CONTENTS

History
Scope of Removable Appliances Classification

Indications
Advantages Disadvantages Limitations Design Components

Patient instructions and Appliance

Care Conclusion

HISTORY
Victor Hugo Jackson

Chief proponent of removable appliances in the US

Charles Hawley

Introduced Hawleys appliance in 1908

Martin Schwartz

In mid 20th century developed a variety of split plate appliances

Philip Adams

Modified arrowhead clasp into Adams Crib Became the basis for English removable appliances Still the most effective clasp for orthodontic purpose

George Crozat

In early 1900s developed a removable appliance entirely in precious metal Heavy gold wires as framework Lighter gold finger springs for desired tooth movement

Norman W. Kingsley (1879)

Described his plate for Jumping the bite Pioneer in orthodontic therapy for the forward positioning of the mandible.

Monobloc by Pierre Robin(1902)

Passive positioning device
Modified from bite jumping v u l c a n i t e ma x i l l a r y g u i d e p l a n e s designed by Norman Kingsley

Indicated in patients with severe

Scope of removable appliances

The quality of outcome is not as high as with fixed appliances Higher chances of discontinuation of treatment associated with the use of removable appliances

The use of removable appliances still varies widely between clinicians, but it is possible to achieve adequate occlusal improvement with these appliances, provided suitable cases are chosen.

It is vital to emphasize that cases suitable for removable appliance treatment are those that require simple t i p p i n g m o v e m e n t s o n l y, a n d surprisingly few malocclusions will fall i n t o t h i s c a t e g o r y.

Definition:
REMOVABLE ORTHODONTIC APPLIANCE: An appliance which can be removed for cleaning by the patient or for adjustment by the orthodontist.

Classification
Given by Graber for removable appliance

Group A :- tooth supported appliances

E.G.- Catlans appliance, inclined planes, etc.

Group B :-tooth/tissue supported

E.G.-Activator, bionator, twin block, etc

Group C :-vestibular positioned appliances with isolated support from tooth/tissue

Frankel appliance, lip bumper,etc

Indications
At present removable appliances are indicated for three major uses

Growth modification

Limited (Tipping) tooth movements

Retention

Advantages
Majority of malocclusions which require simple tipping of teeth can be satisfactorily treated with removable appliance

Can be incorporated with bite platforms to eliminate occlusal interference and displacement
Manufactured in the laboratory and adjustments takes less chair side time.

Can be removed by the patient for cleaning both teeth and appliance. Damaged appliances that apply undesirable forces can be removed.

They

are aesthetically better accepted than fixed appliance.

They

can also be used as a muscle exerciser. They are Inexpensive

removable

fixed

Disadvantages

PATIENT COMPLIANCE Uncooperative patient may sometimes leave out the appliance which prolongs the treatment and uncontrolled drifting of teeth occurs.

Rotation of one or two upper incisors can be dealt but multiple rotations cannot readily be treated.
Lower removable appliances are not well tolerated due to encroachment on tongue space and retention problems.

If the appliance is not adjusted carefully it brings about uncontrolled tipping of teeth.

Patients

may

have

have

excessive

salivation initially

LIMITATIONS

Removable Appliances permit only TIPPING movements Patient will have difficulty in speech initially Appliance can be easily damaged if care is not taken

Components of removable appliances

Retentive Components Baseplate Active components

Retentive Components

IDEAL REQUIREMENTS

Should not impinge Close contact to the tooth Usable in both deciduous and permanent dentition. Adequate retention No active force on the anchor tooth Should be rigid Easy to fabricate and also replace if needed Not interfere with the growth of jaws and eruption of teeth

Circumferential Clasp

Fabricated using wire 0.8 mm -Also known as C clasp or Three Quarter Clasp Simple clasp used to engage buccocervical undercut Adequate retention. Easy to fabricate.
Easy to replace.

Disadvantages

Cannot be used in partially erupted teeth Decalcification of cervical margin. Gingival irritation. Plaque accumulation enhanced. Can easily distort.

