Semi-Fixed Functional Lingual Arch Space Maintainer: A Case Report

Transcription

1 Semi-Fixed Functional Lingual Arch Space Maintainer: A Case Report Jonathan PT 1, Sethi HS 2, Neha 3, Kirtaniya BC 5 1-Post Graduate Student, Department of Paedodontics and Preventive Dentistry, Maharaja Ganga Singh Dental college & Research Centre, Sri Ganganagar, Rajasthan. 2,3-Reader, Department of Paedodontics and Preventive Dentistry, Maharaja Ganga Singh Dental college & Research Centre, Sri Ganganagar, Rajasthan. 4-Professor and HOD, Department of Paedodontics and Preventive Dentistry, Maharaja Ganga Singh Dental college & Research Centre, Sri Ganganagar, Rajasthan. ABSTRACT Correspondence to: Dr. Jonathan PT, Department of Paedodontics and Preventive Dentistry, Maharaja Ganga Singh Dental college & Research Centre, Sri Ganganagar, Rajasthan. Contact Us: A lower lingual arch is always recommended as an arch holding device for mandible when there is a premature loss of all primary molars occurred. This appliance will maintain mandibular arch length and to prevent mesial migration of the mandibular first molars. The major drawback of the appliance is that it is unsuccessful to restore masticatory function as well as it does not prevent the development of lateral tongue thrust habit. The following article describes the novel semifixed functional lingual arch space maintainer in the mixed dentition period in a boy who is just 8 years old. After 6 months follow up, the succedaneous permanent teeth were erupting and it was then replaced by a conventional lingual arch space maintainer. The novel semi-fixed functional lingual arch is an effective appliance for preserving masticatory function, resist tongue thrust habit as well as prevention of supra- eruption of the antagonist teeth. KEYWORDS: Lingual arch appliance, Supra eruption, Space maintainer AASSSAAsasasss INTRODUCTION The loss of single or multiple primary molars in the mixed dentition period, in many situations, often leads to disturbances of the developing dentition unless an appliance is constructed to maintain the relationship of the remaining teeth and guides the eruption of the developing permanent teeth [1]. The consequences of premature loss of primary molars will lead to loss of arch length and as a result of that there will be crowding or impaction of the developing permanent tooth/teeth. In cases of bilateral premature loss of multiple primary molars, there will be difficulty in chewing food which will affect the normal growth and development of the child. The other problem which arises due to a bilateral loss of primary molars is the passive eruption of opposite teeth (Figure 1) which might interfere with the eruption of the succedaneous permanent teeth in the opposite arch and development of lateral tongue thrust habit. The passive eruption of teeth in some cases is so severe that it causes traumatic occlusion which is more commonly seen in adults. Jytte Pedersen et al, 2006 concluded that premature loss of primary teeth would result in an increased frequency of sagittal, vertical as well as transverse malocclusion. Therefore, wherever possible, restoration of the natural primary tooth should be attempted. During unavoidable situations like extraction or avulsion of the natural tooth, maintenance of the space to guide the eruption of permanent tooth is advocated. When the loss of primary tooth occurs closer to the physiological age of exfoliation, acceleration of the permanent successors is evident. This is the technique we utilize normally in the serial extraction cases. On the contrary, when the loss of primary tooth occurs after the root has just started forming bone neoforms over the permanent tooth germ will cause a delayed eruption, mandating the need for space maintenance [2]. The IOPA radiographs can be used to detect the amount of bone covering the permanent tooth bud to assess the need for space maintainer. It usually takes 4 to 6 months by an erupting tooth to move through 1mm of bone [1] and if 2 mm of bone present above the developing tooth, it will take at least 1 year to erupt into the oral cavity. The other factors are also important before placement of a space maintainer for example: erupting tooth adjacent to the edentulous area has a greater effect on the amount of space lost than do fully erupted teeth [3].There will be more space loss in children who are having all these abnormal habits like thumb sucking, tongue thrusting, mouth breathing and lip biting habit. Conventionally, the treatment of choice for multiple teeth loss in the mandible is the placement of a lingual arch space maintainer. But, it does not provide the masticatory function for chewing food as well as it does not prevent passive eruption of the opposite teeth. Hence there is a need for the modification of the conventional lingual arch appliance with a functional component. The purpose of this case report was to describe the novel fixed functional lingual arch space maintainer and present its advantages over the more conventional lingual arch space maintainer, thus encouraging clinicians to prescribe its use in certain clinical situations. How to cite this article: Jonathan PT, Sethi HS, Neha, Kirtaniya BC. Semi-Fixed Functional Lingual Arch Space Maintainer: A Case Report. Int J Oral Health Med Res 2017;4(5): International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 46

