European Journal of Orthodontics, 2017, 170–175

doi:10.1093/ejo/cjw026
Advance Access publication 30 March 2016

Original article

Downloaded from https://academic.oup.com/ejo/article/39/2/170/2629535 by Korea national university of transportation user on 22 September 2020
A comparison between indirect and objective
wear-time assessment of removable orthodontic
appliances
Timm C. Schott1, Hannes Meyer-Gutknecht2,5, Nicolai Mayer1,
Joachim Weber3 and Katja Weimer4
1
Department of Orthodontics and Orofacial Orthopedics, Eberhard Karls University, Tübingen, 2Department of
Orthodontics, University Hospital Aachen—RWTH, Aachen, 3Private Orthodontic Practice, Ludwigshafen and
4
Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany

Present address: Private Orthodontic Practice, Neuss, Germany.

5

Correspondence to: Timm Schott, Department of Orthodontics and Orofacial Orthopedics, Eberhard Karls University Tübin-
gen, Osianderstr. 2-8, 72076 Tübingen, Germany. E-mail: timm.schott@med.uni-tuebingen.de

Summary
Background/Objectives:  Patients do not always adhere to the wear times prescribed for removable
orthodontic appliances. We evaluated the validity and usability of indirect wear-time assessment
methods by comparing wear-time estimates with microelectronically measured wear times in
patients with removable orthodontic appliances.
Methods:  Wear times of 33 expansion plates, 34 functional appliances, and 42 retention plates of
patients aged 6–20 years (12.3 ± 2.9 years, 50.5% female) were indirectly determined by practitioners
using a questionnaire assessing five parameters on a 5-point Likert scale: appliance handling,
appliance appearance, bite shift, tooth movement, and appliance fit. The perceived difficulty in
assessing each parameter was rated. Actual wear times were evaluated with microelectronic
sensors in the appliances.
Results:  Regression analyses revealed that practitioners’ decisions about wear times varied
depending on the type of appliance and criteria used, with only one standard criterion best
predicting estimated wear time for each appliance. Different standard criteria were better
predictors of measured wear time: 22.3% of wear-time variability was explained by expansion
plate appearance, 31.2% by functional appliance handling, and 18.8% by retainer fitting. However,
practitioners rated the difficulty of assessment in most cases as ‘easy’.
Limitations:  The study was not double blinded for technical reasons, and practitioners may have
considered the evaluation criteria more carefully than in normal daily practice.
Conclusions:  Practitioners’ decisions about wear times based on standard criteria strongly vary
depending on the type of appliance and criteria used.

Introduction such as functional appliances and expansion and retention plates (1).
However, the therapeutic success of removable appliances is primar-
Removable, fixed, or a combination of both appliances can be used
ily dependent on adhering to the wear-time prescription provided by
for orthodontic treatment. A questionnaire study of 1538 German
the practitioner (2–6). The extent to which the length and regular-
patients in 2012 showed that 48% of orthodontic patients aged
ity of daily wear times influence the therapeutic progress of each
between 11 and 14  years were treated with removable appliances

