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Comparison of objective wear time between monoblock and twin-block appliances measured by microsensor
Abstract
Objectives
To assess the objective compliance levels in skeletal Class II patients with mandibular retrognathia wearing monoblock and twin-block appliances.
Materials and Methods
A prospective clinical study was conducted with 30 patients between 10 and 15 years old who were equally divided into two study groups. Group 1 was treated with monoblock, and group 2 was treated with twin-block appliances. The patients were instructed to wear their appliance for 15 hours per day. Wear times were monitored by a microsensor. (TheraMon; MCTechnology, Hargelsberg, Austria) for an average of six appointments. Patients were also instructed to record their wear times on a chart, and this record was admitted as subjective wear time. Statistical analysis was performed with the data derived from both the patients' charts and the monitoring records.
Results
The mean wear time by the patients was 10.67 ± 3.93 hours, which was less than the 15 hours prescribed by the orthodontist, with no difference between the two appliances (P > .05). The regular use rate, which included the days with a wear time of 8 hours or more per day, was 75%. Compliance levels decreased by 35% throughout the six control appointments. Patients declared that their wear time was more than their objective wear time by an average of 3.76 hours.
Conclusions
Despite their different designs, there was no significant difference between the monoblock and twin-block appliances in terms of compliance.
... During the retention phase, studies used questionnaires and interviews to investigate adherence to the prescribed wear times of removable retainers by recording self-reported levels of wear time [53][54][55][56][57]. All studies that used and combined both objective and subjective methods to measure adherence compared the time removable appliances were actually worn to patients' self-reported wear times and all found that patients consistently overestimate their wear time [58][59][60][61]. Figure 3 shows the number of articles investigating the different forms of patient adherence highlighted in this review. ...
... Adherence during active orthodontic treatment Adherence to the prescribed wear time of functional appliances was investigated in 18 studies. Of these studies, the wear time of headgear appliances was the subject in four studies [25,32,58,59], the wear time of twin block and monobloc appliances was investigated in five studies [18,24,27,28,60], the wear time of headgear-activators was discussed in one study [17], and the wear time of maxillary expansion appliances in two studies [20,21]. To investigate the influence of the appliance type on wear time adherence, six studies investigated and compared the wear time of multiple appliances [22,23,29,30,61,62]. ...
... The effect of reminder messages was also investigated in other aspects of patient adherence, and it appeared to have a positive effect on treatment outcomes when using intermaxillary elastics [74], in improving the wear time of aligners during CAT [51] and in reducing the number of failed-appointments [45]. Studies on the effect of different types of removable appliances on adherence to the prescribed wear times indicated no difference between headgearactivators, monobloc appliances and twin block appliances [22,60]. Even when comparing appliances used for class II and class III malocclusion treatment no difference in adherence was found [23]. ...
Background
Patient adherence is a key factor in achieving orthodontic treatment success. Despite an evolution in orthodontic healthcare, no recent comprehensive reviews are available on patient adherence in orthodontics. This scoping review provides an evidence-based overview of the literature available on multiple aspects of patient adherence in orthodontics, during both active treatment as well as during the retention phase. Knowledge gaps identified in the literature are listed.
Methods
The protocol for this scoping review was registered in the Open Science Framework ( https://doi.org/10.17605/OSF.IO/EC6QD ). Electronic databases and reference lists of relevant studies were searched up to 9 February 2023. The inclusion criteria were studies investigating any form of patient adherence in orthodontics published in English from 2006 onwards. The exclusion criteria were studies investigating adherence in the following patients: those with an intellectual or physical disability that could affect their ability to coincide with their therapist’s recommendations and advice, those with oral cleft and craniofacial conditions, and those treated solely for obstructive sleep apnoea. Non-peer-reviewed studies and case reports were also excluded.
Results
A total of 3284 articles were identified, 60 of which met the criteria for final inclusion.
Conclusions
There is no conclusive evidence on which factors have a significant impact on patient adherence and how patient adherence can be promoted. The degree of patient adherence is generally not compared to achieved treatment results or stability of treatment results, making it difficult to provide clear statements about the impact of the degree of adherence on desired treatment results or orthodontic stability.
... Obiektywne pomiary czasu noszenia wykazały, że pacjenci noszą aparaty zdejmowane krócej niż jest to zalecane [1,6,7,8,9,10,11]. We wcześniej przeprowadzonych badaniach jako Pojawienie się czujników elektronicznych, które mogą być wbudowywane w zdejmowane aparaty retencyjne stanowi obiecujące narzędzie wspomagające ortodontów w monitorowaniu pacjentów po leczeniu ortodontycznym [14]. ...
... Mikroczujnik odczytuje i zapisuje aktualną temperaturę (z zakresu od 33,5°C do 39,5°C z dokładnością do 0,1°C) co 15 minut. Odczytane wartości są rejestrowane w pamięci wewnętrznej urządzenia [11,16,17,18]. Możliwe jest także przesyłanie danych do 30 aplikacji mobilnej w telefonie. ...
Introduction Removable retainers have been successfully used for many years as an independent or additional form of retention in patients after orthodontic treatment. Unfortunately, it has been proven that most patients do not follow the orthodontist's recommendations and do not use the braces for the number of hours necessary to stabilize the treatment effects. It has therefore become necessary to look for solutions and devices that are able to objectively record the actual time of retainers use. Aim of the study The aim of the study was to assess the usefulness of electronic microsensors in monitoring wear time of removable retainers. Materials and methods A search was conducted using PubMed, Google Scholar, ResearchGate databases. Articles were searched in English using the following key words: “microsensors”, “retention”, “orthodontic”, “TheraMon”, “Smart Retainer”. Results The results of the literature review show that microsensors embedded in the elements of removable retainers are a valuable tool for monitoring the time of their use. Awareness of the presence of electronic sensors increases patient discipline. In addition, they provide data that, apart from objectively documenting the course of retention treatment, may be used in the future to determine optimal retention protocols. Conclusions The retention stage is an indispensable element of orthodontic treatment. The use of microsensors built into removable retainers can help to improve the stability of treatment results. However, further research and work are needed to improve the performance and reliability of this type of electronic sensors.