Jacksons Clasp

- Fabricated using 0.8 mm wire - Also known as Full clasp or U clasp - Engages both bucco-cervical and proximal undercuts Offers adequate retention X Inadequate retention in partially erupted teeth X Difficult to adjust

Triangular Clasp

Fabricated

using 0.6mm wire Used between adjacent posterior teeth Indicated for additional retention Elastics can be engaged Not usefull if adjacent tooth is

ADAMS CLASP
Also known as Liverpool Clasp, Universal Clasp, Modified Arrowhead Clasp Parts Bridge Arrowhead Retentive arms

DESIGN CHARACTERISTICS
Bridge

The bridge is 2/3rd the mesio dital width of the tooth, or slightly less then the distance between mesiobuccal and distobuccal undercuts, or length should be equal to the intercuspal distance. Is 1-2mm away from the buccal surface of the tooth.

o Angulated at 45 to the long axis of the tooth.

Arrowheads
They

should lie in the disto- and mesio buccal undercuts. Shaped according to the curve of the gum margins into the interdental papilla. Long enough to keep the bride at a proper distance. Should not touch the adjacent teeth

ADVANTAGES
Small,

neat, occupies minimum space Rigid, offers excellent retention Used on any tooth in the arch If broken can be repaired by soldering Permits modifications in design

DISADVANTAGES
Extensive

wire bending incorporates stresses in the wire Unwanted palatal tipping if it gets activated. Can be repaired only if fractured through the arrowheads. Cannot be given on proclined anteriors.

Modifications

Adams clasp with single arrowhead

Adams clasp with J hook

Adams clasp with helix

Adams clasp with additional arrowhead

Adams clasp with soldered buccal tube

Adams clasp with distal extension Double clasp on maxillary central incisors

Schwarz Clasp

Designed by C. M. Schwarz
One of the oldest clasps and is considered as the predecessor of the Adams Clasp

Can be used in deciduous or permanent teeth Skill to fabricate

Eyelet Clasp

Similar to triangular clasp Used as single eyelet or multiple eyelet clasp Eyelets placed in embrasures On single tooth does not have firm grip so multiple eyelet clasp is preferred

Southend Clasp

Spans two adjacent margins of anterior teeth Esthetically more pleasing

Ballend Clasp

Wire having a knob or ball like structure on one end utilizes interdental undercuts Indicated when additional retention required

Crozat clasp
It

resembles a full clasp but has a additional piece of wire soldered which engages into the mesial and distal proximal undercut better retention than full clasp

Offers

Baseplate

Greatest portion of removable appliance and is 1-2mm thick It serves 3 main purposes 1. Act as vehicle to carry all parts of the appliance 2. Serve as anchorage 3. Become an active part of appliance itself

Anterior biteplane

Platform behind upper incisor teeth with a 60degree inclination Height enough to separate posterior teeth by 1.5-2mm

Reduces overbite of anterior teeth and causes opening of the bite

Sved Biteplane

Introduced by Sved in 1944 Covers incisal edges of upper anteriors Pressure transmitted axially Provides reinforces anchorage

Posterior Biteplane

Can be used for treating Posterior crossbites Anterior crossbites Anterior openbite after correction appliance acts as a retainer

Lower Inclined Plane

Introduced by Catlan more than 200 yrs ago Used for treating Anterior crossbite Inclined at 45 degrees to the occlusal plane If used for more than 6wksanterior open bite results

Active components

 LABIAL

BOWs SPRINGS ELASTICS SCREWS

LABIAL BOWS
Parts of labial bow
1. Incisor segment 2. Vertical loops 3. Cross over section 4. Retentive arm

May have 2 functions 1) Serve as active element for movement of teeth 2) Hold the plate in place & retain the teeth

Incisor segment
U s u a l l y i n t h e j u n c t i o n o f m i d d l e t h i rd a n d i n c i s a l t h i rd . Right angle bend at the distal third of lateral incisors or mesial third of canine Contacts only the most prominent teeth

Vertical loops

Consists of parallel vertical legs joined by a smooth curve. It is usually 9-12 mm in length, extending 2-3 mm. At the gingival level the loop is 11 . 5 m m a b o v e t h e g i n g i v a l m a rg i n

The various types of labial bows are

Short labial bow Long labial bow Split labial bow Reverse labial bow Roberts retractor Mills retractor High labial bow with apron springs Fitted labial bow Beggs retention bow

Short Labial Bow

Fabricated with a 0.7 mm wire Flexibility depends on vertical height of U loops Used when only minor overjet reduction or incisor alignment required Retentive arm distal to canine.

