Lecture 8&9 1st term

Pedo
yyyy

Preventive orthodontics
Preventive Orthodontics
► It is the actions taken to preserve the integrity of the arches, alignment &harmony of dentition to maintain normal
occlusion.
 The goal of preventive orthodontics :
 Preservation of health and integrity of primary teeth to guide the permanent successors to their normal position.
 Stability between skeletal, dental, and muscular components.
 Prevention of environmental influences on malocclusion like sucking habits, abnormal muscle function, and
occlusal prematurities.
 The practice of preventive orthodontics : knowledge & skill
 It involves early diagnosis of any dental problem through
of the dentist
periodic clinical examination, taking radiographs, and use of study
models in addition to the dentist's knowledge and skill. This includes : Practice
1- Dental care to primary teeth such as fluoride application & pit of
and fissure sealants.
2- Early detection and treatment of carious lesions by properly
Preventiv
contoured restoration especially proximal ones to avoid mesial e ortho.
Patient Parents
shift of distal teeth and decrease in arch length. motivation instruction
3- Early recognition of deviation in eruption pattern and abnormal
root resorption, retained teeth or roots to identify any risk
factors that may lead to malocclusion.
4- Early recognition and elimination of undesirable oral habits that interfere with the normal development of teeth
and jaws.
5- Removal of the supernumerary or ankylosed tooth if the successor is present.
6- Occlusal equilibration& removal of any premature contact.
7- Instructions for health care of the pregnant mother to achieve normal tooth development of the child.
8- Advice for the proper nursing technique which will influence the functional and psychological development of
the child.
9- Encourage breastfeeding of the baby and use proper anatomical designed bottle nipples and pacifiers because
dental changes created with improper nipples or pacifiers like changes created with thumb sucking.
10- Placement of well-constructed space maintainers when extraction of primary teeth is unavoidable.

 Knowledge :-
o Spacing  Important for providing the mesiodistal width between permanent and primary teeth, so it will
make good alignment of dentition in the arch.
o Double raw (‫ )صفين من األسنان‬ (Lower anterior teeth erupted lingually, the tongue pushes them forward
(primary teeth out of occlusion must be extracted).
o Mesiodense teeth  Must be removed because they affect the arch length.

Spacing DoubleMesiodense
raw teeth
 skill
Batch 49
1
 Lecture 8&9 1st term
Pedo
yyyy

o Return the proximal contact area to normal after class II.

o Permanent teeth have contact point and primary teeth have wide area, so if we leave
caries or open contact, Mesial shift will occur so we will need more space to
accommodate the permanent teeth so we should make perfect restoration (loss ‫عشان يقل‬
‫)الـ‬.
o If a patient comes with space between primary teeth, hurry to put space maintainer
until the eruption of the permanent teeth.
o Able to eliminate habits like thumb sucking, pacifier habit and mouth breathing :
 Thumb sucking :
Ä makes the buccinator muscle push the upper arch.
‫ مش‬constricted maxilla ‫ و‬protruded anterior upper teeth ‫ هتعمل‬short lip ‫ و مع‬constricted ‫فـ بتخليه‬ 
.ectopic ‫لكل األسنان و هيكون فيهم‬ accommodation ‫هتعمــــــل‬
 Mouth breathing :
Ä high palate.
.arch ‫ و هيأثر على الـ‬malocclusion ‫) هيعمل‬balance of muscles & tongue in the oral cavity ( ‫مع عدم وجود‬ 
 Pacifier habit :
Ä The pacifier should be chosen anatomically, if not it will do the
same problems of thumb sucking.
Ä The Rose one is better than the green because its shape like the
palate and it is very thin.
Ä Withdrawal with pacifier is much easier than thumb sucking.
 Parents / Patient instructions :- (Child under control from parents)
o They must know tooth brushing, pit & fissure sealing  Caries‫ هيقلل الـ‬.
.‫ مع الطفل‬balanced diet ‫هقول لألم إنها تستخدم‬ o
‫ يبقي نديله بدون سكر‬.. ‫ ولو الزم‬bottle feeding at night ‫و بالش‬ o
‫ هيبقي في سنان كتــيرة‬rampant caries ‫عشان لو وصلت لمرحلة الـ‬
.preventive ortho ‫عايزة تتخلع و ده عكس‬
‫ عشان لما بناكلها مش بيـّد ي‬sticky food between meals ‫بالش‬ o
‫ و بكــدة مش‬washing & naturalization ‫ تعمــل‬saliva ‫وقت للـ‬
.health of teeth ‫هنكون حافظنا على الـ‬

Premature Loss
Ä A tooth is maintained in its
correct relationship in the
dental arch because of the action of a series of forces (figure 1), if one of these forces
is altered, shifting, or tilting of adjacent teeth and the development of space problems
may occur.
Ä The harmful effects of premature loss of one or more primary teeth1:vary
Figure Thein patients
tooth is
of the same age and dentition stage. Most space loss usually occurs within the
maintained in itsfirst 6 months following tooth loss,
and it can occur as early as a few days/weeks. correct relation with a
 Causes of space loss : series of forces.
1- Interproximal caries is the most common cause  (should be controlled by
fluoride & pit and fissure sealing or make cavity then put restoration specially
with GIC).
2- Early exfoliation of primary teeth (hypophosphatasia, prepubertal periodontitis)
 (affects bone → soft, Root → resorbed) make the environment not well
mineralized, results no support from the bone.
3- Ectopic eruption.
Batch 49
2
 Lecture 8&9 1st term
Pedo
yyyy

4- Trauma or infection  (in primary donation can alter the alignment of

teeth & space loss).
5- Loss of interproximal contact, (e.g. teeth rotation).
6- Unfavorable sequence of eruptions.
7- Ankylosed tooth  (Ruin the pathway of eruption of permanent teeth).
.permanent teeth ‫ بتاع الـ‬eruption ‫ فـ تأثر على الـ‬ankylosis ‫ عشان ممكن يحصلها‬reimplantation ‫لو سنة الطفل وقعت بخاف أعمله‬ 
implant ‫ وال‬ortho ‫ ولو مش موجود بحافظ على السنة ألقصي وقت لحد ما اشوف هشتغل‬.. ‫ موجود وال ال‬Successor ‫ عشان اشوف الـ‬X-ray ‫فـ بعمل ف الحالة دي‬ 
.space maintainer ‫ و نحط‬extraction to ankylosed tooth ‫ ولو موجود هعمل‬، ‫وال ايه‬
8-Leukemia  (observed from Inflammation & ulceration).
Ä makes abscess in the sound teeth.
Ä Abnormal leukocytes in blood enters nerves → stagnation → thrombosis → death of tooth due to cut of blood
supply.

