1. MANAGING THE ARCH CIRCUMFERENCE
CASE STUDIES

2. Alternatives No therapy indicated Space maintenance Space regaining
Space creation
Space elimination
Consultation with and/or referral to a specialist

3. If Space Maintenance or Space Regaining Indicate:
Type of appliance
Number of appliances required in regimen: 1, 2 or more
Timing of placement and removal

4. CASE ONE
Johnny is a four year old seeking emergency care for pain and swelling in the mandibular right quadrant. Clinical examination reveals #T (second primary molar) has been completely destroyed by caries and is non-restorable. Radiographic examination reveals the presence of a furcation radiolucency. The mandibular second premolar is developing. You make the decision that extraction is indicated.
How do you manage the arch circumference?

5. COMMENT
Space maintenance is the approach of choice. During the period of the primary dentition space maintenance is indicated in essentially all cases of loss of primary molars. The appliance required in this instanced is a distal shoe (intra-alveolar appliance). This appliance will remain in place until the eruption of the first permanent molar when it will need to be replaced with a lingual arch. The lingual arch will remain in place until the eruption of the second premolar at approximately age 12. Evaluation of the adequacy of the arch circumference and normalcy of the occlusion should be accomplished after the eruption of the incisors and first permanent molars.

6. CASE TWO
Jill is an eight year old who has been seen in your office for routine care since age 4. At the present recall examination you note the presence of a parulis adjacent to #S (first primary molar). The tooth is mobile on examination. During the initial treatment at age four a pulpotomy and stainless steel crown had been accomplished. Radiographic examination reveals the presence of a furcation radioluceny indicating a pulpotomy failure. Extraction is indicated. Additional information you obtain is that the succedaneous tooth is present and its eruption will not be immediate; bone overlies the tooth and approximately 1/3 of the root is formed. The space analysis indicates the arch circumference is adequate. Jill’s profile is orthognathic, and the molar and canine relationships are Class I. Overbite and overjet are normal
What is indicated in managing the arch circumference?

7. COMMENT
No space management techniques are indicated. Loss of the first primary molar(s) after the eruption and inter-digitation of the first permanent molar in a Class I relationship is generally not required.

8. CASE THREE
Suzanne is a seven year old who must have #J (second primary molar) extracted due to pulpal pathology. Clinical and radiographic examination reveals: the succedaneous tooth is present; the arch circumference is adequate based on the results of a space analysis; the profile is retrognathic; the molar and canine relationships are Class II and a 6 mm overjet and 4 mm overbite exist. Your recommended approach to treatment is?

9. COMMENT
Considering the developing Class II malocclusion, consultation with a specialist is indicated before proceeding. It is highly probable that space maintenance will be indicated, but your diagnostic sophistication is not sufficient enough to make this decision. Should the specialist request maintenance of the space, palatal arch (Nance arch) would be the appliance indicated. If specialist consultation is impossible for whatever reason, it is probably wise to maintain the space. It is easier to close excessive space than it is to regain needed space.

10. CASE FOUR
Brian is a five year old who is presenting for his initial oral examination. Examination reveals, among other things, that #L and #S (first primary molars) are completely destroyed by caries and only root fragments remain, requiring extraction. Radiographs reveal the presence of the first premolars. Treatment necessitated is?

11. COMMENT
Space maintenance is indicated until the eruption of the first permanent molars and incisors when a more detailed evaluation of the arch circumference adequacy and occlusion may be accomplished. In this situation bilateral band and loops are the appliance of choice. A full arch appliance is not indicated because of potential to restrict arch width growth and interfere with the eruption of the incisors. Depending on the evaluation during the mixed dentition, the band and loops may be removed after eruption and inter-digitation of the first permanent molars, or a lingual arch may be placed until the eruption of the first premolars.

12. CASE FIVE
Bonnie is an eight year old who is seen by you for the first time. The case history reveals that dental care heretofore has been surgical in nature, with the extraction of #A (second primary molar) at age 5. No provision was made for space maintenance at that time. Examination reveals #3 has drifted mesially and the available arch circumference has thereby been reduced. A space analysis indicates that sufficient space is available for the eruption of the succedaneous teeth with the exception of a discrepancy of approximately 3 mm in the maxillary right quadrant. Bonnie's profile is normal as is the relationship between the maxillary and mandibular arches. Your recommended treatment is?

