healthcare

Systematic Review
“Wire Syndrome” Following Bonded Orthodontic Retainers: A
Systematic Review of the Literature
Carole Charavet 1,2,3, * , France Vives 1,2 , Sofia Aroca 4,5 and Sophie-Myriam Dridi 3,6,7

1 Université Côte d’Azur, Faculté de Chirurgie Dentaire, Département d’Orthodontie, 06000 Nice, France;
f.vives@hotmail.fr
2 Centre Hospitalier Universitaire (CHU) de Nice, Pôle Odontologie, UEC Orthodontie, 06000 Nice, France
3 Laboratoire MICORALIS UPR 7354, Université Côte d’Azur, 06000 Nice, France;
Sophie-Myriam.DRIDI@univ-cotedazur.fr
4 Pratique Privée, 75116 Paris, France; sofiaaroca@me.com
5 University of Bern, Department of Periodontology, 3012 Bern, Switzerland
6 Université Côte d’Azur, Faculté de Chirurgie Dentaire, Département de Parodontologie, 06000 Nice, France
7 Centre Hospitalier Universitaire (CHU) de Nice, Pôle Odontologie, UEC Parodontologie, 06000 Nice, France
* Correspondence: Carole.CHARAVET@univ-cotedazur.fr or c.charavet@gmail.com

Abstract: (1) Background and objective: Tooth movements described as unexplained, aberrant,
unexpected, unwanted, or undesirable can occur in the presence of an intact orthodontic retention
wire, without detachment or fracture. This iatrogenic phenomenon, known little or not by many
practitioners, responsible for significant dental and periodontal complications, both functional and
aesthetic, is called “Wire Syndrome” (WS). It is therefore considered an undesirable event of bonded
orthodontic retainers, which must be differentiated from an orthodontic relapse. The objective was
to perform, for the first time, a systematic review of the literature in order to define the prevalence
of WS and to study its associated clinical characteristics. (2) Methods: A systematic review of



the literature was performed following the guidelines of Preferred Reporting Items for Systematic


Reviews and Meta-Analyses (PRISMA) and recommendations using an electronic search strategy
Citation: Charavet, C.; Vives, F.;
on four databases complemented by a manual search. All the prospective and retrospective clinical
Aroca, S.; Dridi, S.-M. “Wire
Syndrome” Following Bonded
studies, including case reports and series, written in English or French, clearly mentioning the
Orthodontic Retainers: A Systematic description, detection, or management of WS were included. Three independent blinding review
Review of the Literature. Healthcare authors were involved in study selection, data extraction, and bias assessment using the Mixed
2022, 10, 379. https://doi.org/ Methods Appraisal Tool (MMAT). (3) Results: Of 1891 results, 20 articles published between 2007
10.3390/healthcare10020379 and 2021 fulfilled the inclusion criteria, with a globally high risk of bias since 16 articles were case
report/series. The analysis of each article allowed the highlighting of WS through 13 categories, as
Academic Editor: Massimo Corsalini
follows: prevalence, apparition delay, patient characteristics, arch and tooth involved, families of
Received: 24 January 2022 movements, dental and periodontal consequences, type of wire, risk factors, etiologies, treatment, and
Accepted: 15 February 2022 preventive approach. (4) Conclusion: This systematic review of the literature elaborated a synthesis
Published: 17 February 2022
on WS, allowing general practitioners, periodontists, and orthodontists to understand this adverse
Publisher’s Note: MDPI stays neutral event, to facilitate the diagnostic approach, and to underline preventive measures against WS. This
with regard to jurisdictional claims in review was registered in the International Prospective Register of Systematic Reviews (PROSPERO;
published maps and institutional affil- number CRD42021269297).
iations.

Keywords: retainer; bonded retainer; fixed retainer; orthodontic retainer; wire syndrome; unexpected
movement; unwanted movement; wire retainer

Copyright: © 2022 by the authors.

Licensee MDPI, Basel, Switzerland.
This article is an open access article
1. Introduction
distributed under the terms and
conditions of the Creative Commons The long-term follow-up of orthodontic bonded retainers remains a challenge for
Attribution (CC BY) license (https:// orthodontists, but also for periodontists, as well as general practitioners. Whereas fixed
creativecommons.org/licenses/by/ retainer placement is a common procedure after orthodontic treatment, complications,
4.0/). which can be severe, can happen. Indeed, in 2007, Katsaros et al. [1] were the first to

Healthcare 2022, 10, 379. https://doi.org/10.3390/healthcare10020379 https://www.mdpi.com/journal/healthcare

Healthcare 2022, 10, 379 2 of 18

describe this problem, which occurs when the orthodontic retainer is always bonded to the
anterior teeth, inducing serious complications on these teeth under the name “unexpected
complications of bonded mandibular lingual retainers”. This phenomenon was thereafter
described by some authors under different names, such as “severe complication of a bonded
mandibular lingual retainer” [2] in 2012, “Syndrome du Fil” [3] in 2015, “inadvertent tooth
movement with fixed lingual retainers” [4] in 2016, or “extreme complication of a fixed
lingual mandibular lingual retainer” [5] in 2021.
The synthesis of clinical experience evoked by the authors cited above allows us
to define and characterize Wire Syndrome (WS) as follows: Fixed orthodontic retainers
can provoke aberrant, unexpected, unwanted, or unexplained tooth movement on teeth
still bonded by a fixed retainer placed after orthodontic treatment, which could induce
progressively iatrogenic dental and periodontal complications, functional and/or aesthetic,
ranging from minor teeth displacement to teeth expulsion from the bone with loss of vitality.
In the presence of severe WS, the retainer may become detached or fractured. WS is not
a classic orthodontic relapse, and the position of the teeth does not correspond to any
previous situation.
However, neither general practitioners nor dental specialists, such as orthodontists
and periodontists, are aware of the Wire Syndrome phenomenon. Concerning general
practitioners, a lack of knowledge has been detected. A survey in eastern France showed
that only 18.6% of general dentists were aware of the risks of adverse tooth movement
associated with unintentionally active fixed retainers [6]; these results are globally in
agreement with a Swiss survey by Habegger et al. [7]. However, general practitioners are
seeing an increasing number of patients with a bonded retainer, estimated at 2–10 patients
per week [7]. Concerning orthodontists, in a survey conducted by Padmos et al. [8] in
New Zealand, one in eight was not familiar with this problem, and one in five had never
seen any such cases. Padmos et al. [8] therefore concluded that it is necessary for all dental
professionals worldwide to become more knowledgeable about this phenomenon, to be
able to recognize associated cases, and also to prevent the worsening of complications.
Therefore, the aim of this study was to perform the first systematic review of the
literature on Wire Syndrome (WS) in order to define the prevalence, to study its associated
clinical characteristics, and, specifically, to facilitate the diagnostic approach of practitioners
and to underline preventive and curative measures against WS.