© The Author 2016. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
170
For permissions, please email: journals.permissions@oup.com
T. C. Schott et al.
patient is largely unexplained. The usual daily wear-time prescrip-
tion is based on empirical data (7), and a patient following a daily
wear-time prescription in the range of 10–16 hours usually produces
favourable clinical outcomes. However, wear-time adherence of indi-
vidual patients is highly variable (8–10).
Provided that therapy progresses as expected, patient adherence
can be considered adequate. However, in cases of unsatisfactory
therapeutic progress or uncertainty over adherence, the regularity
and adequacy of appliance wear over the treatment period need to
be determined (11,12). The wear time of removable appliances has
traditionally been assessed by indirect methods by the practitioner
(13). A recent survey of 107 orthodontists showed that 96% of wear
behaviour was determined via interviews with patients and parents,
and indirect clinical parameters such as appliance fitting, bite shift,
tooth movements, and appliance appearance and handling were also
commonly used by 69–100% of practitioners (13). Practitioners gen-
erally regarded the clinical parameters as ‘very effective’ for evalu-
ating the wear time of removable appliances, whereas questioning
patients was deemed ‘less effective’ (13). In spite of this confidence
in current practice, the validity of indirect methods for determining
wear times has yet to be evaluated by comparison with objective
wear-time measurement methods. Newly developed microelectronic
wear-time sensors now provide the opportunity for objective evalua-
tion of wear time and are available in daily practice (14–16).
Here we examine, for the first time, the validity of different indi-
rect wear-time methods used by practitioners by comparison with
objectively measured wear times of removable orthodontic appli-
ances. Furthermore, we evaluated practitioner satisfaction with indi-
rect wear-time methods.
Subjects and methods
Data collection
This was a prospective study. Four orthodontists (two employed by
the University, and two in private practice) and five residents (four
working at a University Hospital, and one in a private practice)
collected data between February 2013 and March 2014. At the
time of data collection, the orthodontists had 24 months of clinical
practice experience and the residents had 3–6  months of experi-
ence (overall 11.0 ± 8.1  months) with the microelectronic system,
respectively.
Of 136 patients agreeing to take part in the study (themselves
or by parental agreement), data from 109 patients were available
for final analysis after application of inclusion and exclusion crite-
ria. Inclusion criteria were treatment with a removable orthodontic
appliance into which a TheraMon® sensor was completely embed-
ded; consent to use the sensor for wear-time recording; and appli-
ance application and first follow-up appointment during the study
period. A total of 33 (30.3%) patients were treated with expansion
plates, 34 (31.2%) with functional appliances, and 42 (38.5%) with
retention plates. Exclusion criteria were data outliners beyond 3 SD
from the respective mean resulting in patients older than 20  years
(n  =  1); time between onset and follow-up longer than 300  days
(n  =  2); microelectronic wear-time data unavailable for technical
reasons (n = 3); or incomplete questionnaire (n = 21).
Practitioners were instructed to complete a one-page question-
naire for each patient that met the eligibility criteria (see above) at
the first follow-up appointment after the beginning of treatment. The
questionnaire had two main components: practitioner assessment of
wear-time and patient-reported assessment of wear time; the objec-
tive wear time was only recorded after accrual of these data.
171
The first part of the questionnaire contained two questions on
each of five standard literature-based criteria (17–23): 1)  handling
of the removable appliance by the patient; 2) appliance appearance;
3)  bite shift; 4)  tooth movements; and 5)  fitting of the removable
appliance. The first question was how practitioners rate the wear
time based on the criterion on a 5-point Likert scale from ‘very
good’ to ‘very poor’, and the second question was how difficult it
was to rate the criterion on a 5-point Likert scale from ‘very easy’ to
Downloaded from https://academic.oup.com/ejo/article/39/2/170/2629535 by Korea national university of transportation user on 22 September 2020
‘very difficult’. For statistical analysis, rating scales were coded from
1 = ‘very good’ or ‘very easy’ to 5 = ‘very poor’ or ‘very difficult’.
Practitioners could also rate the wear time as ‘not assessable’.
The second part of the questionnaire asked for socio-demographic
data (age and sex) of participants and the type of orthodontic appli-
ance: an expansion plate, a functional appliance (bite-jumping appli-
ance and standard activator), or a retention plate (modified Hawley
retainer). Finally, practitioners were required to complete the follow-
ing mean wear times in hours per day: wear time prescribed at the
start of treatment, wear times estimated by the practitioner and by
the patient, and wear time objectively measured by a microelectronic
wear-time device.
For objective wear-time documentation, a TheraMon® microsen-
sor (Handelsagentur Gschladt, Hargelsberg, Austria) was completely
embedded in the same position of the base plate of all removable
appliances according to published procedures (24). The sensor meas-
ures 9 × 13 mm and records appliance wear at regular 15-min inter-
vals over 2  years by detecting surrounding temperature changes.
The sensor can detect temperature changes and, therefore, reliably
distinguish typical ‘wear-time’ temperatures (~35°C) from ‘non-
wear-time’ temperatures (room temperature) (25,26). Practitioners
activated and checked the sensor at the start of treatment and down-
loaded recorded data using an appropriate reading station at the
first follow-up appointment. For the purposes of comparative analy-
sis, the mean wear time over the recording period was regarded as
the objectively measured wear time. Practitioners were instructed to
download recorded wear-time measurement after filling in the ques-
tionnaire. Therefore, during completion of the questionnaire, neither
the practitioner nor the patient was aware of the actual wear-time
measured by the sensor.
The ethical review board of the University Hospital of Tübingen,
Germany (study no. 3392012B01) approved the study protocol. The
use of microsensors to determine the wear time of removable appli-
ances has become standard in some orthodontic practices in Germany.
All patients and practitioners gave consent to participate in the study.
Statistical analysis
Due to differences in treatment goals and significant group differences
in wear times, treatment duration, and patient age (see Table 1), data
were analysed separately for each group. Treatment group data were
not normally distributed (Kolmogorov–Smirnov test: all P  <  0.05)
except for objectively measured wear time. Therefore, the Kruskal–
Wallis rank correlation test was used to test for differences between
groups (reported as H), and Spearman’s rank correlation coefficients
(rho, rs) were calculated to test for correlations. Chi-squared tests
(Χ2) were used to test frequency distributions.
Multiple linear regression analyses were performed for predic-
tor analyses, with practitioner-estimated wear time and objectively
measured wear time as dependent variables, respectively, and the five
assessed criteria as predictors. To obtain the best predictive model,
predictors were only included in stepwise procedures if the bivariate
correlation between predictor and dependent variables was signifi-
cant. Stepwise procedures included predictors if their F probability
172 European Journal of Orthodontics, 2017, Vol. 39, No. 2

