Correlates of objective patient compliance with removable appliance wear.

Patient compliance is considered a major problem in orthodontics. Yet, to date, few conclusive findings have been noted on determinants and consequences of failing adherence, probably because of method flaws and a lack of objective criteria. By following an outline of conceptual issues and selected research, we considered an investigation into correlates of patient compliance with removable appliance wear. We studied a sample of 77 university clinic patients ages 9 to 14 years over several months by means of psychologic inventories and electronic measurement of removable appliance wear. The actual compliance rate proved to be associated with many variables. Among those, characteristics of the patient and his family background, such as conformity and degree of consistent parental support and supervision are interpreted as determinants of satisfactory adherence, whereas treatment related and interactional correlates, such as duration of treatment, dominance of provider, and interpersonal perceptions, are conceived of in terms of mutually interdependent and/or consequent variables. The factors identified might be paralleled in the wearing of headgear and intraoral elastics that require a similar degree of active patient cooperation. After a critical discussion of our data in the light of previous findings, suggestions are provided for future research along with conclusions for clinical practice.

[The determinants of wear behavior in treatment with removable orthodontic appliances]. / Determinanten des Trageverhaltens bei der Behandlung mit herausnehmbaren kieferorthopädischen Geräten.

The interplay of significant determinants of patient appliance wear is discussed in terms of a conceptual model reflecting the current state of research in orthodontic compliance. Appliance wear is determined by treatment-related factors such as regimen and perceived comfort, as well as by external factors such as patient personality and parental attitudes. Patient attitudes are the critical link between these influences. In the focus of this article are the patient's experiences and perceptions of treatment and the way they are affected by appliance and prescribed wear. Furthermore, possible measures to enhance compliance are highlighted.

[Recommended times for wearing removable appliances--the results of a survey]. / Tragezeitverordnungen bei herausnehmbaren Geräten--Ergebnisse einer Umfrage.

Since prescribed wear times of removable appliances are, in combination with comfort, relevant to compliance, a questionnaire on the prevalence, the nature and the differentiation of such prescriptions in active orthodontic treatment was sent to 300 orthodontists selected at random among the members of the German Orthodontic Society. On the basis of 172 responses (response rate 57.5%), the following results were obtained: In eight to 16-years olds "active" treatment is administered with Schwartz plates in an average of 43.7%, and with functional orthopaedic appliances in an average of 37.6% of the cases, the classical activator (61.1%) and the bionator (58.7%) being used most frequently. Particular times of day or night are prescribed as wear times by some 60% of responders, while others prescribe merely a certain number of hours of daily wear. Identical prescriptions are given to the majority of patients by 86.6%, and are unchanged throughout the course of active treatment by 73.8%. Wear times actually prescribed average 15 (functional appliances) and 16 hours (plates) daily, while the minimum wear time considered necessary for successful treatment averages 12.8 for functional appliances and 13.9 for plates.

[The wear-timing measuring device in orthodontics--cui bono? Reflections on the state-of-the-art in wear-timing measurement and compliance research in orthodontics]. / Tragezeitmesser in der Kieferorthopädie--cui bono? Uberlegungen zum State-of-the-art bei Tragezeitmessung und Complianceforschung in der Kieferorthopädie.

The recent development of fully functioning timing devices has yielded a new impulse to scientific research on orthodontic compliance. In contrast, promises and risks of the practical application of timing devices have thus far largely gone unheeded. In this survey, possible benefits of this new device are considered along with a critical discussion of technical and sociopsychological issues of its practical application. Following a review of the current state of orthodontic timing technology, basic implications of the collection and utilization of this new type of data are outlined. Short- and long-term perspectives of objective measurement of compliance are presented in terms of optimized treatment devices, enhanced patient compliance and improved orthodontist-patient relations. An evaluation project on benefits and risks of orthodontic timing devices is being called for.

[Source studies on the etiology, diagnosis and treatment of TMJ ankylosis and syngnathia. 1. From classical antiquity to mid-19th century]. / Quellenstudien zur Atiologie, Diagnose und Therapie der Kiefergelenksankylose und Syngnathie. 1: Von der klassischen Antike bis zur Mitte des 19. Jahrhunderts.

The present first part of two of a historical overview on ankylosis of the TMJ and syngnathia covers the period from antiquity to the 2nd half of 19th century. Etiology, case studies and the first therapeutic approaches are documented on the basis of long forgotten and meanwhile hardly accessible original sources.

Subjective appraisal of orthodontic practices. An investigation into perceived practice characteristics associated with patient and parent treatment satisfaction.

