1. MANAGING THE ARCH CIRCUMFERENCE
Diagnosis and Treatment Planning

2. Introduction Managing the arch circumference is a formidable task.
Decisions are frequently tentative.
Learning goal is not sophistication; but basic, foundational knowledge.
Build on knowledge through electives, post-doctoral education, and practice experience.

3. Arch Circumference
The distance from the distal of the second primary molar (or mesial surface of the first permanent molar) on one side of the arch to that same surface on the opposite side of the arch.

4. Arch Circumference
It is the space which during the primary dentition is occupied by the 10 primary teeth, and the space that will be available for the eruption of the 10 succendaneous teeth.

5. Arch Circumference
Arch circumference is relatively unaffected by growth.
It increases slightly with the more anterior (procumbent) positioning of the permanent incisors on their eruption, but it decreases as a result of the mesial migration of the first permanent molars during the canine-premolar transition. (“leeway space”)

6. Two Goals. . . in managing the arch circumference
1. The arch circumference’s integrity is maintained in order that the child’s inherent potential to erupt the succedaneous teeth in normal arch alignment is realized.
2. The succedaneous teeth are assisted in erupting into as normal an arch alignment as possible within the constraints of the size of the arches and the size of the tooth mass.

7. Two Problems . . . in managing the arch circumference
1. Available arch circumference may be lost as a result of pathology, and
2. A discrepancy may exist between the size of the succedaenous teeth and the amount of arch circumference available.

8. Physiologic Forces
A tooth is maintained in its correct relationship by the action of several forces. An alteration in these forces can alter the relationship among the teeth.

12. The Problem of Pathologic Loss of Arch Circumference

13. Physiologic Forces
Of primary concern is the mesial migration of the first permanent molar; any mesial movement, by definition, reduces arch circumference.

15. Primary Causes of Loss of Arch Circumference
Extraction of posterior primary teeth due to pulpal pathology.
Interproximal caries

16. Premature Loss of Primary Tooth (Extraction)

20. Proximal Caries

22. Additional Causes of Loss of Arch Circumference
Ankylosis of primary tooth
Ectopic eruption of the first permanent molar

23. Anklyosis
Ankylosis
An aberration in the eruption of teeth in which the continuity of the periodontal ligament becomes compromised, with fusion of the cementum and bone at one or more locations. Results in the tooth being “submerged” relative to the occlusal plane. Adjacent teeth may tip into space, resulting in loss of arch circumference.

25. Ectopic Eruption Ectopic Eruption
Eruption of first permanent molar into the root of the second primary molar. Prevalence 2-3% Generally self-correcting, but can cause loss of second primary molar if not corrected, with first permanent molar positioning itself anteriorly, with resultant loss of arch circumference.

27. The Problem of Inadequate Arch Circumference

28. Inadequate Arch Circumference
It is frequently the case that a practitioner preserves the integrity of the arch circumference and yet a malocclusion develops due to a basic discrepancy between the size of the succedaneous teeth (mesial-distal width) and the amount of arch circumference available for their eruption.
This is frequently stated as a “tooth size/arch circumference discrepancy.”
Plainly stated, the child’s “teeth are too big for the size of the jaws.”

29. Inadequate Arch Circumference
The first manifestation of this problem is when the first succedaneous teeth erupt, the mandibular permanent incisors.
They may be crowded, rotated, blocked out, or in their eruption cause the exfoliation of one or both of the primary canines; this is referred to as ectoptic eruption of the lateral insisor(s).

30. Ectopic Eruption of Lateral Incisor

31. Management of the arch circumference includes the management of the inadequacy of its circumference relative to the size of the succedaneous tooth mass.

32. DIAGNOSTIC CONSIDERATIONS
In Managing the Arch Circumference

33. Diagnostic Data Base
Diagnosis and treatment can be complex, especially in the mixed dentition.
A valid data base must be gathered in a systematic manner.
Data Base:
Case History
Oral Examination
Radiographic survey
and in the mixed dentition
Diagnostic Casts and a Space Analysis

34. Questions To Be Answered From The Data Base
1. What is the patient’s profile?
2. Has there been premature loss of teeth and/or does it appear that teeth present will have to be extracted prematurely?
3. What is the occlusal development?
4. Is there a discrepancy between the available arch circumference and the size of the permanent succedaneous teeth?

