ORIGINAL ARTICLE

A comparison of children’s experiences

with fixed and removable functional
appliances: A qualitative study
Ohsun Kwon,a Easter Joury,b Fiorella Colonio-Salazar,c Moaiyad Moussa-Pacha,a and Ama Johala
London, United Kingdom

Introduction: The objective of this study was to compare children’s experiences and perceptions of treatment
with Hanks-Herbst (HH) and modified Twin-block (MTB) functional appliances. Methods: A pragmatic nested
qualitative study was undertaken in a single hospital setting. Participants from a randomized controlled trial (In-
ternational Standard Randomised Controlled Trial Number 11717011) wearing HH and/or MTB appliances were
interviewed using a topic guide in a one-to-one, semistructured format. Interviews were recorded and transcribed
verbatim for framework methodology analysis until data saturation was reached. Results: Eighteen participants
(HH, 7: MTB, 4; switched group, 7) were interviewed. Thirteen codes were constructed and grouped into 3
themes: (1) functional impairment and symptoms, (2) psychosocial factors and impacts, and (3) feedback on ap-
pliances and patient care. Both appliances had a negative impact on quality of life, with disruption to children’s
daily routines and psychological well-being. Speaking was more problematic for MTB participants, whereas HH
participants encountered mastication and breakage issues. HH was preferred by most participants, as its
nonremovable feature meant less managing and self-discipline was required. MTB was considered a suitable
option for children with good self-discipline and who preferred a versatile lifestyle. Feedback included wishes
for the availability of multiple appliance options and a degree of autonomy in decision-making processes.
Conclusions: HH and MTB can negatively affect children’s quality of life. Participants preferred HH over
MTB because of its nonremovable feature, and children requested to be empowered during decision-making
processes. (Am J Orthod Dentofacial Orthop 2023;164:423-30)

F
ixed and removable functional appliances are
well-established treatment modalities for children
with Class II malocclusion,1 demonstrating effec-
tiveness in overjet reduction, lowering the risk of dental
trauma,2 and improving psychological well-being in the
short-term.3 Despite these clinical benefits, findings
from patient questionnaire studies indicate that both
appliance types have a marked negative impact on the
a
Centre for Oral Bioengineering, Institute of Dentistry, Queen Mary University of
London, London, United Kingdom.
b
Centre for Dental Public Health and Primary Care, Institute of Dentistry, Queen
Mary University of London, London, United Kingdom.
c
National Audit Office, London, United Kingdom.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Funding has been provided by Queen Mary University of London.
Address correspondence to: Ama Johal, Centre for Oral Bioengineering, Institute
of Dentistry, Queen Mary University of London, The Royal London Dental Hos-
pital, Turner St, London E1 2AD, United Kingdom; e-mail, a.s.johal@qmul.ac.
uk.
Submitted, October 2022; revised and accepted, February 2023.
0889-5406
Crown Copyright Ó 2023. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.ajodo.2023.02.015
child’s quality of life (QOL)4 during treatment, including
problems with discomfort,5,6 difficulties with speech,6-8
mastication,5,6 disruption of sleep,8,9 dissatisfaction
with self-image,10,11 and lower psychological well-
being.8,12
Modern health care has shifted from a traditional,
paternalistic style to a patient-centered care model,13
with a greater emphasis on understanding patient expe-
riences and shared decision-making. It was suggested
that qualitative methodology, including face-to-face in-
terviews and focus groups, can help gain detailed infor-
mation about patients’ perceptions rather than those
relevant to clinician-centered outcomes.14
In current literature, information on the impact of
removable functional appliances on oral health–related
quality of life and factors influencing patients’ adapta-
tion or adherence is limited to removable designs.15-19
In contrast, fixed functional appliances require
fundamentally different patient management
regarding wear regime, oral functions, hygiene and
appliance precautions. Therefore, the present study
uniquely aimed to explore and compare children’s
experiences with fixed and removable functional
423
424
HH appliance
x Stainless steel (SS) Rollo bands on
first permanent molars with buccally-
positioned threaded attachments
x SS lingual arch (mandible),
transpalatal arch or RPE (maxilla)
x Telescoping arms
Fig. Design features of HH and MTB appliances. HH, Hanks-Herbst; MTB, modified Twin-block.
appliances during treatment and understand the effect
of appliance design on children’s perceptions and their
QOL.
