1. Management of Space in Pediatric Dentistry
Dr Seyed Ebrahim Jabbarifar :Associate professor Isfahan Dental School
Pedodontic department 2009

2. 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 syndromes
Hypophosphatasia Rickets Acrodynia
Histiocytosis X triad Leukemia Cherubism
Juvenile Periodontitis Dentinal dysplasia
Cyclic neutropenia Papillon-Lefevre syndrome
Ectopic Eruption of Primary Canine: first clinical sign of a significant arch length-tooth size discrepancy

3. Functions of a Space Maintainer
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
Space Maintainers are recommended to reduce the prevalence and severity of malocclusion following premature loss of primary teeth.

4. Functions of a Space Maintainer
Maintain space
Prevent mvmt adjacent teeth
Provide masticatory fx
Prevent overeruption of opposing teeth
Improve esthetics
Assist in speech (anterior segments)
Aid in control of deleterious oral habits
Note: appliance must neither inhibit nor deflect normal growth changes

5. Ideal Prerequisites of a Space Maintainer
Simple to construct and maintain
Durable, strong, stable
Passive
Easily cleanable and not enhance dental caries or soft tissue pathology
Readily adjustable for flexible application
Passive--must not impose excessive stress of pressures on remaining teeth which might effect orthodontic movements.

6. 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”.

7. Factors to consider when planning a space maintainer:
Dental and periodontal condition
Arch length
Presence/absence of permanent successor
Time elapsed since loss of primary tooth
Status of first permanent molar eruption
Status of permanent successor’s development and eruption potential
Cooperation level of child and parents
Which tooth is lost, in which arch, at what time?

8. 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

9. 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.
Roots:
if 1/3 to 1/2 root dvlpt: then eruption delayed
If 1/2 to 3/4 root dvlpt: then eruption accelerated

10. Adverse Effects Dislodged, broken, and lost appliances
Plaque accumulation
Caries
Interference with successor eruption
Undesirable tooth mvmt
Inhibition of alveolar growth
Soft tissue impingement
Pain

11. 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.
Monitor: assess integrity of cement, evaluate + clean abutment teeth

12. 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
Canine loss: compromises arch length, possibly deepens bite, shift of dental midline toward side of loss

13. 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

14. 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

15. 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
If there is a loss of the 1st primary molar and space maintenance is required…

16. 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/Nance
b) Band & loop
c) Distal shoe appliance - prior to eruption of 1st PM
If there is a loss of the 1st primary molar and space maintenance is required, then the…
Note: B+L and LLHA--used after the 6 is in place
Distal Shoe--used before the 6 is in place

17. Premature loss of posterior teeth: Multiple Teeth
Following appliances are indicated:
a) Transpalatal arch
b) Nance appliance
c) Lingual arch
d) Removable

18. SM: Band and Loop Indications
Loss of primary molar
prior/during period of eruption of 1st perm M.
Anywhere in posterior
following a time lapse b/w loss of tooth and eruption of its permanent successor.
Loss of 2 post teeth or bilateral situations
rarely used

19. SM: Band and Loop Advantages
1. Easy to construct.
2. Inexpensive.
Easily adjusted.
4. Allows eruption of permanent tooth.
5. Non invasive.
6. Painless.

20. SM: Band and Loop Disadvantages
Masticatory function.
Not restored
Extrusion of opposing dentition.
Not prevented
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

21. SM: Band and Loop Construction
Band: stainless steel material inches in thickness
Crib: portion of the wire spanning the edentulous space
Loop: portion of the wire contacting the abutting tooth inches in diameter

22. SM: Lingual Arch Indications
Premature loss of primary posterior teeth.
Base for aesthetic restoration in loss of anterior teeth.
3. Used as a base for habit appliance.

23. SM: Lingual Arch Advantages Disadvantages
1. 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.

24. SM: Fixed Lingual Arch Construction
Band: Stainless steel material inches in thickness (ortho bands)
Lingual arch wire: Stainless steel round wire inches in thickness

25. SM: Nance Appliance Maxillary arch: multiple tooth loss
Indications:
The same as for fixed lingual arch
Construction:
Bands: Stainless steel material inches in thickness
Palatal wire: Stainless steel round wire inches in thickness

26. G.T. age 5 after the removal of a necrotic #85
What would you do?
G.T. age 5 after the removal of a necrotic #85
Q: Tooth missing: #85--single
Q: Choices: Distal shoe
Use: Distal shoe

27. N.S. age 7 requires extraction of tooth #75.
What would you do?
Q: Tooth missing: #74, soon to be 75--multiple
Q: Choices: LLHA, ?B+L, (?partial)
Use: LLHA--loss of multiple teeth
At age 7, need to assess if all perm incisors are in--make modification if necessary.
N.S. age 7 requires extraction of tooth #75.

28. What would you do?
Q: Tooth missing: #64 and 65--multiple, high caries risk--potentially #54 and/or 55 in future
Q: Choices: Nance, ?B+L
Use: Nance
P.G. age 8 requires pulp treatment and stainless steel crown restorations for teeth #54 and #55

29. M.M. age 8 is scheduled for a recall visit.
What would you do?
Recall: assess integrity of cement
evaluate and clean abutment teeth
Note: Space loss in UR Quadrant--may require space regaining appliance/ortho consult
M.M. age 8 is scheduled for a recall visit.

30. Thank You