2. Methods
2.1. Protocol Registration
A systematic review of the literature (SRL) was performed, following as closely as
possible the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) and recommendations (reference). The protocol was registered in the
International Prospective Register of Systematic Review (PROSPERO) (CRD42021269297).

2.2. Article Identification

2.2.1. PICOs Question and Eligibility Criteria
According to the question formulated using the “Population, Intervention, Compari-
son, Outcome and Study Designs (PICOs) model”:
– Participants (P): Patients with “Wire Syndrome” (WS), i.e., dental movements de-
scribed as aberrant, unexpected, unexplained, unwanted, or excessive;
– Interventions (I): Fixed orthodontic retainer bonded at the maxilla and/or mandible
after orthodontic treatment;
– Comparisons (C): Patients not affected by “Wire Syndrome” (only for studies including
a control group);
– Outcomes (O): Define the prevalence of “Wire Syndrome” and the characteristics
associated with it.
– Study designs (S): All prospective and retrospective clinical studies, including case
reports or series, written in English or French, clearly reporting the description, detec-
Healthcare 2022, 10, 379 3 of 18

tion, or management of “Wire Syndrome” or tooth movement described as aberrant,

unexpected, unwanted, or unexplained in the presence of a bonded fixed retainer
placed after orthodontic treatment were included, regardless of the length of the
follow-up. In vitro studies, narrative reviews, author opinions, editorials, or commen-
taries were excluded.

2.2.2. Search Strategy

v Electronic search
A search strategy, tailored to each database, combining keywords, Medical Subject
Headings (MeSH) terms, and Boolean operators was performed without date restriction.
The electronic search was conducted on four different databases on 1 September 2021
(Table 1).

Table 1. Search strategy, according to each database.

Data Base Search Strategy

(orthodontic retainer) AND (((complication OR movement OR
post treatment changes OR version) AND (unexpected OR
PubMed (MEDLINE) unwanted OR inadvertent)) OR (“orthodontic retainers/adverse
effects” (MeSH Terms)) OR (Side effect) OR (Relapse) OR (Torque)
OR (twist effect) OR (Active)
(orthodontic retainer) AND (((complication OR movement OR
post treatment changes OR version) AND (unexpected OR
The Cochrane Library
unwanted OR inadvertent)) OR (adverse event) OR (Side effect)
OR (Relapse) OR (Torque) OR (twist effect) OR (Active)
(orthodontic retainer) AND (((complication OR movement OR
post treatment changes OR version) AND (unexpected OR
Embase
unwanted OR inadvertent)) OR (adverse event) OR (Side effect)
OR (Relapse) OR (Torque) OR (twist effect) OR (Active)
((orthodontic AND retainer) AND (((complication OR movement
OR “post treatment changes” OR version) AND (unexpected OR
Scopus
unwanted OR inadvertent)) OR (“adverse event”) OR (“Side
effect”) OR (relapse) OR (torque) OR (“twist effect”) OR (active))

v Manual search
To complement the electronic searches, a manual search was conducted:
– From the bibliography of articles selected by the electronic search;
– From the search engine of a selection of orthodontic and dental journals:
# American Journal of Orthodontics and Dentofacial Orthopedics;
# European Journal of Orthodontics;
# Journal of Orthodontics;
# Journal of Clinical Orthodontics;
# Orthodontic & Craniofacial Research;
# The Angle Orthodontist;
# Revue d’Orthopédie Dento-Faciale;
# L’information Dentaire.

2.3. Article Selection

2.3.1. Electronic Search
This research was conducted using the reference management software Zotero version
5.0.96.2 (https://www.zotero.org accessed on 1 September 2021). Two authors carried
out the entire procedure independently. In the case of disagreement, a third author was
interviewed, and a mutual discussion was conducted to reach a consensus.
After avoiding duplicates, the inclusion of articles was carried out in three steps:
Healthcare 2022, 10, 379 4 of 18

– Reading of titles;
– Reading of abstracts;
– Reading of the full text.
For articles with no available abstracts, full-text articles were read for eligibility assessment.

2.3.2. Manual Search

The same selection procedure applied to the electronic research was carried out.

2.4. Data Extraction

For the articles selected in this SRL, tables were made to synthesize the important data
of the articles by the same two operators independently, as follows: author names, year of
publication and journal, aim, study design, population, and results summary.
Because the included studies had heterogeneous methods, methodological analyses,
and results, it was not possible to perform a meta-analysis. Therefore, the analysis of the
articles was qualitative and descriptive.

2.5. Risk of Bias Analysis

Given the heterogeneity of the studies selected for this SRL, a tool that can evaluate the
methodological quality of different types of studies within the same SRL was employed: The
“Mixed Methods Appraisal Tool” (MMAT) [9] (http://mixedmethodsappraisaltoolpublic.
pbworks.com accessed on 1 September 2021).

3. Results
3.1. Article Selection
3.1.1. Electronic Search
The electronic search conducted on 1 September 2021 identified 1891 references. After
eliminating duplicates, 1270 references were analyzed. Based on the reading of the title,
211 titles were retained. Then, a reading of the abstract was conducted, retaining 50 articles
for a full reading of the text. After a complete reading of these 50 articles, 15 articles were
finally retained.

3.1.2. Manual Search

The manual search identified 13 additional articles. After applying the selection
procedure on these 13 articles, five articles were retained in the present study.
In total, the applied search strategy resulted in the selection of 20 articles in this SRL
(Figure 1).

3.2. Studies’ Characteristics

Out of the 20 articles selected in our SRL, the study designs were heterogeneous, with
one randomized controlled study [10] and a large majority of case series and case reports.
Additionally, the included studies were conducted worldwide, and the year of publi-
cation varied from 2007 to 2021.
Several different names were attributed to “Wire Syndrome” (Table 2). More specif-
ically, the first article describing “unexpected movements” was by Katsaros et al. [1] in
2007. The French term “Syndrome du Fil” was introduced thereafter by Roussarie et al. [3]
in 2015.
The terms “X effect” and “Twist effect” were first used by Kucera et al. [11] in 2016.
Finally, no conflict of interest in any studies were declared.
Healthcare 2022, 10, 379 5 of 18

Figure 1. Systematic search and selection strategy. PRISMA flow diagram.

Table 2. History of the different definitions/descriptions of Wire Syndrome (WS).

