md 947-a1 1059937
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Student number: 1059937
Assignment 1:
COMPARE AND CONTRAST THE USE OF THE FOLLOWING IN ORTHODONTICS:REMOVABLE APPLIANCES, FUNCTIONAL APPLIANCES, FIXED APPLIANCES
October 2010
Word Count: 3859
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Contents:
Introduction 3
Hardware requirements and construction 4
Ease of use and placement 7
Patient use & compliance 11
Actions of the appliance 13
Conclusions 19
References 21
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Introduction
Following the detection and diagnosis of an orthodontic malocclusion, treatment is planned and
then effected with the use of appliances.
Certain orthodontic problems require the use of one or several types of appliance. This
paper identifies that most of these appliances fall into three loose categories: removable,
functional and fixed (illustration 1).
The author intends to highlight their roles within traditional and contemporary
orthodontics whilst also stating their perceived advantages, disadvantages and limitations, as
well as the potential risks of use.
Illustration1
ORTHODONTIC APPLIANCES
REMOVABLE FUNCTIONAL FIXED
Upper removable fixed labial
Retainers >>Herbst >>Pre adjusted (Straight Wire Appl.)Clear aligners >> Self-ligating
removable lingual>>Twin block >>S.W.A. & self-ligating>>Herbst >>Bonded retainers>>Activator>>Frankel
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Har dware requirements construction
The component parts of orthodontic appliances can vary greatly. This variation means that each
appliance will tend to have a specific set of indications, but also limitations with functions it
cannot perform.
The earliest forms of traditional orthodontic appliances are the removable ones (Littlewood,
2001), namely the URA or upper removable appliance. The simplest way to approach its
construction is by use of the acronym ARAB (Mitchell, 2007), which stands for: Active
components; Retentive components; Anchorage; Base plate. Table 1 (below) lists the types of
components commonly seen in a URA.
Alternative removable appliances include orthodontic retainers and clear aligners both of which
serve very different purposes and will be discussed later in this article.
Table 1
COMPONENT PURPOSE TYPES
Active supply forces to effect tooth movement bows
elastics
screws
springs
Retentive secure the appliance to the dentition bows
clasps
cribs
Anchorage resistance of unwanted tooth movement -
Base plate Binds the other components together and acrylics
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reinforces anchorage
Functional appliances work to modify mandibular growth by harnessing
(utilising/removing/modifying) the forces of the erupting teeth, dento-facial growth and oro-facial
musculature (Millett, 2003). They typically have no active components.
Their construction is slightly more complex compared to URAs (Rock, 1990) and fixed-
appliances due to the nature of its requirements as an appliance. There are several types of
functional appliance and some common examples of these are outlined in table 2 below. Their
component parts and construction are similar to that of upper removable appliances.
Table 2 (modified from Mitchell, 2007)
TYPE EXAMPLES OF COMPONENTS DESCRIPTION
ACTIVATOR
e.g. Bionator No clasps least bulky of the activator appliances
Passive labial bow full time wear except meal times
palatal loop Allows arch expansion
FRANKEL Acrylic pads manages abnormal soft tissue patterns
lower incisor capping expands arches, widens the alveolar processes
buccal shields 4 sub types; FR type I for class II/I cases expensive to fabricate and repair (easily damaged)
HERBST Cemented splints fixed due to cementation, thus full time wear
Telescopic pin and tubes variable posturing of the mandible can be controlled
TWINBLOCK buccal blocks removable appliance
head gear attached via tubes 14-16hours per day for headgear use
Clasps
MagnetsPassive labial bow
Functional appliances are constructed in the laboratory but designed chair side with the patient.
A working bite registration is taken with the patient posturing the mandible forward whilst the
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teeth are out of occlusion (Clark, 2010). These records are sent to the laboratory for fabrication
of the appliance.
Fixed appliances are comprised of a series of selected component parts which are assembled
intra-orally. These are typically mass produced in factories (unlike URA and functional
appliances which are laboratory-made).
Common component parts include (modified from Millett, 2003):
Brackets and bands which are bonded to the teeth and made in a variety of materials
and sizes; these hold the active components in place.
Archwires the key active component of fixed orthodontics; will be either round or
rectangular, and are typically made from stainless steel, nickel titanium, cobalt chrome
(Elgiloy), or Beta-titanium alloys.