Based on a comprehensive in-practice questionnaire survey among 254 school-age patients and their parents, the subjective perception and evaluation of orthodontic care was investigated. By means of refined statistical analysis, three types of practice showing significantly distinct image profiles were identified. Likewise, the set of discriminating variables was reduced and assigned to the fundamental concepts of 'interpersonal satisfaction' and 'perceived efficacy' which appeared to play a crucial part in the crystallization of both patients' and parents' contentedness with the treatment received. To take account of the interdependence of instrumental and social factors, a model of perceived practice similarity is suggested; its significance regarding treatment decisions and future research efforts is pointed out.

[Orthodontic treatment from the patients' and parents' viewpoint--the results of a practical and clinical questionnaire study (II)]. / Die kieferorthopädische Behandlung aus Patienten- und Elternsicht--Ergebnisse einer Fragebogenstudie in Praxis und Klinik (Teil II).

A questionnaire investigation enrolling more than 300 orthodontic patients and their parents was conducted into the subjective appraisal of treatment means and doctor-patient-interaction. The majority of the interviewees showed a positive respectively indifferent attitude toward their treatment. As patients grow older, their views become more differentiated and critical. Impaired speaking was mentioned most frequently; psychosocial disadvantages caused by appliance wear were suggested mostly by parents. In a minor part of patients, the orthodontist's behavior was not in line with their social-emotional needs and expectations. Slight failures of adherence with prescriptions were admitted for the daytime. Parental supervision appeared to be either energetic or formal yet superficial, or insufficient respectively in one third of our cases.

[CT morphology and function of the temporomandibular joint following conservative functional treatment of temporomandibular joint fractures]. / CT-Morphologie und Funktion der Kiefergelenke nach konservativ-funktioneller Behandlung von Kiefergelenksfrakturen.

In 8 adult and 13 adolescent individuals who had undergone conservative treatment for condylar fractures 4.2 and 4.5 years earlier, respectively computed tomography was performed. In addition, joint mobility was examined clinically in 18 of these patients. The results of the radiological examination allow discrimination between high-grade and low-grade remodeling and excessive bone formation. With one exception, high-grade remodeling was invariably observed after childhood fractures. In the adult patients new bone formation was rarely observed. Correlation between the morphologic appearance and joint mobility was detectable only in cases of severely limited function. In the presence of less severe functional lesions, the size of the insertion area of the lateral pterygoid muscle might indicate the degree of functional rehabilitation. The radiological procedure is discussed.

[The bionator with extraoral traction--the Wurzburg concept. 1]. / Der Bionator mit anteriorem Hochzug--Das Würzburger Konzept. I.

In this publication the bionator with extraoral anterior traction is presented. The preparation of the bionator and the headgear fit is demonstrated. The indication for the use of the appliance combination is outlined. The results of a cephalometric study concerning the therapeutic effects are presented. The following changes are especially noteworthy: There is a reduction of the SNA-angle, a significant retrusion of the upper incisors occurs. The mesial drift of the upper 6-year molars is inhibited, a slight posterior rotation of the maxilla is observed. In patients who wore their appliances well, a protrusion of the lower incisors could not be observed.

[Retrospective evaluation and experimental radiographic study on bone reaction concomitant with orthodontic tooth movement]. / Retrospektive Erhebung und klinisch-experimentelle Studie zum Knochenumbau bei orthodontischen Zahnbewegungen.

Concomitant with orthodontic tooth movement a radiographically dense zone of high mineralisation can be observed on the periodontal tension side. This zone consists of the alveolar cortical bone and mineralized osteoid. This bone reaction has not evoked much interest in orthodontic literature in the past. In a retrospective study, orthopantomograms of children in orthodontic treatment were evaluated, and the discussed reaction was studied in relation with different treatment parameters. Opaque bone layers were found in cases in whom the orthopantomogram was made within 6 months after initiating tooth movement. When using elastics for tooth movement the bone reaction under discussion was comparatively rare. There is no proneness to root resorption in teeth showing the described adjacent bone reaction. Bone reaction was also studied with a densitometric radiological procedure. In all 9 cases the bone reaction was observed.

Reliability of patient reports on compliance.

The reliability of subjective estimates of patient appliance wear plays a critical role in scientific research on compliance just as in everyday orthodontic practice. This problem was subjected to scrutiny by means of the recently developed electronic timing device and psychological investigations. Over several months 53 patients between 9 and 14 years of age treated with bionators were followed. Included were objective measurement of wearing time, judgements on compliance by patients, parents, and orthodontists, and questioning about numerous treatment-related and personality variables. These data allowed an assessment of subjective reports. Asked to classify patients as 'good', 'average', or 'poor' co-operators, neither the orthodontists nor the patients in their self-ratings exceeded 43 per cent of hits. From a heuristic model of how misjudgements on compliance arise, indicators were derived to represent certain stages of cognition formation in the patient. A strong association was found between actual compliance and patient credibility, in that generally 'poor co-operators' grossly overstate their wearing time. Consequently, various patient characteristics and features of operator-patient interaction proved significantly correlated with both criteria. Among them, regularity of wear and duration of treatment are most influential. Moreover, patient credibility appeared to be a salient point of the reciprocal perceptions of treatment partners and their personalities. The reliability of patient statements also depends upon: (1) how detailed the operator's questions are; (2) whether he draws his own conclusions from the information received instead of leaving them to the patient. This evidence may lead to greater accuracy in gauging patient compliance.