... However, a randomized controlled trial [7] concluded that PT-wearing is sufficient for FTMA. Therefore, in a series of follow-up clinical studies [8][9][10], removable FTMA appliances were even investigated for their therapeutic effectiveness following PT-wearing protocols. Naturally, this has sparked controversy [11,12]. ...
... To date, however, conclusions of MA effectiveness alteration due to different wearing times are basically drawn from clinical studies [7][8][9][10]. This is largely influenced by patient compliance, which renders a situation of lacking solid and unbiased evidence of histological evaluation and biological mechanisms from reliable fundamental experiments conducted with animal models. ...
Objectives
This study was aimed at resolving the controversy over the wearing time of mandibular advancement (MA) appliances by comparing the differences between part-time and full-time MA (PTMA and FTMA) from the perspective of promoting H-type vessel coupling osteogenesis in the condylar heads.
Materials and methods
Thirty 30-week-old male C57BL/6J mice were randomly divided into 3 groups: the control (Ctrl), PTMA, and FTMA groups. The mandibular condyles were analyzed by morphology, micro-computed tomography, histological staining, and immunofluorescence staining to investigate the changes of the condylar heads in the PTMA and FTMA groups after 31 days.
Results
Both PTMA and FTMA models promoted condylar growth and achieved stable mandibular advancement at day 31. However, compared with PTMA, FTMA has the following characteristics. First, new bone formation in the condylar head was detected in the retrocentral region in addition to the posterior region. Second, the condylar proliferative layer was thicker, and the number of pyknotic cells in the hypertrophic and erosive layers was higher. Moreover, endochondral osteogenesis of the condylar head was more active. Finally, the retrocentral and posterior regions of the condylar head had more vascular loops or arcuate H-type vessel coupling Osterix⁺ osteoprogenitors.
Conclusions
While both PTMA and FTMA induced new bone formation in the condylar heads of middle-aged mice, FTMA promoted more osteogenesis by volume and region. Furthermore, FTMA presented more H-type vessel coupling Osterix⁺ osteoprogenitors in both the retrocentral and posterior regions of the condylar head.
Clinical relevance
FTMA is better at promoting condylar osteogenesis, especially in non-growing patients. We suggest that enhancing H-type angiogenesis could be an effective strategy to achieve favorable MA outcomes, especially for patients unable to meet the FT-wearing requirement or being non-growing.
... 9,10 Adolescents reportedly wear removable devices only 65% of the time required, 9 and their compliance tends to diminish over the course of treatment. 10,11 One possible reason for this reduced cooperation is the bulky design of the appliances, which can cause discomfort and have an unsightly appearance. 12 To improve patient compliance with removable functional appliances, we developed a less invasive and more esthetic device, the F22 Young* clear aligner. ...
The article examines the conceptual provisions of continuous education of
pharmaceutical industry specialists from the point of view of implementing mechanisms for
ensuring their continuous professional development in modern conditions. It was revealed
that the pharmaceutical education system should be constantly improved in view of the
dynamic development of the pharmaceutical industry and European integration processes. The
process of birth and development of pharmaceutical education, pharmaceutical industry and
their management in Ukraine is shown. It was emphasized that the training of specialists in
the pharmaceutical industry should be aimed at their continuous self-development in order to
realize the rights and legitimate interests of citizens in providing affordable and high-quality safe
medicines.
Keywords: pharmaceutical industry, public administration, medical education, continuing
education, principles of continuing European education
Objectives
The aim of this review was to determine whether the type of removable appliance, as well as the age and sex of the patient, may affect the extension or reduction of wear time by assessing the correlation between the mean actual and orthodontist-recommended wear times.
Methods
Randomised case control trials, cohort studies, case series, observational studies, reviews, and retrospective analyses were identified. The quality of the studies was assessed using the Cochrane Collaboration Tool and modified Newcastle-Ottawa Scale. The electronic databases Embase, PubMed, Scopus, and Web of Science were reviewed, and 542 articles were obtained, of which 31 were qualified for qualitative synthesis. The data from 1674 participants were collected and a weighted average was determined for the mean wear time of each appliance.
Results
Regardless of the type of extra- or intraoral appliances, mean wear time was shorter than recommended, although patients using intraoral appliances cooperated more. The best compliance was noted for Schwarz appliances (73.70%) and plate retainers (85%). There was no evidence of an influence of patients’ age and sex on compliance during treatment.
Conclusions
The considerable inconsistency and imprecision of articles could affect the reliability of the results. Previous studies analysing the effectiveness of treatment with removable appliances based on an arbitrarily assumed average wear time need to be revised in order to verify the actual wear time with the use of microsensors.
Introduction:
The aim of this 2-arm parallel study was to compare the dentoalveolar and skeletal changes achieved with Twin-block appliance therapy prescribed on either a part- or full-time basis for 12 months.
Methods:
Sixty-two 10- to 14-year-old patients were randomly allocated to either full-time (FT, 22 hours daily) or part-time (PT, 12 hours daily) wear of a modified Twin-block appliance. Participants were recruited from the Institute of Dentistry, Barts and the London School of Medicine and Dentistry, London, United Kingdom, and recalled at 6- to 8-week intervals. Electronic randomization was undertaken, with group allocation concealed using opaque, sealed envelopes. The outcome assessor was blinded; however, it was not feasible to blind either operator or patients. Study models and cephalograms were taken at baseline and after 12 months of treatment.
