Management of Space in Pediatric Dentistry Dr Seyed Ebrahim Jabbarifar :Associate professor Isfahan Dental School Pedodontic department 2009

Etiology of Early Primary Tooth Loss Extraction or destruction: extensive caries or traumatic injury Premature exfoliation: abnormal root resorption (e.g. ectopic eruption) systemic disorders or hereditary syndromes Hypophosphatasia Rickets Acrodynia Histiocytosis X triad Leukemia Cherubism Juvenile Periodontitis Dentinal dysplasia Cyclic neutropenia Papillon-Lefevre syndrome Ectopic Eruption of Primary Canine: first clinical sign of a significant arch length-tooth size discrepancy

Functions of a Space Maintainer prevent undesirable tooth mvmt following the premature loss of a primary tooth i.e. Mesial migration of posterior segments and lingual collapse of anterior segments Negative Tooth Mvmt: Reduction or loss of space required by succeeding tooth Considerable influence on dental dvlpt well into adolescence and adult age Space Maintainers are recommended to reduce the prevalence and severity of malocclusion following premature loss of primary teeth.

Functions of a Space Maintainer Maintain space Prevent mvmt adjacent teeth Provide masticatory fx Prevent overeruption of opposing teeth Improve esthetics Assist in speech (anterior segments) Aid in control of deleterious oral habits Note: appliance must neither inhibit nor deflect normal growth changes

Ideal Prerequisites of a Space Maintainer Simple to construct and maintain Durable, strong, stable Passive Easily cleanable and not enhance dental caries or soft tissue pathology Readily adjustable for flexible application Passive--must not impose excessive stress of pressures on remaining teeth which might effect orthodontic movements.

Factors to consider when planning a space maintainer: Question: “When should a space maintainer be placed?” General Rule: “Whenever the clinical situation will allow space loss to encroach on the arch length needed for the unerupted permanent teeth, giving due consideration to the patients dental health, motivation, and occlusion status”.

Factors to consider when planning a space maintainer: Dental and periodontal condition Arch length Presence/absence of permanent successor Time elapsed since loss of primary tooth Status of first permanent molar eruption Status of permanent successor’s development and eruption potential Cooperation level of child and parents Which tooth is lost, in which arch, at what time?

A space maintainer may not be required if there is: 1. Existence of cuspal interference. 2. Widely spaced primary dentition. 3. If succeeding tooth is expected to erupt within 6 months. 4. If present space is not adequate for the succeeding tooth. 5. The possibility of future orthodontic work. 6. Where the opposing 6's are locked into a desirable and stable relationship

Suggested that succeeding tooth will most likely erupt within 6 months if: 1. 75% of the root is present on the succeeding tooth. 2. Less than 1 mm of alveolar bone is covering succeeding tooth. 3. Destruction of the alveolar bone occurred when the primary tooth was lost. 4. Mixed-dentition is in its later stages. Roots: if 1/3 to 1/2 root dvlpt: then eruption delayed If 1/2 to 3/4 root dvlpt: then eruption accelerated

Adverse Effects Dislodged, broken, and lost appliances Plaque accumulation Caries Interference with successor eruption Undesirable tooth mvmt Inhibition of alveolar growth Soft tissue impingement Pain

Prior to obtaining the consent, parents should be informed that: 1. Space maintainer requires monitoring. 2. Patient must maintain adequate OH. 3. Appliance may break, requiring repair or replacement. 4. Broken appliances are hazardous to the child and will be ineffective. 5. Even properly maintained appliances may fail to preserve the space. It is necessary to obtain parental awareness and understanding related to space maintenance. Monitor: assess integrity of cement, evaluate + clean abutment teeth

Premature loss of anterior teeth? 1 Incisors: no decrease in intracanine dimensions if loss after eruption of canines Need SM?: Not necessary 1 Canines: common loss due to ectopic eruption of permanent lateral incisors Need SM?: consider LLHA with spur or elective extraction of canine Canine loss: compromises arch length, possibly deepens bite, shift of dental midline toward side of loss

Premature loss of posterior teeth? Comprehensive evaluation: determine if space maint. is indicated for: a) First primary molar b) Second primary molar c) Multiple tooth loss Priority: 2nd M > 1st M > Canine > Incisor