13. COMMENT
Treatment in this situation is space regaining. Appliances which could be used are split saddle, or a headgear. After the space has been regained a space maintainer, transpalatal wire or palatal arch would be required until the eruption of #4 at approximately age 12. Because of the necessity of maintaining this space after regaining, some clinicians prefer to delay regaining until just prior to the anticipated eruption of #4. However, if space regaining is delayed until the later date, care must be exercised to ensure that it is accomplished prior to the eruption of the second permanent molar. As this tooth moves farther in the alveolus toward eruption, distalization of the first permanent molar becomes more difficult.

14. CASE SIX
Billy is an eight year old child whose mother has brought him for his first dental examination with the chief complaint of crowding of the mandibular anterior incisors. No carious lesions are noted in your examination. A moderate amount of crowding of the mandibular incisors is noted. Impressions are obtained and diagnostic casts are made. Space analysis reveals a 3 mm generalized discrepancy in the mandibular arch. The profile is orthognathic, and the relationship between the maxillary and mandibular dentition is normal as manifested by an end to end molar relationship, a Class I canine relationship and normal overbite and overjet.
What treatment alternative is indicated?

15. COMMENT
Space creation. A typical protocol might consist of discing or extracting the canines, distalizing the first permanent molar into a Class I molar relationship and placing a loop lingual arch in the mandibular to advance the incisors and/or hold the "leeway space". If competency with these appliances is not obtained, referral to a specialist is indicated.

16. CASE SEVEN
Kenny is a four year old requiring the extraction of #S and #T (first and second primary molars) due to pulpal pathology. The teeth are destroyed to the extent that pulpal therapy and restoration are precluded.
What treatment alternative is indicated to manage the arch circumference?

17. COMMENT
Space maintenance. An acrylic removable appliance must be fabricated as abutments are not present for fabrication of a fixed appliance. After eruption of the first permanent molar and incisors, re-evaluation of the arch circumference and occlusion should be undertaken. Assuming space maintenance is still indicated a lingual arch should be placed until the eruption of the first and second premolars. On occasion the functional pressure of the removable appliance does not prevent the mesial migration of the first permanent molar. In these situations, space regaining must be considered.

18. CASE EIGHT
Angela is a seven year old that presents with tooth #B (maxillary first primary molar) being non-vital, and requiring extraction. The succedaneous tooth is present. The profile is orthognathic. The first permanent molars have just erupted and are approaching an end to end relationship. The canine relationship is Class I and overjet and overbite are normal.
Treatment indicated is?

19. COMMENT
Space maintenance. With the first permanent molar still in an active state of eruption and not inter-digitating in a Class I relationship the potential exists for mesial migration and loss of arch circumference. A band and loop space maintainer can be used in this situation. The eruption sequence is normally favorable with the first premolar (the tooth the space is being held for) erupting before either of the abutment teeth are lost. This is the only time in the mixed dentition that a "full arch" appliance is not employed.

20. CASE NINE
Jennifer is a beautiful little four year old whose doting mother is grooming her for a movie contract at age seven. Calamity has struck in the form of a traumatic episode on Jennifer's new two-wheeler. Tooth #F (central incisor) has been avulsed and mother is holding it in her hand sobbing and begging you to do something for her darling. You tell her that replantation of primary teeth is not indicated - the mother's "wailing" intensifies. What alternative might you offer to this "dear" mother?

21. COMMENT
A fixed esthetic appliance. Not to maintain the space but to restore esthetics.

22. CASE TEN
Tooth #T (second primary molar) is indicated for extraction on Herman, age eight. Tooth #30 is present. The arch circumference is adequate as indicated by space analysis. The profile is orthognathic and the relationship between maxillary and mandibular dentitions is normal.
What type of therapy is indicated?

23. COMMENT
Space maintenance. A lingual arch is indicated to maintain space until eruption of #29.

24. CASE ELEVEN
Melodie is eight years old. Her parents are very concerned at present because she has just exfoliated two lower primary teeth but only 1 permanent tooth has replaced them. Clinical examination reveals that there has been ectopic eruption of #26 with exfoliation of #Q and #R (primary lateral and canine). The midline has shifted to the right 2 mm. The mandibular incisors remain crowded and rotated as are the maxillary. Space analysis indicates a discrepancy of 6 mm/quadrant between the size of the arch and the size of the succedaneous teeth. The profile is normal. All succedaneous teeth are present and the relationship between the maxilla and mandible is normal. The treatment alternative indicated would be?

25. COMMENT
Consultation with a specialist as space elimination is indicated. Most likely a serial extraction protocol will be initiated similar to the one described in the reading material.