Basic Space Maintainers lecture one

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Basic Space Maintainerslecture one

• Prepared by
• Dr Seyed Ebrahim Jabbarifar Associate professor
• University of Isfahan Department of Pediatric
  Dentistry2009

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Basic Space Maintainers

• Are PASSIVE
• .036 wire is very heavy and should not be used to
  actively move teeth

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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

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Space Maintainers are Simple!

• Name the 4 most basic pediatric space maintainers

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Basic Space Maintainers

• NANCE (Transpalatal Arch with Acrylic
• Button Stop on Palate)
• LOWER LINGUAL HOLDING ARCH (LLHA)
• BAND/CROWN and LOOP
• DISTAL SHOE

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Distal Shoe

• MAXILLARY or MANDIBULAR
• Used when second primary molar requires
  extraction and first permanent molar has not
  erupted

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Distal Shoe

• Should be evaluated with radiograph prior to
  cementation
• Length
• Position
• Will be replaced with another space maintainer
  when permanent teeth erupt.

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Distal Shoe

• Example of use in partial eruption case.

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Nance Appliance

• MAXILLARY ONLY
• Bands on first permanent molars

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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

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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 (?)

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Lower Lingual Holding Arch

• MANDIBULAR ONLY
• Bands on first permanent molars
• Anterior Stop Cinguli of 23-26

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Lower Lingual Holding Arch

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

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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.

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LLHA Omega Loops

• Omega Loops in area of premolars allow slight
  adjustment to fit appliance
• Should not be used to activate appliance

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Appliance Activation Features

• Can be added by attaching light wire features
• This is beyond routine space maintenance

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Band/Crown and Loop

• MAXILLARY or MANDIBULAR
• Unilateral most typical
• Can be bilateral if permanent teeth are not
  present
• Single tooth span

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Crown and Loop

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

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What About Removable Appliances?

• Yes, they are possible, however..
• High failure rate due to breakage and loss
• Parent and patient compliance must be exceptional

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Which Space Maintainer?

• Distal Shoe 2nd Primary Molar Extraction with
  unerupted 1st Permanent Molar
• Nance or Band/Crown Loop Maxillary problem
  with 1st Permanent Molars present
• Lower Lingual Holding Arch Mandibular Problem
  with 1st Permanent Molars and Permanent Incisors
  present
• Band/Crown and Loop Primary 1st Molar
  Extraction

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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 1st premolar, making space maintainer defunct.

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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.

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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?

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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?

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Question 3

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

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Question 4

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

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Question 5

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

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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.

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How old is Ali assuming normal dental
development?
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Alis Bite Wings
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Mandibular Arch Only Chart Dentition on the
Odontogram
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Ali

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

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Ali

• A Moyers 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.

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Ali

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

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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.

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Ali Chart Maxillary Dentition Only on the
Odontogram
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Alis Bite Wings

• Chart any pathology or abnormal findings
  (including caries) for the maxillary arch only on
  the odontogram.

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Ali
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Ali

• A Moyers space analysis predicts 1.2 mm of
  space shortage in the maxilla
• Treatment plan and sequence appointments for the
  Maxillary Arch Only

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Ali
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Discussion
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Question 1

• 5 or 6 y.o. child. Tooth I extracted.

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Question 1

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

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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?

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Question 2

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

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Question 3

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

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Question 3

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

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Question 4

• Teeth K and L extracted

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Question 4

• Lower Lingual Holding Arch (LLHA) 19-30

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Question 5

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

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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.

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Assuming normal dental development, Ali is 8
years old.
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Ali

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

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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.

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Ali

• A Moyers 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.

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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

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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

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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.

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Ali
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Ali

• A Moyers space analysis predicts 1.2 mm of
  space shortage in the maxilla
• Treatment plan and sequence appointments for the
  Maxillary Arch Only

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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-DJ-abscess, 14-MO
• Note 6 and 11 very advanced root development.

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Ali
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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.

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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

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• Thank You!