 Effects of premature loss of primary teeth :

 As a general rule, premature extraction of primary teeth can lead to :-

1- The tooth mesial and distal to the space tends to drift or be forced into the resulting
space (Mesial drift or tilting of adjacent teeth that can affect occlusion by the
presences of premature contacts).
2- The antagonistic tooth to the edentulous space can also over erupted.
3- Loss of arch length and arch circumference. Drifting of teeth due to permanent loss
4- Falling in the anterior segment toward the affected side with resultant
alteration in the overjet and overbite relationship.
5- The possibility of midline shift to the affected side.
6- Development of abnormal oral habits (tongue thrust) and subsequent imbalance muscle
function.
7- Delay or early eruption of the permanent successor.
8- Extrusions of opposing tooth.
9- Speech problem & chewing disability especially the anterior loss.
10- Esthetic and emotional problems.
 Early Loss of Primary Teeth :
 The earlier the extraction and the greater the crowding the more severe will be the loss of space in the dental
arch.
 Space loss : E > D > C
 Anterior teeth loss : Not critical.

 The concern of parents when the anterior teeth are missed  the child looks ugly, or the speech isn’t good.
 The concern of dentist when the anterior teeth are missed  the socket of teeth will be filled by reparative bone and the
soft tissue will be dense, so we will have to do incision to make the eruption pathway and then make modified Nance
appliance.

.lingual ‫ يعني األسنان هتتحرك‬falling in anterior segment ‫ و بيعّض على شفايفه هيحصل‬hyper mentalis muscle ‫ وكمان عنده‬loss canine ‫ لو الطفل عنده‬

 Prim. Incisors  Little Impact.

Batch 49
3
 Lecture 8&9 1st term
Pedo
yyyy

o Loss of primary incisors ordinarily is not a matter of concern

because the mesial movement of adjacent teeth is not generally expected, and space loss is rarely observed. The
main concern is based on aesthetics, speech, and function.
o The major consequences of early loss of maxillary primary incisors are delayed eruption of permanent successor
(as the dense connective tissue and reparative bone cover the site), and potential development of deleterious
habit.

Batch 49
4
 Lecture 8&9 1st term
Pedo
yyyy

 Prim. Canines  Unilateral loss = Centre line shift, Mesial Drift Posteriors, Anterior collapse.
oEarly loss of primary canines is more common due to ectopic erupting of lateral incisors especially when there is
deficiency in the arch length rather than caries. Unilateral loss of the mandibular primary canine is frequently
followed by a midline shift toward the side of loss; the immediate extraction of the other primary canine should
be considered to help maintain arch symmetry.
o In the mandible, premature loss of primary canines may allow the permanent incisors to align themselves at the
expense of the primary canine spaces leading to loss of arch length, blocking out the permanent canines and
lingual collapse of the anterior segment may result, particularly if there are abnormal mentalis muscle activity
premolars.
o In the maxilla, the problem is similar, but the variation in the sequence of eruption and permanent cuspid's
position enhances its chances to move labially, in addition to the distal orthodontic movement of the first
permanent molar to provide room for better placement of cuspids and premolars.
 1st Prim. Molars  Unilateral loss = Centre line shift, Mesial /Distal Drift. (Figure 2)
o The effect of premature loss the of first primary molars is not serious as the loss the of second primary molars;
the severity of the problem depends on the stage of occlusal development, sequence of eruption of succeeding
teeth, and dental age of the patient.
o Arch perimeter loss is most likely to occur when the first
primary molar is lost very early. The potential for space
loss is greater during the eruption of the first permanent
molar, strong eruptive forces of the erupting tooth push
the second primary molar forward into the space
required for the first premolar. In addition, distal and
lingual drifting of anterior teeth may occur.
o If the first primary molar is lost after the eruption of the
first permanent molar, there is less tendency of space
loss due to the intercuspation of permanent molars and
the presence of second primary molars that
prevent excessive mesial migration, in addition Figure 2: Changes due to
to the early eruption of the first premolar. premature loss of lower
 2nd Prim. Molars  Significant Mesial Drift first primary molar.
of 1st Perm. Molar.
o The premature loss of this tooth creates a greater chance for loss of space than any other primary tooth because
they normally serve as a buttress for permanent molar eruption.
o The timing of the loss of the lower second primary molar is a determining factor in the type of movement seen;
when the second primary molar is lost before the eruption of the first permanent

molar, the translation of first the permanent molar during its eruption into the space, causing impaction of the
second premolar may be seen.
o Loss of the second primary molar after the first permanent molar eruption time allows the maxillary first
permanent molars to displace mesial drift and mesio-palatal rotation around its palatal root. Whereas the
mandibular first permanent molars display mesial drifting and tipping, resulting in space loss and reduced arch
perimeter.
 Multiple loss of primary molars 
o The multiple loss of primary molars in the primary or mixed dentition will invariably lead to severe mutilation of
the developing dentition unless an appliance is constructed to maintain the relationship of the remaining teeth and
to guide the eruption of the developing teeth. In addition to arch dimension concerns, reduced masticatory
function is undesirable from a nutritional standpoint.

Batch 49
5
 Lecture 8&9 1st term
Pedo
yyyy

Ectopic eruption & crowding

Extraction of E E Extraction before D Extraction after 7 years, D Extraction before 7

later, eruption of 6, no space maintainer years, must put space
because there is good maintainer because
slight shift of 6 6 may erupt tilted interdigitation between there will be delaying in
upper & lower 6 eruption of 4 from 6 to 8
 Loss of First Permanent Molars : months
o The loss of a first permanent molar in a child can lead to changes in the dental arches including diminished local
function, drifting of teeth, and continued eruption of opposing teeth.
o More forward bodily movement of the second permanent molar will occur with loss of the first permanent molar at
the age of 8–10 years if the loss occurs before the eruption of the second permanent molar and there is an excellent
chance that the second molar will erupt in an acceptable position. This is often the more satisfactory, even though
there will be a difference in the number of molars in the opposing arch. In this situation, orthodontic evaluation is
indicated.
o If the loss occurs after the eruption of the second permanent molar, exaggerated mesial tipping of the second
permanent molar can be expected and there is a tendency of premolars to drift distally, holding the space for
replacement prosthesis is usually the treatment of choice.
o The decision of whether to allow the second molar to drift mesially or to guide it forward in an upright position
may be influenced by the presence of the third molar of normal size.
Loss of 6
Badly caries &
remaining root

oral cavity ‫ فـ بيأثر على الـ‬lower ‫ و‬upper ‫ بين الـ‬harmony ‫ كامل هيأثر على الـ‬primary side ‫لو خلعت‬
.‫كله‬