Results:
Data from 55 of the 62 participants were analyzed. Overjets were reduced by 7 mm (SD, 2.92) in the PT group and 6.5 mm (SD, 2.62) in the FT group, with no statistical difference between the groups (P = 0.587; 95% CI, -1.01, 1.78). Similarly, no clinical or statistical differences were noted for skeletal changes: ANB angle (PT, -1.51°; FT, -1.25°; P = 0.828; 95% CI, -0.68, 0.849), pogonion-sella vertical (PT, 3.25 mm; FT, 3.35 mm) or A-sella vertical (PT, 1.28 mm; FT, 1.06 mm). Mean wear durations were 8.78 hours a day in the PT group and 12.38 hours in the FT group.
Conclusions:
There was no difference in either dental or skeletal changes achieved with PT or FT wear of a Twin-block appliance over 12 months. Less onerous PT wear regimens may therefore be a viable alternative to FT wear of removable functional appliances.
Registration:
NCT02190630.
Protocol:
The protocol was not published before trial commencement.
Background:
The effectiveness of orthodontic treatment with removable appliances arouses controversy concerning the level of patients' compliance. The compliance depends on factors controlled by the orthodontists, by the patients themselves and by their caregivers, and those beyond any control.
Objectives:
The purpose of this study was to assess the extent to which the personality traits of patients and their caregivers affect the cooperation in removable appliance therapy.
Material and methods:
A total of 38 patients (19 boys, 19 girls) aged 9-12 years, presenting malocclusions suitable for removable appliance therapy were randomly selected. The EAS-C Temperament Questionnaire, Generalized Self-Efficacy Scale, NEO-Five Factor Inventory and Parental Attitude Scale developed by Plopa were employed to evaluate the patients' and the caregivers' temperamental dispositions. Electronic sensors were employed to objectively assess patients' cooperation.
Results:
Statistical analysis revealed a high positive correlation between removable appliance wear time and the results of the GSES and the SPR-R, a strongly positive correlation between wear time and the NEOFFIC results and a strongly negative correlation between wear time and the EAS-C-Emo measurement. The level of a generalized sense of efficacy, conscientiousness and the severity of requirements imposed on the child were the factors related to the caregivers, positively correlating with patients' cooperation.
Conclusions:
The cooperation of children treated with removable appliances may be foreseen with observation of the patients' and their caregivers' traits. Objective evaluation of the patients' cooperation and psychological tests may be valuable tools for the re-assessment of the paradigm of early orthodontic treatment.
Introduction:
The primary aims of this systematic review were to assess objective levels of wear of removable orthodontic appliances and components vs both stipulated and self-reported levels. We also aimed to consider patient experiences and the effectiveness of interventions geared at enhancing compliance.
Methods:
Electronic databases and reference lists of relevant studies were searched with no language restriction (PROSPERO: CRD42016036059). Randomized and nonrandomized controlled trials, prospective cohort studies, case series, qualitative and mixed-methods studies objectively assessing compliance levels were identified. The quality of the studies was assessed using the Cochrane Collaboration's risk of bias tool, risk of bias in non-randomized studies of interventions (ROBINS-I), or mixed-methods appraisal tool based on their design.
Results:
Of 4269 records, 80 full texts were obtained, with 24 studies meeting the selection criteria. Of these, 11 were included in the quantitative synthesis. A weighted estimate of objectively assessed compliance levels in relation to stipulated wear time was calculated with the discrepancy highest in the headgear group (5.81 hours per day, 95% confidence interval, 4.98, 6.64) based on 6 studies. The mean discrepancy between self-reported and objectively assessed headgear wear was 5.02 hours per day (95% confidence interval, 3.64, 6.40). Compliance level was not directly related to appliance type (P = 0.211). Thematic synthesis was not undertaken because of the limited number of qualitative studies.
Conclusions:
Compliance with removable orthodontic appliances and adjuncts is suboptimal, and patients routinely overestimate duration of wear. Techniques for improving compliance have promise but require further evaluation in high-level research.
Objective:
To conduct an objective assessment of the level of compliance in young patients prescribed various types of removable appliances and to determine the influence of device type, treatment duration, and patient age, gender, psychological maturity, and awareness of monitoring on compliance.
Materials and methods:
A total of 30 patients were fitted with either a class 2 (Frankel or bionator) or a class 3 (face mask) removable appliance, each bearing a compliance indicator chip, and they were instructed to wear them for 13 hours per day. Compliance was monitored by means of the sensor for an average of 8 months. Of the patients, 14 were informed that their appliance was fitted with a monitoring sensor, and 16 were not. The psychological maturity of all patients was assessed on the Nowicki-Strickland Locus of Control Scale, and the effect on compliance of this score as well as the patient- and treatment-related variables considered were determined via statistical analysis Results: The mean compliance recorded by the chips was 8.6 ± 2.9 hours, far lower than the 13 hours prescribed, and younger patients showed significantly greater compliance than adolescents (P < .01). However, no significant differences in compliance were found between intra- and extraoral appliances, and neither gender, psychological scores, treatment duration, nor awareness of being monitored had any significant effect.
Conclusions:
Compliance is generally very poor in young patients, regardless of their gender and psychological maturity. Although awareness of monitoring does not appear to boost compliance, such systems may be a valuable means of providing a dentist with objective information regarding their patients' compliance.
Objectives:
To systematically compare the efficacy of fixed and removable functional appliances in Class II malocclusion in terms of morphological and patient-centred outcomes.
Search methods:
A comprehensive search of electronic databases without language or time restrictions was undertaken, applying a pre-specified search strategy. Supplementary electronic searching of orthodontics journals and references list of included studies was performed.
Selection criteria:
Randomized (RCTs) and controlled (CCTs) clinical trials involving children under 16 years with Class II malocclusion and overjet more than 5mm were included.
Data collection and analysis:
A range of clinician- and patient-centred outcomes were evaluated and compared. Risk of bias assessment was carried out using the Cochrane Collaboration tool.
Results:
Only four clinical trials were found to meet our criteria, of which two were RCTs, comparing the Herbst and the Twin Block appliances. Two further CCTs, compared the Activator to the Forsus and the Twin Force Bite Corrector, respectively. One study was assessed to be at unclear and the remaining at high risk of bias, precluding meta-analysis. There was also significant clinical heterogeneity in terms of methodology, type of intervention and the measured outcomes. Both modalities were effective in correcting the overjet with little differences found in cephalometric changes and a shortage of data concerning patient-centred outcomes.
