The removable orthodontic app&xwe

Frans P.G.M. van der linden*

Nymegen, The Netherlands

ultibanded orthodontic appliances have been developed, perfected,

and used mainly in the United States. Removable appliances have been im-
proved and employed predominantly in Europe, and in the last 10 years an
increasing interest in multibanded techniques has arisen. Recently American
orthodontists have become more interested in the possibilities of removable
appliances. It may be mentioned that Europeans tend to underestimate the
complexity of multibanded techniques. On the other hand, some Americans
may expect too much of removable appliances and may not be fully aware of
their limitations.
In the United States most removable appliances are used primarily as
retainers in cases requiring little or no movement of teeth. This purpose can be
served effectively by a Hawley type of plate without active parts. Basically,
however, this type of appliance is not capable of extensive tooth movements
and thus is conceptually not a good starting point when an active removable
plate has to be designed.
Another approach was followed in Europe during the 1930’s when methods
were explored to replace the Angle E arch with an appliance that would be
easier to handle. Screws were reintroduced, and clasps and springs were de-
veloped. The appliances were designed primarily to move teeth and, therefore,
auxiliaries adapted to this approach were incorporated.
Two basically different types of removable appliance became popular-the
myofunctional type, such as the monobloc and the activator, and the simple
removable plate used in one jaw only. These two types of removable appliance
have a different theoretical background, and the design and clinieal implica-
tions deviate on many points. This article will deal with some aspects of the
simple removable appliance only. Great variation in detail of design and con-
struction has developed over the years, but the basic principles have remained
the same.
The removable plate can be applied more effectively and with fewer draw-
“Professor of Orthodontics, University of Nymegen.

376
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Fig. 1. The vertical part of the palate can support the anchorage, for example, during the
retraction of upper canines (comparable to a Nance holding arch].

backs in the maxilla than in the mandible. In the maxilla, the large surface of
the palate, with its typical shape, can make a valuable contribution to the
anchorage (Fig. 1). In vertical and transverse as well as sagittal directions,
the palate partly prevents displacement of the plate. In the mandible, the
acrylic part must be small because of the tenderness of the gingival tissues on
the lingual side of the mandible and the undercuts that are usually present.
Displacement of a lower removable plate is difficult to control. The two wings
have little sturdiness and lack support in the transverse direction.
Another factor working against the use of removable plates in the lower
jaw is the limited room available for building in springs. Most auxiliaries
situated on the inside of the dental arch, and to a certain extent also on the
outside, must be smaller for mandibular than for maxillary plates. For small,
d.elicate, continuously working forces, much wire must be used. The design and
construction of a spring situated on the lingual side of the dental arches
d.ependgreatly on the amount of acrylic locally available in the plane in which
the spring has to work.
These factors, as well as some others to be discussed later in connection
with the differences in application of clasps, explain why more can be ac-
complished with removable plates in the upper than in the lower jaw. These
factors also make clear why control over individual teeth, both over those
that are to be moved and those that are to function as anchorage units, is
better in the maxilla than in the mandible. Furthermore, it may become clear
why so many lower plates are worn irregularly and, on the other hand, why
permanent wearing of the upper removable appliance seldom presents diffi-
culties. In many instances, therefore, a lingual arch or a lower lip bumper
(“Denholtz”) may be preferable to a removable plate in the mandible.
Certain tooth movements can easily be accomplished by means of removable
a,ppliances. O ther movements either cannot be brought about or can be only
partly realized. For instance, tipping of teeth as in the retraction of labially
inclined incisors can be carried out efficiently. The point-wise contact of the
wire and the tooth favors this type of displacement. On the other hand, bodily
movement of teeth and torque control are greatly reduced. In extraction cases
in which teeth have to be displaced over a certain distance an undesirable
tipping usually occurs. However, in malocclusions showing a considerable lack
Fig. 2 Fig. 3

Fig. 2. An incisor can be rotated by applying a couple of forces.

Fig. 3. The reactional forces in this case are distributed over all teeth incorporated in the
appliance and over the vertical slope of the palate, which is a favorable situation.