MATERIAL AND METHODS
A pragmatic qualitative study was nested in a ran-
domized controlled trial (RCT) at the Institute of
Dentistry. Ethical approval was acquired from North
West–Greater Manchester South Research Ethics Com-
mittee (reference no. 16/NW/0837). In this trial, children
aged 10-14 years with Class II Division 1 malocclusion
(overjet $7 mm) are allocated to either the Hanks-
Herbst (HH) or the modified Twin-block (MTB) appliance
(Fig). The exclusion criteria were: children with craniofa-
cial deformity or complicated medical conditions and
hyperdivergent facial type (MP/NSP .40 ). Further in-
formation on the trial design can be found on the Inter-
national Standard Randomised Controlled Trial Number
Web site (trial no. 11717011).
Treatment was provided by a single specialist ortho-
dontist (M.M.P.), with appointments scheduled at 6-8
September 2023  Vol 164  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Kwon et al
MTB appliance
x Acrylic maxillary and mandibular base
plates
x 0.7-mm SS Adams clasps on first
premolars and first permanent molars
x Midpalatal expansion screw
x 70° incline interlocking maxillary and
mandibular acrylic blocks
weeks intervals. Standard verbal and written instruc-
tions20 on appliance wear, hygiene and precautions
were given to all participants at the start of treatment.
Participants in the MTB group were instructed to wear
the appliance full-time, except during eating and con-
tact sports. Participants in the MTB group who failed
their treatment were offered the HH appliance as an
alternative option (switched group); no participants in
this trial were required to switch in the opposite direction
(ie, from HH to MTB).
Participants from all 3 groups (HH, MTB, switched)
were invited to participate in the semistructured inter-
view during their appointment or via telephone. Partic-
ipants were also given information leaflets and
additional time before declaring their interest and con-
sent for the study.
Face-to-face interviews were undertaken by 2 re-
searchers, 1 experienced in qualitative research (F.C.S.)
and another (O.K.) who had undertaken appropriate
training. The interviews took place in a separate quiet
room, within the Institute of Dentistry, except for 2
Kwon et al 425

Table I. List of interview participants Table II. Distribution of interview participants by

appliance group and stage of treatment
Appliance
Participant Age Gender group Treatment stage Treatment stage
1 12 y 11 mo Female MTB Functional $7
mo Appliance Functional Functional
2 13 y 11 mo Male HH Functional $7 group 1-6 mo $7 mo Postfunctional Total
mo HH 2 3 2 7
3 12 y 6 mo Male HH Functional $7 MTB 2 2 4
mo Switched 1 6 7
4 13 y 0 mo Male HH Functional 1-6
mo HH, Hanks-Herbst; MTB, modified Twin-block.
5 14 y 11 mo Male HH Postfunctional
6 14 y 6 mo Male MTB Functional $7
mo Data analysis
7 12 y 9 mo Male MTB Functional 1-6
mo Framework methodology21 was used to analyze the
8 13 y 3 mo Male HH Functional 1-6 qualitative data, which involved (1) familiarizing with
mo the contents of interview transcripts; (2) labeling topics
9 12 y 5 mo Male HH Functional $7
mo
identified from each interview as codes; (3) grouping co-
10 15 y 3 mo Male MTB Functional 1-6 des sharing similar characteristics into themes; (4) con-
mo struction of a framework table, with columns of codes
11 17 y 5 mo Male HH Postfunctional and themes, and rows of participants; and (5) mapping
12 16 y 3 mo Female Switched Postfunctional data from each interview into the framework. As data
13 14 y 11 mo Female Switched Postfunctional
14 16 y 6 mo Male Switched Postfunctional
analysis is influenced by researchers’ knowledge and in-
15 13 y 10 mo Male Switched Functional $7 terests, a triangulation technique22 was used to mini-
mo mize interpretation bias; the interview transcripts were
16 18 y 1 mo Female Switched Postfunctional inspected independently by 2 researchers (O.K. and
17 17 y 0 mo Female Switched Postfunctional E.J.), and any disagreement was required to be resolved
18 17 y 1 mo Male Switched Postfunctional
by discussion and consensus.