Conclusion:
There is little evidence concerning the relative effectiveness of fixed and functional appliances or in relation to patient experiences and perceptions of these treatment modalities. Further well-designed clinical trials assessing the relative merits of both clinician- and patient-centred outcomes are needed.
Introduction. Removable appliances belong to one of the orthodontic therapy forms, most frequently selected in the period of dentition exchange. The effectiveness of orthodontic treatment with such appliances is particularly dependent on patients' cooperation. So far, since objective evaluation of such cooperation was not possible, questionnaire studies were used for this purpose. Nowadays, objective evaluation has become possible thanks to the introduction of microsensors. Aim of the study. To perform objective evaluation of cooperation of patients orthodontically treated with removable appliances. Material and methods. 45 children (20 boys and 25 girls) treated with different types of removable appliances were examined. The average age of the examined individuals was 9.2 years (8.9 years for boys and 10.6 years for girls). TheraMon microsensor measuring the temperature change was placed in each removable appliance. It was recommended that appliances should be worn for 9 hours every day. Readings were taken during every control visit with the use of special software. The results were subject to statistical analysis. Results. The average wear time of appliances during day and night was 8.3 hours (8.7 hrs for boys, 7.9 hrs for girls). Medical recommendations were followed by 50% of boys and 33.3% of girls. A statistically significant difference in compliance with medical recommendations with regard to patient's gender was reported. Conclusions. The method of measuring the level of patient's cooperation presented in the study may be helpful in modifying patients' motivation. More importantly, objective measurement of cooperation will allow determining the extent of impact of current therapeutic procedures and/or patients' cooperation on the treatment outcome. It will be a strong argument in discussion concerning the policy of reimbursement of orthodontic treatment in Poland.
Purpose
The relationship between unhealthy body mass index (BMI) and adherence to orthodontic treatment with removable appliances has not previously been evaluated.
Objective
The aim of this study was to quantify the association between BMI and wear time of removable orthodontic appliances and to evaluate BMI changes during orthodontic treatment.
Patients and methods
Fifty-three normal-weight and 39 overweight/obese children and adolescents (7–15 years old) undergoing orthodontic treatment with removable appliances were enrolled into the study. BMI categories were determined using standardized age-specific and sex-specific BMI criteria, using data measured at the beginning of therapy and once during orthodontic treatment. Wear times of removable appliances were measured at 15-minute intervals over a period of 5 months using implanted microelectronic sensors. Median wear-time values were used in the analysis with the Mann–Whitney U-test used to test statistical differences between groups.
Results
The median wear time of removable orthodontic appliances was 9.3 hours for normal-weight patients and 9.2 hours for overweight/obese patients. No statistically significant (P>0.05) or clinically relevant differences in usage or adherence were detected between normal-weight and overweight/obese patients. BMI did not influence wear time or behavior of removable orthodontic appliances by young patients. The majority of patients showed qualitative decreases in BMI during therapy.
Conclusion
The orthodontic treatment of young patients with removable devices does not require BMI-dependent changes in the treatment strategy. However, the use of removable appliances during meal times raises the possibility of reducing food intake, and in this way the orthodontist may have an active role to play in weight reduction.
Objective:
To assess objectively patient compliance with removable orthodontic appliances and the effect of possible influential factors.
Materials and methods:
Wearing times of 45 White patients were recorded with the aid of the TheraMon microsensor. Patient compliance was assessed relative to wear prescription and other parameters, such as age and sex.
Results:
There was high individual variation in most measured variables and in all groups/subgroups. During a median observation period of 186 days (range, 55-318 days) the actual wear time was 9.0 h/d (range, 0.0-16.0 h/d) and did not differ between distinct prescriptions (P = .49). Eight patients wore their appliances less than 2 h/d, and six of them did not wear their appliances at all. Overall, the median wear per day relative to prescription was 62.5% (range, 0.0-89.3%) for the 14 h/d and 112.5% (range, 0.0-200.0%) for the 8 h/d prescription wear (P = .01) groups. There was a strong negative correlation of age (median: 12.5 years) with the daily percentage of actual wear time per day relative to wear prescription (14 h/d prescription: n = 21, rho = -0.61, P = .00; 8 h/d prescription: n = 24, rho = -0.73, P = .00), while sex did not exert a significant influence on compliance (P = .58).
Conclusions:
Despite the fact that patients and parents were informed about wear time recording, compliance was insufficient with regard to functional treatment (14 h/d prescription), while it was sufficient for retention purposes (8 h/d prescription). Objective measures are necessary to assess compliance with removable orthodontic appliances since patient compliance is a highly variable issue.
Objective:
To assess the effect of wear-time recording on subjective and objective wear time.
Materials and methods:
This study retrospectively examined a group of 18 patients and a control group of 14 patients at four appointments over 168 days. The patients were treated with removable appliances with embedded TheraMon-microsensors to be worn for 15 hours per day. The study group was not told about the microsensor until the first appointment after fitting of the appliance. At each appointment patients were asked about their subjective wear time and afterward were told about the objective wear time. The existence of the microsensor was revealed to the control group when the appliance was fitted. Objective wear time was also announced at every appointment.
Results:
Mean wear times did not significantly differ between groups at any appointment or regarding overall wear time. Highly significant differences between subjective and objective wear time were found when patients did not know that their wear time had been monitored.
Conclusion:
Mean wear times assessed in this study concur with data of previous studies. Patients tend to overestimate their wear times but become more realistic once they know wear time is being monitored. Objective measurement of wear time allows a more realistic view of compliance by patient and orthodontist. Knowing that wear time is recorded does not necessarily increase the amount of time removable appliances are worn by the patient.
