holistic improvement of the dento-facial complex, it can be considered to be an acceptable one. ^,

In orthodontic problems related to treatment planning, one of the commonest is a wrong extraction decision. While there are set orthodontic guidelines for the same, opinions may vary as per clinical situations– specifically while addressing complex orthodontic problems. Regarding variability in extraction scenarios– the determining factors are the soft tissue objectives and the cephalometric hard tissue norms like skeletal relationship and incisor inclination. While both extraction and non-extraction modes of treatment have their pros and cons, in re-treatment scenarios it is best to understand the patient’s motivation for re-treatment before determining the treatment protocol. Following guidelines and adhering to schools of thought might not address the patient’s primary concern.

When a patient returns for orthodontic retreatment with protrusive lips and a convex facial profile and was initially treated with a non-extraction protocol, it may be necessary to consider extractions to address their concerns. However, it is equally important to understand why the previous orthodontist chose that specific treatment plan.

For instance, if the presence of a large tongue influenced the decision against extraction due to concerns about significant relapse, then retreatment might be avoided after discussing this with the patient. On the other hand, if the initial treatment was based solely on the orthodontist’s belief in the non-extraction philosophy and failed to address the patient’s chief complaint, then orthodontic retreatment involving extractions becomes an useful option.

On the other hand, a patient may come with a dished-in profile, prominent nose, chin and history of multiple extractions based on previous orthodontic treatment. The previous orthodontist may have considered extraction treatment due to the severe discrepancy between arch length and tooth size that the patient initially presented with.

Suppose the extraction treatment plan was carried out because the previous orthodontist overlooked the soft tissue considerations. In that case, it may be necessary to pursue orthodontic retreatment to address the patient’s soft tissue concerns. This retreatment might involve orthodontically opening the extraction spaces and rehabilitating them with prostheses to address these concerns effectively.

Also, more often than not in some cases, the patient is sceptical about teeth extraction despite an explanation from the clinician that the extraction modality is best suited to achieve his expected aesthetic outcome. With free information available to patients on the internet and social media to promote various appliance systems with non-extraction treatment modalities, the clinician must decide the correct treatment based on patients’ requirements. It is almost inevitable that a treatment plan based on the patient’s opinion or driven by financial aspects and not on evidence proven therapy would call for retreatment at a later date when the patient is not satisfied with the outcome.

The onus lies on the clinician to address the delicate balance between addressing the patient’s chief concern, understanding the previous treatment plan, justifying the same and then pragmatically deciding on a plan if he finds orthodontic retreatment an absolute necessity.

Appliance selection for orthodontic treatment should be based on the clinical situation and treatment objective. Traditionally, pre-adjusted edgewise appliances cater to most dental malocclusions of varying complexity. Along with different configurations of wires, round and rectangular, they provide excellent control in most vectors of tooth movements.

However, with changing social trends, the influence of social media, and rigorous marketing by corporate appliance providers, patients have become increasingly involved in choosing the appliance. With an increasing number of adults taking up orthodontic treatment, the focus has now changed to a more inconspicuous form of appliance design, such as ceramic braces, lingual braces and clear aligners. Orthodontic treatment planning has, therefore, undergone a paradigm change from a treatment-centric to an appliance-centric model.

While patient is in no position to decide on which appliance is best suited to treat his malocclusion but in the age of consumerism the patient’s opinion about appliance system and consent to treatment are given adequate importance. Also, there has been an increasing trend for patients opting for– ‘DIY—Do it yourself’ form of treatment specially aligners. Such unsupervised form of treatment grossly increases the chances of suboptimal treatment outcome. ^,

Therefore, in present day clinical practice the appliance is decided on the basis of cost, social acceptability, current trends rather than merely by its efficiency of tooth movement.

Just for example, clear aligners are effective in segmental distalisation of teeth and tipping type of teeth movement while are poor in correction of rotations and torquing teeth. In spite of that, they may be preferred by adult patients because of being inconspicuous and for their ease of usage.

Preadjusted edgewise appliances on the other hand provide better three-dimensional control of teeth movement and are more biomechanically efficient than clear aligners. They may not be preferred by adult patients considering they are less aesthetic, greater demand for oral hygiene maintenance and restriction in diet.

Therefore, efficiency of the appliance in treating malocclusion is not the only factor determining the choice of appliance system. It ultimately depends on a mutual discussion between the patient and the orthodontist. So, many a times the outcome of the treatment remains compromised and may warrant the need for re-treatment. ^,

Most cases requiring orthodontic retreatment present with anchorage loss in either sagittal, vertical or transverse dimension; many exhibit class II malocclusion. ^{, ,} The aetiology could be multifactorial and have both skeletal and dental origins ( Figs 86.1–86.3 ).

( i ) Classification of class II malocclusion (arising from anchorage loss) on the basis of clinical presentation. ( ii ) Classification of class II malocclusion (arising from anchorage loss) on the basis of aetiology.

Orthodontic retreatment of sagittal problem with full arch distalisation.

Pre-treatment records. This patient has earlier been treated with extractions of upper first premolars, showing significant anchorage loss.

Orthodontic retreatment of sagittal problem with clear aligners.

Pretreatment records.

