Abstract
Aim
To evaluate and compare acceptability and compliance toward conventional removable appliances and novel vivid pedo appliances in 5–12-year-old children.
Materials and methods
A total of 46 children who required treatment with a removable appliance such as a removable orthodontic appliance, habit-breaking appliance, myofunctional appliance, or functional and nonfunctional space maintainers were randomized to either group I—a conventional removable appliance or group II—vivid pedo appliance (colorful/ attractive removable appliance). After diagnosis and treatment plan, the appropriate removable appliance was fabricated using plain pink self-cure acrylic in groups I and II, and it was fabricated using clear self-cure acrylic adding colors, designs, and stickers according to the child's preference. Questionnaires were administered to evaluate the acceptability and compliance toward removable appliance therapy on the day of appliance delivery after 1 and 6 months.
Result
Acceptance and compliance of vivid pedo appliance was more in children compared to conventional removable appliances. The difference was statistically significant.
Conclusion
Vivid pedo appliance improved children's acceptance and compliance toward removable appliance therapy.
Clinical significance
Removable appliances are an inevitable part of pediatric dentistry right from the movement of teeth, influencing tooth eruption as well as growth of jaws. The success of removable appliance therapy mostly depends on children's compliance. Therefore, the goal of this study was to ascertain how the esthetic attractiveness of an appliance influences the acceptability of a removable appliance and how it reflects on entire compliance toward removable appliance therapy.
How to cite this article
Krishnakumar K, Kalaskar R. Evaluation of Children's Attitude toward Conventional Removable Appliances and Novel Vivid Pedo Appliances: A Randomized Controlled Trial. Int J Clin Pediatr Dent 2023;16(5):786–791.
Keywords: Acceptance, Attractive, Children, Colourful, Compliance, Randomized clinical trial, Removable appliance
Introduction
In pediatric dentistry, removable appliances have been utilized extensively. Undoubtedly, it persists as an inevitable part of pediatric dentistry right from the movement of teeth, influencing tooth eruption as well as the growth of jaws. However, children can readily remove this appliance, therefore good compliance is needed to get the intended result. Hence, the success of the removable appliance therapy mostly depends on children's compliance.1,3
Compliance with children refers to how well a child follows the clinician's prescription regarding the duration and frequency of wearing appliances.4 In addition, children's compliance is typically low irrespective of their gender or psychological development.5 In essence, there are standard protocols published in the literature about the amount of time that removable appliances must be worn, and ranges widely from rigorous overnight use to practically 24 hours a day.6,10 In contrast, most of the children won't follow their clinician's directions for wear durations, cleaning, maintenance, or activation of removable appliances in a suitable manner.8
As a result, various research has been carried out to uncover patient-level factors that influence compliance because a substantial portion of children do not follow wear-time prescriptions. Hence, a wide range of colors have been used for removable appliances to improve patient compliance and treatment acceptance, especially in children.4
However, the literature lacked knowledge of children's attitudes toward colorful-attractive removable appliances as a removable therapy appliance. As achieving children's compliance toward a removable appliance is very challenging, we have to figure out options that will amaze them. Moreover, children love to live in a colorful fantasy world with all their favorite cartoon characters in it. It is seen that there is always a positive relationship between the esthetic attractiveness of an object and children's attitude toward it. So, in order to improve children's attitudes toward removable appliances, it is reasonable to provide colorful and attractive removable appliances. Vivid pedo appliance is a novel removable appliance that is colorful and attractive incorporating children's favorite cartoon characters, stickers, emojis, their names, etc.
Therefore, the objective of the study was to ascertain how the esthetic attractiveness of an appliance influences the acceptability of a removable appliance. Also, it reflects on entire compliance toward appliances as children themselves selected their favorite designs, pictures, and colors for their appliances.
Materials and Methods
Trial Design and Study Setting
This study was a single-center, two-arm, parallel-group, randomized controlled trial with an allocation ratio of 1:1, which evaluated children's attitudes toward the use of conventional removable appliances and vivid pedo appliances through a questionnaire. The study was conducted in the Department of Pediatric and Preventive Dentistry over a period of 10 months till October 2021. Around 51 patients were recruited within 2 months and they were considered for screening. The recruitment strategy of the study was “recruitment in person.” After assessing the eligibility and considering inclusion and exclusion criteria, 46 children were enrolled in this study.