To evaluate the color fading in aqueous solutions of the blue dot wear-compliance indicators of the Invisalign Teen® System outside the oral cavity.
The compliance indicators in the Invisalign Teen aligners were tested for color resistance in various aqueous models with no saliva involved.
Color fading was observed as a function of time, pH, and temperature while compliance indicators were stored in drinking water or sour soft drinks and in conjunction with the use of cleaning tablets and a dishwasher. The findings of color fading were consistent with the color changes observed when the aligners were being worn by patients. Color fading, notably as observed in connection with acidic soft drinks and cleaning techniques, introduces uncertainty into the assessment of actual patient compliance, as reflected by the fading colors of compliance indicators.
Compliance indicators are not immune to simple intentional or unintentional manipulations. Therefore, they can best show an estimate of wear time but cannot be recommended as objective wear-time indicators.
Introduction:
This study aimed to evaluate the effects of 3 different fixed or removable functional appliances on the soft tissue changes in patients with Class II Division 1 malocclusion using 3-dimensional images.
Methods:
A total of 60 patients with Class II Division 1 malocclusion (38 girls and 22 boys; mean age, 12.35 ± 1.01 years) were treated with 3 different functional appliances, namely, Twin-block (TB) (group TB, n = 20), mono-block (MB) (group MB, n = 20), or Herbst (H) (group H, n = 20) for 9.55 ± 1.46 months. Three-dimensional photographs of each patient were taken at the baseline and the end of the therapy with a 3dMD Face system (3dMD, Atlanta, Ga). Statistical analyses were performed using the dependent samples t test, 1-way analysis of variance, Kruskal-Wallis, Mann-Whitney U, and Wilcoxon signed rank tests.
Results:
No statistically significant differences were detected for soft tissue changes except for the lower facial width found, at least in group H (P <0.05). Volumetric differences in the mandible were similar between the groups (P >0.05). A statistically significant decrease in total facial height and an increase in convexity angle and facial depth were detected in all groups after treatment compared with the baseline (P <0.05). The upper and lower facial height, lower lip height, and nasal width were statistically significantly increased in the TB and MB groups after treatment compared with the baseline (P <0.05) and similar to those in group H (P >0.05).
Conclusions:
TB, MB, and H appliances may promote the facial soft tissue profile, including volumetric improvement, in the mandibular region.
Background:
Success of orthodontic removable appliance treatment relies on patient compliance. The aim of this quantitative and qualitative study was to explore the compliance and self-reported experience of adolescents in orthodontic treatment with headgear activator (HGA) or twin-block (TB) appliance.
Materials/methods:
The study group comprised 52 adolescents with a mean age of 12.6 (±1.3) years at the start of the treatment. The patients were treated at a free-of-charge public dental clinic. Participants were randomly allocated to two equal groups to be treated with either HGA or TB. Patient compliance was evaluated as appliance wear time and subjective experience. Appliance wear time was recorded with Theramon® microchip, and the self-reported subjective experience using a questionnaire.
Results:
In total, 30 patients completed the treatment during the follow-up period. HGA was worn on average 7 hours per day and TB 9 hours per day by those patients, who successfully completed the treatment. During a mean observation period of 13 months (range 7-23 months), the mean actual wear time was 43 per cent less than the advised 12 or 18 hours per day in the whole patient group, and 55 per cent in those patients, who completed the treatment. Compliance level was unrelated to the appliance type.
Limitations:
Study assessed a relatively small number of patients.
Conclusions/implications:
Adolescent patients wear HGA and TB less than advised. Individual variation in treatment adherence is considerable. Thereby, microelectronic wear-time documentation can be a cost-effective mean of identifying non-compliance.
Introduction:
Lack of compliance during functional appliance therapy may lead to extended treatment or even induce treatment failure. The aims of this study were to explore factors influencing compliance in adolescents treated with a Twin-block appliance.
Methods:
A qualitative study using one-to-one semistructured interviews involving a sample of adolescents undergoing Twin-block therapy with objectively recorded wear durations was undertaken. A topic guide was used to standardize data collection. Participants' views were tape recorded and field notes taken. Data were transcribed verbatim and analyzed with the use of framework methodology.
Results:
A total of 22 participants were interviewed. Factors influencing compliance with removable functional appliance included: self-motivation, peer and authority influence, quality of life impairment and adaptability, perceived treatment progress, and pragmatic and recall issues. These factors were found to exert important roles as enablers, barriers, or both. Patient recommendations to improve compliance included effective communication, tailoring of prescribed wear duration, physical alteration of the appliance, and use of reminding tools.
Conclusions:
The study highlights the multifaceted perceptions of removable functional appliance wear, with compliance fluctuating over time and a range of factors influencing this. The potential for professional and parental influence as well as customized reminders to enhance compliance were also reported.
Objectives:
A broad spectrum of colors for removable appliances, intended to optimize acceptance of treatment and patient cooperation, have been available on the dental market for years. This is the first study to analyze how patient-selected colors are reflected in wear times and wear behavior of removable appliances.
Materials and methods:
The study included 117 children (55 girls and 62 boys) who were treated with active removable plate or functional appliances. All patients were offered to choose from 11 different colors, which were pooled into six groups (black, blue, green, yellow, pink, red) for analysis, or to combine any two to four colors ("multicolored" group) for their appliances. All appliances featured a built-in microsensor (TheraMon; MC Technology, Hargelsberg, Austria) for objective wear-time tracking. Differences between wear times were analyzed using pairwise t tests and Tukey correction.
Results:
The longest median wear times were recorded in the blue and green groups (≈11 h/d) and the shortest ones in the red and pink groups (≈9 h/d), but they were not significantly influenced by the patient-selected colors. The median wear times involved an age-related decrease by 0.56 h/y that was statistically significant ( P = .00005). No gender-specific patterns of wear behavior were observed.
Conclusions:
Patient-selected colors for removable appliances can presumably improve acceptance of treatment, but they are not associated with statistically significant improvements in wear time or wear behavior.