 AAPD Guideline :
 Poor treatment prognosis of FPM.
 Class I Occlusion.
 No missing permanent teeth.
 Dental age 8–10 years (7is not erupted yet, 7 makes severe tilting).
.extraction ‫ وال‬endo ‫ عشان أحدد هعمل‬ortho ‫ و‬endo ‫ مع قسم الـ‬consultation ‫ بعمل‬hopeless ‫لو األشعة‬

Batch 49
6
 Lecture 8&9 1st term
Pedo
yyyy

A problem in 6, so if Loss of 6 but 4 & 5

5 is not erupted, we are erupted
must put space 7 is not erupted yet so
maintainer it will erupt forward
with slightly spacing
or completely bodily
movement

 Factors influencing the rate of space loss : 6 ‫ بتحصل في أول‬space loss ‫أكتر‬
1- Oral habits/Abnormal oral musculature ‫شهور‬
Ä Thumb or finger habits and abnormal high tongue position coupled with a strong
mentalis may accelerate the rate of space loss.
2- Existing malocclusion
Ä The degree of crowding is directly related to the rate and extent of space loss after
premature extraction of primary teeth.
3- Age of the child (Dental age ‫)األهم هو‬
Ä The earlier a tooth is lost, the greater the opportunity for drift and space loss.
4- Stage of occlusal development
Ä In general, more space loss is likely to occur if teeth adjacent to the space are actively
erupting.
block of pathway of 6 ‫ عشان هيعمل‬eruption ‫ محصلوش‬6 ‫ ولسة‬E ‫يعني مينفعش أخلع‬

 Space maintainer :
 It is an intra-oral appliance used to preserve arch length following the premature loss of primary teeth/tooth and
allows the permanent teeth to erupt into proper alignment and occlusion.
 It Prevents undesirable tooth movement (maintain space) following the premature loss of a primary tooth, but when
the space has been lost, space regainer is indicated. i.e. Mesial migration of posterior segments and lingual collapse
of anterior segments.
 When Space Maintainer may not be Required ?
 If there is :
1. Existence of cuspal interference.
2. Widely spaced primary dentition.
3. Succeeding tooth is expected to erupt within 6 months.
4. Present space is not adequate for the succeeding tooth.
5. The possibility of future orthodontic work.
6. When the opposing first molars are locked into a desirable and stable
relationship.
 Ideal Prerequisites of Space Maintainer :
 Simple to construct and maintain.
 Durable, strong, stable.
 Passive not interfering with :-
 Growth and development.
 Eruption of permanent teeth.
Batch 49
7
 Lecture 8&9 1st term
Pedo
yyyy

 Occlusion of remaining teeth.

 Speech, mastication, hygiene, or esthetic.
 Easily cleanable, not enhance dental caries or soft tissue pathology (Not cause damage to teeth nor injury to soft
tissue).
 Readily adjustable.
 Maintain the desired mesiodistal and vertical dimensions of the space.
 Prevent over-eruption of opposing tooth.
 The individual functional movement of the teeth must be maintained.
 Factors to be considered before planning for space maintainer :
or when should a space maintainer be placed ?
(1) Time elapsed since loss of primary tooth :-
 The greatest amount of space closure may occur during the first 6 months after loss of primary tooth, in fact a
decrease in space is evident in many patients within a matter of days.
 So, the best time to insert a space maintainer is immediately after extraction.

(2) Dental age of the patient :-

 The chronologic age of the patient isn’t as important as developmental age.
 The teeth erupt when ¾ root is developed regardless of the child’s chronologic age.
 It was indicated that, the loss of primary molar before 7 years of age will lead to delay emergence of the
succedaneous loss within 6-12 m of normal exfoliation time , whereas the loss after 7 years old of age leads to an
early emergence, because of the developing tooth begins to move occlusally at that age.
(3) Amount of bone covering the unerupted tooth :-
 Space maintainer is required when there is sufficient thickness of bone over erupting Succedaneous tooth.
 An erupting premolar usually requires 4-6 months to erupt or move through 1 mm of bone as measured on a
bitewing radiograph.
 When the bone coverage is destroyed by infection, eruption is accelerated, and the teeth may even sometimes erupt
with minimum of root formation.
(4) Sequence of the eruption of teeth :-
 It is important to observe the relationship of developing and erupting teeth adjacent to the space created by the
ultimately loss of a tooth.
 For example: if the second primary molar has been lost premature and the second permanent molar ahead of the
second premolar in its eruption, there is a possibility that the permanent molar will exert a strong force on the first
permanent molar, drifting it mesially and occupy some of space requires for second premolar.
x- ‫ زي صورة الـ‬5 ‫ أكتر من الـ‬occlusal plane ‫ أقرب للـ‬7 ‫ وكان الـ‬،‫ بدري‬E ‫ يعني لو ُفِقَد الـ‬
‫ في الـ‬mesial ‫ ليه ناحية الـ‬drifting ‫ فيحصل‬،6 ‫ بيضغط على الـ‬7 ‫ في الحالة دي الـ‬، ray
5 ‫ عشان الـ‬space maintainer ‫ بعمل‬E ‫ ولكن الحل إن بعد ما أخلع الـ‬،E ‫ بتاع الـ‬Space
.‫ بتاعه‬path of eruption ‫يظبط الـ‬

(5) Congenital Absence of the permanent tooth :-

 If the second permanent premolar is congenitally
missed, the dentist must decide whether hold the space after extraction of
the second primary molar until a fixed replacement can be provided or extract the second primary molar at age of
7-9 years and allow the first permanent molar to drift mesially this can produce partial or complete space closure.
(6) Cooperation level of child and parents :-
 Explain the existing condition to the parents and discuss the possibility of future malocclusion if the space is not
maintained.
(7) Ankylosed primary teeth :-
 Ankylosed primary teeth usually become retained or submerged causing drifting of adjacent teeth and space loss.
Batch 49
8
 Lecture 8&9 1st term
Pedo
yyyy

 This can delay the eruption of permanent teeth or deflect it from the
normal eruption path. In this case, ankylosed tooth must be removed and put space maintainer.

