space maintainers in primary and mixed dentition .pptx

space maintainers

1. GOOD AFTERNOON

2. Management of Space in Developing Occlusion

3. Why we need to know this

4. Importance of space management

5. Space Maintainers

6. Whenever primary or permanent teeth are lost prematurely, arch integrity is lost. Migration of primary and/or permanent teeth can occur and the available space may be reduced by an amount sufficient to cause some degree of crowding in the permanent dentition. Space maintainers are the appliances which guide the teeth in proper position & thus prevent developing malocclusion . Introduction

7. The deciduous teeth provide a mold for the proper growth of jaws, so that the permanent teeth may have an adequate space for aligning themselves. Premature loss of a deciduous tooth or a group of teeth may lead to following implications; 1. SPACE LOSS 2. ALTERED SPEECH 3. ESTHETICS 4. PSYCHOLOGICAL EFFECT 5. LOSS OF MASTICATORY FUNCTION Importance of deciduous dentition

8. Premature loss of primary teeth Unrestored proximal carious lesions Loss of permanent incisors due to trauma Congenitally missing teeth Ectopic eruption of permanent teeth Dental malformations resulting in small teeth such as peg shaped laterals. Reasons Of Space Loss-

9. Loss of posterior teeth in primary dentition is nearly universal indication for space maintenance therapy. Space loss in primary dentition

10. (1) Timing of permanent tooth eruption- Delayed or accelerated eruption of permanent tooth can be assessed by; a. Amount of bone coverage b.Amount of root development (2)Amount of time elapsed (3) Presence of succedaneous teeth (4)Sequence of the eruption of teeth (5)Factor of age (6)Oral musculature Space loss in mixed dentition

11. The assessment of spacing or crowding of teeth is frequently associated with measurements in mixed dentition stage because accurate and specific prediction of future dental development can be made at this stage. Commonly used mixed dentition analysis are- (1)Hays Nance analysis (2)Moyer’s analysis (3)Tanaka Johnston analysis (4) Huckaba Analysis Space analysis:-

12. “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”. or “It is a mechanical device that preserves the space after premature loss of primary teeth”. Space Maintainer

13. Preservation of primate space. Preservation of the integrity of the dental arches. Preservation of normal occlusal planes. In case of anteriors it should aid in esthetics & phonetics. Objectives

14. It should maintain the desired mesiodistal dimension of the space. Should not interfere with the vertical eruption of the adjacent teeth. Provide mesiodistal space opening when required. Should maintain individual functional movement of teeth. Should not endanger the remaining teeth by imposing excessive stresses on them. Should be easily cleaned & not serve as traps for debris. Ideal Requirements

15. According to hitchcock (1973) Removable, fixed or semifixed With bands or without bands Functional or non functional Active or passive Certain combinations of the above CLASSIFICATION

16. According to Raymond C. Thurow (1978) (1) Removable (2) Complete arch -Lingual arch -Extra oral anchorage (3) Individual tooth CLASSIFICATION

17. According to Hinrichsen (1962) (A) Fixed space maintainers Class –I (a) Non functional types - Bar type - Loop type (b) Functional types - Pontic type - Lingual arch type Class-II Cantilever type - Distal shoe - Band & Loop (B) Removable space maintainers Acrylic partial dentures CLASSIFICATION

18. According to Mathewson- 1.The Band & loop is used to maintain the loss of a single primary first or second molar. 2. The Nance holding arch maintains the maxillary arch length after the premature loss of more than one primary maxillary molar in the same quadrant or after a bilateral loss of primary molars. CLASSIFICATION

19. 3. The fixed lingual arch is used to maintain mandibular arch length and prevent mesial tipping & rotation of the permanent first molars. The fixed lingual arch prevents lingual tipping of the permanent incisors. 4. The intra alveolar (distal shoe) appliance is used to prevent mesial migration of the unerupted permanent first molar after premature loss of the primary second molar.

20. The premature loss of primary molars may require the placement of a space maintainer to prevent the migration of the adjacent teeth. When loss of a primary canine occurs, the dental arch midline may be compromised and the arch length also may be reduced. The premature loss of primary canines may therefore require the placement of a space maintaining appliance to prevent midline deviation and/or loss of arch length, perimeter and/or circumference. Indications

21. BAND AND LOOP It is a unilateral fixed appliance . Band is seated 1mm below the mesial & distal marginal ridges. Loop should parallel the edentulous ridge 1mm off the gingival tissue and should rest against the adjacent tooth at the contact point. The faciolingual dimension of the loop should be approx. 8mm. this dimension should allow the permanent teeth to erupt freely but not impinge on the buccal mucosa or tongue. Loop should not restrict any physiologic tooth movement, such as the increase in intercanine width that occurs during eruption of the permanent lateral incisor. PROFITT

22. BAND AND LOOP Indications: Premature loss of any primary first molar in the primary dentition or the primary maxillary first molar in transitional dentition. In these cases the root length of unerupted premolar is less than one third mature. Premature loss of primary second molar as the permanent first molar is erupting clinically.

