The Concept of Orthodontics Removable - Essay Example

? Orthodontics Removable, Fixed and Functional Appliances Table of Contents Page . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 1 Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Removable Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Fixed Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Functional Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Removable Functional Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Fixed Functional Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 List of Tables Table I. Effects, Reasons and Factors to Consider in Orthodontic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Table II. Components of Removable Appliance . . . . . . . . . . . . . . . . . . . . . . . . 6 Table III. Advantages and Disadvantages of Removable Appliance . . . . . . 7 Table IV. Types of Removable Appliance According to Force Applied . . . . . . 8 Table V. Clinical Observations with Fixed Appliance . . . . . . . . . . . . . . . . . 10 Table VI. Advantages of Functional Appliance . . . . . . . . . . . . . . . . . 12 Table VII. Disadvantages of Removable Functional Appliance . . . . . . . . . . . 15 Table VIII. Twin Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table IX. Advantages and Disadvantages of Fixed Functional Appliance . . . . . 16 Table X. Disadvantages of Fixed Functional Appliance Herbst and Jasper Jumper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Table XI. Ritto Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Table XII. Types of Fixed Functional Appliances . . . . . . . . . . . . . . . . . . 19 Orthodontics Removable, Fixed and Functional Appliances Introduction Orthodontics is a branch of dentistry that deals with facial improvement, development of occlusion, and treatment occlusal displacements (Department of Health 2006). It was credited to physician Pierre Fauchard (regarded as father of dentistry) at the start of 18th century in France who described an appliance called as “Bandlette” (now known as expansion arch (Graber TM 1966, cited in Vijayalakshmi & Veereshi 2010, p. 11). He was the first to attempt moving the teeth using Bandlette, an arched flat strip of metal with holes for threads to pass through and apply force upon the teeth. The first fixed appliance used in orthodontics is attributed to Pierre Fauchard while the first removable appliance recognized in orthodontic practice was the Coffin plate introduced by Coffin during the late 19th century (Vijayalakshmi & Veereshi 2010). The Coffin plate had a spring (still present in the current appliances) made of piano wire (Proffit & Fields 1999; Graber N 1977, cited in Vijayalakshmi & Veereshi 2010). The fixed or removable appliance adjusts the teeth slowly and cautiously to prevent extreme pain and damage to the teeth (Cunningham, Horrocks, Hunt, et al. 2000). Lionel (2005) said that orthodontic therapy affects the dimension of dental arches that could lead to relapse, thus requiring post-treatment. There is also a tendency for malocclusion to recur, he added. Malocclusion refers to the atypical arrangement of the teeth or jaws (Cunningham, Horrocks, Hunt, et al. 2000). Malocclusion should be treated because it may lead to diseases, cause dysfunction of the jaw (that affects speech and mastication, or leads to Tempero-Mandibular Disorder), affects aesthetic features of the face that may have negative psychological implication, and damage to teeth (Mascia n.d.). Table I Effects, Reasons and Factors to Consider in Orthodontic Treatment Reasons Benefits Risks Effects a. Facial aesthetic b. correction of crossbite, overjet and crowding in children a. improved function b. improved aesthetic a. worsened oral health (ex. caries) b. failure to attain end-goal a. diminished patient cooperation due to discomfort (e.g. decreased sensation, constraint in oral cavity, tongue displacement, teeth soreness, pain) b. self-confidence is affected during social interactions (e.g. impaired speech, visible appliance) (Source [a]: Vig et al., cited in Flores-Mir, Major & Major 2006; Peck & Peck 1995, cited in Flores-Mira & Major 2006; Vig, Weyant, & O’Brien et al. 1999, cited in Flores-Mira & Major 2006). (Source [b]: Keski-Nisula 2008). (Source: The Rationale for Orthodontic 2001) (Source: The Rationale for Orthodontic 2001) (Source [a]: Oliver & Knappman 1985, Sergl et al. 1987, 1993; Egolf et al. 1990; Johnson et al. 1998; Sergl & Zentner 1998, cited in Sergl, Klages & Zentner 2000) (Source [b]: Lewis & Brown 1973; Zentner et al. 1996, cited in Sergl, Klages & Zentner 2000) The general categories of appliances used in orthodontics are the fixed appliance and removable appliance (Ghafari n.d.). The functional, removable and fixed appliances can be used simultaneously or after the other type has been removed. Removable Appliance A removable appliance is an