35. What is the patient’s profile?
Important in determining facial growth patterns
Can be determined in a preliminary (non-definitive) manner, that is, without the exposure of a cephalogram, by clinically relating the bony aspects of the maxilla and mandible to one another and the cranial base

36. What is the patient’s profile?
This evaluation is accomplished by:
palpating the basal bone above the roots of the maxillary incisors -- Point A on a cephalogram;
palpating the basal bone below th roots of the mandibular incisors -- Point B on a cephalogram;
palpating the nasal bone -- Nasion on a cephalogram.

37. Profile Landmarks

38. What is the patient’s profile?
Ideally, the bony landmarks should be in a direct line relationship with one another, an orthognathic profile.
A (developing) skeletal Class II is characterized by a retrognathic mandible.
A (developing) skeletal Class III is characterized by a prognathic mandible.

39. Orthognathic Profile 1. Cranium 2. Maxilla 3. Maxillary Dentition
4. Mandibular Dentition
5. Mandible

40. Orthognathic Profile

41. Retrognathic Profile

42. Prognathic Profile

43. Viewing Profile

44. What is the patient’s profile?
In the mixed dentition, children with a developing retrognathia or prognathia should be referred to a specialist for consultation in the context of the generalist managing the arch circumference, as management of the arch circumference exists in the context of a larger skeletal problem. However, it is generally always advisable to maintain the integrity of the arch circumference, even in the context of an overarching skeletal problem.
Space management by the generalist alone is most appropriate and successful in the patient with an orthognathic profile.

45. Has there been premature loss of primary teeth and/or does it appear that primary teeth present will have to be prematurely extracted?
Which teeth? Arch circumference loss is greater with second primary molars that with first primary molars.
Has there already been loss of arch circumference? If not, management man involve simple maintenance of available space. In instances where you remove a tooth and all other factors indicate a need for space maintenance, the appliance should be placed immediately. Watchful waiting for space closure following extraction is never indicated!

47. Premature Loss? If space loss has already occurred:
What is the magnitude of the loss? If it proves to be necessary to regain lost arch circumference, different appliances are used depending on the magnitude of the loss.
Is there still adequate space remaining to permit eruption of the succcedaneous tooth? If so, regaining lost arch circumference may be unnecessary.

48. Premature Loss?
Is it possible that additional arch circumference could be lost? Space closure following extraction of primary molars is generally related to the position and eruption of the first permanent molar. In the late mixed dentition it may be more related to the position and eruption of the second permanent molar. Because of this, space loss may be immediate or delayed. However, it is generally found that significant amounts of space loss will occur within the first six months following extraction. Additional increments of loss may occur at periods associated with the eruption of the permanent molars.

49. Premature Loss?
Is the succedaneous tooth present? The congenital absence of the succedaneous tooth (or teeth) may affect your decision of how to manage the available arch circumference. The second premolars are common congenitally missing teeth. An evaluation of the presence or absence of this tooth is an important consideration. The second premolar is also highly variable in the initiation of its calcification. Formation can begin as late as 8 years of age, so be wary of jumping to conclusions.

52. Premature Loss?
When can the eruption of the succedaneous tooth be expected? The chronologic age of the patient is not as important as the developmental age. Average eruption dates must not influence decision regarding the construction of a space maintainer; there is too much variation in the time of eruption of teeth. Gron found that the premolar teeth erupt when approximately 3/4 of the root is developed, regardless of the child’s chronologic age. Another factor in predicting tooth emergence is the amount of bone overlying the permanent tooth. Again, Gron found that the eruption of the permanent successor is accelerated if that permanent tooth had penetrated from the bone prior to the extraction of the primary tooth.

53. Eruption of the tooth may be retarded if there is still considerable bone overlying the succedaneous tooth. Frequently primary molars are extracted due to chronic pulpal pathology. This pulpal infection may have resulted in considerable resorption of the alveloar bone overlying the succedaneous tooth. In this situation, emergence of the tooth is accelerated. In some instance the tooth may erupt with a minimum of root development. Generally, early extraction of primary molars, before age 9, will retard eruption of the premolars, and late extraction, after age 9, will accelerate their eruption.

55. What is the status of occlusal development?
Have the first permanent molars erupted and are they in occlusion? After their eruption there is considerable dissipation of the strong mesial vector of force that has been active until this time; this affects treatment planning decisions. For example, after the eruption of the first permanent molar it is generally not necessary to place a space maintenance device when premature loss of the first primary molar occurs. However, in the mandible, there can be distal drifting of the primary canine, which can permit a shift in the midline.

