Lec.

25
Space Maintenance for
Areas of Multiple Loss of
Teeth
Assistant Professor
Aseel Haidar
 Lec.25 Pedodontics Fifth stage

Assist. Prof. Dr. Aseel H. Al-Assadi

Space Maintenance for Areas of Multiple Loss of Teeth

Loss of multiple primary molars in the primary or mixed dentition may lead to sever
change and mutilation of the developing dentition unless an appliance is constructed to
maintain relationships of the remaining teeth and to guide eruption of the developing teeth.
In addition to arch dimension concerns, reduced masticatory function is undesirable from
a nutritional standpoint and also a collection of plaque material and food debris after loss
of the normal cleansing function will result in increased dental caries activity and gingival
inflammation. Cross bite of 1st permanent molar and subsequent anterior drifting of the
permanent molars occurs after loss of maxillary primary molar.

Space Maintenance Areas for Multiple Primary Molar Loss

1-Removable acrylic partial dentures:
They have been used successfully in either arch after the loss of multiple teeth, bilateral
loss of deciduous teeth whether it is single or more than one tooth and acrylic partial
denture can be constructed for maxilla and mandible so it can restore function and
mastication.
After treatment of the carious teeth, acrylic partial denture is constructed which should
has good retention and the child should instructed to have good oral hygiene.

2- The passive lingual arch or (Nance appliance).

3- Transpalatal arch.

Full denture for children

When the whole primary teeth are extracted, a full denture is done
which is the same as that for adult and the child can use it and wear it
easily.
It is occasionally necessary to recommend extraction of all the
primary teeth in a preschool child and wear complete dentures before
the eruption of permanent teeth.
A full denture will improve the child appearance and restored
function and may be effective in guiding the first permanent molar into
their correct position.
The denture should be adjusted when the child visit the dentist every interval so when the
teeth is going to erupt a hole should be put at the place of eruption when ¾ of the root is
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formed and this can be done by taking X-ray to follow the eruption of the permanent
successor, when the 1st permanent molar and incisors have erupted, a partial denture S.M.
or a lingual arch can be constructed to serve until remaining permanent teeth erupt.

Loss of First Permanent Molars

The first permanent molar is unquestionably the most important unit of
mastication and is essential in the development of a functionally desirable occlusion. A
caries lesion may develop rapidly in the first permanent molar and occasionally progress
from an incipient lesion to a pulp exposure in a 6-month period. The loss of a first
permanent molar in a child can lead to changes in the dental arches that can be traced
throughout the child’s life.
Unless appropriate corrective measures are instituted, these changes include:
1) Diminished local function.
2) Drifting of teeth.
3) Continued eruption of opposing teeth.
4) The second molars, even if unerupted, start to drift mesially after the loss of the first
permanent molar. A greater degree of forward bodily movement will occur with loss
of the first permanent molar in 8- to 12-year-old children.
In older children, if the loss occurs after eruption of the second permanent molar,
more exaggerated mesial tipping of the second molar can be the expected outcome.
5) Although the premolars undergo the greatest amount of distal drifting, all the teeth
anterior to the space, including the central and lateral incisors on the side where the
loss occurred, may show evidence of movement.
6. Contacts open and the premolars, in particular, rotate as they fall distally. There is
a tendency for the maxillary premolars to move distally in unison, whereas those
in the lower arch may move separately.
7. When the maxillary first permanent molar loses its opponent, it erupts at a faster
rate than the adjacent teeth. The alveolar process is also carried along with the
molars and causes problems when prosthetic replacements are needed.

The treatment of patients with the loss of first permanent molars

must be approached on an individual basis:
1) If the first permanent molars are removed several years before eruption of the
second permanent molars, there is an excellent chance that the second molars will
erupt in an acceptable position. However, the axial inclination of the second molars,
particularly in the lower arch, may be greater than normal. The decision whether to
allow the second molar to drift mesially or to guide it forward in an upright position
may be influenced by the presence of a third molar of normal size.

