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ISSN 0970 - 4388

Glass fiberreinforced composite resin as a space maintainer: A clinical


study
SUBRAMANIAM P.1, BABU G. K. L.2, SUNNY R.3

Abstract
The aim of this study is to evaluate the use of glass fiberreinforced composite resin (GFRCR) as a space maintainer and to
compare it with a conventional band-and-loop space maintainer. A total of 30 children (23 boys and 7 girls) aged 68 years were
selected for the study. Each of these children required maintenance of space due to premature loss of primary first molars in at
least two quadrants. In one quadrant, a GFRCR space maintainer was applied and in the other quadrant a band-and-loop space
maintainer was cemented. Patients were recalled at regular intervals over 12 months and retention of both the types of space
maintainers was evaluated. The retention of the GFRCR space maintainer was found to be superior to that of the band-and-loop
space maintainer, but this difference was not statistically significant.
Keywords: Band-and-loop, glass fiberreinforced composite resin, retention, space maintainer

normal function.[3] It has also been suggested that the bandand-loop space maintainer should be removed once a year
to allow inspection, cleaning, and application of fluoride to
the teeth.[4]

Introduction
When a primary tooth is extracted or is exfoliated
prematurely, the teeth mesial and distal to the space tend
to drift or be forced into it. This may result in the impaction
of the succedaneous tooth, a shift of the midline of the
dental arch to the affected side, and over-eruption of the
opposing tooth, with subsequent impairment of function.
Maintenance of the space may eliminate or reduce these
consequences.[1]

With advances in technology, attempts have been made


to utilize newer materials in the fabrication of space
maintainers.[1] One such material is glass fiberreinforced
composite resin (GFRCR; everStick C and B, Stick Tech Ltd.,
Turku, Finland) [Figure 1]. This material is a translucent,
semi-manufactured product made of glass fiber. Although
fiber-reinforced composite resins have been developed for
dental use, their application in pediatric dental practice is still
limited. GFRCR has been used for making frames of bridges
and crowns, in resin-bonded bridges, for permanent splinting,
in removable dentures, and as intracanal posts.[5] GFRCR
could be an alternative to the conventional and commonly
used band-and-loop space maintainer. Hence, the aim of the
present study was to evaluate GFRCR as a space maintainer
and to compare its efficacy with that of the conventional
band-and-loop space maintainer.

To avoid malocclusion due to premature loss of the primary


teeth, clinicians may advise various types of space maintainers
(removable or fixed appliances), depending on the childs
stage of dental development, the dental arch involved,
and the location of the missing primary teeth. Although
removable space maintainers have certain advantages, such
as being easier to clean and allowing better maintenance of
oral hygiene, they may be removed and worn at the whim of
the patient and may be broken or lost easily and, if they are
not used properly, they will not be effective.[1]
In contrast, fixed appliances, if properly designed, are less
damaging to the oral tissues and are less of a nuisance to
the patient as well as the dentist because they are worn
continuously for a longer period.[1] It has been reported
that a well-designed fixed space maintainer is more
preferable than a removable appliance to both patient and
dentist.[2] The most commonly used fixed space maintainers
for posterior teeth loss are those made of a wire soldered
to a band or a pedodontic crown. Although these fixed
appliances are well tolerated and durable, they do not restore

Materials and Methods


Normal, healthy, and cooperative children were selected for
the study from among the patients attending the Department
of Pedodontics and Preventive Dentistry, The Oxford Dental
College, Hospital and Research Centre, Bangalore, India. A
total of 30 children (23 boys and 7 girls) aged 68 years,
who had no medical condition that would contraindicate
space maintainer therapy, were selected. A brief history
was recorded and a clinical examination was done. Intraoral
periapical radiographs were taken in the areas of tooth loss.
Every child had premature loss of a primary first molar in at
least two quadrants and required space maintenance for the
same. Impressions were made, study models were prepared,
and a space analysis was done for every child. The criteria

Professor and Head, 2Senior Lecturer, 3Former PG Student,


Department of Pedodontics and Preventive Dentistry, The Oxford
Dental College, Hospital and Research Centre, Bommanahalli,
Hosur Road, Bangalore-560 068, Karnataka, India