orthodontic device (with a number of components) that can be placed and removed by the user (Isaacson et al. 2002). Sophisticated removable appliances that use expansion screws were developed during the early part of the 20th century. New removable appliances utilize acrylic baseplates and stainless steel wires. They can move specific teeth, hold them in position, and affect development of the jaws and eruption of tooth (Removable appliances, n.d.). Table II Components of Removable Appliance 1. body made of acrylic baseplate foundation of device provides support to other elements (e.g. springs, clasps) supplements anchorage (through contact with palatal vault and unmoved teeth) normally use cold-cured acrylic but heat-cured preferred in areas (e.g. deep overbite, heavy occlusal forces) with potential breakage 2. spring patterned after the common cantilever force of round wire during deflection rests upon the “elastic limit” of “deflection, the cross-sectional area of the wire and the length” (p. 16) ideal spring provides convenience and easy management for the patient, one with little deflection and can withstand distortion and displacement longer palatal cantilever spring provides greater flexibility 3. screw provides force upon teeth through the acrylic it is in contact with patient is the one who adjusts the screw, using a key, every once or twice a week depending on need force produced by such adjustment is quite high adds up to expense and makes the appliance bulky only suggested when spring might not work satisfactorily 3. elastic placed between appliance and displaced tooth must be regularly changed and monitored to remain within appropriate force limit not usually recommended, generally considered as unsatisfactory method (Source: Isaacson et al. 2002) A removable appliance may also be placed in the opposing arch into a fixed appliance (Isaacson et al. 2002). This would enable the use of intermaxillary elastics, and can also give better anchorage for elastic traction (classes II and III). Table III Advantages and Disadvantages of Removable Appliance Advantages Disadvantages a. there is no friction b. it is easy to wear c. hygienic d. cost less than fixed appliance a. exact control of movement cannot be calculated b. there is no torque or bodily movement c. susceptible to breakage d. needs cooperation of patient for total success (Source: Ghafari n.d.) The modified arrowhead clasp developed by Adams in the 1950s increased the effectiveness of the appliance (Isaacson et al. 2002) as compared with earlier models. It remained the only available device for malocclusions treatments which can be effective for specific cases (Isaacson et al. 2002). The rise of fixed appliance has reduced the application of removable appliance but the latter will remain usable for specific cases. However, removable appliances can be used in conjunction with fixed appliances for localized interceptive movements of tooth in mixed dentition. The removable appliance is very effective in maintaining space and as retention appliance after tooth movements have been treated with fixed appliances. Removable appliances are being used in 16 percent of the cases of malocclusions, together with functional and fixed appliances most of the time, as reported by UK Hospital Service survey. A removable appliance is not suggested to be ideal for all patients, but its cautious application on specific cases can produce excellent results. A removable appliance is more preferable to use than a fixed appliance in some cases due to better anchorage, as in the case of maxillary removable appliance. Table IV Types of Removable Appliance According to Force Applied Intrinsic Force Extrinsic Force a. use active plates and appliance with screws 1. active plates are composed of basic element (e.g. baseplate, clasp) and active elements (e.g. labial wire, spring screws, elastics) active plates has a cantilever spring that applies pressure upon the tooth which is perpendicular to the surface of tooth appliance is not attached to tooth and the spring cannot grasp the tooth either thus, the spring has to intrude at the “correct point” on the surface of tooth to apply pressure (p. 3). friction is not created in the movement because the spring wire and surface of tooth are “hard and polished” ( p. 3). anchorage is supplied by teeth which are not moved and the maxilla palatal surface (the acrylic rests on the palate and teeth surfaces) appliance not attached to the tooth, spring cannot grasp the tooth either 2. appliance with screws has two parts, with a screw inserted into them turning the screw (using key or pin) moves the two parts away from each other screw is turned a quarter for every adjustment and must be expanded slowly to avoid dislocation of appliance a. external or muscular force apply pressure upon the teeth and alveolar process b. removable appliances that use extrinsic