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.
17

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.

18

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

19

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.

20

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.
21

Discussion If the deciduous first molar is lost after the eruption of first permanent molar and are in occlusion with one another, the space loss will occur because of occlusal forces and mesial drift.

-Primary canine area: Early loss of deciduous canines is more common due to erupting lateral incisors rather than caries. Occasionally roots of deciduous canines are absorbed and tooth will be lost. If the loss is unilateral, there will be midline shift due to migration of larger permanent incisor segment into the space in the process of adjustment. The midline will deviate to the side of space loss. The incisor teeth will move into more lingual inclination and will step forward the space. Space maintainer should be placed to prevent space closure and arch collapse. When early loss of primary cuspids has occurred as a result of insufficient length of arch, attention may be directed to the removal of the opposite primary cuspids to permit the permanent incisors to tip towards a symmetrical alignment. Wire stops placed on the lingual arch or removable acrylic space maintainer may aid in preventing asymmetrical shifting of permanent incisors. - 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. Thus it has been felt that space maintainers are not necessary to maintain space which is getting increased with the jaw.
22

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

Discussion dentition. The advantage of the mixed dentition analysis, when correctly used, is that it tells us what the potential spacing or crowding is and direct ones attention to beneficial and possibly inexpensive remedial measures. The perimeter of the arch is reduced during the period from the mixed to permanent dentitions. For cases of mandibular crowding exceeding 2.2mm, the greater the crowding, the less will be the reduction of the perimeter of the arch from mixed to permanent dentitions. 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. During the period of the changeover, the perimeter of the arch usually decreases in the mandible, but remains the same or increase slightly in severely crowded cases. Those cases can be identified by use of the mixed dentition analysis, and the knowledge that the perimeter of the arch will not decrease the average amount can then be used in planning the treatment. There are two approaches for predicting the size of the unerupted permanent canine and premolars in the mixed dentition, namely, with and without the use of radiographs:-

RADIOGRAPHIC METHODS OF PREDICTION:

Revised Hixon - 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. Sta ley and kerber, significantly reduced the standard error of estimate when they generated a revised Hixon and Oldfather prediction equation. The coefficient of correlation of the revised equation was higher
24

Discussion then that of original equation. The original equation was derived primarily from measurements of teeth on the left side of the arch of each subject, whereas revised equation was derived from the means of measurement taken from both right and left side teeth in each subject. 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 addition of one standard error of estimate to the predicted sum would yield a predicted sum of widths at the eighty-four percentile. 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. Proportional ANALYSIS)75 If most of the canines and premolars have erupted and if one or two succaedenous teeth are still un erupted, an alternative prediction method can be used to estimate the mesiodistal width of un erupted permanent tooth. The widths of un erupted teeth (e.g. a second premolar) and an erupted tooth (e.g. a primary second molar) are measured on the same peri apical film. The width of erupted tooth, a primary second molar, is erupted on a plaster cast. 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. If: Unerupted tooth width Unerupted tooth width (x-ray) = Erupted tooth width (cast) Erupted tooth width (x-ray) Equation prediction Method (HUCKABAS

25

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, individually and record them. Measure the width of unerupted mandibular canine and first and second premolars from radiographs. These measurements will indicate the space needed to accommodate permanent teeth anterior to first permanent molars. 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. 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 3.4mm (space loss due to mesial drift of permanent molar) is subtracted. By comparing the two measurements the space available and space required is predicted.48

26

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. On the other hand, these methods are less accurate, as indicated by their larger standard errors of estimate as compared with the suggested radiographic methods.75 MOYERS ANALYSIS(1) Determine the space available for the teeth in the mandibular arch - with the help of boleys gauze measure the mesiodistal width of each mandibular incisor, separately. (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. (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. 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. Repeat this for opposite 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. The combined width of mandibular canines and premolars is then predicted with the help of probability chart.
27

