PATIENT MANAGEMENTAND MANAGEMENT OF REMOVABLE APPLIANCES

Lekshmi S P

JR 1

Department of Orthodontics

Govt. Dental college Kottayam

Contents

Introduction

Fitting a new removable appliance

Subsequent visits

Activation

Headgear

Clinical management of functional appliances

Conclusion

Introduction

It is at the beginning of treatment that the foundations of the future success of

treatment are laid. Chairside management begins with assessment of the patient and

formulation of a treatment plan .

It is at this stage that patient commitment and motivation must be assessed. Failure to

appreciate possible problems and to discuss them with the patient can prejudice the

future cooperation.

A badly designed or constructed appliance will be difficult to wear and can undermine

the cooperation of even the most enthusiastic patient.

From the outset, the orthodontist must determine whether the prospective patient

is a suitable candidate for treatment

For the individual who is convinced he or she will require orthodontics, an

important question is whether any one feature is of great concern than the other.

The orthodontist should make some diagnostic determinations from the doorway

regarding the patient’s face, posture and expression.

One can often tell from the first moment whether the orthodontic problem will be

largely a dental one or a difficult skeletal or facial problem

Records

Good records are essential at the start of any treatment

An aid in the initial diagnosis and treatment planning

Serve as a reference point during treatment.

Study models

The impressions should be taken using trays with deep flanges or built up with wax to

ensure that the full depth of the buccal sulcus is reproduced.

The models should be cast with adequate bases, the upper being trimmed

symmetrically about the medial palatal raphe and the lower correspondingly.

The posterior surfaces of the models are trimmed flush so that the models can be

related in occlusion by laying them backs-down on a flat surface.

Radiographs

Confirm the position of any unerupted teeth

Condition of the alveolar bones.

Important before deciding upon the choice of teeth for extraction

Useful in the event of untoward damage to the teeth during

treatment.

The normal radiograph would be a dental pantomogram (dpt).

For removable appliance lateral skull radiographs are not

essential.

Photographs

Photographs form an important record of the patient's occlusion and

appearance

Intraoral photographs should include an anterior view and right and

left buccal views with the teeth in occlusion.

Extraoral views should show full face and profile.

Fitting a new removable appliance

The appliance should have been designed at the time of taking the impression and

with the patient still in the chair.

It can represent false economy to attempt to move too many teeth with one

appliance.

Show the appliance to the patient and demonstrate the retaining clasps and active

springs.

The appliance should be fitted within 1 or2 weeks after the impression has been

taken.

Adjustment of clasps

Clasps made according to Adams' design offer good retention

When adjusting clasps the operator should avoid, as far as possible, bending the wire at

points where it has already been bent during construction by the technician .

The only exception to this rule is that where the clasps are initially too tight to permit

insertion, it may be necessary to grip each arrowhead in turn with the pliers and bend it

outwards .

Once the appliance can be seated (if necessary with the support of a finger) the accurate

positioning of the arrowheads can be investigated.

Possible faults are as follows:

Horizontal

The arrowheads do not contact the tooth or

else grip it too tightly.

Vertical

The arrowheads grip too far occlusally or else push up into the gingivae.

Bending the wire just beyond the point where it has passed over the embrasure

controls its vertical position.

Bending it nearer to the arrowhead controls its bucco-lingual position

It is important that the clasp does not grip the tooth too tightly and an undercut

of 0.25 mm has been shown to give an adequate clasp.

It Is useless to attempt to tighten the clasp by bending the wire at the point

where it emerges from the acrylic.

The only indication for adjustment at this point occurs in a case where the wire

passes high over the embrasure and interferes with the occlusion

Adjustments to the acrylic

The acrylic will need to be trimmed to permit active tooth movement. This is of

great importance but is frequently overlooked.

The appliance should be inspected in situ to ensure that no part of the acrylic

contacts the tooth to be moved and that this tooth movement will not result in

contact before the next visit

It is also sensible to trim the acrylic so that any desired passive movement might

occur

Bite planes

Any excessive thickness may need to be reduced and bite planes

adjusted to give even contacts.

