removable appliance was pioneered by George Crozat

A. Hamid Zafarmand*, M. Mahdi Zafarmand** in the US [Proffit et al., 2007], however the device was
further developed and integrated into many diverse
*Associate Prof., Dept of Orthodontics, treatment modalities in Europe. Unfortunately, in recent
**Senior Dental Student, decades, intra-oral removable appliances are less discussed
Shahid Beheshti University of Medical Sciences, School of in the orthodontic literature and fewer researchers tend to
Dentistry, Evin Tehra, IR of Iran investigate their indications and advantages.
With the innovation of fixed appliances, the removable
e-mail: [email protected] appliances for tooth movement were gradually less used.
However, there are many conditions in which these would
be the appliances of choice for tooth movement, especially
if early intervention is required and a fixed appliance for
Removable any reason is not indicated. Removable appliances have
advantages and disadvantages [Proffit et al., 2007]: They
orthodontic appliances: are affordable for patients, financially, and easy adjustable
for orthodontists, technically.
new perspectives on Visibility of extra-oral appliances, is socially unacceptable
to adults and even to most children. While the use of
capabilities removable appliances presents obvious advantages for
socially active people, the success of treatment can be very
and efficiency patient-dependent. Although skeletal anchorage (mini-
implant system) is a novel alternative in selected cases
and is becoming a more dependable approach for tooth
movement, it is not applicable for all patients and has also
abstract some restrictions in use [Chung et al., 2010].
In selected cases, however, treatment with fixed
Aim Removable appliances are a dependable choice appliance may be shortened by a previous treatment with
for many patients but like all orthodontic appliances, a removable appliance. The latter is a good choice if oral
they have some limitations in use. Patient selection hygiene with fixed appliance is unmanageable, especially in
and appropriate appliance design are two key factors uncooperative youngsters. Often intra-oral appliances are
for success. Many patients, especially adults, prefer an ideal choice for some patients, particularly adults. For
intra-oral appliances to extra-oral devices. Sometimes a child or adolescent, if an extra-oral gadget is intolerable
a removable intra-oral appliance can solve a dental and repeatedly broken, an intra-oral appliance is usually
problem in a shorter period of time compared to fixed well accepted (Fig. 1).
treatment, and this has also been repeatedly seen in It should be kept in mind that all removable appliances
molar distalisation. From the interceptive perspective, of any kind, are only capable of "tooth tipping" [Satley
the appliance can prevent or alleviate an impending
crowding for erupting permanent incisors.
Case Report This article describes 5 patients with FIG. 1 A repeating problem
different orthodontic problems: impending crowding for by noncompliant patients.
erupting upper canine with 2 approaches, provision of A. A broken and distorted
space for upper cuspids, resolution of chronic attrition of band.
anterior teeth, relief of space shortage for upper canines B. A distorted and frequently
eruption, and reduction of excess overjet. All subjects were broken headgear.
treated with removable appliances of various designs.

Keywords Aesthetics; Clasp; Finger spring;

Intra-oral and extra-oral appliances; Removable
appliances; Tooth tipping.

Introduction
Removable appliances have the longest history in
orthodontic literature and practice. In early 1900, a

