Space maintenance in the primary dentition

Dr. Ola M Omar Professor of Pediatric Dentistry, Taibah University/ Cairo University

Lecture outline

General considerations Appliance therapy Band and loop Lingual arch Distal shoe Removable appliances

Characteristics of normal occlusion in the primary dentition:

At 3y years Spacing between primary teeth A- Incisor spacing B- Primate space C- Spacing between primary molars Molar relationship A- Flush terminal plane B- Mesial step C- Distal step Normal overbite

Good spacing

Primate space Mesial step

THE THREE TYPES OF TERMINAL PLANES

FLUSH PLANE

MESIAL STEP

DISTAL STEP

The premature loss of a primary tooth has a deleterious effect on the occlusion. Proper management of space problems in the primary and mixed dentition stages can prevent unnecessary loss in the arch length.

Effect of premature loss

Why is the tooth maintained in its correct position in the dental arch?

The rate and extent of mesial or distal drift is influenced by the degree of crowding in the dental arch, the primary tooth extracted and the age of the patient. In general the earlier the primary tooth is extracted the greater the opportunity of drifting of teeth.

Anterior tooth loss

Loss of anterior teeth is due to caries or trauma Drifting of anterior teeth and space loss is minimal. Loss of canine is rare Reasons for replacement of primary incisors: Space maintenance, function, speech, esthetics.

Posterior tooth loss

Loss of inter-proximal contact as a result of caries causes space loss If the first primary molar is lost during active eruption of first permanent molar, a strong forward force will be exerted on the second primary molar which tips into the space required for the eruption of the first premolar. Premature loss of second primary molar leads to mesial drifting of first permanent molar and impaction of second premolar.

Space maintenance

Process of maintaining space previously occupied by a tooth or several teeth.

Definition of space maintainer

Appliances used to maintain space created by premature loss of primary teeth till eruption of permanent successor or Extraction of permanent teeth till construction of fixed replacement

Requirements of space maintainer

Easy construction & placement Hygienic , Durable Prevent abnormal tooth position Maintains mesio-distal and vertical dimensions of the space. Does not interfere with tooth eruption. Does not interfere with natural growth. Provides esthetics in case of anterior tooth loss.

Indications for space maintainers (factors affecting placement)

Time elapsed since loss 2. Dental Developmental Age ( chronological age?) 3. Amount of bone ( 4-5 months to move through 1 mm bone) 4. Degree of root development ( if started accelerate eruption)
1.

5.

6.

7.

Sequence of eruption Delayed eruption Congenital absence

If D lost and 2 erupting If E lost and 7 erupting before 5

Selection of a space maintainer

Single/ multiple tooth loss Anterior/ posterior tooth loss Upper/ lower

Space maintainers for missing primary molars

Band and Loop space maintainer Indications Advantages Disadvantages Construction

Band and loop space maintainer

Indications: In case of unilateral single tooth loss; usually the first primary molar or the second primary molar after the eruption of first permanent molar. Bilateral loss of a primary molar before the eruption of permanent incisors The band is adapted on the tooth distal to the space.

Advantages: Easy to construct. Inexpensive. Gives room for erupting permanent teeth. Does not need patient compliance. Can be used for very young patients. Disadvantages: Does not restore masticatory function. Does not prevent over eruption of opposing teeth.

Steps of construction
1- Select a preformed stainless steel band to fit the tooth distal to the space. Using a band pusher adapt the margins of the band closely to the tooth. ( A custom made spot welded band can be also used). 2- With the band on the tooth an alginate impression (or compound) is taken for the abutment tooth including the area of premature loss and the primary canine (quarter-arch impression) . 3- Remove the band from the tooth using band remover and place it accurately in the alginate impression then secure its position using sticky wax. 4- Pour stone into the impression to produce a working model.

5- Adapt a stainless steel wire of 0.7 mm into a loop to fit the band and alveolar ridge. The lop should paralel edentulous ridge 1 mm off gingival tissues and contact the distal surface of the adjacent tooth at the contact point. The BL dimension 8 mm to allow permanent tooth eruption freely. 6- Solder the loop to the band on the stone model. 7- Smooth and polish the appliance.