force: lip bumper (uses pressure from lips to apply force on the molars, relieving the force of the lips on the incisors) inclined plane (steers the maxillary incisors in cases of anterior crossbite) maxillary bite plate (without the active parts, is commonly used together with fixed appliances and also on its own to manipulate too much overbite and in cases of malocclusion of posterior teeth) vestibular oral screen activators other functional appliances (Source: Ghafari n.d.) The types of removable appliances are generally grouped according to the force they exert – intrinsic force and extrinsic force (Ghafari n.d.). To apply intrinsic force or force from the appliance itself, wires, screws or active plates (combines wires and screws) are rigidly affixed to a number of teeth. Observations have shown that removable appliances could cause gingival inflammation, particularly on the palate if oral hygiene is not practiced (The Rationale for Orthodontic 2001). Fixed Appliance Fixed appliances, also called “train track braces,” are steel braces composed of little blocks termed brackets which are affixed unto the teeth (Treatment – Braces n.d., para. 1). The brackets have slots through which the wire passes through and tied together with elastic (Treatment – Braces n.d.). Fixed appliances have changed in the 2000s as new techniques were introduced that include “preformed bands and components, direct bonding techniques, pre-adjusted brackets and . . . pre-formed archwires in stainless steel as well as nonferrous alloys” (Isaacson et al. 2002, p. 2). Several studies have shown that fixed appliances have resulted to greater improvement to patients than removable appliances (Teh, Kerr & McColl 2000). A fixed appliance usually encroaches upon the adjoining tooth and tip it over, and must therefore be properly designed (Isaacson et al. 2002). Fixed appliances have four components: Bands, Brackets, Wires and Accessory appliances (Mechanical Principles n.d.). The brackets can be either a metal bracket, clear bracket, plastic, ceramic (which also includes a metal-reinforced one), and self ligating bracket (Mechanical Principles n.d.). According to Kuncio et al. (2007, cited in Mechanical Principles n.d.), fixed appliances are better than Invisalign or invisible appliance since patients of the latter experience relapse. The Catlan’s appliance or Lower Inclined Bite Plane is one example of a fixed appliance that can treat anterior crossbite (Prakash & Durgesh 2011). Cooperation of the patient is not required in this device. Table V Clinical Observations with Fixed Appliance a. decalcification in 2 to 96 percent of patients (due to cleaning difficulty around components) b. weakened periodontal support (due to lesser access to treated area for cleaning) c. inflammation of gums after insertion of appliance d. greater loss of periodontal support with poor hygiene practices (patient prone to periodontal disease) (Source: The Rationale for Orthodontic 2001) The wires are classified according to type of material (NiTi or Nickel-Titanium wire, TMA or Titanium-Molybdenum-Alloy, stainless steel wire), and shape (round wire, rectangular wire) (Mechanical Principles n.d.). The effectiveness of wire can be judged by the properties it exhibits such as force level, rigidity, formidability, range or springback, etc. The ideal material though should be able to maintain elasticity as well as force over a projected range of movement of the tooth. However, with the current available wire materials with different characteristics, not one meets all the ideal characteristics and functionality. Thus, specific wire materials will be used for specific cases. Friction is another factor to consider in the appliance to be used because it affects the rate at which the tooth moves (Mechanical Principles n.d.). An arch wire with more titanium produces greater resistance and friction than that made of stainless steel. In the same manner, a titanium bracket has higher friction, as with a ceramic bracket (due to its rough and hard surface). A ceramic designed with steel slot has lesser friction. The metal or ceramic brackets (glued to front teeth) and stainless steel bands (affixed at the back) are connected together by the archwire. The patient experiences pain two hours (Ertan Erdinc & Dincer 2004) or four hours (Jones & Chan 1992; Ngan, Kess & Wilson 1989; Wilson, Ngan & Kess 1989; Scheurer, Firestone & Burgin 1996, cited in Miller 2005) after insertion of the archwire and heightens at day one (Ertan Erdinc & Dincer 2004). Such pain is greater than tooth extraction pain (Miller 2005). The pain, however, declines on the third day (Ertan Erdinc & Dincer 2004). The adaptation period of the patient occurs within seven days after placement of the wire (Miller 2005). Functional Appliance The functional appliance was first attributed to Andresen’s “mobile, loose-fitting