O R T H O D O N T IO

C SR T H O D O N T I C S

The Two by Four Appliance:

A Versatile Appliance
H. FIONA MCKEOWN AND JONATHAN SANDLER

Abstract: The 2x4 appliance comprises bonds on the maxillary incisors, bands on the
the clinical effectiveness;2
first permanent maxillary molars and a continuous archwire. The appliance is used in

the influences on the outcome of
the early mixed dentition for treatment of both anterior crossbites and alignment of
ectopic incisors. Four cases using this appliance are presented. This appliance offers
early treatment;3
many advantages over alternative techniques as it provides complete control of anterior
the orthodontists preference;4 and
tooth position, is extremely well tolerated, requires no adjustment by the patient and
psychological influences.5
allows accurate and rapid positioning of the teeth
Many of these studies have tried to
Dent Update 2001; 28: 496500 evaluate the most appropriate time to
start treatment of Class II malocclusions;
Clinical Relevance: The 2x4 appliance is used to correct anterior crossbites and
restore anterior aesthetics in the mixed dentition stage. however, the timing of crossbite
correction has also caused much
concern. White6 states that anterior and
posterior crossbites require early
treatment for functional reasons and
anterior crossbites also for aesthetic

A ctive interceptive measures in mixed

dentition treatment are usually
confined to correction of anterior and
molars. This tubing, if carefully shaped,
maintains correct archform and
strengthens the long unsupported span
reasons. Ninou and Stephens7 conclude
that posterior crossbites with functional
mandibular displacements require
posterior crossbites and alignment of of wire, protecting it from occlusal treatment, and recommend that a maxillary
ectopic incisors. In this regard the 2x4 forces and potential distortion during fixed appliance is used. They also
appliance (combined with a quad helix function. This appliance allows rapid conclude that early mixed dentition
for posterior expansion) used in the correction of many incipient treatment offers advantages in stability
mixed dentition is an extremely malocclusions in a single short phase of but point out that some of these
versatile appliance. fixed appliance therapy in the early crossbites may resolve spontaneously.
This fixed appliance comprises bands mixed dentition stage. Yang and Kiyak4 surveyed
on the first permanent molars and bonds The concept of using sectional orthodontists, most of whom were in
on the erupted maxillary permanent appliances is not new. Johnson private practice in the USA, regarding
incisors. Continuous archwires are used introduced the Twin-wire Arch in the their preferences on treatment timing for
to provide complete control of the 1930s, which comprised incisor and molar crossbites. Approximately 80% stated
anterior dentition as well as a good bands and small-diameter twin wires that they would treat anterior crossbites
archform. The deciduous teeth are sheathed in buccal tubing along with as well as ectopic development and
generally unsuitable for bonding, various auxiliaries such as palatal arches, delayed eruption of the incisors in the
therefore supporting steel tubing is intermaxillary hooks and coil springs. early mixed dentition.
placed in the long spans between the This resulted in an appliance with a Tung and Kiyak5 also investigated
lateral incisors and first permanent flexible anterior section to allow psychological influences on treatment
alignment of imbricated incisors and rigid timing. They questioned 75 children
buccal sections to prevent distortion.1 (mean age of 10.85 years) and their
H. Fiona McKeown, BDS, MMedSci, FDS RCS, There has been much debate in the parents and concluded that younger
MOrth RCS, Registrar in Orthodontics, and literature recently regarding the ideal children are good candidates for early
Jonathan Sandler BDS(Hons), MSc, FDS RCPS, timing of orthodontic treatment. Studies treatment, have high self-esteem and
MOrth RCS, Consultant Orthodontist, Chesterfield have looked at many aspects of body image and expect orthodontics to
Royal Hospital.
orthodontics, including: improve their lives.

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GDP regarding a retained deciduous

