Understanding factors influencing compliance with removable functional appliances: A qualitative study

Patient adherence in orthodontics: a scoping review

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.

The effect of text message reminders on compliance with Twin Block appliances: A randomised controlled trial

AIMS

The aim of this study was to evaluate whether text reminders influence patient compliance with Twin Block appliances. The null hypothesis was that there was no statistically significant differences in Twin Block compliance between those who receive text reminders and those that do not.

DESIGN

Single-blind parallel randomised controlled clinical trial.

SETTING

Health Service Executive (HSE) orthodontic outpatient clinic in Dublin, Ireland.

PARTICIPANTS

A total of 59 patients aged 11-15 years with a 5a Index of Orthodontic Treatment Need (IOTN grade) starting treatment with Twin Block appliances.

METHODS

A computer-generated unstratified allocation sequence was used to randomise the participants into the control group (CG) or the text group (TG). Both groups were asked to wear their appliances full-time. In addition to the same verbal and written instruction received by the CG, the TG received text message reminders, every 3 days, to wear their appliances. The primary outcome measure was wear time reported by Theramon® sensors embedded in the appliances. Data on wear time were uploaded from the Theramon® sensors onto cloud software. Participants in both groups were asked to fill out wear diaries and submit these at each visit. Treating clinicians and the primary investigator were blinded to the allocation group. Participants were followed up for 4 months. Participants were not blinded to their treatment group.

RESULTS

In total, 29 participants were allocated to the CG and 30 to the TG. The data for 53 participants were analysed, 24 from the CG and 29 from the TG. The median hours/day of wear recorded using the Theramon® sensors was 13.77 (interquartile range [IQR] = 10.19) for the CG and 17.72 (IQR = 5.62) for the TG. The difference in wear time recorded was not statistically significant (P = 0.16).

CONCLUSION

The study concluded that text message reminders had no statistically significant influence on patient compliance with Twin Block appliances.

Skeletal and dental effects of function-generating bite appliance compared to rapid palatal expander and untreated controls

INTRODUCTION

Maxillary expansion is a fundamental interceptive orthodontic treatment, which can be achieved through either a rapid expansion protocol or functional devices. However, no data exist about the efficacy of functional devices in achieving skeletal expansion. Therefore, the aim of this study was to compare the effects of the rapid palatal expander (RPE) and the function-generating bite type M (FGB-M) on the transversal dimension of the maxilla, and on the maxillary and mandibular dental arch width.

METHODS

One hundred eighty-one skeletal Class I patients, aged between 6 and 12 years and with a cervical vertebral maturation stage II or III, with maxillary transversal deficiency were retrospectively enrolled; among these 55 were treated with FGB-M, 73 were treated with RPE and 51 were untreated subjects retrieved from historical databases. The pre-treatment (T0) and post-treatment (T1) frontal cephalograms were retrieved, and the maxillary and mandibular widths, and the distance between upper and lower first molars were measured. T1-T0 interval was of 17.3 months (RPE), 24.6 months (FGB-M) and 18.2 months (controls).

RESULTS

The statistical analysis showed that there were no statistically significant differences between the RPE and FGB-M groups regarding skeletal and dental expansion, while the untreated control group differed significantly from the other two groups.

CONCLUSION

The comparison between patients treated with RPE and FGB-M showed that there were no statistically significant differences between the RPE and FGB-M groups regarding the amount of skeletal expansion and dental arch width, suggesting that both appliances can be used to achieve similar results.

Contemporary Twin Block appliance wear protocols: A survey of UK orthodontists

OBJECTIVE

This study was undertaken to determine contemporary trends in the use of the Twin Block appliance among UK orthodontists, including the wear time currently prescribed. In addition, the study explored if there had been any change in wear time prescribed, considering recent research evidence proposing part-time wear.

DESIGN

Cross-sectional, online survey.

PARTICIPANTS

Members of the British Orthodontic Society (BOS).

METHODS

The questionnaire was emailed to all BOS members in November 2021 and hosted on the QualtricsXM platform. The questionnaire was piloted for content validity and tested for reliability.

RESULTS

A response rate of 19% was attained. Nearly all (n = 244, 99%) participants used the Twin Block, and 90% (n = 218) prescribed full-time wear including/excluding eating. Although the majority (n = 168, 69%) had not made changes to their wear time prescriptions, nearly one-third (n = 75, 31%) had. Those who reported a change in their prescriptions currently prescribe less wear time than before, and commonly quoted 'research evidence' as the reason. A wide range in success rates (41%-100%) was reported, with patient compliance as the main reason for treatment discontinuation.

CONCLUSION

The Twin Block is a popular functional appliance among orthodontists in the UK, originally designed by Clark to be worn full time to maximise functional forces applied to the dentition. However, this wear regime may place considerable strain on patient compliance. Most participants prescribed full-time Twin Block wear excluding eating. Approximately one-third of orthodontists made changes to their wear time prescriptions during their practising career, and currently instruct less wear time than before.

A comparison of children's experiences with fixed and removable functional appliances: A qualitative study

INTRODUCTION

The objective of this study was to compare children's experiences and perceptions of treatment with Hanks-Herbst (HH) and modified Twin-block (MTB) functional appliances.

