Basic Space Maintainers lecture one Prepared by Dr

Basic Space Maintainers lecture one Prepared by: Dr Seyed Ebrahim Jabbarifar Associate professor University of Isfahan Department of Pediatric Dentistry 2009

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! Name 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 #3 and #14 around palatal root- this starts mesial migration of #3 and #14 • 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 of #23 -#26

Lower Lingual Holding Arch • Mandibular incisors often erupt lingually and are pushed forward by the tongue • LLHA should not be placed with primary incisors

#K and #T Extractions : LLHA Indicated? • NO- note lingual eruption #23 and #26 • Option: Reverse Crown and Loops #L-19 and #S-30. **LLHA will be placed 2 -3 years later, prior to loss of #L and #S. 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

Crown and Loop • Stronger than band loop • Cementation failure or loss less likely • Excellent choice if tooth needs a restoration

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 = 2 nd Primary Molar Extraction with unerupted 1 st Permanent Molar • Nance or Band/Crown Loop = Maxillary problem with 1 st Permanent Molars present • Lower Lingual Holding Arch = Mandibular Problem with 1 st Permanent Molars and Permanent Incisors present • Band/Crown and Loop= Primary 1 st 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 1 st 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. • Please answer the questions on your worksheets.

Question 1 • What tooth was extracted? How old is this child? • What is the appropriate space maintainer? • Will it have to be replaced with a different space maintainer in the future? If so, with what?

Question 2 • What tooth was extracted? How old is the child? • What is the appropriate space maintainer? • Will it have to be replaced with a different space maintainer in the future? If so, with what?

Question 3 • Which teeth were extracted? How old is the patient? • What is the appropriate space maintainer? • When can the space maintainer be removed?

Question 4 • Which teeth were extracted/ • What is the appropriate space maintainer?

Question 5 • Which teeth have been extracted? How old is the child? • What is the most appropriate space maintenance?

“Somieh” Case • Somieh 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. ”

How old is Ali assuming normal dental development?

Ali’s Bite Wings

Mandibular Arch Only: Chart Dentition on the Odontogram

Ali • Mandibular Arch Only : Chart abnormalities and pathology (including caries ) from the Panorex and Bite Wing Radiographs

Ali 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.

Ali • Assuming normal dental development, at what age will the space maintainer you placed no longer be needed?

“Ali” Case • Ali 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. ”

Ali: Chart Maxillary Dentition Only on the Odontogram

Ali’s Bite Wings • Chart any pathology or abnormal findings (including caries) for the maxillary arch only on the odontogram.

Ali

Ali 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

Ali

Discussion

Question 1 • 5 or 6 y. o. child. Tooth #I extracted.

Question 1 • Band/Crown and Loop #J-H • Will not need replacement. #12 should erupt before #H or J exfoliate

Question 2 • Tooth #L extracted. 3 -5 y. o. child. • What is the appropriate space maintainer? • Will it have to be replaced with a different space maintainer in the future? If so, with what?

Question 2 • Band/Crown Loop #K-M • May need to be replaced by LLHA later. Tooth #M should exfoliate prior to eruption #21.

Question 3 • Teeth #A and #J extracted. Patient 8 -9 y. o.

Question 3 • Nance #3 -#14 • Can be removed when #4 and #13 erupt-around age 12

Question 4 • Teeth #K and L extracted

Question 4 • Lower Lingual Holding Arch (LLHA) #19 -#30

Question 5 • Teeth #K and #S extracted. 5 -6 y. o. child. • Because permanent incisors are not erupted, LLHA not recommended. Options: Reverse band loop #L-#19 and band loop #T-#R.

“Ali” • Ali presented for an initial visit at the Afzal Clinic. He has had dental treatment on and off throughout life. He is in no pain, but mom reports that “we know she has dental problems. ”

Assuming normal dental development, Ali is 8 years old.

Ali • Mandibular Arch Only : Chart abnormalities and pathology (including caries ) from the Panorex and Bite Wing Radiographs

Ali • 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.

Ali 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.

Ali 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

Ali • 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

“Ali” Case • Ali 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. ”

Ali

Ali 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

Ali • 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.

Ali

Ali Tx Plan • Extract all maxillary primary teeth – #A, B, J- Multiple caries and near exfoliation – TE #C and #H due to root formation #6 and #11 • Restore #3 with direct M composite • Restore #14 -MO • Place Nance Space Maintainer- slight space deficiency, but this will be very beneficial.

Ali Tx Sequence • Appt 1 – Fit bands #3 and #14 and Impress for Nance – Restore #14 – TE #H and #J • Appt 2 – Restore #3 – Seat Nance – TE # A, B, C

Thank You!