A Survey To Evaluate Patients’ Acceptance To Various Fixed Functional Appliance

Fixed functional appliances correct class II malocclusion by bringing the mandible forward into a new position. Patients using Fixed Functional Appliances complain of dif iculty in oral hygiene, soft-tissue irritation, appliance breakage, anddif iculty inmastication. Hence, the aimof this studywas to conduct a survey evaluating patients’ acceptance of various ixed functional appliances in a university set up. This questionnaire-based study was a universitybased setting which consisted of 10 closed-ended and open-ended questions out of which 2 were open-ended questions and 8 were close-ended. It covered discomfort, dif iculty in speech, brushing, mastication, oral hygiene and fracture of the appliance. Descriptive statistics were performed. Chi-square test was used to determine the discomfort experienced due to the duration of wear. The signi icance level for the p-value was set at 0.05. Chi-square test reported that statistically, the insigni icant association observed between duration of wear and level of discomfort (p>0.31). All functional appliances have their owndisadvantages anddiscomfort, which is dependent on the intricate fabrication aswell as their implementation. Within the limits of the study, it was observed that discomfort was more in the initial few days but reduced over a period of time as the patients got adapted to the appliance.


INTRODUCTION
Orthodontic appliances are foreign objects inserted into the mouth, which can lead to discomfort in the mouth (Al-Sayagh et al., 2012). Discomfort caused due to orthodontic appliances may cause decreased compliance, dissatisfaction with the treatment and cause of stress between the practitioner and patient (Charavet et al., 2019). Class II skeletal discrepancy is the most commonly observed discrepancy in the ield of orthodontics. It is a discrepancy caused due to either mandibular retrognathism or maxillary prognathism, or a combination of both. The severity of this can range from mild to severe and along with it, other discrepancies such as anteroposterior discrepancy is also observed. Class II malocclusion causes laring of the upper incisors, which if not paid attention to at the earliest causes fracture of the upper incisors and sometimes even leading to non-vital of the teeth (Felicita, 2018(Felicita, , 2017b. Methods to correct this discrepancy include use of extraoral appliances, functional appliances and ixed appliances associated with the use of class II intermaxillary elastics. On the other hand, correction of Class II malocclusion in non-growing patients include orthognathic surgery or selective extraction of permanent premolars with subsequent den-tal camou lage to mask the skeletal discrepancy. On extracting selective premolars for camou lage treatment, en-masse retraction of the anterior teeth has to be carried out to reduce the proclination and correct the skeletal discrepancy (Felicita, 2017a). During this time, it is best to avoid NSAIDs as it can hamper with the en-masse distalization (Krishnan et al., 2015). Retraction can either be carried out by friction or frictionless mechanics. Friction mechanics is with the help of mini-implants which involves the sliding of the arch wire through brackets and tubes. Mini-implants also carry out intrusion if there is excessive proclination along with extruded upper incisors (Sivamurthy and Sundari, 2016;Jain et al., 2014).
Fixed functional appliance aims to correct malocclusion by enhancing the growth of mandible in the sagittal direction (Felicita et al., 2013). This brings about a change in the gonial angle and causes a drastic change in the face, improving the pro ile of the patient (Rubika et al., 2015;Pandian et al., 2018). Rigid ixed functional appliances such as herbst, MARA; ixed lexible, functional appliances such as jasper jumper and ixed hybrid appliances require less patient cooperation. This is a successful bite-jumping treatment for non-compliant patients. Also, it helps the patients suffering from obstructive sleep apnoea as it brings the mandible forward (Viswanath, 2015).
These appliances have advantages and disadvantages regarding oral hygiene, soft-tissue irritation, appliance breakage and limitation of mandibular movements. Effects of the functional appliances on skeletal and dental tissues have been heavily investigated, whereas the patient's perception of these appliances has not been questioned (Samantha, 2017). Stress and compliance from ixed functional appliances should be studied further. The investigations will help evaluate the acceptability of ixed functional appliances and increase awareness (Kamisetty, 2015). Therefore, the aim of the study is to evaluate the acceptance of ixed functional appliances.

Study setting
This questionnaire-based study was a university based setting which consisted of 10 close-ended and open-ended questions. The questions were designed to be simple and comprehensible by the subjects. It consisted of 10 multiple-choice questions. The survey covered issues regarding discomfort, dif iculty in speech, brushing, mastication, oral hygiene and fracture of the appliance.

Inclusion criteria
1. Patients in the age group of 14-20 undergoing ixed functional therapy.
2. Patients at least 2 months into the treatment.