Discussion (7) The estimated canine and premolar size value is subtracted from the measured space.48 TANAKA AND JOHNSON ANALYSISMeasure the mesiodistal widths of mandibular incisors and divide by 2. Add 10.5mm to this value to get the estimated width of mandibular canine and premolar on one side. Half of the width of lower mandibular incisors +11mm=estimated width of maxillary canine and premolars of one side.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.46 It is a mechanical device that preserves the space after premature loss of primary teeth.48

Classification(i) According to Hitchcock (1973) - Removable, fixed or semi fixed - With bands or without bands - Functional or non functional - Active or passive - Certain combinations of above52 (ii) According to Raymond C.Thurow (1978)
28

Discussion - Removable - Complete arch - Lingual arch - Extra oral anchorage - Individual tooth52 (iii) According to Hinrichsen (1962) - 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 - Band and Loop52 (iv)According to Mathewson1. The Band and loop is used to maintain the loss of a single primary first or second molar.
29

Discussion 2. 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. 3. The fixed lingual arch is used to maintain mandibular arch length and prevent mesial tipping and rotation of the permanent first molars. The fixed lingual arch prevents lingual tipping of the permanent incisors. 4. 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.

FIXED SPACE MAINTAINER

Band and Loop space maintainer

The band and loop space maintainer is indicated for the premature loss of single, unilateral or bilateral maxillary or mandibular primary molars. Band and loop space maintainer adjusts easily to accommodate changing dentition. However, it does not aid in mastication and will not prevent the continued eruption of the opposing teeth.14 Indications It is a unilateral fixed appliance. Band is seated 1mm below the mesial & distal marginal ridges.
30

Discussion Loop should parallel the edentulous ridge 1mm off the gingival tissue and should rest against the adjacent tooth at the contact point. The facio lingual dimension of the loop should be approx. 8mm. this dimension should allow the permanent teeth to erupt freely but not impinge on the buccal mucosa or tongue. Loop should not restrict any physiologic tooth movement, such as the increase in inter canine width that occurs during eruption of the permanent lateral incisor.49

Direct Technique or Single setting Technique14 Steps in fabrication 1) The band is pinched. 2) The prefabricated loop is selected. 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. 4) A horizontal mark is made on the band using a marking pencil at the site where the loop contacts the band. Vertical markings are made both on the loop and the band at the anterior most point of contact of the loop with the band. These markings are done both buccally and lingually. 5) The band is then removed from the tooth. Using the above mentioned markings as a reference points, the loop is placed in position on the band and spot welded. 6) The band and loop is then tried Intra orally to confirm the accurate position.
31

Discussion 7) It is taken out of the mouth, excess wire is trimmed and again spot welded for better stability. 8) It is then invested and soldered as usual. 9) The appliance is trimmed and polished. 10) It is cemented using luting cement.14

Indications:

(1) Premature loss of any primary first molar in the primary dentition
or the primary first maxillary molar in the transitional dentition. 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. (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. High dental caries activity. Replacement of primary anterior teeth. Replacement of primary second molars in the transitional dentition with the permanent molar banded. Cases that need guidance of eruption e.g. ectopic loss of primary canine, 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

Discussion Advantages:

Ease of fabrication for the clinician Ease of maintenance for the patient Adjusts easily to accommodate changing dentition44. Disadvantages:

- Opposing tooth may supra erupt. - Does not restore chewing function.
-

- Cant preserve the leeway space 44

Distal Shoe

Indications: Loss of second primary molar prior to eruption of the first permanent molar.

Contraindications:

33

Discussion

If several tooth are missing, 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. 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. This extension acts as a guide plane for the permanent Ist molar to erupt into proper position. 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. The depth of intragingival extension should be 1 to 1.5 mm below the mesial marginal ridge of the permanent molar.

Advantages Maintains the second primary molar space . Disadvantages

34

Discussion (1) Because of its cantilever design appliance can replace only a single tooth. (2) Cant restore occlusal function because of lack of strengt (3) Histologic examination shows that complete epitheliazation does not occur after placement of the appliance45.

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. The palatal portion has an acrylic button that contacts the palatal tissue which provides resistance to the mesial movement of posterior teeth.