appliance” modified to transfer “functioning muscle stimuli to the jaws, teeth and supporting tissues” (Vijayalakshmi & Veereshi 2010, p. 13). In the writings he collaborated with Haupl that describes the appliance description and action interpretation, he termed the procedure “Functional Jaw Orthopedics” (Graber N 1977; Graber S 1975, cited in Vijayalakshmi & Veereshi 2010, p. 13). Andresen’s device was named activator by Haupl due to its “ability to activate muscle forces” (Vijayalakshmi & Veereshi 2010, p. 13). The activator used today is based on the Bionator made by Balters. The development of the complicated myodynamic device is credited to H.P. Bimler but modified by his disciple Stockfish that resulted to the Kinetor. The application of functional appliance is a functional therapy that uses force to stimulate growth and encourage skeletal development (Clark 2002) and posturing of the lower jaw (Treatment – Braces n.d.). Majority of the functional appliances can be detached by the patient (Caldwell & Cook 1999). Functional appliances are generally removable braces for upper and lower jaws (Treatment – Braces n.d.) but modern designs appear as either a fixed or removable (Ritto n.d). They are most suitable for adolescents 12 to 16 years old whose jaws and teeth are still growing (Treatment – Braces n.d.). A functional appliance can control the forces applied to the teeth by the soft tissues and muscles surrounding the mandible, according to Clark (2002). It creates a new functional behavior configuration that sustains the “new position of equilibrium by eliminating unfavorable environmental factors in a developing malocclusion” (Clark 2002, p. 25). The functional concept hinges on a removable appliance capable of altering the dentofacial features through the elimination of myofunctional and occlusal concerns and the improvement of dentition. Table VI Advantages of Functional Appliance a. lessen problems encountered with fixed appliance (e.g. gingival proliferation, decalcification, TMD, extractions) b. Tx of TMD c. lessen crowding by enlarging transverse width of arches d. less time to wear braces e. decrease or elimination of dysfunctional habit f. enhances growth g. hygienic h. positively affects occlusion i. do away with surgical procedure j. simple appliance (Source [a]: Ismail 2002, cited in Mascia n.d.) (Source [b]: Pancherz 1999, cited in Mascia n.d.) (Source [c to d]: Profit 2002, cited in Mascia n.d.) (Source [e to j]: Mascia n.d.) Functional appliances are used to affect the functional surrounding and in the process induce a permanent change to the adjoining hard tissue (Mascia n.d.). A functional appliance’s effect would depend on “maintaining the mandible in a postured position, influencing both the orofacial musculature and dentoalveolar development” (Isaacson et al. 2002, p. 2). Functional appliance is used to correct facial and bone features caused by facial, maxillary and mandibular growth beginning with pubertal age (Mascia n.d.). Some functional appliances utilize the application of both intrinsic and extrinsic forces (Ghafari n.d.). The functional appliances include the activator, bionator, function regulator or corrector (Frankel), Herbst (fixed) and combined functional appliances/headgear (Ghafari n.d.). Rolf Frankel developed the Frankel Function Regulator in the 1950s based on his theory that the “active perioral muscles and tissue mass have potential restraining effect on the outward development of dental arches particularly during the transitional period of development” (Vijayalakshmi & Veereshi 2010, p. 13). In 1977, Hans Pancherz revived Emil Herbst’s Herbst appliance (Pancherz 1979, cited in Ritto 2001; Vijayalakshmi & Veereshi 2010) while Clark introduced the two-piece appliance twin-block appliance (Vijayalakshmi & Veereshi 2010). The functional appliances derived from the monoblock design have joined upper and lower components (Clark 2002). This can cause difficulty in eating and speaking for the patient. A one-piece functional appliance, on the other hand, cannot be worn full time if affixed to the teeth. Thus, earlier designs of the device were intended to be worn at night. The muscles are the primary stimulant in bone growth and modification (Clark 2002). The muscles move the strongest during chewing and eating. Thus, removing the appliance when eating when the muscles are active would have less impact to the desired change. Placement of the appliance after eating would have no “proprioceptive functional stimulus to growth” (Clark 2002, p. 24). Thus, in monoblock-based designs, the patient must fully comply with the requirements for complete success of the treatment. Bishara & Ziaja (1989 1995, cited in Patel, Moseley & Noar 2002) commented that in functional appliances, success of the treatment largely depends on cooperation. Removable Functional Appliance Functional appliances are always