Authors Publication Date Wire Syndrome Definition

Katsaros et al. [1] 2007 Unexpected complications of bonded mandibular lingual retainers
Abudiak et al. [12] 2011 A complication with orthodontic fixed retainers
Renkema et al. [13] 2011 Unexpected posttreatment complications
Alessandri Bonetti et al. [14] 2012 Isolated-type recession defects with an abnormal buccolingual inclination
Pazera et al. [2] 2012 Severe complication of a bonded mandibular lingual retainer
Farret et al. [15] 2015 Extreme labial movement of the root
Roussarie et al. [3] 2015 Syndrome du fil
Kučera et al. [11,16] 2016 Unexpected complications/X effect, Twist effect, and non-specific complications
Laursen et al. [17] 2016 Complications after unintentional tooth displacement by active bonded retainers
Shaughnessy et al. [4] 2016 Inadvertent tooth movement with fixed lingual retainers
Wolf et al. [18] 2016 Undesired tooth movement
Egli et al. [10] 2017 Unexpected posttreatment changes
Jacobs et al. [19] 2017 Single tooth torque problems
Beitlitum et al. [20] 2020 Unwanted effects such as inadvertent tooth movement and torque changes
Kim et al. [21] 2020 Unexpected tooth movements
Klaus et al. [22] 2020 Unwanted tooth movements
Knaup et al. [23] 2021 Side effects of twistflex retainers
Singh et al. [5] 2021 Extreme complication of a fixed mandibular lingual retainer

3.3. Bias Results

The MMAT score was relatively high for each included study, with a mean of 73 ± 18.2%.

3.4. Studies’ Results

A description of each included study is provided in Table 3.
Healthcare 2022, 10, 379 6 of 18

Table 3. Summary description of each included study. AJODO: American Journal of Orthodontics and Dentofacial Orthopedics. * If the article had several aims, only
the one related to Wire Syndrome is mentioned.

Author
(Year Published) Aim * Study Design Population Main Results
Journal
21 patients presented unexpected movements, half of which required
Demonstrate unexpected retreatment. Prevalence: 5%. Arch involved: Mandible. Observed
Katsaros et al. [1] Patients were screened for unexpected
labiolingual changes in the movements: 18 patients had differences in torque between two adjacent
(2007) posttreatment changes in the mandibular anterior
mandibular anterior region Case series mandibular incisors and 3 patients had significant buccal inclination
region during a three-year period for regular
associated with orthodontic and movement of one mandibular canine previously adapted on a
AJODO posttreatment follow-up.
bonded retainers. working dental cast. Retainer: 0.0195 inch, three-strand, heat-treated
twistflex wire bonded to the six mandibular anterior teeth.
The patient presented unexpected movements. Arch involved: Maxilla.
Observed movements: Open bite 13/43–44, height difference between
the clinical crowns of 13 and adjacent teeth, excessive palatal root torque
Abudiak et al. [12] Describe a case of severe 21-year-old patient completed a fixed appliance of 13, and excessive buccal root torque of 12 (apex palpable in the
(2011) unwanted movement, the treatment five years ago and had a fixed maxilla vestibule). Retainer: 0.0195-inch, three-strand, heat-treated twistflex
cause of which is believed to Case report and mandibular retainer bonded to all the teeth wire bonded from canine to canine. Apparition delay: Two years. None
Orthodontic be the activation of a from canine to canine. She observed worsening of these unexpected movements were present at the end of the
Update multistrand bonded retainer. displacement of teeth 12 and 13. treatment and also did not correspond to the initial position of the teeth.
Treatment: Wire removal; orthodontic retreatment; new 0.0195-inch,
twisted, bonded passive retainer fabricated on a study model and
placed using a jig.
Of the 221 patients (75 boys and 146 girls), 6 patients presented
unexpected movements, of which 3 required retreatment. Prevalence:
Long-term effectiveness of 2.7%. Arch involved: Mandible. Observed movements: Five years
Renkeman et al. [13] flexible spiral wire after debonding, three patients had a torque difference between the two
221 patients who received a flexible spiral wire
(2011) canine-to-canine lingual mandibular central incisors, two patients had an increased buccal
Case series canine-to-canine lingual retainer after active
retainers in maintaining inclination and movement of the mandibular left canine, and one
orthodontic treatment.
AJODO alignment of mandibular patient had a torque difference between the two mandibular central
anterior teeth. incisors and increased buccal inclination and movement of the
mandibular left canine. Retainer: 0.0195 inch, three-strand, heat-treated
twist wire, bonded to the six mandibular anterior teeth.
Healthcare 2022, 10, 379 7 of 18

Table 3. Cont.

Author
(Year Published) Aim * Study Design Population Main Results
Journal
Patients presented unexpected movements. Observed movements:
First patient: Labial gingival recession and excessive buccal and lingual
root inclination of 41 and 31, respectively. Second patient: Gingival
recession and buccal dislocation of the root on 42. Apparition delay:
First patient: Five years. Second patient: Four years. Hypothetical
Alessandri Bonetti et al. Two post-orthodontic patients (18 and 22 years old)
Describe the diagnosis and etiology in both: Onychophagia. Retainer in both: Round, twisted,
[14] presented gingival recession limited to one
management of isolated-type stainless steel wire bonded to the six mandibular anterior teeth.
(2012) Case series mandibular incisor associated with abnormal
recession defects of Treatment: First patient: Onychophagia managing; removal retainer;
buccolingual inclination despite six-unit lingual
complex etiology. orthodontic retreatment; periodontal surgery. Second patient: As the
AJODO bonded retainer.
patient refused the treatment, a worsening was observed one year later
that finally induced an acceptance of treatment, as follows: Endodontic
treatment on 42 (vitality loss); orthodontic retreatment; periodontal
surgery; a new multibraided, rectangular, stainless steel wire was
bonded from canine to canine.
The patient presented a serious complication. Arch involved: Mandible.
Observed movements: Excessive buccal root torque (35◦ ) on 43 with
significant lingual inclination of crown and buccal gingival recession.
Pazera et al. [2] 20-year-old patient who previously underwent an
Present a severe complication CBCT revealed that the root and its apex were almost out of the buccal
(2012) orthodontic treatment. He came to the clinic with a
of a lingual flexible spiral Case report bone on its buccal side. Pulp vitality was preserved. Apparition delay:
fracture of his wire retainer four years
wire retainer. Four years. Retainer: Soft, twisted wire bonded to the six anterior teeth
AJODO after debonding.
with a fracture between 42 and 43. Treatment: Orthodontic retreatment;
new 0.0215 × 0.027 inch rounded steel wire bonded to the canines only;
recession was still present but the patient refused periodontal treatment.
The patient presented unexpected movements. Arch involved:
Mandible. Observed movements: Localized open bite 33/12–13,
excessive buccal crown torque of 33, and extreme labial movement of
Describe the case of a patient 36-year-old patient who completed orthodontic the root of 32, but the vitality test was negative. Apparition delay: 21
Farret et al. [15]
who underwent previous treatment 21 years previously but had his years. Retainer: Wire (no detail provided) bonded to the six anterior
(2015)
orthodontic treatment 21 years Case report mandibular bonded retainer partially debonded teeth and fractured between 42 and 43. The mandibular left lateral
ago and had a fixed and broken for four years. He came to the clinic incisor stayed bonded to the retainer and received the entire load of the
AJODO
mandibular bonded retainer. with pain and gingival recession on 32. incisors. Treatment: Orthodontic retreatment; endodontic treatment
followed by apectomy of 32; a slight residual recession remained; a new
0.016 × 0.022 inch stainless steel mandibular fixed retainer was bonded
to the mandible.
Healthcare 2022, 10, 379 8 of 18

Table 3. Cont.