METHODS

A pragmatic nested qualitative study was undertaken in a single hospital setting. Participants from a randomized controlled trial (International Standard Randomised Controlled Trial Number 11717011) wearing HH and/or MTB appliances were interviewed using a topic guide in a one-to-one, semistructured format. Interviews were recorded and transcribed verbatim for framework methodology analysis until data saturation was reached.

RESULTS

Eighteen participants (HH, 7: MTB, 4; switched group, 7) were interviewed. Thirteen codes were constructed and grouped into 3 themes: (1) functional impairment and symptoms, (2) psychosocial factors and impacts, and (3) feedback on appliances and patient care. Both appliances had a negative impact on quality of life, with disruption to children's daily routines and psychological well-being. Speaking was more problematic for MTB participants, whereas HH participants encountered mastication and breakage issues. HH was preferred by most participants, as its nonremovable feature meant less managing and self-discipline was required. MTB was considered a suitable option for children with good self-discipline and who preferred a versatile lifestyle. Feedback included wishes for the availability of multiple appliance options and a degree of autonomy in decision-making processes.

CONCLUSIONS

HH and MTB can negatively affect children's quality of life. Participants preferred HH over MTB because of its nonremovable feature, and children requested to be empowered during decision-making processes.

Does using mobile applications and social media-based interventions induce beneficial behavioral changes among orthodontic patients?

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs) and controlled clinical trials (CCTs). The protocol of the study was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42019157298).

DATA SOURCES

Seven electronic databases (MEDLINE, Web of Science Core Collection, Unpublished Clinical Trials accessed through clinicaltrials.gov, Embase, LILACS, ProQuest Database, The Cochrane Library) were searched. Additionally, the reference lists of the included studies were hand searched.

STUDY SELECTION

Clinical trials (RCT and CCT) that assessed the impact of the interventional use of mobile applications and social media among orthodontic patients were included. The review question was defined in PICO format as follows: population (P) = patients (no age restriction) undergoing orthodontic treatment using fixed, removable, or functional appliances, or patients in the retention phase that are wearing fixed or removable retainers; intervention (I) = mobile applications and social media-based interventions; comparison (C) = control group that did not receive any adjunctive intervention; outcome (O) = behavior changes in orthodontic patients after receipt of the intervention. Two authors independently conducted literature search from inception up to March 2021.

DATA ANALYSIS

Social media-based interventions and mobile applications (or bespoke) were used in the form of reminders (WhatsApp reminders) and provision of information including YouTube videos and Instagram posts. Primary outcomes included adherence to wearing appliances or adjuncts, oral hygiene levels, oral health-related behaviors, periodontal outcomes, appointment attendance, knowledge, and related iatrogenic effects. Treatment-related experiences and patient-reported outcomes were assessed as secondary outcomes.

RESULTS

16 studies (14 RCTs and 2 CCTs) were included in the qualitative synthesis, of which only 7 studies were included in the quantitative synthesis (meta-analysis). Results from meta-analyses showed that the intervention was favored in relation to gingival index (GI) (number of studies = 4, standardized mean difference [SMD] = -0.81, 95% confidence interval [CI] = -1.35 to -0.28, P = 0.00, certainty of evidence = very low), plaque index (PI) (number of studies = 7, SMD = -0.91 [95% CI, -1.64 to -0.19], P = 0.01, certainty of evidence = very low), and bleeding index (BI) (number of studies = 4, SMD = -0.22 [95% CI, -0.50 to 0.05], P = 0.11, certainty of evidence = high). Sensitivity analysis was performed (including additional 3 studies for GI and 5 studies for PI), which also favored the intervention in relation to GI (number of studies = 7, SMD = -0.60 [95% CI, -1.01 to -0.18], P = 0.00, certainty of evidence = very low), and PI (number of studies = 12, SMD = -0.67 [95% CI, -1.14 to -0.19], P = 0.01, certainty of evidence = very low).

CONCLUSIONS

Limited evidence supports beneficial behavior change among orthodontic patients when using mobile applications or social media-based interventions.

The digital Twin Block appliance: Concept, design and fabrication

The Twin Block appliance (TBA) has evolved over the decades to remain a very effective treatment for growing Class II patients. This article introduces how two new versions of the TBA may be produced through an entirely digital workflow, from intra-oral scanning to thermoplastic appliance fabrication, using a novel computer-aided design process.

Evaluation of Local Application of Glucosamine Sulfate and Chondroitin Sulfate on Temporomandibular Joint Response and Alleviation of Pain and Tension During the Functional Treatment of Skeletal Class II Patients: A Randomized Control Clinical Trial

OBJECTIVE

 This study was conducted to assess the effects of applying a gel of combined glucosamine sulfate and chondroitin sulfate on the temporomandibular joint (TMJ) area in patients with skeletal Class II malocclusion treated by removable functional appliances in terms of TMJ internal proportions, levels of pain, and tension.

MATERIALS AND METHODS

The study included 36 patients aged 10-13 years with skeletal Class II malocclusion due to retrusion of the mandible characterized by: 4-8 degrees of the sagittal skeletal discrepancy (ANB) angle, 4-7 mm of overjet, 72-76 degrees of the sagittal mandibular positioning (SNB) angle, and a bone maturity stage located at pubertal growth spurt. Patients were distributed to the experimental group (Twin-Block appliance + Jointance® gel) or the control group (conventional treatment with the Twin-Block appliance). An allocation ratio of 1:1 was employed. Pre- and post-treatment digital lateral cephalometric radiograms were taken, and the TMJ joint spaces were measured using the Viewbox software (dHAL Software, Kifissia, Greece). The pain and discomfort levels were evaluated using a questionnaire with a four-point Likert scale at three assessment times.