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2) When the first permanent molar is lost after the eruption of the second permanent
molar, orthodontic evaluation is indicated, and the following points should be
considered: Is the child in need of corrective treatment other than in the first
permanent molar area? Should the space be maintained for a replacement
prosthesis? Should the second molar be moved forward into the area formerly
occupied by the first molar? The latter choice is often the more satisfactory, even
though there will be a difference in the number of molars in the opposing arch. A
third molar can often be removed to compensate for the difference. Without
treatment, the second molar will tip forward within a matter of weeks.
3) Another option to consider is autotransplantation of a third molar into the first molar
position.

Tooth migration and arch changes

during the development of the occlusion

Development of dental arches and occlusion

The primary (deciduous) dentition phase
The sequence of eruption of the deciduous dentition is:
Central Incisor – Lateral Incisor – First Molar – Canine – Second Molar.
The primary dentition is usually established by 3 years of age following the
eruption of the second deciduous molars and last until about the age of 6 years when the
first permanent molar begin to erupt. From 3-4 years of age, the dental arch is relatively
stable and very few changes occur. From 5-6 years of age, the size of the dental arch begins
to change due to eruptive force of the first permanent molar.

Features of primary dentition period

1) Spacing in primary dentition
2) Terminal plane relation of the deciduous molars
3) Deep bite
4) The dental arches are wide U shaped
5) Flat curve of Spee
6) Shallow cuspal interdigitation
7) Incisors are more vertically placed

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Spacing in primary dentition

Spacing normally exists between the deciduous teeth. These spaces are called
physiological spaces or developmental spaces. The presence of spaces in the primary
dentition is important for the normal development of the permanent dentition and absence
of spaces in the primary dentition is an indication that crowding of teeth may occur when
the larger permanent teeth erupt.
There are two consistent morphologic arch forms of the primary dentition:
1) Generalized spaces between the teeth were present (type I)
2) The teeth were in proximal contact without spacing (type II). Such dentition
is more prone to malocclusion during the development of permanent dentition.
The arch form in both types appears congenital rather than developmental because the
original pattern exhibited upon eruption was maintained from ages 3 to 6 years.
Spaced arches frequently exhibit two distinct diastemas—referred to as
primate spaces—one between the mandibular canine and first
primary molar and the other between the maxillary lateral incisor
and primary canine.
Until the eruption of the permanent first molars, the sagittal
dimension of the primary dental arches remained essentially
unchanged, with the possible exception of a slight decrease as the
result of the development of dental caries on the proximal surfaces
of the molar teeth.
Space maintainers, when primary teeth are lost prematurely,
are the next major consideration in maintaining arch dimensions.
Control of functional problems such as elimination of deleterious thumb-sucking habits
and correction of functional crossbites may also receive attention during the primary
dentition years.

Notes:
** The early-mixed dentition (6 to 9 years of age) is a period much more prone to
localized factors that may result in severe malocclusion problems if undetected

2) Terminal plane relation of the deciduous molars

Types of molar adjustment
There are three distinct kinds of molar adjustment as given by Baume:
1. Terminal plane forming a Mesial step
Distal surface of the lower second primary molar is mesial to the same
surface of the maxillary molar which is most ideal for Class I
development. It allows the first permanent molar to erupt directly into Cl
I occlusion without altering the neighboring teeth.
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2. Flush Terminal Plane

A) A mandibular primate space and a Straight Terminal Plane
If the distal surface of maxillary and mandibular deciduous second molars are in the
same vertical plane; then it is called a flush terminal plane. It will lead to a Cl I molar
occlusion by an early shift of the primary molars into this primate space as the first
mandibular molar erupted.
B) Closed primary arches and straight terminal plane
This will be resulted in a transitory end to end relationship of the first
permanent molars. A class I occlusion occurred through a late mesial
shift of the mandibular first molars subsequent to the exfoliation of the
primary second molars. Any mesial shift will use the leeway space. If
this space is needed for the eruption of the premolars and canines, the
molar shift should be prevented by a holding lingual arch.

