21 Removable Appliances

National Orthodontics Programme Module 21 - Removable Appliances
British Orthodontic Society 1
National Orthodontics Programme

British Orthodontic Society
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Moodduullee 2211
Removable Appliances
About the National Orthodontics Programme

The National Orthodontics Programme was launched in December 2004 following a successful British
Orthodontic Society Foundation Award application. A primary aim of the project was to develop a modular
learning resource housed in a Virtual Learning Environment for postgraduates in orthodontics
(www.ole.bris.ac.uk). This consists of 40 online modules and a series of online assessments. The resource
aims to maximize the use of academic staff time and significantly reduce the amount of traveling to teaching
bases by Specialist Registrars.
The resource has been developed by all UK dental schools as authors or coauthors. It is at the discretion of
each dental school as to how the resource is best used in their courses.
We hope you enjoy using this unique and pioneering resource.
Personal Welcome
Welcome to Module 21. This module is intended to introduce you to removable appliances and the many
uses they may be put to within the field of Orthodontic treatment today. Completion of this module should
include completion of a laboratory based programme to enhance the students understanding of the technical
aspects of removable appliance construction. A suggested programme is included for your guidance.
For the purpose of this module, functional appliances and retention appliances will not be discussed. Please
refer to modules M22 and M25 respectively.
For module content support and guidance, please refer to the discussion board for this module available on
Blackboard.
Module Author
Hugh Bellis
Peer Reviewer
Fraser McDonald
What you will learn

The module will take you through eight sections indicated below:
1. The development of removable appliances in the United Kingdom.
2. The mode of action of a removable appliance.
3. Materials used to construct removable appliances.
4. The various components of a removable appliance.
5. How these components are combined to design an appliance.
6. The fitting and activation of an appliance.
7. Managing the patient at the first review and at follow up.
8. Advantages and disadvantages of removable appliances.
9. Removable appliances in contemporary orthodontics.
10. Laboratory exercises.
Assessment
Assessment will be made through a combination of self-directed learning that are distributed through the
module.
Timing
The approximate total time required for the module and assessment is 20 hours. The
majority of this time will be spent reading relevant literature.
References
A full list of references is included at the end of the module.
1. The development of removable appliances in the United Kingdom
Definition of a Removable Appliance
An appliance designed to be easily removed from the mouth by the patient for cleaning and activation where
required.
Aims and objectives of orthodontic treatment
It is the intention of Orthodontic treatment to align and produce a fully functional occlusion and to achieve a
permanent improvement in the patient’s malocclusion. With this in mind it is prudent to strive for a stable
occlusion, “an aesthetic and functional occlusion” and an occlusion in harmony with the underlying dental
bases and neuromuscular forces.
There are general rules that should be applied for successful removable appliance therapy.
These include: -
a) The dental base relationship cannot be altered.
b) Removable appliances will only tip or tilt teeth.
c) The resultant occlusion must be stable relative to the neuromuscular pattern e.g. endogenous
tongue thrust, high lip line. This may limit your treatment objectives.
d) Lower incisors are usually allowed to find their own position in space anterior posteriorly.
e) Space requirements – where extractions are required, they should be adjacent to the area of
crowding.
f) Extract 1st premolars for spontaneous lower incisor alignment (if canines are mesially inclined).
g) A suitable patient – every treatment must be individualised to suit the patient’s problem and needs.
o Hoyle A. The Development of Removable Appliances in the United

Kingdom. Br Soc Study Orthod 1983; 10: 73-77.
2. Mode of action of a removable appliance

Removable Appliances are only capable of carrying out limited tooth movement. The movements
removable appliances can achieve are listed below:
a) Crown tipping in labio-lingual or mesio-distal directions.

b) Reduction of deep overbites in growing individuals
c) Space maintenance
Tooth Movement
When a force is applied to a point on a smooth surface, it can be resolved into two components, one at right
angles or normal to the surface and the other tangential to it (figure1). Where the surface is curved, the
force is resolved normal and tangential to the point of contact. If the force is applied at an angle to the
surface, tooth movement will be produced by the normal component. Thus, the tooth will not move in the
direction of the applied force.
Although the initial movement must be considered in three dimensions, it is convenient to discuss it in two
planes which span the space: First the plane through the long axis of the tooth and in the direction of the
tooth movement, and second, a plane of cross section.
Movement in the plane of the long axis
When a force is applied to the crown of a tooth, movement is resisted by the periodontal ligament.
Figure 1 Figure 2
Tipping Movements
A force applied as a single point on the crown will tip the tooth about a fulcrum. Although many texts
suggest that tipping takes place about a fulcrum within the apical third of the root, it can be shown that the
centre of rotation is usually about 40% of the length of the root from the apex (Christianson and Burstone
1969; Stephens 1979; Williams and Edmundson, 1984; Yettram et al., 1977). This means that while the
crown moves in one direction, the apex moves in the opposite direction.
(Figure 2)
The exact level of the fulcrum depends on a number of factors which are not under the control of the
Orthodontist: These include root shape and the distribution of fibre bundles within the periodontal ligament.
Bodily Movements
If a tooth is to be moved bodily, a force couple must be applied to the crown in conjunction with the original
force (Figure 3).
This would be necessary to allow precise control over the position of the fulcrum but is not normally a
practical undertaking with removable appliances. It is possible with fixed appliances and to a very limited
extent, with fixed components used in conjunction with removable appliances.
Figure 3:
Bodily movement of teeth:
(a) A force applied at a single