central incisor and delayed eruption of
the maxillary right central incisor. She
presented with a Class I incisor
relationship on a skeletal Class I base
with an average maxillary mandibular
planes angle. She was in the early mixed
dentition phase, both the upper and
lower arches were well aligned and the
overjet and overbite within normal limits. Figure 4. Case 1: At debond.
Radiographs revealed a compound
Figure 1. Case 1: Radiograph of compound odontome preventing the eruption of the
odontome. permanent maxillary right central incisor
(Figure 1).
Surgical removal of the odontome
Shaw et al.8 investigated the extent to and extraction of the deciduous
which dental features expose children to maxillary right central and lateral
nicknaming, teasing and harassment. incisors were carried out in the hope
They found that dental features were the that this would encourage the eruption
fourth most common target for teasing. of the permanent incisors. At review 1
Figure 5. Case 2: Non carious tooth surface loss
However, comments about teeth were year later, both maxillary lateral 11.
considered more hurtful than other incisors had erupted; however, the
features, especially in the 910-year-old right central incisor was unerupted
group, and a short phase of orthodontic and palpable labially. This tooth was Class III skeletal base. He was in the
treatment in the mixed dentition may therefore exposed with an apically mixed dentition stage with mild
prevent this hurtful teasing. repositioned flap (Figure 2) and crowding of the upper labial segment
The four cases outlined below illustrate aligned using a 2x4 appliance. and moderate crowding of the lower
the effectiveness and versatility of the Maxillary first permanent molars were labial segment. There was premature
appliance. banded and the maxillary incisors contact on the upper and lower central
bonded and a 0.016 nickel titanium incisors resulting in an anterior
archwire with stainless steel tubing mandibular displacement and toothwear
CASE 1 supporting the spans placed between of the labial surface of the upper left
An 8-year-old girl was referred by her the incisors and molars (Figure 3). The central incisor (Figure 5).
archwire sequence was 0.016 nickel A 2x4 appliance was placed with
titanium, 0.016 stainless steel and
0.018 stainless steel. Unfortunately, 2
weeks before debond the archwire was
lost, although, apart from some slight
spacing of the incisors, there was no
evidence of any relapse of the right
central incisor. She was therefore
debonded and it was decided not to
place a bonded retainer in this case
but to monitor the position of this
Figure 2. Case 1: 11 exposed with an apically tooth and the developing dentition
repositioned flap. (Figure 4). Figure 6. Case 2: 2x4 appliance.
The total time of active treatment
was six visits over an 8-month period.

CASE 2
A 10-year-old boy was referred by his
GDP who was concerned about
excessive toothwear on the upper left
central incisor. He presented with a
Figure 3. Case 1: 2x4 appliance. Class III incisor relationship on a mild Figure 7. Case 2: End of treatment alignment.

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CASE 3
A 9-year-old girl was referred with a
retained deciduous central incisor. She
was in the mixed dentition and had a
Class I incisor relationship on a Class I
skeletal base, moderate crowding of
both upper and lower labial segments
and overjet and overbite within normal
range. She had a retained deciduous left
central incisor and radiographs revealed Figure 11. Case 3: Bonded retainer.
the presence of two supernumerary
teeth lying palatal to the permanent
central incisor preventing its eruption
Figure 8. Case 3: Radiograph of (Figure 8).
supernumeraries. The supernumerary teeth were
removed under general anaesthetic and
a gold chain bonded to the labial surface
of the maxillary left central incisor. A 2x4
bands on the first molars and bonds on appliance was placed with bands on the
the incisors and an initial 0.016 nickel first molars and bonds on the erupted
Figure 12. Case 4: Removable quad helix.
titanium aligning archwire (Figure 6). incisors. The archwire sequence was
The archwire sequence was 0.016 nickel 0.016 nickel titanium, 0.018 x 0.025 nickel
titanium, 0.018 x 0.025 nickel titanium titanium and 0.019 x 0.025 stainless steel.
and 0.019 x 0.025 stainless steel. Active When in a rectangular nickel titanium 0.018 x 0.025 nickel titanium. On a
treatment time involved five visits over archwire, a 0.016 nickel titanium piggy 0.018 stainless steel base arch a section
an 8-month period. back archwire was used to provide of pushcoil was placed in the spans
At debond a bonded retainer was traction to the left central incisor and between the lateral incisors and first
placed on the palatal surfaces of the align it (Figure 9). The tooth was aligned permanent molars to procline the upper
maxillary incisors. At 6-month review in only 10 months (Figure 10) and at labial segment and elastic chain was
this retainer had been lost but the debond a bonded retainer (Figure 11) used to close the anterior spacing.
positive overbite had maintained the was placed on the palatal surfaces of the Correction of the posterior crossbite,
overjet correction (Figure 7). maxillary incisors. alignment of the maxillary incisors and
space closure required nine visits over a
13-month period (Figure 14).
CASE 4
A 9-year-old girl was referred by her
dentist regarding a unilateral crossbite. DISCUSSION
She presented with a Class III incisor It has been suggested that the use of
relationship on a mild skeletal III base. removable appliances is an appropriate
She was in the mixed dentition stage, method of correcting anterior tooth
with moderate crowding of the upper malpositions, teeth behind the bite or
labial segment and mild crowding of the narrow maxillary arches.9 The problems
lower labial segment. She had a with removable appliances are the lack
unilateral crossbite on the right side
Figure 9. Case 3: 2x4 appliance with piggy back. extending from the right central incisor
to the right permanent molar. The upper
left lateral incisor was also in crossbite
and there was an associated anterior
displacement of 2 mm.
A removable quad helix was placed to
expand the upper arch and to derotate
the mesiopalatally rotated maxillary first
permanent molars (Figure 12). Brackets
were then placed on the upper incisors
and a 0.016 nickel titanium aligning
Figure 10. Case 3: End of treatment alignment. archwire placed (Figure 13), followed by Figure 13. Case 4: 2x4 appliance.