of space, with canines not yet erupted or with pronounced me&al inclination,
extraction of premolars together with the use of removable plates can produce
remarkable improvements. There are no problems in expansion of the maxilla.
Teeth with rather flat lingual and buccal surfaces, such as the incisors, can
easily be rotated by applying a couple of forces (Fig. 2). On the other hand,
teeth with a more or less round cross-sectional crown shape, such as premoIars,
cannot be rotated without using bands as auxiliaries. A definite disadvantage
is that upper molars cannot be rotated adequately with a plate only. The
possibilities for vertical movement of teeth, individually or groupwise, are
limited.
Another factor to be considered is the cooperation of the patient. An ad-
vantage of removable appliances is that cleaning of the teeth is in no way im-
paired. On the other hand the patient must cooperate fully by cleaning his teeth
and always replacing the removable plate after brushing.
The removable appliance is composed of (1) acrylic, (2) fixation devices
(clasps), and (3) active parts.
The acrylic serves different purposes. First of all, it is the body which holds
the clasps and other metal parts. Second, it plays a definite role in the distri-
bution of the reactional forces over the different teeth and bony structures
(Fig. 3). Third, its border can serve as a guide in the control of tooth move-
ment (Fig. 4). Fourth, self-curing acrylic can be added to stabilize accomplished
tooth displacement (Fig. 5). Fifth, the acrylic can be built out to create anterior
or posterior bite planes, either to raise the bite in the buccal region (Fig. 6) or to
create a temporary vertical unlocking of anterior teeth for correction of local
cross-bites (Fig. 7). There is no need to make large, bulky acrylic plates. The
extension to the dorsal is determined primarily by the wire parts which have to
be embedded. However, the latter can be directed anteriorly (Fig. 3). The thick-
ness of the plate at the cervical borders of the teeth does not have to be more
than 1.5 mm. Locally, extra material is needed at the spots where the wires enter
the plate. Finally, the acrylic has to be checked carefully before a plate is put
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Removable orthodontic appliance 379

Fig. 4 Fig. 5

Fig. 7
Fig. 6

b
\
Fig. 4. The border of the acrylic can serve as a guide for the movement of a tooth. The
labial bow serves the same purpose on the buccal side.
Fig. 5. Self-curing acrylic can be added to stabilize accomplished tooth displacements. It
can also serve as vertical support when an anterior bite plane is used during retraction of
the incisors.
Fig. 6. Anterior bite plane to raise the bite. The clearance in the molar region should be
about 1.5 mm. When the appliance is always worn, particularly during meals, molar
contact may be established again in about 6 weeks. If desired, the bite plane can now
be made higher again by means of self-curing acrylic. A groove in the plate for all six
lower anterior teeth presents an orientation to the patient.
Fig. 7. Upper posterior bite plane to create a temporary vertical unlocking of anterior
teeth to correot local cross-bites. Note that the wires crossing the occlusal surface are not
embedded in the acrylic. To facilitate adjustment of the bite block to the occlusion, it is
preferable to start with a bite plane which is too low and build it up wi,th acrylic in the
mouth. Subsequently, the surface facing the lower molars has to be ground in to accom-
modate lateral excursions.

into place. In particular, sharp edgesmust be removed and the interdental septa
must be smoothed.
A typical aspect of the removable appliance is the prevention of its displace-
ment. A passive appliance, such as a retainer, requires certain devices to keep it
Fig. 8 Fig. 9

Fig. 8. A simple clasp can be placed cervically to a headgear tube on a molar band.
Fig. 9. A lingual spring positioned against an inclined surface results in a reaction force
that tends to move the plate dorsally and away from the palate. Clasps should prevent
this movement by proper design and location close to the pertinent region.

in place. In a plate with active parts, the resistance against displacement not
only must cope with the forces associated with normal oral functions and gravity,
but it must also withstand the reactional forces evoked by the activated parts,
The latter aspect can be differentiated from the well-known phenomenon, an-
chorage, with respect to the problems of avoiding undesirable mesial movements
(for example, of the buccal teeth).
Clasps keep the appliance in place by means of undercuts at the buccal re-
gions of the teeth, the mesiobuccal and mesiolingual corners (Adam’s clasps),
or between two adjacent teeth cervical to the contact point. Clasps should have
enough flexibility to permit removal and insertion of the plate without difficulty.
The acrylic should support the clasped teeth lingually and prevent their move-
ment. Properly bent clasps do not damage the gingival tissues and do not cause
tooth movement. They maintain their shape and activity for a long period with
no need for adjustment at each visit. There is a large variety of clasps from
which a choice can be made. Preference depends partly on the anchorage in-
volved. Teeth in the buccal region may be treated as one unit and locked be-
tween two clasps, If bands for a headgear are placed on the upper first pcrumnent
molars, a clasp can be placed cervical to the buccal tubes (Fig. 8). In general,
two clasps should be made in every quadrant. Special attention should be given
to those placed anteriorly in cases of reactional forces which tend to lift the
plate from the palate (Fig. 9). It is important not to let clasps interfere with the
occlusion or articulation. In cases in which this cannot be avoided, the wire
should be in direct contact with the teeth. Biting on clasps can result in unde-
sirable movements and breakage of the wire and, furthermore, it is unpleasant
for the patient.
Typical differences exist between the two jaws with respect to fixation of the
plate by means of clasps. The buccal inclination of the upper premolar% and
 Volume 59 Removable orthodontic appliance 381
Nwn be?’4

Fig. 10 Fig. 11
s4

Fig. 12 Fig. 13

Fig. 10. The inclination of ‘the posterior teeth and the anatomy of the buccal surfaces
present adequate undercuts for the placement of clasps in the upper jaw. Both factors
work in the opposite direction in the lower iaw.
Fig. 11. Clasps in the mandible can easily interfere with articulation, The functional area
involves more of the buccal region of the lower molars than of the upper ones.
Fig. 12. Separate labial bows (Booy). No U-loops are needed.
Fig. 13. Modified labial bow to intrude an incisor.

