The Dynamics of Change










CHAPTER 25 Periodontal Problems in Children and Adolescents 377
a method for monitoring and documenting oral hygiene practices.
Calculus is not as common in young patients as it is in adults,
but it is found in approximately 10% of children and approximately
one-third of teenagers. Patients of all ages should always be checked
for calculus during periodic examinations, and deposits, when
noted, should be removed.
Particularly after the eruption of permanent teeth, attachment
levels should be determined by periodontal probing. Probing of
the permanent incisors and rst permanent molars provides a
diagnostic screening for LAP. Because erupting teeth can be probed
all the way to the cementoenamel junction, transient deep pockets
are a normal nding in the transitional dentition and must be
distinguished from true attachment loss by locating the cemen-
toenamel junction.
When radiographs are available, bone levels should be examined.
Normal crestal height should be within 1 to 2 mm of the cemen-
toenamel junction.
24
After permanent teeth have erupted, the patient
should also be examined for deciencies in the width of attached
gingiva and areas of recession should be noted.
References
1. Tatakis DN, Kumar PS. Etiology and pathogenesis of periodontal
diseases. Dent Clin North Am. 2005;49:491–516.
2. Matsson L. Factors inuencing the susceptibility to gingivitis during
childhood: a review. Int J Paediatr Dent. 1993;3:119–127.
3. Mombelli A, Gusberti FA, van Oosten MA, et al. Gingival health
and gingivitis development during puberty. A 4-year longitudinal
study. J Clin Periodontol. 1989;16:451–456.
4. Tomazoni F, Zanatta F, Tuchtenhagen S, et al. Association of gingivitis
with child oral health-related quality of life. J Periodontol.
2014;85:1157–1565.
5. Dongari A, McDonnell HT, Langlais RP. Drug-induced gingival
overgrowth. Oral Surg Oral Med Oral Pathol. 1993;76:543–548.
6. Andlin-Sobocki A, Bodin L. Dimensional alterations of the gingiva
related to changes of facial/ lingual tooth position in permanent
anterior teeth of children. A 2-year longitudinal study. J Clin Peri-
odontol. 1993;20:219–224.
7. Parra C, Jeong Y, Hawley C. Guided tissue regeneration involving
piercing-induced lingual recession: a case report. Int J Periodontics
Restorative Dent. 2016;36:869–875.
8. Pransky SM, Lago D, Hong P. Breastfeeding diculties and oral
cavity abnormalities: the inuence of posterior ankyloglossia and
upper-lip ties. Int J Pediatr Otorhinolaryngol. 2015;79(10):1714–1717.
9. Messner A, Lalakea M. e eect of ankyloglossia on speech in
children. Otolaryngol Head Neck Surg. 2002;127(6):539–545.
10. Armitage GC. Development of a classication system for periodontal
diseases and conditions. Ann Periodontol. 1999;4:1–6.
11. Bhat M. Periodontal health of 14-17-year-old US schoolchildren. J
Public Health Dent. 1991;51:5–11.
12. Singh T, Arrazola RA, Corey CG, et al. Tobacco use among middle
and high school students—United States, 2011–2015. MMWR Morb
Mortal Wkly Rep. 2016;65:361–367.
13. Sundar IK, Javed F, Romanos GE, et al. E-cigarettes and avorings
induce inammatory and pro-senescence responses in oral epithelial
cells and periodontal broblasts. Oncotarget. 2016;7:77196–77204.
14. Chatham-Stephens K, Law R, Taylor E, et al. Centers for Disease
Control and Prevention (CDC). Notes from the eld: calls to
poison centers for exposures to electronic cigarettes—United States,
September 2010-February 2014. MMWR Morb Mortal Wkly Rep.
2014;63(13):292–293.
15. Shari J, Ahluwalia K, Papapanou P. Relationship between frequent
recreational cannabis (marijuana and hashish) use and periodontitis
in adults in the United States: National Health and Nutrition
Examination Survey 2011 to 2012. J Periodontol. 2017;88(3):273–280.
Neutropenia
Neutropenia is a hematologic disorder characterized by reduced
numbers or complete disappearance of neutrophils from the blood
and bone marrow. In addition to increased susceptibility to recurrent
infections such as otitis media or respiratory and skin infections,
patients with neutropenia generally suer from severe gingivitis
and pronounced alveolar bone loss. Periodontal therapy consists
of rigorous local measures to control plaque, but patients are seldom
able to maintain the level of oral hygiene necessary to prevent the
development and progression of periodontal disease.
Papillon-Lefèvre Syndrome
Papillon-Lefèvre syndrome is a rare disease that has, as a symptom,
the onset of severe periodontitis in the primary or transitional
dentition. It is a genetic disorder that is easily identied on clinical
examination by the nding of hyperkeratosis of the palms of the
hands and soles of the feet. Severe inammation and rapid bone loss
are characteristic of the periodontitis. erapy consists of aggressive
local measures to control plaque formation. Successful treatment
outcomes in children have been reported with antibiotic therapy.
