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Space regainers in pediatric dentistry

Article · January 2015

DOI: 10.15713/ins.idmjar.11

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 International Dental & Medical Journal of Advanced Research (2015), 1, 1–5

REVIEW ARTICLE

Space regainers in pediatric dentistry

Pratiksha Chandak, Sudhindra Baliga, Nilima Thosar
Department of Pedodontics and Preventive Dentistry, Sharad Pawar Dental College, Wardha, Maharashtra, India

Keywords Abstract
Interceptive orthodontics, premature loss of Premature loss of deciduous teeth due to caries or any other iatrogenic factors prevents
deciduous teeth, space regainers
development of normal occlusal relationship. In interceptive orthodontics, the severity
of developing malocclusion and complex orthodontic treatments are minimized or
Correspondence
Dr. Nilima Thosar, M1-11, Meghdootam
reduced which further may help in reducing the overall treatment time. In the recent era,
Apartments, Sawangi (Meghe), for successful resolution of space discrepancies, various interceptive measures involving
Wardha  - wW442 004,Maharashtra, India. non-extraction approaches were satisfactory. This article is an overview which depicts
Email: [email protected] a range of space regaining appliances used to overcome or reduce space discrepancies.

Received 16 March 2015

Accepted 21 April 2015

doi: 10.15713/ins.idmjar.11

Introduction cost to the parents and saves time for both the dentist as well as
for the patient.[3]
Premature exfoliation or extraction of deciduous tooth or
For performing any interceptive measures like space regaining
teeth can frequently lead to the development of malocclusion.
or any mesial or distal movement of teeth, diagnosis is of utmost
Early orthodontic interventions are often in the beginning of
importance. If the attention is not given to the segment in which
developing dentition help to promote favorable developmental
tooth is missing, it may become the frequent cause of failure
changes.[1] The term interceptive orthodontics includes timely
in attempting to regain the space.[1] Treatment considerations
management of hostile features of a developing occlusion.
include the alignment of the teeth and the space required for the
Interceptive orthodontics is defined as a phase of science and
teeth to align in the basal bone, the position of the teeth within
art of orthodontics employed to recognize and eliminate the
the arch, the occlusion in both transverse and sagittal plane, and
potential irregularities and malpositions in the developing
the relation of the maxilla and mandible with the cranium and the
dentofacial complex.[2] Guiding the erupting and developing
deciduous and permanent teeth and developing occlusion forms soft tissue. The diagnostic aids necessary to develop a database for
an essential part of the preventive care of pediatric patients. the above consideration include study models, radiographs of all
Such assistance will lead to the development of a permanent periapical structures, clinical assessment of facial asymmetry and
dentition in a harmonious, functional and esthetically acceptable proportions, and possibly cephalometric analysis. Interceptive
occlusion.[3] In 1998, Hoffding and Kisling reported that orthodontics is employed to recognize and eliminate potential
premature loss of primary teeth caused space loss.[4] As a result irregularities and malposition in the early maxillofacial
of space loss, the permanent tooth may remain impacted, or it complex. The various techniques recommended for reducing or
may erupt buccally or lingually.[5] In the case of premature loss eliminating developing irregularities and malocclusion are serial
of primary second molars, the space closure is much more than extractions, space regaining, etc., In preventive and interceptive
premature loss of primary first molar. In such circumstances, orthodontics, if the right treatment is done at an early age, then
where there is space loss, routinely we require space regainer. no further treatment would be needed.[6]
Various appliances will help for both regaining the lost space as
well as its maintenance for the eruption of the permanent tooth. Diagnosis
At the initial appointment, the appliance is activated to regain the
lost space and then it is kept passive till the tooth is erupted into Radiographs and study models are used for assessing space
the oral cavity. The dual function of the appliance will reduce the required and alignment of the tooth in the arch. The forces

International Dental & Medical Journal of Advanced Research ● Vol. 1 ● 2015 1

Space regainers Chandak et al.

