Maintaining space in temporary and permanent dentition
- Introduction :
The consequences of premature tooth loss, particularly the first permanent molar, are multiple and justify in most cases the installation of a space maintainer. The space maintenance devices available to any practitioner are numerous and the choice is not always easy. If a space maintainer is not placed as soon as possible, the consequences in terms of occlusion, functions, and aesthetics can be serious.
- Definition :
As its name suggests, it is a means that maintains or preserves the space already available for the eruption of permanent teeth following the extraction or loss of temporary teeth. A space maintainer is an orthodontic interception appliance, fixed or removable, whose main purpose is to maintain the arch length in children after premature loss of one or more temporary teeth. Therefore, it is also called an “arch stabilizer”; it holds the permanent teeth that have already erupted in place and prevents them from moving during the eruption of other teeth.
- The etiologies of early tooth loss:
There are many etiologies for tooth loss in primary or permanent dentition. The most common causes are caries and trauma.
*Caries and its complications: due to their morphological and histophysiological characteristics, temporary teeth are particularly sensitive to carious disease and its complications.
*Trauma: Traumatic accidents are also often responsible
early edentulism in the anterior sector In temporary dentition, the plasticity of the temporary alveolar bone and the shorter roots explain the greater frequency of dislocations rather than fractures of the dental tissues
*General pathologies: eradication of infected teeth is necessary in patients with conditions at risk of bacteremia or general diseases accompanied by deteriorating periodontal disease.
*Dental anomalies: some malformation syndromes include in their clinical picture agenesis (dental anomalies by default) affecting both the temporary and permanent dentition.
- The consequences of premature tooth loss:
Premature loss of teeth (temporary or permanent) creates a disruption in the alveolar-dental balance and often has consequences on the child’s growth, chewing, swallowing, phonation, aesthetics and psychology.
These consequences will be expressed at three levels:
* locally:
-The germ will see its evolution modified, on the one hand, because it loses its natural eruption guide
-The dental occlusion may be modified.
-The space created can be closed by the version of the adjacent teeth. The arch perimeter is reduced and a more or less significant dental crowding is created which can block the eruption of the germ.
* At the local-regional level :
-The lack of correct articulation disrupts facial growth, which can lead to the creation of dysmorphoses.
-The absence of occlusion with loss of vertical dimension can be a source of mandibular progression.
– A tooth loss also disrupts neuromuscular balance. Indeed, there is a certain balance between internal (tongue) and external (cheeks, lips) forces; this is the “castle corridor”.
-Alveolar-dental growth is also modified by delayed and decreased growth, aggravated by lingual or labial interposition
* At the general level :
The functional consequences are real and more or less significant depending on the number of teeth lost.
-Chewing is reduced with repercussions on the digestive and height-weight levels.
-Swallowing will remain of the suck-swallow type with residual muscular tics (lingual interposition, lip contraction).
-Premature loss of temporary incisors can have repercussions on phonation and language learning.
-Anterior edentulism can have a psychological impact on the child during socialization.
- The principles:
-The space maintainer must be installed immediately after extraction or within a very short time.
-When the tooth has been lost for several months or even years, the installation of a passive space maintainer is no longer necessary.
-The installation of a space maintainer is not justified if the permanent tooth is going to erupt.
-It is a passive device that does not make any correction (no dental movement).
-Provides existing space for the development of permanent teeth.
-Does not correct dental malpositions.
-Does not correct the offset between the bone bases or their widths.
-Can be used in the upper or lower jaw in temporary or permanent dentition.
-It can be worn fixed or removable.
-It does not create space if there is not enough in the mouth.
- Things to consider before considering a space maintainer :
- Dental age: it is essential to take X-rays in order to have information relating to the stage of development of the permanent teeth and the stages of resorption of the adjacent temporary teeth or those to be avulsed.
- Absence of permanent tooth germs: The absence of the germ will sometimes lead us to opt for a different treatment plan (closing the spaces instead of preserving them for future conventional implant or prosthetic treatment).
- The time elapsed since tooth loss: closing the extraction space is important during the first six months. Therefore, the decision to maintain the space must be made before the extraction:
- The patient’s general condition: the space maintainer will be contraindicated in patients with a general pathology (diabetes, blood disease, etc.), in particular heart disease at risk of Osler’s endocarditis or a disability (cerebral motor insufficiency).
- Patient motivation:
This treatment requires regular monitoring of the patient. Treatment failure is often due to a lack of patient motivation.
- Agenesis of the permanent tooth:
Depending on the treatment plan envisaged, the practitioner can install a space maintainer pending, as in an implant treatment for example.
- Patient cooperation.
- The existence of atypical swallowing, a pernicious habit.
- The amount of bone covering the germ of the permanent tooth.
- The absence of simian diastemas.
- Indications and contraindications
- The indications :
- At the level of the temporary incisors: when the temporary canines are not yet in occlusion, that is to say before 28 months or if we see the loss of several incisors.
- At the level of temporary canines: the maintainer is mainly used at the mandibular level.
- At the level of the first temporary molars:
Before occlusion of the first permanent molar: the space maintainer is indicated.
After occlusion of the first permanent molar:
In the presence of a Class II angle,
In the presence of an angle class I or III with simultaneous absence of the second temporary molars.