23
Histiocytosis
Langerhans cell histiocytosis (LCH), previously known as histio-
cytosis X, is a rare disorder of childhood that presents with histiocytic
inltration of bones, skin, liver, and other organs. In 10% to 20%
of cases, the initial inltrates occur in the oral cavity, usually in
the mandible. Typical ndings include gingival enlargement,
ulcerations, mobility of teeth with alveolar expansion, and discrete,
destructive lesions of bone that can be observed on radiographs.
LCH may be diagnosed by biopsy. erapy consists of local measures
such as radiation and surgery to remove lesions and systemic
chemotherapy for disseminated disease. e prognosis for dis-
seminated early-onset disease is poor, with mortality rates exceeding
60%. On the other hand, mild localized LCH has an excellent
prognosis. e lesions of LCH and the local therapy used to treat
them may result in loss of teeth or arrested development of teeth.
Leukemia
Leukemias are the most common form of childhood cancer. Acute
lymphoblastic leukemia (ALL) is the most common and has the
best prognosis. Acute myeloid leukemia (AML) accounts for
approximately 20% of childhood leukemias and has a poorer
long-term survival rate. AML may present with gingival enlargement
caused by inltrates of leukemic cells. is presentation usually
does not occur with ALL. e lesions associated with the gingival
enlargement are bluish red and may sometimes invade bone. In
addition to the gingival lesions, the patient may have fever, malaise,
gingival or other bleeding, and bone or joint pain. AML may be
diagnosed by a blood cell count. Anemia, abnormal leukocyte and
dierential counts, and thrombocytopenia are usually observed.
Periodontal Examination of Children
e periodontal health of children and adolescents should be
assessed at each examination. The gingival tissues should be
examined for redness, edema, bleeding, or enlargement. Oral hygiene
may be assessed via a plaque index. Use of a disclosant provides
an excellent oral hygiene instruction tool and a plaque index provides

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CHAPTER 25 Periodontal Problems in Children and Adolescents 377 a method for monitoring and documenting oral hygiene practices. Calculus is not as common in young patients as it is in adults, but it is found in approximately 10% of children and approximately one-third of teenagers. Patients of all ages should always be checked for calculus during periodic examinations, and deposits, when noted, should be removed.Particularly after the eruption of permanent teeth, attachment levels should be determined by periodontal probing. Probing of the permanent incisors and rst permanent molars provides a diagnostic screening for LAP. Because erupting teeth can be probed all the way to the cementoenamel junction, transient deep pockets are a normal nding in the transitional dentition and must be distinguished from true attachment loss by locating the cemen-toenamel junction.When radiographs are available, bone levels should be examined. Normal crestal height should be within 1 to 2 mm of the cemen-toenamel junction.24 After permanent teeth have erupted, the patient should also be examined for deciencies in the width of attached gingiva and areas of recession should be noted.References1. Tatakis DN, Kumar PS. Etiology and pathogenesis of periodontal diseases. Dent Clin North Am. 2005;49:491–516.2. Matsson L. Factors inuencing the susceptibility to gingivitis during childhood: a review. Int J Paediatr Dent. 1993;3:119–127.3. Mombelli A, Gusberti FA, van Oosten MA, et al. Gingival health and gingivitis development during puberty. A 4-year longitudinal study. J Clin Periodontol. 1989;16:451–456.4. Tomazoni F, Zanatta F, Tuchtenhagen S, et al. Association of gingivitis with child oral health-related quality of life. J Periodontol. 2014;85:1157–1565.5. Dongari A, McDonnell HT, Langlais RP. Drug-induced gingival overgrowth. Oral Surg Oral Med Oral Pathol. 1993;76:543–548.6. Andlin-Sobocki A, Bodin L. Dimensional alterations of the gingiva related to changes of facial/ lingual tooth position in permanent anterior teeth of children. A 2-year longitudinal study. J Clin Peri-odontol. 1993;20:219–224.7. Parra C, Jeong Y, Hawley C. Guided tissue regeneration involving piercing-induced lingual recession: a case report. Int J Periodontics Restorative Dent. 2016;36:869–875.8. Pransky SM, Lago D, Hong P. Breastfeeding diculties and oral cavity abnormalities: the inuence of posterior ankyloglossia and upper-lip ties. Int J Pediatr Otorhinolaryngol. 2015;79(10):1714–1717.9. Messner A, Lalakea M. e eect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002;127(6):539–545.10. Armitage GC. Development of a classication system for periodontal diseases and conditions. Ann Periodontol. 1999;4:1–6.11. Bhat M. Periodontal health of 14-17-year-old US schoolchildren. J Public Health Dent. 1991;51:5–11.12. Singh T, Arrazola RA, Corey CG, et al. Tobacco use among middle and high school students—United States, 2011–2015. MMWR Morb Mortal Wkly Rep. 2016;65:361–367.13. Sundar IK, Javed F, Romanos GE, et al. E-cigarettes and avorings induce inammatory and pro-senescence responses in oral epithelial cells and periodontal broblasts. Oncotarget. 2016;7:77196–77204.14. Chatham-Stephens K, Law R, Taylor E, et al. Centers for Disease Control and Prevention (CDC). Notes from the eld: calls to poison centers for exposures to electronic cigarettes—United States, September 2010-February 2014. MMWR Morb Mortal Wkly Rep. 2014;63(13):292–293.15. Shari J, Ahluwalia K, Papapanou P. Relationship between frequent recreational cannabis (marijuana and hashish) use and periodontitis in adults in the United States: National Health and Nutrition Examination Survey 2011 to 2012. J Periodontol. 