SPACING AND

CROWDING

BDS FINAL YEAR

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 SPACE RELATED PROBLEMS
Irregular and malaligned teeth in the early mixed dentition arise from two major causes
o Lack of adequate space causing the permanent teeth to erupt an abnormal position
o Interferences with eruption ( drifted and tipped teeth causing space loss and over retained primary teeth, ankylosed primary
teeth, supernumerary teeth, transposed teeth, and ectopically erupting teeth), which prevent a permanent teeth from erupting on
a normal schedule and in the proper position.

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 SPACE RELATED PROBLEMS
 Excess space
 Premature tooth loss with adequate space
 Localized space loss (3mm or less )space regaining
 Mild to moderate crowding of incisors with adequate space
 Moderate severe and generalized crowding

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 EXCESS SPACE
 Generalized spacing of permanent teeth
 Maxillary dental protrusion and spacing
 Missing permanent teeth
 Midline diastema

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 GENERALISED SPACING OF PERMANENT TEETH
o In the absence of incisor protrusion, excess spaces is not a frequent finding in a mixed dentition.
o It could be due to small sized teeth in normal sized arches or normal sized teeth in large arches.
o Unless the space presents an esthetic problem, it is reasonable to allow eruption of remaining permanent teeth before closing
the space with fixed appliance.

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 MAXILLARY DENTAL PROTRUSION AND SPACING
o It is often a sequel to a prolonged finger sucking habit.( eliminating finger habit prior to tooth movement is necessary).
o The more common cause for maxillary incisor protrusion is a class II malocclusion that often has a skeletal larger component,
and in that case, treatment must address the larger problem.
o If there is adequate vertical clearance (not a deep bite) maxillary incisors that are proclined facially can be tipped lingually with
with a removable appliance.(HAWLEY APPLIANCE)
o If overbite is deep, it will bring the upper and lower incisors into vertical contact before the upper incisors can be retracted
enough. This presents a much more complex treatment problem requires skeletal change and comprehensive orthodontic
treatment

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 MISSING PERMANENT TEETH
o The most commonly missing permanent teeth are second premolars (specially mandibular) and maxillary lateral incisors.
MISSING SECOND PREMOLARS
o Maintaining the primary second molar as long as possible.
o If the space, profile, and jaw relationship are good, or somewhat protrusive, it is possible to extract primary second molar that
have no successor at age 7 to 9 and allow the first molar to drift mesialy. This can produce partial or even complete space
closure. It may be necessary to extract teeth in opposing arch to reach a near ideal class I occlusion.

MISSING MAXILLARY LATERAL INCISOR

o Treatment is substitution of the canine for lateral incisors or opening the space for prosthetic lateral replacement.

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 MAXILLARY MIDLINE DIASTEMA
o The unreacted permanent canine often lies superior and distal to lateral incisor root, which forces lateral and central incisors
roots towards the midline while their crown diverge lateral distally.
o In its extreme form, this condition of flared and spaced incisors called ugly duckling stage of development.

UGLY DUCKLING PHASE 8

A small but unaesthetic diastema (2mm or less ) can be closed by removable appliance with clasp, finger spring, anterior bow
with tipping of central incisors together.

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o Diastema( greater than 2mm) supernumerary tooth or intra bony lesion must be suspected
o comprehensive orthodontic treatment is required (2x4 appliance )
o Presence of large or inferiorly attached labial frenum require frenectomy after space closure and retention may be necessary
.therefore frenectomy before treatment is contraindicated.

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 PREMATURE LOSS WITH ADEQUATE SPACE
o Early loss of primary tooth presents a potential alignment problem because drift of permanent or other primary teeth is likely
unless it is prevented.
o If permanent successor will erupt within 6 months a space maintainer will unnecessary.

Band and loop space maintainer

o It is unilateral fixed appliance.
o Indicated for space maintenance in posterior segments.

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 PARTIAL DENTURE SPACE MAINTAINERS
o Indicated for bilateral posterior space maintenance when more than one
tooth has been lost per segment and permanent incisors have not yet erupted

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 DISTAL SHOE SPACE MAINTANER
o Appliance of choice when a primary second molar is lost before eruption of permanent first molar. This appliance
consists of metal or plastic guide planes along which the permanent
molar erupts.

