by Sharon M. Eder, DDS

What works best: fixed or removable appliances? “Old school” or “new school” approaches? It all depends on the case

In today’s society, everything old is new again … or is it? Open up any fashion magazine and you will see trends and fashions of the past being brought back to life. With everything vintage being so trendy, can we orthodontists tell our patients that their new headgear is so “now”? Of course, there are “old school” techniques in orthodontics, such as the aforementioned headgear, and there are “new school” ideas such as TADs. As clinicians, we all know there are many ways to approach the majority of cases we see and that many factors come into play when selecting and implementing a given treatment plan. We all want to be on the forefront of the most contemporary orthodontic technology and employ such techniques in our everyday practice. But we should not forget the tried-and-true techniques and must incorporate the old-school ideas into our new-school world.

Distalization Options

The headgear is one of the most basic distalization appliances. Every parent who walks in the door remembers having to wear their headgear. Today, for whatever reason, every child shudders at the thought of the dreaded appliance—they “don’t do headgear!” Some compliance is seen when the child realizes that the appliance only has to be worn at night. What do you do with the noncompliant patient? You go for the more contemporary idea, the TAD, which can also be used for distalization in some cases. A nice thing to have in your bag of tricks—but we also have old-school Class II elastics, which work very nicely in some cases. The point is that we have to consider the old and the new when choosing the optimum plan for each individual case. In some cases, we can formulate treatment plans and utilize treatment that combines both old and new appliances (such as headgear activator-type appliances).

Figures 1 and 2: Mixed-dentition therapy using a headgear activator.

Functional Appliances

What about functional appliances? Many of these types of appliances combine old-school and new-school ideas. There has been much controversy, discussion, and research regarding the efficacy of such treatment in the mixed dentition. Clinically, we have seen success with such treatment, but the question remains which is better: a fixed appliance, such as a Herbst; or a removable one, such as a headgear activator?

For discussion purposes, I will use these appliances as examples of modalities that are useful in treatment for Class II correction. Many clinicians have definite opinions regarding both, yet one must realize that in most cases, neither one would be wrong. As with many situations, it often comes down to what works better in the treating orthodontist’s hands. There is also an age factor in each of those examples: the headgear activator works better in the growing individual with a mixed dentition. The Herbst is often not used until a majority of the permanent dentition has erupted and the child has commenced orthodontic treatment. There are many differences between the two appliances, but these are both old-school ideas … or are they? In the case of the headgear activator appliance used in our office, patients get a bite plate in a color or design of their choice, thus giving this “older” treatment a more contemporary spin.

There are many different facets of treatment to consider when selecting a functional appliance. One important issue to contemplate is the orthodontic emergency. More often than not, this is a big factor guiding the clinician in whether to use a fixed or removable appliance. If a child is having a problem with a headgear activator that is falling out during the night, or if the lower labial bar is irritating the gingiva, what do we say when we get that Saturday afternoon phone call? “Stop wearing it.” It’s that simple. The patient can be made comfortable if they are calling from their home phone or halfway across the United States on vacation. Some treatment time may be lost, but there is instant gratification.

With the Herbst appliance, however, it isn’t so easy. Whether it’s banded to the teeth or cemented in with stainless steel crowns, there is much more potential for emergencies that cannot be remedied with a simple phone call. I think it’s safe to say we have all seen the Herbst emergency with a patient’s niece or nephew who is visiting from out of state. Not to knock the Herbst appliance, which can deliver beautiful orthodontic results, but emergencies are an important consideration when selecting treatment for a patient. We have all seen the patient who will break everything!