23. Contraindications: An occlusion that is extremely crowded or already exhibits marked space loss. High dental caries activity Cases that need guidance of eruption; eg , sequential extraction GRABER BAND AND LOOP

24. BAND AND LOOP Advantages: Ease of fabrication for the clinician Ease of maintenance for the patient Adjusts easily to accommodate changing dentition.  Disadvantages: Opposing tooth may supererupt Does not restore chewing function Can’t preserve the leeway space

25. CROWN AND LOOP Indications : Loss of first primary molar with significant loss of tooth substance of the abutment tooth.

26. In this type of appliance both the abutment teeth adjacent to the edentulous space are banded. The distance between the abutment teeth is measured and marked on the wire. The wire is cut and soldered on to the bands. The band is cemented on to the abutment tooth. The soldered joint is polished and finished. GRABER BAND AND BAR

27. LINGUAL HOLDING ARCH It consists of two bands cemented on the first permanent molars or second deciduous molars, which are joined by steel wire butting against the four incisors. It helps in maintaining the arch perimeter by preventing the mesial drifting of the molar teeth and also lingual collapse of the anterior teeth.

28. LINGUAL HOLDING ARCH Indications: Loss of second primary molar in the mandible (counterpart to Nance)  Contraindication: Not used in primary dentition because it can interfere with permanent incisor eruption.

29. LINGUAL HOLDING ARCH Advantages: - Controls antero posterior movements along with controlling and preventing an arch perimeter distortion, by controlling the lingual collapse of single tooth or segments of arch. - Maintains the leeway space

30. Disadvantages: - First permanent molars may be susceptible to decalcification. - May be prone to breakage unless the patient is well-informed on maintenance LINGUAL HOLDING ARCH

31. TRANSPALATAL This appliance is designed to prevent the molars from rotating around the palatal roots, which is the first movement resulting in loss of space in the arch perimeter. Indications: When one side of the arch is intact and several teeth are missing on the other side. When primary molars are missing bilaterally.

32. NANCE PALATAL It is simply a maxillary lingual arch that does not contact the anterior teeth but approximates the anterior part of the palate. The palatal portion has an acrylic button that contacts the palatal tissue which provides resistance to the mesial movement of posterior teeth.

33. NANCE PALATAL Indications : Loss of second primary molar in the maxilla. Advantages : Maintains the tooth space and the leeway space  Disadvantages : Meticulous hygiene of the acrylic button is required

34. DISTAL SHOE Indications: Loss of second primary molar prior to eruption of the first permanent molar. Contraindications :   If several tooth are missing, abutments to support a cemented appliance may be absent. Certain medical conditions such as blood dyscrasias , immunosupression , congenital heart defects, history of rheumatic fever, diabetes.

35. DISTAL SHOE Primary Ist molar is banded & the loop extends to the former distal contact of the primary second molar. Piece of stainless steel is soldered to the distal end of the loop & placed 1mm below the mesial marginal ridge of the unerupted molar in the alveolar bone. This extension acts as a guide plane for the permanent Ist molar to erupt into proper position.

36. A radiograph of the appliance should be made prior to placement to determine whether the tissue extension is in proper relationship with the unerupted permanent molar. The depth of intragingival extension should be 1 to 1.5 mm below the mesial marginal ridge of the permanent molar. DISTAL SHOE

37. Advantages: Maintains the second primary molar space  Disadvantages : (1)Because of its cantilever design appliance can replace only a single tooth (2) Can’t restore occlusal function because of lack of strength. (3) Histologic examination shows that complete epitheliazation does not occur after placement of the appliance. PINKHAM DISTAL SHOE

38. REMOVABLE SPACE MAINTAINER Indications: When multiple teeth are lost and the space maintenance and mastication are of concern. In the anterior region premature loss have deleterious effect on the speech & aesthetics, thus replacement is required. In high risk caries child where oral hygiene maintainence is poor.

