Guidance of the eruption and development of the primary and permanent dentitions is an integral part of the care of pediatric patients. Such guidance should contribute to the development of a permanent dentition that is in a harmonious, functional and esthetically acceptable occlusion. But, what diagnostic tools are recommended to assess the developing occlusion? Is a space maintainer always necessary when a primary tooth is lost prematurely? If a space maintainer is necessary, what type is recommended for a given clinical situation? And, what can be done when a tooth is erupting ectopically? The following module should provide information to help you answer these questions.

Following completion of the reading assignment and self-instructional module, the student should be able to:

Properly diagnose the need for management of the developing occlusion. Describe the indications and contraindications of space maintainers. Describe the different types of space maintainers. Describe the causes of ectopic eruption and the various treatment modalities. Describe the diagnosis and treatment of occlusal crossbites.

II. Diagnosis and Treatment Planning

Dentists who care for child patients have the responsibility to recognize, differentiate, and either appropriately manage or refer abnormalities in the developing dentition as dictated by the complexity of the problem and the individual clinician’s training, knowledge, and experience. Early diagnosis and successful treatment of developing malocclusions can have both short-term and long-term benefits while achieving the goals of occlusal harmony, function and dental facial esthetics.

The variables associated with the treatment of the developing dentition which will affect the degree to which treatment is successful include, but are not limited to:

chronologic, mental and emotional age of the patient, to the extend that this affects the ability of the patient to understand and cooperate in the treatment intensity, frequency and duration of an oral habit parental support for the treatment compliance with clinician's instructions craniofacial configuration variations in craniofacial growth concomitant systemic disease or condition accuracy of diagnosis appropriateness of treatment

Many unpredictable factors can affect the management of the developing dental arches and minimize the overall success of any treatment. These factors cannot always be controlled by the dentist. Appropriate pretreatment records should include those deemed necessary by the individual clinician to adequately diagnose the patient’s condition.

Clinical examination should include:

an assessment of overall oral health facial analysis to determine the growth pattern present functional analysis to determine the presence of any deleterious habits and or occlusal dysfunction

 
Diagnostic records (depending upon the clinical situation) may include:

extraoral and intraoral photographs to establish a data base for documenting changes during treatment diagnostic dental casts to assess the occlusal relationship, determine the arch length requirements for intra and inter-arch tooth size relationships intraoral and panoramic radiographs to establish dental age, assess eruption problems, estimate size and presence of unerupted teeth and identify dental anomalies and/or pathology cephalometric analysis to determine dental and skeletal relationships and establish a baseline growth record

III. Space Maintenance

Whenever primary or permanent teeth are lost prematurely and arch integrity is lost, loss of space and arch length, perimeter, or circumference may result. Migration of primary and/or permanent teeth can occur and the available space may be reduced by an amount sufficient to cause some degree of crowding in the permanent dentition.

Indications:

The premature loss of primary molars may require the placement of a space maintainer to prevent the migration of the adjacent teeth, depending upon the teeth present and the arch length. When loss of a primary canine occurs, the dental arch midline may be compromised and the arch length also may be reduced. The premature loss of primary canines may therefore require the placement of a space maintaining appliance to prevent midline deviation and/or loss of arch length, perimeter and/or circumference. The premature loss of primary incisors does not usually require the placement of a dental appliance for the maintenance of space because mesial movement of the adjacent teeth is not generally expected.

Contraindications:

A space maintainer is usually not necessary if there is a sufficient amount of space present to allow for eruption of permanent tooth/teeth. A space maintainer may not be recommended if severe crowding exists, such that space maintenance is of minimal effect and  subsequent orthodontic intervention is indicated. A space maintainer may not be necessary if the succedaneous tooth will be erupting soon.

IV. Types of Space Maintainers

The treatment modalities may include, but are not necessarily limited to, the following types of appliances.

Fixed appliances:

Removable appliances:

Band and Loop Space Maintainer

Crown and Loop Space Maintainer

Distal Shoe (Intra-alveolar Space Maintainer)

Lower Lingual Holding Arch (LLHA)

Nance

Hawley Appliance / Removable Acrylic

V. Interceptive Orthodontics

Crowding is a characteristic feature of a significant number of all classes of malocclusion. Less than two millimeters of mandibular incisor crowding in the mixed dentition may be considered a normal transitional condition, but crowding generally affects the incisor segment as much as, if not more than, other areas of the arch. Crowding must be considered in the context of the patient’s and parent’s chief complaint and the total dental, skeletal, and soft tissues relationships.

The three most common conditions presented are:

Treatment utilizes a Modified Halterman Technique:

A wire is soldered to the band on the second primary molar and fabricated such that an elastic band from the wire to the button distalizes the permanent tooth. Once the permanent tooth is moved away from the second primary molar, the appliance is removed, and the permanent tooth will erupt normally.

Anterior Crossbite in the Permanent Dentition
Treatment should be rendered as soon as the crossbite is diagnosed.Treatment options include:

Tongue blade - Inform parents that they have more to gain than you. Removable appliance Bite plate (if the cross-bite is greater than 1/2 the anatomical crown length) “Z” spring

Posterior Crossbite in the Primary Dentition

Pseudo Crossbite (functional shift cross-bite, cuspid mediated)
Diagnosis:  Have the cuspids edge-to-edge and then have the patient squeeze the teeth; watch for the deflection.
Treatment: Reduce the buccal of mandibular C’s and the lingual of maxillary C’s. Also consider reduction of the incisal edges of these teeth.

True Crossbite:
Treatment: Consider crossbite appliance, depending on patient’s ability to comply with the treatment .

Exercise Answers

Answer 1: If the child is in the complete primary dentition, then yes a space maintainer is necessary to prevent mesial migration of the teeth distal to the one lost. If however, the child is in the transitional dentition, then a space maintainer is not always necessary. If a child loses the primary first molar and has the primary second molar and permanent first molar fully erupted and in occlusion, then a space maintainer may not be indicated.

Answer 2: No, a space maintainer is not necessary in this situation. However, for esthetic reasons a fixed or removable partial denture may be fabricated for the child.

Answer 3: In order for a space maintainer to be effective, it must maintain the available space until the succedaneus tooth erupts. In the situation of the premature loss of a primary second molar, a band and loop would be cemented onto the permanent first molar and would rest against the primary first molar. It is very likely that the primary first molar will exfoliate prior to the eruption of the second premolar. Therefore, the abutment tooth would be lost and the space maintainer would no longer be effective.