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Discussion

DISCUSSION
Dental arch-length is the most important factor of the dental arch dimension in the developing individual. The maintenance of arch length during the primary, mixed, and early permanent dentition is of great significance for the normal development of a functional well-aligned and balanced adult occlusion. Guidance of eruption and development of the primary and permanent dentitions is an integral part of the care of pediatric patients; such guidance should contribute to the development of the permanent dentition that is in a harmonious, functional and esthetically acceptable occlusion. When a primary tooth is prematurely lost, especially a molar, a careful clinical and radiographic examination should be done, in order to determine the correct treatment to maintain the arch-length. If the primary molar is lost during the mixed dentition stage, a set of study models and an analysis of the mixed dentition should be included in the clinical examination. There are however, other independent clinical factors such as: interproximal caries in primary molars, ectopical eruption of first permanent molars, delayed eruption of first permanent molars, delayed eruption and ankylosis of primary molars, congenital absence of permanent teeth and generalized disproportional macrodontia, which also cause loss of arch-length in a developing occlusion. Regardless of the cause, loss of arch length results in a loss of structural balance and functional efficiency.

Space problems: Regardless of the cause, loss of space results in a loss of structural balance and functional efficiency. Loss of space occurred due to early exfoliation of primary teeth, compromise the eruption of succaedenous teeth and harm the normal occlusal development.
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Discussion When the maxillary primary first molar is lost prematurely, the first premolar erupts in a more mesial direction than normal, as a result of the mesial incline of the primary second molar, and consumes the space of the permanent canine, which becomes blocked out. Diagnosing and treating space problems require an understanding of the etiology of crowding and the development of the dentition to render treatment for mild, moderate and severe crowding cases. In cases with 5-9 mm of crowding can be approached with expansion after through diagnosis and treatment planning. Most of these cases will require extraction of permanent teeth to preserve facial esthetics and the integrity of the supporting soft tissue. Serial extraction or guidance of eruption is reserved for treatment of severe tooth-size/arch-size discrepancies.

Etiologic factors responsible for space loss: The loss in the arch length due to early loss of deciduous tooth is considered one of the most frequent etiological causes of space loss in children.4 The other independent clinical causes for space loss in children are: 1. Interproximal caries in primary molars. 2. Ectopic eruption of first permanent molars. 3. Delayed eruption. 4. Ankylosis of primary molars. 5. Generalized disproportional macrodontia. 6. Prolonged retention of deciduous teeth.

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Discussion Space Control Space control and space maintenance are not necessarily synonymous. The former term, which is preferred, refers to a careful supervision of the developing dentition; it reflects an understanding of the dynamic nature of occlusal development. Space maintaining is utilizing an appliance to preserve space without necessarily awareness of the dynamics of the situation71 Some of the choices of management in space control are observing or maintaining existing space, regaining lost space, losing space and creating space( as in arch expansion). Before selecting the management approach, however, numerous variables must be considered and each variable related to the individual.71 Space control may be desirable in anterior or posterior components of dental arch in cases of premature loss of teeth: Loss of teeth may result from extraction owing to dental caries, ectopic eruption, or trauma. Most growth studies are in general agreement that once the primary dentition has been established, the arch length- the measurement from the distal surface of the second primary molar around the arch to a similar position on the opposing side-is constant until the permanent dentition is established. The preservation of the arch length is of paramount importance in the primary and mixed dentitions, for it allows the dental units to “fit” into their relative positions. When primary teeth, particularly molars, are extracted, the dentist may have to intervene with appliance therapy to preserve the integrity of the arch. The need for intervention will depend on the evaluation of the occlusal development of the individual.71

Sequelae to Premature loss of individual Tooth46
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Discussion Natural forces exerted on teeth: The dentition is designed to function as a single unit, retain spatially by the sum of the forces exerted upon each individual number. Three distinct forces i.e. occlusal, muscular and eruptive forces contribute to space closure. Occlusal forces Opposing force of passive eruption exerted by individual teeth maintain a constant vertical relation. Primary teeth assume a 900 orientation to the occlusal plane, an upright arrangement probably responsible at least in part, for physiologic spacing in the primary dentition. Permanent teeth, maintain a mesial inclination during passive eruption. The resulting anterior component of force causes a physiological mesial drift which may contribute to space closure, thereby establishing a continuous arch. Muscular forces Cheek, lip and tongue muscles may tend to limit buccal, labial and lingual movement of the teeth. These forces contribute to dental arch form by maintaining tooth contact and establishing a stable inter molar and inter canine width. Eruptive forces As the arches continue to develop and permanent molar erupt, a powerful mesial force is exerted. An intact dentition anterior to this force offers superficial resistance; however, if arch continuity has been interrupted through loss of a primary or permanent tooth, space closure is inevitable. The result is a decrease in arch length.