Accessories cement lutes for bonding brackets and bands; elastics for inter/intra-
maxillary traction; modules to keep the arch wires inside the bracket slot; springs e.g.
coil springs for space opening/closure; elastomeric chains for traction and derotation.
Comparatively, URA construction is relatively simple in that they are designed by prescription
and manufactured in the laboratory from impressions and a bite registration. This saves the
clinician a considerable amount of chair side time and cost (Mitchell, 2007) compared to
functional appliances which require a more complex treatment planning and prescription, and
greater time allocated to the registration phase and adjustment and fitting stages(Clark, 2010).
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By contrast fixed appliance components come ready made, however necessitate far more
extensive treatment planning and effort during their placement and adjustment (Roberts-Harry,
2004).
It would be wise to also include a brief mention of allergies to dental materials at this
stage. Prior to appliance selection, it is invaluable to know if the patient has any allergies to any
materials used in the construction and components of orthodontic appliances. Common
hypersensitivity reactions can occur with certain acrylic resins (typically the auto polymerizing
types) used to construct the base plate of some removable appliances (Jacobsen, 1989); or to
the nickel an cobalt content in certain types of orthodontic components such as wires and
brackets (Janson, 1998). Alternative material choice can be used to overcome such simple
obstacles to the provision of care.
Ease of use and placement
Removable appliances are relatively simple to use, requiring very simple adjustments prior to
fitting. A URA would be adjusted to ensure a suitable fit and that the patient can remove and
insert it away from the surgery. The retentive components need to be checked or problems such
as anchorage loss and prolonged treatment times may occur. The active components would
then be activated where appropriate, and lastly, detailed post operative instruction (including
appliance hygiene and care) would be given to the patient along with future appointment times
where treatment progress can be monitored and adjustments made.
Clear aligners are simpler to use once the necessary pre-treatment has been performed.
This usually involves interproximal reduction (IPR) to provide sufficient space that will facilitate
tooth movement once the aligners are in situ (Bishop, 2002).
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Lastly is the retainer which must be checked and adjusted carefully before supplying the
patient with post-op instructions detailing the amount of wear time which may very depending on
the nature of the orthodontic treatment provided (McNally, 2003).
Functional appliances are fitted in a similar sequence as most types are a form of removable
appliance. The key difference is in the time required at fit and adjustment appointments which
relate to the complexity of this type of appliance. The overjet when the patient has the appliance
fully seated needs to be measured and checked that it is an appropriate amount (Clark, 2010).
For example, in Twin Block therapy the initial opening between premolars should be 3-5mm
(Rock, 1990). If it is not then adjustments using a straight hand piece and acrylic bur may need
to be used. However if the opening is excessive then the appliance may need to be remade.
This could be due to an error during bite registration or during lab construction and ideally either
should be identified before a remake to avoid the same problem occurring again. As well as
detailed post op instructions for dietary advice and appliance care, the patient may also need to
be informed on when and how to use expansion screws if there is one. Once removable or
functional appliance therapy is complete, there is little or no clean up procedure, except in fixed
Herbst appliances which have been cemented to the arches (Mitchell, 2007).
Fixed appliance placement is far more complicated. The armamentarium required differs from
that used in removable and functional appliance therapy because the appliance is not a
constructed one. Pre treatment records are checked; appropriate brackets, bands and lutes are
chosen in advance and bonded individually or in groups depending on the operators experience
and / or training. Archwires are then applied to the slots in the brackets and held there using
auxiliaries such as elastic modules. This is an oversimplified description of the process of
placing fixed appliances. The essence of placement and use of this appliance type is typically
categorised into the three phases outlined in the table below:
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Table 3 (modified from Gill, 2008)
PHASE AIMS DESCRIPTION
1 LEVELLING & ALIGNMENT bracket placement
use of separators if banding required
Light forces with circular arch wires
2 WORKING ARCHWIRES progression to rectangular arch wires
maintain arch formbodily tooth movements
reduce overbite and overjet
manage space closure
3 FINISHING fine detailed movements
settling the occlusion to improve stability
Debonding the brackets
Retention
The correct placement of the brackets is pivotal to treatment success (Ireland, 2003). It is the
most technique sensitive aspect of fixed appliance therapy. The clinician must first determine
where to position the bracket. Typically this is done by identifying anatomical landmarks on the
facial surfaces of the teeth (see image below).