If simultaneous absence of second temporary molars regardless of the angle class.
- At the level of the second temporary molars:
Before occlusion of the first permanent molar: the space maintainer is indicated.
After occlusion of the first permanent molar:
- Contraindications :
- Patient uncooperative or uncooperative.
- Poor general condition.
- Poor dental hygiene.
- Proximity underlying germ.
- Agenesis of the permanent tooth with an ODF opinion of space closure.
- Presence of diastemas:
- The Space Maintainer’s Port:
*After the space maintainer is fitted, whether fixed or removable, it will take several days to get used to it. The dentist or orthodontist will have to show the child and their parents how to properly clean the appliance to remove dental plaque, and how to brush optimally with a good toothbrush to maintain good oral hygiene.
*If the space maintainer is attached, it is important to avoid eating sticky and sugary foods that could get stuck to the appliance and cause it to loosen.
*Avoid pressing on the spacer with your tongue or fingers to prevent the device from loosening or twisting.
*Professional scaling is required every six months to prevent periodontal disease.
- The advantages:
-Prevent the risk of malocclusions.
-Preserve masticatory and phonetic functions.
-Minimize the need for orthodontists.
-Allows the eruption of permanent teeth in a normal or more or less acceptable alignment.
-Prevent the egression of opposing teeth.
-Maintain the mesio-distal space by preventing pathological migration and version of adjacent teeth.
-Do not hinder maxillary growth for normal bone development.
- The different types of space maintainer:
10.1- Fixed maintainers :
Fixed retainers can be a means of orthodontic interception, and as their name suggests, they are permanently ready, therefore do not require much cooperation from the patient.
a- The preformed pedodontic crown (CPP):
These are anatomical crowns made of nickel-chromium alloy, they are sold in a box (several sizes), they
Requires tooth preparation and adaptation of the crown to the patient’s occlusal context.
*indications:
-Very significant decay of the second baby molar (decayed) to reestablish the terminal plane and to guide the eruption of the first permanent molar.
b-The unilateral fixed space maintainer:
It consists of an anchor, orthodontic ring or (CCP) and an extension means.
*Indications: Reserve for the replacement of a single missing tooth in the lateral sector.
*Advantages: easy and effective to use.
*Disadvantages: -Requires regular check-ups due to the adjustment of the tongue on the baby molars (poor retention).
-Risk of arm tilting under the effect of masticatory forces. c-CPP with distal arm:
It consists of a stainless steel arm placed in the distal root socket of the second baby molar, sealed on the day of extraction.
*Indications: Replacement of the second baby molar when the first permanent molar has not yet erupted.
*Contraindications: in patients with general pathology (diabetes, blood disease, etc.), in particular
heart disease at risk of Osler’s endocarditis or disability (cerebral motor insufficiency).
d. Space maintainer with an intra-alveolar distal arm or distal shoe:
It is an intra-alveolar space maintainer, it is indicated during the early loss of the second temporary molar and when the
first permanent molar has not yet erupted.
Its aim is to prevent mesial drift of the first permanent molar which leads to loss of space and possible impaction of the second premolar.
However, this type of maintainer has contraindications such as patients at risk of infection (diabetic, risk of endocarditis), in these situations the practitioner will turn to a removable maintainer with a distal extension in intra-alveolar resin of 1 to 3 mm placed one week after the avulsion.
The system is removed once the permanent molar begins to erupt:
e-Bilateral fixed space maintainers:
This is a bilateral anchoring solution indicated mainly in cases of early bilateral edentulism. The main advantage is that they are more stable, because secured on the first permanent molars, this family of appliances includes the “lingual arch” in the mandible and the “transpalatal arch” and the “Nance arch” in the maxilla.
*Lingual arch: it is a steel wire (0.9mm) which is welded to the lingual surfaces of the orthodontic bands sealed on the permanent molars and closely fits the lingual surfaces of the permanent incisors. It must have “U” shaped loops in front of the molars.
*Nance arch: this is a steel arch welded to the palatal surface of the upper molar rings, following the shape of the palate with loops at the papillae.
*Transpalatal arch: this is a steel arch welded to the palatal face of the upper molar rings going directly between the palatal faces;
10.2- Removable maintainers :
The loss of temporary teeth, mainly incisors; but also canines and molars, disrupts lingual function, phonation and aesthetics, as well as swallowing due to lingual interposition requiring the placement
of a prosthesis that will serve as a space maintainer. These space maintainers are made of acrylic resin, they
meet the rules of partial denture, can be driven by a jack to control transverse growth.
*Indications: premature loss of several anterior or posterior teeth.
* Benefits :
-easy to clean.
-restoration of aesthetics to the previous level.
-helps chewing and speaking.
*Disadvantages:
-Allergic reaction due to the resin.
-Risk of not being worn regularly.
-Cumbersome.
- conclusion :
The consequences of early extraction of temporary teeth, particularly baby molars, are numerous and fully justify the installation of a space maintainer whenever possible. However, before any therapeutic decision, a careful study of the child’s dentition is necessary to verify the appropriateness of space maintenance and to choose the appropriate appliance. Moreover, this decision cannot be made without the involvement and motivation of those concerned, i.e. the child and his or her parents.
Maintaining space in temporary and permanent dentition
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