Authors: Dr. Monalisa Das, Dr. Shabnam Zahir, Dr. Gautam Kr. Kundu.
Abstract: The first line treatment of non restorable carious deciduous teeth is extraction which may be a curse for the future dentition as well as social activity of a child. A fixed esthetic space maintainer given to a four years old girl child replacing lost maxillary deciduous right central and lateral incisors give a fruitful functional and esthetic result maintaining the required space for the permanent successors.
Introduction: ‘A smile of a child is packaged sunshine and rainbows: Thisgift of God may be hampered by premature loss of teeth which is unfortunately a very common occurrence in children due to lack of knowledge regarding oral hygiene procedures and apathy towards the maintenance of dental health. Many a time parents neglect the health of deciduous teeth thinking that they will exfoliate and do not require attention. 1 The premature loss of deciduous teeth from anterior or posterior segment of a dental arch may be due to early childhood caries, traumatic injury or developmental defects.
Premature tooth loss has a profound effect on the oral health of the child even after eruption of the permanent teeth, which, often tend to cause undesirable tooth movements of primary and /or permanent teeth including loss of arch length. Arch length deficiency can produce or increase the severity of malocclusions 2 with crowding, rotations, ectopic or delayed eruption, impaction, cross bite, extensive over jet or overbite and unfavorable molar relationship due to closure of space previously occupied by the deciduous teeth. Hill et al (1959) in their study in 141 subjects reported that 55.77 % malocclusion was found due to premature loss of the deciduous teeth due to dental caries leading to space closure, which declined to 40.47% after administration of fluoride in the community. In case of premature tooth loss in anterior incisal segment, there is minimum space loss and a linguo-distal inclination of the teeth, causing a collapse of the anteriors lingually, apart from closure of the space and shift of midline (Barber, 1987) 3. It also can lead to parafunctional habits 4 as well as altered behavior including depression, and increased shyness of a child along with poor friend circle and nonacceptable daily life style. Mahmoud K. et al (2009) 5 conducted a study to identify the negative effects of anterior tooth loss on patient’s quality of life and satisfaction with their dentition.
Nature has given the two series of dentition to maintain a smooth conversion of infant`s jaws to the adult form. If there is any deviation, then jaw form and overall facial profile along with the psychology of an individual may be altered. Early loss of maxillary incisors due to caries is very common in case of young children and before the two-third of roots of permanent incisors formed. So, the space should be maintained functionally as well as esthetically by a suitable space maintainer depending on the dental age of the patient. The space maintainer may be of removable, fixed or semi-fixed, functional or non-functional type. This case report represents a simple functional and esthetic rehabilitation of missing deciduous incisors with fixed functional space maintainer. Case report: A four years old girl child reported to the outpatient department of Pedodontics and preventive dentistry, Guru Nanak Institute of Dental Science & Research, Kolkata, with chief complaint of pain and discomfort in upper left back teeth region for last 7 days. The patient was very calm and did not like to open her mouth even for speech. Parent gave history that she does not smile and has a poor peer group relationship. No history of previous systemic illness or drug allergy was found.
Fig 1 Pretreatment facial profile
Fig 2 Pretreatment intraoral view
Fig 3 Soldering Technique
Fig 4 Appliance after acrylization
Fig 5 Post treatment intraoral view
Fig 6 Post treatment facial profile
On examination it was found that 64 is carious exposed which is radiologically supported.54 and 61 were carious without pulpal involvement. In addition 51 and 52 are missing which were extracted due to caries 2 months before, outside the institution. On radiographic examination no primary retained roots found and erupting 11, 21 are in 5th stage of Nolla’s tooth development. After thorough clinical evaluation it is thought that, the altered behaviour of the patient may be due to compromised esthetic which also affects the peer group relation.
On completion of thorough case evaluation it was planned to perform pulpectomy of 64 and restoration of carious teeth, in addition to placement of fixed functional space maintainer replacing 51 and 52. After obtaining written parental consent, in first phase of the treatment the pain is relived by puplectomy of 64 followed by esthetic composite restoration. 54 and 61 are restored with glass ionomer type II cement (Fuji II)
In the 2nd phase, preoperative occlusal analysis done with diagnostic casts .Orthodontic bands (0.005 inches thickness and 0.180 inches width) were adapted in 55 and 65 followed by alginate impression to make the working cast.19 gauge wire is adapted on palatal arch in U form, 0.5mm above the palatal surface and soldered to the bands. Three small pieces of wire were bended like hook to form a mesh in the edentulous region after point soldering with the main palatal wire. The acrylic deciduous right central and lateral teeth are then placed and adjusted between the hooks, the occlusion is checked & acrylization of teeth done with pink coloured cold cure acrylic. After trimming, finishing and polishing the fixed space maintainer is cemented on 55 and 65 with luting glass ionomer cement (Fuji I) and occlusion checked for any premature contact.