2017;88(3):273–280.NeutropeniaNeutropenia is a hematologic disorder characterized by reduced numbers or complete disappearance of neutrophils from the blood and bone marrow. In addition to increased susceptibility to recurrent infections such as otitis media or respiratory and skin infections, patients with neutropenia generally suer from severe gingivitis and pronounced alveolar bone loss. Periodontal therapy consists of rigorous local measures to control plaque, but patients are seldom able to maintain the level of oral hygiene necessary to prevent the development and progression of periodontal disease.Papillon-Lefèvre SyndromePapillon-Lefèvre syndrome is a rare disease that has, as a symptom, the onset of severe periodontitis in the primary or transitional dentition. It is a genetic disorder that is easily identied on clinical examination by the nding of hyperkeratosis of the palms of the hands and soles of the feet. Severe inammation and rapid bone loss are characteristic of the periodontitis. erapy consists of aggressive local measures to control plaque formation. Successful treatment outcomes in children have been reported with antibiotic therapy.23HistiocytosisLangerhans cell histiocytosis (LCH), previously known as histio-cytosis X, is a rare disorder of childhood that presents with histiocytic inltration of bones, skin, liver, and other organs. In 10% to 20% of cases, the initial inltrates occur in the oral cavity, usually in the mandible. Typical ndings include gingival enlargement, ulcerations, mobility of teeth with alveolar expansion, and discrete, destructive lesions of bone that can be observed on radiographs. LCH may be diagnosed by biopsy. erapy consists of local measures such as radiation and surgery to remove lesions and systemic chemotherapy for disseminated disease. e prognosis for dis-seminated early-onset disease is poor, with mortality rates exceeding 60%. On the other hand, mild localized LCH has an excellent prognosis. e lesions of LCH and the local therapy used to treat them may result in loss of teeth or arrested development of teeth.LeukemiaLeukemias are the most common form of childhood cancer. Acute lymphoblastic leukemia (ALL) is the most common and has the best prognosis. Acute myeloid leukemia (AML) accounts for approximately 20% of childhood leukemias and has a poorer long-term survival rate. AML may present with gingival enlargement caused by inltrates of leukemic cells. is presentation usually does not occur with ALL. e lesions associated with the gingival enlargement are bluish red and may sometimes invade bone. In addition to the gingival lesions, the patient may have fever, malaise, gingival or other bleeding, and bone or joint pain. AML may be diagnosed by a blood cell count. Anemia, abnormal leukocyte and dierential counts, and thrombocytopenia are usually observed.Periodontal Examination of Childrene periodontal health of children and adolescents should be assessed at each examination. The gingival tissues should be examined for redness, edema, bleeding, or enlargement. Oral hygiene may be assessed via a plaque index. Use of a disclosant provides an excellent oral hygiene instruction tool and a plaque index provides 378 Part 3 The Primary Dentition Years: Three to Six Years21. Chapple IL. Hypophosphatasia: dental aspects and mode of inheritance. J Clin Periodontol. 1993;20:615–622.22. Watanabe K. Prepubertal periodontitis: a review of diagnostic criteria, pathogenesis, and differential diagnosis. J Periodontal Res. 1990;25:31–48.23. Ishikawa I, Umeda M, Laosrisin N. Clinical, bacteriological, and immunological examinations and the treatment process of two Papillon-Lefèvre syndrome patients. J Periodontol. 1994;65:364–371.24. Sjodin B, Matsson L. Marginal bone level in the normal primary dentition. J Clin Periodontol. 1992;19:672–678.16. Antoniazzi R, Zanatta F, Rösing C, et al. Association between periodontitis and the use of crack cocaine and other illicit drugs. J Periodontol. 2016;87(12):1396–1405.17. Saxen L, Asikainen S. Metronidazole in the treatment of localized juvenile periodontitis. J Clin Periodontol. 1993;20:166–171.18. Position paper: epidemiology of periodontal diseases. American Academy of Periodontology. J Periodontol. 1996;67:935–945.19. de Pommereau V, Dargent-Pare C, Robert JJ, et al. Periodontal status in insulin-dependent diabetic adolescents. J Clin Periodontol. 1992;19:628–632.20. Reuland-Bosma W, van Dijk J. Periodontal disease in Down’s syndrome: a review. J Clin Periodontol. 1986;13:64–73. CHAPTER 25 Periodontal Problems in Children and Adolescents 378.e1 Case Study: Laser FrenectomyAlexander AlcarazThe maxillary labial frenum is a mucosa-covered tissue with dense collagen and elastic and loose connective tissue bers.1 The frenum extends from the mucosa of the upper lip down to the maxillary free or attached gingiva and often to the outer layers of the periosteum at the midline of the alveolar process. The frenum may be pronounced with attachment at or close to the attached gingiva of the upper anterior teeth and extending to the incisive papilla.2 This hypertrophic frenum is often present in newborns and infants. As the child grows the frenum appears to move upward along the facial aspect of the alveolar process and often recedes as the vertical height of the alveolus increases from bone deposition.3 Even with growth the frenum may play a role in displacement of the primary and permanent teeth leading to a midline diastema. This diastema will often close as the permanent maxillary lateral incisors and canines erupt, pushing the central incisors mesially and closing the space.4There is limited evidence about the ideal time to treat a hyperplastic labial frenum. Some advocate for early frenectomy when a hyperplastic frenum impedes in the