Participants and Eligibility Criteria
Children aged 5–12 years who required treatment with removable appliances such as removable orthodontic appliances, habit-breaking appliances, myofunctional appliances, and functional and nonfunctional space maintainers were recruited in this study following proper examination.11,12
Children who were, medically compromised, with poor oral hygiene, lacking patient and parental cooperation, epileptic, with color vision deficiency, blindness, and having an allergy to acrylic material were excluded from the study.
Data obtained from a prior study by Walton et al. were used to estimate the sample size.13 The predicted sample size per group with a 0.05 level of significance and 95% power was 21. Considering the 10% loss of sample, a total of 23 children per group were enrolled in the study.
A purposive sampling technique was used to recruit the sample. Based on a random sequence generated by a computer, randomization was performed. The allocation ratio was 1:1 between the groups. The allocation sequence was concealed up until the time of assignment using an opaque, sealed envelope. Due to the nature of the study operator and patient were not blinded but the data analyst was blinded. By assigning each participant an internal ID number, blinding was carried out. The children were divided randomly into two groups of 23, group I with conventional removable appliances and group II with vivid pedo appliances.
In group I, after diagnosis and treatment plan, an appropriate removable appliance was fabricated using plain pink self-cure acrylic (conventional removable appliance). However, in group II, an appropriate removable appliance was fabricated using clear self-cure acrylic adding colors and designs, stickers, etc., according to the child's preferences (Fig. 1).
Fig. 1A to D.
Photographs of conventional removable appliance and vivid pedo appliance
To evaluate the acceptance of removable appliances children were exposed to validated questionnaires immediately (point A) and the same questions 1 month after the delivery of the appliance (point B). Yes or no questions were asked and yes was given a score of “1” and no as “0.”
Questionnaire (Points A and B)
Q1: Did you like the removable appliance given to you?
Q2: Do you think the removable appliance given to you is attractive?
Q3: Would you like to wear the removable appliance given to you in your mouth?
Q4: Will you wear the removable appliance properly according to the instructions given to you by your dentist?
To evaluate the compliance of children with removable appliances parents were exposed to a validated questionnaire after 6-month treatment. A five-point Likert scale was used to evaluate the compliance, which was very poor, poor, average, good, and excellent with a score of 1, 2, 3, 4, and 5, respectively. On multiplying the score obtained by the number of questions, a maximum of 20 points and a minimum of 4 points were attained. Compliance of each child was classified as very poor, poor, average, good, and excellent compliance.
Questionnaire (Point C)
Q1: How would you describe your child adhering to the clinician's directions regarding wear time, cleaning, maintenance, and activation of removable appliances?
Q2: How would you describe the compliance of removable appliances by your child after 1 month?
Q3: How would you describe your child's compliance with removable appliances during the treatment period of 6 months?
Q4: How would you describe your child's attitude toward the removable appliance throughout the period of 6 months?
The questionnaire was validated and content validation index (CVI) for relevance, simplicity, clarity, and ambiguity was found to be 0.83, 0.85, 1.00, and 0.85, respectively.
Cohen's κ statistics were used to evaluate the test–retest reliability. The value of κ obtained for points A, B, and C was 1.000, 0.875, and 1.000. Points A and C showed almost perfect agreement and point B strong agreement.
By measuring Cronbach's α, the questionnaire's internal consistency was evaluated. Points A and B showed acceptable internal consistency and point C exhibited excellent internal consistency.
The questionnaire was first constructed in English. Then it was translated into the vernacular language—Marathi with the help of language and subject experts. Thereafter, it was back-translated into English under the guidance of another language and subject expert in order to match the back translation. Minor revisions were made to the questionnaire in this phase.
Statistical Analysis
The children's acceptability and compliance toward conventional removable appliances and vivid pedo appliances were presented using frequency distribution. A comparison of acceptance of removable appliance therapy by children on the day of appliance delivery and after 1 month in groups I and II was done using McNemar's test. Comparison of acceptance of removable appliance therapy between the groups by children on the day of appliance delivery and 1 month after delivery was estimated using the Chi-squared test. Overall comparison of points A, B, and C among conventional removable appliances and vivid pedo appliances was assessed using an independent t-test.