FACC - facial axis of the clinical crown
FAP - facial axis point
AP - archwire plane
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Image 1 (taken fromhttp://www.learn-ortho.com/tips-frame1.htm/ )
In traditional fixed appliance systems wire bending was necessary in order to generate the
forces required to effect desirable tooth movements (Rock, 1995). However more contemporary
methods have arisen more recently based around what is commonly called the Andrews
straight wire appliance (S.W.A.). To make life simpler, the brackets of a S.W.A. system have
built-in three-dimensional values (tip, torque, in-out), which saves the operator a tremendous
amount of chair-side time as little or no wire bending is required (Rock, 1995). Another segment
of this paper discusses in more detail the types tooth movements are possible with fixed
appliances.
With time saved with the reduced work-load associated with wire bending, more time can then
be spent on the next phase of placement: bonding. This is the way in which the brackets are
bound to the surfaces of the teeth (obviously varies with lingual orthodontic appliances, hence
the name). Glass ionomer or composite resin lutes are most commonly used (Banks, 2010).
Today the latter is most often used which means that great care with isolation and bonding
procedures is essential to maximise retention of the bracket to the tooth surface. Bonding failure
ultimately will have deleterious effects on the clinicians time and costs, (Brown 2009) but also
prolong the length of treatment for the patient due to delays.
Once bonding is complete, the placement of the archwire and auxiliaries is performed, and
postoperative instructions and appointment times can be given to the patient.
At the end of treatment the brackets must be debonded. Care must be taken at this
stage to make sure that the enamel is not harmed and also to check that no cement has been
left behind.
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After the completion of fixed appliance therapy, bonded lingual retainers may be
employed to resist unwanted tooth movements and orthodontic relapse. These too are typically
bonded with some form of passive wire (e.g. twist-flex) and a composite resin lute (Tabrizi,
2010). Normally they are applied directly by the clinician; however for ease of use some
orthodontic laboratories offer constructed jigs which hold the wire in place during bonding in
order to save the clinician time.
The author would summarise that removable appliances can be the simplest to place and use;
however the complexity of functional and fixed appliance placement and use is outweighed by
their many applications in orthodontics.
Patient use & compliance
The following table highlights the ease of appliance use from the patient perspective. These
factors can affect the levels of patient compliance, which in turn can have significant impact
upon the course of treatment.
Table 4 (modified from Mitchell, 2007)
removable appliance can be cleaned with ease and no obstruction to OH
relatively simple to insert
patient may be inclined not to wear appliance for certain reasons
functional common types are removable >> easy to clean; no obstruction to OH
relatively simple to insert
patient may be inclined not to wear removable typesfixed types will cause obstruction to easy OH
Attachment of head gear may prove cumbersome
Risk of harm from head gear/extra oral attachments
fixed appliance cannot be removed
obstruction to simple OH as not removable
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attachment of head gear and elastics may prove cumbersome
Risk of harm from head gear/extra oral attachments
If an appliance is not worn / cared for correctly or simply not worn regularly at all, then treatment
will either become prolonged or fail (Schott, 2010). For this reason it is crucial at the
assessment stage to ascertain whether the patient is suitable for a particular appliance.
In the case of removable and removable-functional appliances, the most common
compliance issue is that of getting the patient to wear the appliance for the maximum daily time
allocated. Tell-tale signs of a lack of appliance wear would become evident at follow up and
adjustment appointments. This disadvantage is also a great advantage as removable
appliances are far more easily cleaned compared to fixed ones and whilst out of the mouth the
effect of good oral hygiene can be maximised.
The effect on speech can also become a barrier to continued wear, however if the
patient is reassured that speech will acclimatise after a given period of time, compliance may
also improve.
Retainers must also be included here. Because they are removable, patients have the
ability to choose not to wear them as and when directed. The potential disaster here is
orthodontic relapse (McNally, 2003).
Functional appliances are relatively simple for the patient to use, however due to their typically
bulky nature can sometimes spend more time out of the mouth than in. This in some cases is a
design flaw where a patient cannot tolerate the obtrusiveness of the appliance. A key study by
OBrien in 2003 analysed the failure to complete treatment rates for fixed Herbst appliances
were far less than removable Twin block appliances.This related to the prolonged wear times,
aesthetics of the appliance and the amount the bite was opened by.
