The document discusses preventive orthodontics and space maintenance. It defines preventive orthodontics as actions taken to preserve normal occlusion. Space maintenance involves maintaining space left by premature loss of primary teeth using appliances like bands, lingual arches or removable partial dentures. Factors like dental development stage, eruption timing and bone levels determine need for and type of space maintainer used.

1. YOGITA TRIPATHI
1

2.  Introduction
 Definition
 Rationale
 Benefits of early treatment
 Goals
 loss of individual tooth
 Treatment for loss
 Space supervision
 Space maintenance
 Criteria for space maintenance
2

3.  An old saying prevention is better than cure holds
true for preventive orthodontics. For the preventive
approach to be truly effective it needs to apply at
its earliest, i.e at the primary prevention level.
3

4.  Graber in the year 1966 defines preventive
orthodontics as the action taken to preserve the
integrity of what appears to be normal occlusion at
a specific time.
 Interceptive orthodontics is defined as phase of
science and art of orthodontics employed to
recognize and eliminate the potential irregularities
and malpositions in the developing dentofacial
complex (AAO-1969)
4

5.  JC BRAUER IN 1941 defined space maintenance
as the process of maintaining a space in a given
arch previously occupied by a tooth or a group of
teeth.
 Space control- careful supervision of the
developing dentition; it reflects an understanding
of the dynamic nature of occlusal development-
GAINSFORTH 1955
5

6.  Some malocclusions can be prevented or
intercepted.
 It is the dentist’s responsibility to obviate, when
possible, lengthy or complicated treatment.
 Treatment is easier in some cases.
 More alternative methods are available.
6

7.  Possibility of achieving a better result.
 Some forms of treatment can only be done at an
early age.
 Early treatment of serious deleterious habits is
easier than treatment after years of ingrained habit
reinforcement.
 There are psychological advantages to early
treatment in some children.
 Younger patients are often more cooperative and
attentive.
7

8.  Dentition and occlusion
 Musculature: cheek, lip and tongue muscles may tend
to limit buccal, labial, and lingual movement of the teeth.
These forces contribute to dental arch form by
maintaining tooth contact and eastabilising a relatively
stable intermolar and intercanine width.
 Craniofacial skeleton
 Treatment planning
8

9. Congenitally missing teeth-
 Maxillary lateral incisor-
 Mandibular second bicuspids
 Loss of multiple teeth
9

10. PROBLEM ARCH
IMMEDIATE
TREATMENT
FUTURE
TREATMENT
Loss of 1
primary lateral
Upper/lower
Extract antimere
Stripping or
extraction of
primary canine
within 6-12
months
Both primary
laterals
Upper/lower No treatment
necessary
Maxilla only-
reduce midline
diastema
Incisor
crowding<4
Strip primary
canines
Preserve lee
way space
Incisor
crowding>4
Extract primary
canine
Preserve lee
way space or
possible
extraction 10

11. PREMATURE
LOSS OF PRI
CANINE
Without midline
shift
Upper
Lower
Extract antimere
Stop lingual
arch
Preserve lee
way space or
possible
extraction
therapy
Orthodontic
consultation
With midline
shift
Upper/lower Extract antimere Orthodontic
consultation
Lower Lingual arch
11

12. Loss of both
canines
Without
lingual tipping
of incisors
lower Stop lingual
arch
With lingual
tipping
lower Stop lingual
arch
12

13.  Maxillary 1st molar-
 primary cuspid shifts distally
 1st permanent molar and primary 2nd molar shifts
mesially
 An erupting 1st bicuspid is guided along the mesial
surface of the mesially migrating 2nd primary
molar, eventually lying close to the lateral inscisors
13

14.  Loss of maxillary 2nd molar
 The second bicuspid is generally impacted
 Permanent molar shifts mesially
 The cuspid and 1st decideous molar shifts distally
 The resultant lack of space between 1st
permanent molar and 1st bicuspid causes
impaction of 2nd bicuspid
14

