space management.ppt

space management.-Dr.Anoop Harris

1. Space Management
Anoop Harris

2. Space management or maintainence is aimed
at preserving the space required for the
eruption and alignment of permanent dentition.
Premature loss of primary teeth, is one of the
most common controllable causes of
malocclusion.

5. •Orthodontics
Preventive
Interceptive
Corrective

6. •Space Maintenance:
–CoinedbyJCBrauerin1941
–Definedasatheprocessofmaintainingaspaceina
givenarchpreviouslyoccupiedbyatoothoragroup
ofteeth
•Space Maintainer:
–AccordingtoBoucheritisafixedorremovable
appliancedesignedtopreservethespacecreatedby
theprematurelossofaprimarytoothorgroupofteeth

7. •Objectives of space Maintenance
Preservation of primate space
Preservation of intergrity of dental arches
Preservation of normal occlusal plane
In case of anterior, it should aid in esthetics and
phonetics

8. •CAUSES OF SPACE LOSS:
Prematurelossofprimaryteeth.
Unrestoredproximalcariouslesion.
Lossofpermanentincisorsduetotrauma.
Congenitallymissingteeth.
Ectopiceruptionofpermanentteeth.
Dentalmalformations-pegshapedlaterals.

9. •Changes seen after premature loss of teeth
Anterior Segment
Primary canine area:
main reason erupting lateral incisors
If unilateral –midline shift due to migration of incisors
Lingual tipping of permanent incisors by force of orbicularis
oris and associated muscles
Best to remove opposite primary cuspid to permit the
permanent incisors to tip towards a symmetrical
arrangement

10. •Primary incisor area:
–ECC or traumatic injuries
–If normal to age of exfoliation no need of space
maintainer
–If not, space maintainer given for speech
development,esthetics and prevention of social
trauma for child

11. Buccal Segment:
First Primary Molar area:
abnormalhightonguepositioncoupledwithstrong
mentalistandbuccinatormuscleswillresultincollapse
oflowerdentalarchanddistaldriftingofanterior
segment
Mesialdriftingofsecondprimarymolarand1
st
permanentmolar
Potentialforspacelossgreaterduringeruptionoffirst
permanentmolar

12. •Second deciduous molar:
–By mesial drifting of first permanent molar
–Chance for space loss greater as they serve
as buttress for eruption of permanent molars

13. Indications
•Space after premature loss of deciduous teeth shows
signs of closing
•Use of space maintainer will aid in or make the future
orthodontic treatment less complicated
•When space for permanent tooth should be maintained
for 2 years or longer
•To avoid supra eruption of teeth from opposing arch

14. Contraindications
•If signs that succedaneous tooth will erupt soon
•If 2/3
rd
of the root development of succedaneous
teeth is complete
•Space left by primary tooth is greater than the
space needed for the permanent successor
•Space showing no signs of closing

15. Requirements
•Should maintain the entire space created by the
lost tooth
•Prevent supra eruption of opposing tooth
•It should be simple in construction
•Should be strong enough to withstand occlusal
forces
•Should permit maintenance of oral hygiene
•Must not restrict the growth of jaws
•Should not exert undue forces of its own

16. Classification
•According to Hitchcock:
–Removable or fixed or semifixed
–With bands or without bands
–Active or passive
–Functional or non functional
–Certain combinations of the above

17. •According to Raymond C Thurow:
–Removable
–Complete arch
–Individual tooth

18. •According to Hinrichsen:
–Fixed space maintainers
Class I Class II
–Non functional types Cantilever type
»Bar type distal shoe
»Loop type
–Functional types
»Pontic types
»Lingual arch type
–Removable Space maintainers
•Acrylic partial dentures

19. •According to the anchorage and support:
–semi fixed type space maintainer
•Band and loop
•Crown –loop
•Crown distal shoe
–Fixed type space maintainer
•Lingual –holding arch
•Nance holding arch
–Acrylic partial denture
•Acrylic partial denture
•Complete denture

20. Factors to be considered before
planning a Space Maintainer
1.Incidence of tooth loss
All cases of early primary molar loss show some
decrease in arch length
Can be due to mesial migration of molars or
distal migration of anteriors

21. 2. Time elapsed since loss
most of space loss usually takes place
during first 6 months
More in maxillary arch than in mandibular
So insert as soon as extraction is over..