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When connected to extra-oral devices such as head gear, functional appliance use can
become more difficult for the patient. We have to take into account the age of the patient and
that he/she may not alone have the dexterity to make the connections safely. There have been
many papers highlighting the risk of trauma to the soft tissues, in particular the eyes (Travess,
2004), due to the detachment of head gear apparatus from the appliance during night time. To
protect against such iatrogenic risks, patients are routinely given safety goggles.
There have been studies on the levels of compliance with removable appliance types. Some
have even go as far to measure to change in compliance when microsensors are connected to
them, allowing the clinician to monitor wear time and patterns (Ackerman, 2009). This may even
go as far as to be a motivational aid for the patient.
With fixed appliances the key disadvantage is that there are issues with maintaining an
exemplary level or oral hygiene. Otherwise common iatrogenic risks such as enamel
decalcification and periodontal disease are likely to ensue post-treatment (Travess, 2004). This
disadvantage is also a major plus in that full-time wear is guaranteed, meaning that treatment
progresses smoothly without interruptions, saving a lot of time for both the clinician and the
patient.
Fixed bonded retainers guarantee compliance, however common problems include the
inability of the patient to floss. This can lead to the accumulation of calculus which will cause
periodontal problems. Other issues include the likelihood of composite resin leakage (Uysal,
2009), leading to caries which may go undetected for some time, or the passive wire debonding
from the teeth without the patients knowledge, again leading to a caries risk and the chance of
relapse. Regular check ups and the use of floss picks can be used to prevent these problems.
Actions of the Appliance
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The function of retainers is to hold the teeth in their finished state upon completion of
treatment with any of the three orthodontic appliance types. After teeth have been repositioned
a retainer (e.g. Hawley, Essix) may be used between 6-12 months or an indefinite period whilst
the periodontal ligament fibres reorganise and the teeth settle into a state of balance with the
soft tissues (Sheridan, 1993; McNally, 2003).
Functional appliances are used for growth modification, typically in class II cases. The key word
here is growth. If the patient is not growing, or about to enter a stage of growth (i.e. biologically
is an adult) the functional appliance use in contraindicated. In such cases orthodontic
camouflage should be considered (Ireland, 2003). Standing height charts are used by
orthodontists in the assessment and treatment planning stages to ascertain the appropriate
timing and use of functional appliances. Active growth phases for children when functional
appliances are indicated normally lies in the pubertal growth spurt phase. This is typically11 - 13
years of age for girls and 12 - 14 years of ages for boys (Mitchell, 2007).
The essence of functional appliance therapy is to encourage the mandible into a more
forward position whilst either holding back or retruding the maxilla (Gill, 2008). The maxillary
dentition can be retracted and the mandibular dentition proclined. There are a variety of
appliances available, each with distinct purposes. A summary can be seen in Table 5 below.
PASSIVE TOOTH BORNE ACTIVATOR Opens the bite; advances the mandible
BIONATOR forward posturing of mandible; blocks between the teeth to
control vertical dimensions
HERBST bonded splints between arches dictate mandibular position
TWIN BLOCK dual-arch plates with ramps, guiding the mandible forward when
the patient closes
TISSUE BORNE FRANKEL small pad against the lingual mucosa behind mandibular incisors to
stimulate mandibular posturing.serves as an arch expansion as well as jaw growthdevelops soft tissues e.g. lip competency to provide a more stable &balanced result
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Table 5 (modified from Millett, 2003)
The types of change brought about by functional appliance use are usually divided into the
following categories outlined below (modified from Ireland, 2003):
Dento-alveolar
Tipping (retraction / proclination of the incisors)
Arch expansion in the maxilla
Overbite reduction
Mesial and distal movement of the buccal segments
Skeletal & Soft tissue
Impeding maxillary growth and promoting mandibular growth
Altering condylar growth and glenoid fossa position
Increasing mandibular growth (not entirely proven)
Altering neuromuscular function to encourage bone remodelling
For sometime, orthodontic opinion has been divided over whether or not functional appliances
indeed have an effect on increasing mandibular growth (ONeill, 2004), or simply provide tipping
movements (dento-alveolar change). Although there are not enough valid studies that can be
used to measure this, a study by O'Brien in 2003 suggested that 98% of the changes are dento-
alveolar by way of tipping the teeth.
Fixed appliances are able to produce the following tooth movements (modified after Mitchell,
2007):
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First order movements
Tipping movements made in the plane of the archwire, i.e. labial/buccal-lingual/palatal
2nd order movements
Tilting movements made in the vertical plane, i.e. mesio-distal angulation
3rd order movements
Rotational movements (torque) through bucco-lingual/palatal forces.
