Space regainers /certified fixed orthodontic courses by Indian dental academy


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Space regainers /certified fixed orthodontic courses by Indian dental academy

  1. 1. SPACE REGAINERS INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Space regainers are used to regain space lost by drifting of teeth and may be either extra-oral or intra-oral fixed or removable appliances INDICATIONS 1.One or more primary teeth has been lost. 2.Some space in the arch has been lost due to mesial drift of the first permanent molar. “Regaining what was once there is entirely different from creating that which has never been present”.
  3. 3. Space management is a general term that includes four subdivisions a) Space maintenance b) Space regaining c) Space supervision d) Gross discrepancies All problems in space management fall into one of the four categories. The differential diagnosis among them is determined primarily by mixed dentition analysis.
  4. 4. SPACE REGAINING: · Loss of arch perimeter usually is the result of caries or premature loss of primary teeth. · The most frequent cause of arch perimeter loss in the mixed dentition is caries of the primary molars. A carious lesion on the distal surface of the second primary molar, in particular allows the first permanent molar to tip mesially. · Usually when several primary teeth are lost, the arch perimeter is shortened and space regaining is indicated.
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  8. 8. Such cases must be differentiated carefully from those in which the tooth size-osseous base relationship is so poor that there is insufficient space for the permanent teeth. The discussion at this point is centered on patients who once had sufficient length of the arch perimeter but because of environmental reasons, had it shortened by mesial movement of the first permanent molars or by lingual tipping of the incisors.
  9. 9. · Correction should be where the loss has occurred. · Note the molar relationship cuspid interdigitation and overjet, since they provide the key to the site of the shortening.
  10. 10. After locating where the arch has shortened, determine by means of mixed dentition analysis, the exact amount of space that must be regained and the most logical tooth movements to recover that space. Usually distal movement of first permanent molars is required. But before moving first permanent molars distally it is necessary to understand the nature of the mesial movements that caused the shortening of the arch perimeter.
  11. 11. a) Mesial drift of permanent molars Mesial drift of the first permanent molars involves three separate kinds of tooth movements, namely mesial crown tipping, rotation and translation. There are distinct differences in the mode of mesial movement between the upper and lower first molars, differences caused by variations in the crown shape, number of roots, and occlusal relationships.
  12. 12. • Furthermore the time of loss of the crown of the primary second molar is the determining factor in the type of movement seen. • Maxillary first permanent molars quickly tip mesially with the loss of crown substance of the maxillary second primary molars.
  13. 13. Mesial tipping causes the disto-buccal cusp to become more prominent occlusally. Because of the large lingual root of the maxillary first permanent molar, rotation of the crown also is seen with mesial tipping, the disto buccal cusp becoming more prominent buccally as well. When the second primary molar is lost prior to the eruption of the first permanent molar, translation of the first permanent molar during its eruption may be seen.
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  15. 15. Mandibular first permanent molars display mesial tipping, crown rotation, and translation as well but they are more likely to show lingual tipping during mesial movement. The lingual tipping is caused by the absence of the lingual root and the fact that occlusal function occurs buccally to the center of mass of the lower molar, a condition aggravated as the fist molar drifts mesially.
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  17. 17. b)Distal movement of first permanent molars The basic tooth movement necessary in space regaining is distal movement of first permanent molars which must recapitulate in reverse the movements that occurred as the teeth drifted mesially. Therefore the selection of the space regaining appliance is dependent on whether tipping, rotation, translation or combinations of these movements are required.
  18. 18. Some common mistakes in choosing space regaining appliances should be noted. 1. Often too complicated an appliance is chosen when a simple appliance would let the tooth fall back more easily into its former position.
  19. 19. 2 A firm purchase on the tooth often is not necessary except for translation. Actually, tipping and rotation back into position usually occur more readily with the use of finger springs rather than a banded appliance.