Posterior bite planes, careful trimming will usually be necessary to

ensure that the occlusion is evenly distributed.

An anterior bite plane will need to be undermined on an appliance

designed to reduce an overjet before activating the labial spring.

Adjustment to active wirework

It is sensible to provide only very light activation so that the appliance is

self-activating and the springs cannot readily slip into the wrong position.

This will imply activation of about 1 mm for a palatal spring and 0.5 mm for

a 0.7 mm buccal spring.

During the first few days with a new appliance the patient has to get used

to inserting it correctly, must adapt to its presence and perhaps put up with

a mild degree of discomfort

Demonstration to the patient

Show the patient the appliance in the mouth using a mirror, demonstrating how it

should be inserted and removed.

Removal should be achieved by exerting finger pressure on the bridges of the

Adams' clasps on the first molars to disengage them before the front of the

appliance is disengaged.

Allow the patient to remove and replace the appliance in front of you.

Check that the appliance has been seated correctly, paying particular attention to

the position of active springs after the patient has inserted it.

As far as possible, cleaning should be carried out after meals and particular care

should be given to cleaning the fitting surface of the appliance either with a nail

brush or with the patient's own tooth brush.

Keep the appliance in a small, rigid box which will protect it from accidental damage.

Initially the patient will be very aware of the large bulk of the appliance and may

experience excess salivation and difficulty in swallowing.

Reassurance should be given that this is quite normal and that the appliance will

rapidly feel more comfortable.

Difficulties with excessive salivation and swallowing usually disapper within a few

hours. Normal speech may take 24to 48 hours to achieve.

Information

The patient should be given simple verbal instructions:

Sticky sweets must be avoided.

Good oral hygiene is important -keeping the appliance and the mouth clean

If the appliance breaks or causes discomfort or trauma to the cheeks or tongue, the

patient should not wait for a routine visit but contact the doctor for an earlier

appointment.

Where the patient is a child, the parent should be brought into the surgery so that

the instructions can be repeated.

A printed information sheet on the use of the appliance should be given to the patient

to take home

A further appointment should be made for the patient to be seen in approximately 2-3

weeks' time.

Difficulty in fitting an appliance

The wrong appliance

In a busy practice or laboratory incorrect labelling can occur. It is possible that the

wrong appliance has been returned.

Inadequate impression

An impression, which has been removed from the mouth before it is completely

set, will be distorted.

Inadequately extended impressions or those with air blows of any size may

present problems

Anticipation of extractions

If the technician has removed from the model the teeth which are to be

extracted, and the appliance encroaches on this area, it will not fit without

modification until the extractions have been carried out.

Eruption of teeth

The eruption of palatally placed teeth, particularly upper second premolars, can

cause problems.

This usually occurs when there has been a delay in fitting the appliance since the

impression was taken.

Delay since the impression

Forward movement of the buccal segments following orthodontic extractions or

natural loss of deciduous teeth may interfere with fitting.

Excessive undercut

Undercuts need to be blocked out on the model before the appliance is made

because subsequent trimming may weaken the appliance unduly.

Difficulties with clasps

Check the design of the Adams' clasps and ensure that there is adequate

undercut on the first molars.

Over trimming of the model during construction can make the clasps so tight

that insertion is impossible.

In adult patients, trimming is usually unnecessary and even to take the

arrowheads up to the gingivae may mean that excessive undercut is engaged.

Subsequent appliances

Occasionally a subsequent appliance will not fit because movement of the

teeth has occurred since the impression was taken.

This may result because the previous appliance was left active or because

the patient has ceased to wear it.

Either of these events can cause inconvenience and the latter can even

produce the situation where neither the new nor the old appliance will fit.

Subsequent visits

The appliance must be adjusted with care and good records need to be kept.

