17.

7 Fitting a removable appliance

It is always useful to explain again to the patient (and their parent/ guardian) the overall treatment plan
and the role of the appliance that is to be fitted. It is also prudent to delay any permanent extractions
until after an appliance has been fitted and the patient’s ability to achieve full-time wear has been
demonstrated.

Fitting an appliance can be approached in the following way (see also Table 17.2):

1. Check that you have the correct appliance for the patient in the chair and that you prescription
has been followed
2. Show the appliance to the patient and explain how it works. It is advisable to stress to the
patient that they should not remove the appliance by the springs
3. Check the fitting surface for any roughness
4. Try in the appliance.if it does not fit check the following:
- Have any teeth erupted since the impression was taken? If necessary, adjust the acrylic
- Have any teeth moved since the impression was recorded? This usually occurs if any
extractions have been recently carried out. Occasionally, to salvage the situation, it is
necessary to bend the cribs forward to compensate for anterior movement of the molars.
- Has there been a significantdelay between taking the impression and fitting the appliance?
5. Adjust the retention until the appliance just clicks into place
6. If the appliance has a bite-plane or buccal capping, this will need to be trimmed so that it is
active but not too bulky
7. The active element(s) should be gently activated, provided that extractions are not required to
make a space available into which the teeth are to be moved
8. Give the patient a mirror and demonstrate how to insert and remove the appliance. Then let the
patient practice
9. Go through the instruction with the patient (and parent or guardian), stressing the importance
of full-time wear. A sheet outlining the important points and containing details of what to do in
the event of problems is advisable (Table 17.3). medicolegally, it is prudent to note in the
patient’s recordsif instructions have been given
10. Arrange the next appointment

If a working model is available, it is wise to store this with the patient’s study models as it may prove
helpful if the appliance has to be repaired.

Table 17.2 Instrument which are useful

for fitting and adjusting removable
appliance
-Adams pliers (no.64)
-Spring-forming pliers (no.65)
Table 17.3 Sample instructions to patients
-Maun’s wire cutters
for removable appliances
-Pair of autoclavable dividers
-Your appliance should be worn all the
-Steel rule
time, including meals and in bed at
-A straight handpiece and an acrylic bur
(preferably tungsten carbide)
-A pair of robust hollow-chop pliers is a
useful addition, but not essential
 night
-Your appliance should only be removed for
tooth cleaning and during vigorous
sports (when it should be stored in a
strong container)
-It is usual to experience some discomfort
and little difficulty with speech initially,
but this should pass in a few days as
you become accustomed to wearing
the appliance
-It is important to avoid hard or sticky foods
and chewing gum
-If you cannot wear your appliance as
instructed or if it becomes damaged or
causes pain, please contact (…)
immediately

17.8 Monitoring progress

Ideally, patients wearing active removable appliances should be seen around every 4 weeks. Passive
appliance can be seen less frequently, but it is advisable to check, and if necessary adjust, the retention
of the clasps every 3 months.

During active treatment it is important to establish that the patient is wearing the appliance as
instructed. A more accurate answer may be given in response to the question “How much are you
managing to wear your brace?’ Rather than ‘Are you wearing your brace full-time?” indications of a lack
of compliance include the following:

- The appliance shows little evidence of wear and tear;

- The patient lisps (ask the patient to count from 65 to 70 with, and without, their appliance);
- No marks in the patient’s mouth around the gingival margins palatally or across the palate;
- Frequent breakages

17.8.1 At each visit

If wear is satisfactory the following should be checked at each visit:

- The treatment plan: this may seem facetious, but it is all too easy to lose sight of the precise
aims of treatment. Referring back to the original plan will ensure that each step is carried
out methodically and will act as a reminder of how long treatment has been under way, so
that progress can be monitored
- The patient’s oral hygiene
- Record the molar relationship, overjet and overbite
- Anchorage situation
 - Tooth movement since the last visit: a good tip is to use dividers which can be imprinted
into records
- Retention of the appliance by asking the patient and adjusting the clasps or labial bow (see
section 17.4) as indicated
- Whether the active elements of the appliance need adjustment (see section 17.6)
- Whether the bite-plane or bucal capping need to be increased and/or adjusted
- Record what action needs to be undertaken at the next visit