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Discussion From 3-6years of age, most powerful mesially directed force exerted on the dentition, especially in the mandible, occurs during first permanent molar eruption. If spaces are present, this force is most likely responsible for their closure. After age of 6years, there is a continuous tendency for teeth to drift once permanent molars are in occlusion, a condition exaggerated during active eruption period. Molars erupt mesially; premolars and canines erupt distally, if space exists. A mandibular permanent incisor erupt mesially, guided into position by the tooth mesial to it, a maxillary permanent incisor, in a distal direction is assisted into proper alignment by the tooth immediately distal to it, loss of this guiding tooth may result in a maxillary midline shift in the direction of excess. - First primary molar area: The loss of first deciduous molar may be maxillary, mandibular or both and unilateral or bilateral. Space maintainers should always be placed whenever a deciduous molar is lost prematurely. Presence of oral habits like thumb or finger sucking provide abnormal forces on the dental arches resulting in collapse of anterior arch after extraction of mandibular primary molar. When the first deciduous molar is extracted before active eruption of the first permanent molars there is obviously no influence on the arch or on the second deciduous molar teeth to cause space loss. The potential for space los is great during eruption of the first permanent molars since this is the time when the permanent molars exert a strong eruptive force against the distal crown surface of the second deciduous molar. The lower first permanent molar erupts directly against the deciduous distal crown surface and exerts the strong eruptive force.
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Space maintainer should be placed to prevent space closure and arch collapse. Wire stops placed on the lingual arch or removable acrylic space maintainer may aid in preventing asymmetrical shifting of permanent incisors. If the loss is unilateral. -Primary canine area: Early loss of deciduous canines is more common due to erupting lateral incisors rather than caries. the space loss will occur because of occlusal forces and mesial drift. there will be midline shift due to migration of larger permanent incisor segment into the space in the process of adjustment. . When early loss of primary cuspids has occurred as a result of insufficient length of arch. The midline will deviate to the side of space loss.Primary incisors area: Deciduous incisors are lost prematurely through severe dental caries cause by the “bottle mouth” or “baby bottle” syndromes and by traumatic injuries at any stage. It has been generally accepted that the deciduous incisors teeth will become spaced with growth to accommodate larger permanent incisor teeth. 22 . The incisor teeth will move into more lingual inclination and will step forward the space.Discussion If the deciduous first molar is lost after the eruption of first permanent molar and are in occlusion with one another. attention may be directed to the removal of the opposite primary cuspids to permit the permanent incisors to tip towards a symmetrical alignment. Thus it has been felt that space maintainers are not necessary to maintain space which is getting increased with the jaw. Occasionally roots of deciduous canines are absorbed and tooth will be lost.

70 The mixed dentition analysis is much less accurate than the forecast of the size of teeth because the perimeter of the arch does not necessarily change to match the size of the teeth. A temporary appliance should be constructed and inserted within a matter of hours after loss. If space loss already occurred.70 THE MIXED DENTITION ANALYSIS Great care must be exercised at this time to avoid letting any number dictate a decision. regaining should be done and subsequent maintenance is done. They permit one to put similar cases in the same category for which certain questions are most appropriate. Spacing or crowding in the mixed dentition is just as highly correlated with spacing or crowding in the permanent 23 . to prevent space closure. SPACE ANALYSIS Crowding or spacing of the developing dentition has to be a prime concern for dentists treating children. The accumulated sizes of each child‟s teeth may not necessarily be in a perfect relationship to the amount of space in his dental arches for the accommodation of his dentition. The assessment of spacing or crowding of teeth is frequently associated with measurements in mixed dentition stage because accurate and specific prediction of future dental development can be made at this stage. The numbers are merely guides to a decision.Discussion -Permanent incisor area: The loss of permanent anterior teeth requires immediate treatment to intercept intra arch changes. When the accumulated sizes of teeth and the perimeter of the arch are not closely related. as the teeth adjacent to the space will begin to drift within a few days of the loss of tooth. a spaced or crowded dentition results. Within a few weeks several millimeters of space will be lost.

namely. The advantage of the mixed dentition analysis.2mm. significantly reduced the standard error of estimate when they generated a revised Hixon and Oldfather prediction equation. is that it tells us what the potential spacing or crowding is and direct one‟s attention to beneficial and possibly inexpensive remedial measures. and the knowledge that the perimeter of the arch will not decrease the average amount can then be used in planning the treatment. The mixed dentition analysis tells one how much spacing or crowding would exist for the patient in the chair if all the primary teeth were replaced by their permanent successors.Discussion dentition. when correctly used. the less will be the reduction of the perimeter of the arch from mixed to permanent dentitions. Those cases can be identified by use of the mixed dentition analysis. the perimeter of the arch usually decreases in the mandible. The perimeter of the arch is reduced during the period from the mixed to permanent dentitions. the greater the crowding. but remains the same or increase slightly in severely crowded cases.Oldfather Prediction Method for the Mandibular arch47 Hixon and Oldfather were the first to develop an equation to predict the mesiodistal widths of unerupted mandibular canines and premolars in children. There are two approaches for predicting the size of the unerupted permanent canine and premolars in the mixed dentition. The coefficient of correlation of the revised equation was higher 24 . During the period of the changeover. with and without the use of radiographs:- RADIOGRAPHIC METHODS OF PREDICTION: Revised Hixon . For cases of mandibular crowding exceeding 2. Sta ley and kerber.

an alternative prediction method can be used to estimate the mesiodistal width of un erupted permanent tooth. Proportional ANALYSIS)75– If most of the canines and premolars have erupted and if one or two succaedenous teeth are still un erupted. is erupted on a plaster cast. whereas revised equation was derived from the means of measurement taken from both right and left side teeth in each subject. These three measurements comprise the elements of a proportion that can be solved to obtain the widths of the un erupted tooth on the cast. a primary second molar) are measured on the same peri apical film. The width of erupted tooth.g.Discussion then that of original equation. If: Unerupted tooth width Unerupted tooth width (x-ray) = Erupted tooth width (cast) Erupted tooth width (x-ray) Equation prediction Method (HUCKABA’S 25 . The addition of one standard error of estimate to the predicted sum would yield a predicted sum of widths at the eighty-four percentile. The widths of un erupted teeth (e. Records needed to perform the prediction includes a cast on the lower arch and peri apical radiographs of the un erupted lower premolars taken with a long cone paralleling or right angle technique. The original equation was derived primarily from measurements of teeth on the left side of the arch of each subject.g. a primary second molar. a second premolar) and an erupted tooth (e. This would provide assurance that the predicted sum of canine and premolar widths is as large as or larger than the true sum in 84% of all possible patients.

individually and record them.4mm (space loss due to mesial drift of permanent molar) is subtracted.Discussion Then: Unerupted tooth width = (Erupted tooth width cast) (Un erupted tooth width x ray) Erupted tooth width (x-ray) HAYS AND NANCEProcedure – Space requiredMeasure the mesiodistal width of four mandibular permanent incisors. The wire should pass over the buccal cusp of posterior teeth and incisal edges of anterior teeth. The linear measurements of wire are recorded and 3. Space available – A piece of ligature wire is contoured to the arch form and placed on the lower cast extending from mesial surface of 36to mesial surface of 46. Measure the width of unerupted mandibular canine and first and second premolars from radiographs.48 26 . These measurements will indicate the space needed to accommodate permanent teeth anterior to first permanent molars. By comparing the two measurements the space available and space required is predicted.