The patient should be seen 2 or 3 weeks after the appliance has been fitted and

then at monthly intervals.

Inadequate attention to detail at regular visits may mean that something is

overlooked and that progress is slow or erratic.

The acrylic or the occlusion may interfere with tooth movement, unintended

movements may be taking place or anchorage loss may be occurring.

Oral hygiene can also deteriorate, unnoticed, over the course of a few visits.

Preliminary discussion with the patient

Enquire whether the patient has experience any problems with the appliance since the

previous visit.

Avoid leading questions

Excessive looseness may lead the operator to suspect that the patient has developed the

habit of moving the appliance up and down with the tongue.

If you conclude that the appliance has not been worn as directed. raise the matter

directly

The operator should then remove the appliance noting any degree of activation

remaining in the springs.

Changes in the occlusion since the last visit

It is good practice to measure and record changes in tooth position at each visit rather

than simply entering a verbal comment. A simple measurement is often sufficient

Generalized palatal inflammation may reflect the need for more thorough oral

hygiene.

Heaping up of the gingivae around the teeth being moved indicates that the appliance

has not been trimmed away adequately.

Anchorage

It is important to take further measurements at each visit to confirm that

anchorage loss is not occuring.

Where only one arch is being treated it is usually easy to use the other arch

as a reference.

In the case of upper canine retraction a measurement of overjet should be

taken and any increase in this is usually a warning that anchorage is being

lost

The molar relationship will also become more class II. When lower arch

extractions have been carried out assessment can become more difficult.

If marked anchorage loss has occurred, changes in the relationship of the two arches will

become noticeable.

When unwanted movement is discovered, corrective action should be taken at once.

If the active components are exerting too great a force this must be reduced.

Space requirements should be reassessed. If there is space to spare some loss of anchorage

may be accepted

Lack of satisfactory progress

Is the tooth free to move?

If the baseplate is in contact with the tooth, it should be cut away

sufficiently to ensure that further obstruction does not occur.

Make certain that an unerupted tooth or retained root has not been

overlooked.

Has the correct force been applied?

Check that a spring is located correctly and on the right side of the tooth when the

patient inserts the appliance.

Make sure that the spring is adequately activated

The use of heavy pressures will cause hyalinization within the periodontal

ligament and delay resorption, so light pressure should be maintained and the

patient should be warned that treatment will be lengthy.

In very rare cases, treatment may be prolonged by the presence of dense alveolar

bone

Has the appliance been worn as instructed?

It is sensible to look for other signs of poor wear before discussing this with the

patient.

Difficulty in handling and inserting the appliance, speech problems, poor fit, lack

of attrition facets on bite planes and an absence of marks on the palate at the

periphery of the baseplate - all these point to lack of fulltime wear.

Careful questioning of the patient may elicit that it is left out for meals, at night,or

at school.

Activation

For a single rooted tooth a force of 30-40 g is appropriate to produce

controlled movement with minimal tipping.

The thickness and length of the spring will determine the amount of activation

necessary to produce such a force, but a desirable activation is roughly one-

third to one half a unit (about 3 or 4 mm).

If more activation is attempted the appliance may be difficult to insert

correctly.

The chance of the spring being wrongly positioned is increased and the spring

is also more prone to damage.

A thicker or shorter spring may easily produce a force that is too heavy

Unless the patient attends frequently this produces slow movement and

provides a temptation to over activate the appliance.

Results in pain ,anchorage slip and perhaps unwanted tilting of teeth

If the operator has access to a force gauge of the 'Correx' type,it is possible to

check the spring pressure being applied

The labial bow

The general principle of avoiding existing bends during activation and of

carrying out the adjustment at different points still applies.

Where the incisors are irregular it may be necessary to combine careful

selective grinding of the palatal acrylic with activation of the labial wire.

The wire may also be kinked to bring pressure to bear on a particular tooth

and so help in obtaining alignment.