Post treatment instructions: Patient is advised to avoid chewing of hard food up to next 24 hours and warm saline mouth gargle for 7 days with proper oral hygiene maintenance.First recall of patient done after 24 hours followed by check up after every 3 months. Parents were informed that the appliance will be removed by a dentist at an age of approximately 6 years, to prevent interference of erupting permanent successors. Patient is also advised to come immediately if there is any problem with the space maintainer, including distortion or breakage of the same.
Discussion: In every creation in this World, there is a specific balance or proportion between solid and void, and every void has a tendency to be filled up by the surrounding solids. Likely, space created by the early loss of tooth in the dental arch also has a desire to be reduced by the adjacent teeth. The space within the dental arch is the combination of dimensions of the right and left lateral (buccal) segments plus the right and left incisor segments. When this total arch length is considered with respect to space management, it is common to focus only on the segment of the arches anterior to the first permanent molars; for that is the segment occupied by the deciduous arch and is replaced by the permanent successors. Space loss or arch length loss can be produced by a shortening of any of these segments within the arch. The arc of the arch is decreased, with mesial migration of the permanent molars or with lingual migration or inclination of the incisor or buccal segments of the arch. Space loss results from any shortening of the arch for whatever reason. 6
After premature loss of deciduous maxillary anterior teeth, the permanent successors may be proclined and thus arch length or perimeter is increased. In case of mandibular cuspid loss an abnormally strong mentalis musculature may cause distal drifting of the lateral incisor and shift of midline, deepening of the bite. Seward (1965) found the rate of closure of maxillary edentulous space is 1.5mm/year where as 1.0 mm/year in case of mandible. Northway (1984) stated that more space was lost in the first year of extraction than in successive years. Kumari et al (2006) found that the greatest space closure occurs during the first 4 months of the extraction. 3
The premature loss of deciduous incisors is usually given little clinical attention unless severe closure of the space is noticed or there is evidence of an aberrant speech pattern and oral habits developing as a result. The maxillary arch is somewhat retained in its proper position by the intact mandibular arch. The premature loss of mandibular incisor is commonly ignored in the exception that this segment of the arch will widen with growth. Occasionally, the space loss in incisor segment may be severe if there is crowding in deciduous dentition. So careful consideration should be taken during treatment planning or decision making for placement of any space maintainer in incisor segment.Various types of space maintainers (removable or fixed appliances) are fabricated depending on the child’s stage of dental development, dental arch involved, primary teeth missing and which teeth they are. 7,8,9,10
A primary tooth with proper mesio distal width is considered as the best space maintainer. One of the important functions of the primary tooth is to occupy the physiologic space and guide the eruption of its permanent successor. Fixed space maintainers are always acceptable in case in child as they have less desire to wear removable one. The removable space maintainers cover large area of oral tissue causing irritation to ulcer. To improve patient acceptance esthetic functional fixed appliance is reliable. The fixed space maintainer used to replace deciduous central incisor reveal a good success with improvement of esthetic and function with fewer requirements of patient cooperation and less irritation to the oral tissue (Ravi.B. Patil, Rachappa.M.M, 2011). 11
In present case, minimum amount of palatal coverage is done to retain acrylic teeth, causing no or less irritation. Banding of molars done for improved strength instead of bonding. Pink color of acrylic is used to match with gingiva.Vinny Bhasin, Abhilasha S Bhasin(2011) 12 in a case they used bonded space maintainer to maintain the space in primary molar area.In anterior region the esthetic rehabilitation is the prime importance so bonded space maintainer made up of wire component is not acceptable in anterior space maintenance.
The restored primary teeth are the best space maintainers and according to certain school of thoughts anything other than that is a punishment appliance. However, if the primary teeth are non restorable, planning of a space maintainer depending on the dental age of the child patient will be the choice.
Conclusion: Esthetic space maintainer has been found to have a much wider acceptability and compliance of wearing the appliance by the paediatric dental patient. This is indeed a solution of paediatric anterior edentulous arches with compromised speech, esthetic and behavior of the patient including poor social acceptance. In present study, a successful placement of fixed functional space maintainer is being performed and limitations like- long term follow up; improper oral hygiene maintenance; frequent breakage can be overruled by proper education and motivation of the patient and parent.
S. G. Damle, Text book of Pediatric Dentistry, 3rd ed, 110-155.
JYTTE PEDERSEN, KATHRINE STENSGAARD AND BIRTE MEESEN; Prevalence of maloeclusion inrelation to premature loss of primary teeth ;Institute of Orthodontics,Royal Dental College, Aarhus, Denmark; Community Dent. Oral Epidemiol. 1978: 6; 204-209.
Shobha Tandon; Text book of pedodontics; 2nd edition; 446-465.
Keith Da Silva, D.D.S., F.R.C.D. (C); Barnali Roy, D.D.S.; Richard K. Yoon, D.D.S; Early Loss of Primary Incisors Due to Parafunctional Tendency; MARCH 2O12 • The New York State Dental Journal.
Mahmoud K. AL-Omiri, Jumana A. Karasneh, Edward Lynch, Philip-John Lamey, Thomas J. Clifford;Impacts of missing upper anterior teeth on daily living; vol 59; issue 3; June 2009.