1. Mohammed Almuzian, University of Glasgow, 2014 Page 1
Early loss of deciduous dentition
Aetiology
1. Localfactors
 Trauma
 Periapical pathology
 Periodontal problem
 Caries
2. Generalfactors
 Congenital disease, fibrous dysplasia
 Nutritional, vit D defficiency
 Endocrine, diabetes
 Genetic disease, hypophosphatesia or Elhar Danlos sundrome
 Tumour
 Iatrogenic
Amount and rate of space closure is dependent on many variables
1. Stage of eruption of successors
2. Which tooth: spaceloss greater for E`s than D`s by mesial drift of 2o teeth
3. Which arch: rate of spaceclosure is greater in maxilla
4. Amount of crowding: greater spaceloss in crowded dentitions
5. Occlusal interlocks
Balancing & Compensating Extractions
 Balancing extractions: Removal of a second toothin the samearch, but on
the oppositeside, to preserve midline and molar symmetry
 Compensating extractions:Removal of a second tooth on the same side of
the mouth, but in the opposite arch, to preserve the molar relationship

2. Mohammed Almuzian, University of Glasgow, 2014 Page 2
RCSEng guidelines
Recommendations
1. Radiographic screening is highly desirable before extracting primary
molars to check for the presence, position and correctformation of the crowns
and roots of successionalteeth. Potential problems indicate the need to seek
an orthodontic opinion before teeth are removed.
2. Loss of primary incisors – Early loss of primary incisors has little effect
upon the permanent dentition although it does detract from appearance. It is
not necessary to balance or compensate the loss of a primary incisor.
3. Loss of primary canines– Early loss of a primary canine in all but
spaced dentitions is likely to have most effect on centre lines. The more
crowded the dentition, the more the need for balance.
4. Loss of primary first molars –With regard to a primary first molar, a
balancing extraction may be needed in a crowded arch but compensation is not
needed.
5. Loss of primary secondmolars – There is no need to balance the loss of
a primary second molar becausethis will have no appreciable effect on
centreline coincidence. However when a primary second molar has to be
extracted consideration should be given to fitting a spacemaintainer
Space maintenance
Advantages
1. Aesthetic purposes
2. Preserve Lee way space
3. Prevent potential mesial drift of permanent molars
4. Prevent distal drift of incisors
5. Prevent mid-line deviations
6. Prevent overeruption

3. Mohammed Almuzian, University of Glasgow, 2014 Page 3
Disadvantages
1. Need to insert immediately
2. Long treatment
3. No guarantee it will prevent later treatment
4. Compliance, oral hygiene, regular inspection
5. Proclination of labial segements
Indications
1. GoodOH and low caries rate is essential
2. Loss of central incisor for aesthetic purposes
3. Difficult to assess clinically the occlusion at the current stage.
4. In an occlusion with only mild crowding where any further spaceloss would
result in the need for more complex orthodontic treatment
5. In an occlusion with severe crowding where any further spaceloss would
result in more than a single tooth unit of space being required.
6. If a permanent successorwill erupt within 6 months (i.e., if more than one-
half to two-thirds of its root has formed), a spacemaintainer is unnecessary.
7. If there is not enough space forthe permanent tooth or if it is missing,
spacemaintenance alone is inadequate or inappropriate
Techniques include
1. Band and loop
2. Bonded rigid wire
3. URA and partial denture; used if more than one tooth is lost and to
replace anterior tooth
4. Lingual arch
5. Transpalatal arches

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6. Nance appliance
7. Distal Shoe Space Maintainers:
 The distal shoe has a unique application and is the appliance of choice when a
primary second molar is lost before eruption of the permanent first molar.
 It consists of a metal or plastic guide plane along which the permanent molar
erupts. The guide plane is attached to a fixed or removable retaining device
 To be effective, the guide plane must extend into the alveolar process so that it
is located approximately 1 mm below the mesial marginal ridge of the
permanent first molar, at or before its emergence from the bone.
 When fixed, the distal shoeis usually retained with a band instead of a
stainless steel crown so that it can be replaced by another type of space
maintainer after the permanent first molar erupts.
 If primary first and second molars are missing, the appliance must be
removable and the guide plane is incorporated into a partial denture because of
the length of the edentulous span.
 It is contraindicated in patients who are at risk for sub-acute bacterial
endocarditis or are
Space regaining
Procedures can be employed if spacehas been lost due to drifting regained
spaceis limited to 3mm or less
Technique
 Sectional fixed appliance
 URA
 Lip bumper
 HG
 Molar distalization technique can be used to regain space

5. Mohammed Almuzian, University of Glasgow, 2014 Page 5
Managementof Lee way space
Brennan, 2000, Gianelly2000
1. If a lingual arch is placed during the mixed dentition only an arch length
decrease of 0.44 mm has been reported, and gaining 4.44 mm leeway space.
2. Also the stability were good after lingual arch treatment
3. However it was shown that intercanine is increased after using lingual
arch and this bec the 3s migrate distally.
An early mesialshift and late mesialshift
1. If there is spacing in the primary dentition as the permanent maxillary and
mandibular first molars erupt, the spacemesial to lower deciduous molars lets
these teeth move forward, allowing the permanent molars to erupt into a Class
I relationship. This is called an early mesial shift. So, most of the Leeway
spacewill be used to relief incisors crowding
2. if there is no spacing between the deciduous teeth (i.e. a closed primary
dentition), there is no mesial movement of the mandibular deciduous molars as
the permanent molars erupt, and they erupt into a cusp-to-cusp relationship.
The mandibular Leeway spacetherefore allows for mesial migration of the
lower first molars into a Class I relationship as the deciduous molars are shed.
This is called a late mesial shift
3. Therefore, if lower arch length is preserved to use the leeway spaceto
relieve crowding, correction of the molar relationship will require distalization
of the maxillary first molars, often using headgear.