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Free end Space Maintai

nd Space M aintainers: Design, Utilization and Advantages/Tania Lucavechi**/Dora Crdenas***/Mydam Maroto****

Primary molars are a determining actor in the development of occlusion. Given their importance when restora-tive treatme?it is not feasible and a primary molar must beextracted the practitioner should keep in mind therisk of losing space and the consequent malocclusion. Preservation of the space can eliminate or reduce theneed for prolonged orthodontictreatment.For that reason there are various kinds of space maintainers and thepdiatrie dentist must decide which one to utilize on the basis of general and local factors related to thechild.In the selection of a treatment option or space maintenance the greatest complications occur when the irst per-manent molar has not yeterupted.A large variety of appliances have been devised to deal with this situation.This article proposes the use of a removable space maintainer that is open on one end andc nbe employed toguide the irst permanent molar maintaining the integrity of the mucous membrane and serving as a prostheticappliance preventing the complications and contraindications ofien caused by sub-gingival maintainers.Keywords: space maintainers; alterations in eruption; eruption control; free end space maintainerJ Clin Pediatr Dent 31(l):5-8, 2006

dentition plays a very important rolein the child'sI^growth anddevelopment,notonlyintermsof speech, chew-L ing,appearanceand thepreventionofbad habits,butalsoin

ng the eruption of permanent tee th.' ' Primary molars areapar-rly vital elemen tinthe developmentofocclusion, and because

are faced with a duemma:or restoration.*'' When restorative treatmentis notfeasi-

atemporary tooth mustbeextracted, the practitioner shouldinmind thedsk oflosing space and the consequent m alocclu-

Many authors-'' have described the effects of the premature loss

ofProphylaxis, Pdiatrie D entistry and O rthodontics. Facultystry Madrid Com plutense University, Spain.

*Elena Barbera. Director ofth Program for Integral Odontological Treatmentof Pdiatrie Patients. Directorofthe Master in Pdiatrie Dentistry.**Tania Lucavechi. Postgraduate in the Master in Pdiatrie Dentistry. AssistantDoetor on the Program for Integral Odontological Treatment of PdiatriePatients.***Dora Crdenas. Postgraduate in the Master in Pdiatrie Dentistry.****Myriam Maroto. A ssistant Professor. A ssistant Doctor on the Program forIntegral Odontological Treatment of Pediatde Patients. Postgraduate in Masterin Pdiatrie Dentistry.

tad de Odontologa. Plaza de Ramn y Cajal s/n. 28040 Madiid. Spain.

overbite, dental malposition, impaction, arch asymmetryandationsineruption. For this reason, preservationof the dental should playaprincipal goalinpediatde dentistry.

Thereare a large numberof factors that influencethemagof the alterations causedby thepremature lossof primary mamong them dental age, eruption pattems,theamountofbonering the succedaneous tooth bud, and the type of tooth lost.

The second primary molar is fundamental inthe normal eruand positioning of the first perma nent molar.* Early loss of thiscan createa major discrepancy between thespacein thearcdental size . ' '

Preservation of the space can eliminate or reduce the need folonged orthodontic treatment. For that reason, there are vkinds of space maintainers and thepdiatrie dentist must dwhich one to utilize,onthe basisofgeneral and local factors rtothechild,aswellas thedentist's familiarity and experiencedifferent typesof maintainers.^'' ' '

Oneofthe important aspectstoconsider when choosinganancefor space maintenance previously occupiedby aprimarond molar is whetherthe first permanent m olar is erupting,intraosseousor extra-osseous.-''^'*'^

The permanent molar, under normal conditions, erupts with ance from the distal surface of the second primary molaranresult its absence causes mesial migration, space lossdecreased arch length.^ '*Whe n the first permanent molar has notyeterupted,itenta

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with a distal extension, which was ealled the distal shoe, andi-agingival appliance, des'igned to guide the per man ent mo lar's

primary molar, and ann's distal surface.^-' '' ' This bar is subm erged su bgingivally

ng the une mp ted perm anen t molar.*^-' 'Som e authors' ' '- '^ ' *contraindic ate this type of appliance when

ile diabetes, or certain blood diseases and for patients with con-In order to avoid the possibility of such complications, we pro-

R EPA R A TION OF THE PR OS THES IS Compilation of complementary data: models of the patient's

. Evaluation of the permanent molar's position. The X-ray wl

Figure Complementary data is needed to determine the size ofthe maintainer s free edge .

Figure :Measurement of the mesio-distal distance of the sprimary molar to be replaced.

Figure 3:Working model is trimmed and prepared before bsent to the iaboratory.

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Free-end Space MaintainFigure :Clinical and radiographie monitoring of the length andsuitability of the free end.

Impression on the gingiva produced by pressure on theted edge. The prominence of the permanent molar can benoted as it erupts.

Figure 6 :The permanent molar begins to emerge.

a. The first permanent m olar is extraosseous. This situation cidentified by observing in the X-ray the total absence of bon e athe molar's occlusal surface, at least in the mesial area.

b.The permanent molarisstill intraosseous. The appliance wdesigned and situated in the same way as the previous case, buvery important to remember that it wiU not begin its role of mtaining the space and guiding the eruption until the molextraosseous.3 . Determination of the size of the free end by measuring, intraly or using the models, the mesio-distal size of the molar treplaced, if the mesial and distal walls are preserved (Fig. 2). Iis not the case, the size must be obtained by measuring the conteral molar and confirming, in the X-ray the molar to be extrathat the measurement is appropriate.

