Editorial Desk

Vol.-1 | Issue - 2 | 2021 April - June | International Journal of Advanced Dental Science and Research | Page - 60


Editorial Desk ------------------------------------------------------------------------------------------------------------------- 65

Original Article

Retrospective study in partial and complete edentulousness in age group 5-15years --------------- 66-68Vinod Mathew Mulamoottil1, JeenaUmmer N2, Jacob John3, Sheryl Kuriakose4, Anil Kurian5

Incidence and Predisposing Factors of Dry Socket - A Prospective Clinical Study ---------------------- 69-72Eapen Thomas1, George Varghese2, Shali S3

Review Article

How to critically evaluate a scientific paper in Journal Club? ------------------------------------------------------------------ 73-75Benley George1, Rino Roopak Soman2, Minimol K Johny3,

Retrobulbar hemorrhage and its management- Review of literature. -------------------------------------------------------- 76-79Nithin Pratap MDS1, Ravi Rajan MDS2, Indu G. BDS3

A Guide to Choosing Between Screw Retained and Cement Retained Fixed Implant Prosthesis --------------- 80-85Arimboor Maymol Francis1, Aby Mathew T2, Suja Joseph3, Annie Susan Thomas4, Riya Achu Mathew5

Applications of Tissue Engineering in Bone Regeneration ------------------------------------------------------------------------ 86-92G Meenu1, Nebu George Thomas2, Thomas George V.3, Sherin P. Johny4

Lefort 1 Osteotomy- An Overview --------------------------------------------------------------------------------------------------------- 93-100Ravi Rajan1, Eapen Thomas2, Akhilesh Prathap3, Vinesh Udayakumar4, Nithin Pratap5\

Preservation for Prevention -------------------------------------------------------------------------------------------------------------------- 101-107Ashwin Joseph1, Elizabeth Joseph2

Case Report

Non-Healing Extraction Wound– A Case Report ------------------------------------------------------------------------------------- 108-110K.George Varghese1, Nidhin Raj2,

Gummy Smile correction with BOTOX® Cosmetic – A case report ---------------------------------------------------------- 111-115Vinesh Udayakumar1, Vinod Mulamoottil2, JaganLonappan3

Prosthodontic Management of Oro-Antral Fistula Using an Obturator – A Case Report ------------------------- 116-118Pranathi Rajesh1, Annie Susan Thomas2, Aby Mathew T3, Suja Joseph4, Gopika Sali5, Melwin Anna Abraham6

Cont

ents


INTRODUCTIONPrimary teeth play the important role as naturalspace maintainers till eruption of permanentsuccedaneous teeth in addition to their role inmaintaining aesthetics as well as helping inmastication. The most common orthodonticproblem encountered today is the crowding andlack of space in the permanent dentition.[1] Earlyloss of deciduous teeth causes drifting of adjacentteeth into the space created which results inabnormal axial inclination, spacing between theteeth and shifting of dental midline. This earlyloss prevents the normal eruption and deviationof their permanent successors from their normaleruption pathways leading to malocclusion.[2]Prevention of space loss in the deciduous and themixed dentition prevents the development ofmalocclusions in the later period, thereby reducingor eliminating the need for later comprehensiveorthodontic treatment. Space management forms

Preservation for Prevention

Ashwin Joseph1, Elizabeth Joseph2

1PG Student, Professor & HOD, Dept of Pedodontics, Pushpagiri College of Dental Sciences, Perumthuruthy, Tiruvalla, Kerala,

Review Article

Abstract Dental caries, trauma, infection and crowding are few reasons children lose their teeth in early life resultingin spaces in an otherwise intact arch. Maintenance of the space created by the lost teeth especially molarsis crucial till the eruption of their permanent successor teeth. Early interception and prevention of suchirregularities in deciduous and early mixed dentition prevents the development of potential malocclusion inthe late mixed dentition and permanent dentition, thereby, reducing the necessity for later comprehensiveorthodontic treatment. Space maintenance is an integral part of preventive orthodontics. Space maintainersareappliances used for maintenance or regaining minor amount of space created by the lost teeth. This articlediscusses some of the variables to be considered when effecting space maintenance, the factors that dictateappliance selection, the indications and use of space maintainers in children.

Keywords:Premature loss, Space maintenance

an integral part of preventive and interceptiveorthodontics.[1] Space maintenance is anindispensable part of Pediatric Dentistry and isthe primary preventive orthodontic care that isprovided to avoid future dental malocclusions.