56. What is the status of occlusal development?
Are the mandibular permanent incisors erupted? The eruption of the mandibular incisors provides an initial impression as to whether a significant discrepancy exists between the size of the succedaneous teeth and the available arch circumference; this is due to the “incisor liability.” After the eruption of the mandibular incisors it is also possible to perform a space analysis, a basic diagnostic aid in managing the arch circumference in the mixed dentition. Once the mandibular incisors have erupted, and there is any question regarding the adequacy of the arch circumference, space analysis is indicated before placing any space management appliance.

57. What is the status of occlusal development?
What is the molar relationship, canine relationship, overbite, and overjet? These evaluations help to support or reject the presence of dento-skeletal malocclusions that would require the supervision of a specialist. The presence of a Class I or end to end molar, relationship; Class I canine relationship and with an overbite and overjet of 2-3mm supports a preliminary evaluation of an orthognathic skeletal relationship. This evaluation is foundational to managing the arch circumference for a general practitioner of dentistry.

59. Is there a discrepancy between the available arch circumference and the size of the permanent succcedaneous teeth?
This determination is made by performing a space analysis.
Arch circumference is adequate when sufficient space exists around the arch, from one first permanent molar to the contralateral one to accommodate the succedaneous teeth without crowding (broken contacts and rotations), and without excessive protrusion of the teeth and alveloar process. Absent such the arch circumference is inadequate.

60. Is arch circumference adequate?
To determine adequacy:
the amount of space available for the succedaneous teeth is measure on diagnostic casts.
The erupted permanent teeth are measured and the size of the unerupted permanent teeth predicted from a prediction table. This provides the total amount of succedaneous tooth mass to be accommodated in the arches.
A comparison of these two figures permits an assessment of the overall adequacy or inadequacy of the arch.

61. TREATMENT ALTERNATIVES
In Managing the Arch Circumference

62. Four Alternatives MAINTAIN SPACE
By means of appliance therapy provide for the maintenance of the arch circumference present at the time of examination.
REGAIN SPACE
By means of active appliance therapy attempt to regain arch circumference (space) which was at one time available but has now been lost for whatever reason
CREATE SPACE
By a more sophisticated application of knowledge of the developing occlusion and/or by application of biomechanically active appliance therapy increase the amount of space available for the teeth as they erupt and possibly increase overall arch circumference.
ELIMINATE SPACE
Through extraction of permanent teeth with the subsequent closure of excess space, resolve sever discrepancies between tooth size and arch circumference.

63. For Space Management in the Primary Dentition
TREATMENT DECISIONS
For Space Management in the Primary Dentition

64. Treatment Planning Primary Dentition
Decision making regarding space management is not as challenging in the primary dentition as it becomes later in the mixed dentition.
This is due to a meager data base.
At this stage of development it is difficult to ascertain the existence of a tooth size/arch circumference discrepancy, and generally dento-skeletal malocclusions are not identifiable at this time.
Because of these diagnostic constraints, maintenance or preservation of the available space is accomplished should a primary tooth be lost prematurely.

65. Treatment Planning Primary Dentition
It must be emphasized that space maintenance in the primary dentition may well not be definitive treatment.
Significant alteration in treatment rationale and appliance therapy may be necessary after entering the period of the mixed dentition when more information is available to add to the data base.

66. Parental Understanding
It is critically important to inform the parents of the lack of definitiveness of a space maintenance protocol in the primary dentition.
Many parents develop the erroneous idea that a space maintainer placed during the preschool years precludes the development of a malocclusion in later years.
When practitioner and parent are both aware of the purpose or objective to be achieved by the placement of an appliance, misunderstandings can be avoided.

67. Treatment Planning Primary Dentition
As a general rule, loss of a primary molar during the period of the primary dentition requires the placement of a space maintainer in all instances.

68. Treatment Planning Primary Dentition
Unfortunately, a not insignificant number of general practitioners are guilty of extracting primary teeth and not advising the parents of the imperative of space maintenance to preserve the arch circumference.
This is an ethical issue; for in failing to provide for space maintenance when arch circumference will be reduced is doing harm to the patient.
Of course, a practitioner cannot force a parent to pursue space maintenance, however failure to inform, educate, and attempt to persuade must be considered a moral failing; such is below the standard of care for the profession.