point on the crown results in
tipping.
(b) To achieve apical movement,
or (c) bodily movement, a
force couple is required. This
can only be effectively
achieved by a affixed
appliance.
Intrusion
When a bite plane is incorporated in an appliance, an intrusive force is applied to the teeth which contact it.
The amount of true intrusion is small and overbite reduction with removable appliances is largely the result
of eruption of the dentoalveolar segments including the posterior teeth (Figure 4). NOTE: if retention of the
appliance is by Adam’s cribs on the first molars it will be the lower teeth that are able to over-erupt and so
flatten the curve of Spee (Andrews, 1972)
Figure 4: Figure 5:
An anterior bite plane to reduce the overbite by Application of force to the crown of a tooth.
allowing vertical development of the posterior teeth. (a) The palatal cantilever spring is positioned too far
The bite plane should be thick enough to separate posteriorly, the tooth will be moved buccally. The result of
the posterior teeth by 2-3mm and extend sufficiently contact of the spring is also incorrect resulting in unwanted
to engage the lower incisors when the mandible is rotation of the canine.
retruded. (b) Correct application of a palatal finger spring to a canine.
Where an incisor does not occlude perpendicular to an anterior bite plane it may be tipped labially.
Intrusion of teeth may also be produced unintentionally by the incorrect application of a spring. Where, for
example, a spring to retract the canine is applied to the cuspal incline, the tooth will be intruded as well as
retracted. This most often happens when attempts are made to retract a canine which is only partially
erupted. For this reason, it is preferable not to attempt to move a tooth until it is erupted fully.
Movements in the plane of the occlusion
The tooth will move in the direction of the component of force perpendicular to its surface. This is of
particular importance when considering movement of a canine with inappropriate positioning of a palatal
cantilever spring (Figure 5).
Where a palatal cantilever spring is positioned too far posteriorly, the tooth will move buccally and may also
generate an unwanted rotation of the canine. The correct positioning of a palatal cantilever spring
generates the correct movement of the tooth (Figure 6).
The unwanted buccal movement is particularly difficult to avoid when the tooth is buccally positioned in the
first place. In this situation, a buccal spring, which can apply a force at the required point, is essential.
Rotations may be difficult to avoid if the tooth is already slightly rotated. This situation may be controlled by
using a buccally approaching force.
Figure 6
The coil of palatal cantilever spring should lie on a

line from the mid crown point on the tooth to be
moved, perpendicular to the direction of movement.
Rotations
While rotations may inadvertently be introduced as described above, the controlled rotation of a tooth can
only be undertaken with a couple. With an upper central incisor, it may be possible to correct a rotation with
a couple between a labial bow and a palatal spring at the baseplate, but this requires careful management.
o Isaacson KG, Muir JD, Reed RT. Removable Orthodontic Appliances. 2002;
Butterworth Heineman.
3. Materials used to construct removable appliances

• Stainless steel wire
• Elgiloy wire
• Acrylic
Stainless steel wire

The composition of austenitic stainless steel wire used for the construction of removable appliances is:-
• Iron 73%
• Chromium 18%
• Nickel 8%
This form of stainless steel wire is known as 18/8 stainless steel (18 refers to the percentage of Chromium
included whilst 8 refers to the level of Nickel incorporated. Nickel has implications for Nickel allergy [Type IV]
patients) and is available in three forms depending on the manufacturing process of cold working or
annealing. Cold working the wire hardens the wire, a process known as work hardening. Heating the wire
softens the wire, a process known as annealing. Fully annealed stainless steel wires are soft and highly
formable. Stainless steel wire can be obtained in three main forms:-
• Spring hard
• Medium hard
• Soft
For the construction of components of a removable appliance spring hard stainless steel is usually used, but
it is possible to use medium hard in some instances.
Elgiloy wire
The composition of elgiloy wire is:-
• Iron 14%
• Chromium 20%
• Cobalt 40%
• Nickel 16%
• Molybdenum 7%
• Manganese 1.5%
Elgiloy wire is available in four grades:-
• Red : Resilient
• Green : Semi Resilient
• Yellow : Ductile
• Blue : Soft
Elgiloy is used in its blue soft form in general for constructing Southend clasps or other clasp components for
removable appliances. Heat treating the wire increases its strength significantly. After heat treatment of a
soft elgiloy (blue) wire the elgiloy increases its strength equivalent to regular stainless steel.
Acrylic
Composed of a powder or polymer known as poly methyl methacrylate, a peroxide initiator, pigment, a liquid
monomer methyl methacrylate, a stabilizer hydroquinone to prevent polymerization on storage and a cross
linking agent.
The polymerising process may be:-
• Heat cured
• Self cured, cold cured, auto polymerising or chemically activated acrylic is similar to the heat
cure material except the liquid contains an activator, such as dimethyl-p-toluidine. NOTE: there
is a concern that free monomer if in contact with oral mucosa will be irritant (Fernstrom and
Oquist, 1980).
• A light cure material is available as an alternative base plate material but is not based on
methyl methacrylate. Triad visible light cure material (Triad, 2000). Based on a urethane
acrylate this material has been extensively investigated by Eden et al. (2002). This material
has no clinically beneficial factors to offer as a viable alternative to the autopolymerizing acrylic
resins. Its poor strength is its main disadvantage. Despite the advantage of not releasing
unpolymerized monomer which has been reported to cause reactions for both technicians,
dentists and patients:-
1 Technicians and dentists

