 Hello everybody today's topic is space maintainers. So going on so pediatric dentistry now has shifted from more of a conservative approach to a concept of total pediatric patient care. So it's no more just drill and fill it is more of wow what is the cause and what best can be done to save the tooth and if this tooth can be saved then what are the other options that we are looking at now the primary dentition is important. One of the major reasons why we need the primary dentition to be in the best of health is because it's important for guiding the eruption of permanent teeth. Now space maintenance was coined by JC Brewer in 1941. It's said that it is the process of maintaining a space in a given arch previously occupied by a tooth or a group of teeth. A space maintainer was defined by Boucher. He defined it as fixed or removable appliance designed to preserve the space created by the premature laws of a primary tooth or group of teeth. Moving on to the objectives of space maintainers why we need them. One is because we need them to preserve the primate spaces. The primate spaces are the space which are present mesial to the upper canine between the upper canine and the lateral primary upper canine lateral and between the lower primary canine and the first primary molar. Preservation of the integrity of the dental arches we needed to preserve the normal occlusal plane and in case of anterior space maintainers it should aid in the aesthetics and phonetics. Now what happens once we lose an early you know the early laws of a primary teeth. So one it leads to the supriorruption of the opposing tooth it then leads to the drifting of adjacent teeth either the mesial migration from the permanent molar or the second primary molar if in case the first primary molar is lost or by the distant migration of the canine or the nitrous. Loss of arch length and circumference because of the drifting of adjacent teeth, deflection in the eruption of permanent teeth, caries and pedontal diseases are also seen and lastly it leads to a traumatic interference in the and untoward jaw relation. There's some ideal requirements when we talk about space maintainers one it should aid in the preservation of the space it should also help in the eruption of adjacent or the succidinous and the apartment teeth it should not impede or restrict any of these it should lead to the restoration of the masticatory function it should prevent the over eruption or the supriorruption of the antigenose teeth it should be compatible with the soft tissue not lead to any kind of irritation it should not have any atroquoic forces on the apartment teeth it should be economical and also should be resistant to distortion it should also allow for adjustment and minor repair and it should be a universal application. There's some indications it's not like every time our primary tooth is lost a space maintainer should be placed so the indications for space maintainers are space after premature loss of deciduous teeth showing signs of closing when less than two third of the root of the permanent tooth is formed or there's more than one mm bone covering is seen this is because that means the time taken for the eruption of following teeth is going to be more and that space has to be preserved while using a space maintainer third is that the disorder if there's a disorder in the sequence of eruption of teeth and with a use of space maintainer would aid or make the future orthodontic treatment less complicated when space for permanent tooth should be maintained for two years or longer and it should also avoid the supriorruption of opposing teeth it should also improve the physiology of child's masticatory system and restore the dental health optim. Moving on to the contraindications when there's a gross discrepancy requiring future extractions or orthodontic treatment like that case is where you need serial extractions you cannot a space maintainer is not indicated in those cases when the permanent succceding teeth is congenitally absent and space closure is decided when there's no tooth for the space to be maintained for then there's no point in putting a space maintainer and the space left is excess of the mesodistral dimensions requiring for the eruption of and space loss is not expected when the leeway space is more and the width the mesodistral width the tooth considered is less than what this way is less than the space that is already present then a space maintainer is not indicated the fact is considered in the decision of space maintenance firstly it's the incidence of space loss there is always some amount of space loss seen when a premature loss of a primary tooth occurs more so in the maxillary than maxillary region than in the mandible now time elapsed since loss this means that the maximum amount of space loss occurs within the first six months after the space or do this lost so the sooner the space maintainers place the better ideally right after extraction now depending on the stage of development or dental age of the patient this means that if the permanent tooth has two-third of its root formed that means it's an active eruption stage that means that also a space maintainer may not be needed because the tooth is going to erupt soon secondly you should also think of the permanent first molar if it's in an active stage of eruption and a space maintainer has not given post the loss of a primary first molar it can lead to more space loss because the permanent tooth the first time first permanent molar can end up causing more space loss if a space maintainer has not given now next is the amount of space globe space closure as i said though the space closure occurs more in the maxillary region than in the mandible direction of closure in the maxillary the maxillary first permanent molar is known to move have a bodily movement and also there's a meso lingual movement of the molar seam when uh while compared to a mandibular first molar where a tipping motion is a tipping claw kind of closure is seen from the first permanent molar of the mandible next moving on to the eruption timing of the permanent successors again that factor should be kept in mind a small iopa can tell you what is the molar stage of the permanent more tooth that is there below and how much bone is present and what and how many more months or years it can take to erupt amount of bone covering the non erupted tooth it says that every four every