Space regainers /certified fixed orthodontic courses by Indian dental academy

SPACE REGAINERS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Space regainers are used to regain space lost
by drifting of teeth and may be either extra-oral
or intra-oral fixed or removable appliances
INDICATIONS
1.One or more primary teeth has been lost.
2.Some space in the arch has been lost due to
mesial drift of the first permanent molar.
“Regaining what was once there is
entirely different from creating that which
has never been present”.

Space management is a general term that
includes four subdivisions
a) Space maintenance
b) Space regaining
c) Space supervision
d) Gross discrepancies
All problems in space management fall into
one of the four categories. The
differential diagnosis among them is
determined primarily by mixed dentition analysis.

SPACE REGAINING:
· Loss of arch perimeter usually is the result of caries
or premature loss of primary teeth.
· The most frequent cause of arch perimeter loss in
the mixed dentition is caries of the primary molars.
A carious lesion on the distal surface of the second
primary molar, in particular allows the first
permanent molar to tip mesially.
· Usually when several primary teeth are lost,
the arch perimeter is shortened and space
regaining is indicated.

Such cases must be differentiated carefully
from those in which the tooth size-osseous
base relationship is so poor that there is
insufficient space for the permanent teeth.
The discussion at this point is centered on
patients who once had sufficient length of the
arch perimeter but because of environmental
reasons, had it shortened by mesial
movement of the first permanent molars or
by lingual tipping of the incisors.

· Correction should be where the loss has
occurred.
· Note the molar relationship cuspid
interdigitation and overjet, since they provide
the key to the site of the shortening.


After locating where the arch has shortened,
determine by means of mixed dentition
analysis,
the exact amount of space that must be
regained and the most logical tooth movements to
recover that space.
Usually distal movement of first permanent
molars is required.
But before moving first permanent molars distally
it is necessary to understand the
nature of the
mesial movements that caused the
shortening of the arch perimeter.

a) Mesial drift of permanent molars
Mesial drift of the first permanent molars involves
three separate kinds of tooth movements, namely
mesial crown tipping, rotation and translation.
There are distinct differences in the mode of
mesial movement between the upper and lower
first molars, differences caused by variations in the
crown shape, number of roots, and occlusal
relationships.

• Furthermore the time of loss of the crown of
the primary second molar is the determining
factor in the type of movement seen.
• Maxillary first permanent molars quickly
tip
mesially with the loss of crown substance of
the maxillary second primary molars.


Mesial tipping causes the disto-buccal cusp to
become more prominent occlusally. Because of
the large lingual root of the maxillary first
permanent molar, rotation of the crown also is
seen with mesial tipping, the disto buccal
cusp becoming more prominent buccally as
well.
When the second primary molar is lost
prior to the eruption of the first permanent
molar, translation of the first permanent molar
during its eruption may be seen.

Mandibular first permanent molars display
mesial tipping, crown rotation, and translation as
well but they are more likely to show lingual
tipping during mesial movement.
The lingual tipping is caused by the absence of the
lingual root and the fact that occlusal function
occurs buccally to the center of mass of the lower
molar, a condition aggravated as the fist molar
drifts mesially.

b)Distal movement of first permanent molars
The basic tooth movement necessary in
space regaining is distal movement of
first permanent molars which must recapitulate
in reverse the movements that occurred as the
teeth drifted mesially.
Therefore the selection of the space regaining
appliance is dependent on
whether tipping,
rotation, translation or
combinations of these
movements are
required.

Some common mistakes in choosing space
regaining appliances should be noted.
1. Often too complicated an appliance is
chosen when a simple appliance would let
the tooth fall back more easily into its
former position.


2 A firm purchase on the tooth often is not necessary

except for translation. Actually, tipping and rotation
back into position usually occur more readily with
the use of finger springs rather than a banded
appliance.


3. There is failure to achieve all of the necessary
movements.
It should be noted that surprising
amounts of arch perimeter space often are created
just be distal tipping and rotation of the first molar.
Therefore tipping and rotation should be achieved
prior to attempting translation.
Although this
sequence may necessitate the use of two spaceregaining appliances, it often will save months of
treatment time and frequently permits the use of
simpler appliances.


