Such guidance should contribute to the development of a permanent dentition that is in a harmonious, functional and esthetically acceptable occlusion.
Diagnosis and Treatment Planning
Dentists have the responsibility to recognize, differentiate, and either appropriately manage or refer abnormalities in the developing dentition as dictated by the complexity of the problem and the individual clinician’s training, knowledge, and experience. Early diagnosis and successful treatment of developing malocclusion can have both short-term and long-term benefits while achieving the goals of occlusal harmony, function and dental facial aesthetics.
The variables associated with the treatment of the developing dentition which will affect the degree to which treatment is successful include, but are not limited to:
* chronological, mental and emotional age of the patient, to the extend that this affects the ability of the patient to understand and cooperate in the treatment
* intensity, frequency and duration of an oral habit
* parental support for the treatment
* compliance with clinician's instructions
* craniofacial configuration
* variations in craniofacial growth
* concomitant systemic disease or condition
* accuracy of diagnosis
* appropriateness of treatment
Many unpredictable factors can affect the management of the developing dental arches and minimize the overall success of any treatment. These factors cannot always be controlled by the dentist. Appropriate pretreatment records should include those deemed necessary by the individual clinician to adequately diagnose the patient’s condition.
Clinical examination should include:
* an assessment of overall oral health
* facial analysis to determine the growth pattern present
* functional analysis to determine the presence of any deleterious habits and or occlusal dysfunction
Diagnostic records (depending upon the clinical situation) may include:
# extraoral and intraoral photographs to establish a data base for documenting changes during treatment
# diagnostic dental casts to assess the occlusal relationship, determine the arch length requirements for intra and inter-arch tooth size relationships
# intraoral and panoramic radiographs to establish dental age, assess eruption problems, estimate size and presence of unerupted teeth and identify dental anomalies and/or pathology
# cephalometric analysis to determine dental and skeletal relationships and establish a baseline growth record
Space Maintenance
Whenever primary or permanent teeth are lost prematurely and arch integrity is lost, loss of space and arch length, perimeter, or circumference may result. Migration of primary and/or permanent teeth can occur and the available space may be reduced by an amount sufficient to cause some degree of crowding in the permanent dentition.
Indications:
* The premature loss of primary molars may require the placement of a space maintainer to prevent the migration of the adjacent teeth, depending upon the teeth present and the arch length.
* When loss of a primary canine occurs, the dental arch midline may be compromised and the arch length also may be reduced. The premature loss of primary canines may therefore require the placement of a space maintaining appliance to prevent midline deviation and/or loss of arch length, perimeter and/or circumference.
* The premature loss of primary incisors does not usually require the placement of a dental appliance for the maintenance of space because mesial movement of the adjacent teeth is not generally expected.
Contraindications:
* A space maintainer is usually not necessary if there is a sufficient amount of space present to allow for eruption of permanent tooth/teeth.
* A space maintainer may not be recommended if severe crowding exists, such that space maintenance is of minimal effect and subsequent orthodontic intervention is indicated.
* A space maintainer may not be necessary if the succedaneous tooth will be erupting soon.
Types of Space Maintainers
The treatment modalities may include, but are not necessarily limited to, the following types of appliances.
Fixed appliances:
# Band and Loop / Crown and Loop
# Distal Shoe
# Lower Lingual Arch
# Nance Appliance
Removable appliances:
* Hawley appliance / Removable dentures
Band and Loop Space Maintainer
Indications: Loss of first primary molar
Advantages: Ease of fabrication for the clinician and ease of maintenance for the patient
Disadvantages: Opposing tooth may supererupt
Crown and Loop Space Maintainer
Indications: Loss of first primary molar with significant loss of tooth substance of the abutment tooth
Advantages: Same as above
Disadvantages: More difficult to fabricate than band and loop
Distal Shoe (Intra-alveolar Space Maintainer)
Indications: Loss of second primary molar prior to eruption of the first permanent molar
Advantages: Maintains the second primary molar space
Disadvantages: Difficult to fabricate; contraindicated in some medically compromised patients, ie. pathological heart murmur
Lower Lingual Holding Arch (LLHA)
Indications: Loss of second primary molar in the mandible (counterpart to Nance)
Advantages: Maintains the tooth space and the leeway space
Disadvantages: First permanent molars may be susceptible to decalcification; may be prone to breakage unless the patient is well-informed on maintenance
Nance
Indications: Loss of second primary molar in the maxilla-counterpart to LLHA
Advantages: Maintains the tooth space and the leeway space
Disadvantages: Meticulous hygiene of the acrylic button is required
Hawley Appliance / Removable Acrylic
Indications: When multiple teeth are lost and the space maintenance and mastication are of concern
Advantages: Can maintain space as well as aid in mastication
Disadvantages: Susceptible to fracture or loss
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