Author
(Year Published) Aim * Study Design Population Main Results
Journal
60 patients presented Wire Syndrome (WS). Arches involved: Maxilla
Roussarie et al. [3]
and mandible. Observed movements: Of the 40 cases observed in the
(2015)
Describe Wire Syndrome 60 patients presenting Wire Syndrome. Patient’s mandible, 29 had a right canine with exaggerated vestibular crown
associated with maxilla and Case series documentation came from Dr. Roussarie’s office torque, and 11 had a left canine with exaggerated lingual crown torque.
Revue
mandibular bonded retainers. and from colleagues. Of the 20 cases observed in the maxilla, only 2 cases involved canines.
d’Orthopédie
Retainer: Three- or six-stranded twist round wires, flat braided chain,
Dento-Faciale
or 0.036 inch single-stranded wire bonded only on the canines.
38 patients (20.7 ± 8.9 years) presented unexpected complications.
Prevalence: 1.1%. Arch involved: Mandible Observed movements: 21
patients had an opposite inclination of the contralateral canines = twist
effect (89.5% of the left canines were tipped buccally). 12 patients had a
torque difference between two adjacent incisors = X effect. Five patients
had nonspecific complications. Apparition delay: 4 ± 2.8 years
post-treatment. The number of intercepted unexpected complications
Describe different types of 3500 consecutive patients (1423 men; 2077 women) was highest in the first five years after debonding, and then it declined
Kučera et al. [11] unexpected complications who had a mandibular-fixed bonded retainer were with time. Retainer: 0.0215 inch, gold-plated, five-stranded spiral wire
(2016) associated with Retrospective screened for unexpected complications and then OR a 0.0175 inch, six-stranded, co-axial wire bonded to the six anterior
mandibular-fixed retainers, cohort study compared with a randomly selected control group teeth. Etiologies: Patients in the “unexpected complications” group
AJODO assessing their prevalence and of 105 patients (43 men; 62 women; 29.5 ± 9.7 were, at pretreatment, with a higher mandibular plane angle (p <
possible etiological causes. years) without unexpected complications. 0.0001), as well as the position of the mandibular incisors relative to the
Point A-pogonion line (p = 0.029), but no difference was observed for
intercanine distance (p = 0.065) or mandibular incisor inclination to the
mandibular plane (p = 0.151) between the two groups. Patients in the
“unexpected complications” group were also significantly younger at
debonding (p = 0.03), but there was no significant difference in
treatment time (p = 0.270), wire type (p = 1.000), or failure rate (p = 0.562)
between the two groups.
The patient presented an unexpected complication. Arch involved:
Mandible. Observed movements: An anterior open bite, a difference in
height of the clinical crowns in the anterior sector, left canine and incisor
Kučera et al. [16] Describe the interdisciplinary inclined buccally, and right canine and incisor inclined lingually (twist
28-year-old patient completed two orthodontic
(2016) treatment of gingival recession effect). On 42, a gingival recession of 4 mm with exaggerated root
treatments, in which 14/24 and a mandibular
secondary to an unexpected Case report prominence was observed. Finally, on the panoramic, the roots of 32 and
central incisor were extracted. The patient
Journal of Clinical complication associated with a 33 were tipped. Retainer: 0.0155 inch, three-stranded twisted wire,
observed 43 gradually worsening.
Orthodontics fixed mandibular retainer. debonded of the lower left incisor. Treatment: Orthodontic retreatment;
periodontal treatment; a new fixed retainer with a five-stranded,
gold-plated wire of a 0.0215 inch diameter bonded on the six anterior
teeth and extended to the first premolars.
Healthcare 2022, 10, 379 9 of 18

Table 3. Cont.

Author
(Year Published) Aim * Study Design Population Main Results
Journal
The patients had unwanted movements. Arch involved: Mandible.
Observed movements: First patient: 31 had an exaggerated labial root
torque with a labial gingival recession. Second patient: 42 had
exaggerated lingual root torque with a lingual gingival recession
Laursen et al. [17] associated with lingual bone dehiscence. The tooth was still vital.
(2016) Describe how to correct Two patients (24 and 31 years old) completed Apparition delay: First patient: 10 years. Second patient: Five years.
unwanted tooth movements Case series orthodontic treatment and had a Type of wire: First patient: A flexible spiral wire. Second patient: A
Journal of Clinical with rational biomechanics. mandibular-fixed retainer. heat-treated, flexible spiral wire. Treatment: First patient: Retainer
Orthodontics removal; orthodontic retreatment; periodontal treatment. Second
patient: Retainer removal; orthodontic retreatment; periodontal
treatment. In both cases, after retreatment, double retention: A three-
(first patient) or six-stranded (second patient) spiral bonded wire
associated with a vacuum-formed retainer for nighttime wear.
The patient presented unwanted movements. Arches involved:
Mandible. Observed movements: Gingival recessions, lingually on 42
Illustrate inadvertent tooth
and buccally on 41 with differential torque between 41 and 42. A
movement associated with
28-year-old patient that completed an orthodontic difference in the height of the clinical crowns was observed on the
Shaughnessy et al. [4] fixed retainer, debate possible
treatment 15 years prior and presented an intact anterior teeth. In the canines, the opposite inclination of 33 and 43 was
(2016) causes, make Case report with
fixed mandibular retainer. She had regular noted. On the CBCT, bone fenestration was observed on 43 and 41
recommendations, and illustrated discussion
check-ups for the first year, but since then, no buccally and on 42 lingually. Apparition delay: 15 years. Retainer:
AJODO discuss
check-ups have been made. 0.0195 inch twisted wire bonded to the six anterior teeth for the case
orthodontic–periodontic
report. Treatment: Retainer post-treatment; orthodontic retreatment;
management.
periodontal surgery; a removable retainer, according to the patient’s
request.
Prevalence of severe adverse movement: 13%, which required
orthodontic retreatment. Observed movements: Superposition of each
Wolf et al. [18]
digitized and segmented tooth permitted to define the type of the
(2016) Analyzed post-treatment 30 patients aged 24.52 ± 4.36 years completed
movement to which each lower anterior tooth had been subjected, and
changes in the anterior Case series orthodontic treatment (for at least one year of
in-depth analysis revealed that the canines underwent the most
Journal of Orofacial mandibular region. active treatment).
pronounced rotation and translation. Retainer: Dentaflex 0.45 mm,
Orthopedics
three-stranded twisted steel wire bonded to the six mandibular anterior
teeth by the indirect method.
Of the 60 patients, five presented unexpected complications (all in the
Compare direct and indirect
Egli et al. [10] direct bonding group). Prevalence: 17%. Observed movements:
bonded mandibular-fixed 64 consecutive patients were included in a two-arm
(2017) Randomized Lingual crown inclination of 33. For one patient, the movement was
retainers and study RCT, according to an “indirect bonding group”
controlled trial (RCT) considered clinically severe. Apparition delay: Two years. Retainer:
post-treatment changes after versus a “direct bonding group”.
AJODO 0.0215 inch, stainless steel, multistrand wire. Two bonding methods
two years.
(direct and indirect) were employed.
Healthcare 2022, 10, 379 10 of 18

Table 3. Cont.