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 REMOVABLE ORTHODONTIC APPLIANCES: A CASE SERIES

et al., 2001; Proffit et al., 2007], meaning that after Material and methods
repositioning the long axis of the tooth should become
ideal in angulation and torque. Thus, a selected case for Five cases with different problems and various appliance
removable appliance requires the long axis of the tooth designs are presented in this article. Two cases needed
be so malpositioned that after movement the tooth molar distalisation due to reduced space for the erupting
can be located in the proper crown-root torque. This upper cuspid teeth: one case was treated with an appliance
biomechanics concept dictates the orthodontist to be very provided of a spring to push both first and second upper
accurate in case selection. Thus, the removable technique molars (case 1) and the other with an appliance provided
is not considered as an alternative method if a patient of two springs for each molar (case 2). In one case, the
needs comprehensive orthodontic care. treatment plan aimed at closing the anterior diastema to
Technically, appliance design has a key role in success. provide space for the rotated erupting upper laterals (Case
The location and type of clasps (for better retention and 3). Case 4 had an anterior crossbite which was treated
no tissue irritation), the location of finger springs (for with lingual tipping of the lower incisors. The fifth and last
maximum range of activation) and their direction (for case aimed to treat protruded upper anterior teeth.
highest rate of activation) are important considerations in
the design of an appliance. Case 1
Scientifically, some clasps which are routinely included FB was a 14-year-old girl who preferred a removable
in all appliances do not have any designated purpose. It intra-oral appliance. Therefore, the appliance was
should be really revaluated whether an Adams clasp with proposed to resolve the position of the buccally erupting
its tough adjustment, which provides only a little retention upper right canine. This was accomplished with a
and creates serious occlusal interference, causing patient's removable appliance which would distalise the upper right
discomfort, should be preferred over a "C" clasp. The first molar to gradually provide a space for the canine.
design of the “C” clasp creates a contact surface with Transeptal fibers between teeth provided a gradual distal
the anchor tooth rather than a two-point contact (Adams tilt to the second and subsequently the first premolars
clasp), resulting in better retention. In addition, it offers after molar distal relocation. Treatment started in June
the advantages of causing less tissue irritation along with 2009 and activation ended in September Sept 2009, a
easier adjustability and fabrication. Finally, a small and easy 3-month period. The appliance continued to be worn for
to adjust ball clasp in many cases can play a significant additional 5 months (March 2010) as retainer (Fig 2).
role in retention of the appliance. The other consideration
is the type of active part used in the appliance. Clearly, Case 2
the continuous force exerted by a finger spring is more MAT was a 13-year-old boy who did not wear his
effective and less expensive than an opening screw, since headgear as instructed. Thus, after 6 months he was
it is basically fabricated of a .016” x .022” wire. delivered a removable appliance for application of
There are several important points to be considered unilateral distalisation of the upper left first and second
when using a removable appliance for tooth movement: molars. Fortunately, this time he was compliant with the
› A removable appliance may be preferred for a new method. The appliance was equipped with 2 finger
noncompliant patient to an out-of-mouth gadget (i.e. springs to distalise both upper left molars at the same
headgear). time. The labial bow was placed between the upper
› Oral hygiene maintenance is much less complicated for right canine and the upper left lateral incisor to allow
patients. the canine to erupt freely in the proper position. A ball
› Sometimes a removable appliance can promote the clasp between the upper right premolars, and a C clasp
full growth potential and consequently favour teeth on the upper right molar also retained the appliance in
eruption in the proper position. place. Interestingly, the treatment concluded after only
› It can be used for cases that require unilateral mechanics. 5 months. The appliance was used as retainer for an
› It shortens the fixed orthodontic treatment when used additional time until full eruption of the upper left canine
in the preliminary stage of the treatment plan. (Fig 3).
› As an interceptive method, the appliance may be
recommended for those with excess overjet (protruded Case 3
upper anterior teeth) in the middle mixed dentition HER was a 9-year-old boy whose mother was concerned
age. about the eruption of both upper laterals in a tight space.
› It requires simple adjustments at the chairside. An appliance was fabricated with two finger springs
› It has a lower relapse rate during retention period distally to the upper central incisors to close the diastema.
compared to fixed appliances. In other cases the This process took 4 months but the retention period
outcome of the treatment should be maintained with added other 7 months for full eruption of the upper lateral
subsequent fixed treatment. incisors. It appeared there was a reasonable maxillary
› It is more affordable when used for selected cases anterior lateral growth potential during the treatment to
requiring specific designs. compensate for the additional space for incisor laterals.

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 HAMID ZAFARMAND. V AND MAHDI ZAFARMAND M.

FIG. 2 Pt. FB (case 1).

