Royal London Space

Analysis

Dr. Um-e Ayman

Resident Orthodontics
Contents

 Introduction
 Uses / importance
 Parts;
 Assessment of space requirement
 Assessment of additional space creation and use
 Conclusion
 Introduction

The Royal London Space Planning has evolved since 1985 as part of the
postgraduate training program at the Royal London Hospital.
The Royal London Space Planning process is carried out in 2 stages. The first
stage, assessing the space required to attain the treatment objectives.
In Part II, any additional space to be created or used during treatment is
assessed and recorded is special form.
 Uses / Significance

 Specifically, the Royal London Space Planning will help the clinician:
 To define whether the objectives are attainable and modify them if
necessary.
 To anticipate a shortage of anchorage or excess of space.
 To decide the need for extractions and choice of extractions.
 To plan the mechanics of anchorage control.
 To plan the mechanics of correction of arch relationship.
 To improve pretreatment patient information.
 To obtain valid informed consent.
 Assessment of Space Requirement
Six specific aspects of the occlusion are considered :
 Crowding and Spacing.
 Leveling Occlusal Curves.
 Arch Expansion and Contraction.
 Incisor A/P Change.
 Angulation (Mesiodistal Tip).
 Inclination (Torque).
 Assessment of Space Requirement

The measurements are taken and scores recorded to the nearest millimeter or,
at times, half millimeter.
The measurements are positive when space is present or is created (eg,
by arch expansion) and negative when there is crowding or space is
required (e.g. for incisor retraction).
 Assessment of Space Requirement

1. Crowding and Spacing:

Crowding and spacing should be quantified in
relation to the archform that reflects the
majority of teeth, not necessarily the
imaginary arch that passes through the incisal
edge of the most prominent central incisor in
each arch.
Assessment of Space Requirement
 Assessment of space Requirement

Crowding and spacing are assessed anterior to the mesial surface of the first
molars.
When the second primary molars are present, up to 1 mm spacing is allowed
for upper E space (the size difference between primary and permanent tooth)
and up to 2 mm for lower E space.
 What If the patient is at an earlier stage in the mixed dentition?
Estimations of the size of the permanent unerupted teeth can be made with
the aid of radiographs, proportionality tables, or both.
 Assessment of Space Requirement
2 . Leveling Occlusal Curves
An increased occlusal curve is due to a series of slipped contact points in
the vertical dimension.
It is the restoration of the contact point relationships between neighboring
teeth that demands increased space within the dental arch.
This slippage is usually too slight at any one contact point to be recorded as
a form of crowding, but when an arch is taken overall, space is required for
leveling.
 If teeth were parallel-sided (cylindrical), no space would be required when
leveling an occlusal curve. Where the teeth are bulbous, the space
implications are greater.
 Assessment of Space Requirement

 Two other considerations are relevant:

First, the space implication should be recorded only if the premolars have not been
assessed as crowded.
Second, clinical judgment is necessary as occlusal curves need not be leveled
in all cases.
 Allow 1 mm space for 3 mm depth of curve, 1.5 mm for 4 mm depth, and 2 mm
space for a 5 mm curve.
 Assessment of Space Requirement

3 . Arch Expansion and Contraction

It seems logical there should be a direct one-to-one relationship
between arch expansion and the creation of space.
For the purpose of space planning, each millimeter expansion of the
intermolar width will create approximately 0.5 mm space within the arch.
The space created may be greater when overall arch expansion is
achieved by splitting the palatal suture.
 Assessment of Space Requirement

4. Incisor A/P Change

It may be desirable to alter the anteroposterior position of the lower incisors,
in either direction, depending on the specifics of the malocclusion as assessed
clinically and cephalometrically.
The upper incisors are then corrected in the analysis to an overjet of 2 to 3
mm in relation to the position selected for the lower incisors.
 Each millimeter of incisor advancement or retraction will create or consume
2 mm of space within the dental arch.
Assessment of Space Requirement

5 . Angulation (Mesiodistal Tip):