Ethical and Humane Considerations
The Institutional Review Board and Institutional Ethics Committee approved the protocol for the clinical trial (Reference No- IEC/03/12). Thereafter, the study was registered in the Clinical Trials Registry, India (CTRI Registration No: CTRI/2021/02/031163). The trial was ethically carried out according to the Declaration of Helsinki. Before enrolling children in the study, informed written consent was obtained from parents in their vernacular language. Patient information sheets were administered to the parents detailing all the aspects of the study. No adverse events were reported during the study.
Results
Results were analyzed in accordance with the protocol, thus participants who withdrew from the trial after randomization or were otherwise lost to follow-up were not included. However, noncompliance was not a criterion for exclusion. As a result, even when children did not use the removable appliance as recommended, the questionnaires were still collected.
A total of 43 children (21 males and 22 females) participated in the study with a mean age of 8.62 (± 1.40) and 8.32 (± 1.78) in the conventional removable appliance and vivid pedo appliance group, respectively (Table 1).
Table 1.
Demographic details of the children in groups I and II
| Variable | Conventional RA | Vivid pedo appliance |
|---|---|---|
| Mean age | 8.62 (± 1.40) | 8.32 (± 1.78) |
| Male | 11 (52.4%) | 10 (45.5%) |
| Female | 10 (47.6%) | 12 (54.5%) |
RA, removable appliance
Around >70% of the children responded that they liked the conventional removable appliance and were ready to wear the appliance properly according to the instructions given to them immediately after the treatment as well as 1 month after the treatment, the difference was not statistically significant between the two points. Around <50% of the children responded that the appliance was not attractive (Table 2).
Table 2.
Comparison of acceptance of removable appliance therapy by children on the day of appliance delivery and after 1 month in groups I and II
| Group I | Group II | ||||||
|---|---|---|---|---|---|---|---|
| Q | Part | Yes N (%) | No N (%) | p-value | Yes N (%) | No N (%) | p-value |
| Q1 | A | 15 (71.42) | 6 (28.57) | 1.000 (NS) | 20 (90.09) | 2 (9.09) | 1.000 (NS) |
| B | 15 (71.42) | 6 (28.57) | 20 (90.09) | 2 (9.09) | |||
| Q2 | A | 9 (42.85) | 12 (57.14) | 1.000 (NS) | 22 (100.0) | 0 (0.0) | – |
| B | 9 (42.85) | 12 (57.14) | 22 (100.0) | 0 (0.0) | |||
| Q3 | A | 13 (61.90) | 8 (38.09) | 1.000 (NS) | 20 (90.09) | 2 (9.09) | 1.000 (NS) |
| B | 12 (57.14) | 9 (42.85) | 20 (90.09) | 2 (9.09) | |||
| Q4 | A | 18 (85.71) | 3 (14.28) | 1.000 (NS) | 22 (100.0) | 0 (0.0) | – |
| B | 18 (85.71) | 3 (14.28) | 22 (100.0) | 0 (0.0) | |||
A, immediately after the treatment; B, 1 month after the treatment; NS, nonsignificant; Q, question
Around >90% of the children stated that they liked the vivid pedo appliance and were ready to wear the appliance properly according to the instructions given to them immediately after the treatment as well as 1 month after the treatment, the difference was not statistically significant between the two points. Whereas 100% of the children stated that the appliance was attractive (Table 2).
Acceptance of appliances immediately after the treatment revealed vivid pedo appliance (90.9%) was more accepted by children compared to conventional removable appliance (71.4%), the difference was nonsignificant. Nearly 100% of the children said that vivid pedo appliance was attractive and of conventional removable appliances only 42.9%, the difference was statistically significant. It was noted that 90.9% of the children in the vivid pedo appliance group preferred to wear the appliance compared to 61.9% in conventional removable appliances, the difference was statistically significant (Table 3).
Table 3.
