MANAGING THE ARCH CIRCUMFERENCE

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MANAGING THE ARCH CIRCUMFERENCE

• Fabricating Appliances

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Prudent Office Practice

• As fabrication of space management appliances
  will not be a daily routine (or likely even a
  weekly one) in the office of a general
  practitioner, and since such is not an efficient
  use of a practitioners time, it is advisable to
  delegate the fabrication of appliances to a
  commercial laboratory.
• Alternatively, a generalist might utilize the
  services of the laboratory support staff of a
  local pediatric dentist or orthodontist, assuming
  they have in-office staff trained to perform
  such functions. Of course, expect a fee to
  assessed! (Maybe if you are a good and frequent
  referred, they might forgo the fee!)

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Commercial Laboratory Services

• SPACE MAINTAINER LABORATORIES
• Box 91409
• Van Nuys, California 91409
• 1.800.423.3270
• www.smldent.com
• ODONT LABORATORIES
• Box 3636
• Fenton, Missouri 63026
• 1.800.325.3698
• www.ordont.com

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Utilizing Laboratory Services

• When using a commercial laboratory, a written
  prescription should accompany your working cast
  specifying how you wish the appliance to be
  fabricated.
• It is essential that you adapt bands and secure a
  working cast with bands in place before sending
  to the laboratory for fabrication!
• Commercial laboratories will advertise that you
  will just need to sent the childs casts and they
  will adapt the bands to the cast and fabricate
  the appliance. As bands cannot effectively be
  adapted to a stone cast, this practice results in
  a very unsatisfactory space management appliance.

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Learning Intention

• While an objective is for you to be able to
  fabricate the basic space management appliances
  used, should it be necessary for you to do so it
  is not an intention to ensure that you are
  competent to do so.
• Therefore, we will review briefly the basic
  technique for constructing a band and loop space
  maintainer the basic technique for its
  fabrication also applies to the lingual and
  palatal (Nance) arch.
• However, we will focus on the details of
  fabricating a intra-alveolar (distal shoe) space
  maintainer, as it is constructed chairside and
  intra-orally, and is not a laboratory procedure.

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Structural Requirements for Space Maintaining
Appliances

• They should effectively maintain the dimensions
  for which they were designed.
• They should be passive in nature and should not
  cause movement of teeth.
• They should not interfere with the eruption of
  teeth.
• They should be sufficiently sturdy as as not to
  be distorted under masticatory stress.

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Band and Loop Armamentarium

• Stainless Steel Wire .036
• Pliers Bird Beak and Three Prong
• Universal Soldering Torch
• Silver solder and soldering flux
• Caulking putty (Mortite)
• Polishing Materials Green stone, Robinson wheel,
  Tru-chrome polish, rag wheel, rouge
• Cement

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Band and Loop Design the Wire

• On the cast draw the position of the loop running
  from the middle third of the band to the distal
  surface of the canine, contacting it at the
  gingival margin.
• The loop should be wide enough for the premolar
  tooth to erupt through it.
• During the eruption of the permanent lateral
  incisors there is a physiologic movement of the
  primary canine distal-buccally. The contour of
  the loop along the distal surface of the canine
  should should permit this movement by being bent
  to slope toward the distal as it approaches the
  buccal.

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Band and Loop Bend the Wire

• Using the pliers, bend a 3 length of .036 wire
  into a loop.
• Measure the initial length by placing the end of
  the wire even with the distal of the band of the
  molar.
• Mark on the wire with a soft pencil the
  point which corresponds to the distal surface
  of the canine.

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Band and Loop Bend the Wire

• For the first bend, place the round beak of the
  bird-beak pliers on the top of the pencil
  marking.
• Holding the wire firmly, bend the wire over the
  square edge edge with thumb pressure.

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Bird Beak Pliers
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Band and Loop Bend the Wire

• Return the wire to the buccal side of the cast.
• Place the bent wire against the distal surface
  of the canine.
• Place a pencil mark on the wire approximately 2
  mm buccally from the lingual surface.

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Band and Loop Bend the Wire

• For the second bend, place the round beak of the
  bird-beak pliers on top of the pencil mark and
  bend.
• If the wire extends beyond the distal surface of
  the molar, remove the excess with wire cutters.

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Band and Loop Bend the Wire

• Now place the single prong of the three prong
  pliers on the outside of the horizontal wire
  with the double beaks on the inside.
• Hold the ends of the wire with forefinger and
  thumb.
• The purpose of this bend is to contour the loop
  to the distal surface of the anterior abutment.
• Alter the slope to provide for the distal-buccal
  migration of the primary canine!