(2) Determine the space required for incisor alignment (3) Set the gauze to the value of sum of central and lateral incisor of one side. (5) Determine the space available for permanent canine and premolars after incisor alignment (6) Measure the distance from the point marked on the cast to the mesial surface of first permanent molar. (4) Place one point of gauze at midline and let the other end lie along the dental arch on the side of central and lateral incisors whose widths were measured. The combined width of mandibular canines and premolars is then predicted with the help of probability chart. these methods are less accurate.75 MOYERS ANALYSIS(1) Determine the space available for the teeth in the mandibular arch . 27 .with the help of boley‟s gauze measure the mesiodistal width of each mandibular incisor. On the other hand. Mark this point on the cast it represents the point at which the distal surface of the lateral incisor will be when it has been aligned properly. as indicated by their larger standard errors of estimate as compared with the suggested radiographic methods. separately.Discussion NONRADIOGRAPHIC PREDICTION METHOD: The main advantage of non radiographic prediction methods is that they can be performed by measuring the erupted permanent lower incisors or primary teeth without the need of additional measurements from radiographs. Repeat this for opposite side.

With bands or without bands . fixed or semi fixed .Thurow (1978) 28 .Functional or non functional .48 SPACE MAINTAINERS: “Appliances used to maintain space or regain minor amounts of space loss so as to guide un erupted tooth into a proper position in the arch.Discussion (7) The estimated canine and premolar size value is subtracted from the measured space.5mm to this value to get the estimated width of mandibular canine and premolar on one side.48 Classification(i) According to Hitchcock (1973) .”46 “It is a mechanical device that preserves the space after premature loss of primary teeth”. Add 10.Certain combinations of above52 (ii) According to Raymond C.48 TANAKA AND JOHNSON ANALYSISMeasure the mesiodistal widths of mandibular incisors and divide by 2.Removable. Half of the width of lower mandibular incisors +11mm=estimated width of maxillary canine and premolars of one side.Active or passive .

Band and Loop52 (iv)According to Mathewson1.Removable .Fixed space maintainers (A) Class-1 (a) Non functional types -Bar type -Loop type (b) Functional types -Pontic type -Lingual arch type (B) Class-11 Cantilever type (3) Distal shoe .Extra oral anchorage . 29 .Discussion .Individual tooth52 (iii) According to Hinrichsen (1962) . The Band and loop is used to maintain the loss of a single primary first or second molar.Complete arch .Lingual arch .

14 Indications  It is a unilateral fixed appliance. The fixed lingual arch prevents lingual tipping of the permanent incisors. The intra alveolar (distal shoe) appliance is used to prevent mesial migration of the un erupted permanent first molar after premature loss of the primary second molar. 30 . it does not aid in mastication and will not prevent the continued eruption of the opposing teeth.  Band is seated 1mm below the mesial & distal marginal ridges. The Nance holding arch maintains the maxillary arch length after the premature loss of more than one primary maxillary molar in the same quadrant or after a bilateral loss of primary molars. Band and loop space maintainer adjusts easily to accommodate changing dentition. The fixed lingual arch is used to maintain mandibular arch length and prevent mesial tipping and rotation of the permanent first molars. 3. However. unilateral or bilateral maxillary or mandibular primary molars.Discussion 2. FIXED SPACE MAINTAINER Band and Loop space maintainer The band and loop space maintainer is indicated for the premature loss of single. 4.

 The facio lingual dimension of the loop should be approx.49 Direct Technique or Single setting Technique14 Steps in fabrication 1) The band is pinched. Vertical markings are made both on the loop and the band at the anterior most point of contact of the loop with the band. Using the above mentioned markings as a reference points. this dimension should allow the permanent teeth to erupt freely but not impinge on the buccal mucosa or tongue. 6) The band and loop is then tried Intra orally to confirm the accurate position. Loops are made priorly in order to reduce chair side and laboratory time. 3) The loop is then tried in position Intra orally and minor adjustments are carried out. 31 .Discussion  Loop should parallel the edentulous ridge 1mm off the gingival tissue and should rest against the adjacent tooth at the contact point. the loop is placed in position on the band and spot welded. These markings are done both buccally and lingually. 8mm. 4) A horizontal mark is made on the band using a marking pencil at the site where the loop contacts the band.  Loop should not restrict any physiologic tooth movement. 2) The prefabricated loop is selected. such as the increase in inter canine width that occurs during eruption of the permanent lateral incisor. 5) The band is then removed from the tooth.

10) It is cemented using luting cement. In these cases the un erupted premolar usually is more than 2 years from clinical eruption and it s root length is less than one third mature. excess wire is trimmed and again spot welded for better stability.  Replacement of primary second molars in the transitional dentition with the permanent molar banded.14 Indications: (1) Premature loss of any primary first molar in the primary dentition or the primary first maxillary molar in the transitional dentition.  Cases that need guidance of eruption e. which indicate arch perimeter shortage on one side of arch and necessitates removal of the contra lateral primary canine in the mandibular arch for correction of the midline discrepancy44 32 .  High dental caries activity.Discussion 7) It is taken out of the mouth.  Replacement of primary anterior teeth. ectopic loss of primary canine.g. (2) Premature loss of primary second molar as the permanent first molar is erupting clinically44 Contraindications:  An occlusion that is extremely crowded or already exhibits marked space loss. 8) It is then invested and soldered as usual. 9) The appliance is trimmed and polished.

. Contraindications: 33 . - .Discussion Advantages:  Ease of fabrication for the clinician  Ease of maintenance for the patient  Adjusts easily to accommodate changing dentition44. Disadvantages: .Can‟t preserve the leeway space 44 Distal Shoe Indications: Loss of second primary molar prior to eruption of the first permanent molar.Opposing tooth may supra erupt.Does not restore chewing function.