The term space maintenance was given by Sir JCBrauer in 1941. He had defined space maintenanceas the process of maintaining a space in the dentalarch previously occupied by a tooth or a group ofteeth.A space maintainer is used to maintain thespace created by the lost deciduous tooth or teethtill the eruption of their successors. [2]

The objectives of space maintainers arepreservation of primary tooth space after earlyloss, integrity of the dental arches, normal occlusalplanes and to aids in esthetics& phonetics in caseof anterior space maintainer. A successful restoredcarious tooth is the best space maintainer. [2]

Corresponding Author:Elizabeth JosephProfessor & HOD, Dept of Pedodontics, Pushpagiri College of Dental Sciences, Perumthuruthy, Tiruvalla, Kerala, E-mail: [email protected]


Careful considerations of thevarious factorsaffecting planning of space maintainers must becheckedin selecting a space maintainer.Radiographic and space analysis should beconsidered before placing a space maintainer.[2]

Requisites of a space maintainer[2]1) Should maintain mesio-distal width of lost

tooth

2) Simple, easy to fabricate and cost effective

3) Should restore function and prevent overeruption of opposing teeth

4) Should be strong enough to withstand thefunctional forces

5) It must permit maintenance of oral hygiene

6) It must not restrict normal growth anddevelopment which take place during thetransition from deciduous to permanentdentition

Planning for Space MaintenanceThe following considerations are important whenspace maintenance is considered after theuntimely loss of primary teeth [3]:

1. Time elapsed since loss-Space closure usuallytakes place during the first 6 months after the lossof the tooth. When a primary tooth is extracted orexfoliated, all factors indicate the need for spacemaintenance, it is best to insert an appliance assoon as possible.

2. Dental age of the patient-Gron studied theemergence of permanent teeth based on theamount of root development as viewed onradiographs, at the time of emergence. She hadfound that teeth erupt when three-fourths of theroot is developed, regardless of the child’schronologic age.The decision to give a spacemaintainer can be assessed based on the rootformation of the succedaneous teeth.

3. Amount of bone covering the unerupted tooth–Predictions of tooth emergence based on rootdevelopment and influence of the time of primarytooth loss are not reliable, if the bone covering

the developing permanent tooth has beendestroyed by infection.[3] In such a situation theemergence of the permanent tooth is usuallyaccelerated. If there is bone covering the crownof the tooth, it may be readily predicted thateruption will not occur for many months, a space-maintaining appliance is indicated. A guidelinefor predicting emergence is that eruptingpremolars usually require 4-5 months to movethrough 1mm of bone as measured on a bite-wingradiograph.

4. Sequence of eruption of teeth- the dentistshould observe the relationship of developing &erupting teeth adjacent to the space created bythe untimely loss of a tooth. Same situation existsif the first primary molar is lost prematurely andthe permanent lateral incisor is in active state oferuption. The eruption of permanent lateral incisorwill often result in a distal movement of primarycanine and an encroachment on the space neededby first premolar. This condition is frequentlyaccompanied by a shift in midline towards thearea of the loss.

5. Delayed eruption of the permanent tooth- Incase of impacted permanent tooth, it is essentialto extract the primary tooth, construct a spacemaintainer & allow the permanent tooth to eruptat its normal position. It is advisable to incorporatean occlusal stop in the appliance to prevent supra-eruption in the opposing arch, if the permanentteeth of the opposing dentition have erupted.[3]

6. Congenital absence of the permanent tooth-If permanent teeth are congenitally absent, thedentist should decide whether it is wise to holdthe space for many years until a fixed replacementcould be provided or if it is better to allow thespace to close. If it is decided to hold the space, asuitable space maintainer is to be delivered.

7. Presentation of problems to parents–Aninformed consent must be obtained and parentsshould be explained aboutproblems of prematureloss of teeth and its resultant potential space loss.They should also be made to understand the needfor space maintenance.

Ashwin, et al.: Preservation for Prevention - IJADSR


Types of space maintainersI.Space maintenance for missing primarymolarsand canines1. Band and loop space maintainer: The bandand loop space maintainer are indicated for thepremature loss of unilateral or bilateral maxillaryor mandibular deciduous molars. It adjusts easilyto accommodate changing dentition.Maintenanceofspace necessary to hold the second primarymolars in position, especially as the firstpermanent molars erupt and create forces whichotherwise would move the primary molarsforward.[4,5]

It consists of a band around one teeth adjacent tothe edentulous area and a 0.032’’ or 0.036’’stainless steel wire loop that forms a loop fromsoldered attachments on the buccal and the lingualsurfaces of the band to the tooth, on the other side,of the edentulous space.The band is usually placedon the tooth distal to the extraction space. Thecontour of the loop should be close to gingivalcontour positioned just above the contact areawith the arms of the loop placed in the junctionof middle and cervical third. The final width ofthe loop should be wide enough approximately7-8mm to allow eruption of premolar inside theloop. [3]

Modifications of band and loop space maintainerinclude crown and loop, crown-band and loop,reverse band and loop, bonded band and loop,band and bar, long span band and loop.