infant’s latch during breastfeeding.5 Others feel it is better to wait until the permanent canines have completely erupted to determine if the hyperplastic frenum is still causing a maxillary midline diastema.2 Despite an unclear indication for the ideal time to perform a frenectomy, some indications include (1) a persistent midline diastema due to the low frenal attachment2; (2) a thick frenum that traps food and interferes with maintaining good oral hygiene6,7; (3) in combination with orthodontic therapy to close a maxillary diastema and prevent orthodontic relapse8; (4) an esthetic concern for the patient9; and (5) the hyperplastic frenum appears to be affecting an infant’s ability to breastfeed.5Video 25.1 is an example of a laser frenectomy using the Fotona Lightwalker erbium:YAG laser. This laser’s wavelength (2940 nm) is well absorbed by water and produces minimal thermal effects to the surrounding tissues. This may reduce the need for local anesthesia. It is ideal for soft tissue surgery which is not extensive, because less thermal damage speeds the healing process and decreases postoperative sensitivity. The disadvantage is that there is reduced hemostasis, which may not be ideal when the frenum is highly vascular or inamed.10 For this case (see Video 25.1), after the administration of local anesthesia, the laser tip was placed perpendicular to the tissue and the frenum was relieved. After the procedure was completed, there was no need for sutures. If bleeding was not well controlled, the operator could achieve hemostasis with a diode or Nd:YAG laser, which creates more thermal energy and promotes hemostasis. After completion of surgery the patient was given postoperative instructions including a soft diet and avoiding acidic or spicy foods for at least 1 week.Questions1. What happens to the maxillary labial frenum as the child grows?Answer: The frenum tends to recede as the vertical height of the alveolus increases from bone deposition.2. When does a midline diastema close despite a labial frenum?Answer: The midline diastema can close after eruption of the permanent lateral incisors, and canines cause mesial shift of the central incisors and thus closure of the diastema.3. At what age must a hyperplastic maxillary labial frenum be removed?Answer: There is limited evidence and controversy about the ideal time to remove the maxillary frenum. Some indications include (1) persistent diastema; (2) periodontal concerns; (3) to prevent orthodontic relapse; (4) esthetics; and (5) to assist with latching during breastfeeding for an infant or newborn.4. What are the advantages of an erbium:YAG laser for soft tissue surgery?Answer: The erbium:YAG laser is well absorbed by water and produces minimal thermal effects, often requiring little, if any, local anesthesia.5. What are the disadvantages of an erbium:YAG laser for soft tissue surgery?Answer: Because the erbium:YAG laser has fewer thermal effects, it is limited in providing hemostasis, especially in areas with brous or inamed tissue.References1. Henry SW, Levin MP, Tsaknis PJ. Histologic features of the superior labial frenum. J Periodontal. 1976;47:25–28.2. Kaban L, Troulis M. Intraoral soft tissue abnormalities. In: Pediatric Oral and Maxillofacial Surgery. Philadelphia: Saunders; 2004:146–148.3. Edwards JG. The diastema, the frenum, the frenectomy: a clinical study. Am J Orthod. 1977;71:489–508.4. Dewel BF. The labial frenum, midline, diastema, and palatine papilla: a clinical analysis. Dent Clin North Am. 1966;10:175–184.5. Kotlow L. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. J Hum Lact. 2013;29(4):458–464.6. Lawrence GB, Fowler EB, Moore EA, et al. The free gingival graft combined with the frenectomy: a clinical review. Gen Dent. 1999;47:514–518.7. Gontijo I, Navarro R, Haypek P, et al. The applications of diode and Er:YAG lasers in labial frenectomy in infant patients. J Dent Child. 2005;72(1):10–15.8. Suter VG, Heinzmann AE, Grossen J, et al. Does the maxillary midline diastema close after frenectomy? Quintessence Int. 2014;45(1):57–66.9. Gkantidis N, Kolokitha OE, Topouzelis N. Management of maxillary midline diastema with emphasis on etiology. J Clin Pediatr Dent. 2008;32(4):265–272.10. Onisor I, Pecie R, Chaskelis I, et al. Cutting and coagulation during intraoral soft tissue surgery using Er:YAG laser. Eur J Paediatr Dent. 2013;14(2):140–145. 37926 Space Maintenance in the Primary DentitionCLARICE S. LAWCHAPTER OUTLINEGeneral ConsiderationsSpace Maintaining AppliancesFixed Unilateral AppliancesFixed Bilateral AppliancesRemovable AppliancesFabrication and Laboratory ConsiderationsSummaryMissing primary incisors are usually replaced for four reasons: space maintenance, function, speech, and esthetics. ese reasons merit consideration. ere is little evidence to support the concept that early removal of a primary incisor will result in space loss in most situations.5 ere may be some redistribution of space between the remaining incisors, but there is no net loss of space. Intuitively, this makes sense because there is no apparent movement or drifting of teeth when developmental spacing is present in the primary dentition. e exceptions seem to be when incisors are lost prior to the eruption of the primary canines or if there is crowding in the anterior segment.Poor masticatory function has also been proposed as a reason for replacing missing primary incisors. Concerns have been expressed about a child’s ability to eat after all maxillary incisors have been removed due to early childhood caries. ere is little evidence to support this concern. Anecdotally, feeding has not proven to be a problem for children with missing incisors, and when given a proper diet, a child can continue to grow normally.Some investigators have cited slowed