Discussion If several tooth are missing.  The depth of intragingival extension should be 1 to 1.  This extension acts as a guide plane for the permanent Ist molar to erupt into proper position.  Piece of stainless steel is soldered to the distal end of the loop & placed 1mm below the mesial marginal ridge of the unerupted molar in the alveolar bone. abutments to support a cemented a appliance may be absent45 Fabrication  Primary Ist molar is banded & the loop extends to the former distal contact of the primary second molar.  A radiograph of the appliance should be made prior to placement to determine whether the tissue extension is in proper relationship with the unerupted permanent molar. Disadvantages 34 . Advantages Maintains the second primary molar space .5 mm below the mesial marginal ridge of the permanent molar.

The palatal portion has an acrylic button that contacts the palatal tissue which provides resistance to the mesial movement of posterior teeth. (2) Can‟t restore occlusal function because of lack of strengt (3) Histologic examination shows that complete epitheliazation does not occur after placement of the appliance45. It is similar to lingual arch except the anterior portion of the arch wire does not touch the lingual surfaces of the upper front teeth. Instead. contour the 0.Discussion (1) Because of its cantilever design appliance can replace only a single tooth. Nance palatal arch N MMNBZJ Indications:  Loss of second primary molar in the maxilla-counterpart to LLHA It is simply a maxillary lingual arch that does not contact the anterior teeth but approximates the anterior part of the palate. Then cure a small button of acrylic against this portion of the 35 .040-inch arch wire against the slope of the anterior portion of the palate approximately 1cm distal to the lingual surfaces of the central incisors to help retain the cured acrylic45.

covering the u-shaped soldered wire that act as a strengthener for the acrylic button.45 Transpalatal Arch This appliance is designed to prevent the molars from rotating around the palatal roots.50 Advantages: Maintains the tooth space and the leeway space.Discussion appliance. which is the first movement resulting in loss of space in the arch perimeter.45 36 . Disadvantages: Meticulous hygiene of the acrylic button is required. Polish the button and the solder joints where the wire joints the upper molar bands.

18 Indications: The best indication for Transpalatal arch is when on one side of arch is intact. there is a controversy that. It has been clinically observed that it satisfactorily maintain the first permanent molars in their position.8. and several primary teeth on one side are missing. The space maintainers requires banding of both upper first permanent molars and soldering of an 0. It is also indicated when primary molars are lost bilaterally.50 The Transpalatal arch has been recommended for stabilizing the maxillary first permanent molars when the primary molars require extraction. However .Discussion Cross-arch anchorage can be used if only one of the primary second molar is lost and both permanent first molars are erupted. The appliance does not use an acrylic button.Lack of acrylic button so less tissue irritation and more cleansible. The appliance is designed to prevent the molars from rotating around perimeter. which is the first movement resulting in loss of space in arch Advantage .52 .8.Hygenic 37 . It seems to gain it s efficiency through it s rigidity.040-inch blue Elgioly or stainless steel wire contoured close to the palatal surface. 18 the palatal roots. both permanent molars may tip anteriorly despite the transpalatal arch and in these cases a conventional lingual arch or Nance palatal holding arch is preferred.

May not prevent the mesial tipping of teeth. which are joined by steel wire butting against the four incisors. • LLHA should not be placed with primary incisors.Discussion . These help in maintaining the symmetry in the arch in cases of unilateral tooth loss. It helps in maintaining the arch perimeter by preventing the mesial drifting of the molar teeth and also lingual collapse of the anterior teeth. 38 .28 – Disadvantage Lack of anterior stop = possible tooth28 Lingual arch 44 It consists of two bands cemented on the first permanent molars or second deciduous molars. .Indicated for bilateral loss of primary maxillary molars. MODIFICATIONSpurs (projections of wire) can be used as stoppers distal to anterior teeth to prevent their tipping or migration distally in the arch.44 Mandibular incisors often erupt lingually and are pushed forward by the tongue.

28 Indications: (1) Bilateral loss of primary teeth in the mandibular arch during transitional dentition.Anything that would require frequent adjustments. -Extreme mandibular anterior crowding or lingually erupting succaedenous teeth. -Anterior or posterior cross bite. if mandibular teeth are contributing factors and need to be corrected prior to lingual arch placement teeth. and or poor patient cooperation.Discussion • Modified lower lingual arch with clasps to prevent distal tipping of lateral incisors.2 Advantages:  Controls antero posterior movements along with controlling and preventing an arch perimeter distortion. (3) Modified LLA with clasps to prevent distal tipping of lateral incisors.g. (2) Maintenance of arch perimeter and incisors positions. E. 39 . tooth movement or space regaining.Rampant dental caries. . by controlling the lingual collapse of single tooth or segments of arch. Contraindication: . (4) Contraindicated in primary dentition2. high plaque scores.

The soldered joint is polished and finished. Fabrication 40 . The distance between the abutment teeth is measured and marked on the wire.  May be prone to breakage unless the patient is well-informed on maintenance45 BAND AND BARIn this type of appliance both the abutment teeth adjacent to the edentulous space are banded. This should be designed to allow vertical movement of the supporting teeth consistent with normal function demands.Discussion  Maintains the leeway space45 Disadvantages:  First permanent molars may be susceptible to decalcification. The band is cemented on to the abutment tooth.44 MODIFICATION-(Band and bar) broken stress50 This appliance prevents intolerable loads from being thrust on the supporting teeth. The wire is cut and soldered on to the bands.

a vertical tube is then soldered on one crown & L shaped bar is fabricated to fit the edentulous area. exhibits marked hypoplasia.loop is similar to that of the band loop. It is usually necessary between the preparatory appointment and the insertion appointment to place a temporary crown on the abutment tooth. or has been pulpotomized. Removable of appliance for adjustments is difficult. it eliminates sensitivity and if prevents than band and closure of space between the prepared tooth and an adjacent tooth while the appliance is being fabricated. The bar is bent slightly to adjust for any interference.Discussion Stainless steel crown is fitted on the prepared abutment tooth.28 41 . The horizontal end of the bar is soldered to one of the crowns. Restores a grossly decayed abutment tooth. the crown is used in preference to the band when the abutment tooth is highly carious. Most of the space-controlling indications for the band – loop also apply to crown loop. The temporary crown serves two main purposes. The technique for use of crown. However. Stronger loop.