one mm of bone covering four months of time is taken to erupt through one mm of bone abnormal oral musculature uh the if you have an abnormal mentalist activity uh it is seen to have a kind of effect on the mandible teeth especially the mandible anterior and lastly congenital absence of permanent tooth that should also be confirmed via a x-ray and if there is no permanent tooth then a space maintenance moving on to the classification now we have different types of space maintenance they are removal broadly classified as removal or fixed and under removal space maintenance we have either they either the active or passive either the unilateral or bilateral depending on this tooth loss or the teeth loss and thirdly they can also be classified as functional or non-functional while the fixed space maintenance either you have bonded or banded active or passive functional or non-functional moving on to the different types of space maintenance first we would like to talk about the let's talk about the band and loop space maintenance very commonly used it is a fixed non-functional and a passive space maintenance indicated when there's a unilateral loss of primary first molar before the eruption of permanent first molar it is controversial when it is used after the eruption of permanent first molar because the space loss seen post the eruption of a permanent first molar is less mainly because the second primary molar buttresses all the force that is applied by the primary permanent first molar then either when there's a bilateral loss of a primary molar before the eruption of the permanent incisors in mandibular arch moving on to the contra indications an extremely crowded dentition on when there's marked space loss then a space retainer should be thought of because there's already a space loss that has happened cases where they have low oral hygiene or there's a high carous activity banding can increase such kind mainly because the oral hygiene is already low in such children and then banding or tooth can lead to more destruction of cases needing serial extraction what are the advantages and disadvantages of having a banding loop advantages being it's easy to fabricate very little cheddar and inexpensive disadvantages are it does not restore the occlusion function because it's a non functional space maintainer and it also needs to continue supervision there are many modifications of banding loop most commonly is the crown and loop here a crown is placed on the second primary molar and the loop is this why a crown and loop is given is when the second primary molar has extensive carries or the second primary molar is undergone a pulp therapy the disadvantage is being tooth preparation of the primary second molar needs to be done and no repair is possible because the band there's the the wire of the loop is attached to the crown if you have any modification then the entire thing has to be removed or the wire has to be cut moving on long banding loop it's when two more than one tooth is lost or like in this picture as you can see two teeth were lost here the banding was done on the permanent first molar and the loop will extend it till the primary canine a reverse banding loop is when the first primary molar acts as an abutment tooth and the loop is in the reverse direction that is it is touching the first permanent mole the supply has been used in cases where the second primary molar is lost before the complete eruption of the first permanent molar moving on space mean space maintainer it is a non functional space maintainer here as you can see there's a single part single side of the loop that is done it helps in minor adjustments for space control one of the major disadvantages are that it is less stable next is when an additional occlusal rest is present the advantage is being it prevents the slipping into the soft tissue disadvantages are that again tooth preparation is needed to place the occlusal rest third is a banding bar here a bar is bent into an S shaped before touching the next tooth thus destroying the former contact point in these two regions it's an inform of a S shape the second space maintainer that we're talking about now is the distal shoe space maintainer it has many names it's also known as intralvular appliance valence appliance eruption guidance appliance or the cantilever type appliance it is a fixed non-functional passive space maintainer it was first reported by willett in 1932 it is of a bar here this part was of a bar type while roche had made it into a V type in the this is a gingival extension and this was of a shape of a V moving on indications of distal shoe appliance it is given when a premature loss of a second primary molar prior to the eruption of the first permanent molar that means early loss of a second primary molar contraindications it cannot be given when several teeth are lost or when the grossly decayed primary molar first molar because that first primary molar is the abutment too and if that is grossly decayed then a distal shoe is contraindicated. Distal shoe also indicated when there's a history of systemic illnesses such as kidney diseases, rheumatic fever, when they have kids have low resistance to infection, juvenile diabetes, blood dyscariasis, patients with congenital heart defects who are in need of antibiotic prophylaxis the disadvantages of distal shoe space maintenance include can cause a deviation of the permanent tooth bud it may permit tipping if not placed properly it interferes with the epithelization of the socket it also can cause infection the retention is not very good and the construction is difficult it's usually constructed there are two ways to construct a distal shoe space maintenance either direct or an indirect method well a direct method is where it is done right after the extraction in the mouth you the shape of the the shape is barely done and then placed right after extraction while in an indirect method it is first done on a cast or of the mandible and then the tooth is extracted and placed. Moving on to the third type it's a lower legwood holding arch this again is a fixed non-functional passive mandible arch appliance it is also seen in the maxillary teeth also it can be given not very common it is one of the appliances which is very effective in maintaining space as it brings about minor tooth movement. Moving on indications premature loss of multiple primary posterior teeth after eruption of