A wide variety of space – regaining
appliances are available.
No more complicated appliances should be used
than is required to achieve the necessary space.
Do not over extend the space regaining
appliance.
Simple finger springs cannot
move molars bodily nor can they easily
lengthen an arch perimeter past its
original dimensions and retain a permanent result.

Space regaining appliances are intended to
be used solely for recovering space that
once was there.
“SPACE REGAINING IS NOT SPACE
CREATING”


The timing of space regaining is important, since the
position and stage of development of the second
permanent molar often is a limiting factor.
When the simpler space-regaining appliances cannot
complete the task, one may resort to extra oral traction,
but before using extra oral traction, the patient’s case
should be reassessed completely to make certain
that the original diagnosis still obtains.


When the loss of perimeter length is so
extensive as to be beyond the scope of the
simpler appliances, or when there is
insufficient time to recover the space before
the eruption of the bicuspids and second
permanent molars, a far more difficult
clinical situation is present and
comprehensive multibanded appliance
therapy usually is indicated.


MOYERS MIXED DENTITION ANALYSIS:
The purpose of a mixed dentition analysis
is to evaluate the amount of space available
in the arch for the empting permanent carries
and premolars.
In this analysis the size of the unerupted
permanent cuspids and premolars are predicted
from the knowledge of the sizes of
certain
permanent teeth already erupted in the mouth.

The Moyer’s mixed dentition analysis
predicts the combined mesio distal width
of 3, 4 and 5 based on the sum of the
widths of the four
lower permanent incisors.


The mesio distal width of the four lower
incisors are measured and summed up. The
amount of space available for the 3, 4 and 5
after incisor alignment is determined by
measuring the distance between the distal
surface of lateral incisor and the mesial surface
of first permanent molar.
Based on the mesio distal width of the four
mandibular, the expected width of the canines,
first and second premolars are predicted by
referring the probability chart while doing so, the
75% level of probability is considered reliable

The predicted tooth size of 3, 4 and 5
is compared with the arch length available
for them. So as to determine the discrepancy.
If the predicted value is greater than
the available arch length, crowding of teeth
can be expected.


Mixed dentition analysis – radiographic method
This technique makes use of a radiograph as
well as a study cast to determine the width
of the unerupted teeth.
Radiographic measurements of unerupted teeth are
by themselves unreliable due to the distortion
that can occur.
It is possible to determine the measurements of the
unerupted teeth by studying the teeth that have already
erupted in a radiograph and on a cast.

The following formula is used
X1 x Y2
Y1 = -------------X2
Y1 = Width of unerupted tooth whose
measurement is to be determined.
Y2 = Width of unerupted tooth on the radiograph.
X1 = Width of a tooth that has erupted,
measured on the cast.
X2 = Width of a tooth that has erupted,
measured on the radiograph.

Various appliances for space regaining
1.RECURVED HELICAL SPRING
The upper or lower hawley appliance with recurred
helical spring against the mesial surface of a molar
that has drifted forward is effective in molar
distalization.

A removable appliance retained with Adams’ Clasps and
incorporating a helical fingerspring adjacent to the tooth to be
moved is very effective.

This appliance is the ideal design for tipping one molar.
One posterior tooth can be moved upto 3mm distally during 3
to 4 months of full time appliance wear.

The spring is activated approximately 2mm
to produce 1mm of movement per month.
The molar generally will derotate
spontaneously as it is tipped distally.


2. KNEE SPRING
Used in tipping molars distally.
3. CANTILEVER SPRING
The molar can be distalized to regain
space by using removable appliances
that incorporate simple finger springs.


4.SPLIT SADDLE ARCYLIC SPACE REGAINER

Useful when greater distances must be
regained. As the molar moves distally,
the appliance becomes more fragile. It is
then possible to tie the distal portion forward
with a piece of dental floss or stainless steel
ligature to permit the addition of
acrylic posteriorly. In this way the appliance
is reactivated without adjustment of the spring.