participants, who were interviewed virtually (Teams; Mi- The number of participants required for this study
crosoft, Redmond, Wash) because of coronavirus disease was determined by data saturation, when no new infor-
(COVID-19) lockdown restrictions. mation was heard or seen in at least 3 successive inter-
A topic guide was developed by 2 researchers (F.C.S. views.23 A purposive sampling matrix table was used to
and A.J.) on the basis of findings from previous similar ensure a varied mixture of participants were recruited,
studies and contained open-ended questions related to categorizing participants by their appliance group and
the impact of treatment on QOL, including (1) the stage of treatment (1-6 months, $7 months, postfunc-
impact of functional issues and symptoms experienced, tional).
(2) self-esteem and psychosocial impact, and (3) sugges-
tions for improving treatment. At the same time, partic- RESULTS
ipants were given the flexibility to discuss any other Eighteen participants (13 males) in the RCT were
matters relevant to their treatment and not covered in invited, and all agreed to participate in the study
the topic guide. The topic guide was regularly refined (mean age, 14.8 6 1.8 years). Data saturation was
between interviews to enable researchers to continually reached after interviewing the 14th participant, and
add new data, avoid repetition and inquire further on Tables I and II show the distribution of the participants
topics discussed in prior interviews. by appliance group and stage of treatment. Thirteen co-
A digital voice recorder (WS-831; Olympus Corpora- des (A1-4, B1-4, and C1-5) were constructed and group-
tion, Tokyo, Japan) was used to record the interviews ed under 3 themes (Table III).
without including personally identifiable information. Both groups of participants discussed functional
The recorded files were sent to an external company problems and symptoms, including speech and mastica-
(Essential Secretary Ltd, Reynalton, UK) for verbatim tion issues, discomfort, ulceration, hypersalivation and
transcription. Researchers also used a notepad to take xerostomia. Mastication issues were most frequently dis-
field notes and record observations, which would not cussed by participants wearing HH, such as restricted jaw
be captured on the recorder, such as participants’ movement, having food chunks stuck around the appli-
demeanor and researchers’ insights. ance, and taking a longer time to finish meals:

American Journal of Orthodontics and Dentofacial Orthopedics September 2023  Vol 164  Issue 3
426
Table III. List of themes and codes
Themes Codes
A: Functional impairment A1: Degree of functional impairment
and symptoms and symptoms
A2: Impact on daily routines and
social activities
A3: Adaptation and problem-solving
A4: Impact on Twin-block wear
B: Psychosocial factors B1: Feelings and attitudes at the start
and impacts of treatment
B2: Feelings and attitudes during
and after treatment
B3: Influence of family and school
community
B4: Relevance of personalities
C: Feedback on appliances C1: Appliance-related issues
and patient care C2: Preference for the HH
C3: Positives of choosing the
Twin-block
C4: Influence of orthodontist
C5: Suggestions for patient care
“.I used to be breaking it [burger] down into little
parts, but it still wouldn’t even get in my mouth. I’d
have to swallow them so I couldn’t really get the taste
of food..” (Participant 2, HH group)
Speech problems were more evident in the MTB
group, who reported lisping, and difficulties pronounc-
ing certain words or being understood:
“.in my school, they would just tell me, like they
couldn’t understand me [speaking when wearing
MTB]..” (Participant 18, switched group)
The severity of other symptoms varied among partic-
ipants, irrespective of the appliance type. For example,
some reported how discomfort disrupted their daily
routine, whereas others encountered minimal effects:
“The first two weeks [after fitting HH], I would not be
able to sleep at night, because I would have a lot of
pain..” (Participant 16, switched group)
“It [MTB] used to distract me from focusing for
school. when I was trying to write an essay or some-
thing like that, my teeth would hurt a lot..” (Partic-
ipant 17, switched group)
“.you just eventually get used to it [discomfort wear-
ing MTB]. my friends just clocked that I had a lisp.