39. Advantages : Can maintain space as well as aid in mastication. It reproduces a desirable aesthetic appearance. It re-establishes function. It prevents abnormal speech and tongue habits. Disadvantages : Susceptible to fracture or loss Retention- Primary canines do not have large undercuts for clasp engagement. Compliance -children will not tolerate ill fitting appliance. PINKHAM REMOVABLE SPACE MAINTAINER

40. Before primary canine eruption -Space maintainence is required to prevent loss of arch space. This is done by fabricating a fixed appliance bilaterally anchored to the first primary molars including prosthetic teeth to replace the missing incisors. After primary canine eruption -This may result in the adjacent teeth tipping into the space available from the tooth loss but overall arch length and width remain unchanged. PREMATURE LOSS OF PRIMARY INCISOR-

41. If the loss is unilateral, there is often a shift in the position of the permanent incisors toward the side of the loss, creating a midline deviation. The extraction of the contralateral primary canine and the placement of a fixed lower lingual holding arch can prevent undesired drifting of the teeth from occuring midline deviation. PREMATURE LOSS OF PRIMARY CANINE-

42. PREMATURE LOSS OF Ist PRIMARY MOLAR Unilateral – Band and loop space maintainer. Bilateral- In primary dentition-Band & loop on both sides. In mixed dentition-lingual holding arch.

43. PREMATURE LOSS OF IInd PRIMARY MOLAR Unilateral- Band and loop Bilateral- In primary dentition-Band & loop on both sides In mixed dentition-Lingual holding arch

44. Loss of second primary molar before eruption of the first permanent molar Appliance of choice-Distal shoe appliance

45. MODIFICATIONS

46. Broken stress appliance- This appliance prevents intolerable loads from being thrust on the supporting teeth. This should be designed to allow vertical movement of the supporting teeth consistent with normal functional demands. GRABER BAND AND BAR

47. BAND AND BAR Fabrication- Stainless steel crowns are fitted on the prepared abutment teeth, a vertical tube is then soldered on one crown & L shaped bar is fabricated to fit the edentulous area. The bar is bent slightly to adjust for any interference. The horizontal end of the bar is soldered to another crown. The bar should be at proper occlusal height to prevent supereruption of opposing teeth.

48. MAYNE SPACE MAINTAINER It is a type of nonfunctional space maintainer that permits minor adjustments for space control while the tooth in question is erupting

49. GERBER SPACE MAINTAINER It can be used both as space maintainer and space regainer . It can be fabricated directly in the mouth and no lab work is required. Occlusal rest can be added to wire section to reduce cantilever effect. The steel ligature hold stored force in compressed spring.

50. Incorporation of Spurs (projections of wire)- They can be used as stoppers distal to anterior teeth to prevent their tipping or migration distally in the arch. These help in maintaining the symmetry in the arch in cases of unilateral tooth loss. LINGUAL HOLDING ARCH

51. Auxillary springs can be incorporated to bring about minor individual tooth movements. Lingual horizontal tube-This is used as the vertical tube on the uneffected side & it will provide a greater resistance to its movement than on the affected side. LINGUAL HOLDING ARCH

52. Habit breaking- If premature tooth loss is combined with habits like tongue thrusting ,spurs can be incorporated in the acrylic button to break the habit. NANCE PALATAL

53. Guidance of the eruption and development of the primary and permanent dentitions is an integral part of the care of paediatric patients. Such guidance should contribute to the development of a permanent dentition that is in a harmonious, functional and aesthetically acceptable occlusion.. CONCLUSION

54. Case Selection

55. Replacement is done for the following reasons- (a) Space maintenance (b) Function (c) Speech (d) Aesthetics Anterior segment-

56. Replacement is mainly done for the space maintainence because there are more chances of mesial drift in posteriors. Various factors which has to be taken into consideration are- Age of the patient Sex of the patient Status of occlusion Presence or absence of abnormal perioral muscle habit Posterior segment -

57. Mc Donald and Avery- space closure within 6 months Time elapsed since tooth loss

58. Maxillary>mandibular Amount of space loss

59. younger pt > space loss, Most immediate space loss-76 hrs, Breakspear –space loss after loss of Max. 1st molar:0.8mm, Mand . 1st molar:0.9mm, Max. 2nd molar:2.2mm, Mand . 2 molar: 1.7mm. Clinch and Healy- loss before eruption of permanent molar: 6.1 mm & After: 3.7 mm Rate of space closure

60. Rose JS- a)forward migration, b) rotation of teeth Direction of space closure

61. mesial shift-molars, distal tippin -canine Eruption status of the adjacent teeth

