REMOVABLE ORTHODONTIC APPLIANCE FOR AUTISTIC CHILD

CASE HISTORY REPORT

ABSTRACT
A newly designed removable appliance
with a shape-memory wire was used for
the orthodontic treatment of the anterior
teeth in an 11-year-old child who had
autism and intellectual disability. The
device was designed to reduce the lateral incisor crossbite and the central
incisors labial rotation. The child was
treated for 1 year with this removable
appliance. Tooth movement was analyzed using cephalograms and surface
data were derived from study models.
This device proved to be very durable.
The lateral incisor crossbite was corrected, and the inclination of the upper
central incisors and the interincisal angle
were improved. This appliance exerts light
and continuous orthodontic force, without
requiring any adjustments of the spring
wire. The appliance also facilitated orthodontic treatment in a child with intellectual
disability in whom treatment with a standard orthodontic device would be
unsuitable.

KEY WORDS:

autism, pediatric
dentistry, dental treatment

Removable orthodontic appliance with

nickeltitanium spring to reposition the
upper incisors in an autistic patient
Kan Saito, PhD;1 Insan Jang, DDS, PhD;2 Kazumi Kubota, PhD;3
Tomonori Hoshino, PhD;1* Hitoshi Hotokezaka, PhD;3 Noriaki Yoshida, PhD;4
Taku Fujiwara, PhD1
1Department

of Pediatric Dentistry, Nagasaki University Graduate School of Biomedical Sciences,

Nagasaki, Japan; 2Department of Orthodontics, College of Dentistry, Kangnung National University,
Gangneung, South Korea; 3Department of Hygiene and Oral Health, Showa University School of
Dentistry, Ootaku, Tokyo, Japan; 4Department of Orthodontics and Dentofacial Orthopedics, Nagasaki
University Graduate School of Biomedical Sciences, Nagasaki, Japan.
*Corresponding author e-mail: thoshino@nagasaki-u.ac.jp
Spec Care Dentist 33(1): 35-39, 2013

Int r od uct ion

Children with intellectual disability have a higher prevalence of malocclusion than
children without disability. These malocclusions necessitate treatment.1-4 The etiology
of malocclusion in children with disability are abnormal muscle function and habits
such as finger sucking, mouth breathing, and tongue thrusting.5 Especially in patients
with autism, there is a high incidence of malocclusion, characterized as Angle class II
and extreme overjet.6-8 It has been reported in the dental literature that higher incidence of dental trauma is associated with enlarged overjet. When overjet is larger than
3 mm, the risk of anterior dental trauma will be twice as high as in children with
normal overjet.9 The relationship between dental trauma and inadequate lip coverage
has also been reported.10 Furthermore, the frequency of tooth injury in children with
autism has been found to be significantly higher than in controls who do not have
autism.11 In patients with autism, predisposition to tooth injury is linked to malocclusion as well as movement disorders such as unsteady gait and attention deficit.5 Thus,
we suggest that the treatment of malocclusion is essential to preventing tooth injury in
patients with autism.
However, behavioral factors of
autistic spectrum disorder make orthodontic therapy difficult. Symptoms of
autism include impaired intellectual
development, atypical repetitive behavior, hyperactivity, limited attention
span, and a low frustration threshold.12
Patients with autism exhibit tactile and
auditory hypersensitivity and may
show exaggerated reactions to light
and odors.13 Furthermore, individuals
with autism tend to dislike changes
in their environment and may have

2012 Special Care Dentistry Association and Wiley Periodicals, Inc.

doi: 10.1111/j.1754-4505.2012.00291.x

scd_291.indd 35

tantrums even when only slight

changes occur in the familiarity and
continuity of their daily routines.14
Thus, in many cases, dental treatment
of patients with autism is very difficult
and complex.4 For these reasons,
there are few reports of successful
orthodontic treatment for autistic
children.15 In this study, we report a
newly designed removable orthodontic
appliance that is very durable and did
not require adjustment during the
treatment period.

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REMOVABLE ORTHODONTIC APPLIANCE FOR AUTISTIC CHILD

Metho ds
Subject
A boy aged 6.5 years visited our clinic in
the Department of Pediatric Dentistry at
Nagasaki University for dental evaluation, with complaints of an impacted
mesiodens. The patient was diagnosed as
autistic and had intellectual developmental delay (approximately 45 IQ). When
the patient was 7 years old, he underwent extraction of the supernumerary
tooth and treatment for several dental
caries under general anesthesia.
Following treatment, oral hygiene was
maintained and monitored during periodic dental examinations. As his
familiarity with the dental clinics
increased, treatment advanced. He
became more cooperative. The patients
parents subsequently became concerned
about the labial inclination of the central
incisors and the right lateral incisor
crossbite (Figure 1). Orthodontic treatment was started at 10 years of age. At
first, the removable orthodontic appliance with a double loop spring wire
(cobalt-chrome; Co-Cr, 0.5 mm) was
used. However, the patient broke the
appliance after two weeks. Recognizing
the need for a more durable appliance,
we adopted a novel removable orthodontic appliance with a nickeltitanium
(Ni-Ti) spring.