69. Treatment Planning Primary Dentition
Three appliances are used to maintain the available arch circumference in the primary dentition:
Band and loop
Intra- alveolar or distal shoe
Removable acrylic appliance

70. Band and Loop Space Maintainer

71. Band and Loop
The band and loop is used to maintain space subsequent to the loss of the first primary molar.
The band is attached to the second primary molar and the loop extends to the distal of the primary canine.
This effectively reserves the space that is available for the eruption of the first premolar.

72. Band and Loop
After the child enters the mixed dentition and more diagnostic information becomes available (specifically, the results of a space analysis) the decision to maintain the space must be reevaluated.
If it is determined at that time that the space should be maintained the band and loop can continue to function.
It can be removed when the eruption of the first premolar has begun, or when it is determined that no space loss would occur if it were removed, for example, after the complete eruption and intercuspation of the first permanent molar.

77. Intra-Alveolar (Distal Shoe)

78. Intra-Alveolar (Distal Shoe)
The intra-alveolar or distal shoe space maintainer is indicated following premature loss of the second primary molar and prior to the eruption of the first permanent molar.
The abutment tooth is the first primary molar with a wire extending distally to the mesial aspect of the unerupted molar and extending gingivally to contact the mesial surface of the permanent molar.
The gingival extension provides a surface along which the first permanent molar can erupt.
Subsequent to the eruption of the molar at age 6, an alternative appliance (lingual arch) must be placed.
Employment of a distal shoe dictates the employment of 2 appliances to maintain space until the eruption of the second premolar, at age

85. Removable Acrylic Space Maintainer

87. Removable Acrylic Appliance
A removable acrylic appliance is required should multiple posterior teeth be lost in one quadrant.
Extraction of both the first and second primary molars in one arch would prevent the utilization of either a band and loop or a distal shoe.

88. Removable Acrylic Appliance
Unless absolutely dictated by the circumstances, removable acrylic appliances should not be utilized for three reasons:
their success is too dependent on the child’s cooperation and compliance.
their ability to maintain the space for which they were designed is sometimes questionable,
children tend to break and/or lose them.

89. Treatment Planning Primary Dentition
In cases where there is bilateral loss of a single tooth it is preferable to fabricate and place two unilateral appliances than to place one bilateral one.
For example, a lingual arch placed on the second primary molars would interfere with the eruption of the permanent incisors.
Additionally, there is some growth in arch width with the eruption of the permanent incisors, and no appliance should be placed that would restrict this.

92. Treatment Planning Primary Dentition
The need to place a space maintainer in the anterior part of the arch during the primary dentition is an area of some uncertainty and controversy.
There is a question as to whether there is actual loss of arch circumference or merely shifting of the anterior teeth in the available space.
It can be stated that premature loss of anterior teeth does not pose as great a problem as loss of primary posterior teeth.

93. Treatment Planning Primary Dentition
It has been argued that if the anterior tooth is lost before the permanent teeth have developed their mesio-distal width so as to maintain the arch dimension, space closure and actual loss of arch circumference may occur.
This would be the case in primary incisors loss before age 3.
The presence of spacing among the anterior incisors is a further consideration; if spacing is present, there is little chance that space loss will occur with the removal of teeth.

94. Treatment Planning Primary Dentition
Should anterior space maintenance be necessary, the anterior fixed esthetic appliance best suits the design requirements.
This appliance may also be used in situations were space loss is not considered a problem but where the parents are concerned about esthetics.
It may also be employed when the practitioner is concerned that multiple missing anterior teeth may contribute to the development of a deleterious oral habit.

96. Fixed Anterior Esthetic Appliance

98. TREATMENT DECISION MAKING
For Managing Space Problems in the Mixed Dentition

99. Treatment Planning Mixed Dentition
Treatment decision making during the mixed dentition is more complex.
Primary dentition - basically a decision to maintain space
Mixed dentition - decision is to maintain, regain, create, or eliminate space.

100. Learning Objective Mixed Dentition
To enable the student dentist to conceptualize the broad issues of space management, and to understand, in at least a preliminary manner, the strategies of space regaining, creating, and eliminating in the mixed dentition.
Detailed discussions of active appliance therapy and the role of the generalist with the specialist, will be a component of the orthodontics curriculum.
Space maintaining and regaining generally fall under the purview of the generalist, whereas creation and elimination of space are typically accomplished in consultation with a specialist.