RESULTS

 The anterior and posterior glenoid and anterior condylar distances to the pterygoid vertical (PTV) reference plane significantly decreased after treatment (p<.001), and the anterior joint space decreased significantly (p<.001). In contrast, the superior distance of the condyle to the Frankfort horizontal reference plane increased significantly after treatment, and the same results were found for the posterior and superior joint spaces (p<.05). There were no significant differences between the two groups in the evaluated linear variables. No significant differences were found when comparing pain and tension levels between the two groups at each assessment time. A gradual decrease in pain and tension levels was observed between the three evaluation times in both groups.

CONCLUSIONS

 A combination of glucosamine sulfate and chondroitin sulfate did not affect the temporomandibular joint spaces, pain, and tension levels in patients with skeletal Class II malocclusions treated by removable functional appliances.

A qualitative evaluation of attitudes toward extractions among primary care orthodontists in Great Britain

INTRODUCTION

The need to extract permanent teeth as part of orthodontic treatment has been keenly debated over many decades. Changes in the frequency of extraction have been well documented; however, we continue to lack an understanding of what influences clinicians' decisions regarding extracting permanent teeth.

METHODS

Purposive sampling was undertaken to obtain representative views from primary care practitioners across Great Britain with a range of experience representing genders and wide geographic distribution. Twenty participants (9 female, 11 male) took part in in-depth, qualitative, 1-to-1 interviews based on a piloted topic guide. Interviews were conducted via video conferencing software with audio recording and verbatim transcription. Thematic analysis was performed with discussion and agreement to identify the main themes.

RESULTS

Five main themes were identified: (1) patient-related factors, such as age and features of the malocclusion, (2) operator factors, including the level of experience, (3) setting, with regard to geographic location and method of remuneration, (4) mechanical approaches, including variations in appliance systems; and (5) self-directed ongoing education, including both formal continuing professional development and informal learning from peers. These factors acted as barriers, enablers, or both in relation to nonextraction treatment.

CONCLUSIONS

Five key influences on extraction decisions among orthodontists in Great Britain were identified. Extraction choices appear to be influenced by various interrelated factors, evolving over time and with increased experience.

Dentoskeletal and soft-tissue changes of class II malocclusion treatment with modified first class appliances: a prospective clinical trial

Background/Objectives

Intraoral distalizers are effective and conservative alternatives for Class II malocclusion treatment. However, the literature is still controversial regarding the effects of using skeletal anchorage in intraoral distalizers with different designs. The aim of this study is to compare dentoskeletal and soft-tissue changes of Class II malocclusion patients treated with three types of First Class (FC) distalizers.

Materials/Methods

The sample of this prospective clinical trial included 30 consecutive patients divided into three groups: G1—FC conventionally anchored; G2—FC skeletally anchored Type 1; G3—FC skeletally anchored Type 2. Each group consisted of 10 patients. Lateral cephalograms were analyzed in two stages: at pre-treatment (T0) and after distalization (T1). The radiographs were digitized and analyzed using the software Dolphin Imaging 11.5. Comparisons of treatment changes between groups (T1–T0) were performed using one-way analysis of variance (ANOVA), followed by the Tukey test.

Results

Patients treated with the conventionally anchored FC showed significantly greater incisors protrusion and labial inclination, second premolars mesial inclination and mesialization than the FCs skeletally anchored. No differences were observed regarding the amount of molar distalization and molar angulation between groups.

Limitations

It can be considered that the limitation of this study lies in its non-randomized design.

Conclusions/Implications

First Class distalizers with conventional and skeletal anchorage are effective alternatives for Class II molar distalization. Distalization associated with indirect skeletal anchorage reduce the undesirable effects observed in the incisors and premolars during distalization when compared to distalization conventionally anchored.

Patient compliance with Twin Block appliance during treatment of Class II malocclusion: a randomized controlled trial on two check-up prescriptions

BACKGROUND

Compliance is crucial for the treatment outcome with removable appliances. Previous studies on treatment with the Twin Block appliance have focused on effectiveness in relation to other treatment methods or wear-time. Studies on different check-up intervals to improve compliance seem to be lacking.

OBJECTIVES

To compare the impact of two different check-up prescriptions on patient compliance and treatment outcome during treatment with Twin Block.

TRIAL DESIGN

Two-arm parallel group, single-centre, randomized controlled trial.

MATERIALS AND METHODS

Seventy-three patients, 38 boys, and 35 girls, mean age 11.2 years, were included and block-randomized into two groups treated with a Twin Block appliance. Group 1 was called for check-up visit every sixth week and group 2 every fourth week. Compliance was evaluated with a TheraMon® microsensor, moulded into the appliance, measuring wear-time. Overjet, overbite, and molar relationships were assessed on study casts before and after treatment. The treatment outcomes were analysed on an intention-to-treat basis.