Removable appliance
fabrication details
Individual teeth in an upper dental stone
model were separated into single units.
The separated teeth were aligned at ideal
positions over the alveolus. A removable
appliance was fabricated that was
equipped with double Adams clasps that
were prepared from a 0.8 mm Co-Cr
alloy wire and a 0.9 mm labial wire (separate wires were soldered to each other).
This appliance was used to realign the
central incisors lingually. A 0.46-mm
(0.018-inch) rectangular nickeltitanium
(Ni-Ti) alloy wire (Tomy international
Inc., Tokyo, Japan) was used as the active
spring wire. This wire was bent to fit to
the ideally aligned incisors and then
heat-treated using Bender Soarer-II
equipment (Tomy International Inc.).

36 S p e c C a r e D e n t i s t 3 3 ( 1 ) 2 0 1 3

scd_291.indd 36

Figure 1. Oral view before treatment (at 10 years of age).

All wires were fixed in position by

embedding them in a resin plate.

Evaluation
We compared the posttreatment cephalogram with the pretreatment cephalogram.
The study models that were collected at
pretreatment and posttreatment were
scanned in three dimensions using
VMD-25 software (UNISN, Osaka,
Japan); tooth movements were measured
using a superimposition method
described by Jang et al.16 The surface
data from the two 3-D models were then
superimposed using the permanent first
molar and primary second molar as reference points. We employed Imageware 9
software (UGS PLM Solutions, Plano,
Texas) for the analysis.

Force measurement
The force of the spring wire was measured
at 37C (the temperature of the oral cavity)
by using a tension gauge. The 0.018-inch
rectangular Ni-Ti alloy wire, 0.018-inch
round Ni-Ti alloy wire, 0.016-inch round
Co-Cr wire, and 0.5 mm round Co-Cr wire
were also tested. The lengths of all spring
wires were adjusted to 3 cm.

R es ul t s
Taking into consideration the patients
oral hygiene status and rough appliancehandling manner, we constructed a

removable orthodontic appliance containing a shape-memory alloy spring

(Figure 2A). The patient was permitted
to see and touch the appliance until he
became used to it. He gradually became
more cooperative and compliant. When
the patient was completely familiar with
the appliance, we taught him how to correctly position it in his mouth (Figure 2B).
The appliance and oral hygiene of the
patient were checked monthly. His oral
hygiene status was good, and dental
caries was not detected during the treatment period. Although the Adams clasps
needed occasional readjustment, the
other wires of the appliance remained
fixed and intact throughout the treatment. After 12 months, the anterior right
lateral incisor crossbite and the central
incisors protrusion were improved, and
use of the appliance was discontinued
(Figure 3). New posttreatment impressions were made. The posttreatment
dental casts were scanned, and the preand posttreatment surface images were
superimposed (Figure 4). It was found
that the right lateral incisor moved
2.2 mm labially and that the crossbite
was significantly improved. The left lateral incisor shifted 1.1 mm labially. The
right central incisor moved 0.2 mm labially, while the left central incisor moved
2.7 mm palatally. The patients overjet
improved, with the distance between the
upper and lower incisors decreasing from
6.4 to 3.7 mm.

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REMOVABLE ORTHODONTIC APPLIANCE FOR AUTISTIC CHILD

Figure 3. Oral view after treatment (at 11 years of age).

Figure 2. The removable orthodontic appliance

composed of a nickeltitanium alloy (A) and an
image of the patient with autism wearing the
removable appliance (B).

Superimposition of the pre- and posttreatment cephalograms (Figure 5)

revealed forward and downward maxillofacial growth, while the angulation of the
mandibular anterior teeth was not
changed. We measured various angles on
both cephalograms, and asterisked values
that deviated by >1 standard deviation of
the mean for the Japanese population are
shown in Table 1. Since the central incisor was inclined palatally, U1 to SN, U1
to FH, and the interincisal angles were
improved. Since the occlusal interference
was eliminated by the lateral incisor
crossbite correction, the vertical dimension of occlusion was also reduced. As a
result, the mandibular plane to SN and
mandibular plane to FH angles were
improved.
For comparison of dental materials
that we might have selected for the
appliance, we measured the force magnitudes of active spring wires, 3 cm long,
that were made from various alloys and
of different thicknesses (Figure 6). The
force magnitude of a Co-Cr spring wire
increased in proportion to the deflection.
The Co-Cr wire was deformed irreversibly when it was bent more than 3.5 mm.