Band and loop space maintainer

There are some problems with this appliance, withloss of cement being the primary reason for failure.Other complications associated with band and loop

space maintainer includes caries resulting fromcement loss, appliance displacement with wireembedding into gingival tissues, and an inabilityto control for rotations or tipping of abutment teeth.Other disadvantages are the laboratory cost and thechair time for the two appointments associated withfabrication and delivery. [5]

2. Lingual holding arch: It is indicated inbilateral loss of the deciduous posterior teeth, inmandibular arch, especially if the permanentmandibular incisors exhibit crowding. [6]

Lingual arch space maintainer

There are also disadvantages to the lower lingualholding arch: [7]

If lingual arch space maintainer is placed beforethe loss of the primary incisor teeth, lingual wiremay interfere with eruption of the permanentincisors, which may migrate facially from alingual position during development. It has alsobeen suggested that the lower lingual holding archcauses proclamation of the lower incisors, whichhas led some clinicians to suggest avoidingcontact of the lingual arch with the mandibularincisors. However, the retruded wire position isexpected to reduce the ability of the arch to resistmesial movement of the permanent molars.Another disadvantage is that the preservation ofthe leeway space may cause an increase in theprevalence of second molar impactions. The lowerlingual holding arch also has various designs. Therecommended wire size for the lingual arch rangesbetween 0.032 and 0.036 inches in diameter.

In addition to the laboratory fabricated customdesign, the lingual arch appliances is also



available in premade forms. One variation istheprefabricated wires designed to fit inhorizontaltubes welded to lingual surfaces of the molarbands adapted. Another variation has the lingualarch wires designed to fit into vertical tubes.

3. Nance arch holding appliance: It is indicatedin situations where premature bilateral loss ofmaxillary primary teeth is present or when leewayspace must be preserved. It is similar to fixedlingual arch appliance except that it is used in theupper arch and there is an acrylic button in therugae region. [6]

Nance holding arch space maintainer

4. Transpalatal arch: It is also known as theGoshgarian arch, is similar to the other fixedbilateral appliances.[6]

It is indicated in situations where prematureunilateral loss of maxillary primary teeth is present

Transpalatal arch space maintainer

The advantage of TPA over the Nance applianceis reduced food impaction and plaque retentionas well as improved soft tissue compatibility. TPAalso has some orthodontic benefits by providingsome resistance to molar extrusion and allowingorthodontic tooth movement mild dentalexpansion, derotation, and some torque.

5. EZ space maintainer: EZ Space Maintainer(Ortho Technology Inc.) It requires noimpressions, no laboratory construction, and canbe directly bonded during one in-office visit. It isa cost-effective, less time-consuming appliancethan traditional space maintainers. It is moreaesthetic, hygienic, simple and easy to use. Itprovides easy maintenance of the mesio-distaldimension of any lost, deciduous teeth and canbe used as an adjustable appliance by using theNiTi coil included to regain some space.[4]

EZ space maintainer

6. Fiber-reinforced space maintainer: This isintended to take only one appointment with nolaboratory procedures. The appliance consists ofcomposite reinforced with polyethylene or glassfibers direct bonded to the buccal and lingualsurfaces of the abutment teeth.[8] Some studieshave shown this alternative to be comparable insuccess rate to the band and loop. Others suggestlongevity of just 5–6 months. Failures primarilyinvolve debonding at the enamel compositeinterface.[8]



Fiber-reinforced space maintainer

II.Space maintenance with loss of secondprimary molar before eruption of firstpermanent molar

1. Distal shoe space maintainer/ Intra- alveolarappliance:It is indicated when the primary secondmolar is lost before the eruption of the permanentfirst molar.The distal shoe appliance providesgreater control of the path of eruption of uneruptedpermanent first molar and prevents undesirablemesial migration.[6]

Distal shoe space maintainer appliance consistsof a molar band or a stainless steel crown that isadapted to the primary first molar with a wire loopextending over the extraction space/ site. Thereis an additional extension (of either wire or a metalguide plane) that extends subgingivally to contact1mm below the mesial marginal ridge of theunerupted permanent first molar. The length ofdistal extension should be the approximate withof primary second molar.[3,6] A radiograph istaken with appliance in place prior to cementationto verify the position of the distal extension.

Cementation is done on the day of extraction ofthe second primary molar.

