Follow-Up Problems with
Fixed Appliances in Pediatric Dentistry
Timucin Ari, D.D.S., Ph.D.
ABSTRACT
Fixed appliances are commonly used in managing
early orthodontic problems. Despite their widespread
use, they have the potential to impinge on the soft
tissues, interfere with the eruption of adjacent teeth
and become dislodged or broken. These two case re­
ports present the poor outcomes of fixed appliance
treatments if the patient fails to attend follow-up ap­
pointments. A successful outcome of treatment with
fixed appliances depends upon proper patient selec­
tion and the communication skills of the dentist to
help patients/parents understand the importance of
regular checkups.
Guidance of eruption and development during the primary and
mixed dentition stage contributes to a stable, functional and es-
thetically acceptable occlusion in permanent dentition . 1' 3 Beyond
their involvement in esthetics, eating and speech, primary teeth
play an important role in growth and development until perma­
nent successors erupt .4,5 The premature loss of primary teeth may
lead to undesirable consequences, such as loss of arch length and
16 M A R C H 2 0 1 5 • The New York State Dental Journal
crowding due to the drifting of adjacent teeth .3,5' 7 This in turn
may compromise the eruption of succedaneous teeth, which, it
has been suggested, is a main cause of malocclusion.8' 11
An effective approach to limiting the negative effects of premature
loss of primary teeth is the use of space maintainers.4,8,12-14 Both fixed
and removable space maintainer designs can be employed, depend­
ing upon clinical situations. But the most common space maintainer
used in pediatric dentistry is the fixed band and loop space maintain­
er.14,15 This design requires little chair time and is less dependent upon
patient cooperation than removable appliances.4,6,15
Another scenario that has been shown to affect dentofacial
growth and development in children is non-nutritive sucking. 16,17
Thumb sucking, finger sucking and pacifier use are considered
forms of non-nutritive sucking that may result in development of
an anterior open bite . 16,17
just like space problems, correction of a thumb-sucking habit
can be managed by both removable and fixed appliances. Since
removable appliances have not been found to be effective in pro­
ducing significant changes, fixed appliances are usually preferred,
due to better patient cooperation . 18"20 Among fixed appliances,
the fixed thumb crib appliance has been shown to be an effective
device in stopping thumb sucking.21
Although fixed appliances are commonly used effectively in
both of the clinical situations described, they have the potential
to impinge on soft tissues, interfere with the eruption of adjacent
teeth, become dislodged or broken, and may place patients at a
greater risk of caries and gingival inflammation due to their high
, /

plaque retention.2'6,12,14'22’23 Therefore, proper patient selection

that takes into consideration the level of oral hygiene, the caries
risk and the dental attendance pattern should be weighed before
the decision is made to place a fixed appliance.4,24

Case Report One Figure 1. Frontal view of patient.

A healthy 12-year-old female patient presented as a returning pa­
tient for a routine checkup to a pediatric dental clinic within a
university teaching hospital. Her mother was concerned about the
spacing of her anterior teeth and wanted to know whether she
needed orthodontic treatment to improve the aesthetics (Figure 1).
Clinical extraoral examination of the patient presented sym­
metrical facial proportion with competent lip closure. The tem­
poromandibular joint function was within normal limits, with
no tenderness on palpation of either side. Intraoral examination
revealed healthy soft tissues and no signs of caries. The patient
was in the early permanent dentition stage, with missing upper
lateral incisors and the upper left second premolar. She exhibited
a Class II malocclusion on right and left sides, and the lower mid­
Figure 2. Over-retained band and loop from # 3 0 to # 2 8 .
line was 3 mm left of upper midline.
Further intraoral examination revealed two band and loop
space maintainers, the first spanning tooth #30 to tooth #28 (Fig­
ure 2) and the second from tooth #16 to tooth #14 (Figure 3). The
loop of the lower band and loop space maintainer had pushed the
mandibular right first premolar mesially and caused the crowding
and midline shift in the anterior region. The maxillary left first
premolar was rotated and tilted distally due to the retained space
maintainer, with the loop now sitting on its occlusal surface. Spac­
ing was present in the upper anterior region, with 2 mm overjet
and 50% overbite. Radiographic examination revealed congenitally
missing upper lateral incisors (#7 and #10) and impaction of the
upper left second premolar (#13) (Figure 4).
Review of her previous records revealed that band and loop Figure 3. Over-retained space m aintainer sitting on occlusal surface of # 1 2 .
space maintainers had been placed 26 months ago and that de­
spite receiving follow-up appointment reminders, she had never
attended since that time, resulting in the over-retained space
maintainers impacting significantly on her erupting dentition.
The band and loop space maintainers were removed, and the pa­
tient was scheduled for follow-up appointments to address her
orthodontic needs (Figure 5).

Case Report Two

A healthy 10-year-old female patient attended a pediatric dental
clinic within a university teaching hospital complaining of pain
from her gums. Extraoral examination revealed a convex profile
with incompetent lip closure. The temporomandibular joint func­
tion was within normal limits, with no functional shift during Figure 4. Panorex view of patient.