Table 1.  Descriptive statistics of patients and wear times of removable appliances. SD, standard deviation; WT, wear time in hours/day.

Plate (n = 33) Functional (n = 34) Retainer (n = 42)

Mean SD Mean SD Mean SD P-value

Age (years) 10.4 2.2 10.9 1.6 14.9 2.1 <0.001*,**

Treatment duration (days) 63.4 36.8 59.1 26.2 102.8 65.8 0.002*,**
WT prescribed (h) 15.1 0.9 15.2 0.5 13.4 2.7 0.044*,**

Downloaded from https://academic.oup.com/ejo/article/39/2/170/2629535 by Korea national university of transportation user on 22 September 2020
WT by practitioner (h) 11.6 2.7 11.0 3.5 9.4 3.4 0.006*,**
WT by patient (h) 12.0 3.0 12.2*** 3.6 10.1 3.8 0.002*,**
WT by sensor (h) 11.9 3.0 10.2 3.3 9.0 4.9 0.011*
ΔWT**** (h) -0.3 2.9 0.8 2.6 0.4 3.9 0.074

Value Value Value

ΔWT range (h) −6.0 to 6.9 −5.5 to 5.5 −5.5 to 13.0 —
Misvalued WT (n)***** 16 (49%) 14 (41%) 22 (52%) 0.620

*Significant post hoc test between expansion plate and retainer (Mann–Whitney U).
**Significant post hoc test between functional appliance and retainer (Mann–Whitney U).
***Significant post hoc test between WT reported by patient and WT measured (Wilcoxon Z).
****ΔWT, difference between WT assessed by practitioner and WT measured.
*****Amount and percentage of cases in which practitioners’ estimates of WT differed by over +/− 2 hours from the WT measured by the sensor.