15.  Loss of mandibular molar
 in case of loss of mandibular 1st molar, the
permanent molar and second primary molar both
tip forward.
 In case of loss of second primary mandibular
molar, the permanent molar tips forward.
15

16. 16

17. Maxillary central incisors: An acrylic plate with a
pontic of a snug fit should be placed at once and
worn until an age when a permanent restoration
can be inserted. A pontic supported by a wire
frame work held in place by acid etch composite
on lingual side of adjacent teeth.
Maxillary lateral incisor:
Cuspid: Seen rarely. Hold space untill bridge can
be placed
First bicuspid: multibanded mechanotherapy is
required.
17

18.  Premolar may drift into space left by first molar.
 A dipping in the line of occlusion occurs owing to the
change in the axial inclination of the remaining posterior
teeth.
 Closure of bite
18

19. Clinical condition Treatment
suggestion
reason
Intrusion Wait 6-10 weeks for
tooth to reerupt.
Favourable prognosis
for reerution without
incidence
Extract No evidence of
reeruption- 10 weeks
suggests ankylosis
Extrusion Extract Ectopic eruption
Avulsion Do not implant
Coronal fracture Restore fracture Protect pulp
Radicular Extract Ectopic eruption
19

20. Pulp pathology
Concussion observe Possible
reversible reaction
Internal resorption Extraction/pulpect
omy
Reperative
response of pulp
Necrosis Extraction of
pulpectomy
Periapical
infection
20

21.  It is a term applied when it is doubtful, according
to the mixed dentition analysis, whether there will
be room for all the teeth.
 Prognosis for supervision is always questionable,
where as prognosis is always good for regaining
space and for space maintenance.
 Space supervision cases are those that will have a
better chance of getting through the mixed
dentition with clinical guidance than they will
without.
21

22.  Misdiagnosed supervision cases that require
extractions of permanent teeth are more
difficult to treat than gross discrepancy cases-
a. More space closure is needed
b. The patient’s cooperation often lags after the
planned interceptive procedure has failed.
Because of the critical effect of the skeletal
pattern on molar relationship and utilization of
available space three space supervision
protocols are needed:
22

23.  Space supervision is not begun until the
mandibular cuspid and first premolar show
approximately one-quarter to one-third of the root
formed.
 Primary teeth are extracted serially to provide an
eruption sequence of cuspid, first premolar and
second premolar in the maxilla.
 An effort is made to keep the mandibular teeth
erupting well ahead of the maxillary.
 One takes care that a late mesial shift of the
mandibular first molar does not occur.
23

24.  Normal skeletal profile
 Permanent molars are in class 1 molar relation at
the time of instituting space supervision.
 Extraction of mandibular primary cuspid is done
when manibular bicuspid has clearly begun root
formation.
 Removale of primary first molar and slicing of
mesial primary second molar.
 Puropse of second step is to allow allow cuspid to
erup distally and hasten the eruption of first
bicuspid.
24

25.  A holding arch wire is inserted and primary second
molar is extracted.
25

26. 26

27.  The protocol is quite similar to that for a mesial
step- with one expection-
 Since the molars are not in class 1 relationship
and a late mesial shift cannot be allowed to occur,
it is necessary to achieve a class 1 molar
relationship by guidance of the eruption of the
maxillary 1st permanent molar or its movement
distally.
 A sved plate with helical springs may be used.
 The sved plate frees the occlusion, which aids in
the distal tipping of the maxillary 1st permanent
molar, helps flatten the mandibular occlusal plane, 27

28. Maxillary molar is
restrained during
the downward and
forward growth of
maxilla
The maxillary 1st
molar is tipped
distally a slight
amount, thus
changing the axial
inclination of tooth
during subsequent
vertical development
28

29.  Space supervision combined with distal step is a
much more serious matter and the space problem
is quite secondary to the skeletol contributions to
the distal step
29

30.  It is a fixed or removable appliance designed to
preserve the space created by the premature loss
of a primary tooth or a group of teeth- BOUCHER
30