The reasons for orthodontic relapse could be multifactorial– but the two common being improper retention protocol and lack of compliance by the patient during the retention phase.

The other reasons could be persisting growth, persisting habits like mouth breathing, tongue thrusting, and thumb sucking.

From orthodontist perspective, retention protocols should be decided as early as during the treatment planning stage of every case. While crossbites once treated could be self-retentive, cases of severe crowding and spacing due to large tongue or tongue thrusting habit might require long term retention. Therefore, it is essential that the orthodontist understands the etiology of the malocclusion before deciding on the retention protocol. Improper retention protocol may predispose a patient to orthodontic relapse requiring the need for re-treatment.

In addition in spite of proper retention protocols, residual growth in certain cases may cause relapse– like skeletal class III malocclusion where latent mandibular growth may overcome class III correction done at a young age. This might also warrant re-treatment.

From the perspective of the patient, diligent wear of retainers is mandatory to avoid orthodontic relapse. More often than not patient may discontinue removable retainer wear on their own, forget to repair broken fixed retainer or discontinue regular follow up with the orthodontist. These may predispose the dentition to orthodontic relapse which may need orthodontic re-treatment. ^,

While social factors like self-awareness and peer pressure could be motivating for patients to undergo orthodontic re-treatment, it could also be a deterring for a few. One of the main motivating factors for patient willing to undergo a second phase of orthodontic therapy is to improve their facial aesthetics, smile aesthetics and in turn, their self-confidence. Social factors like self-awareness and peer pressure could motivate patients to undergo orthodontic retreatment.

Many patients seeking orthodontic retreatment are upset about the failure of their previous treatment. Therefore, compliance is an issue in retreatment cases mainly because they need more trust towards the treating doctor, considering their past experiences. However, in successfully treated retreatment cases with significant aesthetic improvements, patients are highly motivated, positive and confident, and their trust in the science is restored.

Social factors could be deterring a few patients from taking up orthodontic retreatment. Wearing dental braces for a long time, in some cases, may be considered a social taboo. Since orthodontic treatment usually takes longer than any other dental procedures, often running into years, requiring regular follow-ups and a high level of oral hygiene maintenance, therefore considering retreatment with dental braces might be a psychological burden for many. A highly motivated patient may opt for clear aligners over dental braces, particularly among the adult’s seeking retreatment. ^,

Financial burden and affordability issues are significant reasons for patients to reconsider or decline retreatment. Retreatment in orthodontics can be complex and may require additional tools such as TADs, customised appliance systems or surgical intervention, all of which require a highly skilled operator. Consequently, financial considerations play a crucial role in the decision-making process. Moreover, the financial implications can be even more significant if patients opt for clear aligners for aesthetic reasons. The negative perceptions surrounding retreatment largely stem from the additional costs of these procedures. ^,

Poor oral hygiene and lack of motivation to improve are among the most important contradictions for orthodontic retreatment. Long duration of orthodontic treatment associated with poor oral hygiene predisposes a patient to white spot lesions and dental caries. This can seriously affect the long-term dental health. In retreatment cases, the duration of treatment is even longer. Therefore, the clinician should motivate the patient with oral hygiene maintenance protocols before the start of the procedure. ^,

Increased duration of orthodontic treatment predisposes a patient to orthodontic-induced root resorption. Since orthodontic retreatment is done after a long initial orthodontic treatment, a pre-assessment of root resorption must be done before initiating every retreatment case. Retreatment is done with great caution or avoided in subjects showing root resorption. Retreatment may exacerbate the condition and lead to tooth mobility or loss.

Active periodontal disease and severe bone loss are definite contraindications for orthodontic retreatment. Initially, retreatment cases may present with gingival recession, possibly due to the type of tooth movement and biomechanical considerations associated with the previous treatment or active periodontal disease. Orthodontic retreatment is often related to major complex tooth movements, which might cause jiggling movements and aggravate the compromised periodontal condition, if any. Therefore, the clinician should pre-assess the periodontal status before venturing into retreatment and constantly monitor it during the treatment.

Uncontrolled diabetes, severe osteoporosis, kidney ailment or patients with terminal illness are contraindicated for orthodontic retreatment.

On patients taking medication like bisphosphonates, which affect bone turnover, orthodontic retreatment is contraindicated.

For patients with a history of allergy to nickel and allergic reactions during initial treatment, metal braces and wires should be avoided for retreatment. They can opt for aligners as alternate modes of retreatment.

Psychological factors significantly influence a patient’s decision to pursue or forgo retreatment. If a clinician suspects serious psychological issues, it is essential to seek professional advice, and body dysmorphic disorder (BDD) should be considered. Patients with BDD may have unrealistic expectations that cannot be addressed solely through orthodontic treatment.

Patient aesthetic demands and expectations should be taken seriously; some may require interdisciplinary care, while others may be unrealistic. Those needing orthognathic surgery to achieve aesthetic and functional goals should be clearly defined.

Trust issues are not uncommon for patients seeking retreatment. Therefore, it is essential to provide counselling before initiating any new treatment. A signed written consent from the patient is mandatory for all orthodontic retreatment cases. This consent should outline the details of the treatment plan, including the benefits and risks associated with it. ^,