Free-end Space Maintainers Free-end Space Maintainers: Design, Utilization and Advantages Elena Barberia* / Tania Lucavechi** / Dora irdenas*** / Myriam Maroto**** Primary molars are a determining factor in the development of occlusion. Given their importance, when restora tive treatment is not feasible and a primary molar must be extracied, the practitioner should keep in mind the risk of losing space, and the consequent matocclusion. Preservation of the space can eliminate or reduce the need for prolonged orthodontic treatment, For that reason, there are various kinds of space maintainers and the pediatric dentist must decide which one to uilize, on the basis of general and local factors related 10 the child. Un the selection of a treatment option for space maintenance, the greatest complications occur when the first per ‘manent molar has not yet erupted, A large variety of appliances have been devised to deal with this situation. This article proposes the use of a removable space maintainer that is open on one end and can be employed 10 guide the first permanent molar, maintaining the inegrity of the mucous membrane and serving as a prosthetic ‘appliance, preventing the complications and contraindications offen caused by sub-gingtval maintainers. ‘Keywords: space maintainers; alterations in eruy ‘I.Clin Pediatr Dent 31(1):5-8, 2006 DUCTION. dentition plays a very important role in the child's growth and development, not only in terms of speech, chew- ing, appearance and the prevention of bad habits, but also in iting the eruption of permanent tet” Primary molars are a par vital element in the development of occlusion, and because their importance, pediatric dentists are faced with a dilemma: ‘or restoration. When restorative treatment isnot feasi- and a temporary tooth must be extracted, the practitioner should in mind the risk of losing space and the consequent malocetu- any authors" have described the effects ofthe premature loss ‘molars, including a decreased arch length, increased he Deparment of Frophyas, Piric Dette and Onhadontis. Faculty ‘Madi Complutense Univers Spain, ‘Bena Barteria, Director ofthe Program fe napa Osotslogial Treatment sf Pane Pants, Dietr of te Muster in ede Dest. iia Luevechi: Postgraduate nthe Masri Pitre Denis. Asstt Dosor on th: Program cr nicl Odontol Teameat of Pedic Praens. Cienss. Popa in the Mair in Posie Dentist an Marto. Assistant Professor Aste Dector n the Progra for ‘egrl Odontckogical Treatment of Pediatrie Patients Postgraduate in Muster ‘Peiasic Deny carespondzice shouldbe sett Elena Barteria, Dp. Estomatobogia 1. 1 Odomologia. Plaza ce Rann y Coil wn. 2800 Mal. Spain 1394199. eteis@odnscmcs n; eruption control; free-end space maintainer ‘overbite, dental malposition, impaction, arch asymmetry and alter- ations in eruption. For this reason, preservation of the dental arches should play a principal goal in pediatric dentistry." ‘There are a large number of factors that influence the magnitude Of the alterations caused by the premature loss of primary molars, among them dental age, eruption patterns, the amount of bone cov~ ering the succedaneous tooth bud, and the type of tooth lost. ‘The second primary molar is fundamental in the normal eruption and positioning of the first permanent mola" Early loss of tis tooth ccan create a major discrepancy between the space in the arch and dental size.™®"" Preservation ofthe space can eliminate or reduce the need for pro- longed orthodontic treatment: For that reason, there are various kinds of space maintainers and the pediatric dentist must decide Which one to utilize, on the basis of general and local factors related, to the child, as well asthe dentists familiarity and experience with different types of maintainers." ‘One of the important aspects to consider when choosing an appli= ‘ance for space maintenance previously occupied by a primary sec fond molar is whether the first permanent molar is erupting, or, is intraosseous or extra-osseous.*!"?*" ‘The permanent molar, under normal conditions, erupts with guid- ance from the distal surface of the second primary molar and as a resull its absence causes mesial migration, space loss anda decreased arch length:*" ‘When the first permanent molar has not yet erupted, it enais the greatest complications related to the choice of treatment options for space maintenance. ‘A large variety of appliances have been devised to guide the first permanent molar. In 1930, Willet presented the first space main-Free-end Space Maintainers tainer with a distal extension, which was called the “distal shoe,” and since then many modifications have been made. Generally this type of intragingival appliance, designed to guide the permanent molar’s ‘ruption, consists of a crown fitted on the first primary