31.  If arch integrity is disrupted by early loss of
primary teeth, problems may arise that affect the
alingnment of permanent teeth.
 Miyamoto and colleagues observed the effects of
early loss of primary teeth by measuring crowding
and malalingnment in permanent dentition of 255
school children aged 11years or older.
 Children who had premature loss of one or more
primary canines or molars were more likely to
receive orthodontic treatment in permanent
dentition with the need more than 3 times greater
in children who had lost one or more primary teeth
31

32.  Incidence of space loss
 Time elapsed since loss
 Stage of developmental/dental age of patient
 Amount of space closure
 Direction of closure
 Eruption timing of permanent succesors
 Amount of bone covering the non erupted tooth
 Abnormal oral musculature
 Congenital absence of the permanent teeth
32

33.  Almost all cases of early primary molar loss show
some decrease in arch length.
 The amount of closure is affected by numerous
variables
(tooth involved, time of loss)
33

34.  Space loss usually takes place during the first 6
months after the primary tooth is lost-Mc Donald
 Space closure occurs more rapidly in the maxillary
arch than in the mandible.
 This indicates that when a primary tooth is
removed and factors indicate need for space
maintenance , it is best to insert an appliance as
soon as possible after extraction.
34

35.  More space loss is likely to occur if teeth are
actively erupting adjacent to the area left by
premature loss of the primary tooth.
 Significant space loss is most influenced by the
stage of eruption of the first permanent molar with
the potential particularly high if a primary molar is
lost just before or during eruption of the first
permanent molars.
 If the first primary molar has been lost prematurely
and permanent lateral incisor is in an active state
of eruption , it may result in distal movement of the
primary canine and encroachment on space
35

36.  This condition is frequently accompanied by a shift
in the midline toward the area of the loss.
 In mandibular arch, a lingual collapse of the
anterior segment may occur with a resulting
increased overbite.
36

37.  Helm reported that space closure is more common
in the mandibular segment were as Ronnerman,s
study showed reverse.
 Maxillary second primary molar- 8mm- Mc donald
 Mandibular second primary molar- 4mm
 Ronnerman and Thilander
Mandibular arch
Primary 1st molar 0.8-1.7mm
Primary 2nd molar 2.1-3.1mm
Maxillary arch
Primary 1st molar 0.5-1.4mm
Primary 2nd molar 3.7-4.5mm
37

38.  Olsen, 1959 stated that greater loss occurs in
mandible owing to a mesial axial orientation of 1st
molar.
 Richardson 1965, Cohen 1941, Seipel 1949 sated
that loss of 2nd primary molar will cause greater
space loss.
MAXILL
A
MANDIBL
E
D E D E
1ST
YEAR
1.3 MM 2.8 1.8 2.4
2ND
YEAR
1.8 MM 4.5 2.7 3.1
3RD
YEAR
3.3 MM 8.0 3.3 4.5
38

39.  Preeruption position of the permanent first molar
and the location of yet unformed root apices.
 mesial position of
upper 1st molar roots

distal position
39

40.  As each permanent molar erupts against the distal
crown surface of primary 2nd molar, there is a
normal vertical alingnment of permanent crown
and root to eastablish a slight mesial inclination of
the molar.
40

41.  Maxillary posterior spaces close predominantly by
mesial bodily movement and mesiolingual rotation
around the palatal root of the first permanent
molars- Stewart 1965
 Minimal mesial tipping of first molar is noted.
 Mandibular spaces close primarily by mesial
tipping along with distal movement and
retroinclination of teeth anterior to the space.
 Bodily movement of first molar is not seen in lower
arch.
 Rose JS 1966 stated that, space closure can
occur in two ways: either through forward 41

42.  Teeth normally erupt when three fourths of the root
is developed- Gron
 Studies have indicated that loss of a primary molar
before 7 years of age leads to delayed emergence
of the succedaneous tooth, whereas loss after 7
years of age leads to early emergence.
42

43.  Strong mentalis muscle paterns may have a
pronounced negative effect after loss of
mandibular primary molars or canine with collapse
of the arch and distal drifting of the anterior
segment that is often exhibited.
43