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 0.040-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. Then cure a small button of acrylic against this portion of the
35

Discussion appliance, covering the u-shaped soldered wire that act as a strengthener for the acrylic button. Polish the button and the solder joints where the wire joints the upper molar bands.50

Advantages:

Maintains the tooth space and the leeway space.

Disadvantages: Meticulous hygiene of the acrylic button is required.45

Transpalatal Arch

This appliance is designed to prevent the molars from rotating around the palatal roots, which is the first movement resulting in loss of space in the arch perimeter.45

36

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 space maintainers requires banding of both upper first permanent molars and soldering of an 0.040-inch blue Elgioly or stainless steel wire contoured close to the palatal surface.50

The Transpalatal arch has been recommended for stabilizing the maxillary first permanent molars when the primary molars require extraction. The appliance does not use an acrylic button. It seems to gain it s efficiency through it s rigidity. It has been clinically observed that it satisfactorily maintain the first permanent molars in their position.8, 18 Indications: The best indication for Transpalatal arch is when on one side of arch is intact, and several primary teeth on one side are missing. It is also indicated when primary molars are lost bilaterally. However , there is a controversy that, 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. The appliance is designed to prevent the molars from rotating around perimeter.8, 18 the

palatal roots, which is the first movement resulting in loss of space in arch

Advantage - Lack of acrylic button so less tissue irritation and more cleansible.52 - Hygenic
37

Discussion - Indicated for bilateral loss of primary maxillary molars. - May not prevent the mesial tipping of teeth.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, which are joined by steel wire butting against the four incisors.

It helps in maintaining the arch perimeter by preventing the mesial drifting of the molar teeth and also lingual collapse of the anterior teeth.

MODIFICATIONSpurs (projections of wire) can be used as stoppers distal to anterior teeth to prevent their tipping or migration distally in the arch. These help in maintaining the symmetry in the arch in cases of unilateral tooth loss.44

Mandibular incisors often erupt lingually and are pushed forward by the tongue. LLHA should not be placed with primary incisors.
38

Discussion Modified lower lingual arch with clasps to prevent distal tipping of lateral incisors.28

Indications: (1) Bilateral loss of primary teeth in the mandibular arch during transitional dentition. (2) Maintenance of arch perimeter and incisors positions. (3) Modified LLA with clasps to prevent distal tipping of lateral incisors. (4) Contraindicated in primary dentition2. Contraindication:

- Anything that would require frequent adjustments. E.g. tooth movement or space regaining. - Rampant dental caries, high plaque scores, and or poor patient cooperation. -Anterior or posterior cross bite, if mandibular teeth are contributing factors and need to be corrected prior to lingual arch placement teeth. -Extreme mandibular anterior crowding or lingually erupting succaedenous teeth.2

Advantages: Controls antero posterior movements along with controlling and preventing an arch perimeter distortion, by controlling the lingual collapse of single tooth or segments of arch.
39

Discussion Maintains the leeway space45

Disadvantages: First permanent molars may be susceptible to decalcification.

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. The distance between the abutment teeth is measured and marked on the wire. The wire is cut and soldered on to the bands. The band is cemented on to the abutment tooth. The soldered joint is polished and finished.44

MODIFICATION-(Band and bar) broken stress50

This appliance prevents intolerable loads from being thrust on the supporting teeth. This should be designed to allow vertical movement of the supporting teeth consistent with normal function demands.

Fabrication 40

Discussion Stainless steel crown is fitted on the prepared abutment tooth, a vertical tube is then soldered on one crown & L shaped bar is fabricated to fit the edentulous area. The bar is bent slightly to adjust for any interference. The horizontal end of the bar is soldered to one of the crowns.