Author
(Year Published) Aim * Study Design Population Main Results
Journal
The patients had unwanted movements. Arch involved: Mandible.
Analyze the efficacy and
Jacobs et al. [19] Observed movements: Exaggerated torque on one tooth associated
accuracy of a completely Three patients who completed orthodontic
(2017) with gingival recession. Retainer: A bonded retainer without further
customized lingual appliance Case series treatment. Patients had a torque problem on one
details. For two patients, the wire was partially debonded. Treatment:
regarding the correction of the tooth with gingival recession.
Head & Face Medicine Orthodontic retreatment with a completely customized lingual
torque of a single tooth.
appliance associated with a reduction in the gingival recession.
Etiological hypotheses: The bonded retention wire is “active” due to
errors during bonding, during rebonding (repair), or due to an
interposition of a hard foreign object; or, in presence of a fracture at the
wire/bonding interface and when a force is applied, tooth can
Roussarie et al. [24]
move/rotate around the wire. Recommendation: Wires should be
(2018)
Propose a mechanical theory passive and accurately rebonded if necessary. Retainer should be
115 cases. Patients’ documentation came from Dr.
to explain the apparition of Case series performed with the utmost care. Strengthening the wire/bonding
Revue Roussarie’s office and from colleagues.
Wire Syndrome. interface (avoiding wire contamination before bonding, using a metal
d’Orthopédie
primer after degreasing the wire, sanding the wire surface to be bonded)
Dento-Faciale
should take place. In the case of Wire Syndrome (WS), the wire has to be
removed, and a period of monitoring is recommended to achieve
spontaneous repositioning. Patients should also be aware of the risk of
unwanted movement associated with the presence of a fixed retainer.
Two groups: (1) Bonded lingual retainer removal prior to periodontal
surgery plus removable retainer at night three months after surgery; (2)
Beitlitum et al. [20] Explore the benefits of a
periodontal surgery only (without retainer removal). Arch involved:
(2020) combined 15 patients presented unexpected movements,
Mandible. Retainer: All patients had a lingual bonded retainer without
periodontic–orthodontic despite the presence of a bonded retainer,
Prospective study further details. Results: For group (1), the improvement in the average
International Journal of approach to resolve Miller associated with class III gingival recession were
recession depth was significantly greater (4.0 ± 0.83 mm; improvement:
Environmental Research class III gingival recession in divided into two different groups.
87.2%) compared with group (2), who showed an improvement of 43.8%
and Public Health post-orthodontic patients.
(1.88 ± 1.29 mm) (p = 0.008). Retainer removal prior to the surgery was
beneficial in correcting Miller class III recessions.
Patients had unexpected tooth movements and gingival problems.
Arches involved: Mandible and maxilla. Retainer: Maxillary or
Kim et al. [21] Describe the types, causes, mandibular 0.0175 inch, multistrand wire bonded from canine to canine
(2020) and recommendations for Nine patients who presented an intact fixed with a Duralay resin transfer method and a removable retainer (both
preventing/managing Case series maxilla/mandibular retainer (no failure; arches) for night wearing. Observed movements: Several types of
APOS Trends in complications associated with no fracture). complications were described: Change in the transverse position,
Orthodontics bonded lingual retainers. angulation, or torque of the crown, gingival recession, and non-specific
complications such as space openings, misalignment, and appearance of
black triangle.
Healthcare 2022, 10, 379 11 of 18

Table 3. Cont.

Author
(Year Published) Aim * Study Design Population Main Results
Journal
Of the 163 patients, 44 patients had adverse movements. Prevalence:
27%. Arches involved: Maxilla and mandible. Retainer: 0.018 inch,
six-stranded coaxial wire. Movement observed: Maxillary retainers
Analyze the prevalence of (20.9%) were more concerned than mandibular retainers (14%). Median
Klaus et al. [22] Patients had completed previous orthodontic
undesirable tooth movement amount of tooth movement: 0–0.66 mm with a large interindividual
(2020) Retrospective treatment and had a bonded canine-to-canine
despite an intact fixed bonded variation of up to 2.58 mm. Risk factors: These risk factors, associated
cohort study retainer. Patients with a removable retainer
retainer and identify possible with the occurrence of adverse movements, were dysfunction or
BMC Oral Health were excluded.
predisposing factors. parafunction (p = 0.049) and lacked inter-incisal contact (p < 0.01). No
significant differences were found for the mandibular plane angle before
treatment, amount of incisor proclination, expansion of the inter-canine
distance, and overjet reduction during treatment.
23 teeth were analyzed (12 upper teeth: 10 incisors, two canines; 11
lower teeth: 7 incisors, 4 canines). Arches concerned: Maxillary and
Knaup et al. [23] Patients completed orthodontic treatment,
Measure tooth movement mandibular. Retainer: Flexible, round spiral wire. Observed
(2021) presented a fixed lingual retainer in the
after retainer removal in cases Case series movements: Several types of movements were described and also
upper/lower jaw, and presented visible
of misalignment associated (pilot study) measured. Misaligned teeth bonded to fixed retainers demonstrated
Journal of Orofacial overcrowding. The existing retainers were
with a bonded retainer. movement when those retainers were debonded. These observations
Orthopedics removed to discontinue the present forces.
also highlight the impression that retainers might be able to provoke
active force, which could be responsible for iatrogenic tooth movements.
The patient had a severe complication that required the avulsion of the
right mandibular canine. Involved arch: Mandible. Observed
movements: 43 had torqued 70◦ labially, the apex was short and totally
The patient (26 years old) completed orthodontic exposed. 42 presented lingual root torque. 32 was localized labially, and
Singh et al. [5] Describe a serious treatment with four premolar extractions 10 years the apex was nearly exposed. An anterior and right lateral open bite
(2021) complication (canine earlier. The patient had received a mandibular was present. Generalized root resorptions from 20% to 40% were
Case report
completely avulsed) with a bonded wire from canine to canine and removable observed on the panoramic radiograph. The patient did not report any
AJODO mandible bonded retainer retainers on both jaws. The removable retainers significant pain. Retainer: Supposition: Multistrand, twisted, fractured
were prescribed the first year. between 42 and 43. Apparition delay: 10 years. Treatment: Avulsion
43; retainer removal; nonsurgical periodontal therapy; six-month latency
period. No further orthodontic intervention was advised because of the
periodontal health and the presence of root resorptions.
Healthcare 2022, 10, 379 12 of 18