RESULTS

In group 1, the reduction of overjet was 5.2 mm and the mean wear-time was 6.9 hours. In group 2, the reduction was 4.7 mm and the wear-time was 6.1 hours. Seventy-four per cent of the patients presented an overjet of 4 mm or less. Wear-time did not correlate to age, gender, or severity of malocclusion.

HARMS

No harm was observed in any patient. Lateral open bites were registered during treatment but were normalized at the end of the treatment.

LIMITATIONS

The trial was a single-centre study and long-term effects were not evaluated.

CONCLUSIONS

During treatment with the Twin Block appliance, a 4-week check-up interval did not improve treatment outcome or increase wear-time, compared to a 6-week check-up interval. The mean wear-time was 6.5 hours per day, even if the recommendation was 12 hours.

CLINICAL TRIAL REGISTRATION

NCT05155774.

Factors Influencing Appliance Wearing Time during Orthodontic Treatments: A Literature Review

This review aims to analyze the multiple factors affecting patients’ level of compliance (how much they wear removable devices/clear aligners) during orthodontic treatments and to investigate the available methods and devices to monitor the appliance wearing time and to improve it. A literature search was conducted on electronic databases (Pubmed, Scopus, and Google Scholar). The results of the present study suggest that compliance indicators may misestimate the intraoral wearing time. Compliance is affected by patient-related factors (age, personality traits, the importance of personal appearance, self-perception of malocclusion), appliance-related factors (visibility, pain/discomfort), and clinician-related factors (trust, clear and complete communication, motivation). The motivation of pre-pubertal patients is mostly external, while adolescents/young adults have intrinsic motivation for orthodontic treatment. Patients’ self-reports tend to overestimate the appliance wearing time. Even if there is a lack of evidence, teledentistry might improve patients’ awareness of being monitored, thus increasing the time for which orthodontic devices are worn. Compliance is a key factor for clear aligner treatments, but high-quality studies focusing on this aspect are missing. Further studies should focus on how to handle the lack of cooperation and how to increase compliance in order to maximize the treatment’s results.

Invisalign treatment with mandibular advancement: A retrospective cohort cephalometric appraisal

Objective

To examine the skeletal, dental, and soft-tissue cephalometric effects of class II correction using Invisalign's mandibular advancement feature in growing patients.

Materials and Methods

A retrospective cohort clinical study was performed on cases that were started between 2017 and 2019. A total of 32 patients (13 females, 19 males), with an average age of 13 years old (9.9-14.8 years) had undergone Invisalign treatment (Align Technology, Inc., San Jose, CA) wherein the mandibular advancement phase was completed were included. Photos, digital study models, and cephalograms were taken once during the patients' initial visit and again upon completing the mandibular advancement phase of treatment. The number of aligners worn and the time of treatment in months was recorded for each subject. Cephalometric analysis was performed and overjet and overbite were measured. Statistical analysis was performed using SPSS statistical software (version 25; SPSS, Chicago, Ill) and the level of significance was set at P <0.05. Descriptive statistics were performed to generate means and differences for each cephalometric measurement as well as patient data including age, treatment time, and aligner number. Differences between measurements from patients before treatment (T1) and after treatment (T2) with the mandibular advancement feature were evaluated using a paired t -test.

Results

All 32 patients had multiple jumps staged for the precision wings, i.e., incremental advancement. The average length of treatment for the MA phase was 9.2 months (7.5-13.8 months) and the average number of aligners used during this time was 37 (30-55). Statistically significant differences between T1 and T2, in favor of class II correction, were observed in the ANB angle, WITS appraisal, facial convexity, and mandibular length. The nasolabial angle, overjet, and overbite also showed statistically significant changes between T1 and T2.

Conclusion

Invisalign aligners with the mandibular advancement feature took approximately 9 months for 1.5 mm of overjet correction. The lower incisor angulation was maintained during class II correction. The minimal skeletal changes are in favor of class II correction.

Remote digital monitoring during the retention phase of orthodontic treatment: A prospective feasibility study

Objective

To evaluate if a remote digital monitoring system added at the end of orthodontic treatment could positively influence the retention phase by reducing the occurrence of misfit of removable appliances, number of emergency appointments (EA), and orthodontic relapse.

Methods

Twenty-seven patients who completed active orthodontic treatment were divided into the study and control groups. In addition to the standard chairside follow-up appointments at month 1 (T1), month 3 (T2), month 6 (T3), the study group patients were monitored using Dental Monitoring® with monthly intra-oral scans. Occurrence of misfit of removable retainers, number of EAs, and intercanine width change were recorded for both groups. Differences in EAs and retainer fit were assessed using the chi-square test. Intra-group and inter-group differences in the intercanine width were assessed with Friedman test and Mann-Whitney U test, respectively (α = 0.05).

Results

The study group showed a significantly lower occurrence of misfit of removable retainers (p = 0.027) compared to the control group. No significant inter- and intra-group difference was found in the EAs and intercanine width change at each time-point.

Conclusions

Integrating remote monitoring systems, such as Dental Monitoring®, to the retention phase of the orthodontic treatment may lower the occurrence of misfit of removable retainers. However, a small sample size and a short observation period limit the strength of this evidence. These preliminary results tentatively suggest that remote monitoring technologies may be beneficial, especially during the COVID-19 pandemic, when the regularity of in-office visits might be disrupted.