101. BASIC PREREQUISITES FOR MANAGING ARCH CIRCUMFERENCE IN THE MIXED DENTITION
Profile is orthognathic
Relationship between the maxillary and mandibular dentitions is normal as evidenced by molar relationship, canine relationship, overbite, and overjet
This does not mean that the various management procedures to be discussed are not, or should not be utilized, only that absent the above prerequisites, there is likely an underlying malocclusion that simple management of the arch circumference in one plane of space one not resolve. Referral to a specialist competent to treat the case comprehensively is indicated.

102. Maintaining Arch Circumference (Mixed Dentition)
Indications:
premature loss of the second primary molar
premature loss of the first primary molar, but only if the first permanent molars are not in a Class I relationship
succedaneous tooth present and it appears it eruption will be delayed.
no loss of arch circumference has occurred
adequate arch circumference exists for the eruption of the succedaneous teeth as determined by a space analysis
Profile is orthognathic
Relationship between maxillary and mandibular dentitions is normal as evidenced by molar relationship, canine relationship, overbite and overjet.
Space maintenance may be indicated even if some of the indications are not met. However, consultation with a specialist would be indicated as additional, more complex treatment, may be required.

103. Maintaining Arch Circumference (Mixed Dentition)
Appliances Utilized:
Mandibular Arch - Lingual Arch
Maxillary Arch - Palatal Arch

104. Lingual Arch

105. Lingual Arch

106. Nance (Palatal) Arch

107. Nance (Palatal) Arch

108. Maintaining Arch Circumference (Mixed Dentition)
The utilization of these “full arch” appliances emphasizes the concept of maintaining the integrity of the arch circumference rather than individual tooth spaces.
Single tooth appliances, such as a band and loop, are generally not appropriate in the mixed dentition due to the eruption sequence of teeth.
For example, a band and loop extending from the first permanent molar to the first primary molar would lose its anterior abutment, the first primary molar, prior to the eruption of the succedaneous tooth, the second premolar. The mesial component of force with the erupting second molar could force the first permanent molar forward reducing arch circumference and compromising the space for the second premolar.

109. Regaining Arch Circumference Mixed Dentition
Indications:
Unilateral or bilateral missing second primary molars with mesial tipping of the first permanent molar
Succedaneous tooth is present
Space analysis indicates adequate arch circumference exist for succedaneous teeth with the exception of the localized inadequacy in the quadrant(s) where the regaining is planned.
Localized inadequacy is less than 4 mm
Profile is orthognathic
Relationship between maxillary and mandibular dentitions is normal as evidenced by molar relationship, canine relationship, overbite and overjet.
Space regaining may be indicated even if some of the above criteria are not met. However, consultation with a specialist would be indicated, as more complex treatment may be required.

110. Regaining Arch Circumference Mixed Dentition
Regaining arch circumference is not particularly complex and the prognosis is good.
The objective is simply to regain arch circumference that has been lost; for example, by distalizing first permanent molar(s) that have migrated mesially subsequent to the premature loss of posterior primary teeth.

114. Regaining Arch Circumference Mixed Dentition
Appliances used: Amount to be gained Mandible Maxilla
0-2 mm helical spring helical spring
loop lingual arch headgear
split saddle jackscrew
2-4 mm sling shot split saddle
split saddle headgear
lip bumper jackscrew

115. Loop Lingual Arch

116. Loop Lingual Arch

117. Head Gear

118. Jackscrew Appliance

119. Jackscrew Appliance

120. Helical Spring Appliance

121. Helical Spring Appliance

122. Slingshot Appliance

123. Split Saddle Appliance

124. Creating Arch Circumference Mixed Dentition
Two Definitions:
1. Increasing the arch circumference by moving the first permanent molars distally and/or advancing the incisors labially. Limited by the extent can be accomplished without having a deleterious effect on the periodontium of the incisors, on the profile, or on the eruption of the second permanent molar .

125. Creating Arch Circumference Mixed Dentition
2. Also refers to selectively stripping enamel from the primary teeth and/or selectively removing primary teeth to allow a more favorable eruption path for the permanent tooth. This is variously called “space supervision or eruption guidance.” This type of guidance can often prevent rotated incisors, blocked out canines, and cross-bite positions of the premolars. It does not create additional arch circumference per se, but it does provide for additional space in an area where such is required at a given point in time.

126. Creating Arch Circumference Mixed Dentition
Indications:
Crowding of the permanent incisors; or early loss of the primary canine unilaterally or canines bilaterally, as a result of ectopic eruption of the lateral incisors
Space analysis that demonstrates a moderate generalized tooth size/arch circumference discrepancy of 4 mm or less in the arch.