Adjustment : Compressing of U loop so that the incisor component is displaced palatally by only 1mm

Long Labial Bow

Used

to close space between canine and premolar Provides better control over the position of the canine Used for retention purposes

Split Labial Bow

The flexibility of the wire is increased Used for incisor retraction and Closure of diastemas Adjustment : at the U loop 1-2 mm at a time.

Labial Bow with Reverse Loop

Prevents buccal drifting of canine

Mills Bow /Extended Labial Bow

Made of 0.7mm wire Extensive loops- flexibility greatly increased Indications -Reducing large overjets -Alignment of irregular incisors Lighter forces, longer range of action Due to extensive loops less comfortable

High Labial Bow with Apron Spring

Used mainly for carrying Apron Springs Heavy base arch made of 0.9-1 mm wire Apron spring are made of 0.3-0.4mm wire

 Used

for retraction of teeth with severe proclination Lighter forces Longer range of action

Not well tolerated by the patient Time consuming to fabricate Cannot be used in patients with shallow sulcus

Roberts Retractor

Flexible bow constructed of 0.5mm wire

Steel tubing in the form a buccal sleeve to give support

Fitted Labial Bow

Fabricated with a 0.7 mm wire Adapted closely to labial surface of anterior teeth Used for retention

Beggs Retention Bow

0.7mm wire extends till last erupted molar U loops made between I & II premolars Allows better settling of occlusion

Other Modifications

The labial bow with retractive canine loop

The modified labial bow Function: Engagement of elastics and soldering of springs

The labial bow with vertical M-loop

Function: Alignment of the canine, if it is labially

SPRINGS
These are the most commonly used active elements. Requirements: springs should deliver optimum force should possess high degree of elasticity should have long range of action and apply light forces.

 0.5mm

or 0.6mm wires are used to move single teeth or groups of teeth in 18/8 austenitic stainless steel more wire incorporated, the greater the range of the spring and the lighter the force

Constructed

The

Classification of Springs
Based on direction of tooth movement 1. Springs for mesio-distal tooth movement 2. Spring for labio-lingual tooth movement 3. Springs for expansion of arches II. Based on nature of support 1. Self supported springs 2. Guided springs 3. Auxiliary springs III. Based on presence of loop or helix
I.

Single Cantilever Spring

active arm Parts coil retentive arm Fabricated with a 0.5-0.6mm wire coil with internal diameter of 3mm used to move teeth labio-lingually or mesiodiatally

Double Cantilever Spring / Z spring

Constructed using 0.5 or 0.6 mm wire Spring perpendicular to palatal surface of tooth Indicated where incisors are to be proclined Activation: Done by opening both coils If not perpendicular to palatal surface of teeth, it tends to intrude teeth.

T Spring

Constructed using 0.5 mm wire Used for buccal movement of premolars and molars

Coffin Spring

Described by Walter.H.Coffin in 1881 Made of 1.25 mm wire Can be used for slow dentoalveolar transverse arch expansion

Canine Retractors

used to move canine in distal direction CLASSIFICATION

I.

II.
III.

Based on location -buccal -palatal Based on presence of helix or loop Based on mode of action -push type -pull type

Buccal Self Supported Canine Retractor

Fabricated with a 0.7 mm wire Used when buccally placed canine is to be moved palatally and distally coil just distal to long axis of tooth

U Loop Buccal Canine Retractor

Can be used in shallow sulcus Requires frequent adjustment

Palatal Canine Retractor

-Used for canine placed palatally requiring distal movement

Screws
Types of screws The 2 types of expansion screws are Skeletal expansion screw Dental expansion screw

PITCH OF THE SCREW

When the expansion screw is given one complete turn, i.e., four one-quarter turns, the two halves of the removable orthodontic appliance advance a distance equal to the space between the neighbouring lines often called as threads. The distance moved is called the pitch of the screw.

