PASSIVE SPACE CONTROL

Dr S.E. Jabbarifar;Isfahan Dental School,Pediatric Dentistry Departement 2009

Prerequisite knowledge
Understand that arch length is greatest at age four years Tooth position is maintained by balance of forces shift vs. drift Greatest amount of space closure within first 6 months of premature tooth loss Sequence & timing of exfoliation/eruption

Space control vs. space maintenance

Space control
Dynamic Careful

ongoing supervision of appliance to preserve existing

Space maintenance
Utilization

space Not always the rule!

Variables influencing space control

Oral musculature & habits Time elapsed since extraction Dental age, eruption sequence & bony covering Available space Interdigitation Absence of anomalies

Considerations in premature 1o tooth loss

Preserve the arch length! Causes:
primarily trauma, caries Posterior primarily caries
Anterior

If space lost:
Space

maintenance Space regaining No treatment

Space loss in primary and mixed dentitions

Unrestored interproximal caries reduce arch circumference!
first line of defense = Class II & SSC restorations Natural tooth is the best space maintainer

Planning for space maintenance

No medical contraindications
Patient must be dentally fit Patient must be able to demonstrate good OH

Planning for space maintenance

Parents must all understand costs involved
Parents must understand importance of & be willing to attend regularly for appliance supervision/maintenance teeth lost in primary dentition stage may cause delayed eruption of succedaneous teeth Periodic recementation may be required

Primary Incisors

Primary Incisors

Primary Incisors
Why replace primary incisors?
Primarily Rarely

for esthetic reasons

see long-term effects on speech development and function

Once

1o cuspids have erupted in occlusion the anterior arch length is established

Primary Incisors
Problems with replacement:
Appliances High

are weak

maintenance close monitoring reqd alterations as dentition changes may enhance caries risk

Frequent

Appliance

Primary Incisors

Primary Incisors

Primary Incisors

Primary Incisors

Primary Canine
Loss due to trauma or caries rare Space maintainer: B&L vs. RPD
Must

be removed to accommodate lateral

No space maintainer:
Midline

shift Lingual collapse in mandible

Premature loss of primary molars

Band-loop space maintainer

Indications:

Unilateral loss of the 1st primary molar before eruption of the 1st permanent molar

Unilateral loss of the 1st or 2nd primary molar after eruption of the 1st permanent molar
Bilateral loss of the 1st primary molars before eruption of the permanent incisors and 1st permanent molars Bilateral loss of the 2nd primary molars after eruption of the 1st permanent molar

Early loss of the primary molar

st 1

Early loss of the 2nd primary molar

Other indications

Deflection of succedaneous tooth

Band-loop space maintainer

FABRICATION & DESIGN

Band-loop fabrication
Technique:
Properly

fitting band on abutment tooth (pg. 389 Pinkham) Segmental impression (compound/alginate) Remove band from tooth & secure in impression Create working model

Band-loop fabrication
Sectional impression tray

Green or red compound

Band-loop fabrication

Band-loop fabrication

Band-loop fabrication

Band-loop design
Loop should be wide enough bu-li to allow eruption of bicuspid (8 mm)
Loop should not restrict physiologic movement of adjacent teeth (eg. lateral movement of primary canine)

Band-loop design
Loop should not impinge on soft tissue Loop should be in close approximation to ridge

Band-loop cementation
Apply floss ligature Try-in / seat band completely Loop should contact abutment below contact point No soft tissue impingement Cementation in properly isolated, dry field Check/adjust occlusion

Try it in first!

Loop impingement

Loop impingement

Loop impingement

Lingual arch

Lingual arch
Indications:
Bilateral

single or multiple tooth loss in mandible recommended when primary incisors still present

Not

Lingual arch

Lingual arch design

Archwire should rest on cingulae of incisors 1-1.5 mm above gingival margin
Removable vs. soldered

Lingual arch design

Solder joint should be in mid-third and parallel to band Wilson loops
Archwire should be below plane of occlusion posteriorly

Lingual arch fabrication

Fit molar bands
Compound/alginate impression accurate especially in lingual sulcus & lower incisor area

Lingual arch fabrication

Secure bands in impression

create working model

Lingual arch cementation

Check for passivity on the model and in the mouth before cementation Archwire should be in contact with lower incisor cingulae