2 An 8 year- old boy reported to the Department of Paedodontics and Preventive Dentistry of Maharaja Ganga Singh Dental College and Research Centre with the chief complaint of difficulty in chewing food. Medical history was not relevant, and the child seemed to be healthy. Intra-oral examination revealed a mixed dentition period with the presence of 16,55,54,53,12,11,21,22,63,64,65,26 in maxilla and in the lower arch it was 36,75,74,73,32,31,41,42,83,84,85,46 where 74,75 and 84,85 were badly decayed (Figure 1) which cannot be restored. The upper primary first and second molars on both sides were severely passively erupted (Figure 1) due to the long standing caries which cause premature loss of crown of the above mentioned primary molars (74,75,84,85). cement over the permanent first mandibular molars (Figure 3) after fluoride varnish was applied on 36 and 46. Figure 2: The fixed functional appliance with acrylic teeth for acrylization procedures. Figure 1: Pre-operative view of mandible showing root stumps of 74, 75, 84 and 85 with moderate crowding in incisor region. We decided to contrast a functional, semifixed space maintainer for this patient to prevent the passive eruption of upper teeth and to help for mastication of food. We made two molar bands on permanent first molars on both sides of the mandible and upper - lower alginate impression was taken. The bands were transferred into the impression, and they were fixed with wires for making casts with dental stone. The cast was prepared, and a conventional lingual arch was made with 036 stainless steel wire. The Conventional lingual arch was soldered to the bands on permanent first molars of mandible. The lingual arch was modified above developing teeth with a network of accessory wires to incorporate acrylic teeth (Figure 2).The modified lingual arch was waxed (bite block) to register the bite for occlusion and articulation. In the articulator four molar teeth were added in 74,75,84,85 regions, and it was then flasked (Figure 2), dewaxed and packed with heat cure acrylic resin. The appliance is then cured, finished and delivered to the patient (Figure 3). Before cementing the appliance, bilateral root stumps has been extracted, and haemostasis was attained. The occlusion of the child with the modified lingual arch in the mouth were checked and adjusted thoroughly (Figure 3,4). The prepared semifixed functional lingual arch space maintainer was cemented with luting glass ionomer Figure 3: Post-operative delivery of the fixed functional appliance Figure 4: Right side occlusion of the functional appliance DISCUSSION The exfoliation of mandibular primary molars is usually expected in the late mixed dentition period when the children are about years of age. But the present case reported to us when his chronological age was 8 years, and all the primary molars in mandible were badly damaged (Figure 1). The radiograph is also showing all the premolars are developing (Figure 5), and their roots have just started forming, mandating us to provide a International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 47

3 Figure 5: Pre operative Intra oral periapical radiograph of lower right side. Note the root formation of 44 and 45. space maintainer for him. There was moderate crowding present in the anterior region of the dental arch (Figure 1) for which we extracted both the primary canines to resolve it (crowding) simultaneously. 4 Therefore, we can claim that serial extraction (eruption guidance) and space maintainer simultaneously started in this present case. There was some problem seen in this functional lingual arch space maintainer therapy was that after partial correction of the crowding (Figure 3), the wire framework was interfering with distal movements of incisors. To resolve it, one should make adequate space provision in the wire frame work which runs mesially (make it shorter from mesial side). It is well documented that long standing proximal caries will cause loss of arch length even before the crown is destroyed. The present case reported to us with grossly decayed 74, 75 and 84, 85 which caused arch length deficiency along with moderate crowding in the anterior region. In such circumstances, space maintainer alone may not provide optimal result but space regainer might be also indicated (Figure 3,4,6,7,8) at a later stage. 5 We have successfully preserved the space for the eruption of 34,35 and 44,45 which have erupted but due to arch length deficiency both the permanent canines were crowded (Figure 8). We have to regain some space for those teeth also which is our moral duty to this child. In brief, we want to convey the message to our fellow pedodontists is that space management is more important than space maintainer alone in some special cases. Figure 6: Left side occlusion of the functional appliance Figure 7: Post-operative clinical photograph showing eruption of first and second premolars and partial correction of crowding after 4 months Figure 8: Post-operative clinical photograph showing premature eruption of premolars after 6 months. The arch length deficiency as a result of an early loss of primary teeth may lead to the development of crowding, impaction of teeth and irregularity of the permanent dentition. 6 The early loss of the primary molars usually have the greatest effect on dental arch length and resulted in 2 4 mm of space closure per quadrant in both arches. 7 The greatest space loss has been attributed to mesial movement of the permanent first molars after premature loss of second primary molars in mandible unlike maxilla, where space loss occur due to mesio-lingual rotation of the permanent first molars. A lingual arch space maintainer normally used to maintain arch length by preventing mesial movement of the molars and lingual inclination of the lower incisors. 8 There were reported cases of development of lateral tongue thrust habit as a result of the premature loss of primary molars, but the incidence was very low. The modified lingual arch space maintainer will also prevent the development of this habit as well as preserve the space for premolars. Moyers suggested that as much as 4.8 mm of space can be made available as the permanent canines and premolars replace their primary successors. 4 But according to Nance the leeway space in maxilla is 1.8 mm and in the mandible it is 3.4 mm 9 which is very much lower value than Moyers description. The moderate amount of crowding in the incisor region could be corrected by holding the leeway spaces which we have applied in this case also (Figure 1-7). 4 Brennan and Gianelly studied the efficiency of a lower lingual arch in the mixed dentition stage to preserve arch length and International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 48