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GFRCR as a space maintainer

for inclusion in the study are given in Table 1. The treatment


plan was explained to the parents and their written consent
was obtained before the study. The research protocol of the
study was reviewed by the institutional review board, who
gave ethical clearance to conduct the study.

prevent contraction gap formation.[6] A thin layer of flowable


composite (Filtek Z350 3M) was applied to the buccal
surfaces of the abutment tooth without light-curing it. The
cut length of GFRCR was placed on this flowable composite,
extending from the buccal aspect of primary second molar
to buccal aspect of primary canine. The ends of the fiber
were adapted to the teeth surfaces with a plastic filling
instrument. Preliminary curing was done individually at each
end of the fiber framework for 40 s, during which the other
end was protected from the light source. An additional layer
of flowable composite was applied over the area where the
fiber abutted the tooth surface and this was light-cured for 40
s. A similar procedure was repeated on the lingual aspect of
the abutment teeth. Any uncovered fiber was further covered
with flowable composite. The space maintainer was checked
for gingival clearance and occlusal interference. Finishing
was done using composite finishing burs. Finally, as per the
manufacturers instructions, bonding agent was applied over
the fiber frame and light-cured at multiple points for the
purpose of reactivation.

In each child, the two quadrants that required space


maintainers were either both in the same arch (maxillary
or mandibular) or were in opposing arches (i.e., one in the
maxillary arch and one in the mandibular arch). Patients
selected for this study were aged 68 years. In most of these
children the first permanent molars had not yet completely
erupted into the oral cavity and thus they could not be
banded. Also, many children did not have all their mandibular
permanent incisors erupted. Due to these reasons it was not
possible to give a fixed lingual arch. Moreover, the purpose
of this study was to compare two types of fixed space
maintainers that are indicated for unilateral premature loss
of a single primary molar.
For every selected child [Table 1] oral prophylaxis and other
restorative treatment was done prior to the placement of
space maintainers. In one quadrant a GFRCR space maintainer
was applied and in the other quadrant a band-and-loop space
maintainer was cemented [Figure 2].

In the other quadrant a conventional band-and-loop space


maintainer was given as per the technique described by
Graber[7] and Finn.[8]
Instructions on oral hygiene and appliance maintenance were
given to both children and parents. They were instructed to
return promptly if an appliance was loosened, dislodged, or
broken. All patients were recalled at 1, 3, 6, and 12 months
for evaluation of both types of space maintainers using the
criteria given by Kirzioglu and Erturk[9] and Qudeimat and
Fayle[10] [Table 2]. During evaluation, the space maintainers
were removed if failures had occurred and were either
repaired or replaced; these cases were not considered
for further evaluation in the study [Table 3 & 5]. The data
obtained was tabulated and subjected to statistical analysis
using the chi square test and Fishers exact test.

Technique for GFRCR application


In order to determine the length of GFRCR required, the
distance between the mesiobuccal line angle of the primary
canine and distobuccal line angle of the second primary
molar was measured using a digital vernier caliper. After
administration of adequate anesthesia, isolation was done
using a rubber dam and suction. Both the abutment teeth
(primary canine and second primary molar) were cleaned with
pumice slurry and then etched with 35% orthophosphoric
acid for 40 s. The teeth were rinsed, air-dried, and wetted
with an adhesive (Adper Single Bond-2 3M) that was lightcured for 20 s. This application was repeated 23 times to

Results
At the 1st month follow-up, there were no failures in either
type of space maintainer. At the 3rd month, 80% success was
observed with GFRCR space maintainers. The 20% failure
was mainly due to debonding at the enamel-composite

Table 1: Criteria for inclusion in the study


Clinical criteria[14]
Premature loss of primary first molar in two quadrants
Non-carious buccal and lingual surfaces of abutment teeth
Presence of teeth on the mesial and distal side of edentulous
area
Presence of Angles Class I molar relationship and/or presence
of flush terminal/mesial step primary molar relationship
Absence of abnormal dental conditions such as cross-bite, open
bite, and deep bite.
Radiographic criteria[14]
Absence of pathology
Presence of succedaneous tooth bud
Presence of more than 1 mm of bone overlying the
succedaneous tooth germ[5] and / or less than 1/3rd of the root of
the permanent tooth formed (Nollas stage 7).