3. Distal step
Distal surface of lower second primary molar is distal to the same surface
of the maxillary molar is abnormal and is indicative of a developing class
II malocclusion.

Notes:
** The pattern of transition involving the straight terminal plane is normal but that the
occlusion forming a mesial step is more ideal.

Mixed dentition phase

The mixed dentition period can be divided into three phases:
1. First transitional period
2. Inter transitional period
3. Second transitional period

1. First transitional period

The first transitional period is characterized by:
A) The emergence of the first permanent molars
If any unusual spaces created by the destruction (carious / traumatic) or premature
loss of the primary teeth during this process, mesial shift of the first permanent molar
in various ways (due to the presence of physiological spaces in primary dentition)
may result.

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B) The exchange of the deciduous incisors with the permanent incisors.

During the first transitional period the deciduous incisors are replaced by the
permanent incisors. The mandibular central incisors are usually the first to erupt. The
permanent incisors (the total sum mesiodistal width of the four permanent incisors) are
considerably larger than the deciduous teeth they replace. This difference between the
amount of space needed for the accommodation of the incisors and the amount of space
available for this is called incisal liability. The incisal liability is roughly about 7 mm in
the maxillary arch and about 5 mm in the mandibular arch.
Factors that controlling the arrangement of the four permanent incisors are:
A. Utilization of physiologic spaces seen in primary dentition.
B. Increase in inter-canine width.
C. Growth of the dental arch in the anterior region:
This will provide space to accommodate the larger permanent incisors. Since the
permanent incisors erupt in more labial inclination (2-3 mm from the location of the
primary incisors) they tend to increase the dental arch perimeter. This is another factor that
helps in accommodating the larger permanent incisors.
D. Change in incisor inclination:
One of the differences between deciduous and permanent incisors is their
inclination. The primary incisors are more upright than the permanent incisors.

2. Intertransitional period
This is a relatively quiet (lag) phase and no active tooth eruption is seen. In this
period the maxillary and mandibular arches consist of deciduous and permanent teeth.
Between the permanent incisors and the first permanent molars are the deciduous molars
and canines (the permanent incisors and the permanent molars sandwich the primary
canines and molars). This phase during the mixed dentition period is relatively stable and
no change occurs. Only few changes in the morphology of the primary teeth are seen
because they undergo attrition.

3. Second transitional period

The second transitional period is characterized by the replacement and alignment
of the deciduous molars and canines by the premolars and permanent cuspids respectively.
This takes place around 9-10 years of age and it is very critical for the alignment of the
erupting permanent teeth. The features of second transitional period are:
1. Leeway space.
2. Ugly duckling stage.

1. Leeway space:
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The combined mesiodistal width of the permanent canines and premolars

is usually less than that of the deciduous canines and molars. The surplus space is called
Leeway space of Nance. The amount of leeway space is greater in the mandibular arch
than in the maxillary arch. It is about 1.8 mm (0.9 mm on each side of the arch) in the
maxillary arch and about 3.4 mm (1.7 mm on each side of the arch) in the mandibular arch.
This excess space available after the exchange of the deciduous molars and canines is
utilized for mesial drift of the mandibular molars to establish class I molar relation.

Notes: According to Black,

1. The combined mesiodistal width of the upper buccal primary
teeth is 22.5 mm, while that for the permanent teeth is 21.6 mm, so the
surplus space will be 0.9 mm in the upper dental arch.
2. In lower arch the corresponding deciduous total is 22.6 mm;
whereas the total mesiodistal width of permanent teeth is only 20.9 mm,
leaving a difference of 1.7 mm.
3. The size of the permanent canine and the premolars is larger
than that of their predecessors, therefore although the exchange of the
lateral teeth may be carried out smoothly, there is crowding as each tooth
is exchanged which is transient.