Aim:
To assess whether or not childhood overweight is associated with lower levels of compliance during orthodontic therapy with removable appliances.
Materials and methods:
Starting in 2011, all upper expansion plates and Sander II appliances were equipped with a Theramon® microsensor chip to assess appliance wear time objectively. According to their pre-treatment, BMI normal weight patients were matched to consecutively treated overweight or obese patients by gender, age, and appliance type. Cooperation was assessed with microelectronic wear time documentation over a period of at least 6 months.
Results:
A total of 50 patients (25 overweight, 25 normal weight) with upper expansion plates and 64 patients (32 overweight, 32 normal weight) with Sander II appliances were analysed. Spearman Rho coefficients showed an indirect association between BMI and appliance wear time, indicating that the higher the BMI, the less the patients wore their appliances (P < 0.05). Furthermore, both normal- and overweight children wore upper expansion plates significantly more than Sander II appliances (P < 0.05). Although no gender-specific difference was found (P = 0.723), an age-related correlation could be verified, indicating a decrease in wear time with increasing age (P < 0.05).
Conclusions:
An increased BMI appears to be a risk factor for less appliance wear during orthodontic treatment with removable appliances. Additional factors which influenced cooperation during treatment with removable appliances were patient age and appliance type.
The treatment of children presenting with a Class II division I malocclusion involves one of two approaches. The first provides treatment in two phases; one of intervention during the mixed dentition (phase I) followed by a second definitive course of appliance treatment in early adolescence (phase II). The second approach involves providing a single course of comprehensive therapy during adolescence. The debate for and against early treatment is discussed alongside key, clinically relevant evidence related to Class II division I malocclusions.
Background/objectives:
Patients do not always adhere to the wear times prescribed for removable orthodontic appliances. We evaluated the validity and usability of indirect wear-time assessment methods by comparing wear-time estimates with microelectronically measured wear times in patients with removable orthodontic appliances.
Methods:
Wear times of 33 expansion plates, 34 functional appliances, and 42 retention plates of patients aged 6-20 years (12.3±2.9 years, 50.5% female) were indirectly determined by practitioners using a questionnaire assessing five parameters on a 5-point Likert scale: appliance handling, appliance appearance, bite shift, tooth movement, and appliance fit. The perceived difficulty in assessing each parameter was rated. Actual wear times were evaluated with microelectronic sensors in the appliances.
Results:
Regression analyses revealed that practitioners' decisions about wear times varied depending on the type of appliance and criteria used, with only one standard criterion best predicting estimated wear time for each appliance. Different standard criteria were better predictors of measured wear time: 22.3% of wear-time variability was explained by expansion plate appearance, 31.2% by functional appliance handling, and 18.8% by retainer fitting. However, practitioners rated the difficulty of assessment in most cases as 'easy'.
Limitations:
The study was not double blinded for technical reasons, and practitioners may have considered the evaluation criteria more carefully than in normal daily practice.
Conclusions:
Practitioners' decisions about wear times based on standard criteria strongly vary depending on the type of appliance and criteria used.
Introduction: The aim of this study was to investigate whether microelectronic wear-time documentation can contribute to individualized orthodontic management. Methods: The wear times and behaviors of 281 patients undergoing orthodontic treatment with removable appliances were quantified and analyzed using the TheraMon microelectronic system (Sales Agency Gschladt, Hargelsberg, Austria) over a 6-month treatment period. Results: The 281 study participants wore their removable appliances for a median of 9.0 hours per day, compared with the 12 to 15 hours per day prescribed. Wear behavior was variable and heterogeneous in patients with almost identical median wear times, with fluctuating and numerous zero wear-time periods observed. Conclusions: Both the duration of daily wear time and the wear behavior need to be considered to individualize the prescription for wear time; this is made possible with microelectronic wear-time documentation. Individual prescription changes based on the wear-time documentation can be arranged with patients in a shared decision-making process to achieve effective and successful treatment progress. (Am J Orthod Dentofacial Orthop 2014;146:155-60) I ndication-dependent removable appliances, fixed appliances, and combinations of both are used in or-thodontic treatment. In Europe, the less expensive and less invasive removable appliances are commonly used for orthodontic treatment, mainly in the first phase of 2-phase active treatment but also during the reten-tion phase. 1-3 In the United States, fixed multibracket appliances are largely preferred for the active phase. Removable devices, such as the Hawley retainer (used by 58% of American orthodontists), are used first in the subsequent retention phase. 4,5
Objectives:
The aim of this study was to quantify the wear times of removable appliances during active orthodontic treatment.
Materials and methods:
The wear times of 141 orthodontic patients treated with active removable appliances in different locations were documented over a period of 3 months using an incorporated microsensor. Gender, age, treatment location, health insurance status, and type of device were evaluated with respect to wear time. Significant associations between wear times and patient factors were calculated using non-parametric tests.
Results:
The median daily wear time was 9.7 hours/day for the entire cohort, far less than the 15 hours/day prescribed. Younger patients wore their appliances for longer than older patients (7-9 years 12.1 hours/day, 10-12 years 9.8 hours/day, and 13-15 years 8.5 hours/day; P < 0.0001). The median wear time for females (10.6 hours/day) was 1.4 hours/day longer than males (9.3 hours/day; P = 0.017). Patients treated at different locations wore their devices with a difference of up to 5.0 hours/day. Privately insured patients had significantly longer median wear times than statutorily insured patients. No significant difference in wear time was noted according to device type.
Conclusions:
The daily wear time of removable appliances during the active phase of orthodontic therapy can be routinely quantified using integrated microelectronic sensors. The relationship between orthodontist and patient seems to play a key role in patient adherence. Wear-time documentation provides the basis for more individualized wear-time recommendations for patients with removable appliances. This could result in a more efficient, shorter, and less painful orthodontic therapy.
Original Article
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.