it doesn’t really bother me anyway.” (Participant 10,
MTB group)
Participants gave details on how they adapt to
overcome functional problems, in particular speech,
which again depended more on their ability than
the appliance itself:
September 2023  Vol 164  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Kwon et al
“.it [HH] would stick out a lot more, so it would be a
little bit harder to speak. But after a while I got used
to it and learned how to speak around it.” (Participant
5, HH group)
“It [speech issues with MTB] was permanent, no mat-
ter how much I tried, the speech would not improve.
I tried reading books out loud, because I thought that
would work, but it didn’t work, so I just gave up.”
(Participant 13, switched group)
Participants having mastication problems with the
HH appeared to adapt by choosing softer foods or
blending food:
“.I just reduced hard food. I started eating soft food,
and then after a while I got used to my braces and
could start eating normally again.” (Participant 5,
HH group)
“At first, I had to have my food blended and then I’d
drink my food instead.” (Participant 18, switched
group)
One participant recalled taking 3 different measures
to deal with an ulcer:
“.I went back to the dentist and they gave me wax to
put on it, to help it, but the wax kept coming off, so it
wasn’t really that helpful, but then I had like Bonjela.
it [HH] keeps coming in contact with the ulcer so I had
to eat on that [unaffected] side, so it doesn’t hurt.”
(Participant 4, HH group)
Participants who struggled to adapt to their appli-
ance either (1) accepted the problem, (2) avoided
affected activities, or (3) in the case of the MTB,
chose to remove it:
“Yeah, that [eating with HH] was very inconven-
ient. I never wanted to eat around people, because
I felt uncomfortable, and I used to get food stuck
anywhere and everywhere.” (Participant 12, switched
group)
“.they would just tell me, like they couldn’t under-
stand me and I would take them [MTB] out and tell
them what I was saying.” (Participant 18, switched
group)
Many participants who would remove MTB justified
that in a social setting, the ease with which they can
take part in their activities and routines often took
higher priority (over wearing their appliance):
“I usually wear it [MTB] at night [but not during the
daytime]. because I didn’t like how I couldn’t speak
with it. obviously I go to school, and you need to
speak in school.” (Participant 1, MTB group)
Kwon et al
In contrast, some participants were determined to
ensure that if they had to remove the appliance, the
amount of removal time was kept to a minimum:
“When it started hurting, I took it [MTB] out. for a
few [10-15] minutes, until it calmed down and then
I put it back on.” (Participant 6, MTB group)
Both HH and MTB affected participants’ psycholog-
ical well-being in a similar pattern throughout the treat-
ment. In the beginning, participants felt hopeless and
had doubts about the effectiveness of their appliance
because of the challenges and unfamiliarity:
“[wearing MTB] broke my sleep. then I would get a
bit moody because I hadn’t had enough sleep.”
(Participant 1, MTB group)
“.the first time I put it [MTB] in, I was a bit dubious,
like is it actually going to help..” (Participant 10,
MTB group)
As treatment progressed and participants adapted,
the feelings became positive because of noticing
changes to the position of their teeth and bite:
“.obviously I [first] thought they [MTB] didn’t work,
but then after my first check-up, I heard they moved
like three millimetres, I was like damn, they actually
do work. And I kept on wearing them more and
more, every time I went, because they were obviously
working.” (Participant 10, MTB group)
Nevertheless, the burden of coping meant that they
were relieved to be freed from their appliance:
“I feel relieved that I don’t have to get a robot thing in
my mouth, now I don’t have to have metal stuff in my
mouth..” (Participant 2, HH group)
Family and school classmates had a large influence
on many participants’ emotions, in both a helpful and
unhelpful ways:
“I definitely felt more comfortable being around my
friends without it [MTB] on, and because of the things
people would say, that would lead me to take it off.
