Removable appliances can’t really be regarded as an alternative to fixed ones because they show a different clinical effectiveness. Many tooth movements aren’t possible with removables. This holds true for rotation of teeth, except the four front teeth, as well as the lengthening and shortening of teeth. Because of their limited suitability teeth can only be tielted with these primitive appliances, while in many cases bodily movement of teeth and the uprighting of the dental root are required.
Overly long treatment times
Treatment with a removable brace often normally lasts many years, which puts a great burden on the young patients. Even if the patient’s cooperation is good over the years only unsatisfactory compromises can be achieved with removables, which aren’t acceptable neither for the young patients nor for their parents. This is the reason why the treatment with removables in most cases is continued with fixed appliances. – This treatment sequence is quite absurd because fixed braces are universal appliances which are capable to resolve all orthodontic problems on their own without any pre-treatment.
Additional burden on patients, high failure rate
One of the numerous disadvantages of removable appliances is the severe speech impediment, which puts a great strain on the young patients. This is one of the reasons why removables aren’t worn sufficiently. Studies concerning the wear-time have shown young patients wear their removable appliances for a median of 10 hours a day whereas in most of the cases 16 hours would be necessary. It’s no wonder that about one to two thirds of these treatments are discontinued and end up without any success – after an overly long and demotivating treatment time. It is obvoious that removables are more expensive and uneconomic than fixed appliances. Numerous scientific studies have shown that fixed appliances offer shorter treatment duration, better results and lower costs. This would serve nobody’s interest: A great strain on the patients, overly long treatment times, higher costs – in this light it’s a mystery why removable appliances still exist! One could manage the orthodontic treatment with a single fixed brace – but this is not favoured by German orthodontists.
Poor training of orthodontists and their thirst for profits
This mystery can be easily revealed: The by poor training of German orthodontists is mostly based on ideas of the thirties to sixties of the past century. At that time it was commonly believed that removable appliances somehow had an unvaluable advantage over fixed devices – although was never proven scientifically.
Whereas this problem is solved indirectly by the retirement of old-school university teachers the questionable German system of reimbursement still exists, which renumerates the less intensive and long treatment with removables well, while the short and intensive orthodontic treatment with fixed appliances is renumerated quite badly. It’s obvious that this is an example of how the limited resources of the health service can be directed into inappropriate healthcare – at the expense of the parents and their children. In Germany orthodontic treatment duration takes twice as long as in other European countries, which is related to higher costs but not to better results. For the German orthodontists the outdated removables demand minor skills and few efforts, nonetheless economically are an inexhaustible gold mine. There’s no other task in dentistry, which offers such a huge profit in a short period of time. Using removables is too close to one of the old dream of earning an income without having to work, so that most of the German orthodontists succumb to this temptation.
Fixed braces are the gold standard
For the reasons outlined above using fixed braces is the orthodontic standard treatment: They result in less burden on the patients, short treatment duration and excellent treatment results. It’ s more comfortable for the patients and the fixed devices don’t hinder speaking or eating. Last but not least, fixed braces are even more economic because they lead to the sustained success regularly and in a short period of time. In this light it’s not astonishing that in most developed countries removable appliances are rarely used – only in Germany every orthodontist has his own in-house laboratory and a dental technician who manufactures removable braces. In-house laboratories in orthodontic office are almost unknown in other countries.
Regarding the statements above there are two exceptions to be considered: The treatment of a mandibular retrognathism with a single functional orthodontic device can be reasonable. Even in this case using several removables in a sequence seems absurd and must be rejected – it would be the most dumb and inefficient treatment strategy at all. For the treatment of teens and adults who have minor or moderate malocclusions Invisalign® can be recommended. In Germany it’s only available for self-paying patients, not in the public health insurance.