molar, and ant L-shaped bar, with an inira-alveolar extension soldered to the crown’s distal surface." This bar is submerged subgingivally in the mucous membrane and lead t0 complications in the area affecting the unerupted permanent molar" ‘Some authors’'""""contraindicate this type of appliance when several teeth are lost, when there isa history of systemic illnesses such as kidney disease, sheumatic fever, low resistance to infection, juvenile diabetes, or certain blood diseases and for patients with con- genital heart defects who need prophylactic antibiotics. In order to avoid the possibility of such complications, we pro- pose the utilization of a removable space maintainer, open at one end, that can serve as the guide forthe first permanent molar, thus preserving the integrity of the mucous membrane, avoiding compli- cations and contraindications linked to intragingival maintainers, Clinical management of the free-end maintainer A. PREPARATION OF THE PROSTHES! 1. Compilation of complementary data: models of the patient's ‘upper and lower arches and X-rays of the primary molar to be extracted, and of the permanent molar we intend to guide, This information will make it possible, subsequently, to determine the size of the free end (Fig. 1). 2. Evaluation of the permanent molar’s position. The X-ray will reveal one of two circumstances Figure 1: Complementary data is needed to determine the size of the maintainer's tree edge. Measurement of the mosio-istal distance ofthe primary molar to be replaced, Figure 3: Working model ist mmed and prepared before Bi sent to the laboratory.Figure 4: Clinical and radiographic monitoring of the length and, Figure : Impression on the gingiva produced by pressure on the supported edge. The prominence of the permanent molar can be noted as it erupts. Figure 6: The permanent molar begins to emerge. suitabiliy of the free end. Free-end Space Maintainers a. The frst permanent molars extraosseous. This situation can be identified by observing in the X-ray the total absence of bone above the molars occlusal surface, atleast in the mesial area. bb. The permanent molaris stil intraosseous. The appliance will be ‘designed and situated in the same way as the previous case, but its very important to remember that it will not begin its role OF main taining the space and guiding the eruption until the molar is extra0sseous, 3. Determination of the size ofthe free end by measuring, intraoral ly or using the models, the mesio-distal size of the molar to be replaced, if the mesial and distal walls are preserved (Fig. 2). If that isnot the case, the size must be obtained by measuring the contralat- eral molar and confirming, in the X-ray the molar to be extracted, thatthe measurement is appropriate. ‘One millimeter is always added to the measurement obtained, in order to avoid complications, This will be explained further on in this article, 4 Preparation of the working model for the Inboratory. The dentist rust cut out the molar to be replaced in the plaster I10 3mm below the gum line and parallel to the occlusal plane. The measurement in millimeters to the distal wall isthe same as the measurement deter; ‘mined forthe free end, and the cut will form a straight vestibular-tin- ‘gual plane, The distal and cervical cuts form a perfectly visible right angle (Fig. 3). This cutis the fundamental step, because it will make it possible for the prosthesis (o be placed on the mucous membrane, exerting significant pressure without cutting into the membrane. On the most distal portion, the acrylic resin should have an oecluso cervical mately 9 mum andl a vestibular-ingual thickness tal area, different from the design of any other prosthesis or space maintainer, is what will “rick” nature by simu- lating the cervical part of the root and the distal surface of the sec- ‘ond primary molar. 5, Prosthesis design. The maintainer's design is painted on the cor- responding model, specifying the positioning of the Adams clamps, double or single, and clearly writing on it the number of millimeters Of the free end, If possible, the morphology of the lost tooth should be recreated; otherwise, only acrylic resin is used. This design is sent to the laboratory 6. The molar is extracted and measures for correct healing are car- ried out B. PLACEMENT OF THE PROSTHESIS 7. No more than one week should pass from the time the tooth is extracted until placement of the prosthesis, just as with any other maintainer ‘Upon receiving the prosthesis from the laboratory, and before the patient arrives, the practitioner should confirm that the prosthesis ‘conforms to the design and is the right size. '8. The mucous membrane’s healing process is examined. Give only one week should have transpired, healing is not complete. 