One millimeter is always added to the measurement obtaineorder to avoid complications. This wiU be explained further othis article.4 . Preparation of the working model for the laboratory. The dmust cut out the molar to be replaced in the plaster to 3 mm bthe gum line and parallel to the occlusal plane. The m easurememillimeters to the distal wall is the same as the measurement dmin ed for the fiee end , and the cut will form a straight vestibulagual plane . Th e distal and cervical cuts form a perfectiy visible angle (Fig. 3).

This cut is the fundamental step, because it will make it posfor the prosthesis to be placed on the mucous membrane, exesignificant pressure without cutting into the membrane. On the distal portion, the acrylic resin should have an occluso certhickness of approximately 9 mm and a vestibular-lingual thickof 10 mm. This distal area, different from the design of any prosthesis or space maintainer, is what wul trick nature by slating the cervical part of the root and the distal surface of theond primary molar.5.Prosthesis design. The maintainer's design is painted on theresponding m odel, specifying the positioning of the Adam s cladouble or single, and clearly writing on it the number of millimof the free end. If possible, the morphology of the lost tooth shbe recreated; otherw ise, only acrylic resin is used . This design isto the laboratory.6. The mo lar is extracted and meas ures for correct healing areried out.B PL ACE ME NT OF T HE PROST HE SIS7 No more than one week should pass from the time the tooextracted until placement of the prosthesis, just as with any maintainer.

Upon receiving the prosthesis from the laboratory, and beforpatient arrives, the practitioner should confirm that the prostconforms to the design and is the right size.8. The muco us m emb rane's healing process is examined. Givenonly on e week sho uld have transpired, healing is not com plete9. The prosthesis-maintainer is adjusted in the child's m outh:

a. The practitioner confirms that the distal extension is enough to make contact with the mesied surface of the first penent molar. This can be verified by placing a lead protection us

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Given that the size of the fiiee end h as been estimated 1 mm larg-tuated over the tooth bud ^ i g . 4). The acrylic resin must be cut

simpler than adding on acrylic resin if theb .The practitioner verifies that the occlusion has not been altered,.The patient and parents are instructed in how to insert and clean

In addition, the practitioner continues to take proper measures ton the healing of the mucous mem brane.

FOL L OW UP1 Healing is checked witMn a few weeks. At that time, the mo uth's

.Follow-up visits should b e approximately every two mon ths, inrst permanent mo lar's eruption.

mesial migration, in which case the prosth e-

or use when needed.3 . When the tooth begins to emerge, the appHance is maintained

. Once the first permanent molar has erupted sufficiently, a den-

As a result of the complications involved with the use of intragin-l m ain tai ne rs ' ' and as an altemative to these, proprioceptive

Theoretically the terminal end of this maintainer exerts pressure

The success of this maintainer is determined by the efBciency in

veness of this appliance on num er-

is easy to clean, unlike intragingival maintaineis. Howerequires a high level of cooperation on the child's part andsupport from the parents to motivate the children to us e it.

The foUow-up, subsequent adjustment and maintenance out by the dentist is somewhat more complex than what is rewith other removable maintainers, but it is easy when comwith the clinical management of intragingival maintainers.

In regard to cost effectiveness, these ma intainers m ust b e reor readapted when they have fulfilled their function as eguides and the permanent molar has erupted.R E F E R E N C E S1. Moss S. The relationship between diet, saliva and baby bottle todecay. Int Dent J. 46:399-402. 19962. Chosack A, Eidelman E. Rehabilitation of a fractured incisai upatient's natural crown- Case report. J Dent Chud.31:19-21. 193. Simonsen RJ. Restoration of afracturedcentral incisor using ortoothfragment.J Am Dent Assoc. 105:646-48. 19824. LiebenbergWH.Reattachment of coronalfragments:operative

erations for the repair of anterior teeth. Pract Periodontics Aesthe9:761-72. 19975. Baratieri LN, Mon teiro JrS Andrada MAC . The sandwich teas a base for reattachment of dental fragments. Quintessence In22:81-85.6. Moscovich H, Creugers NHJ. The novel use of extracted teeth astal restorative m aterial: the natural inlay. J Dent. 2 6:21-24, 19987. Santos JFF, Bianch JR. Restoration of severely damaged teeth wresin bonding systems: a case report. Quintessence Int. 22:611-61991.8. BusatoALS,LoguercioAD,Barbosa AN, Sansevedno MCS, MRP,Baldissera RA . Biological restorations using toothfragmentDent. 11:46-49. 19989. Ramires-RomitoACD,Wanderley MT, Oliveira MDM, ImparatCorrea MSNP. Biologic restoration of primary anterior teeth.Quintessence Int.3 1:405-411.200010.Bussadori SK, Rego MA, Pereira RJ, G uedes-PintoAC.Humanel veneer in a deciduous tooth: clinical case. J Clin Pediatr Dent.27:111-16.200311.CardosoAC ,Arcad G M, Zendron MV, MaginiKS .The use of teeth to make removable partial prosthesis and complete prosthescase report. Quintessence Int. 25:239-243. 199412.WaggonerWF.Restoring primary anteriorteeth.Pdiatrie Dent24:511-16.2002

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