permanent incisors like in this case where there were like two teeth on the right side and three teeth on the left side which were lost so here the permanent incisors had already erupted so a lower lingual arch was the maintenance it maintains the arch perimeter there is detention and sterilization and even during serial extractions this can be given and there is resolution of minor anterior crowding as well. Moving on contrary indications well in cases where there rampant caves again maintenance of oral hygiene is really low so banding the permanent molars where it can cause more destruction is again not a indication of giving or not an indication of lower lingual arch when frequent changes are required or there's an anterior or posterior cross bite and extreme mandible crowding these are some of the cases where a lower lingual arch cannot be given. Moving on advantages it's an excellent source of anchorage because it incorporates resistance of several teeth causes little or no inconvenience to the patient allows free individual movement of the teeth while maintaining space it is less bulky than the acrylic space maintainer because there are only wire components in this serves as a space maintainer for more than one succident is to the arch. Moving on man's palatal arch it was given by etch nuance in 1947 it consists of a heavy gauge wire either a 0.9 mm wire or even higher than that even a 1 mm wire can be used to the palatal aspect of the first permanent molar from one side to another where the first permanent molars are padded the wire is directed from the molars anteriorly where an acrylic button is attached to it the disadvantages of this is the acrylic button can cause some amount of tissue hyperplasia or when the patient is allergic to acrylic then this is not indicated. Indications of a man's palatal arch is when it is used to maintain space when a bilateral loss of a maxillary primary teeth is seen it is a means to refuse to reinforce sorry to reinforce and courage it is as acts as a scope of acting as a as a scope of acting as a habit breaker. Moving on transpalatal bar indications of transpalatal bar it is when a unilateral maxillary molar is lost now the design includes a straight bar extending across the palette it is again soldered onto two time molar bands it's either the abutments being either the first permanent molars or the second primary molars can be used. Advantages are that the y-ox follows the vault of the palette it's comfortable and does not interfere with the normal speed palatal soft tissue irritation and inflammation is avoided as there's no acrylic component in this. Moving on transpalatal arch it was there's a difference between the transpalatal bar and the transpalatal arch while the arch was introduced by Robert A. Gorshagiran of in 1972 hence also known as the Gorshagiran appliance. It is similar except there's a u-loop that is present disadvantageous of the transpalatal bar or the arch is that there is some amount of soft tissue irritation the slight grooving of the tongue, ulceration of the tongue can be seen if given with bilateral missing teeth meson migration can occur. If there's bilateral missing teeth go for the nanspalatal arch. Moving on one of the latest types of space maintainers are the bonded space maintainers before all the space maintenance that we spoke about before this where the most commonly of the bonded type where the bonded type is offered your type this uses the acid edge technique or which is either UV rays or chemically curing composite systems it is a simple space maintenance which can be readily made and retained with overall better ginger will help to the tissue around the abutment teeth. Here in this bonded space maintainers fiber reinforces reinforced composites which were introduced by Smith and the 90s 60s are used. The disadvantage is being it is difficult to retain due to the shearing forces of occlusion flexure in the function will depond this appliance it is difficult to adjust. Lastly we are speaking about the removable space maintainers nothing but a partial tension where it's a more of a functional type of space maintainer it is very rarely non-functional it is mostly given to maintain the acidic it also maintains the mesotistical space but also and also ends up maintaining the vertical space indications being if the abutment teeth cannot be supported cannot support a fixed appliance like the band loop or the lower lingual arch so then a permanent teeth which are not completely erupted which cannot be or a band adaptation cannot be done so in those cases a removable appliance can be given when there are multiple loss of teeth or when there's aesthetics is a requirement sometimes kids come in where they've lost the anteriors and the parents are very particular of having the aesthetics because as soon as the child smiles you can see that there are no teeth in the front so in such cases a removable appliance can be given but there are certain cases where you cannot one being the lack of patient cooperation because this mainly depends on the amount of cooperation by a child because it's a removable appliance to learn of very young age group who cannot understand instructions these appliances are avoided epileptic patients sometimes when a patient has has an epileptic attack the patient can end up swallowing the appliance or patients are allergic to acrylic components advantageous of this appliance is that it is easy to clean and permits the teeth also to be clean it facilitates chewing and speaking phonetics are taken care of stimulates the eruption of the permanent teeth it kind of applies a pressure on the ginger so it kind stimulates the eruption of permanent teeth it maintains or restores the vertical dimension specially in a fixed removal appliance sorry enough functional removal appliance it maintains the vertical dimensions and it was also aesthetically desirable lastly I would like to continue missing tooth or teeth can be replaced by using different types of speech maintainers it is there's a plethora of appliances over there so you need to have an educated choice mainly keeping factors such as the patient's age need for space space maintenance compliance design comfort and aesthetics are some of the factors that you need to keep in mind and lastly I would like to say that a space maintenance appliance is considered successful if it has been removed after it has served its thank you