Comparison of acceptance of removable appliance therapy between the groups by children on the day of appliance delivery and 1 month after delivery
| Immediately after therapy | 1 month after the therapy | ||||||
|---|---|---|---|---|---|---|---|
| Q | Gr | Yes | No | p-value | Yes | No | p-value |
| Q1 | I | 15 (71.4%) | 6 (28.6%) | 0.132 (NS) | 15 (71.4%) | 6 (28.6%) | 0.132 (NS) |
| II | 20 (90.9%) | 2 (9.1%) | 20 (90.9%) | 2 (9.1%) | |||
| Q2 | I | 9 (42.9%) | 12 (57.1%) | 0.001a | 9 (42.9%) | 12 (57.1%) | 0.001a |
| II | 22 (100%) | 0 (0%) | 22 (100%) | 0 (0%) | |||
| Q3 | I | 13 (61.9%) | 8 (38.1%) | 0.034a | 12 (57.1%) | 9 (42.9%) | 0.016a |
| II | 20 (90.9%) | 2 (9.1%) | 20 (90.9%) | 2 (9.1%) | |||
| Q4 | I | 18 (85.7%) | 3 (14.3%) | 0.108 (NS) | 18 (85.7%) | 3 (14.3%) | 0.108 (NS) |
| II | 22 (100%) | 0 (0%) | 22 (100%) | 0 (0%) | |||
Gr, group; NS, nonsignificant difference; Q, question, a, indicates significant difference at p ≤ 0.05
After 1 month of therapy, the observations revealed that 90.9% of children found vivid pedo appliances more attractive and preferred to wear the appliance in the future compared to only 57.1% of children in conventional removable appliances. The difference between the groups was statistically significant (Table 3).
The compliance with removable appliance therapy by children between the two groups was compared with a questionnaire administered to parents. It was seen that 85.8% of the parents accepted that the compliance with vivid pedo appliance therapy was above average (good and excellent) as compared to that of 9.09% of the parents in conventional removable appliances. It was also noted that 45.45 and 36.6% of the parents in conventional removable appliances accepted that the compliance of children was poor and average, respectively (Table 4).
Table 4.
Comparison of compliance by children evaluated by parents among conventional removable appliance and vivid pedo appliance
| Likert scale | N (%) | |
|---|---|---|
| Conventional RA | Vivid pedo appliance | |
| Very poor | 2 (9.09%) | 0 (0%) |
| Poor | 10 (45.45%) | 2 (9.5%) |
| Average | 8 (36.36%) | 1 (4.7%) |
| Good | 2 (9.09%) | 11 (52.5%) |
| Excellent | 0.0 (0.0%) | 7 (33.3%) |
RA, removable appliance
Overall acceptance of the removable appliance therapy by children was found considering all four questions asked immediately after appliance delivery. It revealed that the children belonging to the vivid pedo appliance group showed better acceptance and the difference was found statistically significant. Again, overall acceptance of children 1 month after the appliance delivery was found considering the same four questions. It disclosed that children better accepted vivid pedo appliance therapy compared to conventional removable appliances. Overall compliance during the entire treatment also revealed that children on vivid pedo appliance therapy had better compliance compared to conventional. It also exhibited a statistically significant difference (Table 5).
Table 5.
Overall comparison of points A, B, and C among conventional removable appliances and vivid pedo appliance
| Group | N | Mean | Standard deviation | p-value | |
|---|---|---|---|---|---|
| Point A | I | 21 | 2.62 | 1.53 | 0.002a |
| II | 22 | 3.82 | 0.59 | ||
| Part B | I | 21 | 2.57 | 1.50 | 0.001a |
| II | 22 | 3.82 | 0.50 | ||
| Part C | I | 21 | 14.10 | 3.38 | 0.030a |
| II | 22 | 16.05 | 2.10 |
a indicates a significant difference at p ≤ 0.05
Discussion
Removable appliance therapy is considered crucial in pediatric dentistry for habit-breaking, functional therapy, orthodontic corrections, space maintainers, etc. Particularly, removable appliance therapy is indicated over fixed appliance therapy, in cases of children with poor oral hygiene. Continuing with a healthy brushing and flossing regimen, promotes maintaining good oral hygiene, without having to worry about cleaning around the appliance. Furthermore, some treatments can be completed by using only removable appliances. Moreover, prior to a fixed appliance therapy, removable appliances are sometimes used. In the case of orthodontic correction, they are mostly used for the treatment of simple malocclusions or for a short period of time as part of an overall plan. In fact, the removable type of appliance is effective for nearly all cases, regardless of the complexity. The principal advantage of the removable appliance in pediatric dentistry is that children can remove them while eating and brushing their teeth. Hence, there are no food restrictions especially, hard food or dyes. Therefore, this system offers more freedom, more comfort, and better hygiene for children. Admittedly, from the operator's perspective, removable therapy requires less chair-side time and easy fabrication. However, the major factor that influences the success of removable appliance therapy is the acceptance and compliance of children toward the removable appliance.