Labial bow is activated by reducing the size of the loops. Each side is dealt

with individually by holding the loop in the pliers and flexing the bow mesial

to them .

It will be necessary to re-adjust the vertical height of the labial wire because

closure of the loops will cause this to move occlusal.

Flex the loops inward or outward as required to avoid trauma to the alveolus or

lip respectively

Headgear

It is important that headgear should fit snugly and be comfortable

It must be kept clear of ears.

The straps themselves should be broad so that the load is well distributed.

The inner bow must match the arch form and length .It should lie a few

millimetres labial to the upper incisors and be at the level of active lip lne.

Its length can be adjusted at the U loop.

With removable appliance the main concern is that the direction of pull does not tend to

unseat the appliance.

For active retraction of buccal segments ,wear for 12-14 hrs out of each 24 hrs

Patient motivation and monitoring are crucial to its successful use.

The patients are at risk if the facebow becomes dislodged from the appliance.

This can happen if the facebow is removed while still attached by elastics to headcap,

whether intentionally by the patient or inadvertently during play.

If a detachable facebow is used then the ends that engage the tube on the molar clasp

should be of the curved design.so that there is less chance of facial injury.

Safety headgear is available and is designed so that the hook attachment on the headgear

detaches when predetermined force level is exceeded.

Patient instructions

Regular wear of the appliance should be reinforced because the force applied is

intermittent ,patient’s initial acceptance of the appliance is difficult to achieve.

Proper counselling should be given.

Appliance should be worn during evening hours

Should be advised on the safety aspects of the appliance.

Headgear should not be used as a play toy.

When an extraoral appliance is fitted and demonstrated to a patient and parents a

warning of the potential risks should also be given.

Patients are advised to wear the appliance in the evening at home for the first 2

weeks after it has been fitted.

Provided it is being managed satisfactorily the patient is instructed to wear it while

asleep in addition to indoor daytime wear

A record of the adjustment and checking of headgear should be made in the patient’s

notes at every visit.

In headgear patients it is useful to ask the patient to keep a diary of wear.

It is important to ask to see the diary at each visit and to give encouragement or

praise in order to reinforce the patient's efforts.

Patient cooperation is the most important factor in the treatment of a case with

functional appliances.

Educate the patient and the parent with the help of audiovisual aids,the design of the

appliance and its mechanism of action.

Explain to them the results of a few treated cases with the help of study models and

photographs

Emphasize the duration of time taken for treating those cases,to prepare them to accept

the duration of treatment

They should be made to understand that even the best made appliance would not be of

any use,if the patient does not wear it or fail to follow the instructions.

Activator

The appliance is first inserted into the mouth of the patient and seated onto the

maxillary arch.

If there is any interference ,it would be generally due to presence of undercut

Selectively relieve them.

Once the appliance is seated on to the maxillary arch,Ask the patient to gently close the

mandible.

Explain to the patient that the appliance may fall off the mouth or will be discarded

subconsciously sometimes in early period of wearing the appliance during nights.

Reassure the patient,that they will get used to it.

On the first visit insert the appliance and give instructions.

Initially it is worn for 2-3 hrs in a day for 1st week.

Followed by night time wear and 1-3 hrs of day time wear for 2nd week.

The patient is recalled for check up on 3rd week.

Followed by check up appointments every 6 weeks.

Trimming according to the plan is started from 2nd visit once the patient

gets used to the appliance.

The patient activates Jackscrew at 2 week interval if incorporated in the

appliance

Trimming of the Activator

1) A finished activator is generally delivered untrimmed to the patient to

achieve maximum skeletal changes.

2) In subsequent visits trimming is carried out to create guidance planes for

selective eruption of the teeth. The desired tooth movements with the

activator are-

a. Maxillary posteriors –buccaly,distally and Oclusally.

b. Mandibular posteriors-buccaly,mesially and occlusally.

c. Maxillary anteriors –distally(to allow retraction)

3)Mandibular anterior region is not trimmed, in fact teeth are capped

with acrylic to prevent proclination.

