Space Maintainers • Dr. Maan Al- Far • M Dent SCi in Paediatric Dentistry • University of Liverpool (England) • Jordanian Dental Board • Head of pediatric dentistry specialty
Space Maintainers
• Dr. Maan Al- Far
• M Dent SCi in Paediatric Dentistry
• University of Liverpool (England)
• Jordanian Dental Board
• Head of pediatric dentistry specialty
Definition
• Space maintainers are appliances used to maintain space or regain minor amounts of space lost,so as to guide the unerupted tooth into a proper position in the arch.
IDEAL REQUIREMENTS
It should maintain the entire mesio-distal space created by a lost tooth. It must restore the function as far as possible & prevent over-eruption of opposing teeth. It should be simple in construction. It should be strong enough to withstand the functional forces.
IDEAL REQUIREMENTS
It should not exert excessive stress on adjoining teeth. It must permit maintenance of oral hygiene.
IDEAL REQUIREMENTS
It must not restrict normal growth & development and natural adjustments which take place during the transition from deciduous to permanent dentition. It should not come in the way of other functions.
CLASSIFICATION OF SPACE MAINTAINERS
Removable or fixed .
With bands or without bands.
CLASSIFICATION OF SPACE MAINTAINERS
Functional or non-functional.
Active or passive.
Certain combinations of the above.
Fixed space maintainers- CLASS I (a) Non-functional types- i. Bar type. ii. Loop type. (b) Functional types- i. Pontic type. ii. Lingual arch type. CLASS II Cantilever type (distal shoe,band & loop.)
Removable space maintainers- Acrylic partial dentures
PLANNING FOR SPACE MAINTENANCE
Time elapsed since loss- . If space closure occurs, it usually takes place
during the first 6 months after the extraction.
When a primary tooth is removed & all factors indicate the need for space maintenance, it is best to insert an appliance as soon as possible after the extraction. Often the best approach, if possible, is to fabricate an appliance before the extraction & deliver it at the extraction appointment.
Dental age of the patient-
The chronologic age VS dental age
.Gron studied the emergence
of permanent teeth based on the
amount of root development,
as viewed on radiographs,at the time of emergence.she found that teeth erupt when three-fourths of the root is developed,regardless of the child’s chronologic age.
PLANNING FOR SPACE MAINTENANCE
PLANNING FOR SPACE MAINTENANCE
Amount of bone covering the unerupted tooth-
if there is bone covering the crowns, we
can predict that the eruption will not occur for
many months, a space-maintaining appliance is
indicated.
PLANNING FOR SPACE MAINTENANCE
d) Sequence of eruption of teeth-
Observing the relationship of developing &
erupting teeth adjacent to the space created by
the untimely loss of a tooth.
PLANNING FOR SPACE MAINTENANCE
Delayed eruption of the permanent tooth-
In case of impacted permanent tooth,it is necessary to extract the primary tooth,construct a space maintainer & allow the permanent tooth to erupt at its normal position.
If the permanent teeth in the same quadrant of the opposing dentition have erupted,it is advisable to incorporate an occlusal stop in the appliance to prevent overeruption in the opposing arch.
PLANNING FOR SPACE MAINTENANCE
Congenital absence of the permanent tooth-
If permanent teeth are congenitally absent, the dentist must decide whether it is wise to hold the space for many years until a fixed replacement can be provided or it is better to allow the space to close.
If the decision is made to allow the space to close, orthdontic treatment will be needed. referral to orthodontist
Presentation of problems to parents-
Take sufficient time to explain existing conditions
& discuss the possibility of the development of a future malocclusion if steps are not taken to maintain the space or to guide the development of the occlusion. Also explain that the space-maintaining appliance will not correct an existing malocclusion but will only prevent an undesirable condition from becoming worse or more complicated.
•
Fixed space maintainers
Band & loop space maintainer. Crown & loop appliance. Lingual arch. Palatal arch appliance. Transpalatal arch. Distal shoe. Esthetic anterior space maintainer.
Removable space maintainers
Acrylic partial dentures.
Full or complete dentures.
Removable distal shoe space maintainer.
Basic Space Maintainers
• Are PASSIVE
– .036 wire is very heavy and should not be
used to actively move teeth
Before Placing a Space
Maintainer
• Evaluate Arch Length
– Has the space already been lost?
– Is there excess space?
• Appropriate Radiographs
– Succedaneous tooth?
– Time to Eruption?
• Patient/Family Compliance
Space Maintainers are
Simple!
The 4 most basic pediatric space
maintainers
Basic Space Maintainers
• NANCE (Transpalatal Arch with Acrylic
Button Stop on Palate)
• LOWER LINGUAL HOLDING ARCH (LLHA)
• BAND/CROWN and LOOP
• DISTAL SHOE
Distal Shoe
• MAXILLARY or
MANDIBULAR
• Used when second
primary molar
requires extraction
and first permanent
molar has not erupted
Distal Shoe
• Should be evaluated with
radiograph prior to
cementation
– Length
– Position
• Will be replaced with
another space maintainer
when permanent teeth
erupt.
Distal Shoe
• Example of use in
partial eruption case.
Nance Appliance
• MAXILLARY ONLY
• Bands on first
permanent molars
Nance Appliance
• Cross Palatal Bracing prevents rotation and
around palatal root- this starts mesial
migration
• Acrylic Button provides additional stop
Transpalatal Holding Arch (TPA)
• Can be used like a
Nance.