4 concluded that preservation of arch length using a lingual arch resolved crowding in 68 percent of the subjects. 4 Rebellato investigated the efficiency of a lower lingual arch in preventing mesial migration of the first permanent molars. He reported that the lingual arch reduced arch perimeter loss but at the expense of mandibular incisor proclination. 5 However, the incidence of mandibular incisor proclination was reported insignificantly low by most of the authors. Villalobos treated 32 patients with a lower lingual arch to control arch perimeter and finally concluded that the lingual arch space maintainer is an effective appliance for preserving arch length. 8 The management of arch length deficiency and premature loss of teeth in the transitional dentition requires careful thought by the clinician. Clinical and radiographic assessment of each case along with the selection of appropriate appliance is crucial to a successful outcome. No space maintainer-with the exception of the primary tooth-can fulfil all the requirements of an ideal appliance, including: Preservation of space Eruption of adjacent, succedaneous, and abutment teeth Restoration of masticatory function Prevention of over eruption of antagonists Compatibility with soft tissues Effective hindrance of torqueing forces on abutment teeth. Economy of construction and resistance to distortion Allowance for adjustment or minor repair and Universal application. 10 The advantages of using this modified semi-fixed functional lingual arch space maintainer are as follows: Restoration of masticatory function Prevention of over eruption of antagonist teeth Prevents development of lateral tongue thrust habit It stimulates the underlying permanent tooth to erupt fast as compared to conventional lingual arch space maintainer (Figure 7,8). The idea of using artificial teeth in edentulous span was to improve the masticatory efficiency of the child along with space maintenance and prevention of supra eruption of upper teeth. The child, when growing, needs proper nourishment from food for his/her growth and development. This type of appliance will serve the purpose of both space maintenance and masticatory efficiency. The similar type of appliance can be made in the anterior region for nursing bottle caries or rampant dental caries where aesthetic is more important than masticatory functions in growing children (Kirtaniya, 2015). 10 The advantage of using wire framework underneath the artificial teeth was to give support to these artificial teeth and to stabilize the appliance. It also helps to distribute occlusal forces applied on the teeth while mastication as it is soldered to the main component of the conventional lingual arch space maintainer. The drawback of the functional semifixed appliance is that when permanent teeth are erupting this appliance has to be replaced with a conventional lingual arch appliance (Figure 8). It has been observed that when we incorporate artificial teeth in the semi fixed space maintainer, there is a fast eruption of permanent teeth occur through stimulation of the underlying bone by masticatory function (Figure 4-8). From the intraoral periapical radiograph it has been found that the roots of 34, 35, 44, 45 (Figure 9,5) are just forming which are not ready to erupt. Gran s studies suggested that when two third root formations are completed, the teeth should be erupted into the mouth which is not present in this case. 11 There might be excessive bone loss due to long standing caries, above the developing teeth which also helps in premature eruption. Figure 9: Pre operative Intra oral periapical radiograph of lower left side. Note the root formation of 34 and 35. Therefore, in this present case also there was a premature eruption of permanent first and second premolars took place before eruption mandibular canines (Figure 1,2,3 and 8). It has to be noted that the premature eruption of the first and second premolars took place within 4 months after the cementation of this semifixed functional lingual arch space maintainer (Figure 8). The chronological age of the child was just 8 years at the beginning, and he is now 8 1/2 years old which was not the right age to erupt first or second premolars in mandible, but it happened in this case (Figure 9). The upper primary canine, primary first molar, and primary second molars were still present in the mouth that also indirectly indicating that the mandibular first and second premolars erupted prematurely. REFERENCES 1. L. Dean JA, McDonald RE, Avery DR. Management of the developing occlusion. In: Mc Donald RE, Avery Dean JA, eds. Dentistry for the Child and Adolescent. 8th ed. 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5 5. Rebellato J, Lindauer ST, Rubenstein LK, Isaacson RJ, Davidovich M, Vroom K. Lower arch perimeter preservation using the lingual arch. Am J Orthod Dentofacial Orthop 1997; 112: Northway WM, Wainright R L, Demirjian A. Effects of premature loss of deciduous molars. Angle Orthop. 1984, 54: Villalobos FJ, Sinha PK, Nanda RS. Longitudinal assessment of vertical and sagittal control in the mandibular arch by the mandibular fixed lingual arch. Am J Orthod Dentofacial Orthod 2000; 118: Kapala JT. Interceptive orthodontics and management of space problems. In: Braham RL, Morris ME, eds. Textbook of Pediatric Dentistry. Baltimore, Md: Williams and Wilkins: 1980: Nance HN: The limitations of orthodontic treatment - I. Mixed dentition diagnosis and treatment, Am J Orthod1947; 33: Kirtaniya BC, Kaur J, Lyall BS, Pathania V. Modified Nance Palatal Arch: An Aesthetic Approach to Missing Anterior Teeth - A Case Report. Ind J Dent Sci 2015; 7(2): Gran AM: Prediction of tooth emergence, J Dent Res 1962; 41: Source of Support: Nil Conflict of Interest: Nil International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 50