Table 2: Evaluation criteria for space maintainers


Evaluation criteria for GFRCR space maintainer[9]
Debonding at the enamelcomposite interface
Debonding at the fibercomposite interface
Fracture of the fiber frame
Caries or gingival inflammation
Evaluation criteria for band-and-loop space maintainer[10]
Distortion
Cement loss
Fracture of the loop
Caries or gingival inflammation
GFRCR: Glass fiberreinforced composite resin

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GFRCR as a space maintainer


Table 3: Evaluation of glass fiberreinforced composite resin and band-and-loop space maintainer
Glass fiberreinforced composite resin space maintainer
Evaluation
Evaluation period
criteria
3rd month
6th month
12th month
1st month
n = 30
n = 30
n = 24
n = 20
Debonding
0
0
1
0
of composite
(4.2%)
fiber
interface
Debonding
0
3
1
4
of enamel
(10%)
(4.2%)
(20%)
composite
interface
Fracture of
0
3
2
0
fiber frame
(10%)
(8.3)
Caries or
0
0
0
0
gingival
inflammation
Total no.
0
6
4
4
of failures
(20%)
(16.7%)
(20%)

interface (10%) and fracture of the fiber frame (10%). Thirtythree percent [Figure 3] of band-and-loop space maintainers
showed cement loss [Figure 4], i.e., there was 67% success.
At the 6th month, 66.7% success was observed with the
GFRCR space maintainer. Failures were due to debonding at
the enamelcomposite interface (4.2%), fracture of the fiber
frame (8.3%), and debonding at the compositefiber interface
(4.2%). The band-and-loop space maintainer showed 43.3%
success; 25% showed cement loss and 10% showed breakage
[Figure 5]. At the 12th month, the overall success was 53%
for GFRCR and 33.3% for band-and-loop space maintainers.
On analysis, there was statistically no significant difference
in retention between these two types of space maintainers
[Table 4 & Graph 1].

Discussion
The space maintainer most commonly used in the event of
premature loss of a single posterior tooth is reported to be
the band-and-loop or crown-and-loop space maintainer.[11]
These appliances adjust easily to accommodate changing
dentition. But they have disadvantages, such as a tendency
for disintegration of the cement, inability to prevent the

Band-and-loop space maintainer


Evaluation period

Evaluation
criteria

1st month
n = 30
0

3rd month
n = 30
0

6th month
n = 20
0

12th month
n = 13
0

Cement
failure

10
(33.3%)

5
(25%)

3
(23.1%)

Breakage

Caries or
gingival
inflammation
Total no.
of failures

2
(10%)
0

10
(33.3%)

7
(35%)

3
(23.1%)

Distortion

rotation and tipping movement of abutment teeth, a tendency


to get embedded in gingival tissues or for promoting caries
formation , the need for a cast or model, the need for a second
visit, and the possibility of metal allergy.[1,9] These limitations
of the conventional type of space maintainers indicate the
need for newer materials and designs of the appliances.
The recently introduced GFRCR is essentially silanated
Table 4: Comparison of overall success of glass fiber
reinforced composite resin and band-and-loop space
maintainers
Evaluation
period

GFRCR space
maintainer
(n = 30)

Band-and-loop
space
maintainer
(n = 30)
Number
PerNumber
Perof space centage of space
centage
maintainer
maintainer
present
present
At 1st month
30
100.0
30
100.0
At 3rd month
24
80.0
20
66.7
At 6th month
20
66.7
13
43.3
At 12th month 16
53.3
10
33.3

P value

0.243
0.069
0.118

P < 0.05* is significant

Table 5: Types of failures seen with GFRCR and band-and-loop space maintainers
Type of failure
failure (%)
Debonding of enamel
composite interface
Debonding of composite
fiber interface
Fracture of fiber frame
Caries or gingival
inflammation

GFRCR space maintainer


Number of
failure (%)
8 (26.7)

P < 0.0015**

1 (4.2)

1.000

5 (16.7)
0(0)

P < 0.0105*

P value

*P < 0.05 is significant; **P < 0.01 is highly significant

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Type of
failure
Distortion

Band-and-loop space maintainer


Number of
P value
failure (%)
0

Cement
failure
Breakage
Caries or
gingival inflammation

18 (60)