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Three Prong Pliers
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Band and Loop Bend the Wire

• With the three prong pliers contour the wire
  to the alveolar ridge the bucco-lingual
  dimension.

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Band and Loop Bend the Wire

• Using the three prong pliers, contour the
  wire to conform to the lateral aspects of the
  ridge

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Band and Loop Bend the Wire

• Bend the wire so that the wire contacts the band
  for a distance of 2-4 mm on its buccal and
  lingual aspects.
• The wire should terminate just distal to the
  center of the band

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Band and Loop Soldering

• Secure the wire loop to the cast with caulking
  putty (Mortite) over the anterior part of the
  loop.

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Band and Loop Soldering

• Grind out the stone inside the band on the buccal
  and lingual sides in the area of the solder
  joint, if it was not blocked out with cellulose
  ring liner when pouring the working cast.
• Creating an air space at the solder joint allows
  the band and wire to heat rapidly and the solder
  to flow quickly thus minimizing overheating of
  the wire with subsequent loss of its physical
  properties.

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Band and Loop Soldering

• Adjust the soldering torch flame so that it forms
  a blue cone with no yellow.
• The cast should be placed on a heat-resistant
  block and tilted for easy access.
• Sparingly apply flux to the band and wire and
  heat until it dries and then liquefies.
• While the wire is still hot, place a piece of
  silver bar solder at the point of contact between
  the band and the wire.
• Heat it until tit melts and flows around the
  wire. The minimum amount of solder which will
  flow around the wire should be used.
• If the solder does not flow into the joint, the
  surfaces might have been oxidized or dirty they
  must be cleaned and the flux reapplied.

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Band and Loop Soldering

• If the wire is properly soldered, the
  following criteria will have been met
• The solder encircles the wire.
• The solder is confined to the middle third of the
  band and does not extend to the margins.
• The surface of the solder is not pitted with
  voids.

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Band and Loop Soldering

• Immerse the warm cast in water and carefully cut
  away the stone from around the band and loop with
  a plaster knife, and remove the appliance.
• Scrape away any remaining stone from inside the
  band.

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Band and Loop Polishing

• Cut the distal ends of the wire at the solder
  joint.
• Remove excess solder and contour the soldered
  joint with a green stone.
• Smooth the surfaces and eliminate gross scratches
  with a rubber wheel.
• Tu-chrome polish (or Tripoli) is employed on a
  Robinson wheel brush as an intermediate polish.
• Final polish is accomplished with rough on a rag
  wheel.
• The band and loop is then washed clean and dried,
  and is ready to cement.

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Band and Loop Cementation

• Seat the appliance in the mouth and check to
  ensure that
• the band fits tightly and as originally.
• the appliance is passive.
• the wire does not impinge on soft tissue.
• there are no occlusal interferences.

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Band and Loop Cementation

• Remove any plaque that may be present on the
  tooth.
• Isolate the tooth with cotton rolls and dry.
• A thick, creamy mix of cement is prepared
  according to the manufacturers instructions.
• The appliance is placed in the mouth and seated
  to place.
• The band seater and band pusher are used as
  previously to set the band and burnish the
  margins.
• After the cement has set, remove the excess with
  an appropriate instrument.
• Dental floss (with a knot tied in it) is used to
  remove any excess cement interproximally.

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Lingual Arch

• Steps in fabricating a lingual arch are
  essentially the same as those for a band and
  loop.
• The primary differences are in the design and
  bending of the wire.

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Lingual Arch

• On the cast, draw the position of the lingual
  arch wire, extending from the middle third of the
  molar bands, along the gingival third of the
  primary molars, forward to and across the cingula
  of the incisors, slightly above the gingival
  papillae.
• The line is obviously interrupted when a primary
  molar is missing.
• Drawing the line on the case facilitates proper
  wire adaptation.

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Lingual Arch

• With the thumbs, fingers and pliers, shape a
  length of .036 stainless steel wire into a
  U-shape.
• Begin in the middle of the wire and bend it so
  that it contacts the cingula of the incisors
  slightly above the gingival papillae, contacts
  the gingival third of the primary molars and
  extends posteriorly to rest passively on and
  parallel to the middle third of the molar bands
  with approximately 1m,m of excess wire extending
  distal to the molars.
• Three prong and bird-beak pliers are used to bend
  the wire there should be not sharp bends.

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Lingual Arch

• The lingual arch is secured to the working cast,
  soldered, removed from the cast, polished, and
  cemented as the band and loop.
• Criteria for clinical success are the same as for
  the band and loop.