was less than 0.05, and predictors were removed if their probability
was greater than 0.10 at each step, provided that no more predictors
met the criteria for inclusion or exclusion. Linear regression analysis
assumptions were checked and met (autoregression, collinearity, and
distribution of residual errors). Since missing values were randomly
distributed, pairwise exclusion of variables was employed to use as
much data as possible, resulting in slightly different sample sizes for
each pair of variables. For clarity, degrees of freedom (df), but not
each sample size, are reported.
Statistical analyses were performed with SPSS version 22.0 (IBM
Statistics, Chicago, Illinois, USA) and results were considered sig-
nificant if α  <  0.05 (two-tailed). Data are presented as means and
standard deviations (M ± SD) unless otherwise stated.
Results
Sample characteristics
Included patients (n  =  109) were aged between 6 and 20  years
(12.3 ± 2.9 years), and 50.5% were female. The prescribed mean wear
time for all treatments was 14.5 ± 1.9 hours per day compared to a
practitioner-estimated mean daily wear time of 10.6 (± 3.3) hours and
a patient-reported mean wear time of 11.3 (± 3.6) hours per day. The
mean objective daily wear time measured with the microelectronic
sensor was 10.2 (± 4.1) hours. The mean difference between wear
times assessed by practitioners and objectively measured wear time
was −0.3 (± 3.9) hours, with a wide range from −6.0 to 13.0 hours.
Overall, only 15 of the practitioners’ estimates (14%) corresponded
to the actual daily wear time, and 52 (47.7%) of the practitioners’
estimates differed from the actual wear time by over 2 hours. The
respective wear-time values for each patient group treated with differ-
ent removable orthodontic appliances are shown in Table 1. Due to
significant differences in patient age and wear times between groups,
data were analysed separately for each treatment group.
Wear-time assessment decisions
The associations between the four determined wear times (pre-
scribed, patient and practitioner estimated, and objective) and
standard criteria (by orthodontic appliance type) are shown in
Table 2 as Spearman’s rank correlation coefficients (rs). The stand-
ard daily wear time for the therapy prescribed at the beginning of
treatment was not associated with objectively measured wear time
for any orthodontic appliance (Figure  1) nor with any other wear
time assessed by the practitioner, reported by the patient, or objec-
tively measured with the sensor when expansion plates or functional
appliances were used (all P > 0.05). However, the initial wear-time
prescription was significantly correlated with the wear time assessed
by practitioners and reported by patients (rs = 0.460, P < 0.01 and
rs = 0.462, P < 0.01) when retainers were used. Patient-reported wear
time was also significantly correlated with the wear times assessed
by practitioners and objectively measured with the sensor for all
treatment groups (rs values between 0.553 and 0.777, all P < 0.05;
see Supplementary Table 2). Finally, wear times assessed by practi-
tioners were significantly correlated with objectively measured wear
times by the sensor independent of treatment (Figure  2). For all
orthodontic appliances, practitioner-assessed wear times were sig-
nificantly correlated with wear times evaluated based on handling,
tooth movements, and fitting (rs values between −0.332 and −0.672,
all P  <  0.05). Additionally, practitioner-assessed wear times were
correlated with wear times based on signs of use when expansion
plates were used (rs = −0.421, P < 0.05) and dental occlusion when
functional appliances were used (rs = −0.559, P < 0.01). Therefore,
practitioners appeared to take several of the standard criteria into
account when assessing orthodontic appliance wear times.
To test how much of the variance of wear-time assessment by
practitioners was explained by the use of standard criteria and
which standard criteria contributed most to practitioner-assessed
wear-time prediction, multiple linear regression analyses were con-
ducted using both simultaneous inclusion of predictors and step-
wise inclusion of related predictors (see Table  2 for significantly
related predictors). Standard criteria explained 50.1% and 38.1%
of practitioner-assessed wear-time variance for expansion plates
and functional appliances, respectively, but did not explain reten-
tion plate wear times. Stepwise regression revealed that, for each
appliance, only one standard criterion predicted wear time: 43.7%
of wear time was explained by tooth movements when expansion
plates were used, 37.4% by handling of functional appliances, and
14.2% by retainer fitting (see Supplementary Table  1 for detailed
results). Practitioners’ decisions about wear times based on stand-
ard criteria, therefore, strongly varied depending on the type of
appliance and criteria used.
T. C. Schott et al. 173

Table 2.  Correlations between the four determined wear times and standard criteria. WT = wear time.

WT by Dental Tooth
Appliance WT prescribed orthodontist WT by patient Handling Signs of use occlusion movements Fitting

Expansion WT by sensor — 0.417* 0.723*** −0.379* −0.528** — — —

plate WT prescribed — — — — — −0.430* —
WT by practitioner 0.553* −0.639*** −0.421* — −0.672*** −0.398*
WT by patient −0.406* −0.447* — — —

Downloaded from https://academic.oup.com/ejo/article/39/2/170/2629535 by Korea national university of transportation user on 22 September 2020
Functional WT by sensor — 0.692*** 0.691*** −0.465** — — −0.403* −0.504**
appliance WT prescribed — — — — — — —
WT by practitioner 0.777*** −0.613*** — −0.559** −0.434* −0.528**
WT by patient −0.503** — −0.351* — −0.375*
Retainer WT by sensor — 0.630*** 0.727*** −0.446** −0.348* — −0.411* −0.459**
WT prescribed 0.460** 0.462** 0.309* — — — —
WT by practitioner 0.743*** −0.332* — — −0.378* −0.490**
WT by patient — — — −0.370* −0.414**

Values reported are Spearman’s rank correlation coefficients rs; only significant correlations above the diagonal are displayed.
*P < 0.05, **P < 0.01, ***P < 0.001.

