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treatment plan, which should be clearly written down and should include the aims
of treatment, the stages of treatment and any necessary extractions. The intended
retention regimen should also be included.
It is at this stage that patient commitment and motivation must be assessed. Failure
to appreciate possible problems and to discuss them with the patient can prejudice
the future cooperation. A badly designed or constructed appliance will be difficult
to wear and can undermine the cooperation of even the most enthusiastic patient.
Records
Good records are essential at the start of any treatment, both as an aid in the initial
diagnosis and treatment planning and also to serve as a reference point during
treatment.
Study models
Well-trimmed current study models are most important (Figure 10.1). The
impressions should be taken using trays with deep flanges or built up with wax to
ensure that the full depth of the buccal sulcus is reproduced. This enables the form
of the alveolar process to be assessed.
The models should be cast with adequate bases, the upper being trimmed
symmetrically about the medial palatal raphe and the lower correspondingly. This
ensures that any asymmetry of the arches will be recognized. The posterior
surfaces of the models are trimmed flush so that the models can be related in
occlusion by laying them backs-down on a flat surface. At the visit following the
taking of the impressions, the models should be checked to ensure that the
occlusion is correctly recorded with the mandible in centric relation. If there is any
doubt about the articulation of the models the correct position should be registered
by drawing a vertical pencil line through the occlusion of the molars on both sides
and the models returned to the laboratory for re-trimming.
Radiographs
Good radiographic records are necessary to confirm the position of any unerupted
teeth and the condition of the alveolar bones. This is obviously important before
deciding upon the choice of teeth for extraction, but it may also be useful in the
event of untoward damage to the teeth during treatment. The normal radiograph
would be a dental pantomogram (DPT). Should there be any doubt about the
Different manufacturers produce pliers with varying handle shapes and sizes. Find
a pair that feels comfortable before you buy them. Reserve the plier tips for
adjusting the lighter wires and springs. Where heavy gauge wires (for example
extraoral facebows) require adjustment, grasp the wire closer to the hinge to avoid
damage.
Maun cutting pliers
These are a robust pair of wire cutting pliers, which will be suitable for cutting
stainless steel wires of the dimensions commonly used for removable appliances
(Figure 10.4). If these are not available a pair of wire cutters that can cut wire up to
1.25 mm in diameter will be needed.
Measuring instruments
A pair of stainless steel spring dividers enables the distances between teeth to be
measured (Figure 10.5) and a 15 cm rule in millimeter divisions is useful for
measuring overjet and treatment changes.
INTRODUCTION
Successful management of orthodontic treatment depends upon the careful
assessment at each visit so that lack of progress of unwanted tooth movement can
be recognized early.
Show the appliance to the patient and demonstrate the retaining clasps and active
springs, drawing attention to the need to take care not to distort any of the active
parts of the appliance during its insertion and removal.
FITTING A REMOVABLE APPLIANCE
Comfort
The blebs or sharp edges on the fitting surfaces should be examined, it is removed
and then the appliance is tried in.
Wire components must not cause blanching.
Buccal springs and bows should lie close to the alveolar mucosa but not in contact
with it and must be clear of the base of the buccal sulcus and buccal frenii when
cheek is displaced laterally.
Retention
This should always be checked carefully. If the appliance is well made little
adjustment will be necessary. It should snap easily into place with finger pressure
and be a firm fit, although readily removable. Retention may be poor because the
appliance is badly designed to resist the displacing forces to which it is subjected.
Attention to design should avoid this.
Adjustment of clasps
Clasps made according to Adams' design offer good retention. Frequently,
however, the operator is presented with an appliance on which the clasps are faulty
and adjustments may be necessary.
When adjusting clasps the operator should avoid, as far as possible, bending the
wire at points where it has already been bent during construction by the technician.
The only exception to this rule is that where the clasps are initially too tight to
permit insertion, it may be necessary to grip each arrowhead in turn with the pliers
and bend it outwards (Figure 10.6). Once the appliance can be seated (if necessary
with the support of a finger) the accurate positioning of the arrowheads can be
investigated.
Possible faults are as follows:
Horizontal
The arrowheads do not contact the tooth or else grip it too tightly.
Vertical
The arrowheads grip too far occlusally or else push up into the gingivae.
These faults can be corrected in most cases by a combination of bends at two
points (Figure 10.7). Bending the wire just beyond the point where it has passed
over the embrasure controls its vertical position. Bending it nearer to the
arrowhead controls its bucco-lingual position.
Take as an example a clasp that is found to have an arrowhead pushing into the
gingivae (Figure 10.8a). The wire can be bent at point X to move the arrowhead
occlusally (Figure 10.8b). The height will be corrected but the adjustment will also
have the effect of moving the arrowhead away from the tooth. A bend can then be
placed at point Y to compensate for this (Figure 10.8c).