Undoubtedly, acceptance and compliance are a multifactorial issue. The acceptance and wear time of removable appliances is influenced by patient-related factors such as age, personality traits, the importance of personal appearance, and the self-perception of malocclusions by the children. Age, personality attributes, the emphasis placed on personal appearance, and how children perceive their own malocclusions are the patient-related factors that affect the acceptance and compliance of removable appliances. On the contrary, the appliance-related factors are visibility of the appliance, pain, discomfort, etc. Finally, the acceptance and compliance of removable appliance therapy in children are influenced by clinician-related characteristics such as trust, clear, and thorough communication with the children, motivation offered by the therapist, etc.12
The present study validates the influence of the attractiveness of removable appliances on the acceptance and compliance of treatment among children. Indeed, the overall acceptance and compliance of vivid pedo appliance therapy was found superior to conventional removable appliance therapy. Furthermore, the acceptance of removable appliance therapy by children was seen as consistent from the day of appliance delivery till the completion of therapy. Moreover, the majority of children on vivid pedo appliance therapy showed overall good compliance. In contrast, the majority of children on conventional removable appliance therapy showed overall poor compliance.
Similarly, a study conducted by Schott and Menne4 also concluded that patient-selected colors for removable appliances can presumably improve acceptance of treatment. The children were pooled into six groups (black, blue, green, yellow, pink, and red) for analysis, or to combine any two to four colors (“multi-colored” group) for their appliances. All appliances featured a built-in microsensor for objective wear-time tracking. Nevertheless, the study showed no statistically significant improvements in wear time or wear behavior.
Similarly, a study by Schott and Menne4 came to the same conclusion that removable appliances in which colors were chosen by the children improved treatment acceptance. The children were divided into six groups (black, blue, green, yellow, pink, and red) for analysis or into a “multi-colored group” for their appliances, which combined any two to four colors. A built-in microsensor was present in every appliance to track wear time objectively. However, neither the wear time nor the wear behavior revealed any statistically significant improvements.
However, the current study didn't restrict the color to be chosen by children. They had the freedom to choose the colors according to their preferences. Particularly, it was found that the children who belonged to the vivid pedo appliance group were so excited to select the color they preferred. Indeed, they are positively involved in the process of customizing the appliance. Furthermore, the majority of children were particular about the stickers as well as the glittering sprinkles they ought to incorporate into the appliance. Moreover, the majority of children who belonged to the vivid pedo appliance group were observed to be exhilarated to receive the appliance. This attitude might have positively influenced the compliance of children during the entire treatment. On the contrary, children who belonged to the conventional appliance group were not provided with the option of customization.
Similar to this, a study by Walton et al.13 assessed the acceptance and preferences of orthodontic appliances in children and adolescents. A computer-based survey was constructed using pictures of previously recorded and standardized orthodontic appliances. The subjects then gave each image a grade based on its acceptability and appeal. According to the study's findings, children's preferences for orthodontic appliances vary by sex and age. The study also emphasized that adolescent and children's choices are distinct from adult preferences. The current study, however, was unable to distinguish between children of different ages and sexes in terms of their acceptance and compliance.
Similarly, a previous study conducted by Abu and Karajeh14 used a questionnaire to assess the acceptance of various intraoral and extraoral orthodontic appliances. According to the survey, orthodontic appliances were graded in order of attractiveness. The study also examined the roadblocks to orthodontic treatment acceptance. The study came to the conclusion that both gender and age had an impact on the acceptance of various orthodontic appliances. On the contrary, the present study couldn't compare the acceptance and compliance of different categories of removable appliances. Undoubtedly, different categories of removable appliances show variation in compliance by children due to the nature of the appliance.
In fact, the current study made sure that simple “yes” or “no” questions were asked to children. Hence, resolved the complexity of differentiating the usual Likert scale classification by children. Also, the study ensured that compliance was evaluated from the questionnaire administered to parents. These can be considered as the strengths of this study.
Considering the fact that achieving children's compliance toward removable appliance therapy is challenging, the study proved that the esthetic attractiveness of the removable appliance has positively influenced the children's acceptance and compliance. The study's unexpected finding was the active involvement of children in customizing the appliances in the vivid pedo appliance group. Therefore, this study will assist practitioners in identifying and accommodating children's needs in their practice.
Although to find acceptance of removable appliance therapy by children, the questionnaire is the best evaluation method, compliance of children with appliances could have been evaluated objectively. This Study could have used devices like sensors to track and record the duration of appliances wore by the children. Additionally, standardization of the category of appliance in both groups could have been done in the study. These can be considered as the limitations of the study. Therefore, this novel appliance can be objectively evaluated using tracking devices and can be considered for potential future research.