Predictive validity of standard criteria for wear-time

Figure 1.  Wear time measured by sensor in respect to wear time prescribed.
Data are shown as mean hours per day. Separate regression lines are shown
for expansion plates (blue crosses and dashed line), functional appliances
(green triangles and dotted line), and retainers (black circles and solid line;
R2 = 0.002, 0.009, and 0.063, respectively; all P > 0.05).
assessment
To examine how much of the objectively measured wear-time vari-
ance was predicted by standard clinical criteria, simultaneous and
stepwise multiple linear regression analyses were performed as
above. For expansion plate treatments, significantly correlated
standard criteria explained 19.9% of objective wear-time variance.
Stepwise inclusion of variables revealed that signs of use only pre-
dicted 22.3% of the objective variance; no other predictors contrib-
uted. For functional appliance treatments, related standard criteria
predicted 29.1% of the objective wear-time variance, whereas only
handling was included in the stepwise procedure, which explained
31.2% of the variance. For retainer treatments, related standard
criteria did not explain any of the variance, but stepwise inclusion
revealed that only fitting explained 18.8% of the objective wear-
time variance. Therefore, standard orthodontic criteria for wear-time
assessment predict between 20% and 31% of objective wear times,
depending on orthodontic appliance.
Difficulties in clinical wear-time assessment
Practitioners rated wear times as ‘not assessable’ by dental occlu-
sion in 50 (45.9%) patients, particularly in those wearing expansion
plates or retainers compared to functional appliances (in 22, 26, and
2 patients, respectively; Χ2  =  32.0, P  <  0.001). Furthermore, wear
time could not be assessed based on tooth movements in 20 (18.3%)
patients, independent of the orthodontic appliance type.
In all other cases, practitioners rated the difficulty of wear-time
assessment based on all criteria as ‘easy’ (median = 2.0). Wear time
was more difficult to rate based on tooth movements only when
patients wore functional appliances rather than expansion plates
and retainers (mean ranks of 56.4, 40.3, and 36.1, respectively;
H = 12.3, P = 0.002; see Supplementary Table 2 for detailed results).