5.SLINGSHOT REGAINER
A light elastic is joined to
buccal and lingual hooks
.


6.SLIDING YOKE SPACE REGAINER
Buccal view – A steel edgewise wire
0.022 inch x 0.028 inch is used. A ball of solder
is placed mesial to the cuspid bend of the wire.
A coil spring is then threaded onto the wire, the
sliding yoke is added, and the wire is bent well distal
to the molar to be moved.
The sliding yoke is an edgewise buccal tube the inside
diameter of which is exactly that of the wire.


To the buccal tube is soldered at a right angle a small
piece of stiff wire to engage the mesial of the
molar.
The acrylic must be trimmed in a straight line on the
lingual.
This appliance is best anchored on the opposite side
by an Adams Clasp.
It is more efficient in the maxillary than in the
mandibular arch.

7.JACK SCREW
Space regaining can be brought about using
jack screws placed in such a way that an
increase in arch length is obtained by
distalization of the molar. The appliance
consists of a split acrylic plate with a jack
screw in relation to the edentulous space
and is retained using Adam’s Clasps.

8.GERBER SPACE REGAINER
A seamless orthodontic band or a crown is selected
for the tooth to be distalized.
This space regainer consists of a ‘U’ shaped hollow tubing
and a ‘U’ shaped rod that enters the tubing.
The tube is soldered or welded on the mesial aspect of the
first molar to be moved distally.
The ‘U’ shaped wire or rod is fitted into the tube, in such a
way that the base of the ‘U’ rod contacts the tooth mesial to
the edentulous area.

Open coil springs of adequatelength are
placed around the free ends of the ‘U’
shaped rod and inserted into the tubing
assembly.
The forces generated by the compressed open
coil springs bring about a distal movement
of the first molar.


9.MAXILLARY PLATE (CETLIN) REGAINER

Palatal anchorage is given and eyelets
in the arch wire are placed for
extra-oral anchorage.


10.HUMPHREY APPLIANCE
 If the second primary molar has not been lost as the
result of the erosion of its roots by the ectopically
erupting maxillary first molar, an interesting fixed
appliance has been proposed by Humphrey.
 The second primary molar is fitted with an orthodontic
band. Then, an S shaped wire can be formed from 0.028
yellow Elgiloy wire and soldered to the buccal surface of
the band. The sharpened end of this wire is inserted into the
central pit of the ectopically erupting permanent molar.

 The band is cemented in place and the wire may
be adjusted over a period of weeks to open the
spring and thereby produce the force todistalize
the ectopic molar.
 The adjustments may be made directly in the
child’s mouth with a Howe pliers or a light-wire
bird beak pliers.
 Instead of using the S shaped wire described by
Humphrey, a helical spring has been found to be
more effective.


11.CLASPRING
A combination of a clasp and a spring, can
produce distal molar movement while holding
the appliance on teeth.
Its retentive element resembles the Adam’s clasp.
Its active elements consist of two helical
finger springs that pass through the inter
proximal areas and are held together
buccally or labially by the bridge that connects
the retentive portion.

Advantages of Claspring:
a. Better control of root movement is achieved
by a two point contact with the tooth. The
mesio-distal contact, although unable to
generate pure bodily movement, seems to
reduce the degree of crown tipping.
b. The improved control of sagittal tooth
movement results in less extrusion of
posterior teeth, thus better control of the
vertical dimension.
c. The retentive capability of the claspring
provides adequate overall support.

13.HEAD GEAR
For tipping both maxillary molars distally or for
bodily movement in maxillary molars, extra oral force
via a facebow to the molars is the most effective
and straight forward method.
The force is directed specifically to the teeth that need to be
moved, and reciprocal forces are not distributed on the
other teeth that are in the correct positions.
The force should be as nearly constant as possible
to provide effective tooth movement and should be
light because it is concentrated against only two teeth.

The more the child wears the headgear, the
better. 14 to 16 hours per day is minimal.
Approximately100gm of force per side is
appropriate.
The teeth should move at the rate of
1mm/month.