Conclusion
Vivid pedo appliances improved children's attitudes significantly toward removable appliance therapy. The acceptance of vivid pedo appliances by children was more during the removable appliance therapy. Furthermore, the compliance of children with removable appliance therapy has shown significant improvement with vivid pedo appliances.
Orcid
Karthika KK https://orcid.org/0000-0002-6011-7337
Ritesh Kalaskar https://orcid.org/0000-0001-7403-3364
Acknowledgment
The authors wish to thank all research and medical personnel involved in the design and execution of this study.
Footnotes
Source of support: Nil
Conflict of interest: None
References
- 1.Tsomos G, Ludwig B, Grossen J, et al. Objective assessment of patient compliance with removable orthodontic appliances: a cross-sectional cohort study. Angle Orthod. 2014;84(1):56–61. doi: 10.2319/042313-315.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Pratt MC, Kluemper GT, Hartsfield JK, Jr, et al. Evaluation of retention protocols among members of the American Association of Orthodontists in the United States. Am J Orthod Dentofac Orthop. 2011;140(4):520–526. doi: 10.1016/j.ajodo.2010.10.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Mortensen MG, Kiyak HA, Omnell L. Patient and parent understanding of informed consent in orthodontics. Am J Orthod Dentofac Orthop. 2003;124(5):541–550. doi: 10.1016/s0889-5406(03)00639-5. [DOI] [PubMed] [Google Scholar]
- 4.Schott TC, Menne D. How patient-selected colors for removable appliances are reflected in electronically tracked compliance (wear times and wear behavior). Angle Orthod. 2018;88(4):458–464. doi: 10.2319/101617-700.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Amin E, Bangash AA. Removable orthodontic appliances and patient perceived problems. Pak Arm Force Med J. 2020;70(1):101–105. [Google Scholar]
- 6.Godoy F, Godoy-Bezerra J, Rosenblatt A. Treatment of posterior crossbite comparing 2 appliances: a community-based trial. Am J Orthod Dentofacial Orthop. 2011;139(1):e45–e52. doi: 10.1016/j.ajodo.2010.06.017. [DOI] [PubMed] [Google Scholar]
- 7.Miethke RR, Wronski C. What can be achieved with removable orthodontic appliances? J Orofac Orthop. 2009;70(3):185–199. doi: 10.1007/s00056-009-0818-x. [DOI] [PubMed] [Google Scholar]
- 8.Petren S, Bjerklin K, Marke LA, et al. Early correction of posterior crossbite—a cost-minimization analysis. Eur J Orthod. 2013;35(1):14–21. doi: 10.1093/ejo/cjr047. [DOI] [PubMed] [Google Scholar]
- 9.Tai K, Park JH, Mishima K, et al. 3-Dimensional conebeam computed tomography analysis of transverse changes with Schwarz appliances on both jaws. Angle Orthod. 2011;81:670–677. doi: 10.2319/110910-655.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Varlik SK, Gultan A, Tumer N. Comparison of the effects of twin block and activator treatment on the soft tissue profile. Eur J Orthod. 2008;30(2):128–134. doi: 10.1093/ejo/cjm121. [DOI] [PubMed] [Google Scholar]
- 11.Klages U, Sergl HG. Theoretical approaches for improved motivation of orthodontic patients. Fortschr Kieferorthop. 1987;48(2):112–116. doi: 10.1007/BF02175613. [DOI] [PubMed] [Google Scholar]
- 12.Torsello F, D’Amico G, Staderini E, et al. Factors influencing appliance wearing time during orthodontic treatments: a literature review. Appl Sci. 2022;12(15):7807. doi: 10.3390/app12157807. [DOI] [Google Scholar]
- 13.Walton DK, Fields HW, Johnston WM, et al. Orthodontic appliance preferences of children and adolescents. Am J Orthod Dentofacial Orthop. 2010;138(6):698.e1–612. doi: 10.1016/j.ajodo.2010.06.012. [DOI] [PubMed] [Google Scholar]
- 14.Abu EA, Karajeh MA. Acceptability and attractiveness of intra-and extra-oral orthodontic appliances. Int J Orthod Milwaukee. 2013;24(1):11–17. [PubMed] [Google Scholar]