P < 0.00025**

2 (6.7)
0 (0)

P < 0.7615

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GFRCR as a space maintainer

100

100%
100

90

80%

80

Percentage(%)

70

66.7%

66.7%

60

53.3%

50

43.3%

40

33.3%

30
20

GFRCR SPACE MAINTAINER

10

BAND & LOOP SPACE MAINTAINER


0
First month

Third month

Sixth month

Twelfth month

Graph 1: Comparison of overall success of GFRCR and bandand-loop space maintainers


Figure 1: Glass fi berreinforced composite resin material

Figure 2: GFRCR space maintainer and band-and-loop space


maintainer applied bilaterally
Figure 3: Failure of GFRCR space maintainer (debonding at
enamelcomposite interface)

Figure 4: Failure of band-and-loop space maintainer (cement


loss leading to displacement of band)

glass E-fibers that are pre-impregnated. These glass fibers


are linked to each other by linear polymethyl methacrylate
(PMMA) chains and cross-linking monomers of bis-GMA.
GFRCR can be cured with light-cure composites and its
translucency makes it an excellent esthetic choice .

Figure 5: Failure of band-and-loop space maintainer (breakage


of band)

There are limited reports on the clinical efficacy of space


maintainers and how variables such as design, construction,
and materials used affect their survival time and longevity.
Hence, the present study was undertaken to evaluate the
retention of GFRCR fixed space maintainers and compare it

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GFRCR as a space maintainer

with that of conventional band-and-loop space maintainers


over a period of 12 months.
Both for ethical reasons as well as for the purpose of
comparison both types of space maintainers (GFRCR and
band-and-loop space maintainers) were given in each child,
since we selected children requiring space maintenance in at
least two quadrants. Thus, no child was denied the benefits
of either type of space maintainer. Also, we hypothesized that
since both types of space maintainers were in the same oral
cavity they would both be exposed to the same environment,
e.g., diet, oral hygiene, and occlusal forces.
As moisture contamination has been reported to be one of
the main reasons for failure of the GFRCR space maintainer,[12]
all GFRCR space maintainers in our study were applied under
rubber dam isolation and the use of high-volume suction. The
presence of a chairside dental assistant further facilitated
effective patient and time management.
In order to improve the retention of the GFRCR space
maintainer, different designs and materials have been
used.[1,9] In an earlier study, the fiber was placed only on the
lingual surface to minimize the occlusal forces acting upon
it. However, there was a high failure rate, which was probably
due to a change in the available occluso-gingival dimension.
[9]
In order to increase the surface area and thus improve
retention, in our design, an additional length of fiber was
adapted to the buccal aspect of the abutment teeth.
No grooves or slots were prepared on the abutment
teeth in order to prevent unnecessary loss of tooth
structure.[9] However, it has been recommended to use
small cavity preparations, where caries or filled surfaces
are detected.[1]
Initially, both types of space maintainers showed no failures.
This may have been because patients were more careful in
the immediate post-appliance-placement period. It is also
possible that the parents were more vigilant and more
strictly compliant with post-treatment instructions during
this period.
With the GFRCR space maintainers, debonding at the enamel
composite interface was observed as early as 3 months and
continued to be the main reason for failure at subsequent
evaluations. As all the GFRCR space maintainers were placed
on primary teeth, the presence of prismless enamel could
have negatively influenced the retention of resin. In another
study, which did not use rubber dam isolation, a relatively
high percentage (32%) of GFRCR space maintainers showed
debonding at the enamelcomposite interface during the first
month of placement.[9] Wire and composite, observed for 30
months showed 4% failure at the end of 6 months.[13] However,
Swaine and Wright reported 30% failure for a similar type of
space maintainer evaluated for the same period.[14]
J Indian Soc Pedod Prevent Dent - Supplement 2008