- Contact dermatitis
- Asthma, drowsiness, headache, anorexia, and decrease in gastric
motor activity
- Paraesthesia of the finger tips in the form of a burning sensation,
tingling and slight numbness
2 Patients
- Unpleasant taste
- Oedematous reaction accompanied by a burning sensation
4. The components of a removable appliance.
a. Retentive component
b. Active component
c. Anchorage
d. Base plate
(use the acronym RAAB to remember this)
Active Component: -
Means by which force is applied to bring about the required tooth movement.
• Springs
• Screws
• Bows
• Elastics
Springs Cantilever Spring : Hard Stainless Steel
Force dependent on : Wire length

Radius of wire
Elastic Modules
Wire Length Coil increases effective length of the spring
Diameter : 2.5 mm
Position close to attachment point to the base plate

Double radius: increase stiffness by - 16

Double length: reduce stiffness by - 8
Force 25 – 50 gms.
Deflection 2 - 4 mm optimum
Wire Thickness 0.5 – 0.7 mm SS.
Increasing diameter from 0.5 – 0.7 mm increase force x 4
Point of Contact Tooth will move in direction of resultant force

(i.e. perpendicular to the tangent at the point of contact)
Types of Spring Palatal cantilever – boxed and guarded (0.5 mm SS)

(0.7 mm for molars)
Buccal spring – self supporting (0.7 mm SS)
Supported (0.5 mm in tubing)
Cranked cantilever or “Z” spring (0.5mm)
Double cantilever or “Z” spring (0.5 mm)
Crossed cantilever spring (0.5 mm)
“T” spring (0.5 mm)
Coffin spring (1.25 mm)
Figure 7 Orientation of a coil for the ideal spring.
(a) A coil spring, which is activated by

being ‘wound up’, is more efficient than a
coil spring activated in the opposite
direction (b)
Incisor Retraction
Labial bow with reverse loops (mesial to (5|5) 0.8 mm

Labial bow with U loops 0.7 mm
Labial bow with large “C” loops 0.7 mm
Split labial bow (reduces stiffness) 0.7 mm

Self-straightening bow (0.4 mm wire on a labial bow)
High labial bow with apron spring (Base arch 1 mm)
(Bow 0.4 or 0.5 mm)
Roberts’ retractor (0.5 mm supported)
Other Active Components
Screws - Arch Expansion

- Arch Contraction
- Space Opening
- Space Closing
Elastics - Overjet Reduction

- Traction to impacted teeth
Write short notes on each active component, describe how they work, the type of force they
generate and the duration of the force once activated.
Retentive Component: -
Means by which the appliance resists displacement.
• Adams Clasps (0.7 mm molars, 0.6 mm premolars)
• Southend Clasp (0.7 mm SS, or 0.7 mm elgiloy)
• C Clasp (0.7 mm)
• Ball Ended Clasp (0.7 mm or 0.8 mm)
• Fitted Labial Bow (0.7 mm)
• Acrylated Labial Bow.
Adams Clasp Adjustment

Adams clasps, when constructed appropriately offer good retention. Frequently the operator will need to
adjust these clasps in order to achieve the desired retention. Adjustment of the clasps should be carried out
at points where they have not already been bent during the construction process. Accurate positioning of the
arrow heads is important and each and every clasp should be checked for the correct positioning of the
arrow heads to achieve maximum retention (Figure 8 and 9)
Figure 8.
The fit of a clasp can be adjusted by bending the wire at two points, Adjustment at X moved the arrowhead
vertically, adjustment at Y moves it horizontally.
F
Figure 8.
(a) Where an arrowhead grips too far gingivally,
(b) Adjust crib at point X to lift the arrowhead away from the gingival tissue,
(c) A second adjustment is required at Y to restore tooth contact with the arrowhead at the correct height.
Arrowhead clasps often fracture if misused. It is important to realise that previous working of the steel in the
arrowhead area makes the wire work hardened. Equally, if poorly made with the pliers slipping during
construction, this is the area where surface scratches develop which act as stress concentrators. As a
consequence adjustment at the arrowhead may lead to fracture of the wire. Repeated stress applied to the
arrowhead, by a patient continually taking the appliance in and out, will also lead to stress fracture of the
wire at a stress concentration such as a surface scratch.
Write short notes on each of the retentive components described above.

Indicate the thickness of wire you would use in their construction and describe how they
would work.
Anchorage: -
Anchorage is the force created as a reaction to the active components of the appliance
and may be dissipated through the metal or acrylic components of the appliance or the
contact point of adjacent teeth. It is also referred to as the resistance to unwanted
tooth movement or resistance to reaction forces but can be used to achieve treatment
objectives. It should be considered in all 3 planes; antero-posterior, transverse and
vertical.
Anchorage is provided by:

• Other teeth
• The base plate
• Extraoral forces
Other Teeth
1. The greater number of teeth incorporated in the appliance increases the anchorage component.
2. Teeth with larger root surface areas incorporated within the appliance may increase the anchorage
component.
3. The use of light forces reduces the burden on the anchorage components.
4. Intermaxillary anchorage used frequently in fixed appliance wear with elastics running from the
upper to the lower arch may be used and utilised for removable appliance therapy. This does
however increase the demand on the retentive part of the appliance and an operator needs to be
confident in the retentive component of his or her appliance.
5. Reciprocal anchorage where equal and opposite movements of two teeth are required by tipping
either by the activation of two finger springs in opposite directions or by means of a screw plate
achieving equal and opposite forces.
Base Plate
1. A large well fitting base plate provides excellent vertical and lateral anchorage.
2. Where a high vaulted palate is present this will add additionally to the AP anchorage component.
3. Vertical tooth movements are particularly suited to an upper removable appliance.
Extraoral Anchorage
1. Head Caps
2. Neck Straps
3. Combination
4. Face Masks
For further information on extraoral anchorage please refer to Module 19.
Base Plates: -
Connects all components of the appliance.
Constructed from self polymerizing or heat polymerizing polymethyle methacrylate
Write a brief description of the ideal base plate and what additional features you may require
of a base plate during treatment.
Discuss the importance of planning these additional features prior to the construction phase
to enable the fitting of the appliance to be simplified.
5. How components are combined to design an appliance

Appliance design in conjunction with good diagnosis is the key to successfully treating an orthodontic
problem. An inappropriately designed appliance, no matter how well made, is unlikely to achieve optimum
tooth movement and thus the desired end result.
The stages of appliance design are as follows:
A decision must be made on the active components desired to achieve the type and direction of tooth
movements required.
The retentive components should then be planned to enable the appliance to remain in its desired position
within the mouth and not to be displaced when the active components are activated appropriately.
The base plate holding active and retentive components together must be designed to hold all these
components together. Thought must be given to patient comfort. Additional features that need to be
considered at this stage include the addition of any of the following components:-
1. Anterior bite plane, this may be flat or inclined

2. Posterior bite plane
3. Single or multiple screws for expansion, distalisation, space closure or
proclination of an upper labial segment
4. Anchorage requirements - relate the desired tooth movements against the undesirable reactive tooth
movements that are likely to occur. An estimate of additional anchorage requirements would be
required at this stage as to whether the base plate alone with the retentive clasps are sufficient for the
type of tooth movement that is desired or whether additional anchorage requirements would be
required such as:
o The addition of headgear (distal movement, protraction)

o Inter maxillary elastics
Laboratory Request Form

A typical laboratory request form is shown below. The Appliance design is entered along with any additional
information which may aid the technician in the constructing of the required appliance. Written and
diagrammatical representation of the appliance is desirable together with the appropriate wire dimensions.
The prescription should be signed by the clinician.
Medical Devices
All Dental manufacturing Laboratories and Suppliers must be registered with the Medical Devices Agency.
Compliance with the Medical Devices Directive 93/42/EEC is mandatory.
All removable appliances are classified as a custom made device and as such must conform to the guidelines
laid down by the Medical Devices Directive 93/42/EEC.(Appendix 1,2,3,)
View the CD present in the textbook Removable Orthodontic Appliances by Issacson, Muir
and Read for examples of appliance designs.
N.B. Treatment will be better controlled and completed quicker if a separate appliance is used
for each group of tooth movements. Do not over complicate your appliance design.
6. The fitting and activation of an appliance
Equipment
The following equipment is required for the correct adjustment and management of a removable appliance.
Wire bending pliers:
• Adams universal pliers :(with tips impregnated with tungsten carbide) are the most useful for
the adjustment of removable appliances.
• Spring forming pliers.
Heavy duty cutters: A robust pair of wire cutting pliers is required that can cut wire up to 1.25 mm in
diameter.
Measuring instruments:
• A pair of stainless steel dividers for measuring the distance between individual teeth and to
measure the distances moved during treatment.
• A stainless steel centimetre ruler is also required.
Marker pencil: A chinograph pencil or other such wax marking tool is required to mark areas on an
appliance for adjustment.
The First Fitting of an Appliance
1. Check the appliance is the correct appliance for the patient.

2. Check the appliance has been made to the correct appliance design and finished appropriately.
3. Pick the appliance up and run your finger over the base plate particularly on the fitting surface,
checking for any sharp areas. Air bubbles on the model can produce roughness of the acrylic, but such
areas can be quickly smoothed as can any sharp ends of wire.
4. Show the appliance to the patient and explain the different components of the appliance including
retaining clasps, the active springs, and draw attention to the need to take care not to distort any of
the components of the appliance during its insertion and removal and wear.
5. Try the appliance in the mouth and scrutinise the fit around the teeth and check the clasps or
retention.
6. Adjust the clasps appropriately to generate sufficient retention to hold the appliance snugly in the
mouth, not too tight and not too slack.
7. Instruct the patient on how to handle the appliance, how to take it out of the mouth, how to put the
appliance back in. It is appropriate at this stage to get the patient to learn how to take the appliance in
and out by sitting up in the chair and having a go at this task.
8. Activate the appliance and where necessary trim acrylic to enable the appropriate tooth movements to
occur.
9. Final try in.
10. Instruct the patient fully on how to look after the appliance, the patient must be informed of all the
following detail and an information leaflet on managing removable appliances provided.
i. Time appliance is to be worn (it is often appropriate to detail the period of wear: appliances must be
worn for 23 hours and 50 minutes of every day; five minutes in the morning and evening are for
cleaning the appliance and the teeth.
Ii. Activating screws or adding elastics as necessary.
iii. Appliance hygiene including detail on keeping the appliance in good condition.
iv. How to handle emergencies, who to contact and when.
Medical Devices Agency Compliance Leaflet (appendix 1,2,3)
Appliance Home Care
• Cleaning.
• Safe storage when out of mouth.
Isaacson KG, Muir JD, Reed RT. Removable Orthodontic Appliances. 2002; Butterworth
Heineman.
The Design and Construction of Removable Orthodontic Appliances - Adams CP
B.O.S. Removable appliance information leaflet
Review the appropriate sections of these texts and make notes on adjustments of an
Adams clasp, adjusting acrylic base plate including bite planes and finally adjustment of
the active components of an appliance.
o Write short notes on the advice you would give your patients after fitting their
removable appliance.
7. Managing the patient at the first review appointment