  20. 20. 3. There is failure to achieve all of the necessary movements. It should be noted that surprising amounts of arch perimeter space often are created just be distal tipping and rotation of the first molar. Therefore tipping and rotation should be achieved prior to attempting translation. Although this sequence may necessitate the use of two spaceregaining appliances, it often will save months of treatment time and frequently permits the use of simpler appliances.
  21. 21. A wide variety of space – regaining appliances are available. No more complicated appliances should be used than is required to achieve the necessary space. Do not over extend the space regaining appliance. Simple finger springs cannot move molars bodily nor can they easily lengthen an arch perimeter past its original dimensions and retain a permanent result.
  22. 22. Space regaining appliances are intended to be used solely for recovering space that once was there. “SPACE REGAINING IS NOT SPACE CREATING”
  23. 23. The timing of space regaining is important, since the position and stage of development of the second permanent molar often is a limiting factor. When the simpler space-regaining appliances cannot complete the task, one may resort to extra oral traction, but before using extra oral traction, the patient’s case should be reassessed completely to make certain that the original diagnosis still obtains.
  24. 24. When the loss of perimeter length is so extensive as to be beyond the scope of the simpler appliances, or when there is insufficient time to recover the space before the eruption of the bicuspids and second permanent molars, a far more difficult clinical situation is present and comprehensive multibanded appliance therapy usually is indicated.
  25. 25. MOYERS MIXED DENTITION ANALYSIS: The purpose of a mixed dentition analysis is to evaluate the amount of space available in the arch for the empting permanent carries and premolars. In this analysis the size of the unerupted permanent cuspids and premolars are predicted from the knowledge of the sizes of certain permanent teeth already erupted in the mouth.
  26. 26. The Moyer’s mixed dentition analysis predicts the combined mesio distal width of 3, 4 and 5 based on the sum of the widths of the four lower permanent incisors.
  27. 27. The mesio distal width of the four lower incisors are measured and summed up. The amount of space available for the 3, 4 and 5 after incisor alignment is determined by measuring the distance between the distal surface of lateral incisor and the mesial surface of first permanent molar. Based on the mesio distal width of the four mandibular, the expected width of the canines, first and second premolars are predicted by referring the probability chart while doing so, the 75% level of probability is considered reliable
  28. 28. The predicted tooth size of 3, 4 and 5 is compared with the arch length available for them. So as to determine the discrepancy. If the predicted value is greater than the available arch length, crowding of teeth can be expected.
  29. 29. Mixed dentition analysis – radiographic method This technique makes use of a radiograph as well as a study cast to determine the width of the unerupted teeth. Radiographic measurements of unerupted teeth are by themselves unreliable due to the distortion that can occur. It is possible to determine the measurements of the unerupted teeth by studying the teeth that have already erupted in a radiograph and on a cast.
  30. 30. The following formula is used X1 x Y2 Y1 = -------------X2 Y1 = Width of unerupted tooth whose measurement is to be determined. Y2 = Width of unerupted tooth on the radiograph. X1 = Width of a tooth that has erupted, measured on the cast. X2 = Width of a tooth that has erupted, measured on the radiograph.
  31. 31. Various appliances for space regaining 1.RECURVED HELICAL SPRING The upper or lower hawley appliance with recurred helical spring against the mesial surface of a molar that has drifted forward is effective in molar distalization. A removable appliance retained with Adams’ Clasps and incorporating a helical fingerspring adjacent to the tooth to be moved is very effective. This appliance is the ideal design for tipping one molar. One posterior tooth can be moved upto 3mm distally during 3 to 4 months of full time appliance wear.
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  33. 33. The spring is activated approximately 2mm to produce 1mm of movement per month. The molar generally will derotate spontaneously as it is tipped distally.
  34. 34. 2. KNEE SPRING Used in tipping molars distally. 3. CANTILEVER SPRING The molar can be distalized to regain space by using removable appliances that incorporate simple finger springs.
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  36. 36. 4.SPLIT SADDLE ARCYLIC SPACE REGAINER Useful when greater distances must be regained. As the molar moves distally, the appliance becomes more fragile. It is then possible to tie the distal portion forward with a piece of dental floss or stainless steel ligature to permit the addition of acrylic posteriorly. In this way the appliance is reactivated without adjustment of the spring.