or altered speech develop-ment as a justication for replacing missing maxillary incisors. is may be valid if the child has lost several teeth very early and is just beginning to develop speech. Many sounds are made with the tongue touching the lingual surfaces of the maxillary incisors, and inappropriate speech compensations may develop if these teeth are missing. However, if the child has already acquired speech skills, the loss of an incisor is not particularly important because any speech problems that may develop tend to be transient and resolve when the permanent incisors erupt.5Probably the most valid reason for replacing missing incisors is esthetics. e literature regarding the attitudes of young children toward dental esthetics is controversial.5 However, parents are more likely to express esthetic concerns. e diculty is when parents wish to replace the teeth but the child’s behavior does not allow the clinician to construct and place the appliance. If parents do not indicate a desire to replace missing anterior teeth, no treatment is certainly appropriate.Loss of a primary canine as a result of trauma or decay is rare. Because it is so rare, there is some debate about whether space loss will occur if there is no space maintenance. If the clinician is concerned about future space loss, either a band and loop space maintainer or a removable partial denture may be placed if the patient is cooperative. ese appliances may need to be remade when the permanent lateral incisor erupts. It is speculated that the upper or lower midline may shift to the aected side if no General ConsiderationsManagement of premature tooth loss in the primary dentition requires careful thought by the clinician because the consequences of proper or improper space maintenance may inuence dental development well into adolescence.1 Early loss of primary teeth may compromise the eruption of succedaneous teeth if there is a reduction in the arch length. On the other hand, timely intervention may save space for the eruption of the permanent dentition. e key to space maintenance in the primary dentition is in knowing which problems to treat.2Premature tooth loss in this age group is best thought of in terms of anterior (incisors and canines) and posterior (molars) teeth. e causes and treatment of missing teeth dier in these two regions. Anterior tooth loss is due primarily to trauma and tooth decay. Children in this age group are still developing gross motor skills, so injuries to the primary incisors are common. In addition, despite eorts at promoting preventive care, a number of children still suer from early childhood caries.3,4 ese decay patterns result in both anterior and posterior tooth loss. e majority of posterior tooth loss is due to dental caries; rarely are primary molars lost to trauma. If no space loss has occurred immediately after tooth loss, space maintenance is appropriate because the permanent successor will not erupt for several years. If space loss has occurred, a compre-hensive evaluation is required to determine whether space regaining or no treatment is indicated. is type of evaluation and decision-making is described in the discussions of the mixed dentition (see Chapter 31) because most attempts at regaining space are made at that time. 380 Part 3 The Primary Dentition Years: Three to Six Yearsappliance. ese aspects of care should be considered during treatment planning.Space Maintaining Appliancese Code on Dental Procedures and Nomenclature (Code) CDT 2017 lists four categories for space maintenance appliances8: xed unilateral, xed bilateral, removable unilateral, and removable bilateral. ere is no specicity for the stage of dentition during which these are used. Unilateral appliances are used to maintain space for a single missing tooth. Fixed unilateral appliances include the band and loop, crown and loop, and the distal shoe. Interestingly, the distal shoe has a code in the CDT distinct from the xed unilateral appliances. Removable unilateral appliances are rarely mentioned in the literature and, if so, mainly with cautions against use due to their small size. Bilateral appliances maintain space for two adjacent teeth or in cases where one or more teeth are missing in dierent quadrants within the same arch. e Nance appliance, transpalatal arch (TPA), and passive lingual arch or lower lingual holding arch are included as examples of xed bilateral space maintainers. Removable bilateral appliances are more commonly used than unilateral designs particularly in cases where multiple teeth have been lost prematurely. ese generally consist of variations on the Hawley type retainer.Fixed Unilateral AppliancesOne of the most common appliances used in the primary dentition is the band and loop. It is frequently used to maintain space for unilateral loss of the primary rst molar before or after eruption of the permanent rst molar (Fig. 26.2). It consists of a band that is cemented to the primary second molar with the loop contacting the distal surface of the primary canine. e appliance provides resistance to the pressure of the early mesial shift that occurs as the permanent rst molar begins its eruption, as well as the distal drift of the adjacent canine. e band and loop can also be used to provide space maintenance for premature loss of a primary second molar but requires the permanent rst molar be erupted suciently to fully seat a band. In some cases a variation called the reverse band and loop is used to hold the space of the missing primary second molar. e band is seated on an intact primary rst molar with the loop extending distally to contact the mesial space maintenance is used, although there are no data to support or refute this claim.Because loss of primary incisors is not typically associated with