Successful management of Orthodontic treatment depends upon careful assessment at each visit to assess
appropriate progress is being made. Recognising unwanted tooth movements at an early stage and
undertaking remedial action at this stage is of the utmost importance. The appliance must be adjusted with
care and good records need to be kept.
The patient should be seen within a 2 to 3 week period after the initial fitting of the appliance, thereafter at
monthly intervals. Inadequate attention to detail at regular visits may mean that something is overlooked
and the progress of treatment is not as required. Oral hygiene must be monitored closely and any
deterioration must not be accepted and patients must be instructed on how to rectify the situation.
At the First Review Appointment

Welcome the patient into the surgery and initially ask the patient how they have got on with their appliance.
Have they had any problems? Make sure that the patient has the appliance in the mouth and is duly talking
with the appliance so that you can gauge quality of speech etc. as this may be an indication as to whether
the patient has been wearing the appliance appropriately. The operator should be alert for any signs of
poor cooperation. Coming into the surgery with the appliance out of the mouth or poor speech are often
symptoms of inadequate wear (Coote, 1973)
Inspection
1. Check inside the mouth prior to the removal of the appliance, simply check the oral condition in general
for oral hygiene, any trauma spots and indications of appliance wear.
2. Check that the springs are correctly positioned and that the appliance does not have excessive
looseness at this stage as this may indicate that the patient has been flicking the appliance up and
down with the tongue and has made the appliance loose. This is also a sure method of producing
multiple fractures of the wire components during treatment.
3. Remove the appliance noting any degree of activation remaining in the springs, check the fitting
surface of the appliance and the fitting surface within the mouth, looking for oral hygiene status around
the gingival area and oral mucosa, and in particular the areas covered by the appliance.
4. Check for relevant tooth movements. Good practice is to measure the tooth position from a fixed point
and mark within the patients notes the distance that the relevant tooth is moving or the distance an
overjet is reducing.
5. Check molar relationships for slippage, similarly check the overjet to make sure the overjet is not
increasing in size, all signs that may indicate that the anchorage component is slipping.
Trouble shooting
1. Check that the teeth are free to move in the correct direction making sure that there are no
interferences either by the acrylic base plate, that the base plate has been trimmed appropriately or
that other teeth are not interfering with tooth movements.
2. Check whether the appliance has been worn or not.
3. Check the activation of the active components of the appliance. Where a spring has been used make
sure that this is activated appropriately and where a screw has been used then obviously check the
number of turns on a screw in comparison with the prescribed activation regime.
This type of checking procedure is simple, and once a habit has been obtained this can be very quickly and
easily handled to optimise the efficiency of the use of removable appliances.
o Munns D. An analysis of broken removable appliances. Transactions of the B.S.S.O 1971;

2: 449-452.
o Kerr WJ . Appliance Breakages. Transactions of the B.S.S.O 1984; 11: 137-142.
o Coote JD. Removable Appliance Therapy Patient Co operation and its Assessment. Br
Dent J 1973; 134: 91-94.
o Huddart AG, Scott MF. Common Faults with Removable Appliances. 1960; 59-61 .
o B.O.S. patient information leaflet - Removable Appliances.
1. Write short notes on the reasons for appliance breakages, and the most common breakages that
may occur.
2. Inflammation of the palatal mucosa is a well recognised complication of removable appliance
wear. Detail the features you may see and describe how you would handle such a problem?
8. Advantages and disadvantages of removable appliances

Removable appliances may not be used as the sole appliances for producing correction of malocclusions in
modern day Orthodontics. However, they still have their place and are particularly effective when used as
an adjunct to fixed or functional appliance therapy.
Advantages:
1. They are removable, therefore easy to clean.

2. They have good vertical and horizontal anchorage components (palatal coverage).
3. They produce efficient overbite reduction in growing children.
4. They can transmit forces to blocks of teeth e.g. arch expansion.
5. They provide an excellent device for space maintenance.
6. They can produce simple tooth movements when desired eg tipping teeth.
7. They are very efficient for extruding teeth such as impacted palatal canines.
8. They are a cheap appliance to use
9. Remove occlusal interferences
10. Less chairside time than fixed
11. Less clinic inventory required
Disadvantages:
1. Removable appliances can easily be left out of the mouth and therefore rely very heavily on patient
cooperation.
2. Only tilting movements are possible with these appliances. Cannot correct rotations, produce bodily
tooth movement or generate torque.
3. They can affect speech and therefore affect patient compliance.
4. They require a technician’s input in construction.
5. Inter maxillary traction is difficult as good retention is required.
6. They are inefficient for multiple tooth movement.

7. Lower appliances particularly difficult to tolerate.
8. Can generate unwanted tooth movements, particularly rotations when a crown is being translated.
o Indications for the use of fixed and removable appliances. Ray WJ, Stevens CD,
o The contemporary use of removable orthodontic appliances. Ward S, Read MJF.
o Use of removable appliances as an adjunct to fixed appliance therapy. Turner PJ.
9. Removable appliances in contemporary orthodontics
Uses of Removable Appliances in Modern Day Orthodontics (and as recommended by

the General Dental Council)
• Interceptive treatment in the mixed dentition (short duration treatment)
• Correction of crossbites. These may be anterior or posterior.
• Space maintenance.
1. Early loss of deciduous teeth.