Fracture of the fiber frame was the other significant type of


failure seen with the GFRCR space maintainer at evaluation
at the end of both the 3rd month and the 6th month. Such
fractures have not been reported in earlier studies.[1,9,15] In
our study, the fiber frame fractured because the patient had
chewed on hard foods. With longer intervals of time, there
is a possibility of supraeruption of the opposing tooth and
its impingement on the fiber frame. This could result in
increased concentration of mechanical stresses on the fiber
frame and its subsequent fracture.
Another type of failure observed at the 6th month evaluation
was debonding at the compositefiber interface. Overzealous
finishing of the space maintainer could have resulted in
excessive removal of the resin overlying the fiber. Further
wearing away of this thin layer of composite during
mastication could have debonded the composite from the
fiber frame.
In this study, cement loss was considered as one of the
criteria for failure of the band-and-loop space maintainer.
Although recementation of the appliance was carried out,
these patients were excluded from further evaluation in
the study. Cement loss was initially seen at the 3rd month of
evaluation (33.3%) and continued to be observed till the end
of the study. This was consistent with the findings of Moore
et al.[16] and may have been because of non-application of
rubber dam during cementation.
Some studies have reported cement loss to be the most
common cause of failure of fixed space maintainers.[16,17]
Although glass ionomer cement has low oral solubility,
cement loss could be due to difficulty in achieving complete
isolation during cementation, especially in young patients. In
comparison to resins and reinforced glass ionomer cements,
the conventional glass ionomers have low flexural strength.
[18]
Also, the mechanical bonding between the band material
and the luting cement is less strong than the combined
mechanical and chemical adhesion of glass ionomer to
tooth enamel. According to certain studies, cases of failure
classified as being due to cement loss are likely to be due
to poor band fit.[16]
Approximately 7% of the band-and-loop space maintainers
placed in the present study showed breakage of the wire
loop at the 6th month. Such a high rate of mechanical failure
could have been due to the poor quality of construction, for
example, an incomplete solder joint,[8,17,19] overheating of the
wire during soldering,[8,19,20] thinning of wire by polishing, and
failure to encase the wire in the solder.[21]
When comparing the retention of both types of space
maintainers, GFRCR space maintainers showed a higher
success of 53%, while only 33% success was seen with the
band-and-loop space maintainer. However, this difference
was not statistically significant. Non-application of rubber

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GFRCR as a space maintainer

dam during cementation could be one reason for the


lower rates of success with the band-and-loop space
maintainers. In addition to being applied under rubber
dam isolation, the GFRCR space maintainer has the
advantage that resins are virtually insoluble in oral fluids.
[22]
The improvised design of the GFRCR space maintainer
allowed for bonding on both buccal and lingual surfaces
of the two abutment teeth; this provided adequate
surface area for firm bonding and micro-mechanical
retention.
According to Baroni et al., in the long-term use of space
maintainers, the mechanical stresses to which the appliance
is subjected is more important than its design.[17] It has been
reported that children prefer the right side of the mouth for
chewing.[23] This could imply that space maintainers placed on
the right side of the mouth are more prone to occlusal stress
and early loss.[23] In our study, GFRCR space maintainers were
placed on the right side of the mouth in 26 children and 46%
of them showed a failure.
The GFRCR space maintainer seems to be a suitable
alternative to the conventional fixed space maintainer.
GFRCR space maintainers are easy to apply and require
only one visit. There is no need for making impressions
and cumbersome laboratory procedures are eliminated.
Patients are satisfied because these space maintainers are
esthetic, less bulky, occupy less space in the oral cavity,
and feel natural. In the design of a band-and-loop space
maintainer, the band encompasses the entire circumference
of the abutment tooth; whereas, in our study, the GFRCR
space maintainer was bonded only to the middle third of
the abutment teeth surfaces. Also, the design of the GFRCR
space maintainer provided ample clearance between the
fiber frame and the underlying tissue. Thus, the GFRCR
space maintainer is likely to permit better oral hygiene
maintenance and cause fewer traumas to the gingival
tissue.

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It is our hope that the findings of this study will enable


the pediatric dentist to follow a simple method for space
maintainer application, while making the appliance more
comfortable and esthetically pleasing for young patients.

21.
22.
23.

Conclusion
The following conclusion was drawn from this study:
GFRCR space maintainers showed superior retention (53%)
compared to band-and-loop space maintainers (33.3%),
but this difference was not statistically significant.

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Reprint request to:


Dr. Priya Subramaniam
Department of Pedodontics and Preventive Dentistry, The Oxford Dental
College, Hospital and Research Centre, Bommanahalli, Hosur Road,
Bangalore-560 068, Karnataka, India.
E-mail: drpriyapedo@yahoo.com

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