4) Untrimmed gingival portion guides the teeth buccally .

Procedure

Materials

1 Long narrow tapered acrylic bur

2 Micromotor

3 Glass marking pencil

i) Mark the areas to be trimmed with white marker pencil

a)Maxillary posteriors-occlusal 1/2 of distal embrasure

b) Mandibular posteriors occlusal 1/2 of mesial embrasure

c)The acrylic resin behind maxillary incisors trimmed up to the

alveolar region to allow retraction of the anteriors

Ii) Confirm that all marked areas are trimmed, unmarked areas

will be appear shiny.

Iii) Place the activator on the mounted cast; confirm that there is

no obstruction to desired tooth movement as mentioned

previously

iv) Properly trimmed activator shows “honey comb” appearance

on side view.

v) finally trimming is checked inside the mouth.

Bionator

Clinical management

1. After insertion of the appliance, a written appointment should be given in a

week to check for sore spot.

After this, appointment at 4-6 weeks interval are quite adequate.

In the average case, one year to 1 1/2years would be reasonable estimate of

the time needed to achieve correction.

2. The same appliance is worn during retention and is worn only during

night.If correction was achieved very rapidly, day time wearing should not be

abandoned at once.

The appliance is worn gradually less and less frequently in night.

The patient must be instructed to wear the appliance more frequently again if after an

interval a slight muscular tension is felt when the appliance is inserted.

Relatively few problems are encountered in handling of bionator.

The bionator is considered by many to be best type of functional jaw orthopaedic

appliance because of its relatively simple nature.24 hr wear makes it better appliance

to achieve correction and prevent relapse.

Frankel appliance

clinical handling

Timing of treatment

According to Frankel the optimum time to start treatment is the transitional

phase from early to late mixed dentition when child is 7-81/2years old.

Patient cooperation is key to success in FR treatment:

It is important to realize that FR works only if it worn during the day and

successful muscle training can be achieved only if it is carried out

gradually.

2 ) Appliance delivery

All margins are checked for smoothness .Particular attention should be paid that the

labial pads of the FR are constructed properly and are tear drop in shape in cross

sections.

-It is imperative that the appliance be anchored in the maxilla, when used to change

mandibular postural position.Hence check if the separation is sufficient between the

teeth to cross over wires.

In mixed definition the seating grooves cut in cast have to be replicated in the patient

mouth using a diamond disk or cylinder.

Notch the distal surface of the second deciduous molars .But first

permanent molars not to be notched.

-To check the appliance fit:Place 2 index fingers under the inferior aspect of

vestibular shields and push the appliance vertically upward, this is done to

check if the cross over wires are properly seated in maxillary dentition.

Check for overextension of vestibular shields in posterior and canine

regions.The peripheral portion of the shield should properly contact the

sulcus tissue without blanching it.

The shields should be away from the alveolar mucosa and dentition only as

much it is required to achieve the necessary expansion.

Most likely place of tissue impingement is the area of lower margins of lip pads.If

blanching is seen in the mandibular anterior sulcus trim the lip pads(lower margins)

and polish again.

This can be avoided by placing lip pads correctly in the vertical direction, if not placed

correctly the lower margins tilts forwards resulting in soreness and ulceration of the

corresponding regions of the lower lip.

It is important to check the wax up of lip pads properly to prevent improper slant as

faulty position of lip pads, can rarely be corrected by grinding adjustments during

delivery and may distort the appliance,

Instruction to patient

Instruct on how to put the appliance:

Child should hold the appliance in one hand and the cheek at the corner of

mouth with the other and rotate the appliance in on one side . Use of mirror

greatly facilitates appliance insertion.

The face should be palpated on the outside to make sure there are no sharp

edges sticking into the cheeks of the lip pads.

Encourage adaptation by asking the patient to pronounce his name out along

with the appliance in place few times.

The FR does not restrict tongue movement

Wearing the appliance:

successful treatment with FR is only possible if the appliance is worn during the

day with lips together.