If the arrowhead grips too far occlusally it can be moved buccally by an adjustment
at point Y. A further adjustment at point X will then bring it into contact at the
correct position (Figure 10.9). It is important that the clasp does not grip the tooth
too tightly and an undercut of 0.25 mm has been shown to give an adequate clasp.
It is useless to attempt to tighten the clasp by bending the wire at the point where it
emerges from the acrylic. This will merely interfere with the passage of the wire
across the embrasure and prevent full seating of the appliance. The only indication
for adjustment at this point occurs in a case where the wire passes high over the
embrasure and interferes with the occlusion. Poor retention may be due to a
conically shaped tooth, which offers little undercut. This is especially common
when second molars are being clasped.
Base Plate
Bite planes are adjusted for height. Posterior bite planes are trimmed so that the
patient occludes evenly on both sides and are thinned, so that the occlusion is
propped open by sufficient amount to clear occlusion.
Anterior bite planes are checked for depth. Patient occludes with at least two or
three lower teeth. Bite plane will be levelled by additions of cold cure acrylic.
When incisors are to be retracted, anterior bite plane will be trimmed away from
them. Too small a gap between base plate and tooth will encourage food packing
and gingival hyperplasia and tooth may be prevented from moving.
Adjustment to active wirework
The appliance should now be easy to fit and have adequate retention. Before
activating springs the labial wires, loops and buccal springs should be adjusted if
necessary so that they lie at the correct height and do not traumatize the cheeks,
lips and gingivae.
During the first few days with a new appliance the patient has to get used to
inserting it correctly, must adapt to its presence and perhaps put up with a mild
degree of discomfort. It is sensible to provide only very hght activation so that the
appliance is self-activating and the springs cannot readily slip into the wrong
position. This will imply activation of about 1 mm for a palatal spring and 0.5 mm
for a 0.7 mm buccal spring. It will often not be possible to position a palatal spring
close to the gingival margin at the first visit because of contact with the
neighbouring tooth. This can be corrected at the next visit when some movement
should have taken place.
Anchorage
Anchorage is determined at design stage. If extraoral reinforcement is to be used,
the headgear should be fitted at this visit. Retention by base plate is checked.
Demonstration to the patient
Show the patient the appliance in the mouth using a mirror, demonstrating how it
should be inserted and removed. (During fitting, any anterior clasp on the incisors
will generally be engaged and the position of the springs checked before upward
pressure is applied to the palatal acrylic with a finger or thumb (Figure 10.10).
Removal should be achieved by exerting finger pressure on the bridges of the
Adams' clasps on the first molars to disengage them before the front of the
appliance is disengaged.)
Allow the patient to remove and replace the appliance in front of you.
Check that the appliance has been seated correctly, paying particular attention to
the position of active springs after the patient has inserted it.
The patient should be instructed to wear the appliance full time, i.e. all day, all
night, for meals and, as far as possible, for sports. Wear during meals is especially
important, particularly if bite opening has to be achieved or if the teeth are being
moved across the bite. As far as possible, cleaning should be carried out after
meals and particular care should be given to cleaning the fitting surface of the
appliance, either with a nail brush or with the patient's own tooth brush. If, on
occasion, circumstances do not permit this then the appliance should at least be
removed from the mouth and rinsed under a tap. If it does prove necessary to
remove the appliance from the mouth other than for cleaning, for example during
contact sports or the playing of a wind instrument, the patient should be instructed
to keep the appliance in a small, rigid box which will protect it from accidental
damage. Initially the patient will be very aware of the large bulk of the appliance
and may experience excess salivation and difficulty in swallowing. Reassurance
should be given that this is quite normal and that the appliance will rapidly feel
more comfortable. Difficulties with excessive salivation and swallowing usually
disappear within a few hours. Normal speech may take 24 to 48 hours to achieve.
The most difficult adaptation is to accept the wear of the appliance at meal times
and this may take several days to accomplish. The patient should be encouraged to
persevere until this has been achieved.
Information
1. The patient should be instructed not to disturb or distort the wire
components.
2. The patient should be instructed to wear the appliance for 24 hours a day and to
remove the appliance only while brushing, eating and also during contact sports
and swimming.
3. The patient should be instructed to clean the appliance by brushing it with soap
and water.
4. In case of pain or any damage or loose fitting, patient must report to the dentist.
5. The patient should be instructed to keep the appliance in the container with the
water whenever the appliance is not being worn.
The patient should be given simple verbal instructions:
Sticky sweets must be avoided. Chewing gum - other than one especially
formulated for denture wearers - will adhere to the acrylic.
Good oral hygiene is important - keeping the appliance and the mouth clean.
If the appliance breaks or causes discomfort or trauma to the cheeks or tongue,
the patient should not wait for a routine visit but contact the practice for an earlier
appointment.
The patient should continue to wear the appliance for some hours each day if
possible to maintain its fit. If the appliance cannot be worn it should be kept moist.
A printed information sheet on the use of the appliance should be given to the
patient to take home (Appendix 2).