removable and classified as “removable appliances” (Isaacson et al. 2002, p. 2). Taneja (2006) agreed that earlier functional appliances were removable, and require patient compliance. Newer designs of the 20th century proved to be effective in addressing malocclusion problems and aesthetic issues (Clark 2002). To lessen reliance upon “non-motivated, noncompliant patients,” fixed functional devices were developed (Taneja 2006, p. 1). According to Flores-Mira and Major (2006), only a minor percentage of those who resort to the use of removable functional appliances suffers from soft tissue changes. The appliance affects the movement of muscle groups, and thus affects the function and location of the mandible. Such alteration transmits a force upon the dentition and basal bone (Bishara & Ziaja 1989; 1995, cited in Patel, Moseley & Noar 2002). The removable functional devices and headgears can produce good results when correctly worn, but requires great patient cooperation (Dentofacial Orthopedics 2009). The Jasper Jumper is one of the newer fixed appliances that are functional (Blackwood 1991, cited in Flores-Mir, Major & Major 2006). Around 34 to 49 percent of patients, as shown by studies, failed to use the removable functional appliances as instructed (O Brien, Wright, Conboy, et al. 2003; Caldwell & Cook 1999, cited in Bass 2006). Caldwell and Cook (1999) said that a persisting problem with removable functional appliance treatment is patient cooperation. Table VII Disadvantages of Removable Functional Appliance a. very bulky b. unstable fixation c. uncomfortable d. diminished sensing e. puts pressure on mucous (encourage gingivitis) f. lessen tongue movement g. affects speech h. affects facial appearance i. altering mandibular position adds difficulty j. adapting and accepting appliance difficult (Source [a to h]: Olivier & Knappman 1985; Ngan, Kess & Wilson 1989, cited in Ritto 2001; Ritto n.d). (Source [i to j]: Ritto n.d). The removable twin-block appliance made by Clark in 1988 retains its popularity in the UK (Chadwick et al. 1997, cited in Read 2001; Caldwell & Cook 1999; Clark 1988, cited in Flores-Mira & Major 2006; Gill, Sharma & Naini et al., cited in Flores-Mira & Major 2006). There is also a twin block designed to be a fixed appliance (Fixed Twin Blocks n.d.). Table VIII Twin Block Clinical Observations Clinical Features a. mesial migration of maxillary teeth inhibited b. mesial movement of mandibular teeth c. maxillary alveolar height increase inhibited d. extrusion of mandibular molars e. forward growth of the maxilla inhibited f. increased mandibular growth g. change in condylar growth direction h. anterior relocation and remodeling of glenoid fossa a. not bulky as monoblocks b. more freedom in mandibular movements c. better than removable functional monoblocks (Source: Vargervik & Harvold 1985; 1988, cited in Patel, Moseley & Noar 2002) (Source: Flores-Mira & Major 2006) Fixed Functional Appliance The use of fixed functional appliance allows fixed treatment phase to be done with functional treatment simultaneously, thus benefiting both patient and orthodontist (Taneja 2006). The use of this device has grown in younger adults, as the Pancherz study showed that TMJ area growth continues even after pubertal age. The first modern fixed functional appliance was said to be the Herbst appliance (Taneja 2006; Herbst 1910, cited in Ritto 2001) and followed by the Jasper Jumper developed by James Jasper (Taneja 2006). According to Ramirez-Yanez (2007), combining functional and fixed appliances improves the oral functions and bone discrepancies for open bite malocclusion. Table IX Advantages and Disadvantages of Fixed Functional Appliance Advantages over Removable Functional Appliance Disadvantages a. not require patient compliance b. can be used with brackets c. encourages mandibular growth d. encourages horizontal condylar growth e. continued stimulus to mandible, worn 24 hours a day f. smaller size, better adaptation for chewing, swallowing, speaking and breathing g. force directly transmitted to teeth through support system h. not removable by patient, greater control by orthodontist i. can treat Class I, Class II (division 1 and 2) and Class III malocclusion a. susceptible to breakage b. difficult to clean c. difficult to remove d. the dental movement during treatment may not be the most suitable for the type of malocclusion concerned (Source [a to d]: Flores-Mir, Major & Major 2006; O’Brien, Wright, Conboy et al. 2003, cited in Flores-Mir, Major & Major 2006) (Source [e to g]: Al-Swerki 2007) (Source [h]: Ritto 2001) (Source [i]: Ritto n.d.) (Source [a to c] Flores-Mir, Major & Major 2006; O’Brien, Wright, Conboy et al. 2003, cited in Flores-Mir, Major & Major 2006) (Source [d]: Al-Swerki 2007; Ritto 2001) A fixed functional appliance would not require compliance by the patient unlike the removable appliance, and