resin was cut of the same length. present both mesial and distal to the created space tends to drift in to the space. The shade of the natural teeth was recorded using a proper shade guide. Grooves were made on the palatal surface of acrylic tooth so as to enhance the bonding between the acrylic resin and the composite 42 . An esthetic functional space maintainer is thus fabricated to take care of the esthetics and maintain function as well. right central incisor) of the appropriate shade was selected and was trimmed properly to replace the missing tooth in an esthetic manner. Now an acrylic tooth (max. An alginate impression is made for both maxillary and mandibular arch and was poured in gypsum stone. When a primary tooth is lost prematurely the teeth. In this situation where an anterior primary tooth is lost before the schedule. The FRC strip was adapted over the palatal surface extending from the distal surface of the maxillary right primary left incisor through the distal surface of the maxillary left primary central incisor. The distance from the distal surface of the maxillary right primary lateral incisor to the distal surface of the maxillary left primary central incisor was measured on the cast and a strip of fiber reinforced composite. the drifting of adjacent teeth in to the space created rarely occurs but these results into an unaesthetic smile and difficult in biting.Discussion Anterior esthetic functional space maintainer Premature loss of primary tooth is one of the most common etiologies for malocclusion.

Discussion 43 .

A thin layer of flow able composite was also applied over the etched surfaces of the abutment teeth. The FRC and flow able composite were light cured together from the palatal aspect of the cast.Discussion resin. Bonding agent was applied and was cured. The FRC strip and the acrylic tooth were placed in position over the cast. The appliance was placed in a position and then the flow able composite was cured using a light cure unit. The occlusion was checked over the cast to remove any premature contact. Modified bonded bridge space maintainer 44 . Now flow able composite was applied throughout the length of FRC and over the palatal surface of acrylic tooth. Now the appliance was removed and the palatal surfaces of the tooth on either side of the edentulous space were acid etched.

Discussion Despite contemporary techniques. Removable appliances with a mastication area are useful for replacing several teeth. The most used are made up of wire soldered to a band. In spite of good tolerance and durability. this space maintainer is modified bonded bridge. Description of appliance In fact. But when a small number of teeth are concerned. The most probable and first evident consequence will be the tipping of adjacent teeth. unilateral mastication and lingual dysfunction. deviation of the midline. So it can be removed when needed without damage to the teeth. they do not restore a normal function. but strong enough to not decrease the strength of a fixed bonded bridge. In these cases. some Ankylosis etc. we prefer the use of fixed space maintainers. which interferes with the eruption sequences of permanent teeth. There is a large diversity of fixed space maintainers. Modifications are made in order to decrease the cost and to adapt the bridge for primary and permanent teeth. the traumatic avulsions. induce the premature loss of teeth. the teeth must be reduced. but this solution is not realistic because the cost is too high. which will induce a decrease of the available space. the adjacent tooth can be a permanent one and the chair time is too long for children.radicular infections. it does not seem possible to save all primary teeth. The inter. Teeth preparation 45 . The other consequences could be over eruption of the antagonist. the disadvantages are problematic. A good replacement should be bridge. and they require a reduction of the teeth before placing a crown. the internal resorption.

This model allows the eruption of permanent teeth. Firstly. load the injection type into the impression and around the prepared teeth and replace the tray in mouth. The buccal and lingual grooves are most useful for retention of the bridge. The appliance could be incorporated into a proximal cavity like an inlay. After having removed the tray. In fact. The wings are sand blasted prior to bonding for best retention. Bonding 46 .g. load the putty type into a bite tray and place a position in a mouth. Impression After several clinical tests and for the comfort of the children. The pontic has the form of sanitary pontic.Discussion In order to increase retention. The pontic should have an occlusal surface. Secondly. a unilateral two-stage impression with two materials is used. we dry the teeth. Teeth anatomy allows the alloy to continue to the occlusal side. slots and occlusal rests should be made. When permanent teeth are concerned. slots are made on primary teeth and rests on buccal and lingual occlusal surfaces are also made. the wings will have a large area for a good bonding and retention. either from the proximal side or the most often from the buccal groove of the mandibular first permanent molar. which respects the anatomy of the lost tooth and is adapted to the occlusion. it is necessary to remove the spacer and the gingival pack. Description of the maintainer Because of the undesirability to cut some teeth. place plastic separators between the teeth. At this stage. 2types of vinyl polysiloxane of different viscosities. permanent teeth anatomy can be used for a good stability. The alloy is made of chrome-cobalt in place of nickel-chrome beryllium. e.

and dry these teeth with air syringe. Loss of more than two primary molars. 2. Impression taking and occlusal registration. 3. Removable appliances are often preferred to distal shoes as they are simple to fabricate and place. Removable space maintainer76 Removable appliances are particularly used in cases of multiple spacing. The acceptance of removable appliances in children may be improved by using multicolored acrylics and by minimizing the number of wires needed anteriorly for retention. We rinse with air and water syringe for 30 seconds. Technique and fabrication: 1. We place the bonding material ( super-bond) on the wings and place the maintainer on the teeth with pressure. Drawing of the outline. and a recent study discussed their usage for free – end space maintenance following very early loss of primary second molars. Loss of anterior teeth. 2. Loss of more than one primary tooth bilaterally. It is a sound principle to draw the outline shorter at the buccal and labial and much wider on the lingual side. Indications: 1. removable appliances are rely on patient compliance and are less likely to be worn and can be damaged or lost more easily then fixed appliances. However.Discussion After the cleaning of teeth support and the placement of rubber dam. and by maintaining the integrity of the gingival tissues they avoid the complications of sub gingival appliances. This design 47 . we etch with phosphoric acid for 45 seconds.