A simple method to check for position of the resultant
force relative to the centre of resistance is to watch the
portion of the headgear where the inner and outer bows
meet, between the lips.
If connecting the outer bow to the neckstrap or head cap
raises this junction point of the inner and outer bows, the
roots will more distally.
If the junction moves down, the crown is going to tip
distally. When the junction is stable, bodily movement
will result.

14.ASYMMETRIC HEAD GEAR
Sometimes both molars have to be moved
distally but one requires more movement than
the other.
To accomplish this, an asymmetric
face bow with a neckstrap attachment can be
used to deliver more force to one tooth than
the other.
This will result in more movement
in the side with the longer outer bow but will
also move that tooth toward lingual cross bite.

For space regaining, it should be used only to deal with
bilateral but asymmetric space loss not true unilateral space
loss.

Disadvantages:
· Asymmetric cervical head gear is neither as easy
to adjust nor as comfortable to wear as symmetric
head gear.
· Requires excellent patient compliance.


15.TRANSPALATAL ARCH
The mildest from of maxillary space loss is
mesiolingual rotation of the maxillary molars around the
large lingual root.
This can result from modest mesial drift into space lost
because of proximal caries or minor space loss after early
extraction of maxillary second primary molars.


This type of space loss can be recognized by the
lack of molar buccal offset (the facial surface is
normally more prominent than the primary molar
or premolars)and an end to end permanent molar
relationship.

Bilateral derotation of these teeth with a soldered
or removable 36 mil transpalatal arch with an
adjustment loop has been advocated to improve
alignment and distalize the teeth, increasing arch
perimeter.

16.LINGUAL ARCH
MAXILLARY:
For bodily distal molar movement a lingual arch
with an acrylic pad against the anterior palate to
provide anchorage, can be used. Often the anterior
teeth also are bonded and stabilized with an arch
wire. Then a force to move the molar distally is
generated with a helical spring, stainless steel or
super elastic coil springs.
Indications:
Bodily distal movement of one or both
permanent maxillary first molars.
Disadvantages :
Complexity and costwww.indiandentalacademy.com
of apparatus.

MANDIBULAR:
For unilateral mandibular space regaining a lingual arch
can be used to support the tooth movement and provide
anchorage when used in conjunction with a segmental
arch wire and coil spring.
But a mandibular lingual arch is less stable than a
maxillary one.
Usually the lower lingual arch runs from one permanent
first molar to the opposing primary first molar on the side
where the space is to be regained.
This primary molar also has a bracket on the facial surface
of the band.

A coil spring then can be compressed on a
segmental arch wire between the primary and
permanent molars.
The regained space must be maintained,
preferably with a passive lingual arch to
bands on both permanent first molars.


17. LIP BUMPER
Fixed appliance for mandibular space regaining.
It is a labial appliance fitted to tubes on the
molar teeth.
The idea is that the appliance
presses against the lip, which creates a distal
force to tip the molars posteriorly.
Althoughsome posterior movement of the molars
can be observed when a lip bumper is used,
the appliance also alters the equilibrium of
forces against the incisors, removing any
restraint from the lip on these teeth.

RECENT ADVANCES:
UNILATERAL DISTAL MOLAR MOVEMENT
WITH AN IMPLANT-SUPPORTED DISTAL JET
APPLIANCE.
A.I. Karaman,
F.A. Basciftci,
O. Polat
A distal jet appliance consists on an acrylic Nance button
and stainless steel wires.
The appliance can easily be converted
to a Nance appliance when the distalization is complete.

Although the need for minimum patient cooperation
and ease in use are among the advantages of this
appliance the distal molar movement occurs
mainly by tipping and rotation of the crowns, and
an anchorage loss does occur in the premolars and
incisors.
Implant supported modified distal jet appliance has
the advantagesof implants and intraoral
distalization appliances.


Case
The left maxillary molar was tipped mesially as a result of
premature loss of the maxillary left deciduous molar.
There was inadequate space for the eruption of the
second premolar in the upper left buccal segment.
There was adequate overjet and overbite.
The canines had not yet erupted.
The mandibular teeth had a favourable alignment and
eruption pattern.