62. McDonald- 1mm of bone resorbs 4-5 months Amount of bone coverage over the tooth

63. Root completion Eruption status of the succedaneous tooth

64. last tooth erupted in oral cavity in normal eruption sequence Dental age of pt

65. Delayed eruption of permanent teeth

66. flat for deciduous dentition Curve of spee

67. Abnormal oral habits

68. Available space

69. SPACE ANALYSIS: A comparison of available arch length to predicted size of unerupted permanent canines and premolars (required arch length) at a given point in time. INDICATIONS OF MIXED DENTITION ANALYSIS 1. To determine need for space maintenance 2. To determine need for minor tooth movement 3. To aid in determining approach for minor tooth movement 4. To evaluate need for guided eruption procedures 5. To determine need for orthodontic referral: a.Comprehensive orthodontics b.Serial extraction ARCH-LENGTH ANALYSIS

70. 1.NANCE ANALYSIS. Leeway space of Nance: 1.7 mm per side in mandible = ( mesiodistal widths) primary canine and first and second primary molars - responding permanent teeth(3+4+5). Leeway space of Nance: 0.9 mm per side in maxilla. Seldom used, partly because is require a complete set of periapical radiographs. 2.MOYERS MIXED DENTITION ANALYSIS. In mouth & on casts, and for both arches. Based on correlation of tooth size; measure a tooth or a group of teeth and predict accurately size of other teeth in same mouth. The mandibular incisors measurement to predict size of upper, as well as lower, posterior teeth, using prediction table.

71. 3.TANAKA AND JOHNSTON ANALYSIS. Prediction table is not. sum of widths of mandibular permanent incisors divided by 2. For lower arch, 10.5 mm is added to result and, for upper arch, 11 mm is added to result to obtain the total estimated widths of the canines and premolars. Hixon and Oldfather method is more accurate 4.BOLTON ANALYSIS. (Sum mandibular)/(Sum maxillary) x 100 = Tooth mass ratio, For overall ratio (12 teeth versus 12 teeth), the mean is 91.3 (±1.91)%. For anterior ratio (6 teeth versus 6 teeth), the mean is 77.2 (±1.65)%. When significant discrepancy present, tooth mass is a problem solved by slenderization of anterior teeth or bonding to increase mesiodistal width of lateral incisors.

72. Treatment planning

73. Before primary canine eruption -Space maintainence is required to prevent loss of arch space. This is done by fabricating a fixed appliance bilaterally anchored to the first primary molars including prosthetic teeth to replace the missing incisors. After primary canine eruption -This may result in the adjacent teeth tipping into the space available from the tooth loss but overall arch length and width remain unchanged. PREMATURE LOSS OF PRIMARY INCISOR-

74. If the loss is unilateral, there is often a shift in the position of the permanent incisors toward the side of the loss, creating a midline deviation. The extraction of the contralateral primary canine and the placement of a fixed lower lingual holding arch can prevent undesired drifting of the teeth from occuring midline deviation. PREMATURE LOSS OF PRIMARY CANINE-

75. PREMATURE LOSS OF MANDIBULAR Ist PRIMARY MOLAR Unilateral – Band and loop space maintainer. Bilateral- In primary dentition-Band & loop on both sides. In mixed dentition-lingual holding arch. * distal shoe.

76. PREMATURE LOSS OF MANDIBULAR IInd PRIMARY MOLAR Unilateral- Band and loop Bilateral- In primary dentition-Band & loop on both sides In mixed dentition-Lingual holding arch * distal shoe.

77. Unilateral- Band and loop, transpaletal arch. Bilateral- In primary dentition-Band & loop on both sides, Nance palatal arch In mixed dentition-Nance palatal arch. * distal shoe. PREMATURE LOSS OF MAXILLARY Ist PRIMARY MOLAR

78. Unilateral- Band and loop, transpaletal arch. Bilateral- In primary dentition-Band & loop on both sides, Nance palatal arch In mixed dentition-Nance palatal arch. * distal shoe. PREMATURE LOSS OF MAXILLARY IInd PRIMARY MOLAR

79. Conclusion The best space maintainer is a well maintained primary tooth. But when these important natural space maintainers are lost, it is essential to implement a space management strategy. Appropriate space management therapy can save a child from esthetic and functional disfigurement and save a family from lot of financial expenditure in later orthodontic treatment costs. The dentist must review the variables and re-evaluate his decisions according to the dynamic development of the patient's dentition and plan accordingly.

80. “If you think every kid deserves good dental care, join the club.” Thank you..!