(8) Space available in the arch :-

 Space maintainer is indicated when there is adequate space after premature loss of primary teeth.
 If drifting of teeth and space closure has occurred, space regainer is constructed to regain the lost space prior to
holding space maintainer.
 Diagnostic aids/Guideline :
 Careful diagnostic and selection of cases will assure a higher percentage of satisfactory treatment results.
(1) Radiograph :- To observe
 Sequence and pathway of eruption.
 The stage of tooth development.
(2) Profile :-
 An evaluation of the patient’s profile is important in determining his facial growth pattern.
 Space management is most successful in skeletal class I pattern.
(3) Study Models :-
 Study models enable accurate measurement of the dental arches and spaces available for permanent teeth.
(4) Arch length Analysis :-
 Three main approaches have been used to estimate the mesiodistal crown width of the permanent canines and
premolars in the mixed dentition :
I. Nance Analysis.
II. Moyers Analysis.
III. Tanaka Johnston Analysis.
I. Nance Analysis :
 The length of the dental arch from the mesial surface of one mandibular first permanent molar to the mesial surface
corresponding tooth on the opposite side is always shortened during the transition from the mixed to the
permanent dentition.
 This is due to mesial shift.
 Nance was the first to quantify radiographically the space differential between primary canines and molars and
their successive unerupted canines and premolars seen in radiographs.
 He noted that the differences between the total mesiodistal width of the three primary teeth and the corresponding
permanent teeth are 1.7mm per side in the mandible and 0.9mm in the maxilla.
 The procedure of Nance analysis includes measuring the width of the erupted four permanent incisors from the
study model and the width of the un-erupted permanent canine and premolars from the periapical radiograph, then
adding together to get the required space needed for accommodation of all the permanent teeth anterior to the first
permanent molar.

 Determine the available space or eruption of the permanent teeth by measuring the distance from the mesial
surface of the first permanent molar on one side to the mesial surface of the corresponding molar on the other side
using brass wire.
o If required space equals available space i.e., arch length adequacy.
o If required space is more than available space i.e., crowding.
o If the required space is less than the available space i.e., spacing.
Space available > space ‫ لو طلع الـ‬، ‫ هطرحهم من بعض‬، Space available and Space Required ‫دلوقتي انا معايا الـ‬ 
.arch ‫ في الـ‬crowding ‫ لكن لو العكس هيحصل‬، permanent canines & premolars ‫ لطلوع الـ‬، ‫ إذن المسافة كافية وزيادة كمان‬، required
o Currently, the Nance arch length analysis is seldom used because the involved procedures for this analysis require a
complete set of periapical radiographs.
II. Moyers Mixed Dentition Analysis :
Batch 49
9
 Lecture 8&9 1st term
Pedo
yyyy

 The analysis is based on a probability chart or tables (figure 3)

at which the sum of lower incisors since they erupt early with less size variation than the upper was used to predict
the widths of the unerupted permanent canines and premolars (required space) at various levels of probability.
 Measure the available space in the arch for the eruption of the permanent canine and premolars from the distal
surface of the lateral incisor to the mesial surface of the first permanent molar in each quadrant, then the two
measurements are compared to estimate the adequacy of space for unerupted permanent canine and premolars.
 Moyer's analysis has the advantage of being easily completed in the mouth as well as on the cast and can be used
for both arches.
‫ بنفس فكـــرة الــــلى قبلـــه وعن طريـــق القيمـــة اللي بيطلعهـــا بيقارنهـــا بالـ‬mouth ‫ أو من الـ‬model ‫ من على الـ‬lower incisors ‫ بتـــاعت الـ‬width ‫بقيس الـ‬ 
.permanent canines & premolars ‫ بتاع الـ‬width ‫ وبيتنبأ بالـ‬،‫ بتاعه‬probability table

‫ركز على‬
%75

III. Tanaka Johnston Analysis :

 It is a variation of Moyer’s analysis except that a predication table is not needed. Figure 3: Probability
 The sum of the width of the mandibular permanent incisors is measured and divided chart used for Moyer
by 2. mixed dentition
analysis.
 For the lower arch → 10.5 mm added to the result.
 For the upper arch → 11 mm added to the result.
 The width of 3, 4 and 5 teeth is called Estimated Width ,calculated by adding 11.0mm and 10.5 mm respectively
to the half sum of the width of the mandibular permanent incisors.
 Then add the calculated canine and premolar on both sides (required space) and compare with the available space
to give positive or negative arch space.
 The Best space maintainer is the tooth structure.

 Classification of Space Maintainer :

 According to the Hitchcock space maintainer, may be classified in various ways :-
1. Removable, Fixed & Semi-fixed.
a. Removable :-
o e.g., acrylic partial denture (figure 4).
o Removed and inserted by patient.
o Modifications of Hawley retainer design.

o It can be functional or non-functional. Figure 4: Removable space maintainer.

 Functional  tooth Provided to aid in mastication, speech and esthetics.
 Non-functional  only an acrylic extension edentulous area to prevent space closure.

Batch 49
10
 Lecture 8&9 1st term
Pedo
yyyy
Advantages Disadvantages
1. Restore function. 1. Needs cooperative patient.
2. More esthetics. 2. Liability to breakage(high failure rate).
3. Prevent tongue habit and speech problem.
4. Easy to clean.
5. Restore vertical dimension. 3. Restrict lateral growth of jaw if clasps are made
6. Stimulates eruption of permanent teeth. incorrectly.
7. Band construction is not necessary, thus reduce the
chair side time.
8. Room can be made for eruption of teeth without
4. May irritate the soft tissues.
making a new appliance.
b. Fixed (figure 5) :-
 The band cemented to the teeth and cannot be removed by the patient and
include :
o Band /crown and loop.
o Band /crown with distal shoe extension.
o Lingual arch. Figure 5: Fixed band and
o Transpalatal arch / Nance appliance. loop space maintainer.