2. Traumatic loss of an incisor.
3. Hold space after extraction of permanent teeth to allow eruption of maxillary canines.
Removable Appliances as an Adjunct to Fixed or Functional Appliance Therapy.

1. Initial appliance before functional appliances to procline incisors in a Class II Division 2 case and
expand the upper arch.
2. Aid distal movement by adding headgear therapy.
3. Overbite correction (in a growing child using an anterior bite plane).
4. Disengage occlusion with bite planes to enhance tooth movement by removing occlusal interferences.
Declining Use of Removable Appliances
Richmond et al. (1993) and Kerr et al. (1993) both investigated the effectiveness of removable appliances in
treating malocclusions using the PAR index. Richmond et al. (1993) showed a significantly higher number of
patients treated within the General Dental Services with removable appliances finished treatment with a
poorer than expected end result. The assessment of treatment outcomes suggest the quality of treatment is
often not as high, and there is a higher discontinuation of treatment rate for patients treated with removable
appliances.
It would also seem that fewer GDP’s are willing to undertake Orthodontic treatment within the general
dental services resulting in a higher referral rate of patients to specialists who prefer fixed appliance
treatments.
o Littlewood S et al. The role of removable appliances in contemporary orthodontics. Br

Dent J 2001 191: 304-6, 309-10.
o Lewis DH, Fox NA. Distal movement without headgear: the use of an upper removable
appliance for the retraction of upper first molars. Br J Orthod 1996; 23: 305-12.
o Ward S and Read MJ. The contemporary use of removable appliances. Dent Update.
2004; 31: 215-8.
o Turner PJ. The use of removable appliances as an adjunct to fixed appliance therapy.
Dent Update 1993; 20: 428-32.
o Ninou S, Stephens C, The early treatment of posterior crossbites, a review of continuing
controversies. Dent Update 1994; 21: 420-6.
10. Laboratory exercises.
Construction exercises.
• Casting and trimming study models to exam standard
• Adams clasps (molar and premolar) and EOT tubes
• Southend clasp
• Hawley labial bow and acrylated labial bow
• Fitted labial bow (21/12)
• Palatal finger spring
• “Z” Spring
• Supported buccal canine retractor
• Base plate construction including functional anterior bite plane
• Quadhelix appliance taped and soldered to molar bands
• Adjustment of
o preformed quadhelix (Mia Quad)
o preformed palatal arch
• URA construction:-
o To produce Adams clasps (6/6)

o Palatal finger spring upper right canine (3/)
o Buccal canine retractor upper left (/3)
o “Z” spring upper left (2/)
o Functional anterior bite plane
o Southend Clasp (1/1)
• Construct a Twist Flex Retainer – upper and lower
• Construct Essex Retainer
• Repair techniques – cribs / base plate / finger springs.
• Construct Newport Twin Block appliance (include reactivation)