The Use of Microsensors to Assess the Daily Wear Time of Removable Orthodontic Appliances: A Prospective Cohort Study

Orthodontic treatment with removable appliances is still common in children and adolescents. However, their effectiveness depends primarily on the patients’ compliance. Currently, it is possible to check the daily wear time (DWT) of the removable appliances using special microsensors. The aim of this prospective cohort study was to assess the degree of patients’ compliance depending on the type of removable appliance used. In total, 167 patients (87 F, 80 M) were enrolled in the study and were treated with block appliances (Klammt, Twin-Block), Schwarz plates, and block appliances in combination with headgear. All patients were followed up for 6 months with the mean daily wear time checked at followup visits using TheraMon^® microsensors fitted in the appliances. It has been shown that the type of appliance influences the patients’ compliance. The DWT for the Twin Block was significantly longer compared to the DWT for the other appliances. Girls have been shown to wear removable appliances better than boys. It has been proven that the majority of patients do not follow the orthodontist’s recommendations, wearing removable appliances for just over half of the recommended time. Microsensors can be used for objective verification of patients’ compliance, which allows for a reliable assessment of the effectiveness of treatment with removable appliances.

The reach, influence and tenor of professional orthodontic societies on social media: A cross-sectional content analysis

BACKGROUND AND OBJECTIVES

Orthodontic societies should support the profession and improve patient awareness. We aimed to investigate the scope and influence of orthodontic societies on social media.

METHOD

A total of 120 orthodontic societies were identified on the World Federation of Orthodontists (WFO) affiliates list. Presence of orthodontic societies on Instagram, Facebook and Twitter was ascertained. All societies with Instagram accounts were included for further analysis of the nature and content of posts as well as user engagement. Pilot coding and thematic analysis were undertaken (n=200 posts). The most recent 20% of the total number of posts for each account were then analysed for content.

RESULTS

Only 10 (8.3%), 34 (28.3%) and 52 (43.3%) orthodontic societies had accounts on Twitter, Instagram and Facebook, respectively. A total of 2124 Instagram posts were analysed. On average, 318 posts were identified per account (range=1 to 1901). The average number of followers was 2337 (range=85 to 11,400) with average user engagement of 1.25% (range=0.0%-7.17%). A total of 6 themes (subthemes; n=28) were identified including "announcements on professional events" (51.6%), "patient education, enlightenment and commendation" (26%), "running and operation of the society" (9.1%), "highlighting research and evidence" (3.1%), "COVID-related advice and updates" (4%) and "observance and commemoration" (10.4%). The posts targeting patients were limited (18.7%).

CONCLUSIONS

The limited reach of the accounts of international orthodontic societies highlights the need to develop a more effective and influential social media presence. Orthodontic societies should involve members, providers and patients in developing more effective social media resources.

ADOLESCENTS WITH REMOVABLE CLASS II CORRECTORS EXPRESS HIGHER DISSATISFACTION AND ARE MORE LIKELY TO DISCONTINUE TREATMENT

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Pacha MM, Fleming PS, Johal A. Complications, impacts, and success rates of different approaches to treatment of Class II malocclusion in adolescents: A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2020;158:477-494.e7. doi: 10.1016/j.ajodo.2020.03.021. Epub 2020 Sep 2. PMID: 32888735.

SOURCE OF FUNDING

There is no information about funding.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis.

The influence of mobile applications and social media-based interventions in producing behavior change among orthodontic patients: A systematic review and meta-analysis

INTRODUCTION

The objective of this project was to systematically review the effectiveness of mobile applications and social media-based interventions in producing a behavioral change in orthodontic patients.

METHODS

Electronic databases and reference lists of relevant studies were searched on March 1, 2021, with no language restrictions (PROSPERO: CRD42019157298). Randomized and nonrandomized controlled trials assessing the impact of mobile applications and social media-based interventions on orthodontic patients were identified. Primary outcomes included adherence to wear, appointment attendance, knowledge, oral health-related behaviors, oral hygiene levels, periodontal outcomes, and related iatrogenic effects. The quality of the included trials was assessed using the Cochrane risk of bias tools. A weighted treatment effect of interventions on periodontal outcomes was calculated. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

A total of 3617 articles were identified. Of these, 16 studies (14 randomized controlled trials and 2 nonrandomized controlled trials) were deemed eligible. Nine randomized controlled trials were judged to be of either low or unclear risk of bias. The intervention was favored in relation to gingival and plaque indexes, standardized mean difference: -0.81 (95% confidence intervals [CI], -1.35 to -0.28) and -0.91 (95% CI, -1.64 to -0.19), respectively. However, no significant effect was observed in bleeding on probing (standardized mean difference: -0.22; 95% CI, -0.5 to 0.05). The level of evidence was high in probing depth and bleeding on probing outcomes.

CONCLUSIONS

A very low to moderate level of evidence supports the effects of mobile applications and social media-based interventions in producing positive behavioral changes in orthodontic patients. Further high-quality trials would assist in further elucidating the potential of these approaches to influence orthodontic treatment outcomes and experiences.