Crown and loop Band and loop Band with distal shoe extension

Transpalatal Arch
Lingual arch Nance Palatal Arch

Advantages Disadvantages
1. Under complete control of the dentist. 1. Doesn’t restore chewing function.
2. Not prevent the continued eruption of the
2. Usually no breaking problem.
opposing teeth.
3. More hygienic.
3. Needs a good patient recall system for frequent
4. Allows the eruption of permanent teeth. check-up

c. Semi- fixed :-
 It can be made semi-fixed by welding a molar tube on the bands to
allow the arch wire to pass into the tube instead of soldering to the
band (the distant end of the lingual arch is placed in lingual sheath

Batch 49
11
Figure 6: semi-fixed type.
 Lecture 8&9 1st term
Pedo
yyyy

(tube) present on the molar band, and it is tied with ligature wire). In
this type, part of the design (band) is fixed, and the other part (arch wire) is removable (figure 6).
 Advantages : The ease of adjustment of the appliance intraorally.
2. Functional & non-functional :-
Function Fixed space maintainer :
 A partial denture is a functional maintainer that can restore
mastication, resist forces of occlusion, and prevent over-  Add teeth for:
eruption of the opposing teeth. The rest of the space  esthetic & speech (anterior).
maintainers are non-functional.  mastication (posterior).
3. Active & passive :-
 The passive maintainer does not exert any force, while the
active exerts force to regain the space loss called the space
regainer.
4. With or without band :- Fixed bridge Modified Nance

 The arch wire forming the loop may be soldered to the band or bonded with composite resin on the
abutment teeth mesial and distal to the extracted space called bonded space maintainer.

Space Maintainer for First Primary Molar

I. Unilateral Space Maintainer :-
1) Band & Loop Space Maintainer (Cantilever) : [‫]ناحية ثابتة و ناحية بتتحرك‬
 Used when single tooth is missing in the posterior segment.
 It can also be given in bilateral posterior tooth loss, before the eruption of permanent anteriors in the
mandible, where two band and loop space maintainer can be used instead of removable or arch wire space
maintainers because the permanent incisors erupt behind the primary incisors and the arch wire may interfere
with the eruption (figure 7).
two ‫ إلن في الحالــة دي عنــدي‬four anterior teeth ‫ على الـ‬rested ‫ (لسه هيتشرح قدام) إلن هــو بيكــون‬lingual arch ‫ مينفعش هنا أعمل الـ‬:‫ملحوظة‬ 
wire ‫ فلما تطلع وتالقي الـ‬lingual ‫ بتطلع‬permanent lateral ‫ وأصال الـ‬permanent central incisors and two primary lateral incisors
.‫ بتاعها‬eruption ‫ عن مكان الـ‬deflection ‫هيحصلها‬

Figure 7: Band and loop space maintainer.

 Construction :-
 Choose the stainless-steel band (Preformed or custom-made), adapted it on the abutment
tooth, and extend 1 mm subgingivally.
 Alginate impression of the arch is made, then the band is removed from the tooth and placed in
the impression with an occlusal portion of the band facing towards the alginate and secured
with wax, and a stone cast is prepared.
 Loop is formed with 0.8/0.9 mm hard round stainless, extending from the middle of the band
from either side to reach the distal surface of the anterior abutment tooth just below the
contact point and above the gingival margin (figure 8).
 The loop is then soldered to the band, finished and polished.
Batch 49
12
 Lecture 8&9 1st term
Pedo
yyyy

 The band
is

cemented with glass ionomer or polycarboxylate cement.

Figure 8: Construction of band and loop.

2) Crown & Loop Space Maintainer :

 A crown is replaced instead of a band when the abutment tooth requires the
placement of a crown for some reasons such as gross caries, hypoplastic tooth or,
an endodontic treated tooth (figure 9).
 Stronger than band and loop.
 Cementation failure or loss is less likely. Figure 9: Crown and loop
 Excellent choice if tooth needs a restoration. space maintainer applied
 Disadvantage : The crown is difficult to remove if solder joint fails or the wire after premature loss of
breaks (better to fit a band on the crown). right primary first molar.
‫ وبنستخدمه في الحاالت اللي اتقالت دي لكن له عيوب وهي أنه لو‬crown ‫ ب‬band ‫ لكن هستبدل‬band and loop ‫نفس فكرة‬
‫ ف لو‬section ‫ وقع ف علشان أشيل الكراون هضطر اعمله‬loop ‫ يعني‬point of soldering ‫ علي‬fracture ‫حصل‬
‫ مش كراون‬tooth structure ‫ عادي كأنها علي‬loop ‫ فك هنسي اني حاطة كراون بقا واجيب باند جديدة واركب‬soldering
‫ بتاعه مش عالية وهيحصله‬durability ‫ ألن‬cement ‫ ومينفعش احط‬metal to metal ‫ النه‬adhesive ‫والزم استخدم‬
dissolution

3) Transpalatal Holding Arch (TPHA) : It can be used like a Nance.

 It is used when there is unilateral loss of primary molars in the upper arch for stabilizing the maxillary permanent
molars.
 The best indication of transpalatal arch is when more than one primary tooth is missing on one side and the other
side of the arch is intact. This type is not preferred to be used in bilateral loss as both the permanent molars can
rotate and tip mesially simultaneously.
 The arch wire extends from the palatal aspect of the band, cross the midline transversely at
right angles to the mid palatine raphe (figure 10).
 Advantage : Lack of acrylic button so less tissue irritation and more cleansable.
 Disadvantage : Lack of anterior stop=possible tooth shift.

‫ في حالة‬inter molar area ‫ماشي بالعرض بيوسعلي‬ Figure 10: Transpalatal arch space maintainer.
arch ‫ ل‬constriction ‫أن ف‬

‫ وممكن‬unilateral loss mainly ‫يستخدم في حالة‬

‫ أساسي‬uni ‫ بس ف االم سي كيو‬bi ‫يكون‬

Batch 49
13
 Lecture 8&9 1st term
Pedo
yyyy

most posterior abutment ‫ بحطها علي‬band ‫المفروض أن‬

4) Modified Types : ‫ ف مش‬partially erupted 6 ‫ ألن‬reversed ‫لكن هنا هتبقي‬
 Verse crown/ band & loop (figure 11 A) :- ‫ ليا بس‬guide ‫ ك‬anterior ‫هعرف احط عليه باند ف هحطها علي‬
 This situation usually arises when the distal abutment tooth is ‫ اشيله أو اقلبه‬6 ‫ ل‬full eruption ‫وممكن لما يحصل‬
not fully erupted, so the mesial abutment tooth is banded or
crowned, and the loop is extended distally.
 Band & bar space maintainer :-
‫ هعمله كأنه بيحرسها كدا‬abutment ‫ وف‬D ‫لو عندي مشكلة ف‬

 Instead of a cantilever design both the abutment teeth are

banded, and the bar is placed in between them instead of a loop, but it may interfere with the eruption of the
permanent tooth as the bar is positioned on the center
of the ridge (figure 11 B).