Treatment objectives
The treatment objectives included achieving a
Class I molar relationship with distalization of the
upper left first molar, eruption of the impacted
premolar, and controlled eruption of all of the
erupting teeth.
Treatment progress:
Distal movement of the upper left first molar was
planned. To achieve this movement, the use of
intraoral distalization mechanics was planned.

Applicance Fabrication:
Molar bands with palatal tubes were fitted to the upper
first molars.
An anchorage screw three mm in diameter and 14 mm
in length was placed at the anterior palatal suture,
two-three mm posterior to the canalis incissivus
under
local anesthesia.
During the same visit, alginate impressions were taken,
and model casts were obtained for the constructionof
the appliance.

On the upper dental cast, a stainless steel tube
one mm in diameter was adjusted to the implant.
Anchor wires 0.8 mm in diameter were soldered
to the tubes for occlusal rests on the first premolars.
The 0.9 mm wire extended through each tube,
ending in a bayonet bend that was inserted into
the palatal tube of the first molar band. For force
application, nickel-titanium open-coil springs
0.76 mm in diameter were adjusted.

The implant-supported modified distal jet
appliance was attached to the anchor premolars
with light-cured composite adhesive.
The joint between the implant and the tubes was
secured with composite material to eliminate
plaque retention and increase the stability
of the appliance.
Force arms were placed in the tubes, and the
appliance was activated.

Two months after the insertion of the appliance, the
space between left first premolar and first molar
had increased to 4.5mm without anchorage loss.
At the fourth visit four months after insertion
of the appliance, an 8mm space for the eruption
of the second premolar was achieved. Mean-while,
space for the canine was maintained.


Treatment Results
After a treatment period of four months, the left
maxillary molar had been moved five mm distally
without anterior movement of the anchor premolars.
There was a two mm intrusion of the left first
molar.
Because the coil spring on the right arm was
not activated, the position of the right molar showed
no signs of change.

C-SPACE REGAINER FOR MOLAR DISTALIZATION
Kyu-Rhim Chung
Young-Guk Park
Su-Jin Ko
This appliance can be used to intrude teeth as well
as to move them distally or sagittally.


Its indications include:
· Mesial drift of the first molar following premature loss of the deciduous molar in the mixed
dentition.
· Mild arch-length discrepancy treated by extraction
of second or third molars.
· Open bite
· Class II malocclusion
· Class III malocclusion


Fabrication:
The C-space regainer consists of a labial framework,
formed from .036” stainless steel wire, and an acrylic
splint.
A closed helix, as wide in diameter as comfort will allow, is
bent into the framework in each canine region.
The labial framework is extended distally to lie as close to
the buccal molar tubes as possible, allowing easy insertion
into the headgear tubes and improving the precision of the
distal-driving force.

The distal ends of the framework should be
polished down for a loose fit in the molar
tubes.
An .010” x .040” open-coil spring is soldered
immediately distal to the helix, and .028”
ball clasps are used to retain the appliance.


Appliance Placement:
The open-coil spring when compressed, will exert 200g
of force and move the molars distally about 1-1.5 mm
per month.
The patient should be checked every three weeks for the
constant application of coil-spring pressure.
When reactivation is needed, the helix is squeezed with
a heavy-wire or three-prong plier, moving the labial wire
extension and the coil spring distally.
When the labial wire is reinserted in the headgear tube,
the initial compressive force will be regained.

A molar overcorrection of at least 2mm distal to
the normal Class I position will be needed
because of the inevitable mesial relapse.
A Nance button should be placed immediately
after removal of the C-space regainer to hold the
molars
in position and allow the maxillary
buccal segments
to drift distally while the
transseptal fibers reorient.

Conclusion:
The molar distalization demonstrated in this
article was almost all bodily movement,
with only minor distal tipping and rotation.
Some slight labial movement of the anterior
teeth was observed as a counteraction to the
distal movement of the molars, but the
acrylic splint kept this flaring to a
minimum.

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Space regainers /certified fixed orthodontic courses by Indian dental academy

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