17.8.2 Common problems during treatment

Slow rate of tooth movement
Normally tooth movement should proceed at approximately 1 mm per month in children, and
slightly less in adults. If progress is slow, check the following:
 Is the patient wearing the appliance full time? If the appliance is not being worn as much as
required, the implications of this need to be discussed with the patient (and if applicable, the
parent). If poor co-operation continues, resulting in a lack of progress, consideration will
have to be given to abandoning treatment.
 Are the springs correctly positioned? If not, explain again to the patient the purpose of the
spring and show them how to insert the appliance correctly.
 Are the springs underactive, overactive, or distorted? Check that the patient is not using them
to remove the appliance or putting it in their pocket during meals.
 Is tooth movement obstructed by the acrylic or wires of the appliance? If this is the case,
these should be removed or adjusted.
 Is tooth movement prevented by occlusion with the opposing arch? It may be necessary to
increase the bite-plane or buccal capping to free the occlusion.

Frequent breakage of the appliance

The main reasons for this are as follows:
 The appliance is not being worn full-time.
 The patient has a habit of clicking the appliance in and out (see below).
 The patient is eating inappropriate foods whilst wearing the appliance. Success lies in
dissuading the patient from eating hard and/or sticky foods altogether. Partial success is a
patient who removes their appliance to eat hard or sticky foods!

Appliance quickly becomes loose fitting

The most common cause of this is a patient who is clicking the appliance in and out. This habit
can also lead to intrusion of the teeth which are clasped by the appliance and to frequent
breakages. The patient’s close family are often very grateful if the habit is stopped, as the
clicking noise that it generates can be very irritating.

Excessive tilting of tooth being moved

Removable appliances are only capable of tilting movement. However, this is exaggerated by the
following:
 The further that the spring is from the centre of resistance of the tooth the greater is the
degree of tilting. Therefore a spring should be adjusted so that it is as near the gingival
margin as possible without causing gingival trauma.
 Excessive force is being applied to the tooth, as this has the effect of moving the centre of
resistance more apically.

Anchorage loss
This can be increased by the following:
 Part-time appliance wear, thus allowing the anchor teeth to drift forwards.
 The forces being applied by the active elements exceed the anchorage resistance of the
appliance. Care is required to ensure that the springs, etc. are not being overactivated or that
too much active tooth movement is being attempted at the time.

If anchorage loss is a problem see Chapter 15.

Palatal inflammation
This can occur for two reasons:
(1) Poor oral hygiene. In the majority of cases the extent of the inflammation exactly matches the
coverage of the appliance and is caused by a mixed fungal and bacterial infection (Fig.
17.19). this may occur in conjunction with angular cheilitis. Management of this condition

Fig. 17.19 Inflammation of the palate corresponding to the coverage of a removable

appliance
 must address the underlying problem, which is usually poor oral hygiene. However, in
marked cases it may be wise to supplement this with an antifungal agent (e.g. nystatin,
amphotericin, or miconazole gel) which is applied to the fitting surface of the appliance four
times daily. If associated with angular cheilitis, miconazole cream may be helpful.
(2) Entrapment of the gingivae between the acrylic and the tooth/teeth being moved.

Lack of overbite reduction

Lack of progress with overbite reduction can be a problem in patients who are not actively
growing vertically, such as adults or those with a horizontal direction of mandibular growth. In
this situation, alternative means of overbite reduction should be considered. In children, the most
common reason for lack of progress with overbite reduction is that the appliance is not being
worn during meals. Patients should be advised that their treatment will be quicker and more
successful if they wear their appliance for eating, and that adaptation will be enhanced if they
start with softer foods.

17.9 Appliance repairs

Before arranging for a removable appliance to be repaired the following should be considered:

- How was the appliance broken? If a breakage has been caused by the patient failing to
follow instructions, it is important to be sure any co-operation problems have been
overcome before proceeding with the repair
- Would it be more cost-effective to make a new appliance?
- Occasionally it is possible to adapt what remains of the spring or another component of the
appliance to continue the desired movement
- Is the working model available, or is an up-to-date impression required to facilitate the
repair?
- How will the tooth movements which have been achieved be retained while the repair is
being carried out? Often there is no alternative but to try and carry out the repair in the
shortest possible time

Key points
Removable appliance are:
- Only capable of tipping movement of
individual teeth
- Useful for moving blocks of teeth
- Useful for freeing the occlusion with
the opposing arch
- Useful as passive appliances (e.g. for
retention)
- More commonly use nowadays as an
adjunct to fixed appliances (rather
than the sole appliance to correct a
 malocclusion)
- Should only be used by appropriately
trained staff