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Palatal (Nance) Arch

• The palatal arch is fabricated similarly to the
  band and loop and lingual arch.
• On the cast draw the position of the palatal
  wire. Draw a U-shaped line from the lingual of
  the molar bands to the junction of the horizontal
  and vertical components of the hard palate.
• Positioning the anterior portion of the appliance
  in the rugae area eliminates interference from
  the mandibular teeth.
• Use the thumb, fingers, and pliers, as with the
  lingual arch to contour a .036 round stainless
  steel wore to the design on the cast.
• The wire should be adapted to passively touch the
  molar bands.

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Palatal (Nance) Arch

• After soldering, place a layer of separating
  medium on the cast in the rugae area with a
  brush, where the acrylic button is projected to
  be placed.
• Use quick cure acrylic (squeeze bottle for powder
  and dropper for liquid), and construct a button
  of acrylic approximately 12-1.5 cm in diameter
  and 3 mm thick, surrounding the anterior portion
  of the wire.
• The acrylic prevents the arch wire from becoming
  embedded in the soft tissue.

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Palatal (Nance) Arch

• The palatal (Nance) arch is removed from the
  cast, polished, and cemented as the band and
  loop, and lingual arch.
• Criteria for clinical success are the same as for
  the band and loop, and lingual arch.

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Removable Acrylic Appliance

• Denture base is made of acrylic resin, providing
  a means for fixation of the retainers and
  artificial teeth.
• It should be approximately 2-3 mm thick to have
  sufficient strength to meet functional demands
  and so that the retention clasps embedded in the
  denture base will be covered.

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Removable Acrylic Appliance

• Retainers (clasps) are used to provide for
  retention of the denture base and to complement
  the tissue support it receives from the soft
  tissues.
• Retainers used in appliances for children are
  usually made of stainless steel wire and .028 in
  diameter.
• Common retainers are the Adams clasp, ball clasp
  and circumferential clasp.

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Removable Acrylic Appliance

• Maxillary and mandibular alginate impressions are
  obtained, centric occlusion registered, and cast
  recovered.
• The casts may be sent to a commercial laboratory
  with an appropriate prescription specifying the
  design requirements.
• If desired, the appliance can be fabricated by
  the practitioner.
• Basic principles of removable prosthodontics
  should be employed they will not be elaborated
  on here.
• Primary teeth may be purchased from Space
  Maintainers Laboratory, identified previously.

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Distal Shoe Armamentarium

• Unitek Primary First Molar Crowns
• Unitek Space Maintainer Tubes, Wide, 385-003
• Unitek Distal Shoes, Wide, 381-003
• Unitek Tube Crimping Pliers, 800-419
• Spot Welder

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Distal Shoe Band Adaptation

• Preformed bands are not manufactured for first
  primary molars, the tooth to be banded in the
  case of the distal shoe, therefore one must be
  made.
• The easiest and most effective way to accomplish
  this is to select a first primary molar stainless
  steel crown that fits over the tooth, and then
  cut out the occlusal surface with an old carbide
  bur.
• The band is then seated and adapted as
  discussed previously.

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Distal Shoe Bracket Placement

• The Unitek space maintainer tube (female portion)
  is spot welded to the distal of the band in such
  a fashion that the bracket is centered on the
  distal surfaced of the band, 1 mm above the
  gingival margin.
• The assembly is tried-in to evaluate the
  placement of the bracket.
• If the bracket is appropriately located it is
  soldered to the band.

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Distal Shoe Unit Assembly

• Determine the position of the unerupted tooth
  from a bite-wing radiograph.
• Assemble the unit by sliding the distal shoe
  segment into the bracket tubes the desired amount
  in order to engage the mesial surface of the
  unerupted molar.
• Make light crimps to the tubes with the pliers to
  limit movement during try in this will hold the
  unit but allow for required adjustments.

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Distal Shoe Preliminary Insertion

• Seat the unit and press the distal shoe into the
  alveolus.
• Check that the unit is not in hyper-occlusion.
  Bitewing radiographs are obtained to demonstrate
  that the distal shoe contact the occlusal third
  of the mesial surface of the unerupted first
  molar.

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Distal Shoe Soldering

• When judged satisfactory, both sides of the
  tube are crimped securely with the tube crimping
  pliers, and spot welded and/or soldered, fixing
  the male and female sections at the appropriate
  length.

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Distal Shoe Cementation

• The distal shoe is cemented to place as
  previously described for the band and loop.
• Criteria for clinical success are the same as
  previously described.

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Distal Shoe Timing of Insertion

• Ideally the distal shoe space maintainer is
  placed at the same time as the required
  extraction of the second primary molar.
• If the second primary molar was extracted
  previously then then a small slit must be made
  with a scalpel on the alveolar ridge in the area
  of the projected insertion point for the distal
  shoe thus allowing for the insertion of the shoe
  through the soft tissue.

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