Management of URA before Delivery

It’s important to explain to the patient what the Upper Removable Appliance is for and why it is needed. 

1. You want to make sure this is the right appliance for the patient in the chair and check that the design is correct and what you asked for.
2. Check the URA for any sharp areas of acrylic or metal-work and try the appliance on the study model to assess the fit. 
3. Make sure the active components are able to move freely under the acrylic baseplate (1).

Management of URA on Delivery

1. Try in the appliance and ask the patient if it’s comfortable. Incorrect fitting could be due to: new partially erupted teeth (if so, adjust the acrylic), if any extractions have taken place since the impression was done (if so bend, the cribs forwards) or it could be due to a significant delay between the impression and fitting of the URA.
2. Check with hand mirror for any soft tissue blanching due to wire work (if so, adjust to relieve).
3. Check the stability of the appliance and that the bite plane is the correct height – ensure the opposing occlusion has even contact.
4. Demonstrate how to insert and remove the appliance and let the patient practice (1).

The URA is not active at this moment as it’s best to let the patient get used to wearing the appliance for around 1-2 weeks before activation (2). This will generate patient confidence and help them get used to the feeling of the different components without the added distress of any pain from tooth movement.  

Patient Guide to Management of their Appliance

1. Wear the appliance at all times unless otherwise advised (e.g. contact sports and musical instruments where it should be stored in a protective box).
2. After each meal, the URA should be removed and cleaned/rinsed thoroughly taking care not to distort any wirework. 
3. Avoid hard, sticky and chewy foods.
4. It is normal to experience speech difficulty and increased saliva production initially, however, this will pass in a couple of days when you become accustomed to the appliance (Tip: practice reading out loud at home during first couple of days).
5. If unable to wear appliance as instructed/appliance gets damaged, please contact the clinic immediately to have URA adjusted or repaired (1, 3).

Adjustments of Retentive Components

Can be done using Adam’s 64 Pliers (5). 

Adams Clasp

This is commonly constructed using 0.7mm hard stainless steel and engages in 1mm of undercut in a fully erupted first permanent molar. The arrowhead should lie at or just above the gingival margin in children (4).

The Adams Clasp can be adjusted in two areas to improve the retentive features (remember it should still be passive). 

1. Bending near the arrowhead will move it horizontally in towards the tooth and have little effect on the vertical plane.
2. Bending the flyaway will move the arrowheads down and in towards the gingival crevice resulting in vertical plane movement (1). 

Be careful not to over adjust as this could lead to difficulty inserting and removing the appliance and if it’s too retentive it could actually cause the tooth to tip inwards! 

Southend Clasp

This clasp uses the undercuts beneath the contact points of two incisors to aid in retention. It’s usually formulated in 0.7mm hard stainless steel. 

Adjustment should be done after the Adams Clasp.

Adjust the areas over the contact points (red circles) to ensure the clasp fits the tooth and is retentive (where the wire just exits the acrylic). Ensure these points remain retentive and fitted to the tooth during active therapy as it’s a common area for distortion, especially when the patient uses the clasp to aid in the removal of the appliance. Once the ends of the clasp are adjusted then move to the middle where the ‘U’ bend is (blue circle) - ensure it’s contoured over the undercuts as this is the point of most retention (5).

Labial Bow

Made using 0.7mm hard stainless steel, this retentive component should lie in the middle third of the anterior teeth with the end ‘U’ loops adjacent to the canines. Ideally it should contact as many of the incisors as possible (this will depend on how well aligned the anterior teeth are to begin with). 

Adjustment is done by gently contracting the ‘U’ loops and this will move the bow palatally and more incisal, improving the retention (5).

Activation of Active Components

'Z' Spring

This is the spring of choice for treatment of an anterior crossbite and is appropriate for moving a single tooth bucally. Good anterior retention is needed to counteract the displacement effect of this spring.