 Open - Face space maintainer :- Figure 11: A) Reverse crown and loop. B) Band and bar space maintainer
 Stainless steel crown was used to restore the distal
abutment tooth which the space maintainer also indicated. At the same time, a fixed space maintainer (loop) was
attached between the window in the facial surface of the crown and the other abutment tooth with flowable
composite resin (figure 12).
‫ ألن طبعا مادام‬.. crown & loop ‫ بتاع‬fracture ‫عملناه علشان نتغلب علي مشكلة‬
‫ وبعمل‬bur ‫ بين حاجتين اتوقع انه ممكن تحصل مشكلة ف هنا بجيب‬soldering ‫في‬
‫ ب‬bonding ‫ وبعدين‬etching ‫ واقص الواير واعمل‬labial surface ‫نقط علي‬ Figure 12: Open-face
composite ‫ وبعدين احط الواير واغطي كل دا ب‬flowable composite space maintainer.

 Glass Fiber-reinforced composite space maintainer :-

 In this type, bar of polyethylene or glass fiber was adapted close to the contact of the abutment mesial & distal to
the space and attached with composite resin, the bar fiber is first wetted with unfilled adhesive resin and covered
with a flowable composite resin (figure 13 A).
.)Metal ‫ اتضح إنه ضعيف (أضعف من أنواع الـ‬،‫مع األبحاث‬ 
‫ وعليه كمبوزيت‬etching,bonding ‫ وبعمل‬adhesive ‫ عبارة عن شريط من الشاش بمسكه ب‬polyethylene fiber ‫ أو‬glass fiber ‫عندنا حاجات جديدة طلعت زي‬
‫ ف‬caries ‫ وف‬class 2 ‫ بفضله ف حالة أن عندي‬.. ‫ شهور‬6 ‫ بينه وبين الكمبوزيت ف ممكن آخره‬attachment ‫ بتاعه قليل النه بيعتمد علي‬retention ‫لكن المشكلة أن‬
‫ مع الكمبوزيت‬core ‫ ك‬fiber ‫هحط‬

.. polyethylene fiber ‫ وعندنا هنا‬flowable composite ‫ ب‬space maintainer ‫ ل‬attachment ‫حاليا كل االتجاهات اني اعمل‬

 Direct bonded space maintainer :-

 In the directly bonded type, the space maintainer was attached between the facial surfaces of the two abutments
and bonded with a flowable composite (figure 13 B).
Figure 13: A) Fiber-
reinforced composite
A space maintainer.
B
B) Direct bonded
space maintainer.
‫ هل هيحصل‬free ‫ هيكون‬lingual ‫ بس طب‬buccal ‫طب هنا انا هبقي ماسك من ناحية‬.. adhesive ‫ ب‬wire ‫هنا بمسك‬
6 ‫ لو عند‬permanent ‫ أما مع‬vertical ‫ ألنها واقفة‬shift ‫ مش هيحصل‬primary ‫ ؟ اإلجابة ي صاحبي أنه مع االسنان‬shift
‫ بسيط جدا ف اللي هو اشطا يعني نعديها‬shift ‫مثال هيحصل‬
Batch 49
14
 Lecture 8&9 1st term
Pedo
yyyy

‫ موجود بدخله الداتا اللي عايزها وبيطلعلي الديزاين اللي انا‬cad cam ‫معلومة علي جنب حاليا‬
‫ اللهم‬.. finishing, polishing ‫ جاهز تعمله بس‬space maintainer ‫عايزه وبعدين يطلع‬
‫ارزقنا يعني‬

 Chairside band and loop space maintainer :-

 The chairside band and loop space maintainer is prefabricated space maintainer inserted immediately with the lack
of laboratory expenses and the elimination of a second visit. The correct band size was selected to fit the abutment
tooth tightly, the space maintainer wire end (loop) was inserted into the tube, and the trial fit assembly in the
mouth. The wire was slid to the desired length enough to rest against the anterior abutment tooth at the contact
area (figure 14).
insertion ‫ يعني معمول كله ف المعمل ودا احنا بنفضله ألننا ممكن اعدل فيه و‬prefabricated ‫دا بيكون‬
‫ ف نفس اليوم‬extraction ‫ وكمان لو عاملة‬one visit ‫بتاعه بيكون معتمد علي الضغط بس وميزته أنه ف‬
‫ العادي الن اللي بيحصل هنا هو‬band & loop ‫ عن‬more hygienic ‫ممكن اعمله عادي دا غير أنه‬
‫ سواء بالحرارة أو الكهربا من غير‬metals 2 ‫ ل‬melting ‫ ودا بيختلف أنه بعمل‬soldering ‫ مش‬welding
‫اي مادة تالتة‬

Figure 14: Chairside band and loop.

II. Bilateral Space Maintainer :-

1) Lower passive Lingual Arch(For mandible only) :

 It is indicated in the lower arch, when there is a bilateral loss of first or second primary molars
after the eruption of permanent incisors to avoid interference with normal incisors positioning in
addition to the abutting against primary incisors as anterior stops does not offer sufficient
anchorage to prevent significant loss of arch length.
 A 'U' shaped arch wire extends passively from the lingual surface of the molar bands to the
lingual surface of the anteriors above the cingulum of the lower incisors and located 1-1½ mm
below the gingival margin or the edentulous ridge in the posterior region away from the eruption
path of buccal segment teeth and to avoid tongue irritation (figure 15).

‫ ف هيمنع‬cingulum ‫ علي‬resting ‫ بيكون‬arch ‫ بتاع‬anterior portion ‫ ألن‬complete eruption of permanent anteriors ‫ بشرط‬multiple loss ‫لو عندي‬
Figure 15.. ‫طلعوا‬ ‫مكنوش لسه‬
: Lower ‫ لو‬permanent
passive anterior
lingual arch space‫بتاع‬maintainer.
eruption

‫ ف بدل ما أشيل واركب واحد‬growth ‫ مع‬cingulum ‫ علي‬resting ‫ مش هيكون‬wire ‫ هنا‬early loss ‫ أو لو عندي‬6 ‫ ل‬distalization ‫ في حالة اني محتاج‬active ‫هعمله‬
‫ وخالص‬active ‫جديد بعمله‬

‫ بس لو سبتهم كدا هياخدوا راحتهم ويوسعوا ف الزم احط‬rearrangement ‫ يحصلهم‬anteriors 4 ‫ علشان‬canine ‫ بضطر أشيل‬class1 ‫ في‬anterior crowding ‫لو عندي‬
‫ علشان مياخدوش مساحة أكبر‬space maintainer
♣ Modified lingual arch (active) :
- Spurs can be attached to the arch wire to control incisor positioning and prevent encroachment on the permanent
canine eruption positions when primary canines are lost prematurely (figure 16 A).
- A ' U ' loop in the premolars area or a ' Z ' spring in the anterior region can be incorporated in the arch wire to make
it active, and aid in molar distalization and proclination of the collapsed incisors (figure 16 B).
- Lingual arch can be used also as a semifixed type by welding a molar tube in the lingual side of each band and the
arch wire is passed into the tube instead of soldering.
Figure 16: A) Lower passive
lingual arch with spur.