there were always the boys that would either make fun
of, you know, the way I spoke..” (Participant 12,
switched group)
The benefits of having a companion who went through
the treatment were reported by several participants, who
can listen and empathize with their experiences; it gives
them a sense of belonging and reassurances that their dif-
ficulties were usual and expected:
“Because it gives them [children] the sense that they’re
not the only one [wearing MTB]. it would definitely
American Journal of Orthodontics and Dentofacial Orthopedics
427
be easier if they had someone else to relate to..”
(Participant 13, switched group)
In addition to these external factors, participants
acknowledged how their emotions were influenced by
their personality traits, such as self-discipline, self-con-
sciousness, and curiosity:
“.when I knew that I had something that was fixed
[HH] on my teeth, then I wouldn’t have taken it off
because I’d be like okay then I’ll have to just cope
with it, but I knew I could take it [MTB] off if it hurts,
that was the main thing, so I was like oh why not, I’ll
just take advantage of it.” (Participant 17, switched
group)
“.for example, at lunchtime I had to take them [MTB]
out. and people would make fun of me. So, I
wouldn’t like to wear it at school because of that
reason.” (Participant 12, switched group)
Breakages were more problematic for participants
with the HH (molar band debonding, loosening of
telescopic arm screws), though it did not completely
affect their daily activities, and they were happy to
wait a few days for their emergency appointment.
Some participants with the MTB showed dissatisfac-
tion with their facial aesthetics, as the vertical bulk
of the appliance had increased their mouth opening.
One participant from the switched group compared
both appliances from this perspective:
“.one thing was my jaw was really forward [wearing
MTB], so I always looked moody, I was making like a
really stern face. [with HH] people would say like
I’ve got like a robot in my mouth... This one [HH]
wasn’t as bad, it didn’t look as bad and my mouth
wasn’t always open and obviously I could close it
easier.” (Participant 12, switched group)
For all 3 groups, HH was the preferred choice if they
were to start the treatment again. Participants believed
that wearing an appliance that they could not remove
was beneficial, as it would avoid problems of forgetful-
ness, accidental mishandling, and interruption to their
treatment progress:
“.if you take them [MTB] out and you forget to put
like the top one in then, and you only have the bottom
one in then that kind of affects your treatment, but
these [HH] are both top and bottom so you don’t
forget because they’re already in your mouth.” (Partic-
ipant 2, HH group)
“.like accidentally break it or put it in the wrong way
so then it doesn’t do what it’s supposed to and messes
up my teeth..” (Participant 4, HH group)
September 2023  Vol 164  Issue 3
428
“.the fixed one is always going to be on, so it’s al-
ways going to do what it’s supposed to do, but then
the removable one, if you take it off before going to
sleep then it won’t work when you’re sleeping.”