[Initial attitudes to orthodontic treatment--the results of a practical and clinical questionnaire study (I)]. / Initiale Einstellungen zur kieferorthopädischen Behandlung--Ergebnisse einer Fragebogenstudie in Praxis und Klinik (Teil I).

312 patients from one clinic and nine offices, between eight and 15 years of age treated with bionators, their parents and a control group were questioned on various aspects of their treatment. Findings regarding opinions about dentofacial appearance, initial motives and expectations are presented. Aesthetic motives proved preponderant by seeking treatment though the children's ability to verbally differentiate aesthetic concepts was poor. Above all, they expected visible treatment progress, absence of appliance-caused psychosomatic impairment and rather factual information than personal communication with the orthodontist.

[The realization of a wear-timing device for clarifying the scientific questions presented in orthodontics]. / Vorstellung eines Tragezeitmessers zur Abklärung wissenschaftlicher Fragestellungen in der Kieferorthopädie.

A timing device for removable orthodontic appliances is described. The measurement system includes a quartz digital clock at the timer. A reed switch serves as a sensor and is activated by a magnetic device fastened directly or by an orthodontic band to a molar tooth. A changeover reedswitch prevents manipulation by the patient. As a timing device the system provides great accuracy. The high-speed capability of the device permits further scientific application: Installation of two timing devices in a single Bionator permits selective timing (e.g. biting contact during wear of the appliance).

Micro-electronic monitoring of functional appliance wear.

Measurement of actual bionator wear has so far been confined to a few studies involving only small samples. In this study a micro-electronic timing device was used in a greater number of patients (53 children) after the system proved to be reliable in a pretest involving 18 subjects. The patients were 9-14 years of age and had a timing device fitted in their bionators over a period of 3-6 months. The data were read from the memory chip at the regular treatment sessions every 3-4 weeks. There was evidence that the patients averaged 7.65 hours per day of wear, thus fulfilling only 50-60 per cent of the orthodontist's requirements. Further details and implications of the measurements are discussed.

[Remodeling after condylar dislocation fractures in growing individuals]. / Zur Remodellation nach Kondylusluxationsfrakturen bei Heranwachsenden.

A longitudinal study of the remodelling process in three growing individuals who had suffered low condylar fractures with luxation was made utilizing computerized tomography. The small fragment of the condyle is partially resorbed during the remodeling process, while new bone is formed on the lateral aspect. Below the fracture site in the ascending ramus bone apposition was observed. Each of these remodeling responses was more vigorous in the one child examined than in the two adolescents.

[TMJ morphology after condylar dislocation fractures in childhood]. / Zur Morphologie der Kiefergelenke nach Kondylusluxationsfrakturen im Kindesalter.

In a CT- and NMR-study, condylar remodeling after conservative treatment of condylar dislocation fractures in growing individuals was evaluated. The regenerated condyles displayed great similarities. Two condylar parts could be differentiated--one with and one without muscular attachment. The medial part represents the former small fragment and the lateral part a bony outgrowth. One of the patients studied demonstrated a bifid condyle. NMR-records were remarkable in that each of the three patients presented a lateral pterygoid muscle with the two heads oriented one above the other rather than side by side. This does not seem to support the observation made in experiments, that the disc remains fixed to the caput in low condylar fractures.

[Joint-sparing mobilization of TMJ ankylosis]. / Das Lösen der Kiefergelenkankylose unter Schonung des Restgelenks. Vorstellung zweier Behandlungsfälle.

The causes leading to ankylosis are reviewed and operative approaches to avoid "block-resection" are briefly outlined. 2 patients with fibrous ankylosis are presented, with the affected area visualized through computer-tomograms. Each patient underwent only resection of the lateral exostosis causing restricted movement. Follow-up tomograms of the 2 patients are offered.

Long-term results after childhood condylar fractures. A computer-tomographic study.

A computer-tomographic study of the remodelling process of the TMJ was made of 12 patients who had suffered condylar fractures during their growth period. The most interesting results were exhibited by patients with low fractures of the condyle and medial luxation of the small fragment. The remodelled condyles consisted of 2 parts, a medial part, probably the remainder of the small fragment and a lateral part, probably callus formation. In some patients a flattening of the fossa characterized by thickening of the roof was clearly observed. The case presentation additionally included one patient with post-traumatic ankylosis and one patient presenting a bifid condyle.