B) Lower active lingual arch with

A ' U ' loop or ' Z ' spring.
B

2) Nance Palatal Arch (For maxillary only) :

Batch 49
15
 Lecture 8&9 1st term
Pedo
yyyy

 Indicated when there is bilateral loss of primary molars in the upper arch
(figure 17).
 The first permanent molars are banded; the arched wire extends from the palatal surface of one molar band to the other
and it extends anteriorly up to the rugae area embedding in an acrylic button which provides additional stop.

food impaction ‫ عالية ف ممكن يحصل‬oral hygiene ‫ واالكريل محتاج‬upper . ‫ في‬multiple loss ‫لو عندي‬
Figure 17: Nance palatal arch space maintainer.
irritation ‫وتعملي‬
Space Maintainer for Second Primary Molar
I. After eruption of first permanent molar :
a. Band or crown & loop.
b. Modified types.
c. Passive lingual arch or Nance appliance: is perhaps the best treatment when bilateral loss is present

II. Before eruption of first permanent molar :

A. Distal Shoe Space Maintainer :-
 It is an intra-alveolar appliance, in which a portion of the appliance is extended into the alveolus.
 Used only when one tooth is lost on one quadrant as the strength of the appliance is limited.
 The distal shoe space maintainer is normally not indicated in a maxillary arch because the maxillary permanent molars
have a distally inclined path of eruption initially, as they become more horizontally positioned after the eruption. In
such a situation the mesial migration of the erupting tooth is very rare.
mesial to ‫ بتبقى‬bone ‫ من تحت لحد ما توصل‬soft tissue ‫ بتدخل ف‬appliance ‫ إن في جزئية من‬distal show sm ‫معنى‬ 
.first l ‫ بتاع‬mesial surface
‫متطلعش ف المكان ده إطلع ف مكانك الطبيعى متعديش ع‬6 ‫يعنى بدفع‬: intra alveolar extension or vertical bar ‫معنى‬ 
.‫ بتاعه‬path of eruption ‫ يخليه يطلع ف‬mesial drift ‫ متعملش‬5 ‫ بتاع‬space
 Should be evaluated with radiograph prior to cementation length position.
 Will be replaced with another space maintainer when permanent teeth erupt.

‫ هيبقي ضعيف‬strength ‫ فقط فلو أنا طولت أكتر من كدة‬srainles steel crown or band in d ‫فقط عشان بركب‬e ‫مخلوعين هو‬d, e ‫مينفعش‬ 
.‫خالص‬
‫للحالة‬impression ‫ وبعدين أخد‬crown or band in d‫ ب‬adaptation ‫ باجى قبل ما اخلع خالص للمريض‬: distal shoe sm ‫بعمل إزاى‬ 
6 ‫ للحالة عشان أقدر أحدد بالظبط‬prepical xray ‫ وده ثابت ع الكراون والباند وقبل كل ده بعمل‬study model ‫بالكراون أو الباند وبعدين يطلع‬
‫ واخلع السنة‬study model ‫ وبعدين نرجع ل‬، mesial to mesial surface of 6 ‫ أد إيه بحيث ينزل‬vertical bur ‫فين يعنى محتاج انزل‬
intra ‫ اللى هيطلع أعمل حفرة وادخل الواير بتاعى وابدأ أعمل‬mesial of 6 ‫ بتاعه اللى هي‬distal ‫ ناحية‬E ‫ وف نهاية خلع‬model ‫ ع‬E ‫نفسها‬
‫ اللى‬crown or band ‫ ب‬soldering ‫ والجزئية كلها أعملها‬arrows horizontal ‫ بتاعى اللى هي‬loop ‫ وابدأ اعلى‬alveolar extension
‫ بتاعى فساعتها‬appliance ‫ أبدأ اركب‬level ‫ ف نفس‬intra oral ‫ بيجيلى المريض بعد كدة اخلع السنة‬، appliance ‫موجودة وبكدة عملت‬
vertical bar ‫ كلها ويفضل جزء مفتوح بيدخل منه‬socket ‫ للـ‬heeling ‫ بتاع السنة اللى اتخلعت وبيحصل‬soket ‫ هيدخل ف‬vertical bar
.‫ بس بنضطر نعمله‬un hygienic ‫ ده‬appliance ‫واصال‬
 Contraindications :
 Multiple teeth loss.
 Poor oral hygiene.
 Lack of patience and parent cooperation.

Batch 49
16
 Lecture 8&9 1st term
Pedo
yyyy

 Presence of medical conditions such as blood dyscrasias, congenital

cardiac defect predisposing to subacute bacterial endocarditis, history of rheumatic fever, diabetes.
 Construction of distal shoe :

 The band/crown is adapted on the first primary molar and an alginate impression is made. The
band/crown is removed from the tooth and placed in the impression and the cast is prepared with
the band/crown on the cast.
 A periapical radiograph is taken to determine the distance between the alveolar surface and the
mesial marginal ridge of the first permanent molar (depth of the intra- alveolar extension) and to
also measure the distance between the distal surface of the first primary molar and the mesial
surface of the first permanent molar.
 On the cast the position of the mesial surface of the first permanent molar is marked. A ‘V” shaped
notch is made at the marked point. The depth of the notch extends to about 1mm below the mesial
marginal ridge of the first permanent molar (figure 18).
 A loop is fabricated that extends from the band /crown on the first primary molar up to the slot and
the space in between the two portions of the loop can be filled with solder.
 The loop is then soldered to the band, finished, polished, and sterilized before trying in the
patient’s mouth.
 It is advised to extract the tooth just before cementation of the appliance as it minimizes the risk of
mesial migration of the first permanent molar.

A C

Figure 18: A) Distal shoe space maintainer. B) radiographic presentation before cementation.