(Participant 9, HH group)
Participants with low self-discipline admitted that
keeping the appliance fixed to their teeth was the only
viable way to restrain their temptation (of taking out
their appliance):
“. these ones [HH] are fixed, so I would’ve kept with
them anyways, I wouldn’t have complained. It’s like
because they’re there on my teeth already. What am
I actually going to do, like, rip them out? No. So, I
would’ve like wore them or whatever.” (Participant
17, switched group)
Although HH was the preferred choice by the major-
ity, MTB was considered an ideal option for children with
good self-discipline and preferring to eat and play sports
without wearing the appliance:
“.if they do quite a lot of sports, then I’d say probably
the removable one [MTB], because it wouldn’t get in
the way, like [playing] a sport which can hit you in
your face then it [HH] can obviously break..” (Partic-
ipant 4, HH group)
“.if the person doesn’t really care and will give them-
selves discipline to keep them in, then those [MTB]
would be better for them, as they wouldn’t face as
much issues when it comes to eating and break-
ages..” (Participant 18, switched group)
Orthodontists were regarded to play a vital role in pa-
tient care, as participants relied on their advice to
address their questions and concerns. One participant
discussed how important it is for orthodontists to set
correct expectations to avoid surprises and disappoint-
ment:
“So maybe don’t sugar-coat it, maybe just be straight
up like it will hurt, you know, just tell them how it’s
going to go. I think they should kind of just be
honest with you and say, it might be a bit inconvenient
but it’s really important to keep it on.” (Participant 12,
switched group)
Many participants queried whether the appliance
design could be improved, for example, by making
them smaller (MTB) and interfering less with oral func-
tions (HH):
“I think maybe what could happen is you maybe start
off with a smaller Twin-block and then as you wear it
more and there’s a change you can wear the bigger one
after, maybe that might help the progress..” (Partic-
ipant 1, MTB group)
September 2023  Vol 164  Issue 3
Kwon et al
“.like this part was annoying me, so maybe make it
[the HH as a whole] less annoying. Like make it
round.” (Participant 9, HH group)
Other participants wished to reduce the wear
hours of the MTB to a part-time basis, to suit their
daily routines:
“I think, for me the best way would be just to go sleep
with it. just wear it through the night and in the
morning take it off.” (Participant 1, MTB group)
There was consensus among participants that chil-
dren should be offered multiple appliance choices and
empowered to make decisions with their treatment:
“. It’s the having a choice, between the two [HH and
MTB], that makes you feel like you have that authority,
so you get to pick, so then the person who’s most likely
to be more happy.” (Participant 13, switched group)
“. teenagers really lack having free choices, and
decide on what they want to do by themselves.”
(Participant 16, switched group)
There were also views that, because of the burden of
wearing functional appliances, the treatment should
start when the child is older and has settled into school
life:
“.with that one [HH] you’ll constantly be in pain, at
such a young age. For example, eleven or twelve [year-
olds] are in year seven and I can imagine that people,
you don’t really know each other yet and if you have
that it [HH] kind of just makes everything worse.”
(Participant 12, switched group)
DISCUSSION
Previous qualitative studies15-19 have highlighted the
negative impact of functional appliances on eating and
their psychological well-being, how children adapt and
cope with these difficulties, and factors that act as bar-
riers to adherence to appliance wear. Conversations in
this study have mirrored these findings, as participants
discussed their QOL regarding functional impairment
and symptoms (Theme A) and psychological well-being
(Theme B).
This study offers a unique opportunity to compare
the participants’ experiences in relation to the fixed
(HH) and removable (MTB) designs. Although most
symptoms reported from previous questionnaire studies4
also affected both HH and MTB participants in this
study, there were a few notable differences; speech
was more difficult with the MTB, whereas mastication
and breakages were problematic with the HH. The au-
thors anticipated the latter finding, as participants
American Journal of Orthodontics and Dentofacial Orthopedics
Kwon et al
wearing the MTB were instructed to remove their appli-
ance during eating. Had they been instructed otherwise,
it is expected that mastication problems would have
featured like in previous qualitative15 and quantitative24
studies.
Although there were differences in participants’ ex-
periences between the HH and MTB appliances, it was
also evident that the impact of these issues on QOL
was widely variable among participants within each
group in terms of its extent, duration, effect on daily
routines and wear adherence. Therefore, it would
be intuitive for the orthodontists to effectively commu-
nicate and carefully manage patient expectations, espe-
cially as some participants in this study have compared
their experiences to their orthodontist’s instructions
(eg, being told by the orthodontist that discomfort
would usually resolve in a week, but participant found
it last longer).
We found that the design features of the HH and MTB
influenced participants’ experience in the following 3
ways: (1) components that caused ulcers and irritation
(eg, telescoping arms of HH and cribs of MTB); (2) how
the appliance would change their facial profile, which
was more noticeable with the MTB by the participants;
and (3) drawbacks and inconveniences of having to re-
move and refit the MTB appliance. For the latter 2 reasons,
the HH was the preferred choice for most participants.