Saito et al.

scd_291.indd 37

Figure 4. Three-dimensional scanning study of orthodontic movement after treatment with the
removable appliance. The light area indicates a pretreatment upper jaw and tooth positions, and
the dark area is posttreatment.

In contrast, wires made from Ni-Ti alloy

returned to their original state when
they were deflected up to 4 mm. The
magnitude of force exerted by these
wires reached a plateau when the wire
deflection was greater than 1.0 mm.
Furthermore, the force magnitudes were
much smaller for Ni-Ti wires than for
Co-Cr wires. The force magnitudes of
the 0.016-inch Ni-Ti round wire, 0.018inch Ni-Ti round wire, and 0.018-Ni-Ti
rectangular wire were <60, <70, and
<120 g, respectively. The small diameter
Ni-Ti wire proved to be the one with the
best properties for producing gentle
constant physiological tooth movement
forces.

D is cus s ion
The definition and diagnostic criteria for
autistic disorder are mentioned in fourth
edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) in
the section Pervasive Developmental
Disorders.13 The diagnostic criteria in
DSM-IV encompass qualitative impairments in social interaction and
communication as well as deviant patterns of social behavior, restricted
interests, and ritualistic engagement in
repetitive activities. The patient
described in this study was diagnosed
with autism according to the DSM-IV
criteria and showed clear intellectual

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REMOVABLE ORTHODONTIC APPLIANCE FOR AUTISTIC CHILD

Table 1. Comparison between cephalometric measurements preand posttreatment ().

Pretreatment

Posttreatment

Mean SD

Mandibular plane to SN

33.5*

36.2

39.4 5.0

Mandibular plane to FH

26.9*

27.8

32.4 4.5

Gonial angle

120.2*

125.3

128.3 3.7

U1 to SN

120.4*

104.3

103.6 1.6

U1 to FH

127.0*

112.8

110.6 4.8

Interincisal angle

102.4*

121.4

122.7 8.4

Figure 5. Superimpositions of lateral cephalograms. The doted lines indicate pretreatment

(patient at 10 years of age) and the solid lines
show posttreatment (patient at 11 years of
age) findings.

disability (approximately 45 IQ). Patients

with autism often show characteristics
such as impaired ability to empathize
with other individuals, abnormal development of communication, stereotypical
pattern of behavior, repetitive engagement in limited activities, and restricted
capacity for imagination.13 Thus, it is
very difficult for individuals with autism
to learn to correctly use orthodontic
appliances. Having said this, the repetitive behavioral trait is potentially
advantageous for orthodontic treatment.
Indeed, our patient learned to use the
removable orthodontic appliance as one
of his repetitive behavioral patterns and
showed no signs of stress while attending
regular hospital appointments for about
4 years. Furthermore, since we used the
Treatment and Education of Autistic and
Related Communication Handicapped
Children (TEACCH) method,17 the
patient easily adapted to using the appliance. The TEACCH model is a
comprehensive educational concept that
has been in use since 1972.17 By utilizing
visual pedagogy, children with autism

38 S p e c C a r e D e n t i s t 3 3 ( 1 ) 2 0 1 3

scd_291.indd 38

Figure 6. Load-deflection curve of the spring wires. The force magnitudes of the double spring and
Ni-Ti alloy spring of the removable appliance that was used to treat the patient were measured.

can easily learn how to perform various

tasks, and the visual approach method
helps them to cooperate during the treatment process.18
We decided to use a removable orthodontic appliance rather than a fixed
lingual arch because the ability to see and
handle the device may be an effective
visual pedagogical strategy. Moreover, the
lingual arch cannot be removed for cleaning and is easily deformed. Becker et al.19
reported that the application of a fixed
appliance is more difficult than that of a
removable appliance for children with
intellectual disability. Thus, a removable
appliance is the best option for children
with autism. Patients with autism have a
higher risk of Angle class II and III malocclusion.6 With the development of
removable orthodontic appliances, it is
likely that the number of patients with
autism who undergo orthodontic treatment will increase. Our removable
appliance should be studied in greater

detail in clinical studies and may need to

be further improved.
The force magnitude required to
reposition teeth was one of the main
reasons why this treatment was successful. When four incisors are moved
together, the 0.018-inch Ni-Ti rectangular wire may be sufficient, since the
optimum force for a tipping movement
is between 35 and 60 g.20 On the other
hand, if only one incisor is moved, the
0.016-inch Ni-Ti round wire that exerts
70 g of force should be sufficient to
reposition the tooth. The following
points are important to ensure successful treatment:
The removable appliance should be as
small as possible, because most patients
with autism have hyperesthesia.
The appliance should be reinforced by
wires.
The Ni-Ti wire must not touch the
opposing teeth, because occlusal forces
may fracture the wire.