C) Intraoral crown with distal shoe space maintainer.

Batch 49
17
 Lecture 8&9 1st term
Pedo
yyyy

B-Acrylic Plate Space Maintainer :

 It is indicated if the first permanent molar has not erupted but its position is marked by bulge on the crest of the
alveolar ridge (figure 19).
 A removable partial plate (inactive S.M) constructed with the distal end of the plate at the position just mesial to the
visible bulge of the first permanent molar as a guide.
 After the full eruption of it, the acrylic plate may be substituted with another maintainer.

Figure 19: Acrylic plate appliance

Space Maintainer for Multiple Loss of Primary Molar

 The acrylic partial denture has been used successfully after the multiple loss of teeth in the mandible or the maxillary
arch. If artificial teeth are included in the denture, an essentially normal degree of function will be restored.
Retention is important, particularly during the initial period of insertion, the wire clasps and resin contact areas may
be present.
 However, the acrylic partial denture space maintainer is not without disadvantages; parental and patient cooperation is
imperative, breakage of the appliance is a potential factor, and the accumulation of plaque material and food debris
after the loss of normal cleansing function will often result in increased dental caries activity and gingival
inflammation.
Space Maintainer for Primary Anterior Area
I. Removable Space Maintainer :
‫ دا‬RBD ‫ مثال عندنا‬anterior ‫في حالة اني شايلة اسنان كتير أو ف منطقة‬
 Acrylic partial dentures have been successful in the ‫بيكون بناءا علي طلب البيشنت والوالدين ألنهم المسئولين عن استمرارية التأثير‬
replacement of single and multiple primary incisors (figure ‫بتاعه وغالبا الولد بيعاند ومش بيرضي يلبسه أو صحابه يتنمروا عليه ايا كان اي‬
20 A). It may be considered to satisfy esthetic and ‫ وهي اني ازود‬modified nance ‫ زي‬fixed ‫السبب يعني فكرنا نعمل حاجة‬
functional needs. ‫االكريل واطلعه لقدام شوية‬
 Indications :- B
1. Bilateral loss of posterior teeth before eruption of
permanent incisors.
2. Premature loss of anterior teeth.
II. Fixed Space Maintainer :
 The Fixed approach is designed by attaching the anterior replacement teeth to the lug attached to stainless steel
wire framework retained with bands or crowns on the second primary molars (figure 20 B) or using a modified
Nance and cover the ridge with acrylic resin and incorporated artificial primary anterior teeth on the appliance
C
(figure 20 C).
C

Figure 20: A) Removable space maintainer. B) Fixed appliance. C) Modified Nance.

Space Regainer

Batch 49
18
 Lecture 8&9 1st term
Pedo
yyyy

‫ هو اللي‬6 ‫ وعايزة ارجعه وغالبا‬loss of space ‫لو عندي‬

 It is an active type of space ‫ ف بحتاج اعمله‬mesial shift ‫بيكون حصله‬
maintainer indicated when there is space closure following the ‫ ميكونش لسه طلع أما لو طلع‬7 ‫ بشرط أن‬distalization
‫هحتاج اورثو‬
premature loss of primary molars by mesial drifting of the first
permanent molar. The procedure should be limited to situations in which the occlusion is class I, the second
permanent molar is unerupted.
 Effective for opening space where premature loss of a permanent or deciduous tooth has occurred.
 Space is regained by compressing the labial and lingual open coil springs against the molar tubes.
 Distal movement of the posterior segment as well as mesial movement of the anterior segment is achieved.
 The space regaining procedure can be accomplished more easily in the maxillary arch than in the mandibular
arch due to increased anchorage provided by the palatal vault and maxillary cancellous bone compared to the
compact bone of the mandible.
a. Removable Appliance :
 A removable appliance retained with Adams’ clasp and incorporating a helical finger spring adjacent to the tooth
to be moved is very effective for unilateral space regaining in the maxillary arch, while in the mandibular arch is
less satisfactory and prone to breakage and lack of palatal anchorage support (figure 21 A).
 The spring is activated twice to produce 1mm of movement per month one posterior tooth can be moved up to
3mm distally during 3 to 4 months of full mouth appliance wear.
o The appliance incorporates multiple Adams' clasps and a 28 mil helical spring that is activated 1 to 2 mm per
month.
o Premature loss of the primary second molar has led to mesial drift and rotation of the permanent first molar.
o Treatment time to move a molar distally 4 mm is about 4 months, assuming 1 mm per month of tooth movement.
 A removable appliance with a sectional screw can be used for space regaining which will incorporate an
expansion screw in the edentulous space; this space is opened by expanding the plates anteroposteriorly (figure
21
A B).
Figure 21: A) Space regainer with
helical finger spring.

B) Space regainer with sectional

screw.
B

b. Fixed Appliance :
1) Open Coiled space regainer (Gerber space regainer) :
 The open coil wire is usually used in cases where greater amounts of space must be regained. Generally, the
permanent first molar is the tooth to be distalized to regain space.
 Construction :
o The adapted band with buccal and lingual tubes is used.
o An impression is taken with the band seated on the tooth, then the band is seated in the impression and a stone
cast is prepared.
o A 0.7 mm stainless steel wire is then bent to a ‘U' shape, which will fit passively in both the buccal and lingual
tubes, and the anterior part contacts the distal outline of the first premolar.
o The compressed coil spring is slipped on the wire before inserting it in the tubes, and then the appliance is
cemented (figure 22 A).

2) Lip pumper.
2:3 ‫ لورا بيكون ف فاصل من‬anteriors ‫ ألن العادة دي بترجع‬lip biting ‫في حالة‬
‫ طب سؤال لو عندي‬.. ‫مللي بحيث يدي فرصة لالسنان أنهم يرجعوا مكانهم‬
Batch
‫ اللي انا مش محتاجه هيفضل مفتوح‬space ‫هل ال‬49
space ‫ في‬unilateral loss
19 ‫ يقفل الني لسه ف‬space ‫اإلجابة ي سطا أنه ال اول ما تشيل الجهاز دا هيرجع تاني‬
 Lecture 8&9 1st term
Pedo
yyyy

3) Active lingual arch.

 Also, lingual arch can be used to support the tooth movement and provide anchorage from the
permanent and primary molars when used in conjunction with a segmental arch wire and coil spring
for moving the molars distally in the mandibular arch especially unilaterally (figure 22 B).
A B

Figure 22: A) Gerber space regainer. B) Lingual arch with coil spring.

Batch 49
20