Removable functional appliances have higher
discontinuation rates4 than fixed functional appliances,
as they rely on patient adherence with appliance wear.
This trend featured again in this RCT, in which a minority
of MTB participants switched to the HH because of non-
adherence with wear hours. Therefore, this problem was
identified by researchers as an important study topic,
thus the decision to include the switched group in the
sampling matrix. It was initially anticipated that this de-
cision would skew the results in favor of the HH appli-
ance; however, the researchers found that the switched
group participants discussed the merits and drawbacks
of both appliances. They were able to recognize that
their own experience would not always apply to
everyone and that there are differences in individual
needs in terms of their lifestyle, coping abilities, and per-
sonal preferences. This merges into their views of the
benefits of giving children multiple appliance options
and autonomy during decision-making.
A one-to-one semistructured format was used for the
present study, selected in favor of other techniques (eg,
focus groups or field studies) to provide a private and
confidential setting for participants to discuss their ex-
periences in depth. As the interviews relied on partici-
pants’ memory, there would be recall bias, especially in
participants who were interviewed later in treatment.
American Journal of Orthodontics and Dentofacial Orthopedics
429
However, the strength of this approach was that they
would have a more complete range of experiences with
their appliances.
Participants for this study were recruited from an RCT
in a single hospital, whose local population is mostly
from an Asian, low socioeconomic background. Partici-
pants did not require to pay for their appliances, which
were provided under the terms of the National Health
Service. Therefore, the transferability of the current find-
ings would apply to similar populations and care set-
tings. Future studies could consider various functional
appliance designs and different population settings to
evaluate further how these characteristics may affect
children’s treatment experiences.
CONCLUSIONS
This study explains how fixed (HH) and removable
(MTB) functional appliances can negatively affect a
child’s QOL and behaviors.
MTB was viewed as the suitable option for children
with self-discipline and an active lifestyle; however,
HH was preferred by the majority for the convenience
of requiring less management and dependence on self-
discipline.
Children also wished to be given greater autonomy,
with appliance choices and involvement in decision-
making.
AUTHOR CREDIT STATEMENT
Ohsun Kwon contributed to conceptualization, data
curation, formal analysis, investigation, methodology,
visualization, original draft preparation, and manuscript
review and editing; Easter Joury contributed to data cu-
ration, formal analysis, investigation, methodology, su-
pervision, validation, original draft preparation, and
manuscript review and editing; Fiorella Colonio-
Salazar contributed to conceptualization, data curation,
formal analysis, investigation, methodology, supervi-
sion, validation, visualization, original draft preparation,
and manuscript review and editing; Moaiyad Moussa-
Pacha contributed to investigation, methodology, orig-
inal draft manuscript, and manuscript review and edit-
ing; and Ama Johal contributed to conceptualization,
data curation, formal analysis, investigation, methodol-
ogy, project administration, resources, software, super-
vision, validation, visualization, original draft
preparation, and manuscript review and editing.
ACKNOWLEDGMENTS
The authors thank the participants for volunteering
their time in interviews.
September 2023  Vol 164  Issue 3
430
REFERENCES
1. Fleming P, Lee R. Orthodontic functional appliances. 1st ed. Wiley
Blackwell; 2016.
2. Batista KB, Thiruvenkatachari B, Harrison JE, O’Brien KD. Ortho-
dontic treatment for prominent upper front teeth (Class II maloc-
clusion) in children and adolescents. Cochrane Database Syst Rev
2018;3:CD003452.
3. O’Brien K, Wright J, Conboy F, Chadwick S, Connolly I, Cook P,
et al. Effectiveness of early orthodontic treatment with the
Twin-block appliance: a multicenter, randomized, controlled trial.
Part 2: psychosocial effects. Am J Orthod Dentofacial Orthop
2003;124:488-94; discussion 494-5.
4. Pacha MM, Fleming PS, Johal A. Complications, impacts, and suc-
cess rates of different approaches to treatment of Class II maloc-
clusion in adolescents: a systematic review and meta-analysis.
Am J Orthod Dentofacial Orthop 2020;158:477-94.e7.