44.  1mm of bone resorbs in 4 to 5 months
 So if bone is present over succedaneous tooth it is
an indication for space maintainer.
44

45.  NANCE
 LOWER LINGUAL HOLDING ARCH (LLHA)
 BAND/CROWN and LOOP
 DISTAL SHOE
45

46. SPACE
MAINTAINER
ACTIVI
TY
ACTIVE PASSIV
E
RETENT
ION
FIXED
SEMI
FIXED
REMOV
ABLE
FUNCT
ION
FUNCTI
ONAL
NONFUNTIONAL
46

47.  Removable or fixed or semi-fixed.
 With bands or without bands.
 Functional or non-functional.
 Active or passive.
 Certain combinations of the above
47

48.  Removable
 Complete arch
 Lingual arch
 Extra-oral anchorage
 Individual tooth
48

49. Fixed space maintainers-
CLASS I (a) Non-functional types-
i. Bar type.
ii. Loop type.
(b) Functional types-
i. Pontic type.
ii. Lingual arch type.
CLASS II Cantilever type (distal
shoe,band & loop.)
Removable space maintainers-
Acrylic partial dentures
49

50. Space
maintainer
Maxillary
Nance
palatal arch
Transpalatal
arch
Mandibular Lingual arch
50

51.  Unilateral
 Non functional
 Passive
 Fixed appliance
INDICATION
Premature loss of single primary molar
Bilateral loss of single primary molar before eruption of
permanent incisors
Second primary molar is lost after eruption of 1st permanent
molar
51

52. ADVANTAGES DISADVANTAGES
EASY TO CONSTRUCT CANNOT STABILIZE THE ARCH
LESS APPOINTMENT NON FUNCTIONAL
MODIFICATIONS ARE POSSIBLE SLIPAGE OF LOOP BY
MASTICATORY FORCES
MOST OF THE TIME PRIMARY 2ND
MOLAR IS LOST BEFORE
ERUPTION OF PREMOLAR
52

53.  Stoppers can be usd to prevent gingival as well as
buccal movements of loop.
 Crown and loop.
 Crown-band and loop.
 Meyne’s space maintainer.
 Reverse band and loop
 Band and bar
53

54. INDICATION
Multiple loss of primary molars when there is no loss of space in arch
Bilateral loss of primary molars after eruption of lower central incisors
Unilateral loss of primary molars after eruption of lower lateral incisors
54

55. ADVANTAGE
Arch holding
space
maintainer
Used to
regain space
DISADVANTAGE
Construction
is difficult
Distortion of
appliance by
tongue
pressure
May cause
unwanted
movements
55

56.  Hotz lingual arch- with u loop used for space
regaining.
 Removable lingual arch
 Omega bands- in canine region to prevent
interference.
56

57.  Maxillary 1st permanent molar positioning when
there is bilateral premature loss of primary teeth
with no loss of space in arch and a favourable
mixed dentition analysis.
 Advantage- arch stabilizing
 Disadvantage-
a. Tissue hyperplasia
b. Irritation to palatal tissues
c. Pressure effect
d. Cannot be used in patients allergic to acrylic.
57

58.  One side of arch is intact and several primary
teeth on the other side are misssing.
 Primary molars are lost bilaterally.
 Its is designed to prevent the molars from rotation.
 In arch expansion
58

59. 59

60.  Intra alveolar appliance.
 Used when second primary molar requires extraction
and first permanent molar has not erupted.
 An unerupted permanent first molar drifts mesially within
the alveolar bone if the primary second molar is lost
prematurely .The result of the mesial drifts is loss of arch
length & possible impaction of the second premolar.
60

61.  Mcdonald – 9th edition
 PAEDITRIC DENTISTRY-Ray E Stewart
 Hand book of orthodontics-Moyer’s
 Text book of paediatrictric dentistry- Raymond
Brahman
 Nikhil Marwah
 Sobha Tondon
61

62. 62