Figure 2.  Wear time measured by sensor in respect to wear time assessed
by orthodontist. Data are shown as mean hours per day. Separate regression
lines are shown for expansion plates (blue crosses and dashed line),
functional appliances (green triangles and dotted line), and retainers (black
circles and solid line; R2 = 0.252, 0.502, and 0.367, respectively, all P < 0.05).
Discussion
This study aimed to investigate the validity and usability of the indi-
rect standard criteria used by practitioners during the active thera-
peutic phase and the early retention phase to assess the wear times
of removable orthodontic appliances in daily practice. During this
part of therapy, patients tend to be below the age of 10 years: older
patients are often already in a long retention period and therefore
were not included in the study. Furthermore, removable appliances
174
are often used in children with mixed dentition, so this group of
young patients seemed particularly important to study.
We confirmed a number of recent results demonstrating that most
patients do not adhere to empirically derived standard wear-time
prescriptions for removable orthodontic appliances (4,6,23,26–32).
For example, preliminary microelectronic wear-time measurements
of intraoral appliances showed that patients only fulfilled approxi-
mately 50–60% of the wear time prescribed (33). The quantitative
assessment of headgear compliance shows that the mean actual
hours of daily wear relative to the practitioners’ requirement was
about 57% (5). Meaningful differences of reported time of headgear
(8) or removable appliances (34,35) use with electronically meas-
ured actual usage was also reported. Since there were medium to
high correlations between the most commonly used indirect wear-
time assessment parameters and the overall estimated wear time,
practitioners seem to consider these criteria when assessing wear
times. Stepwise regression analyses, however, showed that only one
particular parameter was predictive of wear time depending on the
appliance used, with the other parameters not adding benefit.
The patients were told during consent process that estimated wear
times be compared to objective, microelectronically measured wear
times. Patients may therefore have estimated their wear times more
carefully. Furthermore, clinicians might have gradually would have
become more aware of the discrepancy between patient-reported
and microsensor recorded time during the study, thereby estimat-
ing wear times better and introducing a potential bias. The valid-
ity of wear-time estimation by the practitioner, therefore, crucially
depended on the correct choice of parameter used in indirect assess-
ment of the appliance wear time. Additionally, the high variability
of mismatched wear times assessed by practitioners compared to
objectively measured wear times ranged between −6 and +13 hours
mirroring the difficulty in assessing wear times by indirect methods.
Practitioners’ estimates of real wear times differed by over 2 hours
in nearly half of the cases (47.7%) assessed. Due to the significant
high correlation with measured wear times but no correlation with
prescribed wear times, we assume that patients tend to report their
wear times accurately but might be more dishonest in daily practice.
Although a double-blind study protocol is generally considered a
superior clinical study design, such an approach would have been dif-
ficult to execute: both the practitioner and patient can easily see the
embedded microsensor, and the patient would need to be informed of
microelectronic measurements as an ethical consideration. However, we
do not believe that practitioner and patient awareness of microelectronic
monitoring limited this study, since the main aim was to evaluate asso-
ciations between subjectively estimated and experimentally measured
wear times of removable appliances; we did not attempt to evaluate
parameters that might influence practitioner and patient estimations,
which would specifically demand a double-blind study protocol. Since
everyone knew that their estimates would be remeasured electronically,
participants may have, in fact, estimated wear times particularly care-
fully; therefore, a double-blind study would be expected to produce
similar or worse correlations between estimated and measured values.
The results of our study may be surprising to practitioners, who
have probably not questioned the validity of standard indirect wear-
time evaluation methods and who rated them as relatively ‘easy’ to
implement. However, practitioners may have considered the evalua-
tion criteria more carefully than in daily practice due to the lack of
blinding and the use of a structured questionnaire.
The study results confirm that there are two major problems chal-
lenging successful orthodontic treatment with removable appliances:
1) patients do not adhere to prescribed wear times, and 2) indirect
European Journal of Orthodontics, 2017, Vol. 39, No. 2
wear-time assessment via patient interviews and the commonly used