This concept needs to be understood both by the parents and the child.

The parents must remind the child to wear the appliance before leaving school.

The sheet of paper /tongue blade should be kept between the lips during T V

watching and homework.

Whenever appliance is not in the mouth it should be kept in a container with water

for safe keeping

Orthopeadic training with FR is started slowly.

For first two weeks wear 1-3hrs in the afternoon only

This hour depends upon type and severity of malocclusion.

Patient usually get adjust to FR 3 more easily than FR I and FR 2.

Recall visit

First check up after 2 weeks of delivery where one checks for

1. Stripping of gingiva

2. Ulceration and violation of muscle attachment

3. Excessive tissue redness

Presence of these indicates that they are not properly extended.

Speech impairment with FR is minimal but if it continuous either patient

is not wearing the appliance or insufficient lip oral training

In this cas,speaking exercise are encouraged

2 weeks later patient should wear appliance for 4-6 hrs

2. It takes at least 3-4 months for patient to adapt full time wear.

Night time wear should not be rushed into, because in presence of

mandibular retrusion the jaw will open down and back during sleep the

lingual shield will then slide over the mandibular anteriors and tip them

labially.

In class III, FR 3 can be worn at night after 3-4 weeks except in case of

hyper divergent face pattern,which requires intensive lip seal training.

FR3 to be worn at night only when progress in training of sealing muscles is

identified.

Check after every 4 weeks for:

1 Mucosa of the vestibule

2 Stabilization of appliance in maxillary arch

3 Cross over wires not moving in interdental tissues.

Appliance adjustment

With FR I it may be necessary to bend the canine loops occlusally and the

molar rests gingivally to prevent irritation on the interdental papillae when

deciduous molars are lost and premolars erupt.

Labial bows can be activated to retract the maxillary incisors and to close

spacing between anteriors

.Lingual wires may need to be bent to protrude the mandibular incisors

which are inclined lingually.

In severe mandibular retrusion the lingual shields/lip pads of FR1 ,FR 2

may have to be advanced forward.

Treatment progress:

Check after 8-12 weeks.

After 2 months of appliance wear ,expansion of arches should be apparent.

Transverse distance is measured between deciduous molars and first

permanent molars of maxillary and mandibular arches.

Likewise changes in :

Overjet

Overbite

Sagittal improvement in class II relation is measured

If patient is very cooperative with full time wear, within 6 -8 months change

in relation from distoocclusion to neutroocclusion will be noticed.

Patient will have difficulty in positioning the lower jaw posteriorly.

This indicates that the new postural performances pattern of the suspending

musculature has been established.

Concomitant decrease in mentalis muscle hyperactivity should be noticed.

FR worn as retainer

Use of FR appliances retainer is particularly in those cases where the muscle

training achieved in active treatment phase is not entirely satisfying.

FR still being used as retainer on few hrs in the afternoon and at night.

2hrs in afternoon,6hrs at night for 6 months

Only at night -1 yr.

After active treatment phase if certain tooth positions are not where they

should be they can be altered with fixed appliance.

Twinblock

Clinical handling

Appliance delivery

Before delivery of twinblock –

1)Check whether the appliance is correctly fabricated and amount of activation

introduced.

2) Patient is shown how to place appliance in mouth properly.

3)Check fit of appliance-by trying upper and lower components separately

4)Adjust the delta clasps and ball clasps.

5)Both parts of appliance should be anchored in place and should not float loosly

in mouth.

6)It should be confirmed that the patient closes consistently on inclined planes

with the mandible protruded in its new position.

7)Overjet should be measured with mandible fully retruded and checked at

every visit to monitor progress.

Instructions to the patient:

1) Appliance should be worn full time ,especially during eating ,and removed only

for cleaning.

2) At first the appliance will feel large in mouth ,but within a few days it will be

comfortable and easy to wear.