Slow expansion RAPID MAXILLARY EXPANSION6.Discussion takes into consideration the lateral expansion of the jaws into growth. EXPANSION Expansion is one of the non-invasive methods of gaining space. the disto-lingual end of the appliance should be extended to the centre portion of that tooth. 3. Clasps and Cribs: It is usually unnecessary to attach clasps and cribs for stabilizing the appliance in cases where there are teeth present on the distal end of edentulous saddle. should be designed so as to be spaced about 1-2mm away from lingual surface. If there is a tooth present on the distal end of the appliance. The anterior lingual aspect of the appliance. the maxillary arch width is increased to allow normal vertical closure. -Rapid expansion . so that second primary molar or first permanent molar will provide better stability and maintenance.e. it is better to enhance the stability of the appliance by bow and or simple clasps such as the Adams clasps on the molars. 21 It is the technique of increasing maxillary arch width at it s apical base by placing heavy forces across the maxillary dental arch so that of the 48 . To correct the transverse deficiencies during the primary or transitional dentition. Increased maxillary arch width may be accomplished by palatal expansion that can be done in two ways i. thus avoiding unnecessary movement of erupting teeth. where it contacts the permanent incisors. In cases where no tooth exists in the distal end or where there is a unilateral loss of the primary molar. which involves the process of resorption on the internal surface and apposition on the external surface of the jaws.

Cleft lip and patients with collapsed maxillae are also RME candidates.  Patients who have a single tooth in cross bite. 2. patients with skeletal class11 div. 1 with or without a posterior crossbite.g. patient with class 111 malocclusions are citied as reasons to consider RME. Applications used for RME: 1. Contraindications:  Un cooperative patients. steep mandibular planes and convex profiles. Indications: 1. Removable appliance 2. Fixed appliance 49 . 3. and adults with severe anteroposterior and vertical skeletal discrepancies are not good candidates for RME. recurrent ear and nasal infection. Antero posterior discrepancies e.Discussion separation of the mid-palatal sutures occurs with induction of new bone to form in the palate and with minimal concomitant movement of posterior teeth within the alveolus.  Patients who have skeletal asymmetry of the maxilla or mandible.  Patients who have anterior open bites. 4. poor nasal airway. The medical indications for rapid maxillary expansion include nasal stenosis. Patients who have lateral discrepancies that result in either unilateral or bilateral posterior crossbite involving several teeth‟s are candidates for RME. septal deformities.

Derichsweiler type 2. Issacson type 2.Discussion 1. 50 . Banded type Tooth and Tissue born appliances 1. For these appliances to be effective. HYRAX type Removable appliances: The reliability of these appliances in producing skeletal expansion is highly questionable mid palatal spitting with such appliances is possible but not predictable. Bonded type 2. Fixed appliances a) Derichsweiler type: Wire tags are welded and soldered onto the palatal aspect of banded first premolar‟s and first molar to provide attachment for the acrylic palate incorporating a screw at it s centre. they must be used in the deciduous or early mixed dentition and must have sufficient retention to be stable during expansion phase. Hass type Tooth borne appliances 1.

The lingual wire is kept longer so as to extend past and band both anteriorly and posteriorly.mm wire is soldered on the lingual aspects of banded premolar and molar. c) Isaacson type: This appliance uses special spring loaded screw called a MINE expander. The split palatal acrylic has a midline screw. The expander consists of a coil spring having a nut 51 . These extensions are bent palatally to get embedded in the palatal acrylic. The plate does not extend over rugae area. Metal flanges are soldered onto buccal and lingual sides. The first premolars and molars are banded.Discussion b) Hass type: A thick stainless s lingual steel wire of 1.

d) Hyrax type appliance: This appliance also require a special screw called HYRAX( Hygiene Rapid Expander ) The screw have heavy gauge wire extension that are adapted to follow the palatal contour and are soldered to bands on premolars and molars.Discussion which can compress the spring. SLOW EXPANSION Slow expansion procedures incorporate force symmetrical of several ounces up to approx. 2 pounds. The slower expansion procedures increase the 52 . The expander is activated by closing the nut so that the spring gets compressed.

The appliance consists of an omega shaped wire of 1. Appliances: Jackscrews A typical expansion screw consists of an oblong body divided into two halve movements. It can also be activated by using three. placed in the mid-palatal region.pronged pliers. 53 . Each half has a threaded inner side that receives on end of a double ended screw. The spring is activated by pulling the two sides apart manually. The screw has a control bossing with 4 holes. Coffin spring is believed to bring about dentoalveolar expansion. The turning of screw by 900 brings about a linear movement of 0.18mm. Coffin spring The appliance was designed by Walter coffin around the beginning of the century. 25mm thickness.Discussion percentage of orthodontic movements as the tensile strength of the suture elements is not overwhelmed. Jack screws space regainer exerts consistent force on adjacent teeth by activation by the segment of open coil with compression lugs. the free ends of the omega wire are embedded in acrylic covering the slopes of the palate.

The addition of four helical loops to the appliance provided increase wire length for a greater range in force delivery.Discussion Quad-helix appliance: This fixed appliance was developed through modification of the W-arch. allowed for increased flexibility and also provide the ability to control molar rotations. Indications: 54 .

Space creating can be accomplished in arches with slight crowding where no space has been occurred. Nickel titanium expanders come in light different intermolar widths ranging from 26mm to 47mm that generate forces of 180-300g. with or without posterior crossbite. temperature activated palatal expander with the ability to produce light.Discussion  Correction of constricted maxillary arch. rotating and distalizing the maxillary first molars. Crowding in such situations is not the result of space loss but is caused by arch size/tooth size discrepancy. continuous pressure on the mid-palatal suture while simultaneously Uprighting. SPACE REGAINING Space regaining in the mixed dentition involves regaining lost space or creating needed space.  For reduction of arch length deficiencies. nickel titanium. It has been demonstrated that quad-helix therapy in young patients may result in intermolar width of upto 8mm. arch perimeter increases of upto 4mm have been demonstrated through early expansion of the buccal segments. Nickel Titanium Palatal Expander The fixed-removable appliance is a tandem-loop.67 55 .69.  For use a thumb habit appliance that anterior bridge area of the quadhelix may be positioned to break appliance to act as an additional reminder. It was adjustable stainless steel wire extensions and is inserted into standard horizontal lingual sheets that are spot welded to the molar bands.