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 LINGUAL ARCH SPACE MAINTANER
o A lingual arch is indicated for space maintenance when multiple primary
posterior teeth are missing and permanent incisors have erupted.

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 LOCALIZED LOSS (3mm or LESS)
SPACE SPACEREGAINING
 Maxillary space regaining
 Mandibular space regaining

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 MAXILLARY SPACE REGAINING
o A removable appliance retained with Adams clasp and a helical finger spring can be used to regain space by distally tipping
permanent first molar. One posterior tooth can be moved up to 3mm distally during 3 to 4 month of full time appliance wear.

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 MAXILLARY SPACE REGAINING
o A fixed appliance can be used to regain space in maxillary posterior region, with a coil spring generating the distalizing force
o Palatal anchorage was gained using a Nance arch and the erupted teeth

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 MANDIBULAR SPACE REGAINING
o Lingual arch is used for unilateral space regaining
o Lip bumper is used for bilateral space regaining

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MILD TO MODERATE CROWDING OF INCISORS WITH
ADEQUATE SPACE
o Up to 2mm of incisors crowding can may resolve spontaneously.
o Up to 3-4mm crowding can be resolved by disking the Interproximal surfaces with remaining primary canine and first primary
molars. This can be help with faciolingual discrepancy not for rotation.

o Correction of rotation caused by crowding can be resolved by using arch wire and bonded attachment to derotate the involve
teeth. 19
 MODERATE SEVERE AND GENERALIZED CROWDING
o Maxillary dental or skeletal expansion, moving teeth facially or opening the midpalatal suture.
o Mandibular buccal segment expansion by facial movement of teeth.
o Advancement of incisors and distal movement the molars in either arch.

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Moderate arch length increase can be accomplished using a multiple bonded and banded appliance and mechanism of expansion. A)this
patient has moderate lower arch crowding and space shortage B) in this coil spring served to generate tooth moving force, lingual arch
control the transverse molar dimension C)the lingual arch is adjusted by opening the loops and advancing the arch so it can serve as
retainer following removal of arch wire and bonded bracket.

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Maxillary expansion can be done with the help of jackscrew by opening the mid palatal suture.

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LATE MIXED DENTITION TREATMENT FOR SEVERE
CRPWDING
o DISTAL MOLAR MOVEMENT
o EXTRA ORAL APPLIANCE (head gear)
o Serial extraction

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 DISTAL MOLAR MOVEMENT
Several options to distalize molar
o Helical spring (pendulum)
o Magnates
o TADS
o Steel and super elastic coil spring
o Temporary anchorage device for molar distalization
not indicated for patient younger than 12 years due
to bone density and TADS instability.

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 EXTRA ORAL APPLIANCE (headgear)
o Force (100 gm )
o duration 14 to 16 hrs.)
o Rate of tooth movement 1mmper month

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 EARLY SERIAL EXTRACTION
In many children with severe crowding, a decision can be made during the early mixed dentition that expansion is not advisable and
some permanent teeth have to be extracted to make room for others.
The sequence often termed as serial extraction simply involves the timed extraction of primary, and ultimately permanent teeth to
relieve severe crowding.

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 INDICATIIONS
o Space discrepancy greater than 10mm per arch
o No any skeletal problem
o Normal overjet and overbite
o Class 1 molar relation
o Straight profile

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A)Severe space deficiency and marked incisors crowding.
B)Primary canines are extracted to align the incisors.

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C)Primary first molar are extracted when half to two third of roots of premolar is formed
to speed up its eruption.
D)Extraction of first premolars after their eruption and canine erupt into the extraction
space.
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 Alternative approach

Extraction of first primary molar to speed up the eruption of first premolar.

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C ) when first premolars have erupted, they are extracted and the canines erupt into the remaining extraction
space.
D) The residual space is closed by drifting and tipping of the posterior teeth.

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Complication of serial extraction is premature eruption of permanent canine, when this occur, the first premolar
are impacted between the canine and second premolar, in this situation the first premolar usually have to be
surgically removed (a procedure often called enucleation.

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THANK YOU

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