Most of the space-controlling indications for the band loop also apply to crown loop. However, the crown is used in preference to the band when the abutment tooth is highly carious,

exhibits marked hypoplasia, or has been pulpotomized. Stronger loop. The technique for use of crown- 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. The temporary crown serves two main purposes; 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. Restores a grossly decayed abutment tooth. Removable of appliance for adjustments is difficult.28

41

Discussion

Anterior esthetic functional space maintainer

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

42

Discussion

43

Discussion

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

Modified bonded bridge space maintainer

44

Discussion Despite contemporary techniques, it does not seem possible to save all primary teeth. The inter- radicular infections, the internal resorption, the traumatic avulsions, some Ankylosis etc. induce the premature loss of teeth, which interferes with the eruption sequences of permanent teeth. The most probable and first evident consequence will be the tipping of adjacent teeth, which will induce a decrease of the available space. The other consequences could be over eruption of the antagonist, deviation of the midline, unilateral mastication and lingual dysfunction. Removable appliances with a mastication area are useful for replacing several teeth. But when a small number of teeth are concerned, the disadvantages are problematic. In these cases, we prefer the use of fixed space maintainers. There is a large diversity of fixed space maintainers. The most used are made up of wire soldered to a band. In spite of good tolerance and durability, they do not restore a normal function, and they require a reduction of the teeth before placing a crown. A good replacement should be bridge, but this solution is not realistic because the cost is too high, the teeth must be reduced, the adjacent tooth can be a permanent one and the chair time is too long for children.

Description of appliance In fact, this space maintainer is modified bonded bridge. Modifications are made in order to decrease the cost and to adapt the bridge for primary and permanent teeth. So it can be removed when needed without damage to the teeth, but strong enough to not decrease the strength of a fixed bonded bridge.

Teeth preparation
45

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

Discussion After the cleaning of teeth support and the placement of rubber dam, we etch with phosphoric acid for 45 seconds. We rinse with air and water syringe for 30 seconds, and dry these teeth with air syringe. We place the bonding material ( super-bond) on the wings and place the maintainer on the teeth with pressure.

Removable space maintainer76

Removable appliances are particularly used in cases of multiple spacing, and a recent study discussed their usage for free end space maintenance following very early loss of primary second molars. Removable appliances are often preferred to distal shoes as they are simple to fabricate and place, and by maintaining the integrity of the gingival tissues they avoid the complications of sub gingival appliances. However, 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. 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. Indications: 1. Loss of more than two primary molars. 2. Loss of more than one primary tooth bilaterally. 3. Loss of anterior teeth. Technique and fabrication: 1. Impression taking and occlusal registration. 2. Drawing of the outline. It is a sound principle to draw the outline shorter at the buccal and labial and much wider on the lingual side. This design
47

Discussion takes into consideration the lateral expansion of the jaws into growth, which involves the process of resorption on the internal surface and apposition on the external surface of the jaws. If there is a tooth present on the distal end of the appliance, the disto-lingual end of the appliance should be extended to the centre portion of that tooth, so that second primary molar or first permanent molar will provide better stability and maintenance. The anterior lingual aspect of the appliance, where it contacts the permanent incisors, should be designed so as to be spaced about 1-2mm away from lingual surface, thus avoiding unnecessary movement of erupting teeth. 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. In cases where no tooth exists in the distal end or where there is a unilateral loss of the primary molar, it is better to enhance the stability of the appliance by bow and or simple clasps such as the Adams clasps on the molars.

EXPANSION
Expansion is one of the non-invasive methods of gaining space. To correct the transverse deficiencies during the primary or transitional dentition, the maxillary arch width is increased to allow normal vertical closure. Increased maxillary arch width may be accomplished by palatal expansion that can be done in two ways i.e. -Rapid expansion - Slow expansion RAPID MAXILLARY EXPANSION6, 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