3)For first few days , speech will be affected ,but will steadily improve and should

return to normal within a week.

4)Expansion screw should be turned one quarter turn per week.

Adjustments

STAGE 1: ACTIVE PHASE

1) appliance fitting

- Patient should be able to bite comfortably in protrusive bite with inclined

planes occluding correctly.

- Important to relieve appliance slightly lingual to lower incisors to avoid

gingival irritation during first few days.

- Labial bow ,if present ,should be out of contact with upper incisors.

2) Initial adjustments(After 10 days to 1 week)

Initial discomfort should have resolved.

Patient should be biting consistently in protruded position.

Upper screw turned one quarter turn/weeks.

In treatment of deep overbite-upper bite block trimmed clear of lower molars

leaving a clearance of 1-2 mm.

If patient unable to position the mandible comfortably in protruded position ,the

angulation of inclined planes reduced to 450.

3)After 4 weeks

-Positive progress should be noted in facial muscle balance

-Screws should be checked

Labial bow adjusted so that it is out of contact upper incisors

-In treatment of deep overbite lower molars should be relieved

4)Routine adjustment –time interval 6 weeks

-Check for correction of distal occlusion

-Check for upper arch expansion

-Trimming should be continued until all occlusal cover is removed from upper

molars to allow lower molars to erupt completely into occlusion.

Trimming of twinblock- Management of deep overbite

Overbite reduction achieved by trimming occlusal blocks on upper appliance ,so as

to encourage eruption of lower molars.

Increase lower facial height and to improve facial balance by controlling the vertical

dimension.

Trimming initiated at start of treatment so as to permit eruption of lower molars.

Upper bite block trimmed occlusodistally to allow lower molars to erupt.

Trimming continued progressively at each visit- permitting only a small vertical

clearance of 1-2 mm over lower molars to allow their eruption.

This sequence of trimming does not allow tongue to spread laterally between teeth to

prevent eruption of lower molars ,and results in a more rapid development of vertical

dimensions.

Normally, it takes 6-9 months for molars to erupt into occlusion. Mandible should be

supported in a protruded position throughout trimming sequence.

After molars have erupted into occlusion,final adjustment at end of twinblock stage

aims to reduce the lateral openbite by trimming the upper occlusal surface of lower bite

block over the premolars by 2mm.

Occlusal height of upper premolars is maintained by interdental clasps that

effectively prevent their eruption

STAGE 2 :SUPPORT PHASE

Upper appliance with anterior inclined plane

Retention

Treatment followed by normal period of retention, after occlusion is fully

established.

Appliance wear can be gradually reduced to night time wear

Time table of treatment

Average treatment time:18 months

Active phase-6-9months to achieve full reduction of overjet to normal incisor

relationship and to correct distal occlusion.

Support phase-3-6months for molars to erupt into occlusion and for premolars to

eruption

Retention-9 months ,reducing appliance wear when position is stabilized.

Generally ,each time a patient presents during treatment, the treatment plan

has to be reconsidered in light of the treatment response and some elements

of the original problem that might have been overlooked.

In the contemporary paradigm,the orthodontist no longer makes decisions

alone but now does so jointly with the patient and /or parent

CONCLUSION

Patient management is an important criteria in achieving

clinical results

Efficient patient management helps to cultivate a good-patient

doctor rapport .

If expectations of both the patient and the doctor are realistic

then treatment result will be a rewarding experience for both

Take home message

We should realize that from a patient’s or parent’s perspective,

the appearance and psychosocial benefits of orthodontic

enhancement often have higher values than occlusal outcome of

treatment.

Stated bluntly, an orthodontist who views his role in society

simply as one who corrects dental occlusion is clearly missing the

larger picture.

Reference

Removable Orthodontic Appliances –K.G Issacson,J.D.Muir,R.T.Reed

Orthodontics Current principles and techniques-Graber. Vanarsdall. Vig(5th edition)

Dentofacial Orthopedics with functional appliance-GRP (2nd edition)