Unilateral Scissor Bite Managed with Prefabricated Functional Appliances in Primary Dentition—A New Interceptive Orthodontic Protocol

A unilateral scissor bite is a type of severe malocclusion in primary dentition that can influence the development of the mandible and face. The present case report describes an interceptive treatment on a 4-year-old girl with a unilateral scissor bite combined with an anterior crossbite, increased reverse overjet, and overbite on a skeletal Class III base. The patient was treated with a new Prefabricated Functional Appliance (PFA) which was modified from a Frankel-III appliance to induce a mandible to move backwards and relieve an occlusion discrepancy of the dental arch, and a functional dental rehabilitation with resin and myofunctional exercises with a PFA which was modified from an oral screen appliance were performed during the treatment. The total treatment time was 11 months and a satisfactory improvement of occlusion and facial esthetics was achieved. This case report presents a new PFA system and treatment protocol in primary dentition which results in a favorable outcome, and the clinical effectiveness of this appliance system warrants further investigation.

Comparison of objective wear time between monoblock and twin-block appliances measured by microsensor

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.

Investigation and comparison of patient experiences with removable functional appliances

OBJECTIVES

To compare patients' experiences with the Invisalign Teen with Mandibular Advancement® (ITMA) and Twin Block (TB) appliances, both initially and after several months of wear.

MATERIALS AND METHODS

Sixty-eight patients completed an anonymous survey after at least 2 months of wearing ITMA or TB. Forty-five patients treated with ITMA (18 boys, 27 girls, mean age 13.6 years, SD ± 1.54) and 23 patients treated with TB (13 boys, 10 girls, mean age 10.60 years, SD ± 1.92) were included.

RESULTS

More patients using the TB found their appliance to be visually intimidating as compared with patients using the ITMA (21.7% vs 8.9%). TB was more noticeable than the ITMA (69.6% vs 25%). Appliance insertion was more difficult for TB patients (21.8% vs 4.44% for ITMA). After several months, there were more reports of tooth soreness and lip/cheek soreness in the ITMA group. TB patients were more embarrassed even after several months (14.3% vs 0% for ITMA). More TB patients required extra appointments for breakage (50% vs 22.2% for ITMA). Speech, drooling, and jaw and lip/cheek soreness worsened initially for both groups but improved over time. There were no differences between the groups regarding visible facial changes, satisfaction with treatment experience, or time to acclimatize to the appliance.

CONCLUSIONS

TB and ITMA patients shared similar experiences for most of the parameters measured, but there were significant differences between the groups regarding appliance wear and management, discomfort, and function.

Predictors of patient compliance during Class II division 1 malocclusion functional orthodontic treatment

OBJECTIVES

To determine factors that could predict Class II/1 malocclusion patient compliance during functional treatment.

MATERIALS AND METHODS

The sample consisted of 77 subjects (aged 11-13 years; 47% girls) presenting with Class II/1 malocclusion. Inclusion criteria were distal molar relationship, overjet greater than 5 mm, and confirmed pubertal growth spurt. Removable functional appliances (62% Twin Block [TB], 38% Sander Bite Jumping [BJ]) with built-in maxillary expansion screws were used. Follow-up period was 1 year. Patients and parents independently filled out the Child Perception Questionnaire, Parental/Caregiver Perception Questionnaire, and Family Impact Scale to assess emotional and social well-being, oral symptoms, functional limitations, parental emotions, family activities, conflicts, and financial burden as possible predictors of compliance during treatment. Sex, overjet, and appliance type were also analyzed.

RESULTS

There were more noncompliant than compliant patients (55% vs 45%). Parental perception of altered emotional well-being of their children was the strongest predictor, increasing compliance odds 3.4 times (95% confidence interval [CI], 1.2-9.4; P = .017). Patients were 3.2 times (95% CI, 1.1-9.3; P = .033) more likely to cooperate with TB compared with BJ appliance. OJ ≥ 8 mm increased compliance odds 3.1 times (95% CI, 1.0-9.4; P = .044).

CONCLUSIONS

Parental perception of child's emotional well-being alteration, severity of malocclusion, and type of appliance are major predictors of compliance. Psychosocial issues and oral function limitations reported by children and family impact are of negligible influence.

Three-Dimensional Evaluation of Soft Tissue Changes after Functional Therapy

This study was aimed at proposing a three-dimensional (3D) evaluation method for the soft tissue effects of Twin Block (TB) functional appliance therapy by using cone beam computed tomography (CBCT) images. In this retrospective study, a total of 60 pre- and posttreatment (T0 and T1) CBCT images of Class II patients with mandibular retrognathia treated with a TB appliance were used. Volumetric and linear soft tissue changes were evaluated quantitatively with 3D measurements and qualitatively with color mapping visual. Linear (NV-A and NV-Pog) and angular (SNA, SNB, and ANB) skeletal changes were also measured on 3D images. The Wilcoxon signed-rank test was used to compare statistical differences, and the scores of male and female participant differences were observed with the Mann-Whitney U test. In this study, a decrease was observed in SNA (p < 0.05), ANB (p < 0.01), and NV-Pog (p < 0.05) while an increase in SNB (p < 0.01) was found. However, decrease in NV-A distance was not statistically significant (p > 0.05). As a result of the evaluation of soft tissue changes, while the anterior reposition of the lower lip, soft tissue pogonion, and soft tissue gnathion was found to be significant (p < 0.01, p < 0.01, and p < 0.05, respectively), the upper lip and subnasale repositions were not statistically significant (p > 0.05). 3D soft tissue changes after TB therapy can be evaluated quantitatively and qualitatively by using CBCT images. Anterior repositioning of the mandible with functional therapy also provides improvement in soft tissue profile, especially in the lower facial region.