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. Indications: 1. Patients who have lateral discrepancies that result in either unilateral or bilateral posterior crossbite involving several teeths are candidates for RME. 2. Antero posterior discrepancies e.g. patients with skeletal class11 div. 1 with or without a posterior crossbite, patient with class 111 malocclusions are citied as reasons to consider RME. 3. Cleft lip and patients with collapsed maxillae are also RME candidates. 4. The medical indications for rapid maxillary expansion include nasal stenosis, poor nasal airway, septal deformities, recurrent ear and nasal infection. Contraindications: Un cooperative patients. Patients who have a single tooth in cross bite. Patients who have anterior open bites, steep mandibular planes and convex profiles. Patients who have skeletal asymmetry of the maxilla or mandible, and adults with severe anteroposterior and vertical skeletal discrepancies are not good candidates for RME. Applications used for RME: 1. Removable appliance 2. Fixed appliance
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Discussion 1. Bonded type 2. Banded type

Tooth and Tissue born appliances 1. Derichsweiler type 2. Hass type

Tooth borne appliances 1. Issacson type 2. 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. For these appliances to be effective, they must be used in the deciduous or early mixed dentition and must have sufficient retention to be stable during expansion phase.

Fixed appliances
a) Derichsweiler type: Wire tags are welded and soldered onto the palatal aspect of banded first premolars and first molar to provide attachment for the acrylic palate incorporating a screw at it s centre.

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Discussion

b) Hass type: A thick stainless s lingual steel wire of 1.mm wire is soldered on the lingual aspects of banded premolar and molar. The lingual wire is kept longer so as to extend past and band both anteriorly and posteriorly. These extensions are bent palatally to get embedded in the palatal acrylic. The split palatal acrylic has a midline screw. The plate does not extend over rugae area.

c) Isaacson type: This appliance uses special spring loaded screw called a MINE expander. The first premolars and molars are banded. Metal flanges are soldered onto buccal and lingual sides. The expander consists of a coil spring having a nut
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Discussion which can compress the spring. The expander is activated by closing the nut so that the spring gets compressed.

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.

SLOW EXPANSION
Slow expansion procedures incorporate force symmetrical of several ounces up to approx. 2 pounds. The slower expansion procedures increase the

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Discussion percentage of orthodontic movements as the tensile strength of the suture elements is not overwhelmed.

Appliances: Jackscrews A typical expansion screw consists of an oblong body divided into two halve movements. Each half has a threaded inner side that receives on end of a double ended screw. The screw has a control bossing with 4 holes. The turning of screw by 900 brings about a linear movement of 0.18mm.

Jack screws space regainer exerts consistent force on adjacent teeth by activation by the segment of open coil with compression lugs.

Coffin spring The appliance was designed by Walter coffin around the beginning of the century. The appliance consists of an omega shaped wire of 1. 25mm thickness, placed in the mid-palatal region, the free ends of the omega wire are embedded in acrylic covering the slopes of the palate. The spring is activated by pulling the two sides apart manually. It can also be activated by using three- pronged pliers. Coffin spring is believed to bring about dentoalveolar expansion.

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Discussion

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

Indications:

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Discussion Correction of constricted maxillary arch, with or without posterior crossbite. It has been demonstrated that quad-helix therapy in young patients may result in intermolar width of upto 8mm. For reduction of arch length deficiencies, arch perimeter increases of upto 4mm have been demonstrated through early expansion of the

buccal segments. 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.

Nickel Titanium Palatal Expander

The fixed-removable appliance is a tandem-loop, nickel titanium, temperature activated palatal expander with the ability to produce light, continuous pressure on the mid-palatal suture while simultaneously Uprighting, rotating and distalizing the maxillary first molars. It was adjustable stainless steel wire extensions and is inserted into standard horizontal lingual sheets that are spot welded to the molar bands. Nickel titanium expanders come in light different intermolar widths ranging from 26mm to 47mm that generate forces of 180-300g.

SPACE REGAINING
Space regaining in the mixed dentition involves regaining lost space or creating needed space. Space creating can be accomplished in arches with slight crowding where no space has been occurred. Crowding in such situations is not the result of space loss but is caused by arch size/tooth size discrepancy.69,67

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Discussion Creating additional space in a crowded arch involves increasing the arch circumference by distal movement of the permanent molars, labial movement of the incisors, or to a limited extent, arch expansion.