space loss and isolated loss of canines is rare, space maintenance during the primary dentition years is aimed primarily at the replacement of primary molars. Extraction of a primary molar can result in space loss. e tooth distal to the newly created space drifts mesial; more with loss of the second molar than the rst molar. In fact, there is some evidence that loss of a primary rst molar may not result in any overall space loss as long as the permanent rst molar is well interdigitated with the opposing molar.6 It seems that the occlusion keeps the molars from tipping or moving mesial. On the other hand, loss of a primary second molar has a high probability of space loss due to unhindered mesial drift of the permanent rst molar. ere is also evidence that the tooth mesial to the aected molar can drift distal into the space; this is more common with the primary rst molar than the second.7 us loss of space or arch length can occur from both directions (Fig. 26.1). Space loss can even occur without losing a primary tooth if interproximal cavitations are not treated, resulting in loss of the interproximal contact. Similarly, space loss can also occur when teeth adjacent to an ankylosed tooth continue to erupt and tip over the ankylosed molar due to the loss of a contact point.Space maintenance begins with good restorative dentistry. e dentist should strive for ideal restoration of all interproximal contours. Early restoration of interproximal caries ensures that no space loss occurs. However, in some instances, large carious lesions may make ideal restoration of the tooth impossible, and space loss is inevitable. Even if the pulpal tissues have been compromised, pulp therapy should be initiated and the tooth maintained, if at all possible, because the natural tooth is still superior to the best space maintainer available; it is functional, the correct size, and exfoliates appropriately. In cases of ankylosis the tooth should be maintained until space loss is imminent; it is then extracted and the space maintained. Ankylosed teeth show limited vertical change in the primary dentition years.Teeth lost during the primary dentition years can cause later-than-normal eruption of the succedaneous teeth. is means that the appliances should be monitored, adjusted, and possibly replaced over a longer period of time. Abutment teeth for appliances may exfoliate or interfere with adjacent erupting teeth. Abutment teeth are also at greater risk of decay and decalcication due to the AB• Figure 26.1 Premature loss of the primary rst molar can result in loss of space from both directions. The primary mandibular second molar drifts mesially, and the primary canine drifts distally, but predomi-nantly there is movement from the anterior in the posterior direction for the mandibular arch. (A) Arch perimeter has been lost on both sides. (B) Panoramic radiograph shows the canine and two premolars attempting to erupt into the limited space on the patient’s right. The left mandibular second premolar is missing. CHAPTER 26 Space Maintenance in the Primary Dentition 381 crown and loop appliance intraorally. e crown must be cut o, a new crown tted, and the wire resoldered. It is much easier to restore the abutment tooth with a stainless steel crown and then make a band and loop that ts the crown.e distal shoe appliance is used to maintain the space of a primary second molar that has been lost before the eruption of the permanent rst molar (Fig. 26.4). An unerupted permanent rst molar drifts mesial within the alveolar bone if the primary second molar is lost prematurely. e result of the mesial drift is loss of arch length and possible impaction of the second premolar.ere are many problems associated with the distal shoe appli-ance. Because of its cantilever design, the appliance can replace only a single tooth. In addition, the occlusal convergence of the crown of the primary rst molar makes proper band t dicult and increases band fragility. In some cases, cutting the top o a stainless crown and trimming the gingival margin to resemble a band will work best. Occlusal function should not be restored because of this lack of strength. Finally, histologic examination shows that complete epithelialization does not occur after placement of the appliance.9 Because the epithelium is not intact, the distal shoe appliance is contraindicated in medically compromised patients and patients at risk for infective endocarditis.e distal shoe can have modications. It can also be fabricated with the crown and distal shoe modication in design. Although feasible, like the crown and loop, it is dicult to modify and repair. e reverse band and loop described previously can be used as a substitute for the distal shoe, with the appliance designed so that the wire of the loop rests on the soft tissue (sometimes with mild pressure) approximately where the distal surface of the lost primary second molar was located. e goal is to minimize mesial movement of the unerupted permanent rst molar. To date, there are several case reports but no clinical trials to support this recommendation.Fixed Bilateral Appliancese second category of appliances used to maintain posterior space in the primary dentition consists of xed bilateral appliances. ese appliances are indicated when teeth are lost in both quadrants of the same arch or multiple teeth have been lost within a quadrant.surface of the permanent molar. Overall, the band and loop appli-ance is inexpensive and easy to fabricate. However, its use requires continuous supervision and care, and it does not restore the occlusal function of the missing tooth.e band and loop appliance is also commonly used in the primary dentition for bilateral loss of primary molars before the eruption of the permanent incisors (Fig. 26.3). More