Lingual arch cementation

Dry field GI or polycarboxylate cement No soft tissue impingement

Transpalatal arch

Transpalatal arch
Rarely recommended for bilateral tooth loss in maxilla Can prevent mesio-palatal rotation of palatal root of Mx 1st permanent molar but allows mesial tipping of molars & space loss

Transpalatal arch
May have an indication for use when one side of the arch is intact but several primary teeth are missing contralaterally Some designs incorporate omega loop: when active can prevent bodily movement of molars

Nance arch

Nance arch
Used commonly in maxilla for bilateral tooth loss Incorporates acrylic button in contact with palate to prevent molars from tipping
Can be very unhygenic

Nance arch

Nance arch fabrication

Bands fitted on molars
Mx impression in compound/alginate Working model

Nance arch fabrication

Archwire will traverse the palatal vault

Nance arch fabrication

Adapted archwire is soldered to bands

Acrylic button is added to embed the wire

Nance arch fabrication

Completed arch ready for try-in and cementation Ensure acrylic button in firm contact with palate

Crown-loop space maintainer

Crown-loop space maintainer

Indications:
As

for band-loop

Abutment

tooth requires full coverage SSC due to multi-surface caries or pulp treatment

Crown-loop fabrication
Abutment tooth prepared for SSC Properly contoured SSC seated, but not cemented Compound impression SSC placed into impression Working model Another SSC fitted and cemented with temporary cement

Crown-loop space maintainer

Crown-loop space maintainer

Crown-loop space maintainer

Crown-loop cementation
Temporary SSC removed, under LA if necessary Try-in crown-loop to verify loop contours Cementation in dry field

Crown-loop space maintainer

Disadvantages:
If

solder joint fails, there is no way to repair the appliance without entire re-make is higher (extra SSC)

Cost

Band-loop over SSC

Band can be fitted over SSC as alternative to crownloop

Bonded space maintainer

Difficult to retain due to shearing forces of occlusion Flexure in function will de-bond Difficult to adjust

Removable appliances
Indicated for mulitple primary tooth loss when no suitable abutment teeth exist Need to restore occlusal function over longer span Clasping difficult for primary teeth therefore retention a problem Compliance issues

Removable appliances

INTRA-ALVEOLAR SPACE MAINTENANCE

D362/QP362 Division of Orthodontics and Paediatric Dentistry 2004-2005 Karen M. Campbell, DDS

Premature loss of the 2nd primary molar

If the 1st permanent molar is erupted, can use conventional B & L from 6 to D

Premature loss of the 2nd primary molar

Band & loop from D to 6 Difficult to band Ds

Indications for intra-alveolar space maintenance

Premature loss of the 2nd primary molar prior to the eruption of the 1st permanent molar

Contraindications
Medically compromised:

Cardiac patients requiring SBE prophylaxis

Immunosuppression
Chemotherapy/radiation therapy, pre-BMT

Demonstrated lack of commitment to follow-up

Distal Shoe
Provides a guiding plane for the eruption of the 1st permanent molar

Dentists responsibility
Mark on the working model the distal terminus of the appliance

Dentists responsibility
Provide measurement from radiograph
Mark depth of shoe with cut on model Shoe should be 1 mm below mes marginal ridge of the 1st permanent molar

Completed appliance

Immediate insertion
Follows extraction can better visualize placement of shoe Area already anesthetized
eliminates potential for 1st permanent molar drift

Cemented appliance

Crown with distal shoe

D prepared for SSC; E to be extracted at later appt

Crown with distal shoe

Segmental impression with crown inserted

Crown with distal shoe

Tooth temporized with SSC

Crown with distal shoe

Crown with distal shoe

Extraction of the E and preparation for cementation

Crown with distal shoe

Cementation

Confirmation by radiograph

Following eruption of the 1st permanent molar

Distal shoe no longer appropriate 1st permanent molar may tip mesially above shoe Parents must be aware of need for second appliance from the beginning Conventional B & L or lingual arch may be required

Drawbacks of the appliance

Can only replace a single tooth due to its cantilever design Inherent lack of strength Cannot restore occlusal function Ds are very difficult to fit bands Epithelium perforated in area of distal shoe