Adherence to oral appliance treatment and its determinants in obstructive sleep apnoea patients

BACKGROUND AND OBJECTIVES

Treatment effectiveness, in terms of health benefits, is a composite of efficacy and adherence. Oral appliance (OA) usage is mainly based on self-reports, but nowadays, objective adherence monitoring for OAs is available. This study investigated the objective OA adherence and its determinants in obstructive sleep apnoea (OSA) patients.

MATERIALS AND METHODS

There were 29 subjects who were treated with OA; mean [SD] age 51.4 [11.1]; mean apnoea-hypopnoea index (AHI) [SD] 19.5 [10.0]. Anthropometric and sociodemographic parameters, AHI, daytime sleepiness, snoring, and adverse effects of OA as potential determinants were evaluated. Patients were classified as regular users if they wore OA at least 4 hours nightly 5-7 nights a week. Statistical analyses included the chi-square test, t-test, Mann-Whitney U-test, and linear regression analyses.

RESULTS

At the 3-month follow-up, 68% of subjects were regular users and at 12-month follow-up, 64%. AHI, sociodemographic parameters, or adverse effects were not associated with OA adherence. Snoring seemed to improve weakly adherence, whereas mandibular retrusion reduced the weekly use, and smoking the nightly use of OAs.

LIMITATIONS

The follow-up time was short, and there were a relatively small number of patients with obtainable adherence data, therefore it is difficult to establish if OA therapy alone is a successful long-term treatment option for OSA patients.

CONCLUSIONS/IMPLICATIONS

Adherence to OA therapy is mainly the outcome of patients' subjective comfort in everyday life through eliminating social disturbance of snoring. To best meet a subject's individual treatment need and to prevent suboptimal use of OA, a patient-tailored therapy including digital wear-time documentation is recommended.

A national survey of orthodontists in Malaysia and their use of functional appliances for Class II malocclusions

Objectives

The aim of this study was to evaluate the use of functional appliances by the currently practising orthodontists in Malaysia. The objectives were to identify the different types of functional appliances used by Malaysian orthodontists and to investigate the variation in treatment protocols when attempting growth modification.

Methods

An online questionnaire consisting of 24 open-ended and multiple-choice questions was emailed to members of the Malaysian Association of Orthodontists (MAO) (n = 183). The survey was based on a previous study conducted by members of the British Orthodontic Society and was modified to suit the Malaysian population. The data were analysed using SPSS to generate frequency tables and descriptive statistics.

Results

Seventy-two responses were received from current Malaysian orthodontists. Of the respondents, 71% practised in a government setting and 29% were in private practice. The Clark Twin Block was the most frequently used functional appliance by 90% of Malaysian orthodontists. Many of the respondents (57%) prescribed full-time wear of removable functional appliances for 6–9 months (except during mealtimes) (51%). Following active removable functional appliance therapy, 91% prescribed a period of retention which involved a reduction in the duration of wear. The retention phase extended for 2 to 3 months (41%) or for 4 to 6 months (39%) for the majority of the respondents.

Conclusions

The Clark Twin Block is the most frequently-used functional appliance for the management of a Class II malocclusion by orthodontists currently practising in Malaysia.

Radiographic Assessment of Pediatric Condylar Fractures after Conservative Treatment with Functional Appliances-A Systematic Review

BACKGROUND

To evaluate the effectiveness of conservative treatment with functional appliances for condylar fractures in pediatric age.

METHODS

Four electronic databases (PubMed, EBSCO, Scopus, and Web of Science) were consulted with no restriction of publication status or year, up to 31 August 2020.

SELECTION CRITERIA

based on the PICOS criteria, the selection criteria were set for observational human studies, with at least 10 patients and six months of follow-up. The study population included pediatric patients (aged 5-16 years), with unilateral or bilateral condylar fracture, treated with functional appliances. Condylar remodeling and mandibular growth were analyzed through sequential radiographic examinations.

DATA COLLECTION AND ANALYSIS

Two independent reviewers carried out title-abstract screening, and a senior investigator was involved to solve any disagreement. The quality of the evidence was assessed through the Canada Institute of Health Economics (IHE) quality appraisal checklist, and the National Institutes of Health (NIH) quality assessment tool.

RESULTS

A total of 971 articles were retrieved from the electronic search; among them, three studies met the eligibility criteria. A moderate risk of bias was detected in all the studies, due to common limitations (absence of multicenter studies, prospective design, blindness of the investigators, patients' drop-out). At follow-up examinations (between 6 months and 4.9 years), the difference of condylar neck length between the "injured" and "healthy" side was approximately 2 mm, while the anteroposterior condylar width discrepancy was recorded up to 1 mm.

CONCLUSIONS

Short- and long-term data revealed that conservative treatment with functional appliances led to partial or full radiological recovery of the joint morphology, along with good to excellent functional results. Patients' age has a crucial role on the treatment choice, and the type of fracture (presence of condylar displacement, or dislocation) is also a major prognostic indicator of the radiologic outcome.