Space regaining appliances, like space maintainers, may be fixed, removable or semi removable. Fixed appliances are lingual or palatal arch wires with active components. Removable devices are acrylic resins plates with active components such as finger springs or jackscrews, lip bumpers or head gear appliances. 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.

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, the lost space may be regained by an up righting or distal movement of the first permanent molar to it s normal position. If the loss of space is less than 3mm, this space can generally be regained by the distal movement of the first permanent molar, while serial extraction will be the method of choice for cases in which the space shortage is 5mm or greater. The border line cases, in which space loss is between 3-5mm, must be carefully dealt with on a case-by-care basis, using good clinical judgment. Unilateral space regainer77 It is effective for opening the space where premature loss of permanent or deciduous tooth has occurred, while maintaining the arch length. Space is regained by compressing the labial and lingual NiTi open coil springs against the molar tubes. Distal movement of the posterior segment as well as mesial movement of the anterior segment is achieved.
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Discussion

Active loop space regainer77

The active loop space regainer utilizes a finger spring that is activated by a simple adjustment of the loop.

TYPES OF SPACE REGAINERS - REMOVABLE FIXED

a) Removable type space regainers:

There are designed to produce distal movement of the first permanent molar.
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Discussion

Sling- shot type space regainer:

From the distal end of this appliance, hooks are attached on the buccal and lingual sides of the first permanent molar, which needs to be moved distally. An elastic band is slung between the hooks, and the tension force from the elastic band then produces the distal movement of the first permanent molar. The force that acts to produce the distal movement of tooth is very gentle and physiological; however , the distal movement is limited to 12mm in distance. This appliance is so named because of it s resemblance to a Sling-shot.

Screw type space regainer:

An expansion screw can be embedded in the resin base of a removable appliance. By expanding the screw, distal movement of the first permanent molar is achieved. The expansion of screw is performed by the patient once a week. The first permanent molar can be distalised by the maximum opening width of the screw, which is about 3mm. Further movement can be achieved by using a second appliance with a new screw.

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Discussion

Spring type space regainer: The distal movement of the first permanent molar can be achieved through the force produced by a spring using 0.7mm wire.

Split saddle type space regainer: This appliance is more commonly used in the lower arch. 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. The distal

movement is limited to 1-2mm, this appliance contraindicated where no space is present in the mesial aspect of the first permanent molar. The other important criteria for their success are adequate stability is adequate stability and anchorage of the appliance.

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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, attached to the lingual side. Anchorage is very important in assuring that sufficient force is exerted to move the first permanent molar distally.

Gerber space regainer: This type of appliance may be fabricated directly in the mouth during one relatively short appointment .A stainless steel orthodontic band or crown is selected for the abutment tooth and fitted, and the mesial surface is marked for the placement of U assembly, which may be welded or soldered in place with silver solder and fluoride flux. The U section is fitted in the tube; the appliance placed and wire section extended to contact the mesial to edentulous area. Assembly is removed and welded or soldered at this point. The occlusal rest is added to wire section to reduce cantilever effect. When the appliance is to be used as spring loaded space regainer tube and the wire
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Discussion U to band; 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. The length of the push coil spring is established by placing the band-tubewire assembly in the mouth, 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, plus 1-2mm to ensure spring activation, and cut springs to this length, load springs, the floss or steel ligature through eyelet and over V wire hold stored force in compressed spring. Be sure to compress spring enough to allow the assembly to fit the edentulous area. After cementation, cut the ligature and remove to activate regainer.

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- determined pattern to guide the erupting permanent teeth into a amore favorable position.