The ability of fixed appliances to produce tooth movement in these three dimensions created the
following indications for their use (modified after Mitchell 2007):
bodily tooth movements to correct most skeletal discrepancies
tooth intrusion (and therefore overbite reduction)
tooth extrusion
tooth rotation
closure of spaces (bodily movements)
generate multiple tooth movements simultaneously (unlike removable appliances)
Self-ligating bracket systems (e.g. Damon) are an alternative to traditional straight wire
appliance systems. This more contemporary approach negates the need for wire or elastic
ligatures to hold the wire closely within the bracket slot to effect desired tooth movements. In the
Damon system there is a sliding mechanism which replaces conventional ligatures. The effect of
ligatures is friction, or resistance against the wire (Reznikov, 2010). This friction a) slows down
the alignment of the teeth, potentially increasing treatment times; and b) increases forces upon
the teeth, restricting the vascular supply (Profitt, 1993), which can add to patient discomfort
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during treatment. Another benefit ofDamon brackets include the fact that some are generally
smaller in size (as no attachment for ligatures is required), which mean reduced visibility. This
can increase patient acceptance, but not necessarily compliance which is related to the
appliance being fixed. However there is now lower profile ceramic / glass brackets (e.g.
Radiance) for conventional fixed appliance use which also offer a better aesthetic appearance
during treatment times.
As with most dental procedures there are risks associated with orthodontic treatment. Iatrogenic
(e.g. trauma to soft tissues), periodontal and enamel decalcification (i.e. oral hygiene) risks have
been highlighted earlier, where they relate more to the compliance with and the appropriate use
of an appliance.
However there are also risks associated with tooth movements. The most common of
these is root resorption (Roberts-Harry, 2004). This risk is most applicable to fixed appliances
where there is a prolonged force upon the teeth. A high level of resorption is seen in 3-5% of
orthodontic cases using fixed appliances (Roberts-Harry, 2004). Although this is hard to
manage once the harm has already occurred, it is best avoided by checking the pre-operative
radiographs for blunted, shortened, or pipette-shaped roots (Mitchell, 2007), as these are more
likely to undergo resorptive changes during treatment. This must be outlined to the
patient/parent/guardian during the consent stage of the examination. Other causes can include
a previous history of trauma to the teeth, root treatments, and previous orthodontic treatment
(Roberts-Harry, 2004).
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C onclusions
Rather than attempt to define which is the best appliance system within orthodontics, this paper
has attempted to identify the indications, limitations and risks associated with orthodontic
appliances.
The history of their use would suggest that traditionally upper removable appliances were
favoured because of their ease of construction and use, but also because there lacked an
appropriate level of postgraduate training to use fixed appliance systems that developed in the
United States (Littlewood, 2001). Cost was also a significant factor. However once the
advantages of fixed appliances became more widely recognised; the ability for appropriate
training more accessible; and associated costs reduced, a decline in the use of removable
appliances followed (Littlewood, 2001). This does not mean that they have completely lost their
place in orthodontics, as they have significant advantages over fixed treatments as outlined
within this paper. There has even begun a new trend in removable orthodontic aligners e.g.
Inman aligner, to treat mild anterior crowding in adults, and Invisalign orClearstep to treat more
demanding cases in a more aesthetic manner compared to fixed appliances.
Functional appliance use has always been limited to use in the growing patient, typically to treat
class II div I malocclusions (but also class II div II, and class III cases). There are still on going
studies that aim to answer the debate on the exact effect of functional appliances on skeletal
growth and modification, but despite the clear lack of evidence base are commonly used in
conjunction with fixed appliances to treat a wide range of orthodontic discrepancies. Regardless
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of the literature, functional appliances are able to produce significant changes in tooth position
to improve a malocclusion.
Fixed appliance use continues to rapidly change and expand. Depending on the operators
training and experience, a variety of fixed systems may be employed. We are currently seeing
an increase in the use of self - ligation systems e.g. Damon and lingual orthodontic systems.
Compared to removable and functional appliances, fixed appliances offer a wider range of
indications for use. However treatment times can range from 12 to 24 months, and the risks of
treatment can lead to severely negative effects on the dentition, such as root resorption and
decalcification. Patient selection must therefore be made very carefully to ensure that the
benefits of treatment outweigh the risks, and this applies to both removable and functional
appliances also.
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