9. The prosthesis-maintainer is adjusted in the child's mouth: ‘a. The practitioner confirms that the distal extension is long ‘enough to make contact with the mesial surface of the first perma- rent molar. This can be verified by placing a lead protection used in periapical X-rays lining the maintainer's distal wall . The appliance i placed in the mouth and the periapical X-ray ofthe area is taken ig. 4), thatFree-end Space Maintainers Given that the size of the free end has been estimated | mm larg- er than the extracted molar, it is possible to observe that the device is situated over the tooth bud (Fig. 4). The acrylic resin must be cut {0 the appropriate dimension and the straightedge design must be ‘maintained, This is much simpler than adding on acrylic resin if the device is too short 'b. The practitioner verifies that the occlusion has not been altered, retouching the appliance if necessary. 10. The patient and parents are instructed in how to insert and clean the appliance, explaining that it should be wor all day, including ‘mealtimes. The practitioner emphasizes that the maintainer should only be removed when the patient brushes his teeth and cleans the appliance. {In addition, the practitioner continues to take proper measures to aid in the healing of the mucous membrane. C. FOLLOW-UP. 11. Healing is checked within a few weeks. At that time, the mouth's ‘adaptation tothe appliance is observed and adjustments are made if ‘necessary. At this time, the clinical image is usually very character- istic: the acrylic resin has made an impression in the gingival tissue (Fig. 5) resulting from the pressure exerted by the maintainer on the ‘edge. This indicates that the maintainer is functioning properly. 12. Follow-up visits should be approximately every two months, in ‘order to observe the progress ofthe first permanent molars eruption, When the maintainer is placed before the tooth bud becomes ‘extraosscous, it must be monitored even more rigorously, because the bud may present a. mesial migration in which case the prosthe- sis will imerfere with the eruption. If there isa high risk of mesial ‘migration at an early stage, screws or other accessories can be added, for use when needed. 13. When the tooth begins to emerge, the appliance is maintained ‘and the practitioner verifies that it does not create any interferences (Fig. 6) 14. Once the first permanent molar has erupted sufficiently, a den- tally supported maintainer should be utilized. A basket crown or a lingual arch can be employed, or altematively the same prosthesis ‘can be transformed into a dentally supported maintainer, incomporat- ing into its design an Adams clasp into the first permanent molar, DISCUSSION ‘Asa result of the complications involved withthe use of intragin aival maintainers" and as an altemative to these, proprioceptive ‘maintainers have emerged, with the objective of taking advantage of the periodontal ligament’s capacity for proprioceptive reception." ‘Theoretically the terminal end of this maintainer exerts pressure which is received by the neuromuscular spindles in the area, also called proprioceptive receptors, which absorb directional informa: tion regarding the ooth's eruptive movement, hypothetically permit. ‘ing an eruption without mesial migration. ‘The success of this maintainer is determined by the efficiency in which it serves as a guide for the emengence of the unerupted frst permanent molar~ sagitaly, transversely and even vertically ~ px venting the extrusion of antagonists, In their clinical practice, the ‘authors have confirmed the effectiveness of this appliance on numer us occasions Furthermore, given that these patients are children with great saries tendency, this removable maintainer has the advantage tht it is ewsy (© clean, unlike intragingival maintainers. However, j requires a high level of cooperation onthe chills par and stong support from the parents to motivate the children to use it ‘The follow-up, subsequent adjustment and maintenance carried ‘ut by the dentist is somewhat more complex than what i required with other removable maintainers, but it is easy when compared with the clinical management of intragingival maintainers In regard to cost effectiveness, these maintainers must be replace for readapted when they have fulfilled their function as eruptive ‘Quides and the permanent molar has erupted. eeBibliographic References 1. Barberia Leache E, Boj Quesada JR, Catala Pizarro M, Garcia Ballesta C, Mendoza Mendoza A. Odontopediatria, "ed, Barcelona: Masson Ed. (2001). 2 Ngan P, Atkire RG, Fields H. Management of space problems in the primary and ‘mixed dentitions. J Am Dent Assoc 1999;130 (9):1330-9. 3. Ostos MJ. Mantenedores de espacio intragingivales. 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