Palatal Attachments

Key questions this course answers:

• What are the differences between palatal & vestibular attachments?
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• When are palatal attachments indicated?
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• Do palatal attachments affect the patient phonetically?

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Attachments come in all shapes and sizes, and no doubt you will have already noticed that they can also be positioned on various parts of the teeth. Don’t forget that this can also include the palatal or lingual surfaces!

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The Why

Unlike traditional fixed braces, aligners are all about pushing the teeth rather than pulling them. The idea behind an attachment is really twofold:

1. It can act as a handle where a pushing surface doesn’t exist, e.g. when extruding an upper incisor, without an attachment there is nothing for the aligner to push against, or rotating a conical tooth like a canine there is a need to add a surface to push against.
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2. It can provide an extra pushing surface for control in instances where the movement of the tooth may have undesirable side effects, e.g. when pushing an upper premolar buccally, it is likely to simply tip and “lean over”, in order to keep the tooth upright an attachment is needed on the buccal surface to push down as the tooth is being pushed out - this will keep the tooth upright.

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For this reason, you can see that generally the direction of the force on the teeth will indicate where the best site is to place an attachment. Generally speaking, we tend to be moving the teeth buccally and slightly expanding arches for broader smiles, so many attachments will fall into category 2 above. If we are correcting rotations or extruding we just need a pushing surface and it can be buccal or palatal/lingual.

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Side Effects

I’m sure it doesn’t take much imagination to picture that lingual attachments run the risk of irritating the tongue and probably won’t endear you to your patients. However, one area where patients often prefer not to have buccal attachments is the upper incisors. Patients choosing aligner treatment are often doing so as a more discreet appliance and the fewer attachments in the aesthetic zone the better. Fortunately attachments on the palatal aspect of the upper incisors are rarely to disruptive to the tongue so this is a good option if these teeth require extrusion or challenging rotational movements.

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It’s always the case that aligner treatment can affect speech of course - the upper aligner will always interfere slightly with existing speech patterns. In cases where there are palatal attachments the advice is the same as usual - bear with it and practice speaking by reading a book aloud or stating the ABCs. Within two days their speech should be perfect!

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As with everything in orthodontics, the better you know your patient the smoother the treatment will be. Try to get a good read on what the patient’s feelings are with the aesthetics of aligner treatment. However, be mindful that palatal attachments might not always be the most efficient or effective choice, so there will be certain cases where it’s still the best choice to have visible attachments on the incisors.

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