A: Occlusal view: UR3 is
erupting in an insufficient
space.
B: Right lateral view: The
semi-erupted position of the
canine.
C: A removable appliance is
fabricated with 2 ball clasps,
a labial bow and a simple
finger spring to be placed
between second premolar
and first molar. Note that
the labial bow is, rather,
extended from UR2 to UL3
to permit distal drifting of
canine and premolars.
D: The appliance is being
checked for easy fitting; and
the patient was instructed for
properly wearing.
E: Space provision after 3
month visits as the result of
molar distalization. Note that
transeptal fibers facilitate
distal drifting of the canine
and premolars with no
further intervention.
F: The clinical stability of the
results after 4 months out of
treatment.

Thus, the appliance was a perfect facilitator for growth normal overjet and overbite (Fig. 5).
potential to allow alignment of the laterals. This process
exactly occurs at this stage of dentition or between the Case 5
ages of 8 and 9 (Fig. 4) [Pinkham, 2010]. KO was a 14-year-old girl complaining of prominent
upper anterior teeth and, as all youngsters with excessive
Case 4 overjet, she was due to excess overjet. In these cases a
PJ was a 42-year-old female who sought orthodontic Hawley retainer with circumferential wire for maxillary arch
treatment for lower anterior crowding resulting in severe with gradual tightening loops could reduce the overjet.
incisal attrition due to zero overjet. She was concerned The acrylic resin was selectively reduced on the palatal
about the length of treatment. She also exhibited side of the anterior teeth. A space maintainer was used
crowding of the lower and upper arch. A combination for the lower arch. It took around 7 months to achieve an
plan of orthodontic treatment and restorative procedures acceptable result. Stability of the treatment after one year
was tailored for her. A removable appliance, rather was evident (Fig 6).
than a fixed treatment, was delivered to the patient to
resolve the lower anterior crowding, moving the lower
central incisors lingually and the lateral incisors slightly Discussion
labially. The adjunct procedure was reproximation of the
central incisors. Finally, the patient underwent aesthetic In this case series, selected from a large group of
restoration of the upper and lower incisors, and the case successful cases, removable appliances with different
was finished with an acceptable aesthetic smile and designs were used to test the suitability of this technique.

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 REMOVABLE ORTHODONTIC APPLIANCES: A CASE SERIES

FIG. 3 Pt. MAT (case 2).

A: UL3 has no enough space
to erupt; however, a right
treatment plan and a timely
intervention can prevent
later malposition of canine.
B: A removable appliance
fabricated with a “c” and
a ball clasp, plus a labial
bow. Two finger springs is
designated to distalize second
and first molars in ULQ. Again,
the labial bow is wrapped
at the distal of UL2, not to
interfere with canine eruption
and its distal drifting. Note
that no clasp was placed on
premolars for freely distal
drifting.
C: The appliance is viewed
in mouth from the left lateral
view.
D: Space is opened
(overcorrection) in ULQ after
5 months and the appliance
is continued to be worn for
retention till full alignment of
cuspid and bicuspids.

FIG. 4 Pt. HER (case 3) in

mixed dentition.
A: UL2 & UR2 have no
enough space to erupt; a
little space exists between
upper centrals. An early
intervention can prevent
later malposition of laterals.
B: A removable appliance
was ordered with four “c”
clasps on UD’s and UE’s for
full retention, and 2 finger
springs are designed to move
the U1’s toward midline.
Note, no labial bow included
in the appliance. For comfort
of patient, the acrylic plate
was only extended to distal
of primary second molars.
C, D: 7 months later, the
goals of treatment was
achieved and maintained
for a few extra month.
The laterals are in perfect
alignment and the adjacent
teeth are not malposed.

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 HAMID ZAFARMAND. V AND MAHDI ZAFARMAND M.