If upper incisors are too vertical, they take up
less space in the arch than if correctly
angulated.
Very occasionally, teeth are over
angulated, and space is gained by
correction to normal angulation.
Applies only to maxillary incisors. Allow
0.5 mm space for correction of each
parallel sided vertical tooth (usually no
allowance is necessary).
 Assessment of Space Requirement

6. Inclination (Torque)

Applies only to maxillary incisors. Allow 1 mm space

for every 5° change affecting all 4 incisors, and 0.5
mm space if only 2 teeth are affected.
This principle does not generally apply to the lower
incisors because unless they are particularly proclined
the contact points are closer to the incisal edges.
Guidance notes
 Integration of space requirement
component

Among the 6 factors considered, only crowding and spacing, arch width change,
and incisor anteroposterior change can have substantial space implications.
The difference in the total space required for the upper and lower arches
requires clarification:
Class I molars  equal space requirement in both arches.
 Assuming 7 mm premolars, bilateral full unit Class II occlusions  an upper
space requirement 14 mm greater (more negative) than the lower; a 7 mm
discrepancy would imply one half unit Class II molars.
 Exercise One

A 13 years old female patient with a chief complain of sticking-out upper

front teeth. Clinically she presented with a class II Div 1 malocclusion on a
class II skeletal base and average lower vertical facial proportion. Her
malocclusion was complicated by:
 Moderate upper arch crowding (-7 mm)
 Mild lower arch crowding (-3 mm)
 Increased overjet (6 mm)
 Proclined upper inciosrs (UIMP = 119°)
 Increased lower curve of spee (4 mm)
Exercise One

Space requirements LOWER UPPER

Crowding and spacing -7mm -3mm
Level occlusal curve -1.5mm -------
Arch width change ------ -------
Incisor A/P change: ------ -8mm
Angulation/inclination ------ -1mm
change
Total -8.5mm -12mm
 Exercise Two

A 14 years old female patient with a chief complain of Front to back bite.
Clinically she presented with a class III malocclusion on a class I skeletal
base and average lower vertical facial proportion. Her malocclusion was
complicated by:
 Moderate upper arch crowding (-5 mm)
 Lower arch spacing (2 mm)
 Reversed overjet (-1 mm)
 Unilateral posterior corssbite ( maxilla in narrow by 2 mm)
 Proclined 11 and 21(UIPP = 130°)
 Mesially angulated upper central incisors(10°) {normal value is 4°}
Space requirements LOWER UPPER
Crowding and spacing +2mm -5mm
Level occlusal curve ------ ------
Arch width change ----- +1mm
Incisor A/P change: ----- +6mm
Angulation/inclination ----- -2.75mm
change
Total +2mm -0.75
ASSESSMENT OF ADDITIONAL
SPACE CREATION AND USE
 Introduction

The procedures that may have an effect on the space are:

 Tooth enlargement or reduction.
 Tooth extraction.
 The creation of space for prosthetic replacement.
 Mesial and distal molar movement.
 The effects of favorable and unfavorable growth.
 ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE

1. Tooth Reduction and Enlargement:

Good occlusion can only be achieved when the amount of tooth
material in both arches is in proportion.

Therefore, space is required to enlarge small tooth (e.g. peg shaped

laterals)
Conversely, space is gained from reducing the mesiodistal width of
an unusually broad tooth by proximal enamel reduction.
 ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE
2. Extractions:
The space gained by extraction is not entirely available for relief of anterior
crowding unless the posterior teeth are prevented from moving forward.
Where no anchorage reinforcement is used, the net space available is
determined by several factors, including the following:
 Which teeth are extracted.
 Which arch is considered.
 Whether second molars are banded.
 ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE
 Whether the crowding is located anteriorly or in the buccal segments.
The degree of incisor crowding and therefore the amount of canine
retraction.
The angulation and inclination changes needed mesial of the extraction spaces.
 The angulation of teeth distal to the extraction spaces.

It is therefore wise to think of a range of space availability from

extractions, and it is thus necessary to base clinical judgments on the
anchorage in terms with demands of each case.
 ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE

Typically, 40% to 65% of first premolar space will be available for the
benefit of the labial segment without anchorage reinforcement.