Analysis of the results allowed the synthesis of said results around 13 categories. Note
that not all articles presented information in all categories.
Prevalence: The prevalence varied from 1.1% to 43.0%. The lowest prevalence estimate
of 1.1% was found in a retrospective study by Kučera et al. [11], which had the largest
sample size, with 3500 patients included. The highest prevalence was found in the study
of Wolf et al. [18], which included only 30 patients, with a prevalence of 13% and 30% in
severe and moderate WS, respectively.
Apparition delay: Kucera et al. [11] showed that WS appeared in a mean interval of
4 ± 2.8 years. The apparition delay found in the included case reports and series was mostly
(80%) within this range, except for five publications that were above this range [3,4,15,17].
The shortest apparition delay reported was one year in the study of Katsaros et al. [1], and
the longest time reported was 21 years after placement of a bonded retainer in the case
report of Farret et al. [15].
Patient characteristics: Gender: The overall publications included 40 men and 81 women.
Age: The youngest WS patient identified in this SRL was 13.5 years old [1], and the oldest
was 56 years old [20]. The study by Kucera et al. [11] calculated the average age of its 38 WS
patients and found it to be 20.7 ± 8.9 years. The ages of the patients included in the case
reports and series mostly corresponded to this range, except for three [15,17,20], who were
above this range. Parafunction: Only Alessandri Bonetti et al. [14] mentioned parafunctions,
where, for two patients with WS, onychophagia was demonstrated by questioning and
exobuccal examination (nail deformation).
Arch and tooth involved: WS was found in 72 cases in the maxilla versus 179 cases
described in the mandible. Additionally, WS involved 39 maxillary incisors, 6 maxillary
canines, 64 mandibular incisors, and 100 mandibular canines.
Families of movements: Although WS shows significant interindividual variation, the
movements can be categorized into four groups (Table 4).

Table 4. Wire Syndrome (WS) movement families. N.B.: The terms “X effect©” and “twist effect©”
were introduced by Kucera et al. [11,16].

Movement Families Associated with WS

X effect
Torque differential between two adjacent incisors
Twist effect
Opposite inclination between the two contralateral canines
Excessive crown and/or root torque
Incisors or canines, which presents an exaggerated modification of the torque
Non-specific complications
Diastema openings, differences in incisor heights, etc.
Associated movements
“X effect” AND Torque modification; “X effect” AND “twist effect”
Or any other possible combination

Dental consequences: WS is responsible for displacement of the affected teeth in all

spatial dimensions with a large range of variations. These displacements can be slight,
according to the study by Klaus et al. [22], which mentioned a median magnitude of
unwanted movement from 0 to 0.66 mm. However, extreme movement of the tooth can
cause rupture of the vascular–nervous bundle and loss of vitality of the tooth [14,15]
associated with the exposure of the root until the apex [5].
Periodontal consequences: Tooth WS displacements can contribute to vestibular or
lingual gingival recessions, dehiscences, or fenestrations apparition, responsible for aes-
thetic repercussions and/or exposure of the root, leading to discomfort or pain, particularly
due to hypersensitivity [20]. In severe cases, displacement of the root out of its socket may
Healthcare 2022, 10, 379 13 of 18

result in resorption of the entire vestibular or lingual wall, depending on the direction of
tooth movement [15]. The root (and its apex) may be projected out of the bone [2].
Type of retention wire: Several different types of wires are involved in the occurrence
and development of WS, as follows:
v Flat, braided chains (Ortho FlexTech).
v Single-stranded, round wire bonded on the canines only; diameter: 0.036 inch.
v Round, twisted, stainless steel wire:
• Unknows strands with diameter: 0.0175 inch; 0.0215 inch; 0.0195 inch;
• Three strands with a diameter of 0.0155, 0.0195, or 0.0195 inches (heat treatment);
• Five strands with a diameter of 0.0215 inched (gold-plated);
• Six strands with a diameter of 0.0175 inches.
v Round, coaxial, stainless steel wire:
• Six strands with a diameter of 0.018 inches.
Most cases of WS are seen in the presence of round, twisted, stainless steel
wires [1–5,10–14,16–18,21,23], although flat, braided chains are also concerned [3], as well
as single-stranded, round wires bonded only on the canines [5] and round, coaxial, stainless
steel wires [22].
Risk Factors: Predisposing factors of WS were investigated in three studies [11,18,22]:
v Patient-related factors: Different parameters were found to be significant in WS
patients, such as lower facial level increase (p < 0.0001) [11], vestibulo-position of
mandibular incisors before orthodontic treatment (p = 0.029) [11], and presence of
dysfunctions/parafunctions (p = 0.049) [22]. However, Klaus et al. [22] did not find
any significant difference in WS patients regarding mandibular plane angle or initial
vestibulo-version of the incisors.
v Orthodontic treatment-related factors: Different parameters were found to be signifi-
cant in WS patients, such as debonded at a young age (p = 0.03) [11], canine expansion
and overjet reduction during treatment [18], and absence of inter-incisal contact at
the end of treatment (p < 0.01) [22]. In contrast, Klaus et al. [22] found no significant
difference in WS patients regarding expansion of the inter-canine distance and reduc-
tion in overjet. Kucera et al. [11] showed no significant difference regarding treatment
duration (p = 0.270), inter-canine distance (p = 0.065), or change in incisor inclination
(p = 0.151).
v Wire-related factors: No significant differences were found in patients with WS re-
garding debonded wire (p ≤ 0.05) [22], (p = 0.562) [11] and type of wire (p = 1.000) [11].
Etiologies: Different etiological hypotheses were mentioned in the included studies,
which can be grouped into three categories, as follows (Table 5): practitioner-, wire-, and
patient-related etiologies.

Table 5. Etiological hypotheses of Wire Syndrome (WS).