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  38. 38. 5.SLINGSHOT REGAINER A light elastic is joined to buccal and lingual hooks .
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  40. 40. 6.SLIDING YOKE SPACE REGAINER Buccal view – A steel edgewise wire 0.022 inch x 0.028 inch is used. A ball of solder is placed mesial to the cuspid bend of the wire. A coil spring is then threaded onto the wire, the sliding yoke is added, and the wire is bent well distal to the molar to be moved. The sliding yoke is an edgewise buccal tube the inside diameter of which is exactly that of the wire.
  41. 41. To the buccal tube is soldered at a right angle a small piece of stiff wire to engage the mesial of the molar. The acrylic must be trimmed in a straight line on the lingual. This appliance is best anchored on the opposite side by an Adams Clasp. It is more efficient in the maxillary than in the mandibular arch.
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  43. 43. 7.JACK SCREW Space regaining can be brought about using jack screws placed in such a way that an increase in arch length is obtained by distalization of the molar. The appliance consists of a split acrylic plate with a jack screw in relation to the edentulous space and is retained using Adam’s Clasps.
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  45. 45. 8.GERBER SPACE REGAINER A seamless orthodontic band or a crown is selected for the tooth to be distalized. This space regainer consists of a ‘U’ shaped hollow tubing and a ‘U’ shaped rod that enters the tubing. The tube is soldered or welded on the mesial aspect of the first molar to be moved distally. The ‘U’ shaped wire or rod is fitted into the tube, in such a way that the base of the ‘U’ rod contacts the tooth mesial to the edentulous area.
  46. 46. Open coil springs of adequatelength are placed around the free ends of the ‘U’ shaped rod and inserted into the tubing assembly. The forces generated by the compressed open coil springs bring about a distal movement of the first molar.
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  48. 48. 9.MAXILLARY PLATE (CETLIN) REGAINER Palatal anchorage is given and eyelets in the arch wire are placed for extra-oral anchorage.
  49. 49. 10.HUMPHREY APPLIANCE  If the second primary molar has not been lost as the result of the erosion of its roots by the ectopically erupting maxillary first molar, an interesting fixed appliance has been proposed by Humphrey.  The second primary molar is fitted with an orthodontic band. Then, an S shaped wire can be formed from 0.028 yellow Elgiloy wire and soldered to the buccal surface of the band. The sharpened end of this wire is inserted into the central pit of the ectopically erupting permanent molar.
  50. 50.  The band is cemented in place and the wire may be adjusted over a period of weeks to open the spring and thereby produce the force todistalize the ectopic molar.  The adjustments may be made directly in the child’s mouth with a Howe pliers or a light-wire bird beak pliers.  Instead of using the S shaped wire described by Humphrey, a helical spring has been found to be more effective.
  51. 51. 11.CLASPRING A combination of a clasp and a spring, can produce distal molar movement while holding the appliance on teeth. Its retentive element resembles the Adam’s clasp. Its active elements consist of two helical finger springs that pass through the inter proximal areas and are held together buccally or labially by the bridge that connects the retentive portion.
  52. 52. Advantages of Claspring: a. Better control of root movement is achieved by a two point contact with the tooth. The mesio-distal contact, although unable to generate pure bodily movement, seems to reduce the degree of crown tipping. b. The improved control of sagittal tooth movement results in less extrusion of posterior teeth, thus better control of the vertical dimension. c. The retentive capability of the claspring provides adequate overall support.
  53. 53. 13.HEAD GEAR For tipping both maxillary molars distally or for bodily movement in maxillary molars, extra oral force via a facebow to the molars is the most effective and straight forward method. The force is directed specifically to the teeth that need to be moved, and reciprocal forces are not distributed on the other teeth that are in the correct positions. The force should be as nearly constant as possible to provide effective tooth movement and should be light because it is concentrated against only two teeth.