Exclusion criteria
Patients who have already undergone orthodontic treatment.

Sampling
After applying the inclusion and exclusion criteria, a total of 10 subjects (7 males and 3 females) were sent the questionnaire for this study. The sampling method carried out was randomized sampling and to minimize sampling bias, simple random sampling was carried out.

Data collection
Data of the subjects undergoing ixed functional therapy was recovered from patients' record in saveetha dental college and hospital. The questionnaire was sent on their electronic mail IDs after their contact details recovered from the same.

Statistical analysis
After collection of the data from the subjects, the data was analyzed. Descriptive statistics using percentages and mean used to analyze the results. Chisquare test was done using IBM SPSS statistical software (Version 22.0) to determine a statistically signi icant linear relationship between the discomfort experienced due to the duration of wear. P < 0.05 was considered as statistically signi icant.

RESULTS AND DISCUSSION
It was observed that 90% of subjects observed a signi icant change in the face after wearing the appliance (Figure 1). Figure 2: Discomfort immediately after insertion of the appliance 100% of them experienced dif iculty just after insertion of the appliance (Figure 2).

Figure 1: Frequency distribution on pro ile improvement after insertion of the appliance
After a few days of insertion, 90% of the subjects still experienced discomfort and pain in the jaws (Figure 3).

Figure 3: Discomfort experienced after a few days of insertion of the appliance
Most of them complained of ulcerations in the mouth immediately after the insertion of the appliance (90%) (Figure 4).   (Figure 8).

Figure 6: Pie depicting over-all pleasant experience
80% reported to the hospital in between their regular appointments to their orthodontists (Figure 7).

Figure 7: A pie chart depicting the need for in-between appointments
Overall 80% had a good experience with the appliance ( Figure 6).
There was a statistically non signi icant association observed between the discomfort experienced due to the duration of wear of the appliance on performing chi-square test. Figure 9 shows that X-axis represents the duration of appliance wear in months and Y-axis represents the no. of patients who responded to discomfort as yes or no. Chi square test was done and found to be not signi icant(Chi square test value-1.071, p value =.30, p>0.05). Discomfort associated with FFA : Bar graph representing the association between duration and discomfort on wearing the appliance reduced in the second month when compared to the irst month. Depicts the association between duration and discomfort of wearing the appliance (p=.30, p<0.05).
In the initial few weeks after insertion of the appliance, the indings of the study indicated that the majority of the subjects faced dif iculty in adjusting to it. They complained of ulcerations in the mouth due to the constant rubbing of the appliance against the mucosa of the soft tissues and also faced dificulty in brushing, mastication, breakage of appliances, etc. Due to these dif iculties, they had to visit the orthodontist in the irst week, but as they got used to the appliance, they complained of less dificulty. The likelihood of patient cooperation is one of the most important factors in luencing ixed functional appliances (Kumar et al., 2011;Dinesh et al., 2013). The present study reported a statistically insigni icant association observed on the discomfort and duration of wear.
The majority complained of pain and dif iculty while eating and brushing teeth in the initial week. This study did not evaluate the long-term effects of the appliance. Lena Y et al. reported in their study that the longer the duration of wear, less compliance and more discomfort was experienced by the patient but did not evaluate the acceptance of the appliance (Lena et al., 2017). Sergl et al reported similar indings and also reported that the patients' attitude was important as it in luenced the wear of appliances (Nanda and Kierl, 1992;Lena et al., 2017).
Other studies such as Celikoglu et al. reported that patient's compliance is not required on delivering a ixed functional appliance as it is ixed in the mouth and cannot be removed by patient thus eliminating the need of compliance, but they did not evaluate patients' acceptance (Celikoglu, 2014;Vikram, 2017). Similarly, Ishaq et al reported that ixed appliances eliminated the need for compliance (Ishaq, 2016). Chaudhary et al reported that a ixed appliance causes less dependency and less compliance (Chaudhry, 2015).
The small sample size is a limitation of this study. Also, a long-term evaluation of the patient-related problems of the ixed appliance was not carried out. Future scope of this study includes a good understanding of the patient's attitude towards the appliance allowing the orthodontist to explore and use other appliances.

CONCLUSIONS
Within the limitations of the study, it can be concluded that the overall patient acceptance was satisfactory with ixed functional appliances. They were associated with some discomfort in the initial period, which subsided later, but this inding is not supported by statistics since there was no signi icant association between duration and discomfort on wearing the appliance.