Practitioner-Related Etiologies [1,2,4,5,10–12,16,18,20–22]

- Insufficient passivity
- Wire iatrogenic deformation during bonding
Wire-related etiologies [1,2,4,5,10–12,14,16,18–22,24]
- Wire deformation (chewing force or hard foods, traumatic application after dental floss, other harmful habits,
or by parafunctions such as onychophagia)
- Modification or instability of the mechanical properties of wires: Wire fatigue, wire activation, and
“despiralization” of the wire strands
- Adhesive failure at the adhesive/wire interface with the application of an external force
- Undetected wire debonded
- Fracture of the wire (remaining bonded to one or more teeth)
Patient-related etiologies [18,19]
- Physiological changes
Healthcare 2022, 10, 379 14 of 18

Treatment: Treatment depends on the severity of WS. It should be noted that in the
three cases where treatment was not performed [14,21], clinical aggravation occurred.
v Mild severity: The most common treatment was retainer removal. Some authors [10,23]
observed significant improvement up to spontaneous repositioning. Stripping was
recommended by Roussarie et al. [3] to facilitate teeth repositioning and avoid re-
lapse. The correction of parafunctions was also recommended [14]. For two research
teams [3,5], an observation period of six months to one year was performed after
wire removal.
v Moderate severity: The wire is also removed, but orthodontic retreatment is required
to correct malposition and to properly reposition the root in the alveolar bone, in
order to improve surgical conditions [2,3,12,14,15,19,20].
v Significant severity: Orthodontic retreatment combined with endodontic and/or
periodontal treatment is indicated. Endodontic treatment is performed when the
displacement of the tooth is so important that it has caused a rupture of the vascular–
nervous bundle. Endodontic surgery may be associated if necessary [14,15]. In cases
where periodontal surgery is indicated, the removal of retainers is beneficial [20]. In
cases of extreme WS, dental avulsion is sometimes the only solution [5].
Recommendations: The authors of the included studies described some recommenda-
tions to avoid the development of WS (Table 6).

Table 6. Recommendations to avoid Wire Syndrome (WS).

Recommendations to Bond the Retainer

- Careful manufacture of a passive wire on a dental model (precise adaptation, avoid any
stress) [4,19,21]
- Indirect bonding method is indicated to avoid wire deformation by finger or instrument
pressure [4,21]
- Bonding canines and central incisors only to improve patient sensitivity in the case of
debonding [4]
- Strengthen the wire/adhesive liaison (avoid wire contamination before bonding, using a metal
primer after degreasing the wire and sanding the wire surface to be bonded [24])
- Prescribe a removable retainer, in addition to the fixed retainer, for nighttime wear [4,5,18,21]
Recommendations for follow-up after retainer placement
- Regular check-ups [4,5,13,15,19]
- Early detection with systematic search for all signs of WS during retainer
visits [1,2,4,5,11,13–15,21]
- Educate and inform patients about WS [1,2,11,13,15,21,24]
- Educate and inform all dental practitioners (general practitioners, periodontists, and
orthodontists) about WS [2,3,5,13,21]

4. Discussion
To the best of our knowledge, the present publication is the first systematic review
of the literature on the subject of Wire Syndrome (WS). After identifying 1891 articles,
20 articles were selected and analyzed, with a globally high risk of bias. Given the limited
number of existing publications on WS and the relevant information found in the case
reports and case series, these types of study designs were included.
The description of WS is recent; the first publication on WS appeared in 2007 [1],
followed by an increase in publications, and the distinction between classic relapse and WS
is also a very new concept. Since the introduction of fixed bonded retainers in the 1970s by
Zachrisson, fixed retainers have been progressively preferred to removable thermoplastic
application by patients and practitioners [22,25], and, parallelly, there has been an increasing
number of orthodontic treatments. The prevalence of WS is therefore likely to rise and
also to attract more research interest. Concerning specifically the prevalence of WS, six
studies estimated the prevalence of adverse movements associated with bonded retainers,
in which the prevalence varied from 1% (3500 patients studied [11]) to 43% (30 patients
Healthcare 2022, 10, 379 15 of 18

studied [18]). This wide range can be explained by the differences in sample size between
these two monocentric studies. Moreover, the protocols (patient selection, practitioners,
type of wire, bonded protocol, etc.) were very different between the studies.
Regarding the delay in apparition, WS appeared between 1 and 21 years after the place-
ment of a retainer in the included studies. The majority of cases of WS appeared within the
first five years after the placement of the retainer. This time interval should be considered
with caution for several reasons. First of all, it is difficult to date the apparition of WS with
precision, as retainer visits are intermittent. Moreover, it is difficult to detect early WS,
and the patient often consults when complications are already severe [20]. Concerning the
characteristics of the patients, all ages, particularly young people under 30 years of age, are
affected by WS. Twice as many women as men seem to be affected. Orthodontic treatment
is usually performed in adolescence, and WS occurs also a few years after the end of or-
thodontic treatment. In addition, one study showed the presence of onychophagia in both
patients with WS [14]. This parafunction could therefore increase the risk of developing
WS in our patients. Additionally, concerning the arch and tooth concerned, WS was first
described in the mandible in 2007 by Katsaros et al. [1], although the first case described in
the maxillary arch was in 2011 [12]. Moreover, although in the study by Klaus et al. [22]
maxillary teeth are more affected by WS than mandibular teeth (20.9% versus 14%), most
WS cases occur in the mandible. Indeed, more fixed retainers are placed in the mandible
than in the maxilla, where thermoplastic retainers are preferred [8,26]. Placement of a max-
illary bonded retainer requires composite plots that can create interference/occlusal trauma
with the mandibular arch, resulting in more failures [27]. In addition, when a maxillary
bonded retainer is indicated, wires are most often placed from lateral incisor to the lateral
incisor than from canine to canine to avoid the previously mentioned difficulties [28], so
WS on maxillary canines is rare. However, it should also be noted that WS in the maxilla
is more quickly detected than WS in the mandible because it affects the patient’s smile,
which leads to early consultation [3]. Finally, the teeth most often affected by WS are the
mandibular canines. It would seem that WS preferentially affects the “terminal” teeth that
are always contained by the fixed bonded retainer.
In the presence of WS, the bonded retainer is intact in most cases but, in severe cases,
the wire may become partially debonded or fractured due to important dental movement.
In any situation, various and different clinical dental and periodontal signs can be found.
The detection of one sign related to WS must immediately alert the practitioner to the
possible presence of WS in order to stop the iatrogenic evolutive process and to start adapted
therapy. Indeed, this syndrome is progressive and starts with minor dental and periodontal
consequences until the loss of vitality and/or tooth expulsion. In addition, when treatment
is not carried out [14,21], clinical worsening can occur [2,24]. Movements due to WS do
not correspond to a relapse or a physiological process: The situation of the teeth does not
correspond to their position before orthodontic treatment, nor to their position at the time
of debonding, as underlined by Kastaros et al. [1]. WS can therefore be qualified as a new
malposition observed after placement of a fixed bonded retainer following orthodontic
treatment [18,22], although no value or threshold has been scientifically determined [22].
Thus, a severe WS is easily identified because the clinical signs are more marked, contrary
to an early WS, whose clinical signs are mild; the identification of complex cases is easy,
while early detection remains difficult. In the case of mild movements, differentiation
of movements related to a classic relapse from WS also remains arduous. Therefore, the
challenge for orthodontists during follow-up visits is to detect incipient WS. Additionally,
general practitioners, as well as periodontists, also have an important role to play in the
early detection of WS. Finally, the patient must also be actively involved in monitoring [1,13].
Patients should be alerted to the need for maintenance and the plausible occurrence of
adverse effects related to the presence of the retainer wire.
With regard to WS prevention, the most important preventive measure is the use
of a bonded passive retainer. The use of a dental model to perfectly fit the retainer to
the teeth before placement is recommended, as well as an indirect bonding protocol.
Healthcare 2022, 10, 379 16 of 18