  54. 54. The more the child wears the headgear, the better. 14 to 16 hours per day is minimal. Approximately100gm of force per side is appropriate. The teeth should move at the rate of 1mm/month.
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  56. 56. A simple method to check for position of the resultant force relative to the centre of resistance is to watch the portion of the headgear where the inner and outer bows meet, between the lips. If connecting the outer bow to the neckstrap or head cap raises this junction point of the inner and outer bows, the roots will more distally. If the junction moves down, the crown is going to tip distally. When the junction is stable, bodily movement will result.
  57. 57. 14.ASYMMETRIC HEAD GEAR Sometimes both molars have to be moved distally but one requires more movement than the other. To accomplish this, an asymmetric face bow with a neckstrap attachment can be used to deliver more force to one tooth than the other. This will result in more movement in the side with the longer outer bow but will also move that tooth toward lingual cross bite.
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  59. 59. For space regaining, it should be used only to deal with bilateral but asymmetric space loss not true unilateral space loss. Disadvantages: · Asymmetric cervical head gear is neither as easy to adjust nor as comfortable to wear as symmetric head gear. · Requires excellent patient compliance.
  60. 60. 15.TRANSPALATAL ARCH The mildest from of maxillary space loss is mesiolingual rotation of the maxillary molars around the large lingual root. This can result from modest mesial drift into space lost because of proximal caries or minor space loss after early extraction of maxillary second primary molars.
  61. 61. This type of space loss can be recognized by the lack of molar buccal offset (the facial surface is normally more prominent than the primary molar or premolars)and an end to end permanent molar relationship. Bilateral derotation of these teeth with a soldered or removable 36 mil transpalatal arch with an adjustment loop has been advocated to improve alignment and distalize the teeth, increasing arch perimeter.
  62. 62. 16.LINGUAL ARCH MAXILLARY: For bodily distal molar movement a lingual arch with an acrylic pad against the anterior palate to provide anchorage, can be used. Often the anterior teeth also are bonded and stabilized with an arch wire. Then a force to move the molar distally is generated with a helical spring, stainless steel or super elastic coil springs. Indications: Bodily distal movement of one or both permanent maxillary first molars. Disadvantages : Complexity and of apparatus.
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  64. 64. MANDIBULAR: For unilateral mandibular space regaining a lingual arch can be used to support the tooth movement and provide anchorage when used in conjunction with a segmental arch wire and coil spring. But a mandibular lingual arch is less stable than a maxillary one. Usually the lower lingual arch runs from one permanent first molar to the opposing primary first molar on the side where the space is to be regained. This primary molar also has a bracket on the facial surface of the band.
  65. 65. A coil spring then can be compressed on a segmental arch wire between the primary and permanent molars. The regained space must be maintained, preferably with a passive lingual arch to bands on both permanent first molars.
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  67. 67. 17. LIP BUMPER Fixed appliance for mandibular space regaining. It is a labial appliance fitted to tubes on the molar teeth. The idea is that the appliance presses against the lip, which creates a distal force to tip the molars posteriorly. Althoughsome posterior movement of the molars can be observed when a lip bumper is used, the appliance also alters the equilibrium of forces against the incisors, removing any restraint from the lip on these teeth.
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  69. 69. RECENT ADVANCES: UNILATERAL DISTAL MOLAR MOVEMENT WITH AN IMPLANT-SUPPORTED DISTAL JET APPLIANCE. A.I. Karaman, F.A. Basciftci, O. Polat A distal jet appliance consists on an acrylic Nance button and stainless steel wires. The appliance can easily be converted to a Nance appliance when the distalization is complete.
  70. 70. Although the need for minimum patient cooperation and ease in use are among the advantages of this appliance the distal molar movement occurs mainly by tipping and rotation of the crowns, and an anchorage loss does occur in the premolars and incisors. Implant supported modified distal jet appliance has the advantagesof implants and intraoral distalization appliances.
  71. 71. Case The left maxillary molar was tipped mesially as a result of premature loss of the maxillary left deciduous molar. There was inadequate space for the eruption of the second premolar in the upper left buccal segment. There was adequate overjet and overbite. The canines had not yet erupted. The mandibular teeth had a favourable alignment and eruption pattern.