molars favors a good retention. In addition, the anatomy of those teeth presents
useful undercuts at the buccal surfaces. In the mandible not only does the in-
clination of the corresponding teeth counteract a profitable use of clasps, but
also the buccal surfaces are bell shaped, showing no undercut or a barely usable
one at the gingival border (Fig. 10). The use of clasps in the lower jaw is further
complicated by the fact that in most cases they cross the embrasures in such a
way that interference with occlusion and articulation cannot be avoided. As a
rule, the buccal parts of the upper teeth have less contact with their antagonists
as compared to the corresponding parts of the lower premolars and molars.
Therefore, clasps in the mandible can easily interfere with normal function
(Fig:ll).
The active parts of a removable appliance cause the teeth to move. The forces
 Amer. J. Orthodont.
Apti 1971

Fig. 14 Fig. 15

Fig. 14. Modified labial bow to move a premolar lingually.

Fig. 15. The acrylic must be ground away, not only at the cervical border but also in the
area where the alveolar process is to be remodeled.

exerted should be small, of a continuous character, and lasting for a long period
of time. The point of application, the range of activation, and the force m a g n i-
tude should be easily adjustable and controllable. Continuous labial bows, as used
in a Hawley retainer, do not meet these requirements. Preference can be given to
separate labial bows, allowing delicate activation and proper force control2
(Fig. 12). Furthermore, separate labial bows can be changed easily, either to
intrude an incisor (Fig. 13) or to move a canine or a premolar 1inguaIly (Fig.
14).
Many kinds of spring have been designed to move teeth individually or in
groups. Adams’ distinguishes between guided springs and those which are self-
supporting, depending on the thickness and length of the wires and the con-
sequencesfor their stability. Most springs located on the lingual side are of the
first type. They can be guided and supported by the overlapping acrylic or by
an extra piece of wire. Springs located on the palatal side are generally pse-
ferred over those placed buccally. The latter have to cross the oeclusal region,
frequently are more difficult to control in their action, and more readily lead to
inconveniencesfor the patient.
Now that some aspects of the different parts constituting a removable appli-
ance have been discussed,a few practical comments may be made.
Teeth cannot move when the appropriate space is not available or when an
opposing tooth, metal parts, or acrylic interferes with the displacement.Acrylic
must be ground away in the dire&ion of the movement anticipated, not only at
the cervical border but also in the area where the alveolar process is to be re-
m o d e led (Fig. 15).
Proper fitting of the appliance and good fixation are essential. W h e n all six
front teeth must be moved dorsally, with a m inimal loss of anchorage,the canines
should be moved first. After the canines have been incorporated in the buccal
auchorage units, the acrylic behind the ineiaors can be gromd away and the
 Removable orthodontic appliance 383

Fig. 16. a to d, Dental casts of a 17-year-old boy with lingually placed permanent upper
canines and persisting deciduous canines. The second right upper premolar was extracted.
e and f, The removable appliance used for 7 months; the posterior bite blocks were re-
moved later, Note the reciprocal action of the canine springs. One labial bow was
modified in the last stage of treatment to intrude the right lateral incisor.
Fig. 17. a to d, The dental casts after treatment. The occlusion is not optimal. Also, the
space closure is incomplete. These two aspects are among the limitations inherent in the
removable appliance approach. e and f, Oral photographs before and after treatment.

labial bows can be activated. Additional substantial arl~~horage support can be

provided by a headgear.
The removable appliance can effectively move nonadjacent teeth. reciprocally
and thus avoid undesirable reactionary forces. This phenomenon and a number
VolunLe 59 Renzovable orthodontic appliance 385
Number 4

of other aspects discussed in this article are illustrated in the case presented in
Figs. 16 and 17.
Hypertrophy and inflammation of the gingival tissues occasionally occur
when a removable appliance is used. These problems may be caused by in-
su.fficient stability of the appliance, sharp edges, extra sensitivity of the patient,
or other factors such as poor oral hygiene.
The indications for the use of a removable appliance as an adjunct to multi-
banded techniques have been described elsewhere and will not be repeated here.”

Some principles involved in the use of simple removable appliances are dis-
cussed. The reasons that removable plates are better suited for use in the upper
jaw are explained. The possibilities and limitations of removable appliances are
indicated. The component parts are discussed briefly. Some general remarks and
a case illustrating several aspects of the use of removable appliances conclude the
article.
REFERENCES
1. Adams, C. I’.: The design and construction of removable orthodontic appliances, ed. 4,
Bristol, 1970, John Wright & Sons, Ltd.
2. Booy, C.: De orthodontische behandeling van volwassenen, T. Tandheelk. 65: 295318, 1958.
3. Van der Linden, F. P. G. M.: The application of removable orthodontic appliances in
multiband techniques, Angle Orthodont. 39: 114-117, 1969.

“Heyendael”
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