Practice: Orthodontics. Part 5: Appliance Choices
Practice: Orthodontics. Part 5: Appliance Choices
Practice: Orthodontics. Part 5: Appliance Choices
1 JANUARY 10 2004 9
PRACTICE
Orthodontics. Part 5: Appliance choices
D. Roberts-Harry
1
and J. Sandy
2
There are bewildering array of different orthodontic appliances. However, they fall into four
main categories of removable, fixed, functional and extra-oral devices. The appliance has to
be selected with care and used correctly as inappropriate use can make the malocclusion
worse. Removable appliances are only capable of very simple movements whereas fixed
appliances are sophisticated devices, which can precisely position the teeth. Functional
appliances are useful in difficult cases and are primarily used for Class II Division I
malocciusions. Extra-oral devices are used to re-enforce anchorage and can be an aid in
both opening and closing spaces.
1
Orthodontic Department, Leeds Dental
Institute, Clarendon Way, Leeds LS2 9LU;
2
Division of Child Dental Health, University
of Bristol Dental School, Lower Maudlin
Street, Bristol BS1 2LY
Refereed Paper
doi:10.1038/sj.bdj.4810872
British Dental Journal 2004; 196:
918
The correct appliance choice is essential for optimum treatment outcome
Removable appliances have an important but limited role in contemporary orthodontics
Fixed appliances are usually the appliance of choice
Functional appliances are helpful in difficult cases but may not have an effect on
facial growth
Extra-oral devices include headgear, face-masks and chin-caps
I N BRI E F
There are four main types of types of appliance
that can be used for orthodontic treatment.
These are removable, fixed, functional and extra
oral devices.
REMOVABLE APPLIANCES
In general these are only capable of simple tooth
movement, such as tipping teeth. Bodily move-
ment is very difficult to achieve with any degree
of consistency and precise tooth detailing and
multiple tooth movements are rarely satisfactory.
These appliances have received bad press over
the past few years because studies have shown
that the treatment outcomes achieved can often
be poor.
1,2
In these studies as many as 50% of
cases treated with removable appliances were
either not improved or worse than at the start of
treatment. When faced with evidence such as
this, one might be justified in discarding remov-
able appliances completely. However, provided
they are used in properly selected cases they still
can be very useful devices and the treatment
outcome can be satisfactory.
3
In general, remov-
able appliances are only recommended for the
following:
Thumb deterrent
Tipping teeth
Block movements
Overbite reduction
Space maintenance
Retention
Thumb deterrent
Digit sucking habits which persist into the
teenage years can sometimes be hard to break
and may result in either a posterior buccal cross
bite or an anterior open bite with proclination of
the upper and retroclination of the lower inci-
sors. In general, if the habit stops before facial
growth is complete then the anterior open bite
usually resolves spontaneously and the overjet
returns to normal.
4
Figs. 1ac show a case with an anterior
open bite associated with an avid digit suck-
ing habit. A simple upper removable appliance
was used successfully to stop the habit. The
appliance simply makes the habit feel less of a
comfort and acts as a reminder to the patient
that they should stop sucking the thumb.
Complex appliances with bars or tongue cribs
are rarely needed. In this patient once the
habit had stopped the open bite closed down
on its own without the need for further ortho-
dontic treatment.
Tipping
One of the major uses of removable appliances
is to move one incisor over the bite as shown in
Figs 2ad. A simple upper removable appliance
utilized a T spring constructed from 0.5 mm
wire activated 12 mm which delivered a force
of about 30 g to the tooth. After only a few
weeks the cross bite was corrected without the
need for complex treatment. Note the anterior
5
ORTHODONTICS
1. Who needs
orthodontics?
2. Patient assessment and
examination I
3. Patient assessment and
examination II
4. Treatment planning
5. Appliance choices
6. Risks in orthodontic
treatment
7. Fact and fantasy in
orthodontics
8. Extractions in
orthodontics
9. Anchorage control and
distal movement
10. Impacted teeth
11. Orthodontic tooth
movement
12. Combined orthodontic
treatment
VERIFIABLE
CPD PAPER
NOW AVAILABLE
AS A BDJ BOOK
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10 BRITISH DENTAL JOURNAL VOLUME 196 NO. 1 JANUARY 10 2004
retaining clasp that prevents the appliance
from displacing downwards when the spring is
activated.
If teeth are to be pushed over the bite with
removable appliances, a stable result is more
likely to be achieved if the tooth is retroclined in
the first instance, the overbite is deep and there
is an anterior mandibular displacement associ-
ated with a premature contact. Tipping teeth
tends to reduce the overbite because the tip of
the tooth moves along the arc of a circle as
shown in Figure 3a. Excessive tipping may also
make the tooth too horizontal which can be not
only aesthetically unacceptable but may also
Fig. 1ac A 9 year-old patient with an anterior
open bite caused by a thumb sucking habit. Note
the wear on the thumb as a result of this. She
was fitted with a simple upper removable
appliance and gently encouraged to stop the
habit. She did so successfully and the open bite
closed down spontaneously in 6 months
Fig. 2a an anterior cross bite involving the upper
left and lower left central incisors
Fig. 2c The appliance in place. The T spring is
activated 12 mm every 4 weeks
Fig. 2d The completed case. Active treatment took
12 weeks
Fig. 2b An upper removable appliance with Adams
cribs for retention made from 0.7 mm wire on the
first permanent molars and the upper left central
incisor. A T spring made from 0.5 mm wire is
used to push the tooth over the bite. The anterior
retention is to prevent the front of the appliance
being displaced as the spring is activated
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BRITISH DENTAL JOURNAL VOLUME 196 NO. 1 JANUARY 10 2004 11
result in excessive non-axial loading of the
tooth as illustrated in Figure 3b.
Overbite reduction when teeth are over pro-
clined is illustrated in Figures 4ad. In this case
both the upper lateral incisors were pushed over
the bite with an upper removable appliance. The
cross bite was corrected but note the reduction
in overbite on the lateral incisors. Six months
after completion of treatment the upper right
lateral had relapsed back into cross bite.
Block movements
If a cross bite involves a number of teeth, for
example a unilateral buccal cross bite, remov-
able appliances can be used to correct this. The
sequence of events is shown in Figures 5af.
Adams cribs are generally placed on the first
premolars and the first permanent molars and a
midline expansion screw is incorporated into
the base plate. This midline screw is opened
0.25 mm (one quarter turn) twice a week until
the cross bite is slightly overcorrected. Posteri-
or buccal capping can also be used to disen-
gage the bite and prevent concomitant expan-
sion of the lower arch. Once the cross bite is
corrected the buccal capping can be removed
and the appliance used as a retainer to allow
the buccal occlusion to settle in. Occasionally
two appliances will be needed if a considerable
amount of expansion is needed.
Fig. 3a The effect of tipping anterior
teeth on the overbite. As the teeth
move around a centre of rotation the
incisal tip moves along the arc of a
circle. By the laws of geometry, as
the tooth is proclined the overbite
reduces once it moves past the
vertical
Fig. 3b Excessive tipping not only
reduces the overbite but also makes
the axial inclination of
the teeth too horizontal. In these
situations stability is reduced, the
appearance is poor and the tooth may
suffer from unwanted
non-axial loading