standard criteria can be insufficient for accurate assessment. Future
studies will need to investigate how microelectronic wear-time sensors
can be used to objectively monitor orthodontic treatments by default
and enhance patient adherence. Practitioner-assessed wear time based
on clinical parameters did not markedly differ from patient-estimated
wear times. Due to the wide distribution of wear times, we speculate
that a single standard wear-time prescription applied to all patients
Downloaded from https://academic.oup.com/ejo/article/39/2/170/2629535 by Korea national university of transportation user on 22 September 2020
does not adequately capture individual patient situations. By using
an objective wear-time documentation, previous discussions between
patient and practitioner about an assumed insufficient adherence can
be avoided from the outset. Objective and reliable wear-time meas-
urement might allow practitioners and patients to agree on feasible
but necessary wear times. Furthermore, practitioners can provide
feedback about treatment success based on real wear times rather
than on (maybe falsely) reported wear times. Finally, most patients
with long wear-time prescriptions were non-adherent (36,37).
Conclusion
The decisions about adherence based on the normally used indirect
standard parameter strongly vary depending on the type of appli-
ance and criteria used. This indirect wear-time evaluation in the past
cannot be longer recommended as a reliable determination of wear
time in respect to the new objective microelectronically wear-time
documentation.
In cases of unsatisfactory therapeutic progress or uncertainty
over adherence, objective documentation of wear time and behav-
iour may make it easier to determine how adherence to wear-time
prescription affects treatment progress. Practitioners can individual-
ize wear times over the course of treatment at routine appointments
based on the individual therapeutic progress and objectively meas-
ured wear times, which has hitherto not been possible with standard
indirect wear-time detection methods.
Supplementary material
Supplementary material is available at European Journal of
Orthodontics online.
Acknowledgements
The authors would like to thank the residents at University of Tübingen,
Germany and Dres. Sarah Schrey and Fabian Liebegall for their assistance
with data collection.
References
1. Krey, K.F. and Hirsch, C. (2012) Frequency of orthodontic treatment in
German children and adolescents: influence of age, gender, and socio-eco-
nomic status. European Journal of Orthodontics, 34, 152–157.
2. Allan, T.K. and Hodgson, E.W. (1968) The use of personality measure-
ments as a determinant of patient cooperation in an orthodontic practice.
American Journal of Orthodontics, 54, 433–440.
3. Bartsch, A., Witt, E., Sahm, G. and Schneider, S. (1993) Correlates of
objective patient compliance with removable appliance wear. American
Journal of Orthodontics and Dentofacial Orthopedics, 104, 378–386.
4. Bos, A., Kleverlaan, C.J., Hoogstraten, J., Prahl-Andersen, B. and Kuitert,
R. (2007) Comparing subjective and objective measures of headgear com-
pliance. American Journal of Orthodontics and Dentofacial Orthopedics,
132, 801–805.
5. Brandao, M., Pinho, H.S. and Urias, D. (2006) Clinical and quantitative
assessment of headgear compliance: a pilot study. American Journal of
Orthodontics and Dentofacial Orthopedics, 129, 239–244.
T. C. Schott et al.
6. Casutt, C., Pancherz, H., Gawora, M. and Ruf, S. (2007) Success rate and
efficiency of activator treatment. European Journal of Orthodontics, 29,
614–621.
7. Witt, E., Bartsch, D.-P.A. and Sahm, G. (1992) Tragezeitverordnungen
bei herausnehmbaren Geräten-Ergebnisse einer Umfrage. Fortschritte der
Kieferorthopädie, 53, 124–130.
8. Cole, W.A. (2002) Accuracy of patient reporting as an indication of head-
gear compliance. American Journal of Orthodontics and Dentofacial
Orthopedics, 121, 419–423.
9. Cureton, S.L., Regennitter, F.J. and Yancey, J.M. (1993) Clinical versus
quantitative assessment of headgear compliance. American Journal of
Orthodontics and Dentofacial Orthopedics, 104, 277–284.
10. Schott, T.C. and Ludwig, B. (2014) Microelectronic wear-time documenta-
tion of removable orthodontic devices detects heterogeneous wear behav-
ior and individualizes treatment planning. American Journal of Orthodon-
tics and Dentofacial Orthopedics, 146, 155–160.
11. Bos, A., Hoogstraten, J. and Prahl-Andersen, B. (2005) Towards a com-
prehensive model for the study of compliance in orthodontics. European
Journal of Orthodontics, 27, 296–301.
12. Haynes, R.B. and Sackett, D.L. (1979) Compliance in Health Care. Johns
Hopkins University Press, Baltimore, MD.
13. Meyer-Gutknecht, H., Fritz, U. and Schott, T.C. (2014) Methods to evalu-
ate compliance of patients with removable appliances-survey results. Jour-
nal of Orofacial Orthopedics, 75, 144–153.
14. Schott, T.C. and Göz, G. (2010) Applicative characteristics of new micro-