498 Dental Update December 2001

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for wearing and adjusting the appliance; permanent dentition, but early treatment
the treatment will not work if this co- in these cases will not only quickly
operation is not forthcoming. Removable restore anterior aesthetics but may also
appliances produce only buccal tipping reduce the complexity and duration of
of the molars during expansion, any subsequent treatment required.
compared with quad helices, which may
produce some buccal translation of the
teeth during crossbite correction. REFERENCES
All the above listed problems can be 1. Johnson JE. A new orthodontic appliance The
Figure 14. Case 4: Alignment. overcome if an alternative to the twin wire alignment appliance. Int J Orthod 1934;
removable appliances is found. A 2x4 946.
2. Tulloch JFC, Philips C, Koch G, Proffit WR. The
sectional fixed appliance (combined with effect of early intervention on skeletal pattern in
of control they have over tooth position a quad helix for posterior expansion) class II malocclusion:A randomised clinical trial. Am
and the fact that they can exert only offers more effective and efficient tooth J Orthod Dentofac Orthop 1997; 111: 391400.
single-point contact on teeth, leading to positioning as it allows three- 3. Tulloch JFC, Proffit WR, Philips C. Influences on
the outcome of early treatment for class II
unsophisticated tipping movements in dimensional control of the involved malocclusion. Am J Orthod Dentofac Orthop 1997;
most cases. In addition, these teeth during correction of anterior 111: 533542.
appliances can be difficult and awkward crossbites or aligning ectopic incisors. 4. Yang EY, Kiyak HA. Orthodontic treatment timing:
for the patients to fit and will not be Rotations, diastemas and incorrect tooth A survey of orthodontists. Am J Orthod Dentofac
Orthop 1998; 113: 96103.
worn if they are either too loose or too inclinations and angulations may 5. Tung AW, Kiyak HA. Psychological influences on
tight causing excessive pressures on the therefore be treated very quickly using the timing of orthodontic treatment. Am J Orthod
teeth. Patients often have a tendency to this versatile technique. Dentofac Orthop 1998; 113: 2939.
6. White L. Early orthodontic intervention. Am J
flick the appliances in and out, which
Orthod Dentofac Orthop 1998; 113: 2428.
leads to stress fracture of the retaining 7. Ninou S, Stephens C. The early treatment of
cribs or clasps, and the resulting loss of CONCLUSION posterior crossbites: A review of continuing
retention will encourage the patients to The four cases above demonstrate the controversies. Dent Update 1994; 21: 420426.
8. Shaw WC, Meek SC, Jones DS. Nicknames,
leave them out. versatility of the 2x4 appliance in the
teasing, harassment and the salience of dental
Ninou and Stephens7 listed the main correction of anterior crossbites and features among school children. Br J Orthod 1980;
problems of removable expansion alignment of the incisors. The treatment 7: 7580.
appliances as patient co-operation and objectives are achieved with a short 9. OBrien K. Guest Editorial: Undergraduate
orthodontic education: what should we teach
retention of the appliance. The success course of treatment and alignment is rather than what can we teach? Br J Orthod 1997;
of removable appliances obviously maintained with a bonded retainer. 24: 333334.
depends upon patient compliance, both Further treatment may be required in the

principal reason for the placement of the recurrent or residual.

ABSTRACT initial restoration, and secondary caries The authors suggest that direct
the principal reason for their educational endeavours should be made
DOES THAT RESTORATION REALLY replacement. However, material failure to reinforce a preventive approach to
NEED REPLACING? (marginal degradation, discoloration, restorative dentistry.
An Overview of Reasons for the bulk fracture and loss of anatomic form) Peter Carrotte
Placement and Replacement of accounted for the replacement of more Glasgow Dental School
Restorations. V. Deligeorgi, I.A. Mjr composite restorations than amalgam.
and N.H.F. Wilson. Primary Dental Care It is observed that, in spite of modern PLEASE NOTE
2001; 8: 511. dental education emphasizing a
preventive approach, repair and CPD is starting in January/February
This paper reviews the data of ten refurbishment of restorations as 2002 issue of Dental Update.
surveys from Scandinavia, UK and USA, opposed to their total replacement is
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the placement and replacement of 32,777 that younger and less-experienced and key in your password; or
restorations. It was found that the ratio dentists tend to replace restorations
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1:2.4 for amalgam, and 1:3.8 for composite evidence presented from the surveys as N.B. Please submit your answers
materials. Not surprisingly, caries has to whether the secondary caries within the month of that issue to
consistently been found to be the necessitating replacement was claim your verifiable CPD.

500 Dental Update December 2001