• Advantage
– Lack of acrylic button
so less tissue irritation
and more cleansible
• Disadvantage
– Lack of anterior stop =
possible tooth shift (?)
Lower Lingual Holding Arch
• MANDIBULAR
ONLY
• Bands on first
permanent molars
• Anterior Stop =
Cinguli
Lower Lingual Holding Arch
• Mandibular incisors
often erupt lingually
and are pushed
forward by the tongue
• LLHA should not be
placed with primary
incisors
Extractions : LLHA Indicated?
• NO- note lingual
eruption
• Option: Reverse
Crown and Loops
**LLHA will be placed 2-
3 years later, prior to
loss . Simply cut off
loop and leave SSCs.
LLHA Omega Loops
• Omega Loops in area
of premolars allow
slight adjustment to fit
appliance
• Should not be used
to activate appliance
Appliance Activation Features
• Can be added by
attaching light wire
features
• This is beyond routine
space maintenance
Band/Crown and Loop
• MAXILLARY or
MANDIBULAR
• Unilateral most typical
• Can be bilateral if
permanent teeth are
not present
• Single tooth span
What About Removable
Appliances?
• Yes, they are possible, however………..
• High failure rate due to breakage and loss
• Parent and patient compliance must be exceptional
Which Space Maintainer?
• Distal Shoe = 2nd Primary Molar Extraction with
unerupted 1st Permanent Molar
• Nance or Band/Crown Loop = Maxillary
problem with 1st Permanent Molars present
• Lower Lingual Holding Arch = Mandibular
Problem with 1st Permanent Molars and
Permanent Incisors present
• Band/Crown and Loop= Primary 1st Molar
Extraction
Must I Plan to Replace a
Band/Crown and Loop ?
• All depends on ERUPTION SEQUENCE
– No, in maxillary arch
– Yes, in mandibular arch
– - may need LLHA later – Why? Canine should exfoliate
– prior to eruption of 1st premolar
– , making space maintainer defunct.
Space Maintainer Competency
• The following cases require space
maintainer consideration. Assume that
radiographs have been taken, there is no
abnormal pathology (other than dental
caries), and a successor is developing.
• Space analysis
Classification
• mixed dentition analysis
• Moyers
• Tanaka johonson
• Hixon and old father
• Ballard and wilie
Principles of space analysis
Non-radiographic space analysis
a. Moyer’s
b. Tanaka johnston
c. Ballard and wilie
. Radiographic analysis
a. Nance’s
b. Huckaba’s
Principles of space analysis
Combination of radiographs and prediction
charts
a. Hixon and old father
b. Staley kerber
Tanaka johnston analysis
Mandibular Arch Only: Chart
Dentition on the Odontogram
• Mandibular Arch Only : Chart
abnormalities and pathology (including
caries ) from the Panorex and Bite Wing
Radiographs
A Moyer’s space analysis predicted there
to be 2.3 mm of excess space in the
mandible.
Case no. 2
• child was referred by his general dentist
for ‘ tooth decay and crowding.’
Chart Maxillary Dentition Only on
the Odontogram
A Moyer’s space analysis predicts 1.2 mm
of space shortage in the maxilla
Treatment plan and sequence appointments
for the Maxillary Arch Only
Thank you
Discussion
Question 5
• Teeth #K and #S extracted. 5-6 y.o. child.
• Because permanent incisors are not erupted, LLHA not recommended. Options: Reverse band and loop #L-#19 and band and loop #T-#R.
“Cheyenne”
• Cheyenne presented for an initial visit at
the COD. She has had dental treatment on
and off throughout life. She is in no pain,
but mom reports that “we know she has
dental problems.”
Assuming normal dental development,
Cheyenne is 8 years old.
Cheyenne
• Mandibular Arch Only : Chart
abnormalities and pathology (including
caries ) from the Panorex and Bite Wing
Radiographs
Cheyenne
• Teeth Present:
19, K,L,M,23,24,25,26,R,S,T,30
Restorations: SSC #L
Pathology/Caries: #L and #S abscessed,
#28 severely ectopic.
Cheyenne
A Moyer’s space analysis predicted there
to be 2.3 mm of excess space in the
mandible.
Make a treatment plan and appointment
sequence for the mandibular arch only.
Cheyenne Tx Plan
• Extract #L,S and T and Place LLHA • #L and S due to abscess
• #T due to ectopic #28
– Appt #1: Fit bands and Impress for LLHA
Extract #L
– Appt. #2: Seat LLHA
Extract #S, T
Cheyenne
• Assuming normal dental development, at
what age will the space maintainer you
placed no longer be needed?
• Answer: When #21,28 and 29 erupt.
• Around age 12 years
“Justin” Case
• Justin was referred by his general dentist
for ‘ tooth decay and crowding.’
• The family does not believe they can
afford comprehensive orthodontic care ,
but does have dental insurance for
“routine dental care.”
Justin
A Moyer’s space analysis predicts 1.2 mm
of space shortage in the maxilla
Treatment plan and sequence appointments
for the Maxillary Arch Only
Justin
Please Evaluate This
Teaching Module
Thank You!
Question 4
• Lower Lingual Holding Arch (LLHA) #19-#30
Justin
• Teeth Present:
#3,A,B,C,7,8,9,10,H,12,J,14
• Restorations: #A-MO, #B-DO.
• Pathology/Caries: #3-M; #A-D; #B-M;
#H-D;#J-abscess, #14-MO
Note: #6 and #11 very advanced root
development.