128. Creating Arch Circumference Mixed Dentition
Typical appliance therapy might consist of using a headgear in the maxillary arch to distalize the first permanent molars, and a loop lingual arch in the mandibular to advance the incisors.
If the discrepancy is small, 1-2 mm, it may be possible to provide additional space in the anterior region to permit favorable alignment of the permanent incisors by selective stripping of the primary canines and/or sequential extraction without employing active appliance therapy. The option for ‘creating space’ in this manner is due to the existence of the leeway space; essentially borrowing space from the posterior for the anterior. Another way of saying it is using the leeway space to overcome incisor liability.

129. Leeway Space
Nota Bene
Remember that the majority of the leeway space is ‘housed’ in the primary second molar/second premolar differential.

133. Creating Arch Circumference Mixed Dentition
Typical space creation protocol:
Removal of primary canines to allow for the alignment of the permanent incisors. One of the incisors may have been lost due to ectopic eruption of the lateral inciosr. Should this have occurred, extraction of the contra-lateral canine should be accomplished to preserve the midlines.
Placement of a lingual arch. Failure to place a lingual arch will result in the incisors positioning themselves lingually. This will close the canine space and shorten the arch circumference.
Removal of first primary molar and stripping of mesial surface of second primary molar. This is accomplished when it appears the canine cannot erupt normally; thus allowing the canine to erupt distally.
Removal of second primary molar when the first premolar is erupting to allow room for its eruption.
Removal of the lingual arch after eruption of the second premolar.

134. Lingual Arch

136. Creating Arch Circumference Mixed Dentition
This protocol is employed when the first permanent molars are in a Class I molar relationship. If the first permanent molars are in an end to end relationship, then the maxillary molars may be distalized in order to create additional space in the maxilla, and a Class I molar relationship.

137. Eliminating Arch Circumference Mixed Dentition
If the arch discrepancy is large, 4 mm/quadrant (8mm/arch), it is unlikely adequate arch circumference can be created by the aforementioned methods, or even potentially by functional appliance therapy or multi-banded therapy. Therefore, it is often necessary to extract permanent teeth, usually four premolars, to allow the remaining teeth to achieve a normal occlusion. This course of therapy should only be taking in consultation with a specialist or referral to one.
Space elimination is also referred to as serial extraction.

138. Eliminating Arch Circumference Mixed Dentition
Space elimination would be considered, in consultation with an specialist, when the following criteria are met:
Arch circumference discrepancy of at least mm/quadrant, as determined by space analysis
Profile is orthognathic
Relationship between maxillary and mandibular dentitions is normal as evidenced by molar relationship, canine relationship, overbite and overjet.

139. Eliminating Arch Circumference Mixed Dentition
The following protocol is one generally followed, in consultation with a specialist; there are alternatives depending on a variety of conditions and objectives:
Extract of mandibular first primary molar when 1/3 of root of the mandibular first premolar is formed.
Extract maxillary first primary molar when mandibular first premolar emerges
Extract mandibular first premolar when it has erupted to the approximate height of its clinical crown. It is unwise to extract it earlier because its eruption forms alveolar bone at the site where the canine will eventually move.
Extract the maxillary first premolar when it is fully erupted.

140. COMMUNICATION SPACE MANAGEMENT TO THE PARENT
As with any procedure or protocol with children, it is imperative that the parent understand the goal(s) of treatment, treatment alternatives, advantages or benefits versus disadvantages or risks; prognosis and the financial investment required. These are also the elements of an informed consent, which the parent must provide for the minor child. This information should be discussed interactively with the parent(s), but also documented in written form, such as in the Parent’s Notes, as previously discussed.

141. COMMUNICATION SPACE MANAGEMENT TO THE PARENT
As we will primarily be providing space maintenance therapy in pediatric dentistry, the following are statements appropriate for the Parent’s Notes:
“There is enough space for all the way the permanent teeth and the manner in which the teeth meet is acceptable. The space maintainer be placed will probably be the only appliance required.”
“There are additional problems with the way the teeth and jaws relate, and the space maintainer alone will not resolve the problem. It will maintain space, but further, more definitive treatment will be required later.”
“The space maintainer being placed will need to be replaced with a different type of space maintainer when the permanent incisors and first molars have erupted.”
“A slight amount of space loss has already occurred, and the space maintainer will prevent the problem from worsening.”
“A space analysis cannot be done yet, and the space maintainer will be placed until this can be accomplished at about age 7; only then can a more definitive diagnosis be established.”