Level of Evidence
1b
Purpose
To determine the psychosocial benefits that result from the use of the Twin-block appliance in Class II Division I malocclusions during the mixed dentition
Source of Funding
Information not available
Type of Study/Design
Randomized controlled trial
Treatment options for Class II malocclusion include orthognathic surgery. Treatment choices are particularly difficult for young patients because of the uncertainty regarding future growth. Surgical treatment has generally been considered necessary for older patients with more severe Class II problems. The treatment records of more than 500 patients with Class II malocclusion were reviewed. Patients were grouped according to their initial treatment plan (surgery or orthodontics) and treatment outcome (overjet [OJ] reduced to <4 mm or not). Discriminant function analyses using data from the patient's pretreatment cephalogram were used to determine whether age, in combination with malocclusion severity, could predict the choice of treatment, and whether a simple set of pretreatment variables could predict the success or failure of OJ reduction. The derived equations were tested in a similar group of growing Class II children. Although the data showed clinicians use patient's age in determining treatment choice, age did not seem to be associated with treatment outcome. The majority of the variability that determined the success or failure of OJ reduction was not explained by patient's age or malocclusion severity. These findings suggest other factors, including psychosocial variables, need to be explored if we are to gain a better understanding of why treatments succeed or fail.
According to a recently performed unpublished survey of 6 major orthodontic laboratories in the United States, the Herbst appliance has grown to be the most popular functional appliance for the treatment of Class II malocclusions. This article gives a historical overview of the development of the Herbst appliance with special reference to the different anchorage forms used in the past and in the present. The development of Herbst appliance hybrids and derivatives will also be addressed.
Removable retainer wear is most related to patient comfort and acceptance. Patient compliance is essential for retention and maintenance of the orthodontic treatment results. Even though patients are educated about the need for prolonged retention after active treatment and asked to sign informed consent regarding the risk of noncompliance (relapse) prior to treatment, most orthodontists would estimate that at least half of their teenage patients do not comply at optimal levels. The aim of the present study was to quantify teenage patient compliance with removable maxillary retention and compare actual usage vs prescribed usage between subjects who knew they were being monitored via an implanted microsensor in the retainer and those subjects who were unaware of any monitoring. The final sample consisted of 9 subjects in the test group (5 males and 4 females) and 10 subjects in the control group (4 males and 6 females). The evidence suggests that individuals who were made aware of the orthodontist's ability to monitor compliance wore the device for a significantly larger number of hours per day than those who were unaware of this fact. Patients reporting full usage of the retainer wore the appliance a mean of 4.3 hours more per day than those reporting less than full usage, holding all other variables constant. Patients who misrepresented their retainer use (reported full usage but wore the device less than 19 hours per day) wore the appliance a mean 12.4 hours less than the more honest patients who participated in the study.
To ascertain the extent to which the new microelectronic sensors Smart Retainer® and TheraMon® are suitable for measuring wear times in orthodontic treatment.
The Smart Retainer® wear-time sensor and a prototype of the TheraMon® microsensor were each polymerized into upper plates. The orthodontic appliances were exposed to periodically altered temperatures in a thermostatic water bath.
The wear-time sensors recorded the changes in water temperatures as "wear time" (~35 °C) or "non-wear time" (room temperature). The wear times stored in the sensors were displayed and printed outside the water bath as "wear-time graphs" via readout stations and computers. To be better able to predict their reliability and applicability in orthodontic treatment, we measured the accuracy of the two wear-time sensors by comparing the wear times recorded by the Smart Retainer® and TheraMon® with the programmed water temperatures.
Both microelectronic sensors fulfilled the basic requirements for use as objective wear-time sensors in orthodontic appliances in clinical trials and routine orthodontic practice. As it can be incorporated into different orthodontic appliances, the smaller TheraMon® system offers greater versatility than the Smart Retainer®. The TheraMon® also permits the accurate documentation and analysis of wear times down to the minute.
How effective is a therapy which relies solely on removable orthodontic appliances?
A group of 276 consecutive patients, whose mean age was 9.50 years, diagnosed with various types of malocclusion, whose records were complete, and who were treated solely with removable appliances.
Measurement of the PAR Index of the pre- and post-treatment study casts, standard statistical analyses, calculation of the correlation coefficients, and method error.
The mean pre-treatment PAR score was 19.5, the mean post-treatment PAR score 5.9. In the PAR nomogram, 79% of the patients were classified as "improved", and 16% as "greatly improved". In contrast, 5% had to be classified as "worse/no different". The overall situation improved by a mean of 14 PAR points, corresponding to a mean improvement of 68%.
Using the PAR Index as a standard, removable appliances can be used successfully to correct malocclusions, providing the indication is correct and the clinician's expertise in this field of the speciality is very high.
The major primary factors in the dental equilibrium appear to be resting pressures of tongue and lips, and forces created within the periodontal membrane, analogous to the forces of eruption. Forces from occlusion probably also play a role in the vertical position of teeth by affecting eruption. Respiratory needs influence head, jaw and tongue posture and thereby alter the equilibrium. "Deviate swallowing" is more likely to be an adaptation than a cause of tooth changes. Patients with failure of eruption have been recognized and alterations in the eruption mechanism may be more important clinically than has been recognized previously.
This study was undertaken to determine the role of the headgear calendar and its relationship to headgear compliance. Headgear timers were used covertly to monitor actual headgear wear of 28 patients for three consecutive orthodontic appointments. Fourteen patients were asked to monitor their daily headgear wear by using a headgear calendar. The other 14 did not use a calendar. The results show that patients who monitor their headgear wear with a headgear calendar are more compliant than those patients who do not (7.9 hours compared with 5.3 hours). All age groups in this study wore their headgear more when a headgear calendar was used with the exception of the > 16-year-old group. There is a high degree of correlation (r2 = 0.60) between the number of hours recorded on the calendar compared with the number of hours actually worn. There was a poor correlation (r2 = 0.02) between the number of hours the patient said he wore his headgear compared with the actual number of hours worn.