5. Lena Y, Bozkurt AP, Yetkiner E. Patients’ and parents’ perception of
functional appliances: a survey study. Turk J Orthod 2017;30:33-41.
6. Johnson PD, Cohen DA, Aiosa L, McGorray S, Wheeler T. Attitudes
and compliance of pre-adolescent children during early treatment
of Class II malocclusion. Clin Orthod Res 1998;1:20-8.
7. Alzoubi EE, Hariri R, Mulligan K, Attard N. An evaluation of oral
health-related quality of life in orthodontic patients treated with
fixed and Twin blocks appliances. J Orthod Sci 2017;6:65-70.
8. Kadkhoda S, Nedjat S, Shirazi M. Comparison of oral-health-
related quality of life during treatment with headgear and func-
tional appliances. Int J Paediatr Dent 2011;21:369-73.
9. Hedlund C, Feldmann I. Success rate, costs and long-term stability
of treatment with activator/headgear combinations. Swed Dent J
2016;40:67-77.
10. Elkordy SA, Fayed MMS, Abouelezz AM, Attia KH. Comparison of
patient acceptance of the Forsus Fatigue Resistant Device with and
without mini-implant anchorage: a randomized controlled trial.
Am J Orthod Dentofacial Orthop 2015;148:755-64.
11. Heinig N, G€ oz G. Clinical application and effects of the Forsus
spring. A study of a new Herbst hybrid. J Orofac Orthop 2001;
62:436-50.
12. Goel M, Batra P, Gandhi P. Relative comparison and assessment of
patient’s attitude and discomfort between two different types of
September 2023  Vol 164  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Kwon et al
fixed functional appliances: a comprehensive survey. J Orthod
Res 2013;1:83.
13. Institute of Medicine. Crossing the quality chasm. Washington,
DC: The National Academies Press; 2001.
14. Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research
practice: A guide for social science students and researchers. 2nd
ed. SAGE Publications Ltd; 2013.
15. Carter LA, Geldenhuys M, Moynihan PJ, Slater DR, Exley CE,
Rolland SL. The impact of orthodontic appliances on eating -
young people’s views and experiences. J Orthod 2015;42:114-22.
16. Kettle JE, Hyde AC, Frawley T, Granger C, Longstaff SJ, Benson PE.
Managing orthodontic appliances in everyday life: a qualitative
study of young people’s experiences with removable functional
appliances, fixed appliances and retainers. J Orthod 2020;47:
47-54.
17. El-Huni A, Colonio Salazar FB, Sharma PK, Fleming PS. Under-
standing factors influencing compliance with removable func-
tional appliances: a qualitative study. Am J Orthod Dentofacial
Orthop 2019;155:173-81.
 c E, Kjellberg H, Hansen K, Lepp M. Adolescents’ experiences
18. Cirgi
of using removable functional appliances. Orthod Craniofac Res
2015;18:165-74.
19. Trulsson U, Linl€av L, Mohlin B, Strandmark M. Age dependence of
compliance with orthodontic treatment in children with large
overjet. An interview study. Swed Dent J 2004;28:101-9.
20. British Orthodontic Society. Patient information leaflets. Available
at: https://www.bos.org.uk/Public-Patients/Patient-Information-
Leaflets. Accessed December 4, 2019.
21. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the
framework method for the analysis of qualitative data in multi-
disciplinary health research. BMC Med Res Methodol 2013;13:117.
22. Denzin NK, Lincoln YS. The sage handbook of qualitative research.
5th ed. Safe Publications, Inc; 2017.
23. Glaser BG, Strauss AL. The discovery of grounded theory: strategies
for qualitative research. Aldine Publishing Company; 1967.
24. O’Brien K, Wright J, Conboy F, Sanjie Y, Mandall N,
Chadwick S, et al. Effectiveness of treatment for Class II
malocclusion with the Herbst or Twin-block appliances: a ran-
domized, controlled trial. Am J Orthod Dentofacial Orthop
2003;124:128-37.