22. 3. Stage of development/dental age of the patient
More likely to occur if tooth actively erupting to the area
left by premature loss of primary tooth
Most influenced by the first permanent molar. Very high
during active stage of eruption
Less if molars are erupted and into occlusion
If first primary molars lost and permanent lateral is in
active stage of eruption:
Shift of primary canine distally resulting in midline
shift
In mandibular arch lingual collapse of anterior
segment with a resulting increased overbite

23. 4. Amount of space closure
Loss of maxillary second molars result in
greatest amount of closure( 8mm in a quadrant)
loss of mandibular second primary molars
shows the next greatest amount (4mm/quadrant)
Loss of upper and lower first primary molars,
space loss almost equal but influenced by the
timing of loss

24. Loss of second primary molars will result
in significant space loss even after first
permanent molars have erupted into
occlusion
Loss of first primary molar with retention of
second primary molar shows less space
loss as second primary molar will act as a
buttress

25. 5.Directionofclosure:
Max:posteriorspacespredominantlybymesial
bodilymovementsandmesiolingualrotation
aroundthepalatalrootoffirstpermanentmolars
Mand:spacesbymesialtippingoffirstpermanent
molarsalongwithdistalmovementand
retroclinationofteethanteriortothespace

26. 6. Eruption timing of Permanent Successors:
Teeth normally erupts when 3/4
th
root is complete
Loss of primary molar before 7 years of age leads to
delayed emergence
Loss after 7 years leads to early emergence
If primary molar lost at 4 years –delayed upto 1 year
Loss occurs at 6 years –delay of 6 months
Loss within 6 –12 months of exfoliation –early eruption
If any delay in eruption of teeth even after tooth
formation is complete –extract the primary and keep a
space maintainer

27. 7.Amount of bone covering unerupted tooth
If bone covering erupting tooth destroyed by
infection, will erupt faster
If bone covering is thick eruption will be delayed
Guide: premolars require 4 –6 months to travel
through 1 mm of bone

28. 8. Abnormal oral musculature:
Strongmentalismusclepatternmaycollapseof
archbydistaldriftingofanteriorsegmentin
mandibulararch
thumborfingerhabitsmayproduceabnormal
forcesresultingincollapseofdentalarchesif
thereisprematurelossofteeth

29. •9. Sequence of eruption of teeth
the dentist should observe the relationship
of developing & erupting teeth adjacent to
thespace created by the untimely loss of a
tooth.
-

30. 10. Congenital absence of permanent tooth:
If succedaneous teeth absent
Can hold the space for future prosthesis

31. Removable Space Maintainers
•That can be removed and reinserted into the
oral cavity by the patients
•Classification (Brauer)
–Class 1: Unilateral maxillary posterior
–Class 2: Unilateral Mandibular Posterior
–Class 3: Bilateral maxillary posterior
–Class 4: Bilateral Mandibular Posterior
–Class 5: Bilateral Maxillary ant/post
–Class 6: Bilateral Mandibular ant/post
–Class 7: One or more primary or perm: of anterior
–Class 8: complete primary

32. •Indications:
–Esthetics is of importance
–Abutment teeth cannot support a fixed appl:
–Cleft palate patient
–Perm: teeth not fully erupted for adaptation of
bands
–Multiple loss of deciduous teeth

33. •Contraindications:
–Lack of patient cooperation
–Child below 3 years
–Patients allergic to acrylic materials
–Epileptic patients
–High caries activity

34. •Advantages:
–Easy to clean and permit maintance of proper oral
hygiene
–Restore vertical dimension
–Help in mastication
–Stimulate eruption of underlying tooth
–Alterations can be made
–Elaborate skills not needed

35. •Disadvantages:
–Cannot be used in uncooperative patients
–Patient may not wear them
–Lateral jaw growth can be hampered
–Can cause irritation and allergy to underlying
tissues

36. Fixed space maintainers
For Maxillary
Band and Loop
Nance Palatal arch
Trans palatal arch
For Mandibular
Band and Loop
Lingual Arch
Distal Shoe Space Maintainer

37. Band and Loop
Unilateral/bilateral,nonfunctional,passive,fixed
applianceindicatedforspacemaintaincein
posteriorsegment

38. •Indications:
Preserving space created by premature loss of single
primary molar
Bilateral loss of single primary molar before eruption of
permanent incisors in mandibular arch

39. •Design:
band in the abutment tooth
Loop
Arms of the loop should be placed at the junction of middle and cervical
third, not interfering with occlusion
Contour should be similar and as close as possible to gingival contour
Width of the loop enough to allow the eruption of succedaeneous tooth

40. •Advantages:
–Construction is easy
–Few appoinments
–Modifications possible
•Disadvantages:
–Cannot stabilize the arch
–Non-Functional
–Slippage of loop by masticatory forces

41. •Modifications:
–Crown and loop
–Crown band and loop
–Meyne’s space maintainer:
–Reverse band and loop
–Band and Bar
–Long Band and Loop

42. Lingual Arch
•Bilateral, non functional, active/passive mandibular fixed
appliance.
•Helps in maintaining the arch perimeter by preventing
the mesial drifting and lingual movement of molar teeth
and also lingual collapse of anterior teeth

43. •Indications:
–Unilateral/bilateral space maintance created
by multiple loss of tooth
–Unilateral/bilateral loss of primary molars after
eruption of lower incisors
–minor space regaining.