Activation is done by pulling the spring in a 45 degrees angle approximately 1-2mm away from the baseplate in the direction of desired tooth movement. Deflection should be done in small increments and shouldn’t exceed 3mm to avoid over activation. 

Adjustment should be done on the palatal arm first followed by the free arm (4).  

'T' Spring

Used for correction of a localised posterior crossbite. Again, good retention is needed and adjustment is done by pulling the spring out at a 45 degrees angle away from the acrylic. The springs often come with adjustment loops too which can be opened up as well; care should be taken not to exceed a 3mm deflection. 

Palatal Finger Spring (PFS)

This spring moves the tooth in a mesial/distal direction and is usually boxed in acrylic with a guard wire to prevent distortion. It should be at the level of the gingival margin at 90 degrees to the direction of planned tooth movement. 

Activation can be done anywhere from the coil to the point of where the spring emerges from underneath the guard wire (4). The coil is opened up to activate the spring and as tooth movement occurs it will slowly wind up to deliver force. 

Tip: For optimal force delivery activate just under ½ of the tooth width!

Buccal Canine Retractor

Used for retraction of bucally displaced upper canines. The spring engages with the mesial aspect of the tooth and activation is achieved by moving the anterior leg in the direction of movement desired (as shown below). 

Screws

When blocks of teeth are to be moved, a screw is placed in the palate of the URA and also has the added benefit of retention as these teeth to be moved can be clasped at the same time. A common use is for upper arch expansion to correct a posterior crossbite (1).

Unlike the other active components, the screw is activated by the patient! A ¼ turn of the screw twice a week using the key provided will activate the two sections of the appliance by 0.25mm. 

How to confirm the Patient has been wearing their Appliance

1. Asking the patient an open-ended question such as “How much are you managing to wear your brace?” rather than “Are you wearing you brace all the time?” will allow for a more realistic and honest answer. It’s also important to note any adverse speech effects (e.g. a lisp) because if the patient has been wearing it, they should be speaking normally!
2. Next, ask the patient to remove their brace and observe how they do this. They should be manually dextrous with the action and have no trouble.
3. Inspect the appliance for wear, scruffs and scratches, including dullness of the metal components which are all indications of compliance. 
4. Examine the soft tissues of the patient for any signs of wear e.g. at the gingival margins and across the palate.
5. The active components should be inactive and retentive components should be loose (1). 

How to Work on Patient Motivation

1. Patient Education - explaining concepts to the patient in terms they understand by offering visual, oral and written instructions which aren’t complicated to process (big headings and short sentences). This will help relay the value of compliance.
2. Enthusiasm – showing interest in the patient, making conversation, a relaxed attitude and an informal manner can make the patient feel at ease and relate to you, hence listen to what you have to say!
3. Transitional Insecurity – the patient may have low self-esteem and little confidence in themselves, especially during the transitional phase from child to adult. Respecting their boundaries, showing empathy and giving emphasis to the intrinsic values of orthodontic treatment and the transformation it can provide will give them something to work towards and look forward to (6). 

Tip: Don’t sell them false hope/overpromise! It’s important to be realistic yet positive. 

Clinical Examination during Treatment/Follow-Up Appointments

1. Ask the patient if they’ve had any difficulties since the last appointment and examine both the patient and URA for evidence of wear.
2. Measure tooth movement using a pair of dividers and marking the width in the patient’s notes (e.g. measure width from tooth being moved to its abutment tooth and compare it to width on study models taken at the start of treatment)
3. Refer back to original treatment plan and ensure each step is being carried out. Note how long treatment has been under way with reference to predicted length of treatment and monitor if correct progress is being made.
4. Assess patient’s oral hygiene and reinforce if required.
5. Check for anchorage loss by measuring overjet and buccal segment relationship.
6. Assess retention and adjust if loose.
7. Reactivate active component.
8. Make sure appliance is stable, everything fits correctly and patient is happy! (1).