Laboratory discussion topics
• Adjusting
o Adams Cribs
o Southend Clasp
o Palatal Cantilever Spring
o Buccal Canine Retractor
o Labial Bow including Roberts Retractor
• Position of screws
o Mid line expansion
o Distal movement
• R.M.E. Appliances
• Functional appliances
o Bionator
o Twin Blocks
o Frankels
o Activators
o Sleep Apnoea Appliances
o Advancement of Twin Blocks
o Fixed Twin Blocks
End of laboratory module assessment
1) Devise a treatment plan for a selected set of study models utilising an upper removable appliance
2) Complete the laboratory form
3) Construct the appliance
4) Discuss options on other designs on completion and explain why you proceeded with your chosen
design
Bibliography
Text books
Adams CP. The Design and Construction of Removable Orthodontic Appliances. Bristol, Wright.
Houston WJB et al. A Text Book of Orthodontics, 2nd Edition, 1993; Write, Oxford
Houston WJB, Issacson KG. Orthodontic Treatment with Removable Appliances. Dental Practitioner
Handbook –No.25 2nd Edition.
Issacson KG, Muir JD, Read RT. Removable Orthodontic Appliances. 2002; Wright
N Atack et al. Post Graduate Notes in Orthodontics 3rd Edition. 2003; University of Bristol
Mitchell L. An Introduction to Orthodontics,2nd edition. 2001; Oxford University Press.
Proffitt WR. Contemporary Orthodontics 3rd Edition. 2000; Mosby.
Papers
Adams CP, Shinji H. The Physical Characteristics of the Stabilised Canine Retractor. Br J Orthod 1985; 12: 27
– 32.
Andrews LF. The six keys to normal occlusion. Am J Orthod 1972; 62: 296-309.
B.O.S. Patient information leaflet. Removable appliances.
Brown ID. The Closure Residual Extraction Spaces By Means of Traction Screws. A Report of 2 Cases.
Br Ed Orthod 1989; 16: 95 – 101.
Christianson RL, Burstone CJ. Centers of rotation within the periodontal space. Am J Orthod 1969; 55: 353-
369.
Coote JD. Removable Appliance Therapy Patient Co-operation and its Assessment. Br Dent J 1973; 134: 91 –
94.
Cousins, AJP, Brown WAB, Harkness EM. An investigation into the effect of the maxillary bite plane on the
height of the lower incisor teeth. Transactions of the BSSO 1969; 55: 105-109.
Eden SE, Kerr WJS, Brown J. A clinical trial of light cure acrylic resin for orthodontic use. J Orthod 2002; 29:
51-55.
Fernstrom AI, Oquist G. Location of the allergenic monomer in warm-polymerized acrylic dentures. Part I:
Causes of denture sore mouth, incidence of allergy, different allergens and test methods on suspicion of
allergy to denture material - a survey of the literature. Case report, allergenic analysis of denture and test
casting. Swed Dent J 1980; 4: 241-252.
Galloway H, Clarke JD. A Removable Appliance for the Preliminary Vertical Movement Subsequent Buccal
Movement of Palatally Impacted Canines. Br J Orthod 1985; 12: 208 – 211.
Gleed P. Elgiloy: is it worth it? Dent Tech 1995; Nov: 11- 12.
Har-Zion G, Brin L, SteinerJ. Psychophysical testing of taste and flavour reactivity in young patients
undergoing treatment with removable orthodontic appliances. Eur J Orthod 2004; 26: 73-78.
Hoyle A. The Development of Removable Appliance in the United Kingdom. Br J Orthod 1983; 10: 73 – 77.
Huddart AG, Scott MF. Common Faults with Removable Appliances; 1960.
Kerr WJS. Appliance Breakages. Br J Orthod 1984; 11: 137 – 142.
Kerr WJS, Buchanan IB, McCall JH. Use of the PAR Index in Assessing the Effectiveness of Removable
Orthodontic Appliances. Br J Orthod 1993; 20: 351 – 357.
Kerr WJS, Buchanan IB, McNair FI, McNair JH. Factors influencing the outcome and duration of removable
appliance treatment. Eur J Orthod 1994; 16: 181-186.
Kerr WJS, McCall JH, Frostik L. The Use of Removable Orthodontic Appliances in the General Dental Services.
Br Dent J 1996; 181: 18 – 22.
Lewis DH, Fox ND. Distal Movement without headgear: the use of an upper removable appliance for the
retraction of upper first molars. Br J Orthod 1996; 23: 305-312.
Littlewood SJ, Tait AG, Mandall NA, Lewis DH. The Role of Removable Appliances in Contemporary
Orthodontics. Br Dent J 2001; 191: 304 – 310.
Munns D. An Analysis of Broken Removable Appliances. Transactions of the BSSO 1971; 2: 449 – 452.
Nicholson PT. Extra Oral Anchorage to Upper Removable Appliances. Br Dent J 1979; 147: 45 – 46.
Ninou S, Stephens C. The Early Treatment of Posterior Crossbites. A Review of Continuing Controversies.
Dent Update 1994; 21: 420-426.
Noble PM, Butcher GW. A Removable Appliance 3 Dimensional Movement of Ectopic Maxillary Canines. Br J
Orthod 1991; 18: 135 – 138.
Ray WJ, Stevens CD. Indications for the Use of Fixed and Removable Orthodontic Appliances. Dent Update
1993; 20: 25 – 32.
Richmond S, Andrew M, Roberts CT. The Provision of Orthodontic Care in the General Dental Services of
England and Wales: extraction patterns, treatment duration appliance types and standards. Br J Orthod
1993; 20: 345-350.
Richmond S, Shaw WC, Stephens CD, Webb WG, Roberts CT, Andrews M. Orthodontics in the general dental
service of England and Wales: a critical assessment of standards. Br Dent J 1993; 174: 315-329.
Seel D. A rationalization of some clasping problems. Dental Pract 1967; 17: 188-195.
Stephens CD. The Southend Clasp. Br J Orthod 1977; 6: 183-185.
Stephens CD. The orthodontic center of rotation of the maxillary central incisor. Am J Orthod 1979; 76: 209-
217.
Toms AP. The Corrosion of Orthodontic Wire. Eur J Orthod 1988; 10: 87-87.
Turner PJ. Use of Removable Appliances as an Adjunct to Fixed Appliance Therapy. Dent Update 1993; 20:
428 – 432.
Turner PJ. Extra Oral Traction. Dent Update 1991; 18: 197 – 203.
Ward S, Read MJF. The Contemporary Use of Removable Orthodontic Appliances. Dent Update 2004; 31:
215-217.
Williams KR, Edmundson JT. Orthodontic tooth movement analysed by the Finite Element Method.
Biomaterials 1984; 5: 347-351.
Yettram AL, Wright KW, Houston WJ. Centre of rotation of a maxillary central incisor under orthodontic
loading. Br J Orthod 1977; 4: 23-27.
(Appendix 1)
CERTIFICATE OF CONFORMITY
THE ORTHODONTIC LABORATORY
DORSET COUNTY HOSPITAL
WILLIAMS AVENUE DORCHESTER DORSET DT1 2JY
This is a custom made appliance

for the exclusive use of:
Record number: Laboratory card number
Details of Appliance:
Date of manufacture:
Clinician:
STATEMENT
This Device conforms to the relevant essential requirements set out in Annexe 1 of the
Medical Devices Directive (93/42/EEC). If there are any relevant essential
requirements not met these will be listed overleaf with reasons stated.
Registration number of manufacturer with Medical Devices

Agency is CA 003410
Medical devices directive 93/42/EEC

(Appendix 2)
MANUFACTURER’S STATEMENT TO USER
Product name:- REMOVABLE APPLIANCES
Our name and address: - ORTHODONTIC DEPARTMENT