2. Ugly duckling stage (Broadbent phenomenon):

It is a transient or self-correcting malocclusion seen in the maxillary
incisor region between 8-9 years of age, seen during the eruption of the permanent canines.
As the developing permanent canines erupt, they displace the roots of the lateral incisors
mesially. This results in transmitting of the force onto the roots of the central incisors which
also get displaced mesially. A resultant distal divergence of the crowns of the incisors
occurs leading to creation of diastema in the incisor region. Broadbent named this as the
ugly duckling stage as children tend to look ugly during this phase of development. Parents
are often apprehensive during this stage and consult the dentist. This condition usually
corrects by itself when canines erupt as the pressure is transferred from the roots to the
crown of the incisors.

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Permanent dentition phase

This stage begins with the eruption of the permanent second molar at 12 years of
age, after the exchange of lateral teeth is completed and the dental arch up to the first molar
is established. With the eruption of second permanent molar, the arch circumference may
become shorter than that of the primary arch by utilization of the Leeway space. The
transient malocclusion seen in the mixed dentition period gets corrected and the occlusion
is stabilized. Due to the opening of the bite, anterior deep bite gets corrected.

ARCH-LENGTH ANALYSIS
1. Nance Analysis.
As a result of comprehensive studies, Nance concluded the followings:
1. The length of the dental arch from the mesial surface of one mandibular first permanent
molar to the mesial surface of the corresponding tooth on the opposite side is always
shortened during the transition from the mixed to the permanent dentition.
2. Nance observed that in the average patient's mandibular arch a leeway of 1.7 mm per
side exists between the combined mesiodistal widths of the primary mandibular canine and
first and second primary molars and the mesiodistal widths of the corresponding permanent
teeth, with the primary teeth being larger.
3. This difference in the total mesiodistal width of the corresponding three primary teeth
in the maxillary arch compared with the width of the three permanent teeth that succeed
them is only 0.9 mm per side.
Recently, Nance arch length analysis is seldom used, partly because:
The involved procedures for this analysis require a complete set of periapical
radiographs.
The clinical reliability of other analyses that do not use radiographs is
sufficient for determining major arch-length inadequacies.
It is time consuming.

2. Moyers Mixed Dentition Analysis.

This method is more widely used, because it has minimal systematic errors and the
range of such errors is known. The advantages of this technique are:
 It can be completed in the mouth as well as on casts.
 It may be used for both arches.

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 The analysis is based on a correlation of tooth size; one may measure a tooth
or a group of teeth and predict accurately the size of the other teeth in the same
mouth.
 The mandibular incisors, because they erupt early in the mixed dentition and
may be measured accurately, have been chosen for the measurement to predict
the size of the upper, as well as the lower, posterior teeth.

3. Tanaka and Johnston Analysis.

The Tanaka and Johnston method of arch-length analysis is a variation of Moyers'
analysis except that a prediction table is not needed. In this technique:
1. The sum of the widths of the mandibular permanent incisors is measured and divided
by 2.
2. For the lower arch, 10.5 mm is added to the result
3. For the upper arch, 11 mm is added to the result to obtain the total estimated widths of
the canines and premolars. For example, if the width of the lower incisors is 23 mm, divide
by 2 and add 10.5 mm for the lower arch. The result is 22 mm compared with 22.2 mm
obtained from Moyers' table.
4. One can then take these tooth mass predictions and compare them with the total
measured arch length and obtain any inadequacies in the arch length.

4. Bolton analysis.
This analysis addresses tooth mass discrepancies between the maxillary and
mandibular arches. It can be used to compare the sum of the mesiodistal widths of the 12
maxillary teeth with that of the 12 mandibular teeth, from the first molar to first molar, and
to compare the 6 maxillary teeth with the 6 mandibular teeth, canine to canine.
The Bolton analysis ratio is as follows:
(Sum mandibular)/ (Sum maxillary) x 100 = Tooth mass ratio
 For the overall ratio (12 teeth versus 12 teeth), the mean is 91.3 (±1.91) %.
 For the anterior ratio (6 teeth versus 6 teeth), the mean is 77.2 (±1.65) %.
 When a significant discrepancy with these ratios is noted, the clinician must assess
where the tooth mass problem is located and decide on the best method to resolve it.