discussion on this will take place in the subsequent section on xed bilateral appliances. A variation of the band and loop appliance that is not highly recommended is the crown and loop appliance. e crown and loop technique requires preparation of the abutment tooth for a stainless steel crown followed by soldering of a space-maintaining wire directly to the crown. Care and maintenance of the crown and loop is more dicult than for the band and loop if there is damage or if modications are required. If the solder joint fails and the wire breaks loose, there is no way to repair the • Figure 26.2 The band and loop appliance is used to maintain the space after the premature loss of a single tooth. The band and loop appli-ance is indicated when there is unilateral loss of a primary rst molar before or after the eruption of the permanent rst molar. The loop is constructed of 36-mil round wire and is soldered to the band. • Figure 26.3 If both primary rst molars are lost prematurely in the mandibular arch and the permanent incisors have not erupted, bilateral band and loop appliances are used to maintain space. A lingual arch is not indicated in this situation because it may interfere with the subsequent eruption of the permanent mandibular incisors. • Figure 26.4 The distal shoe appliance is used to maintain the space of a primary second molar that has been lost prematurely before the erup-tion of the permanent rst molar. A stainless steel extension is soldered to the distal end of the band and 36-mil loop; this extension is positioned 1 mm below the mesial marginal ridge of the unerupted permanent rst molar. The extension serves to guide the eruption of the permanent rst molar. 382 Part 3 The Primary Dentition Years: Three to Six Yearsthe TPA is a cleaner appliance and is easier to construct, many clinicians think it allows the teeth to move and tip mesially, resulting in space loss.Fixed bilateral appliances can also be options for children who have had incisors extracted (Fig. 26.7). Prosthetic primary teeth can be axed to a lingual arch extending from banded molars to serve as replacements for the missing incisors. ese appliances, often called Groper xed anterior bridges or pediatric partials, generally address esthetics but can serve functional purposes if posterior teeth have been extracted. Because the permanent incisors erupt much sooner than canines and premolars, appliances serving dual functions as esthetic incisor replacements and posterior space maintainers will require alternate options in the mixed dentition.Removable AppliancesRemovable appliances make up the third category of appliances used to maintain space in the primary dentition (Fig. 26.8). Like The lower lingual holding arch is commonly used in the mandibular arch during the mixed dentition period. However, because the permanent incisor tooth buds develop and erupt lingual to their primary precursors in the lower arch, a mandibular lingual arch is not recommended in the primary dentition; the wire resting adjacent to the primary incisors might interfere with the eruption of the permanent dentition (Fig. 26.5). Instead, two band and loop appliances are recommended when there is bilateral tooth loss in the mandibular arch. When the permanent molars and incisors erupt, a lower lingual holding arch can be considered as a replacement for the band and loop appliances.A maxillary xed bilateral appliance is feasible in the primary dentition because the appliance can be constructed to rest away from the incisors. Two types of lingual arch designs are used to maintain maxillary space—the Nance arch and TPA. ese appli-ances use a large wire (0.036 inches) to connect the banded primary teeth on both sides of the arch distal to the extraction site. e dierence between the two appliances is where the wire is placed in the palate. e Nance arch incorporates an acrylic button that rests directly on the palatal rugae. In some cases the acrylic button may irritate the palatal tissue. e TPA is made from a wire that traverses the palate directly without touching it (Fig. 26.6). Although • Figure 26.5 Lingual eruption of the permanent mandibular incisors is not uncommon. A mandibular lingual arch is not recommended as a space maintainer in the primary dentition because it may interfere with the eruption of these incisors. Bilateral band and loop appliances are recom-mended when both primary mandibular rst molars are lost prematurely. • Figure 26.6 The transpalatal arch (TPA) is a xed lingual arch appliance used to maintain space following bilateral loss of maxillary teeth. The TPA is more hygienic than the Nance appliance because it consists of only the 36-mil palatal wire, but it can allow the abutment teeth to tip mesially in some cases, resulting in space loss. • Figure 26.7 A xed (as shown here) or removable partial denture can be used to replace missing anterior teeth in the primary dentition. In most cases the partial denture is placed for esthetic reasons rather than to prevent space loss in the anterior dental arch. • Figure 26.8 A removable partial denture is used to maintain space in the primary dentition when more than one tooth in a quadrant is lost. This appliance is an alternative to the lingual arch with teeth attached. In the patient portrayed here, only anterior teeth have been replaced. CHAPTER 26 Space Maintenance in the Primary Dentition 383 Fabrication and Laboratory Considerationse classic method of constructing a xed appliance is a two- or three-visit process. If there is tight interproximal contact of the molars, the rst visit is to place separators. If there is interdental spacing the rst appointment involves tting a band and obtaining an impression. e nal appointment is to deliver the appliance.e initial step in constructing