44. •Design:
Bands are adapted
Arch wire should contact the erupted permanent incisors at the
cingulum
Arch wire should be located 2mm below the gingival margin in
the posterior region to prevent distortion
Should be located 1-2 mm lingual to the posterior teeth for
erupting premolars

45. •Contraindication:
–Should not be given before the eruption of permanent
incisors
•Modifications
–Hotz lingual arch
–Removable lingual arch
–Omega bends in canine region

46. Distal shoe space maintainer
•Intra alveolar appliance
•Eruption guidance appliance

47. •Indication:
–When SECOND PRIMARY MOLAR lost
before the eruption of FIRST PERMANENT
MOLAR
•Contraindication:
–Poor oral hygiene
–Medically compromised patients
–Congenitally missing permanent first molar..

48. •Banding or crown irt to first primary molar
•How to determine the length of the distal
extension??
–If primary second molar is present easy to detemine
the length
–If not has to calculate from IOPA and cast..(distal
surface of primary molar and mesial surface of
permanent molar)

49. •Depth of the gingival extension?
–If too long possible harm to developing second
premolar
–If too short molar will erupt underneath it..
–Gingival extension should be 1 mm below the mesial
margin of first permanent molar

50. •Advantages:
–Only space maintainer which can be used if there is
premature loss of second primary molar before the
eruption of first permanent molar
•Disadvantages:
–Can cause deviation of permanent tooth bud
–Interfere with epithelization of socket
–Can cause infection
–May permit tipping if not properly placed
–Construction is difficult

51. Nance Palatal Arch
•Bilateral, non functional, passive, maxillary fixed
appliance
•Approximates the anterior palate via an acrylic button
that contacts the palatal tissue which provides resistance
to the anterior movement of posterior teeth in a
horizontal direction

52. •Design:
–Bands in the posterior most tooth
–Arch wire should extend along the palatal surface of the alveolar
ridge (2mm) to the opposite teeth
–At rugae a small ‘U’ shaped bend should be incorporated which
is 1 –2 mm away from tissue
–An acrylic button is placed usually on the descending portion of
palatal vault 1 –2 mm below the incisive papilla.

53. •Indications:
–Bilateral space maintance in maxillary arch
•Advantages:
–Arch Stabilizing
•Disadvantages:
–May cause tissue hyperplasia
–Irritation to palatal tissues
–Cannot be used in patients allergic to acrylic

54. •Modification:
–Hollywood bridge

55. Trans palatal Arch
•Unilateral, non functional, passive, maxillary
fixed appliance
•Indications:
–Unilateral space maintainance
–In arch expansion
–Prevents molars from rotation

56. •Banding of posterior most tooth in both sides
•Arch wire should run across the palate without
touching the soft tissues
•An ‘U’ shaped bend given in the middle of the
palate

57. •Advantages:
–Unilateral space loss
–Can be used for expansion
•Disadvantages
–Both molars may tip together

58. Space Regainer
•Radiographs and Study Models
•Mixed Dentition Analysis
•Anchorage Considerations

59. Removable Space Regainers
•Free end loop Space regainer:
–Labial arch wire for stability and retention
–Back action loop spring constructed of
No:0.025 wire
–Movement of permanent molar achived by
activating the free end of the wire loop at
specific intervals of time

60. •Split Saddle Space maintainer
•Functional part of the appliance consist an acrylic block
that is split buccolingually and joined by No: 0.025 wire
in the form of a buccal and lingual loop
•the appliance is activated by periodic spreading of loops

61. •Sling Shot Space Regainer:
•Consists of wire elastic holder with hooks
instead of wire that transmits a force to the molar
to be distalized
•Hooks placed adjacent to developmental groove
on the lingual aspect
•Distal to developmental groove on buccal aspect
•Elastics changed everyday

62. •Jack Screw type
•By incorporating an expansion screw in
the edentulous space.

63. Fixed Space Regainers
•Open coil space regainer
•Band is adapted
•Molar tubes soldered
•Stainless steel wire selected and bend into a ‘ U’ shape
contacting the first premolar at its greatest distal
convexity
•A stop placed in the both arms 1-2 mm from the
premolar
•Space calculated and a spaced coil spring is cut 2-3 mm
more than the desired space and is compressed and
placed in the wire
•Cemented and review every 3 weeks

64. •Gerber Space regainer
•Construction same as open coil space
regainer
•Arm welded or soldered to the bands
•The arm should follow the gingival countor
•Push coil spring is used

65. •Hotz Lingual Arch:
•Used when first molar has shifted mesially
and no distal shifting of premolars
•Space should be present between the first
and second molars
•Should contact all the tooth for better
anchorage

66. •Lip Bumper or Plumber
•Used mainly for bilateral space regaining
•Consists of an heavy labial arch wire over which an
acrylic flange is prepared in the anterior region
•Helps to relieve the lip pressure
•By incorporating loops in the arch wire just before it
enters the buccal tube
•Utilizing a coil spring

67. •Sectional Arch Technique
•Upto 4 mm space can be regained..

68. •Conclusion
–Space management definitions
–Factors to be considered in planning for a
space maintainer
–Fixed space maintainers
–Space regainers