Concepts in Space Management

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					Basic Space Maintainers
      lecture one
                  Prepared by:
   Dr Seyed Ebrahim Jabbarifar Associate
                    professor
 University of Isfahan Department of Pediatric
                  Dentistry2009
    Basic Space Maintainers


• Are PASSIVE

  – .036 wire is very heavy and should not be
    used to actively move teeth
     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
Space Maintainers are
      Simple!
 Name the 4 most basic pediatric
       space maintainers
    Basic Space Maintainers
• NANCE (Transpalatal Arch with Acrylic
         Button Stop on Palate)
• LOWER LINGUAL HOLDING ARCH
  (LLHA)

• BAND/CROWN and LOOP

• DISTAL SHOE
               Distal Shoe
• MAXILLARY or
  MANDIBULAR

• Used when second
  primary molar
  requires extraction
  and first permanent
  molar has not erupted
                  Distal Shoe
• Should be evaluated with
  radiograph prior to
  cementation
   – Length
   – Position


• Will be replaced with
  another space maintainer
  when permanent teeth
  erupt.
                 Distal Shoe

• Example of use in
  partial eruption case.
           Nance Appliance


• MAXILLARY ONLY

• Bands on first
  permanent molars
           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
  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 (?)
   Lower Lingual Holding Arch


• MANDIBULAR
  ONLY
• Bands on first
  permanent molars
• Anterior Stop =
  Cinguli of #23-#26
   Lower Lingual Holding Arch


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


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

• Can be added by
  attaching light wire
  features

• This is beyond routine
  space maintenance
        Band/Crown and Loop

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

• Stronger than band
  and loop
• Cementation failure or
  loss less likely

• Excellent choice if
  tooth needs a
  restoration
         What About Removable
              Appliances?




• Yes, they are possible, however………..
• High failure rate due to breakage and loss
• Parent and patient compliance must be exceptional
     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
      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.
 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.
                 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?
                    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?
                   Question 3




• Which teeth were extracted? How old is the patient?
• What is the appropriate space maintainer?
• When can the space maintainer be removed?
                Question 4




• Which teeth were extracted/
• What is the appropriate space maintainer?
                  Question 5




• Which teeth have been extracted? How old is the child?
• What is the most appropriate space maintenance?
            “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.”
How old is Ali assuming normal
    dental development?
Ali’s Bite Wings
Mandibular Arch Only: Chart
Dentition on the Odontogram
                    Ali
• Mandibular Arch Only : Chart
  abnormalities and pathology (including
  caries ) from the Panorex and Bite Wing
  Radiographs
                   Ali

 A Moyer’s 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.
                   Ali
• Assuming normal dental development, at
  what age will the space maintainer you
  placed no longer be needed?
                “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.”
Ali: Chart Maxillary Dentition Only
       on the Odontogram
             Ali’s Bite Wings




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

 A Moyer’s space analysis predicts 1.2 mm
 of space shortage in the maxilla

Treatment plan and sequence appointments
  for the Maxillary Arch Only
Ali
Discussion
                 Question 1




• 5 or 6 y.o. child. Tooth #I extracted.
               Question 1




• Band/Crown and Loop #J-H
• Will not need replacement. #12 should erupt
  before #H or J exfoliate
                    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?
               Question 2




• Band/Crown Loop #K-M
• May need to be replaced by LLHA later. Tooth
  #M should exfoliate prior to eruption #21.
                Question 3




• Teeth #A and #J extracted. Patient 8-9 y.o.
                 Question 3




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




• Teeth #K and L extracted
               Question 4




• Lower Lingual Holding Arch (LLHA) #19-#30
                 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.
                     “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.”
Assuming normal dental development, Ali
           is 8 years old.
                    Ali
• Mandibular Arch Only : Chart
  abnormalities and pathology (including
  caries ) from the Panorex and Bite Wing
  Radiographs
                   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.
                   Ali

 A Moyer’s 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.
                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
                   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
                “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.”
Ali
                  Ali

 A Moyer’s space analysis predicts 1.2 mm
 of space shortage in the maxilla

Treatment plan and sequence appointments
  for the Maxillary Arch Only
                   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-D;#J-abscess, #14-MO

Note: #6 and #11 very advanced root
 development.
Ali
                    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.
           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
Thank You!

				
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