FIG. 5 PJ is an adult patient

(case 4).
A: Frontal view shows
severe attrition due to long-
term edge-to-edge incisor
relationship with a very
unpleasant smile.
B: Mandibular occlusal view
indicates anterior crowding
with labial displacement
of centerals and lingual
displacement of laterals.
C: Maxillary occlusal
view depicts rotational
displacement of centerals.
D: A removable appliance
is fabricated with 4 “ball”
clasps, and a labial bow is
designed to force centrals
lingually and to retain
the appliance, as well. A
lingual bow is included
to push laterals labially,
simultaneously. Two occlusal
rest on 6’s hold the appliance
vertically.
E: The appliance is delivered
to patient with no discomfort
in place.
F: A neat reproximation
was performed on mesial of
centrals, followed by fluoride
application. The labial bow
was activated using 3-prong
pliers along the labial surface
of centrals, while the lingual
bow gently pushes laterals
forward.
G: After the final restorative
consult, the orthodontic
treatment was finished and
patient was referred for
restorative procedures.
H: The patient’s smile 8
months after treatment.

Many children and definitely adults, if they are to wear an considered when employing springs: First, location and
appliance, would prefer a less visible one. If the patient is second direction of the spring loop are both important
compliant, the speech disturbances will resolve in a short for efficient tooth movement. The finger spring should
period of time. Tongue usually will adapt with the newly be located on the midway of the mesiodistal aspect of
defined intra-oral space. the molar, while the loop on the opposite direction
Although one finger spring is capable of exerting of movement. Third, to permit passive distal drifting of
enough force to move even two molar teeth at the canines and premolars no clasp should placed on the
same time, it is not unjustifiable if one decides to move named teeth. Forth, interdental acrylic extension between
the molars sequentially (Case 1). Four factors should be canines and premolar of the appliance should be removed

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 REMOVABLE ORTHODONTIC APPLIANCES: A CASE SERIES

FIG. 6 KO is a 14-year old

girl (case 5).
A: She was suffering of
protruded anterior teeth.
Frontal view indicates the
excessive overjet which
makes teeth prone to
traumatic injuries.
B: A Hawley retainer with
a circumferential wire was
fabricated for maxillary arch.
Gradual tightening of loops
and simultaneous acryl
reduction on the palatal side
of anterior teeth permits
gradual lingual tipping of
anterior teeth.
C: Maxillary occlusal
view depicts the result of
treatment 7 months after
post-treatment.
D: Recall of the patient after
one year presents stability of
the result.

for the abvoe purpose, as well. these appliances are more effective than than devices
Maxillary canines are the last teeth to erupt in the of complicated design and provided with screws. Cost-
upper jaw, and therefore they often face space shortage, wise, the appliance is the best choice for patients.
resulting in impaction which requires additional treatment Another advantage is represented by less oral hygiene
procedures with multiple considerations [Zafarmand et al., complications. Finally, the device is simple to adjust for the
2009]. The growth potential may also play a significant orthodontist, and the easy management of the appliance
role in the success of treatment. A removable appliance by the patient ranks it as a very dependable treatment
can facilitate eruption of the canine in the right position. option in orthodontics.
The attempt to reproximate the primary canines would
be absolutely unjustified. Although the result can be the
alignment of lateral ones, this happens at the cost of the References
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› Proffit WR, Fields, Jr HW, Sarver DM- Contemporary orthodontic appliances-
decision, an evolving process that shapes our philosophy Chapt 11, in: Contemporary Orthodontics- Mosby Elsevier 4th ed 2007,
of treatment. :396-432.
› Satley RN, Reske NT- Treatment of Class I non-extraction problems,
principles of appliance construction, and retention appliances- Chapt 19 in:
Conclusion Bishara SE, Textbook of Orthodontics- W B Saunders Company 1st ed 2001,
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› Sheridan JJ, LeDoux W, McMinn R: Essix retainers: fabrication and supervision
Intra-oral removable appliances are the appliance of for permanent retention- J Clinical Orthodontics. 1993; 27:37-45.
choice for many youngster and definitely adult patients. › Zafarmand AH, Gholami GA- Evaluation of the periodontal status of
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