8- Fit and adjust appliance if necessary. 9- Cement the appliance onto dry clean abutment with zinc phosphate or glass ionomer. 10- Recall every 6 months The appliance should be constructed and fitted as soon as possible after extraction.

Band and Loop space maintainer

Construction

0.7 mm wire

Modifications of band and loop

Construction: Contoured wire bonded with composite. Disadvantage: 1. Breaks easily due to shear forces of occlusion 2. Very difficult to adjust

Bonded space maintainer

Modifications of band and loop

Crown and loop appliance

Disadvantage: Failure of the solder and wire break cannot be repaired intraorally and necessitates new crown. Alternative : If the abutment tooth requires stainless steel crown it is preferred to adjust a band and loop space maintainer that fits the crown.

Variations of band and loop

Distal shoe space maintainer

If the second primary molar is lost before eruption of the first permanent molar. The space maintainer to be used should guide the first permanent molar into its normal position such as crown or band maintainer with distal shoe extension or intragingival extension. The first primary molar distal to the space is used as the abutment tooth.

Contruction
1- Select a band. 2- An alginate impression is taken. 3- If the second primary molar is planned for extraction but has not yet been removed, it should be cut off the prepared model. A hole that simulates the position of the position of the distal root of the extracted tooth is drilled in the model. 4- If the second primary molar has been removed previously, the position of the tissue extension may be determined with dividers and a bite-wing radiograph.

5- The tissue bearing loop is contoured with a wire extending distally then downwards into the prepared opening on the model (forming a v-shaped extension). The free ends of the loop are soldered to the band. 6- The band and loop appliance is removed from the model and the v of the tissue extension is filled in and soldered with pieces of gold.

7- If the second primary molar has previously been extracted and the extraction site has healed, a knife edge is formed at the apex of the V-shaped extension so that it can be forced through the anesthetized area of the ridge. 8- If it is delivered at the time of extraction, the intragingival extension is just polished but not sharpened. 9- Before cementation of the maintainer, a radiograph of the appliance should be taken to determine whether the tissue extension is in proper relationship with the un-erupted first permanent molar.

If the first permanent molar un-erupted Distal shoe space maintainer

Keep in mind

The depth of the intra-gingival extension should be about 1 mm below the mesial marginal ridge of the molar, or just sufficient to capture its mesial surface as the tooth erupts and moves forward. After eruption of the molar the intragingival extension is removed.

Disadvantages of distal shoe

Cantilever design therefore fragile Does not restore occlusal function Complete epithelialization does not occur so contra-indicated in medically compromised children.

Lingual arch

It is a bilateral fixed space maintainer indicated in case of multiple teeth loss. Constructed if the lower permanent incisors are erupted. In case of presence of primary incisors a bilateral band and loop is indicated. Maxillary lingual arch can be used in the primary dentition.

There are two types of lingual arch: Nance Transpalatal arch

Transpalatal arch
Bands are adapted to the maxillary first permanent molar and wire traverses the palate without touching it will be soldered to the bands. Hygenic Can allow mesial tipping of abutment

Transpalatal arch

Nance appliance
It is similar to the lingual arch except that it incorporates an acrylic button that rests on palatal rugae. Disadvantages: Unhygienic and causes tissue irritation and inflammation in the area of the acrylic button.

Nance appliance

Removable appliances
Removable partial denture: Indicated in case more than one tooth are lost. Stainless steel wire clasps are difficult to contour for the canines as they do not have large undercut. Stainless steel wire rests for the molars on the opposite side aid in retention. Needs compliance thus recommended only in case of cooperative children.

Advantages: It can be easily adjusted to allow for the eruption of teeth. It restores normal masticatory function and esthetics. Prevents abnormal speech and tongue habits. Disadvantages: It is easily broken from a child. If the appliance is removed from the mouth even for few days, changes in the denture base will occur and drifting of teeth may make it impossible for the child to replace the appliance unless extensive adjustment has to be done by the dentist. There is a possibility of the development of new carious lesions unless proper cleaning of the teeth and denture is performed.

Space maintenance for multiple loss of posterior mandibular teeth

Modified fixed partial denture

(Pinkham, Ch. 25 page 423-430)