DORSET COUNT HOSPITAL
WILLIAMS AVENUE
DORCHESTER
DORSET
DT1 2JY
STORAGE: -
• Our removable appliances are supplies within a plastic bag and should be immediately replaced in
storage container after use. It should be stored in a cool place away from a heat source or direct
sunlight.
USE: -
• Our removable appliances are for the exclusive use of the patient it has been made for.
CLEANING: -
• Our removable appliances may be disinfected in any proprietary brand of disinfectant solution.
• Our removable appliances should be cleaned in cold soapy water and then rinsed under running
cold drinking water.
• Our removable appliances should not be cleaned with any abrasive substances or toothpastes.
MAINTENANCE: -
• Our removable appliances should not be altered in any way.
SERVICING: -
• Our removable appliances are serviceable by a trained orthodontist, or technician.
ACCESSORIES: -
• Our removable appliances may be supplied with a Face Bow.
OBSOLESCENCE:
• Our removable appliances should not be used after you have been told to stop using them.
ADDITIONAL IMPORTANT INFORMATION:
• If the removable appliance is subjected to a force in an injury it should be replaced.
• If changes to the mouth occur which effect the fit of the removable appliance it should be replaced.
• Do not allow your removable appliance to be immersed in warm or boiling water or put into a
tumble drier.
(Appendix 3)
MANUFACTURING PROCESS
All the appliances constructed in the Orthodontic Laboratory, Dorset County Hospital, are manufactured to
the following standard.
MANUFACTURING CONTROL
Only CE approved materials are used for the construction of our appliances where possible. If CE marked
materials are unavailable then we will use materials that have historically proven to be suitable for use in the
oral cavity.
We adopt best practice methods for the construction of all appliances manufactured in the laboratory, this
ensures that all necessary manufacturing control procedures are adhered to.
INSPECTION
All appliances are given a final inspection by a suitably qualified technician before leaving the laboratory.
HANDLING, STORAGE AND PACKAGING
Appliances are placed in self sealing polythene bags with write on panels. Patient’s name, record number,
clinician and clinic are shown on the bags.
Also attached to the bag are instructions for handling, storage and use of the appliance. The clinician is
given a certificate of conformity which should be kept with the patient’s notes. This certificate indicates that
the appliance is a “custom made appliance” for the exclusive use of the named patient and that it has been
manufactured in accordance with the Medical devices directive 93/94EEC.
ESSENTIAL MAINTENANCE OF EQUIPMENT
All equipment used in the dental laboratory for the manufacture of appliances is maintained and calibrated in
accordance with the relevant hospital policies.
Visit the discussion board to discuss any of the thoughts outlined above
Congratulations -You have now completed Module 21.

Please remember to complete the module assessment so we can keep improving the module content.

21 Removable Appliances

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21 Removable Appliances

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National Orthodontics Programme Module 21 - Removable Appliances

British Orthodontic Society 1

National Orthodontics Programme

About the National Orthodontics Programme

What you will learn

1. The development of removable appliances in the United Kingdom

Definition of a Removable Appliance

Aims and objectives of orthodontic treatment

o Hoyle A. The Development of Removable Appliances in the United

2. Mode of action of a removable appliance

a) Crown tipping in labio-lingual or mesio-distal directions.

Movement in the plane of the long axis

Bodily movement of teeth:

(a) A force applied at a single

Movements in the plane of the occlusion

The coil of palatal cantilever spring should lie on a

3. Materials used to construct removable appliances

Stainless steel wire

Elgiloy wire is available in four grades:-

The polymerising process may be:-

1 Technicians and dentists

4. The components of a removable appliance.

Springs Cantilever Spring : Hard Stainless Steel

Force dependent on : Wire length

Wire Length Coil increases effective length of the spring

Position close to attachment point to the base plate

Double radius: increase stiffness by - 16

Wire Thickness 0.5 – 0.7 mm SS.

Increasing diameter from 0.5 – 0.7 mm increase force x 4

Point of Contact Tooth will move in direction of resultant force

Types of Spring Palatal cantilever – boxed and guarded (0.5 mm SS)

Figure 7 Orientation of a coil for the ideal spring.

(a) A coil spring, which is activated by

Labial bow with reverse loops (mesial to (5|5) 0.8 mm

Split labial bow (reduces stiffness) 0.7 mm

Other Active Components

Screws - Arch Expansion

Elastics - Overjet Reduction

Adams Clasp Adjustment

Write short notes on each of the retentive components described above.

Anchorage is provided by:

Connects all components of the appliance.

Constructed from self polymerizing or heat polymerizing polymethyle methacrylate

5. How components are combined to design an appliance

The stages of appliance design are as follows:

1. Anterior bite plane, this may be flat or inclined

o The addition of headgear (distal movement, protraction)

Laboratory Request Form

6. The fitting and activation of an appliance

Wire bending pliers:

• Spring forming pliers.

• A stainless steel centimetre ruler is also required.

The First Fitting of an Appliance

1. Check the appliance is the correct appliance for the patient.

Medical Devices Agency Compliance Leaflet (appendix 1,2,3)

Appliance Home Care

The Design and Construction of Removable Orthodontic Appliances - Adams CP

B.O.S. Removable appliance information leaflet

7. Managing the patient at the first review appointment

At the First Review Appointment

o Munns D. An analysis of broken removable appliances. Transactions of the B.S.S.O 1971;

8. Advantages and disadvantages of removable appliances