The New York State Dental Journal • M A R C H 2 0 1 5 17


Figure 5. R em oval o f bond and loops.
Figure 6. A n te rio r open b ite .
Figure 8. R em oval o f a p plian ce.
18 IV IA R C H 2 0 1 5 • The New York State Dental Journal
opening. Intraoral examination indicated late mixed dentition
stage with Class II molar relationship on both sides. An anterior
open-bite was observed; and her clinical records indicated that
a fixed thumb crib appliance had been placed 10 months earlier
to stop a thumb-sucking habit. Despite being informed of the
importance of regular follow-up and several appointments being
scheduled, the family had not attended any appointments since
that date. The mother reported disappointment that the thum b­
sucking habit had continued during that time.
On clinical examination, gingival trauma and inflammation
were noted on the anterior area of the palatal mucosa, which was
directly attributed to impingement of the crib appliance in this
area (Figure 7). Therefore, the crib appliance was removed. An
alternative strategy without appliance therapy was implemented
using a psychological approach and positive reinforcement. A
contingency contract was made between the child and her par­
ents, simply stating that the child should be rewarded and praised
for not sucking her thumb for a specific time (Figure 8).
D iscussion
Fixed space maintainers are commonly used in children because
of their benefit in eliminating compliance problems. The success
rate of various different designs of fixed appliances can vary from
27% to 91.5%.s,i2,22,24,26-31 Regardiess 0f the design chosen, this
doesn’t eliminate the need for regular follow-up. With fixed ap­
pliances, vigilance is critical. This allows the practitioner to assess
the integrity of the space maintainer and to ensure removal of
the appliance in coordination with eruption of the permanent
successor.12,22,24,26,29
A primary tooth is the ideal space maintainer; this is why
every effort should be made to preserve arch length in both the
primary and mixed dentition. If early loss of a primary tooth is
unavoidable, and nothing is done to preserve the space, the per­
manent first molars usually move mesially into this space and
eventually a decrease in arch length is observed.4,9,10,25
In case one, following the early extraction of the primary mo­
lars, fixed space maintainers were placed to control arch length
and to prevent potential orthodontic problems.1,3,6,14 According
to the patient’s chart, the parents were told of the importance
of regular checkups for both space maintainers and congenital­
ly missing lateral incisors. Despite this explanation, the patient
failed to attend any recall appointments until such a time that the
mother became concerned about her daughter’s esthetic prob­
lems. Unfortunately, the consequence of their non-adherence to
the review schedule resulted in the appliance exacerbating her
previous orthodontic problem, resulting in impaction of tooth
#13 and increased crowding in the mandibular anterior region.
In the second case, a fixed thumb crib appliance was placed
to control a thumb-sucking habit. The incidence of soft-tissue
lesions resulting from impingement of fixed appliances has been
Buying or
reported to be as high as 11%.22'24 Clinical records indicated there
was no problem with the fit of the appliance and that, again,
the parents were informed about care and follow-up regarding
Selling a
the maintenance of the appliance. Non-adherence to the post
placement review regime resulted in failure of the appliance, most
likely due to biting forces in the anterior region or continued ex­
Practice?
cessive thumb sucking by the patient. The appliance consequently
dislodged superiorly and impinged on the mucosa. This could
have been prevented by simple adjustment or by changing to a
psychological approach far earlier during regular visits.
We've got
A successful outcome of treatment with fixed appliances de­
pends upon the parents/caregivers and patients understanding and
you covered.
complying with advice given related to oral hygiene, device mainte­
nance and commitment to periodical review appointments. Failure * Mount
Kisco
Ringwood • Ossining
to adhere to any of these components may result in a poor outcome • Tarrytown S ta m fo r d
Bloomingdale «
and potential problems, as illustrated by these two case reports. Pompton Lakes Plains Greenwich
Yonkers • R',e
Such problems include damage to oral structures, increased dura­ Rockaway P a te rs o n
•H a c k e n s a c k " . . N e w R o c h e lle
Wharton C lift o n # • M ount
tion of treatment or worsening of a malocclusion. Morristown * V e rn o n • Glen Cove Selden
Mendham* E a s t . J e r s e y . U n io n c i t y • Pod W a s s o n ___ •Commack *
Deer M e d fo rd
The practitioner must always keep in mind the parents’ level . Madison O ra n g e . A M.neola, Jencho Parit . Brentwood
Bernardsvilie ., « . « « • N e w a rk W N e W Y o r k H e m p s te a d . .BayShore
of understanding regarding the risks involved in placing fixed West
P la in f ie ld . E liz a b e t h B a y o n n e • B r o o k ly n
Somerville
appliances in children. Dentists should take care that they use Middlesex
effective communication methods and choose language appro­ . P e r th A m b o y
• N e w B r u n s w ic k
Milltown .
priate to the literacy levels of the parents32 in order to explain , • Spotswood
U n io n
B each • Highlands
•Jamesburg
the importance of regular review. The use of techniques such as
Lincroft
• Hightstown • L o n g B ra n c h
motivational interviewing could also encourage better adherence •T r e n to n Freehold .Asbury Park
•Neptune City
to dental attendance regimens to minimize the potential risks to U » Belmar
Hornerstown
•Manasquan
oral health from over-retained appliances. A M ount Lakew ood Point Pleasant
H o lly
B ro w n s Mantoloking
M i lls T o rh s
• Seaside Heights
Queries about this article can be sent to Dr. Ari at timucin.ari@schulich.uwo.ca.

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