  72. 72. Treatment objectives The treatment objectives included achieving a Class I molar relationship with distalization of the upper left first molar, eruption of the impacted premolar, and controlled eruption of all of the erupting teeth. Treatment progress: Distal movement of the upper left first molar was planned. To achieve this movement, the use of intraoral distalization mechanics was planned.
  73. 73. Applicance Fabrication: Molar bands with palatal tubes were fitted to the upper first molars. An anchorage screw three mm in diameter and 14 mm in length was placed at the anterior palatal suture, two-three mm posterior to the canalis incissivus under local anesthesia. During the same visit, alginate impressions were taken, and model casts were obtained for the constructionof the appliance.
  74. 74. On the upper dental cast, a stainless steel tube one mm in diameter was adjusted to the implant. Anchor wires 0.8 mm in diameter were soldered to the tubes for occlusal rests on the first premolars. The 0.9 mm wire extended through each tube, ending in a bayonet bend that was inserted into the palatal tube of the first molar band. For force application, nickel-titanium open-coil springs 0.76 mm in diameter were adjusted.
  75. 75. The implant-supported modified distal jet appliance was attached to the anchor premolars with light-cured composite adhesive. The joint between the implant and the tubes was secured with composite material to eliminate plaque retention and increase the stability of the appliance. Force arms were placed in the tubes, and the appliance was activated.
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  77. 77. Two months after the insertion of the appliance, the space between left first premolar and first molar had increased to 4.5mm without anchorage loss. At the fourth visit four months after insertion of the appliance, an 8mm space for the eruption of the second premolar was achieved. Mean-while, space for the canine was maintained.
  78. 78. Treatment Results After a treatment period of four months, the left maxillary molar had been moved five mm distally without anterior movement of the anchor premolars. There was a two mm intrusion of the left first molar. Because the coil spring on the right arm was not activated, the position of the right molar showed no signs of change.
  79. 79. C-SPACE REGAINER FOR MOLAR DISTALIZATION Kyu-Rhim Chung Young-Guk Park Su-Jin Ko This appliance can be used to intrude teeth as well as to move them distally or sagittally.
  80. 80. Its indications include: · Mesial drift of the first molar following premature loss of the deciduous molar in the mixed dentition. · Mild arch-length discrepancy treated by extraction of second or third molars. · Open bite · Class II malocclusion · Class III malocclusion
  81. 81. Fabrication: The C-space regainer consists of a labial framework, formed from .036” stainless steel wire, and an acrylic splint. A closed helix, as wide in diameter as comfort will allow, is bent into the framework in each canine region. The labial framework is extended distally to lie as close to the buccal molar tubes as possible, allowing easy insertion into the headgear tubes and improving the precision of the distal-driving force.
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  83. 83. The distal ends of the framework should be polished down for a loose fit in the molar tubes. An .010” x .040” open-coil spring is soldered immediately distal to the helix, and .028” ball clasps are used to retain the appliance.
  84. 84. Appliance Placement: The open-coil spring when compressed, will exert 200g of force and move the molars distally about 1-1.5 mm per month. The patient should be checked every three weeks for the constant application of coil-spring pressure. When reactivation is needed, the helix is squeezed with a heavy-wire or three-prong plier, moving the labial wire extension and the coil spring distally. When the labial wire is reinserted in the headgear tube, the initial compressive force will be regained.
  85. 85. A molar overcorrection of at least 2mm distal to the normal Class I position will be needed because of the inevitable mesial relapse. A Nance button should be placed immediately after removal of the C-space regainer to hold the molars in position and allow the maxillary buccal segments to drift distally while the transseptal fibers reorient.
  86. 86. Conclusion: The molar distalization demonstrated in this article was almost all bodily movement, with only minor distal tipping and rotation. Some slight labial movement of the anterior teeth was observed as a counteraction to the distal movement of the molars, but the acrylic splint kept this flaring to a minimum.
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