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Management of Space in Pediatric Dentistry
Julie Maniate DMD, FRCD(C), ABPDNovember 15, 2008
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Etiology of Early Primary Tooth Loss
Extraction or destruction: – extensive caries or traumatic injury
Premature exfoliation: – abnormal root resorption (e.g. ectopic eruption)
– systemic disorders or hereditary syndromesHypophosphatasia Rickets AcrodyniaHistiocytosis X triad Leukemia CherubismJuvenile Periodontitis Dentinal dysplasiaCyclic neutropenia Papillon-Lefevre syndrome
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Functions of a Space Maintainer
Function: – prevent undesirable tooth mvmt following the premature
loss of a primary tooth• i.e. Mesial migration of posterior segments and lingual
collapse of anterior segments
Negative Tooth Mvmt: – Reduction or loss of space required by succeeding tooth– Considerable influence on dental dvlpt well into
adolescence and adult age
Functions of a Space Maintainer
1. Maintain space2. Prevent mvmt adjacent teeth3. Provide masticatory fx4. Prevent overeruption of opposing teeth
5. Improve esthetics6. Assist in speech (anterior segments)7. Aid in control of deleterious oral habits
Note: appliance must neither inhibit nor deflect normal growth changes
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Ideal Prerequisites of a Space Maintainer
1. Simple to construct and maintain
2. Durable, strong, stable
3. Passive
4. Easily cleanable and not enhance dental caries or soft tissue pathology
5. Readily adjustable for flexible application
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Factors to consider when planning a space
maintainer:Question: “When should a space maintainer be placed?”
General Rule: “Whenever the clinical situation will allow space loss
to encroach on the arch length needed for the unerupted permanent teeth, giving due consideration to the patients dental health, motivation, and occlusion status”.
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Factors to consider when planning a space
maintainer:1. Dental and periodontal condition
2. Arch length
3. Presence/absence of permanent successor
4. Time elapsed since loss of primary tooth
5. Status of first permanent molar eruption
6. Status of permanent successor’s development and eruption potential
7. Cooperation level of child and parents
8. Which tooth is lost, in which arch, at what time?
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A space maintainer may not be required if there is:
1. Existence of cuspal interference.2. Widely spaced primary dentition.3. If succeeding tooth is expected to erupt
within 6 months.
4. If present space is not adequate for the succeeding tooth.
5. The possibility of future orthodontic work.6. Where the opposing 6's are locked into a
desirable and stable relationship
Suggested that succeeding tooth will most likely erupt within 6
months if:
1. 75% of the root is present on the succeeding tooth.
2. Less than 1 mm of alveolar bone is covering succeeding tooth.
3. Destruction of the alveolar bone occurred when the primary tooth was lost.
4. Mixed-dentition is in its later stages.
Adverse Effects
1. Dislodged, broken, and lost appliances
2. Plaque accumulation
3. Caries
4. Interference with successor eruption
5. Undesirable tooth mvmt
6. Inhibition of alveolar growth
7. Soft tissue impingement
8. Pain
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Prior to obtaining the consent, parents should be informed that:
1. Space maintainer requires monitoring.2. Patient must maintain adequate OH.3. Appliance may break, requiring repair or replacement.
4. Broken appliances are hazardous to the child and will be ineffective.5. Even properly maintained appliances may fail to preserve the space.
It is necessary to obtain parental awareness and understanding related to space maintenance.
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Premature loss of anterior teeth?
1 Incisors: – no decrease in intracanine dimensions if loss after
eruption of canines– Need SM?: Not necessary
1 Canines: – common loss due to ectopic eruption of permanent
lateral incisors– Need SM?: consider LLHA with spur or elective
extraction of canine
Premature loss of posterior teeth?
Comprehensive evaluation:
determine if space maint. is indicated for:
a) First primary molar
b) Second primary molar
c) Multiple tooth loss
Priority: 2nd M > 1st M > Canine > Incisor
Classification and Types of Space Maintainer Appliances
Unilateral fixed:– Band & loop / Crown & loop– Distal shoe
Bilateral fixed– Lower lingual holding arch– Transpalatal arch– Nance appliance
Removable– Modifications of Hawley retainer design
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Premature loss of posterior teeth: 1st Primary Molar
Little/no space loss prior to eruption of 1st PM
Need SM if: in full primary dentition or approximating eruption of 1st PM
No SM if: after 1st PM have erupted
Following appliances are indicated:
a) Band and loop
b) SSC and loop
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Premature loss of posterior teeth: 2nd Primary Molar
Max molar: M tipping, bodily mvmt, MB rotation around palatal root
Mand molar: M and lingual tipping, slight bodliy mvmt; also retroclination of anterior teeth
Following appliances are indicated:a) Lingual arch/TPA/Nanceb) Band & loopc) Distal shoe appliance - prior to eruption of 1st PM
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Premature loss of posterior teeth: Multiple Teeth
Following appliances are indicated:a) Transpalatal arch
b) Nance appliance
c) Lingual arch
d) Removable
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SM: Band and LoopIndications
1. Loss of primary molarprior/during period of eruption of 1st perm M.
2. Anywhere in posteriorfollowing a time lapse b/w loss of tooth and eruption of its permanent successor.
3. Loss of 2 post teeth or bilateral situations
rarely used
SM: Band and LoopAdvantages
1. Easy to construct.
2. Inexpensive.
3. Easily adjusted.
4. Allows eruption of permanent tooth.
5. Non invasive.
6. Painless.
SM: Band and LoopDisadvantages
1. Masticatory function.Not restored
2. Extrusion of opposing dentition.Not prevented
3. Normal distal mvmt of primary cuspids during eruption of perm lateral incisor
Not allowed if placed for the early loss of mand 1st primary molar
SM: Band and LoopConstruction
Band: stainless steel material 0.005 inches in thickness
Crib: portion of the wire spanning the edentulous space
Loop: portion of the wire contacting the abutting tooth 0.032 inches in diameter
SM: Lingual ArchIndications
1. Premature loss of primary posterior teeth.
2. Base for aesthetic restoration in loss of anterior teeth.
3. Used as a base for habit appliance.
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SM: Lingual ArchAdvantages
Disadvantages1. Maintains est. arch form.
2. Allows eruption of perm teeth w/o interference.
3. Not easily displaced.
4. Ease of cleaning for proper OH.
5. Can be modified easily to serve in many situations.
6. Patient comfort.
1. Does not prevent extrusion of opposing teeth.
2. Not advisable to band teeth which are:
• Hypoplastic• Hypocalcified• Highly prone to caries.
3. Can promote decay in non-compliant patients.
SM: Fixed Lingual ArchConstruction
Band: Stainless steel material 0.005 inches in thickness (ortho bands)
Lingual arch wire: Stainless steel round wire 0.036 inches in thickness
SM: Nance Appliance Maxillary arch: multiple
tooth lossIndications:
The same as for fixed lingual archConstruction:
Bands: Stainless steel material 0.005 inches in thicknessPalatal wire: Stainless steel round wire 0.036 inches in thickness
What would you do?
G.T. age 5 after the removal of a necrotic #85
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What would you do?
N.S. age 7 requires extraction of tooth #75.
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What would you do?
P.G. age 8 requires pulp treatment and stainless steel crown restorations for teeth #54 and #55
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What would you do?
M.M. age 8 is scheduled for a recall visit.
Thank You