can be used together with brackets (Flores-Mir, Major & Major 2006). It also encourages growth of the mandible and horizontal condyle growth as compared with the removable functional appliance (Shen, Hagg & Darendeliler 2005, cited in Flores-Mir, Major & Major 2006). Table X Disadvantages of Fixed Functional Appliance Herbst and Jasper Jumper Herbst Jasper Jumper a. stiff b. not flexible c. difficult to chew d. difficult to clean tooth e. fitting is time-intensive and costly f. expensive g. difficult to make h. subject to breakage a. flexible but force module is large and bulges out (very uncomfortable for patient) b. not hygienic, plastic covering prone to plaque and bacteria colonization c. high breakage rate d. fatigues after three months, needs spring replacement for effective positioning (Source [a to e]: McNamara, Howe & Dischinger 1990, cited in Taneja 2006) (Source [f to h]: Read 2001) (Source [a &b]: Taneja 2006) (Source [c]: Stuki & Bengt 1998, cited in Taneja 2006) (Source [d]: Weiland & Bantleon 1995, cited in Taneja 2006) The Herbst appliance and Jasper Jumper remain the most used fixed functional appliance but they have inherent disadvantages (Taneja 2006). The Ritto Appliance is a miniature telescopic fixed functional device (Ritto n.d.). Although fixed functional appliances are regarded as non-compliant, a high degree of cooperation is a requirement, otherwise, the desired objectives will not be achieved (Ritto 2001). Table XI Ritto Appliance Advantages Clinical Features a. not disengage after reaching maximum extension b. small size helps adapting to device c. not affect facial feature d. not affect speech e. one design can be used on both sides f. easy to use g. comfortable to wear h. not expensive i. can resist breakage j. patient cooperation not required a. corrects Class II, division 1 and 2, malocclusions b. aligns mandible c. good anchorage in Class I and Class II treatment, extraction and non-extraction d. corrects Class II lingual discrepancies e. can be used as anchorage in adult treatment f. complements recapturing of articular disc (Source: Ritto n.d.) The Herbst appliance is an upper and lower device linked by a small mechanism (Read 2001). The mechanism fixes the mandible frontward in a protruding position to alter mandibular growth. The Herbst appliance though is expensive, quite complicated to make and susceptible to breakage. Table XII Types of Fixed Functional Appliances a. Herbst appliance b. Forsus c. Crossbow d. MARA e. MPA f. EVAA g. Churro Jumper h. Universal Bite Jumper (UBJ) i. Andresen Activator j. Bass appliance k. Bionator (and variants) l. Elastic Bite-block m. Elastic Open Activator n. Frankel FR-2 Functional Regulator o. Harvold Activator p. Herren Activator q. Modified Bionator r. Orthopaedic corrector (1 and 2) s. Stockli Type Activator t. Robin Monobloc u. Teuscher appliance v. Twin Block w. Woodside Type Activator (Source [a]: Flores-Mir, Major & Major 2006; Collett 2000) (Source [b to d]: Flores-Mir, Major & Major 2006) (Source [e to h]: Taneja 2006) (Source [i to w]: Collett 2000) Conclusion In orthodontic treatment that requires some manipulation of the tooth and bones, there is always a risk involved in the process. Damage or ulceration of the soft tissue is observed in both fixed appliance and removable appliance (The Rationale for Orthodontic 2001). However, soft tissue damage is more prevalent in fixed appliances since a removable appliance can be removed when it becomes uncomfortable. It is also reported that excessive apical movement can lessen the supply of blood to the pulp, which may eventually destroy the pulp. Other consequences of undergoing orthodontic treatment are root resorption, loss of periodontal support and decalcification. A fixed appliance treatment that lasts for two years can result to a 1 mm loss in root length. But the loss can be predicted to be the same with all patients, being more prominent with others who are more susceptible. No two patients will have the same case, thus, the orthodontist must properly plan, calculate and design the appliance that will be used for the specific case of the patient. The cooperation of the patient is a necessary requirement in this type of dental treatment (The Rationale for Orthodontic 2001). As shown by evidence, a more favorable result is achieved when the practitioner has advance training in orthodontics. The responses to treatment differ and can be attributed to the different appliances used, and their results cannot be compared with each other (Patel, Moseley & Noar 2002). References Active tooth movement in Class 1. 2002. Removable Orthodontic Appliances. Isaacson KG, Muir JD and Reed RT. . [Accessed 5 April 2011]. Alkhadra T n.d. Functional Appliances: An Overview in Using Functional Appliances in Treating Class II. . [Accessed 3 April 2011]. 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