LIMITATION

To confirm the effectiveness of functional appliances, more prospective clinical long-term follow-up studies with homogeneous samples of condylar fractures are deemed necessary. Registration: The study protocol was registered on PROSPERO (CRD42020205650).

Treatment compliance of adolescent orthodontic patients with headgear activator and twin-block appliance assessed prospectively using microelectronic wear-time documentation

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.

Evaluation of the effectiveness of a tailored mobile application in increasing the duration of wear of thermoplastic retainers: a randomized controlled trial

Background

The ‘My Retainers’ mobile application is a patient-informed intervention designed to enhance removable retainer wear and associated patient experiences during the retention phase.

Objectives

To evaluate the effect of receiving the ‘My Retainers’ application on objectively assessed thermoplastic retainer (TPR) wear time, stability, periodontal outcomes, patient experiences, and knowledge related to retainers.

Materials and methods

Eighty-four participants planned for removable retention with TPRs were assigned either to receive the ‘My Retainers’ application or to control not receiving electronic reminders during the 3-month period. Randomization was based on computer-generated random numbers and allocation was concealed using opaque, sealed envelopes. The primary outcome was objectively assessed retainer wear recorded using an embedded TheraMon® micro-electronic sensor. Secondary outcomes, including irregularity of the maxillary and mandibular incisors, plaque levels, bleeding on probing and probing depth, were assessed at baseline and 3-month follow-up; and analysed using a series of mixed models. Experiences and knowledge related to orthodontic retainers were recorded using questionnaires. The outcome assessor was blinded when possible.

Results

Receipt of the mobile application resulted in slightly higher median wear time (0.91 hours/day); however, this difference was not statistically significant (P = 0.56; 95% confidence interval [CI]: −2.19, 4.01). No significant differences were found between the treatment groups in terms of stability (P = 0.92; 95% CI: −0.03, 0.04), plaque levels (P = 0.44; 95% CI: −0.07, 0.03), bleeding on probing (P = 0.61; 95% CI: −0.05, 0.03) and probing depth (P = 0.79; 95% CI: −0.09, 0.07). Furthermore, similar levels of patient experiences (P = 0.94) and knowledge related to retainers (P = 0.26) were found. However, marginally better levels of knowledge were identified in the intervention group. No harms were observed.

Limitations

A relatively short follow-up period with the study confined to a single-center in a university-based hospital.

Conclusions

Provision of the bespoke ‘My Retainers’ application did not lead to an improvement in adherence with TPR wear over a 3-month follow-up period. Further refinement and research are required to develop and investigate means of enhancing adherence levels.

Clinical registration

NCT03224481.

The Psychological Impact of Dental Aesthetics in Patients with Juvenile Idiopathic Arthritis Compared with Healthy Peers: A Cross-Sectional Study

This study aimed to assess whether dental aesthetics had a different impact on the psychosocial domains of adolescents with juvenile idiopathic arthritis (JIA) as compared with healthy peers. Fifty JIA patients and eighty controls aged between 13 and 17 years were enrolled. The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) was administered along with tools for the self-assessment of malocclusion and self-esteem. An objective evaluation of malocclusion severity was performed through a clinical evaluation with the Dental Aesthetic Index (DAI). The sample was divided according to the DAI stages of malocclusion severity; a two-way analysis of variance (ANOVA) was performed to assess whether there was a difference in the studied variables according to the malocclusion and the presence of JIA. The results showed no interaction between the malocclusion severity and the presence of JIA in all analyzed variables (all p > 0.05). According to the DAI stages, the Dental Self-Confidence domain of the PIDAQ and the Perception of Occlusion Scale showed statistically significant differences only within the controls (p = 0.027 and p = 0.014, respectively). Therefore, JIA adolescents seem to be less concerned about their dental aesthetics compared with healthy peers, and clinicians should take particular care when proposing orthodontic treatments aiming only to improve dental aesthetics.

Factors influencing adherence to vacuum-formed retainer wear: A qualitative study

Objective:

To explore factors influencing adherence to vacuum-formed retainer wear over a minimum period of four years.

Design:

A qualitative study based on a randomised controlled trial assessing the effectiveness of orthodontic retainers.

Setting:

Institute of Dentistry, Queen Mary University of London.

Participants:

Fifteen participants wearing vacuum-formed retainers for at least four years.

Methods:

One-to-one semi-structured interviews were undertaken on a criterion-based purposive sample of participants wearing vacuum-formed retainers. The interviews were audio-recorded, transcribed verbatim and analysed using Framework Methodology.

Results:

High self-reported levels of adherence in the early stages of retention were linked to a desire to maintain orthodontic outcomes and the negative perception of potential post-treatment changes. However, adherence typically reduced over time due to a combination of factors including the negative impact of retainers on quality of life and pragmatic issues related to retainer wear. Network support was found to be important in the short and long term, with instances of self-directed wear and negative beliefs concerning the importance of retainer wear and predisposition to post-treatment changes. Lack of follow-up appointments and immaturity of participants prompted independent decisions to cease retainer wear.

Conclusions:

Six key influencers of prolonged adherence with vacuum-formed retainer wear were identified. Future strategies to improve adherence should account for these while also being responsive to time elapsed since debond and patient age.