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REMOVABLE ORTHODONTIC APPLIANCE FOR AUTISTIC CHILD

We conclude that a removable appliance with a reinforced resin base and a

Ni-Ti alloy wire can be utilized for orthodontic treatment in children with
intellectual disability.

References
1.

2.

3.

4.

5.
6.

Utomi IL, Onyeaso CO. Malocclusion and

orthodontic treatment need of mentally
handicapped children in Lagos, Nigeria.
Pesq Bras Odontopediatr Clin Integr 2009;
9:7-11.
Onyeaso CO. Comparison of malocclusions
and orthodontic treatment needs of handicapped and normal children in Ibadan using
the Dental Aesthetic Index (DAI). Niger
Postgrad Med J 2004;11:40-4.
Dinesh RB, Arnitha HM, Munshi AK.
Malocclusion and orthodontic treatment
need of handicapped individuals in South
Canara, India. Int Dent J 2003;53:13-8.
Fahlvik-Planefeldt C, Herrstrm P. Dental
care of autistic children within the nonspecialized Public Dental Service. Swed Dent
J 2001;25:113-8.
Rix B. A perspective of mental handicap.
J R Soc Health 1986;106:161-5.
Vittek J, Winik S, Winik A, Sioris C,
Tarangelo AM, Chou M. Analysis of ortho-

Saito et al.

scd_291.indd 39

dontic anomalies in mentally retarded

developmentally disabled (MRDD) persons.
Spec Care Dentist 1994;14:198-202.
7. Luppanapornlarp S, Leelataweewud P,
Putongkam P, Ketanont S. Periodontal status
and orthodontic treatment need of autistic
children. World J Orthod 2010;11:256-61.
8. Orellana LM, Silvestre FJ, Martnez-Sanchis
S, Martnez-Mihi V, Bautista D. Oral manifestations in a group of adults with autism
spectrum disorder. Med Oral Patol Oral Cir
Bucal 2012;17:e415-9.
9. Nguyen QV, Bezemer PD, Habets L, PrahlAndersen B. A systematic review of the
relationship between overjet size and traumatic dental injuries. Eur J Orthod
1999;21:503-15.
10. Gupta S, Kumar-Jindal S, Bansal M, Singla A.
Prevalence of traumatic dental injuries and
role of incisal overjet and inadequate lip coverage as risk factors among 415 years old
government school children in BaddiBarotiwala Area, Himachal Pradesh, India.
Med Oral Patol Oral Cir Bucal 2011;16:e960-5.
11. Altun C, Guven G, Yorbik O, Acikel C.
Dental injuries in autistic patients. Pediatr
Dent 2010;32:343-6.
12. Kamen S, Skier J. Dental management of
the autistic child. Spec Care Dentist 1985;5:
20-3.

13. American Psychiatric Association. Diagnostic

and statistical manual of mental disorders:
DSM-IV, 4th ed. Washington, DC: American
Psychiatric Press; 1994.
14. McDonald RE, Avery DR. Dentistry for the
child and adolescent, 6th ed. St. Louis: Mosby
Co.; 1994:601-5.
15. Ayers KM, Meldrum AM, Harding WJ,
Quick AN. Management of a simple
anterior crossbite in a child with autism: a
review and case report. N Z Dent J 2003;99:
72-5.
16. Jang I, Tanaka M, Koga Y, et al. A
novel method for the assessment of threedimensional tooth movement during
orthodontic treatment. Angle Orthod
2008;79:447-53.
17. Schopler E, Reichler R, Lansing MD.
Teaching strategies for parents and professionals: volume II. Austin, TX: Pro-Ed; 1980.
18. Bckman B, Pilebro C. Visual pedagogy in
dentistry for children with autism. ASDC J
Dent Child 1999;66:325-31.
19. Becker A, Shapira J, Chaushu S.
Orthodontic treatment for disabled childrena survey of patient and appliance
management. J Orthod 2001;28:39-44.
20. Proffit WR, Fields HW Jr., Sarver DM.
Contemporary orthodontics, 4th ed. St. Louis:
Mosby Inc.; 2006:340.

S p e c C a r e D e n t i s t 3 3 ( 1 ) 2 0 1 3 39

15/12/12 5:26 PM