Distal shoe is contraindicated for those patientswith systemic diseases that affect the healingprocess or cardiac anomaly patients requiringantibiotic prophylaxis.[4]

Distal shoe space maintainer

III. Space maintenance for primary andpermanent incisor area1. Groper appliance or the pedi partialappliance: This also has a very specific indicationas a replacement for missing maxillaryincisors.This pedi partial/groper’s appliancealthoughprimarily used for esthetic purposesas theearly loss of incisors results only in minimal/veryless space loss, this appliance can also be usedfor cases, in which posterior teeth are lost inaddition to the incisors.[4]

Groper appliance or the pedi partial appliancePre-Op and Post-Op

2. Pin and tube space maintainer: It is a fixedtype of space maintainer used in cases where thereis early loss of primary incisors. [5]

IV. Space maintenance for areas of multipletooth loss1. Removable partial denture/ Functional spacemaintainer: It incorporates functional units likeartificial teeth in an acrylic plate. It helps inmastication in the posterior region, improvesesthetics in the anterior region, prevent abnormalspeech and tongue habits[3].

Functional space maintainer



2. Simple acrylic plate: non-functional spacemaintainer [9]

It doesn’t incorporate functional units like teethand consists of an acrylic plate only extendingthe edentulous span.

Pre-Op and Post- Op of non-functional spacemaintainer

Advantages of removable space maintainers [7]· Permits better maintenance of oral hygiene· Maintains or restores vertical dimension· Helps in keeping the tongue within its

boundary· Easy to fabricate and requires less chair side

time· Can be made aesthetic by incorporating teeth

Disadvantages of removable space maintainers [7]· Patient compliance is necessary· Appliance may be lost or broken· It restricts the lateral growth of the jaw if

clasps are incorporated· It may irritate the soft tissue

Failuresof space maintainers[10]For each clinical situation, in which an early toothloss may be experienced, more than a single spacemaintainer may be considered appropriate.Therefore, potential for longevity should beassessed when determining the best option foreach situation.

1. Loss of abutment teeth prior to eruption of thesuccessors of the missing tooth being maintained-In such situation, some appliances may need tobe replaced by different variations as the dentitiondevelops.

2. As for failure of space maintainers, one of themost common reasons is cement loss. Cement lossranges from 15% to 36% of space maintainer

failures and is more common with the band andloop space maintainer than with the lower lingualholding arch or Nance appliance.

3. Breakage at the solder joint, which has variablefailure rates.

4. Splitting of bands is also seen with a higherincidencebeing recorded in literature with thelower lingual holding arch than the Nanceappliance or the band and loop. The most commonfailure of the band and loop can be addressed bysimply recementing the loose or displacedappliance as opposed to remaking a broken fixedbilateral appliance, many would conclude that theband and loop has less complications, making ita more common choice for space maintenance.

Ongoing Monitoring and Evaluation of In PlaceSpace Maintainers[10]Follow-up should be done at regular intervals.Sufficient clinical retention of the applianceshould be evaluated along with soft tissue healthalso being monitored.The intra-oral radiographsshould be taken at appropriate intervals to evaluatethe eruption status of the permanent tooth/teethfor which a space maintainer has been placed.When the tooth is visible or erupting between thewires of loop, it is time for removing themaintainer. Also, if one of the deciduous teethsupporting the appliance sheds/exfoliates, thespace maintainer should be removed.

ConclusionThe best space maintainer is a well maintainedprimary tooth retained in the arch till theirpermanent successors erupt. But when theseimportant natural space maintainers are lostprematurely, it is essential to implement a spacemanagement strategy. Appropriate spacemanagement therapy can save a child fromesthetic and functional disfigurement and save afamily from lot of financial expenditure in laterorthodontic treatment costs. The dentist mustreview the variables/ factors and re-evaluate his/her decisions according to the dynamicdevelopment of the patient’s dentition and planspace maintenance accordingly.




References1. Khanna P, et al. “Keep My Space”- A Review

Article. International Journal of Oral HealthDentistry, 2015;1(1):11-15.

2. Singh PH, et al. Modern concepts of spacemaintainers and space regainers: a reviewarticle.ejpmr, 2020,7(3).

3. Mcdonald, Avery & Dean. Dentistry for thechild & adolescent. 8th edition.

4. Laing E, Ashley P, Naini FB, Gill DS. Spacemaintenance. Int J Paediatr Dent. 2009May;19(3):155- 62

5. Rajab LD. Clinical performance and survivalof space maintainers: Evaluation over a periodof 5 years. ASDC J Dent Child 2002;69:156-60, 124.

6. Mathewson R. Fundamentals of PediatricDentistry. 3rd edition.

7. Marwah N. Textbook of Pediatric Dentistry.4th edition. Jaypee brothers;2019.

8. Kulkarni G, Lau D, Hafezi S. Developmentand testing of fiber reinforced compositespace maintainers. J Dent Child (Chic)2009;76:204-8.

9. Simon T, Nwabueze I, Oueis H, Stenger J.Space maintenance in the primary and mixeddentitions. J Mich Dent Assoc. 2012Jan;94(1):38-40

10. Moore TR, Kennedy DB. Bilateral spacemaintainers: A 7-year retrospective study fromprivate practice. Pediatr Dent 2006;28:499-505.

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