In choosing a removable appliance, we must consider the patient’s tendency for compliance as well. Sometimes this becomes a function of patient management; as clinicians, we get to know our patients and know what they are capable of tolerating. Not every patient who would benefit from a headgear activator will necessarily wear it consistently. Optimum wear of such an appliance is approximately 12 to 14 hours per day, which is what we tell our patients in our office. This means after school when they are doing homework, e-mailing, or whatever it is they do, and then to sleep. This is usually acceptable to patients. The children who are seeking treatment at such an early age (approximately 9 years old) usually have quite a noticeable overjet (greater than 6 mm) and overbite (usually 100%), and are self-conscious about their appearance. Unfortunately, they have usually been bullied or teased because of their “buck” teeth. Thus, there is high motivation for treatment compliance; they want to be accepted by their peers, and in today’s appearance-driven society, what better incentive? They are also at a psychological age at which they like to please. They still for the most part listen to their parents, teachers, and other authority figures (such as their orthodontist), which works to our advantage as well.

The Herbst is noncompliance-based, which can be viewed as a definite advantage. The patient’s vanity and self-motivation will also play a role in accepting the Herbst. Initially, there is a “getting used to” stage, as there is with any treatment. In accommodating the new bite posture and the intraoral appliances, however, the patient may need some reinforcement and encouragement to adapt to treatment. This holds true for most treatment plans we implement; there is an adjustment period whether fixed or removable appliances are used. We can’t forget that there are people behind the malocclusion we are treating.

The dental age of our patients does not always match their chronological age, and their chronological age does not always correspond with their maturity level. We have all had the patient referred for treatment who won’t stop crying, or pulls out the impression tray before the alginate sets, or just won’t sit still in the chair. In selecting fixed versus removable appliances, old-school or new-school, we must consider our target audience. If a younger child who would benefit from a removable appliance as an early treatment option will not tolerate it, it may be in the patient’s best interest to delay orthodontic treatment. In many cases, orthodontic treatment is “optional.” If a child is traumatized by treatment, even though he or she may benefit from it, is it worth it? This is when we may look back to the old-school method of waiting and formulate treatment options that may not take advantage of the younger patient’s growth potential. Early treatment can be called new-school, in that it is a relatively newer approach to treatment for some orthodontic cases, taking advantage of the malleability of the growing child, helping us redirect and take advantage of growth.

The bottom line is that we as clinicians should not blindly adopt everything new and dispose of everything old. Too many times we are criticized by our colleagues for using removable appliances that require patient cooperation. The typical comment is, “Oh, they won’t wear it,” never actually giving the patient the benefit of the doubt. One can always resort to a fixed appliance if cooperation is not ideal, but to immediately dismiss a successful device based on bias is unreasonable.

Fiigures 3 and 4: Before and after photos of a case using the headgear activator.

Clinical Results

Consider the results of mixed-dentition therapy using a headgear activator (Figures 1 and 2). The headgear acts to both distalize and hold the appliance in place. The lower jaw is held forward as the patient bites, and the lower incisors are capped with acrylic.

The patient in Figures 3 and 4 promised to do whatever it took to reduce the “Bugs Bunny” look. Why would we immediately assume that there would be no cooperation? In fact, the patient was thrilled to wear the appliance, because it was easy, clean, there were no fixed braces, and the results were quick, even though she only wore the appliance at home. The results shown are incredible for this type of case: the teeth were aligned, facial balance was achieved, and phase 2 with braces was almost optional!

Interestingly, results like this are routine for this type of removable appliance therapy. Case after case shows significant reduction in overjet, Class II correction, and establishment of facial balance. In order to achieve the same results with fixed appliances, a series of appliances would have been necessary, which might have included a Herbst and maxillary braces to retract the incisors. If you then consider chairtime and the risk of breakage, the removable appliance may actually be more effective.

As orthodontists today, we have many appliance options, both fixed and removable. A multitude of factors come into play when selecting the optimum treatment plan for your patient. We have a plethora of information available to us today. Some of the new-school ideas play on old-school ideas of the past. (For example, modern bite correctors are quite similar in their mechanics to the Herbst appliance). The foundation that earlier clinicians have provided for us on which to base our contemporary treatment plans is invaluable. One could say that orthodontics today is like a bottle of fine vintage wine: contemporary ideas of today have only become better, and possible, with age.

Sharon M. Eder, DDS, is in private practice in Mount Kisco and Katonah, NY. She can be reached at (914) 666-8997.