Patient compliance is considered a major problem in orthodontics. Yet, to date, few conclusive findings have been noted on determinants and consequences of failing adherence, probably because of method flaws and a lack of objective criteria. By following an outline of conceptual issues and selected research, we considered an investigation into correlates of patient compliance with removable appliance wear. We studied a sample of 77 university clinic patients ages 9 to 14 years over several months by means of psychologic inventories and electronic measurement of removable appliance wear. The actual compliance rate proved to be associated with many variables. Among those, characteristics of the patient and his family background, such as conformity and degree of consistent parental support and supervision are interpreted as determinants of satisfactory adherence, whereas treatment related and interactional correlates, such as duration of treatment, dominance of provider, and interpersonal perceptions, are conceived of in terms of mutually interdependent and/or consequent variables. The factors identified might be paralleled in the wearing of headgear and intraoral elastics that require a similar degree of active patient cooperation. After a critical discussion of our data in the light of previous findings, suggestions are provided for future research along with conclusions for clinical practice.
Functional appliances, which are used in the early treatment period of skeletal Class II malocclusions, induce the forward displacement of the mandible by altering the postural activity of the muscles and causing some changes in both skeletal and dentoalveolar structures. The purpose of this investigation was to evaluate the differences between monoblock and twin-block appliances. Two treatment groups composed of 26 growing patients with skeletal and dental Class II, Division 1, malocclusions, were compared to an untreated control group of 13 patients with the same morphologic characteristics and growth rate. These groups were matched according to their age, sex, and vertical and sagittal skeletal cephalometric and dental characteristics. Monoblock was worn by the subjects for 16 hours/day, whereas twin-block was worn 24 hours/day, even while eating. Patients of the control group were followed without any intervention. Treatment effects were identified with a conventional cephalometric analysis. The findings of this study revealed that by using these different functional appliances, the stimulation of the growth of the lower jaw and the correction of Angle Class II relationship were achieved. In the twin-block group, the mandibular plane angle and gonial angle increased, although a decrease in the degree of overbite occurred. In the monoblock group, upper incisors demonstrated a greater degree of retrusion. However, within the twin-block group, the lower incisors showed a greater degree of proclination.
The early treatment of severe Class II malocclusion remains a surprisingly controversial issue despite the publication of 3 large randomized controlled trials in the United States. 1-3 Perhaps a main reason is the belief that these trials were carried out on selected populations who received treatment at dental schools. As a result, these studies measured the efficacy of treatment—treatment delivered in “ideal” conditions. But what is the effectiveness of the treatment—how does it fare in the real world of orthodontic practice outside dental schools? We recently attempted to address this problem in a large multicenter trial in the United Kingdom. 4 Importantly, the treatment was provided by many operators using the most popular functional appliance in this country—the Twin-block. The results of this study were recently published in the AJO-DO, and I will describe here only the main findings and some preliminary data on the long-term follow up. Fourteen hospital-based orthodontic specialists in the United Kingdom took part in the study. Each had undergone basic specialty training and 3 years of higher training in the treatment of severe malocclusions. All operators were based in orthodontic departments, working in the National Health Service. In this system, the orthodontist receives a salary, and treatment is provided at no direct cost to the patient and family.
The aim of this systematic review of the literature was to assess the scientific evidence on the efficiency of functional appliances in enhancing mandibular growth in Class II subjects. A literature survey was performed by applying the Medline database (Entrez PubMed). The survey covered the period from January 1966 to January 2005 and used the medical subject headings (MeSH). The following study types that reported data on treatment effects were included: randomized clinical trials (RCTs), and prospective and retrospective longitudinal controlled clinical trials (CCTs) with untreated Class II controls. The search strategy resulted in 704 articles. After selection according to the inclusion/exclusion criteria, 22 articles qualified for the final analysis. Four RCTs and 18 CCTs were retrieved. The quality standards of these investigations ranged from low (3 studies) to medium/high (6 studies). Two-thirds of the samples in the 22 studies reported a clinically significant supplementary elongation in total mandibular length (a change greater than 2.0 mm in the treated group compared with the untreated group) as a result of overall active treatment with functional appliances. The amount of supplementary mandibular growth appears to be significantly larger if the functional treatment is performed at the pubertal peak in skeletal maturation. None of the 4 RCTs reported a clinically significant change in mandibular length induced by functional appliances; 3 of the 4 RCTs treated subjects at a prepubertal stage of skeletal maturity. The Herbst appliance showed the highest coefficient of efficiency (0.28 mm per month) followed by the Twin-block (0.23 mm per month).
In a retrospective multicentre study, the success rate and efficiency of activator treatment were analysed. All patients from two University clinics (Giessen, Germany and Berne, Switzerland) that fulfilled the selection criteria (Class II division 1 malocclusion, activator treatment, no aplasia, no extraction of permanent teeth, no syndromes, no previous orthodontic treatment except transverse maxillary expansion, full available records) were included in the study. The subject material amounted to 222 patients with a mean age of 10.6 years. Patient records, lateral head films, and dental casts were evaluated. Treatment was classified as successful if the molar relationship improved by at least half to three-fourths cusp width depending on whether or not the leeway space was used during treatment. Group comparisons were carried out using Wilcoxon two-sample and Kruskal–Wallis tests. For discrete data, chi-square analysis was used and Fisher's exact test when the sample size was small. Stepwise logistic regression was also employed.
The success rate was 64 per cent in Giessen and 66 per cent in Berne. The only factor that significantly (P < 0.001) influenced treatment success was the level of co-operation. In approximately 27 per cent of the patients at both centres, the post-treatment occlusion was an ‘ideal’ Class I. In an additional 38 per cent of the patients, marked improvements in occlusal relationships were found.
In subjects with Class II division 1 malocclusions, in which orthodontic treatment is performed by means of activators, a marked improvement of the Class II dental arch relationships can be expected in approximately 65 per cent of subjects. Activator treatment is more efficient in the late than in the early mixed dentition.