electronic sensors Smart Retainer® and TheraMon® for measuring wear
time. Journal of Orofacial Orthopedics, 71, 339–347.
15. Schott, T.C. and Göz, G. (2011) Wearing times of orthodontic devices as
measured by the TheraMon® microsensor. Journal of Orofacial Orthope-
dics, 72, 103–110.
16. Schott, T.C., Ludwig, B., Glasl, B.A. and Lisson, J.A. (2011) A microsensor
for monitoring removable-appliance wear. Journal of Clinical Orthodon-
tics, 45, 518–520; quiz 516.
17. Heinen, M., Kahl-Nieke, B., Pies, S., Hegmann, M. and Schwarze, C.W.
(1994) Retroskoptive Akzeptanzprüfung herausnehmbarer Geräte.
Fortschritte der Kieferorthopädie, 55, 290–296.
18. Hotz, R. (1955) Die funktionelle Beurteilung der Bißlage als Ausgang-
spunkt für die Prognose und die Begrenzung des Behandlungszieles.
Forschritte der Kieferorthopädie, 16, 255–262.
19. Mühlemann, H.R. (1951) Die physiologische und pathologische Zahnbe-
weglichkeit. Medizinische Habilitation. Schweizerische Monatsschrift für
Zahnheilkunde, Zürich, Switzerland, Vol. 61.
20. Schopf, P. (2008) Kieferorthopädische Apparatsysteme (Teil 1). In Schopf,
P. (ed.), Curriculum Kieferorthopädie. Quintessenz-Verlag, Berlin, Ger-
many, Vol. 1, pp. 297–438.
21. Schulze, C. (1978) Allgemeine Gesichtspunkte kieferorthopädischer Ther-
apie und das Ziel der Behandlung. In Schulze, C. (ed.), Lehrbuch der Kief-
erorthopädie. Quintessenz-Verlag, Berlin, Germany, Vol. 2, pp. 27–34.
22. Slakter, M.J., Albino, J.E., Fox, R.N. and Lewis, E.A. (1980) Reliability
and stability of the orthodontic Patient Cooperation Scale. American Jour-
nal of Orthodontics and Dentofacial Orthopedics, 78, 559–563.
175
23. Tervonen, M.M., Pirttiniemi, P. and Lahti, S. (2011) Development of a
measure for orthodontists to evaluate patient compliance. American Jour-
nal of Orthodontics and Dentofacial Orthopedics, 139, 791–796.
24. Schott, T.C. (2011) Einbau eines Mikrosensors in herausnehmbare kiefer-
orthopädische Geräte. Quintessenz Zahntechnik, 37, 898–904.
25. Schott, T.C. and Göz, G. (2010) Young patients’ attitudes toward remov-
able appliance wear times, wear-time instructions and electronic wear-
time measurements - results of a questionnaire study. Journal of Orofacial
Downloaded from https://academic.oup.com/ejo/article/39/2/170/2629535 by Korea national university of transportation user on 22 September 2020
Orthopedics, 71, 108–116.
26. Schott, T.C. and Ludwig, B. (2014) Quantification of wear-time adher-
ence of removable appliances in young orthodontic patients in relation
to their BMI: a preliminary study. Patient Preference and Adherence, 8,
1587–1595.
27. Hyun, P., Preston, C.B., Al-Jewair, T.S., Park-Hyun, E. and Tabbaa, S.
(2015) Patient compliance with Hawley retainers fitted with the SMART®
sensor: a prospective clinical pilot study. The Angle Orthodontist, 85,
263–269.
28. Kacer, K.A., Valiathan, M., Narendran, S. and Hans, M.G. (2010) Retainer
wear and compliance in the first 2  years after active orthodontic treat-
ment. American Journal of Orthodontics and Dentofacial Orthopedics,
138, 592–598.
29. Kawala, B., Antoszewska, J., Sarul, M. and Kozanecka, A. (2013) Applica-
tion of microsensors to measure real wear time of removable orthodontic
appliances. Journal of Stomatology, 66, 321–330.
30. Pratt, M.C., Kluemper, G.T. and Lindstrom, A.F. (2011) Patient compli-
ance with orthodontic retainers in the postretention phase. American Jour-
nal of Orthodontics and Dentofacial Orthopedics, 140, 196–201.
31. Schott, T.C., Fritz, U. and Meyer-Gutknecht, H. (2014) Maxillary expan-
sion therapy with plates featuring a transverse screw: implications of
patient compliance with wear-time and screw activation requirements.
Journal of Orofacial Orthopedics, 75, 107–117.
32. Tsomos, G., Ludwig, B., Grossen, J., Pazera, P. and Gkantidis, N. (2014) Objec-
tive assessment of patient compliance with removable orthodontic appliances:
a cross-sectional cohort study. The Angle Orthodontist, 84, 56–61.
33. Sahm, G., Bartsch, A. and Witt, E. (1990) Micro-electronic monitoring of
functional appliance wear. European Journal of Orthodontics, 12, 297–
301.
34. Ackerman, M.B. and Thornton, B. (2011) Posttreatment compliance with
removable maxillary retention in a teenage population: a short-term rand-
omized clinical trial. Orthodontics (Chic), 12, 22–27.
35. Pauls, A., Nienkemper, M., Panayotidis, A., Wilmes, B. and Drescher, D.
(2013) Effects of wear time recording on the patient’s compliance. The
Angle Orthodontist, 83, 1002–1008.
36. Schäfer, K., Ludwig, B., Meyer-Gutknecht, H. and Schott, T.C. (2015)
Quantifying patient adherence during active orthodontic treatment with
removable appliances using microelectronic wear-time documentation.
European Journal of Orthodontics, 37, 73–80.
37. Schott, T.C., Schlipf, C., Glasl, B., Schwarzer, C.L., Weber, J. and Ludwig,
B. (2013) Quantification of patient compliance with Hawley retainers and
removable functional appliances during the retention phase. American
Journal of Orthodontics and Dentofacial Orthopedics, 144, 533–540.