Activation
Whenever the screw is turned 90 degrees it will drive the parts of the plate apart by 0.2 mm which narrows periodontal ligament by 0.1 mm on each side.
In the case of adult patient 1 quarter turn/week 0.2mm approx which is less than width of periodontal ligament fibre

Uses : Baseplate divided into sections driven

apart by one or more screws
1)

Split along midline For correcting Bilateral crossbites

2)

Split into a larger and a smaller part

Y-Plates For saggital and lateral expansion

Elastics

Resembles rubber band Made of latex rubber Available in various diameters force applied depends on their diameter Colour coded for easy identification Uses : For movement of singe teeth and groups of teeth For intermaxillary traction

Molar intrusion with removable a appliance

Intermaxillary elastics with removable plates can be used for the treatment of Class II and Class III

Instuctions to the patients and Appliance Care

Appliance

should be worn all

the time. Remove the appliance using the clasps only. Remove the appliance only during brushing and for

 Never wrap the appliance in napkin or in pocket

The

patient should avoid playing with the appliance using the tongue. Initial problems faced by patient like discomfort, pain ,excessive salivation ,plastic taste and difficulty in speech. Storing the appliance in a proper

PROBLEM 1: UPPER INCISOR INSIDE BITE

RETENTION: Adams cribs 6/6 and 4/4

Active component: Z-spring to 1/

BITE OPENING: Posterior bite capping to 654 / 456 (more comfortable for patient)

BASEPLATE: to connect everything together, also some anchorage

ACTIVATE THE Z-SPRING....

PROBLEM 2: All four incisors inside bite, with deep reverse overbite

RETENTION: Adams cribs 6/6 and 4/4

ANTERIOR RETENTION: Southend clasp 1/1

ACTIVE COMPONENT: Expansion screw to section 21/12

BITE OPENING: occlusal capping posteriorly

Screw is opened by one quarter turn twice a week and pushes upper incisors forward over the bite

PROBLEM 3: Increased overjet, proclined incisors

Extract 4/4 to allow overjet reduction

RETENTION: Adams cribs on 6/6 , Southend clasp 1/1

ACTIVE COMPONENTS: Palatal finger springs 3/3 with wire guards for stability

Trim acrylic

BITE OPENING: flat anterior bite plane

3/3 at end of canine retraction

Canines retracted. Now the incisors must be retracted

RETENTION: Adams cribs 6/6 with arrowhead extensions to 5/5

Metal stops mesial to 3/3 to prevent these teeth from moving forward

ACTIVE COMPONENT: Labial bow in 0.7 mm wire with large U-loops to allow activation

BITE OPENING: flat anterior bite plane

Labial bow activated 1-2 mm at each visit by squeezing vertical legs of U-loops together. Palatal acrylic must be trimmed away by the same amount.

End of incisor retraction

Where canines are bucally placed, use buccal canine retractors, made in either 0.7mm wire or 0.5mm wire supported by 0.5mm internal diameter tubing where it emerges from the acrylic

Canines can be pushed palatally into the line of the arch as they move distally

The labial segment can be retracted also with a 0.5mm labial bow with tubing support.

ACTIVATION OF LABIAL BOW: Press the vertical leg towards the tubing

PROBLEM 4: /5 deflected palatally, /6 has drifted mesially

RETENTION: Adams cribs 6 / 46 , southend clasp 1/1

ACTIVE COMPONENT: Screw section to /6 , Z-spring to /5

PROBLEM 5: Buccally placed canine /3

Retention: Adams cribs 6/6 and 4/4

ANCHORAGE REINFORCEMENT: Headgear tubes on 6/6

ACTIVE COMPONENT: Screw section to distalise /456

ANCHORAGE REINFORCEMENT: headgear to tubes on 6/6

Problem 6: Class II div 1, and both upper first permanent molars are carious

Adams cribs on 73/37, finger springs 5/5 and 4/4, fitted labial bow 21/12

Extract 6/6

Retract 5/5 (with or without headgear support)

Retract 4/4

Adams cribs 74/47, finger springs 3/3, Southend clasp 1/1

Upper 3/3 retracted

URA with labial bow to retract 21/12

Conclusion
Removable and fixed appliances are the two facets of the orthodontic world. The science and art of designing and constructing removable orthodontic appliances forms the basis for managing most of the orthodontic patients Sound theoretical knowledge of orthodontics helps us in designing a removable orthodontic appliance where as the construction of removable appliance is more of an art which has to be learned meticulously following the procedure and by repeated practice.

References

Orthodontic treatment with removable appliances- W. W.J.B. Houston, K.G. Issacson The Design, construction and use or Removable Orthodontic Appliances C. Philip Adams Removable Orthodontic Appliances- T.M. Graber, Bedrich Neumann Orthodontics Principles and Practice- T.M. Graber Contemporary Orthodontics- Proffit