Effect of serial extraction on crowding17

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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. In cases of severe crowding that requires extraction, however, 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. Serial extraction without accompanying orthodontic therapy has not been considered appropriate. However, it is obvious that they reduce length of time of active appliances. Furthermore, under appropriate indications, serial extractions could be used for the handicapped patients who have rejected orthodontic therapy. 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. M any children with arch-length inadequacy have spectacular growth when least expected and may be treated successfully without sacrificing permanent teeth. The primary canine is removed first, the first primary molar second, and the first premolar last in the serial extraction procedure. The interval between extractions varies from 6 to 15 months. After removal of the primary canines, there is degree of self corrections in the position and alignment of the permanent incisors. The parents must be informed that, without follow up orthodontic treatment, the serial extraction procedure may not result in favorable occlusion. There is frequently occurrence of persistent spacing at the extraction sites, the development of closed bite, lingually tipped lower incisors, distally tipped canines, and mesially tipped second premolars; none of these is desirable. Serial extraction has a limited place in dental practice and requires regular
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Discussion reassessment to determine whether the serial extraction plan should be continued.78 Crowding of more then 5mm is considered severe. This amount of crowding is treated either by generalized arch expansion or by removal of selected permanent teeth. The decision to extract teeth is based on the factors influenced by the location of crowding, the position of the dental midline, and the dental and skeletal relationships of the patients. 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, incisor protrusion, molar relationships problems, or crowding. Other teeth can be removed depending on the specifics of the case. In some children, crowding is so severe in the mixed dentition that expansion is not feasible, ad extractions are necessary to obtain a suitable occlusion that is harmony with the supporting structures and facial profile. In these cases, 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, which will make subsequent orthodontic treatment easier and quicker. 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.45 In some cases, the primary first molar is removed but the permanent canine still erupts before the first premolar. This can lead to the impaction of the first premolar, requiring surgical removal. Similarly, it may become apparent that the permanent canine will erupt before the first premolar regardless of the extraction sequence. In this situation, the primary first molar and the first

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

Contra- indications: 1) Class11 and Class 111 malocclusion with skeletal abnormalities. 2) Spaced dentition.
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Discussion 3) Midline Diastema 4) Open bite and deep bite 5) Extensive caries or heavily filled first permanent molars. Procedure A number of methods or sequences of extraction have been described. Three of the popular methods are:a) Dewels method b) Tweeds method c) Nance method

Dewels method
Dewel has proposed a 3 step serial extraction procedure. 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. A year later, the deciduous first molar are extracted so that the eruption of first premolar is accelerated. This is followed by the extraction of the erupting first premolar to permit the permanent canines to erupt in their place.

In some cases a modified Dewels technique is followed where in the first premolars are enucleated at the time of extraction of the first deciduous molars. This is frequently necessary in the mandibular arch where the canines often erupt before the first premolars.

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Discussion

Tweeds 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.

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Discussion

Nance method
This is similar to the tweeds technique and involves the extraction of the deciduous first molars followed by the extraction of first premolars and the deciduous canines.

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.

CROWDING20, 70
Crowding or spacing of the developing dentition has to be a prime concerns for dentists treating children. The accumulated sizes of each childs teeth may not be necessarily in a perfect relationship to the amount of space in his dental arches for the accommodation of his dentition. When the accumulated sizes of teeth and the perimeter of arch are not closely correlated, a spaced or crowd dentition results. Mandibular anterior crowding is one of the most common problems resolved by orthodontic treatment. The space necessary for alignment can be obtained by a number of non extraction and extraction strategies. For crowding, procedure should be start in mixed dentition stage of development in order to use the leeway space for alignment.

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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, when treatment can be started in the late mixed dentition after eruption of the first premolars. In the stage of mixed dentition, 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, 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. Or if the extraction treatment is preferred, the first premolars can be immediately extracted.

Treatment Gaining space Crowded teeth require space for their normal alignment. On an average for every 1mm of crowding, an equal amount of space is required for correction. Thus the amount of crowding should be calculated and the means of obtaining this space should be determined. The various methods of gaining space include proximal stripping, expansion, extraction, molar distalization, derotation and Uprighting of posterior teeth and Proclination of anteriors.
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Discussion Use of removable appliance Once the provision for space is made, teeth can be moved to normal noncrowded positions by using removable appliances that incorporate coil springs, canine retractors, labial bows etc. Use of fixed appliance Whenever multiple rotations of teeth are present, the appliance of choice should be fixed appliance. Derotation can be brought by use of derotation springs or elastics. 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.

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