This reduces to 25% to 50% for second premolar extractions.

The net space available is less in the upper arch than for the equivalent lower
extraction.
 ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE
 The analysis:

In the analysis, the entire mesiodistal width of the permanent teeth to be

extracted is recorded, and mesial movement of the posterior teeth is
recorded separately.
ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE

3 . Absent Teeth
The initial assessment of crowding and spacing does not take absent teeth
into consideration.
Thus, the decision to open space for the prosthetic replacement of absent
teeth is an extension of the principle of building up small teeth
ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE
4 . Distal and Mesial Molar Movement
The distal and mesial movement of molars requires particularly careful
consideration.
Except in unusual cases where the molar relationship is perfect Class I at the
outset, or where treatment is carried out in one arch only, changes in molar
relationship will inevitably involve a combination of relative mesial and distal
movements.
The changes in the molar relationship will usually
involve some of the following:

 Natural growth.
 Distalizing headgear.
 Protraction headgear.
 Intra-arch traction.
 Anchorage loss.
 Intermaxillary elastics.
 Functional appliances.
 Orthognathic surgery.
ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE

Clearly, this aspect of space planning is undertaken at the same

time as decisions on mechanotherapy are being made.
For example, should a given Class II molar relationship be converted
to Class I by means of headgear, intermaxillary elastics, or functional
appliances, or will orthognathic surgery be necessary?
The anchorage demands of the labial segments are also relevant.
ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE
5 . Differenti al Maxillary/Mandibular Growth
Space planning requires an assessment of the difference in A/P growth
between the maxilla and mandible.
In the majority of cases in the permanent dentition  little quantifiable
difference between upper and lower anteroposterior growth during the
period of treatment.
The most relevant are Class II and Class III malocclusions.
 ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE

Favorable mandibular growth in some Class IIpatients reduce the

overjet. This additional mandibular growth reducing upper arch space
requirements, and a +2 mm upper arch score (1 mm per side) might be
given in appropriate cases.
Conversely, the deterioration in Class III no impact on the upper arch
but can significantly increase the space requirement in the lower arch.
 ASSESSMENT OF ADDITIONAL SPACE
CREATION AND USE

 Residual Space at Completion of the Analysis

Once all the aspects of treatment planning and the space implications of the
mechanics are assessed, the residual space requirement for each arch should
return to zero.
If this cannot be achieved, it may signify either that the treatment objectives
cannot be attained or that different treatment mechanics are necessary.
 Case report
 This patient presented at 11 years with a Class II Division 2 incisor relationship.
Cephalometric values
 Case report

 Upper arch crowding = 6 mm

 Lower arch crowding = 5 mm
 Upper occlusal curve = 5 mm
 Lower occlusal curve = 3 mm
 Upper arch is narrow by 2 mm
Case report
Upper and lower A-P incisor
position?
 Upper incisor torque?
Case report
Case report
 CONCLUSION
The Royal London Space Planning process integrates space analysis with
treatment planning.
The first stage quantifies the space required in each dental arch to attain the
treatment objectives.
The second stage combines this information with the space implications of
planned treatment procedures.
The outcome is an ability to identify whether the treatment objectives are
attainable and whether the planned treatment mechanics are appropriate.
One of the strengths of the Royal London Space Planning is that it is not
linked to any particular treatment philosophy or appliance technique.
References

Contemporary Orthodontics 5th edition; Proffit, William R, Henry W. Fields,

and David M. Sarver.
Handbook of Orthodontics. 1st edition; Cobourne, Martyn T, and Andrew T.
DiBiase.
Clinical cases in orthodontics; Martyn T. Cobourne, Padhraig S. Fleming,
Andrew T. DiBiase, Sofia Ahmad
Essentials of orthodontics: Diagnosis and Treatment; Robert N. Staley, Neil T.
Reske
Orthodontics: Current Principles & Techniques 5th edition; Graber, Lee W,
Robert L.
Vanarsdall, and Katherine W. L. Vig