arch expansion. or to a limited extent. this space can generally be regained by the distal movement of the first permanent molar. Removable devices are acrylic resins plates with active components such as finger springs or jackscrews. labial movement of the incisors. while serial extraction will be the method of choice for cases in which the space shortage is 5mm or greater.Discussion Creating additional space in a crowded arch involves increasing the arch circumference by distal movement of the permanent molars. removable or semi removable. Fixed appliances are lingual or palatal arch wires with active components. With cases in which dental decay has caused a premature loss of the primary molars and the first permanent molar has then shifted or inclined mesially. 56 . Space regaining appliances. using good clinical judgment. lip bumpers or head gear appliances. Distal movement of the posterior segment as well as mesial movement of the anterior segment is achieved. Semi removable appliances are lingual or palatal arches with the active components not soldered but attached by welded sheaths to supporting bands and labial arch wires with coil springs or elastics. Unilateral space regainer77 It is effective for opening the space where premature loss of permanent or deciduous tooth has occurred. in which space loss is between 3-5mm. the lost space may be regained by an up righting or distal movement of the first permanent molar to it s normal position. may be fixed. like space maintainers. while maintaining the arch length. Space is regained by compressing the labial and lingual NiTi open coil springs against the molar tubes. The border line cases. If the loss of space is less than 3mm. must be carefully dealt with on a case-by-care basis.

57 . TYPES OF SPACE REGAINERS .Discussion Active loop space regainer77 The active loop space regainer utilizes a finger spring that is activated by a simple adjustment of the loop.REMOVABLE FIXED a) Removable type space regainers: There are designed to produce distal movement of the first permanent molar.

which is about 3mm. By expanding the screw. Further movement can be achieved by using a second appliance with a new screw. The first permanent molar can be distalised by the maximum opening width of the screw. The force that acts to produce the distal movement of tooth is very gentle and physiological. hooks are attached on the buccal and lingual sides of the first permanent molar. This appliance is so named because of it s resemblance to a “Sling-shot”. which needs to be moved distally. 58 . distal movement of the first permanent molar is achieved.Discussion Sling. Screw type space regainer: An expansion screw can be embedded in the resin base of a removable appliance. the distal movement is limited to 12mm in distance.shot type space regainer: From the distal end of this appliance. An elastic band is slung between the hooks. The expansion of screw is performed by the patient once a week. and the tension force from the elastic band then produces the distal movement of the first permanent molar. however .

The other important criteria for their success are adequate stability is adequate stability and anchorage of the appliance. Split saddle type space regainer: This appliance is more commonly used in the lower arch.7mm wire. A distal movement of the first permanent molar is achieved by flattening the bent portion of the wire connecting the split saddles of the acrylic base plate. this appliance contraindicated where no space is present in the mesial aspect of the first permanent molar. 59 .Discussion Spring type space regainer: The distal movement of the first permanent molar can be achieved through the force produced by a spring using 0. The distal movement is limited to 1-2mm.

The „U‟ section is fitted in the tube. Assembly is removed and welded or soldered at this point. When the appliance is to be used as spring loaded space regainer tube and the wire 60 . Gerber space regainer: This type of appliance may be fabricated directly in the mouth during one relatively short appointment .Discussion b) Fixed space regainer: Lingual arch space regainer A distal movement of the first permanent molar is achieved by means of a wire spring. and the mesial surface is marked for the placement of „U‟ assembly. The occlusal rest is added to wire section to reduce cantilever effect. Anchorage is very important in assuring that sufficient force is exerted to move the first permanent molar distally. attached to the lingual side. the appliance placed and wire section extended to contact the mesial to edentulous area.A stainless steel orthodontic band or crown is selected for the abutment tooth and fitted. which may be welded or soldered in place with silver solder and fluoride flux.

cut the ligature and remove to activate regainer.determined pattern to guide the erupting permanent teeth into a amore favorable position. in contact with the mesial tooth and measuring the distance between the tube stops on the wire and the end of „U‟ tube. To this distance add the amount of space needed in the regainer.Discussion „U‟ to band. plus 1-2mm to ensure spring activation. Be sure to compress spring enough to allow the assembly to fit the edentulous area. the floss or steel ligature through eyelet and over „V‟ wire hold stored force in compressed spring. The length of the push coil spring is established by placing the band-tubewire assembly in the mouth. Serial extraction Serial extraction is an interceptive orthodontic procedure usually initiated in early mixed dentition when one can recognize and anticipative potential irregularities in the dento-facial complex and is corrected by a procedure that includes the planned extraction of certain deciduous teeth and later specific permanent teeth in an orderly sequence and pre. welded tube stops are soldered on the wire portion and open coil springs sections are cut to fit over wire between „slops‟ and ends of „V‟ tube. load springs. Effect of serial extraction on crowding17 61 . and cut springs to this length. After cementation.

The parents must be informed that. it is obvious that they reduce length of time of active appliances. M any children with arch-length inadequacy have spectacular growth when least expected and may be treated successfully without sacrificing permanent teeth.Discussion Serial extraction is based on premise that in the mixed dentition it is possible to predict whether the increase in arch size and intercanine width will not be sufficient to accommodate all permanent teeth in regular alignment. serial extraction starting from the mixed dentition stage is a valid method of treatment. Serial extractions are useful for the purpose of correcting or reducing crowding in most class 1cases. none of these is desirable. Serial extraction without accompanying orthodontic therapy has not been considered appropriate. The interval between extractions varies from 6 to 15 months. There is frequently occurrence of persistent spacing at the extraction sites. without follow up orthodontic treatment. however. After removal of the primary canines. the serial extraction procedure may not result in favorable occlusion. Serial extraction has a limited place in dental practice and requires regular 62 . Serial extraction is indicated primarily in severe class 1 malocclusions in the child with mixed dentition who has insufficient arch length for the amount of tooth material. and the first premolar last in the serial extraction procedure. the first primary molar second. there is degree of self corrections in the position and alignment of the permanent incisors. serial extractions could be used for the handicapped patients who have rejected orthodontic therapy. under appropriate indications. Furthermore. and mesially tipped second premolars. However. distally tipped canines. The primary canine is removed first. In cases of severe crowding that requires extraction. the development of closed bite. lingually tipped lower incisors.