Furthermore, special care should also be taken when the fixed retainer needs to be repaired.
When a composite comes loose, small tooth movements may have already occurred and
the wire is no longer a perfect fit. In this case, using an instrument to “push” the wire
to better fit the teeth results in an active wire that could potentially be responsible for
subsequent WS. Therefore, a new passive wire should be bonded rather than repaired.
Another strategy for preventing WS is double retention, which combines a fixed bonded
retainer with a removable thermoplastic retainer [4,5,8,18]. Finally, the number of WS
cases increases during the first five years according to Kucera et al. [11], suggesting that
monitoring in the orthodontic office should be preferred, at least during this interval.
Treatment depends on the severity of the case, from non-invasive treatment, through a
multidisciplinary endodontic/periodontal approach, to extraction of the involved tooth
in extreme cases. In the case of early WS, the most important reflex is to remove the fixed
retainer to immediately stop the iatrogenic WS process; spontaneous correction of tooth
malposition may occur [10,23].
Although there are explanatory hypotheses that could justify the risk factors men-
tioned by the authors, not all studies agreed. Indeed, WS seems to be due to a combination
of different and multifactorial etiologies. In addition, it appears that the delay in apparition
varies with etiology [29]. Early WS could probably be explained by an error in wire adapta-
tion (lack of passivity) or bonding [29]. When WS appears several years after orthodontic
placement, wire-related etiologies are preferred. Regarding dysfunction, some authors
hypothesized that oro-vestibular forces exerted by the tongue could cause undesirable
movement [2,22,29], although Shaugnessy et al. excluded the role of the tongue because its
pressure would be less than that required to deform the wire [4]. In addition, the risk of wire
deformation also increases with time due to the progressive wear of the composite, which
results in a larger section of the wire being exposed to deformation [29]. Additionally, a
change or instability in the mechanical properties of the wires, whether inborn or acquired,
could be involved in WS. A fixed retainer could become unintentionally active. Moreover, a
break in adhesion at the wire–composite interface can cause a “pivot effect”, resulting in tor-
sion of the teeth around the wire, which then acts as a center of rotation [8,15,29]. The tooth
pivots around the wire, which could explain the unwanted torque of the teeth involved
in WS. After observing the rotational movements of the six anterior teeth, Wolf et al. [18]
hypothesized that the fixed wire causes forces that rotate the entire block of interconnected
anterior teeth stiffened by the wire in the vestibular direction on one side and lingual on
the other due to physiological transverse constriction.
The type of wire seems to have an influence on the occurrence of WS. In the study of
Padmos et al. [25], the mechanical properties of round multistrand wires were incriminated.
Indeed, most of the included studies in this systematic review described WS as being as-
sociated with round, multistrand twisted wires [1–5,10–14,16–18,21,23]. Engeler et al. [30]
assured that all documented adverse movements are present only with multistrand wires,
whereas Roussarie et al. [24] showed that no wire is immune to WS. While some authors
expressed a preference for the type of wire to be used to avoid the development of WS, no
consensus on wire selection could be advanced. In addition, the diversity of materials and
bonding protocols make it difficult to draw any conclusions. Recently, Gelin et al. [31] inves-
tigated the effect of rectangular, 0.014 × 0.014 inch, memory shape-customized CAD/CAM
nitinol retainers (Memotain TM ; CA Digital GmbH, Mettmann, Germany) versus round,
0.0175 inch (in), six-stranded, twisted, stainless steel wire retainers (Supra-FlexTM; RMO
Europe, Illkirch-Graffenstaden, France) and showed no significant difference between these
two types of retainer after one year of placement. To reach a consensus on the preferred
type of wire to use, randomized controlled studies must be conducted on a large sample
size and over long observation periods.
Finally, some additional points should be made regarding this systematic review of
the literature. First, only one study designed as a randomized controlled trial was included
for analysis, and the risk of bias was considered high, as the majority of included stud-
ies were designed as case series/reports. Second, there was a lack of information in the
Healthcare 2022, 10, 379 17 of 18

included studies. For example, few data were provided on patient characteristics prior
to orthodontic treatment (e.g., baseline crowding and cephalometric measurement), or-
thodontic biomechanics employed to treat the patient (e.g., elastics employed and brackets
prescribed), bonding and retainer placement protocol, history of retainer failures (e.g., num-
ber of breakages, detachment, or re-bonding), etc. Furthermore, the periodontal conditions,
such as type of phenotype [32], traction of labial frenum, or oral hygiene quality, were
not investigated in each study. However, these parameters may have an influence on the
development of WS, probably from a multifactorial origin. Moreover, the selected studies
have extreme heterogeneity in terms of the variables compared and the outcomes measured.
Concomitantly, the enormous heterogeneity of the included studies made it impossible to
perform a meta-analysis. All of this represents a limitation that is important to consider.

5. Conclusions
This first review of the literature on Wire Syndrome (WS) included 20 articles published
between 2007 and 2021, with a majority of case report/series leading to a globally high
risk of bias. However, the analysis of the overall article provided an understanding of this
adverse event associated with fixed orthodontic retainers, emphasized the importance of an
early diagnosis, and highlighted preventive measures against WS for dental professionals
worldwide, including general practitioners (GP), periodontists, and orthodontists. Indeed,
the WS problem must involve all the dental health professions, including the general
practitioners who will be able to refer, if necessary, the patient to a specialist practitioner;
the continuity of the collaboration and the “ortho–paro–gp” link will then be prolonged
during the therapeutic time, thus guaranteeing optimal patient care. Further studies are
needed to improve the knowledge about fixed orthodontic retainers, based on a large,
well-documented sample and conducted over a very long observation period.

Author Contributions: Conceptualization, C.C., F.V. and S.-M.D.; methodology, C.C., F.V. and
S.-M.D.; software, C.C. and F.V.; validation, C.C., F.V., S.A. and S.-M.D.; formal analysis, C.C.,
F.V., S.A. and S.-M.D.; investigation, C.C., F.V., S.A. and S.-M.D.; resources, C.C., F.V., S.A. and S.-M.D.;
data curation, C.C., F.V., S.A. and S.-M.D.; writing—original draft preparation, C.C.; writing—review
and editing, C.C., F.V., S.A. and S.-M.D.; visualization, C.C., F.V., S.A. and S.-M.D.; supervision, C.C.,
S.A. and S.-M.D.; project administration, C.C. and S.-M.D. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Data Availability Statement: The data underlying this article are available in the article.
Acknowledgments: The authors warmly thank Léa Graveline for proofreading the English version.
Conflicts of Interest: The authors declare no conflict of interest.

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