Classification and Types of Space Maintainer Appliances Unilateral fixed: Band & loop / Crown & loop Distal shoe Bilateral fixed Lower lingual holding arch Transpalatal arch Nance appliance Removable Modifications of Hawley retainer design

Premature loss of posterior teeth: 1st Primary Molar Little/no space loss prior to eruption of 1st PM Need SM if: in full primary dentition or approximating eruption of 1st PM No SM if: after 1st PM have erupted Following appliances are indicated: a) Band and loop b) SSC and loop If there is a loss of the 1st primary molar and space maintenance is required…

Premature loss of posterior teeth: 2nd Primary Molar Max molar: M tipping, bodily mvmt, MB rotation around palatal root Mand molar: M and lingual tipping, slight bodliy mvmt; also retroclination of anterior teeth Following appliances are indicated: a) Lingual arch/TPA/Nance b) Band & loop c) Distal shoe appliance - prior to eruption of 1st PM If there is a loss of the 1st primary molar and space maintenance is required, then the… Note: B+L and LLHA--used after the 6 is in place Distal Shoe--used before the 6 is in place

Premature loss of posterior teeth: Multiple Teeth Following appliances are indicated: a) Transpalatal arch b) Nance appliance c) Lingual arch d) Removable

SM: Band and Loop Indications Loss of primary molar prior/during period of eruption of 1st perm M. Anywhere in posterior following a time lapse b/w loss of tooth and eruption of its permanent successor. Loss of 2 post teeth or bilateral situations rarely used

SM: Band and Loop Advantages 1. Easy to construct. 2. Inexpensive. Easily adjusted. 4. Allows eruption of permanent tooth. 5. Non invasive. 6. Painless.

SM: Band and Loop Disadvantages Masticatory function. Not restored Extrusion of opposing dentition. Not prevented Normal distal mvmt of primary cuspids during eruption of perm lateral incisor Not allowed if placed for the early loss of mand 1st primary molar

SM: Band and Loop Construction Band: stainless steel material 0.005 inches in thickness Crib: portion of the wire spanning the edentulous space Loop: portion of the wire contacting the abutting tooth 0.032 inches in diameter

SM: Lingual Arch Indications Premature loss of primary posterior teeth. Base for aesthetic restoration in loss of anterior teeth. 3. Used as a base for habit appliance.

SM: Lingual Arch Advantages Disadvantages 1. Maintains est. arch form. 2. Allows eruption of perm teeth w/o interference. 3. Not easily displaced. 4. Ease of cleaning for proper OH. 5. Can be modified easily to serve in many situations. 6. Patient comfort. 1. Does not prevent extrusion of opposing teeth. 2. Not advisable to band teeth which are: Hypoplastic Hypocalcified Highly prone to caries. 3. Can promote decay in non-compliant patients.

SM: Fixed Lingual Arch Construction Band: Stainless steel material 0.005 inches in thickness (ortho bands) Lingual arch wire: Stainless steel round wire 0.036 inches in thickness

SM: Nance Appliance Maxillary arch: multiple tooth loss Indications: The same as for fixed lingual arch Construction: Bands: Stainless steel material 0.005 inches in thickness Palatal wire: Stainless steel round wire 0.036 inches in thickness

G.T. age 5 after the removal of a necrotic #85 What would you do? G.T. age 5 after the removal of a necrotic #85 Q: Tooth missing: #85--single Q: Choices: Distal shoe Use: Distal shoe

N.S. age 7 requires extraction of tooth #75. What would you do? Q: Tooth missing: #74, soon to be 75--multiple Q: Choices: LLHA, ?B+L, (?partial) Use: LLHA--loss of multiple teeth At age 7, need to assess if all perm incisors are in--make modification if necessary. N.S. age 7 requires extraction of tooth #75.

What would you do? Q: Tooth missing: #64 and 65--multiple, high caries risk--potentially #54 and/or 55 in future Q: Choices: Nance, ?B+L Use: Nance P.G. age 8 requires pulp treatment and stainless steel crown restorations for teeth #54 and #55

M.M. age 8 is scheduled for a recall visit. What would you do? Recall: assess integrity of cement evaluate and clean abutment teeth Note: Space loss in UR Quadrant--may require space regaining appliance/ortho consult M.M. age 8 is scheduled for a recall visit.

Thank You