The permanent first premolar is most often selected for extraction because it is located at a midpoint in the arch and because space it occupies can be used to correct midline problems. requiring surgical removal. molar relationships problems.78 Crowding of more then 5mm is considered severe. a planned sequence of extractions of primary and permanent teeth can benefit the patient by reducing the incisor crowding and irregularity in the early mixed dentition. This can lead to the impaction of the first premolar. it may become apparent that the permanent canine will erupt before the first premolar regardless of the extraction sequence. ad extractions are necessary to obtain a suitable occlusion that is harmony with the supporting structures and facial profile. incisor protrusion. In these cases.Discussion reassessment to determine whether the serial extraction plan should be continued. which will make subsequent orthodontic treatment easier and quicker. or crowding.45 In some cases. This amount of crowding is treated either by generalized arch expansion or by removal of selected permanent teeth. the position of the dental midline. the primary first molar and the first 63 . The decision to extract teeth is based on the factors influenced by the location of crowding. The extractions also make room for teeth to erupt over the alveolus and through keratinized tissue rather then being forced buccally or lingually into positions that may affect the periodontal health of the teeth. the primary first molar is removed but the permanent canine still erupts before the first premolar. In some children. and the dental and skeletal relationships of the patients. Similarly. Other teeth can be removed depending on the specifics of the case. In this situation. crowding is so severe in the mixed dentition that expansion is not feasible.

4) Patients with straight profile and pleasing appearance. Surgical soft tissue defects resolve infrequently. which somewhat defeats the goal of the selective tooth removal to encourage good dental alignment. Contra. Surgical removal of the teeth from within the alveolar bone should be avoided if possible because it carries the potential for creating bone and the soft tissue defects. 2) Spaced dentition. New alveolar bone will not be stimulated to form because no tooth will erupt through this area. Indications: 1) Class 1 malocclusion showing harmony between skeletal and muscular system.indications: 1) Class11 and Class 111 malocclusion with skeletal abnormalities.Discussion premolar are both removed at the same time. 3) Where growth is not enough to overcome the discrepancy between tooth material and basal bone. The primary canine is often extracted at the same time as the premolar or is left to exfoliate when the permanent canine erupts. This procedure is called enucleation because the premolar is removed from within the alveolar bone. 64 . The drawback of this alternative is that substantial incisor crowding is not readily resolved. Theses occur if the alveolar bone is fractured or removed. 2) Arch length deficiency as compared to tooth material is the most important indication for serial extraction.

A year later. Three of the popular methods are:a) Dewel‟s method b) Tweed‟s method c) Nance method Dewel’s method Dewel has proposed a 3 step serial extraction procedure. In some cases a modified Dewel‟s technique is followed where in the first premolars are enucleated at the time of extraction of the first deciduous molars. 65 . In the first step the deciduous canine are extracted to create a space for the alignment of incisors. This step is carried out at 8-9 years of age.Discussion 3) Midline Diastema 4) Open bite and deep bite 5) Extensive caries or heavily filled first permanent molars. the deciduous first molar are extracted so that the eruption of first premolar is accelerated. This is frequently necessary in the mandibular arch where the canines often erupt before the first premolars. This is followed by the extraction of the erupting first premolar to permit the permanent canines to erupt in their place. Procedure A number of methods or sequences of extraction have been described.

Discussion Tweed’s method This method involves the extraction of deciduous first molars around 8years of age. This is followed by the extraction of first premolars and the deciduous canines. 66 .

67 . Post serial extraction fixed therapy Most cases of serial extraction need fixed appliance therapy for the correction of axial inclination and detailing of the occlusion. For crowding.Discussion Nance method This is similar to the tweed‟s technique and involves the extraction of the deciduous first molars followed by the extraction of first premolars and the deciduous canines. Mandibular anterior crowding is one of the most common problems resolved by orthodontic treatment. 70 Crowding or spacing of the developing dentition has to be a prime concerns for dentists treating children. The space necessary for alignment can be obtained by a number of non extraction and extraction strategies. a spaced or crowd dentition results. procedure should be start in mixed dentition stage of development in order to use the leeway space for alignment. The accumulated sizes of each child‟s teeth may not be necessarily in a perfect relationship to the amount of space in his dental arches for the accommodation of his dentition. CROWDING20. When the accumulated sizes of teeth and the perimeter of arch are not closely correlated.

Thus the amount of crowding should be calculated and the means of obtaining this space should be determined. extraction. Treatment Gaining space Crowded teeth require space for their normal alignment. 68 . it appears to be related to the amount of crowding in the mixed dentition. A non extraction strategy can be pursued in the vast majority of the patients simply by preserving the arch length and/ or moving the mandibular molars 1mm distally. the first premolars can be immediately extracted. estimates the size of unerupted teeth are more accurate then estimates of future spacing or crowding because the perimeters of the arch does not diminish the same amount in all cases. Instead. The various methods of gaining space include proximal stripping. Or if the extraction treatment is preferred. derotation and Uprighting of posterior teeth and Proclination of anteriors.Discussion The reason for endorsing this plan of treatment is the finding that the arch length preservation can provide adequate space to accommodate an aligned dentition in the vast majority of individuals. Crowding can be easily resolved with a non extraction approach. molar distalization. an equal amount of space is required for correction. In the stage of mixed dentition. when treatment can be started in the late mixed dentition after eruption of the first premolars. On an average for every 1mm of crowding. expansion.

Discussion Use of removable appliance Once the provision for space is made. Use of fixed appliance Whenever multiple rotations of teeth are present. 69 . teeth can be moved to normal noncrowded positions by using removable appliances that incorporate coil springs. Derotation can be brought by use of derotation springs or elastics. the appliance of choice should be fixed appliance. labial bows etc. canine retractors. Retention of rotations Rotations have a high risk of relapse due to stretching of supra-alveolar and trans-septal gingival fibers which readapt u slowly to new position.