a xed appliance is to select and t a band on the abutment tooth or teeth (Fig. 26.9). e next step is to obtain an impression of the banded tooth and edentulous area. Alginate impression material is most commonly used. A quarter-arch tray may be used for the unilateral appliances. e next step varies depending on the oce or laboratory preference. e band(s) is removed from the tooth with a band remover and stabilized in the impression. e impression is poured in stone with the band(s) in place. An alternative approach is to pour the dental casts without the band(s) in place and send the appropriately sized band(s) to the laboratory to be seated by the technician during appliance fabrication. Other oces obtain only impressions and ask the laboratory to t bands and fabricate the appliance on the dental cast. Intraoral scanning may also be used. A digital scan provides information to print a three-dimensional (3D) model on which the appliance is constructed. e dentist, an in-oce techni-cian, or a commercial dental laboratory will bend a 0.036-inch wire into the appropriate appliance.e appliance is commonly delivered in a separate visit. First, it is tried in and adjusted to t. e interior of the band is cleaned thoroughly, and the cement is loaded along the gingival margin. If the cement is loaded on the occlusal side, there is a risk there xed bilateral appliances, removable appliances are typically used when more than one tooth has been lost in a quadrant. e removable appliance is often the only alternative because there are no suitable abutment teeth and because the cantilever design of the distal shoe or the band and loop appliance is too weak to withstand occlusal forces over a two-tooth span. Removable appli-ances can also be an alternative to xed bilateral appliances for the replacement of missing incisors. Not only can the partial denture replace more than one tooth, but it also replaces occlusal function.Two drawbacks of the appliance are retention and compliance. Retention is a problem because primary canines do not have large undercuts for clasp engagement. If multiple tooth loss is unilateral, retention problems can be overcome by placing sturdy retention clasps on the opposite side of the arch. However, if multiple teeth are lost bilaterally, retention problems are almost inevitable.e problem of compliance is closely related to that of retention. Children aged 3 to 6 years will not tolerate an ill-tting appliance and may not use it. In fact, some children will not tolerate a retentive appliance. e dentist is then resigned to waiting until the permanent teeth (molars) erupt so that they can be used as abutments for a conventional lingual arch appliance. Partial dentures occasionally require clasp adjustment and acrylic modication to maintain good retention and allow eruption of the underlying or adjacent permanent teeth. Some children are compliant in wearing an appliance but not in cleaning the appliance and the underlying tissue. is can result in decay, tissue irritation, and hyperplasia.WORKING WITH THE DENTAL LABORATORYSteven H. GrossDental laboratory technology is a science and an art. Because each dental patient’s needs are different, the duties of a dental laboratory technician are comprehensive, varied, and an important part of your dental team. There are steps a dental ofce can take to make sure their lab work is returned on time and the t is ideal. The following are recommendations for the dental team.Comprehensive Signed PrescriptionEach prescription should include a due date and a patient appointment date. A detailed and unambiguous prescription will ensure that the laboratory provides the dentist and patient with a properly fabricated appliance. If there is a problem in meeting the due date, the lab can call and choose a delivery method to ensure on-time delivery.Accurate ModelsAn accurate yellow stone cast that captures all the teeth and soft tissues of interest is the most importation step to ensure an excellent tting appliance. It has been suggested that 30% of all models, impressions, and digital scans sent to laboratories are inadequate for appliance fabrication. Having each cast poured and inspected by the doctor for bubbles or distortion before the patient is released would be good practice to improve appliance quality. Air bubbles or holes on tooth surfaces are unacceptable. Good-quality impression materials such as alginate or polyvinyl siloxane (PVS) are best. Compound impressions are the number one cause of distorted models and should be avoided. Simple precautions can save the ofce valuable chair time, expense, and the inconvenience of calling a patient back for new impressions.BandsMost labs prefer that preformed bands not be poured-up on the model. Simply tape bands to the prescription slip and label the bands—right or left and upper or lower. Then take impressions without the bands in place. Teeth to be banded should be fully exposed. If they are not, it is difcult for the lab to guarantee band and appliance t.Sending the CaseThe ofce should provide the lab with an accurate wax construction bite. Each cast should be wrapped individually in foam. The casts should be carefully placed in a sturdy corrugated box—many labs will provide boxes with either a delivery company or a prepaid mailing label. It is best to pour models with as small a base as possible (or trim the casts) to save weight and extra cost.CommunicationOpen communication with the laboratory is key to provide excellent care for the patient. The doctor and laboratory should be able to discuss cases openly and exchange ideas when there are questions on how to design an appliance. Open communication will lead to a long and mutually benecial relationship.

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