required for tipping teeth for aligning the teeth are easily acrylic base of the appliance. At certain intervals of time, the free
manageable than the forces required to bodily return tooth end of the loop is activated to achieve desirable movement of
to its proper position in the arch. So it is essential to diagnose the tooth. A light force on the tooth to be moved is desired. The
whether teeth have moved bodily into the space or tipped axially. appliance should be checked and adjusted as often as necessary
Another important aspect in the diagnosis is the position of the to maintain the light force on the molar. The type of loop spring
erupting tooth distal to the tooth to be moved, i.e. permanent wire can be changed to fit any situation, depending on the
second molars as they have the potential to be impacted by the position of the tooth and the distance it needs to be moved.[3]
severe distalization of permanent first molar. Radiographs of the A free-end loop space regainer for the lower arch has a shorter
periapical structures are necessary.[1,2] wire loop, resulting in less distortion when the child inserts the
Space regaining procedure required certain dental alignment appliance.
considerations that are rotation of the tooth, improper
contacts and transverse relation of teeth. Study models will Split-block space regainer
provide the best data resource for these considerations. Study Split- block space regainer or split saddle space regainer differs
models permit visualization of vertical, transverse and sagittal from the free end spring type of space regainer. It consists
dental relationship that might hinder stability of Moyer’s of a dumbel constructed with a no. 0.025 wire which extend
mixed dentition analysis and will be a good aid to determine buccolingually and an acrylic block that is split buccolingually.
measurement of space loss against an estimation of the space The acrylic plate is split with the disk to form an activator portion,
needed by the unerupted permanent tooth. Estimation based and the appliance is activated buccolingually periodically
on radiographs demonstrates variance because of difficulties in for tooth movement. The activator portion of the split block
standardized film placement, especially in the small mouth of the appliance is essentially the same as one that has been designed
child with early mixed dentition.[6] to establish a space for fixed bridge therapy. The unilateral type
Several problems are associated with the regaining procedures. used for adults should not be used in the child’s mouth, however
Usually, minimal space loss can be regained better. The space because of the risks of loss of swallowing[2] [Figure 1a].
regaining procedure that involves tipping of first permanent
molar can be accomplished more easily in the maxillary arch Fixed loop-spring space regainer
than in the mandibular arch. The procedure should be limited
It differs from other types only in the design of the spring
to those cases in which the occlusion is Class I, there is adequate
activation. This appliance resists breakage and provides a
anchorage, the second permanent molar is unerupted and there
satisfactory method of moving the molar distally. The mesial
is favorable relationship of second permanent molar with the
portion of the spring loop is embedded in the resin and passed
first permanent molar.[6]
out through the edentulous space. This portion of the wire
For positioning the first permanent molars with use of an should contact the distal surface of the tooth which is mesial to
appliance, the reciprocal force which will be produced will get the space. This prevents distal movement of this tooth. A loop
dissipated on the anterior teeth and surrounding supporting is then formed, and the wire returned back to contact the mesial
tissues which ultimately can lead to a detrimental movement of surface of the first permanent molar. At this end, the wire is
teeth anterior to the space loss e.g. flaring of the anterior teeth. bent around a stable embedded in the resin. The spring loop
This particularly occurs during the mixed dentition period should be allowed to move freshly on the staple. Retention of
when the permanent incisors are incompletely erupted and
adversely influenced by even minimal forces. Furthermore,
the forward movement of the unerupted, second permanent
molar accompanies the forward movement of first molar, and
any attempt to tip or reposition the first permanent molar may
produce an impaction of the second molar.[6]
In favorable situations, an effort should be made to regain
space. Various removable and fixed appliances are used for space
regaining. However, distalization or bodily movement of molars
a b
can be most satisfactorily achieved by headgear appliance.[2]

Removable Space Regainers

Goodale described three types of removable space regainers.

Free end loop spring space regainer

It utilizes a labial archwire which provides stability and c
retention, a back-action loop spring of no. 0.025 wire and an Figure 1: (a) split saddle, (b) fixed loop and spring, (c) sling shot

2 International Dental & Medical Journal of Advanced Research ● Vol. 1 ● 2015

Chandak et al Space regainers

this appliance is gained by the use of wire clasps. Orthodontic require tedious laboratory procedures. A band is prepared for
wire of no. 0.025 or no. 0.030 dimension is embedded in the the abutment tooth and fitted, and the mesial surface is marked
acrylic resin, brought through the embrasure and then bent for placement of “U” loop, which may be stabilized by welding
down to contact the teeth below the contact points. After the or soldering. The wire “U” assembly is placed in the molar tube,
desired movement of the permanent molar has been attained, and the appliance is allowed to contact the tooth mesial to the
the appliance may be used as a space maintainer by soldering edentulous space. Expanded center and lower left views show
the activator portion of the spring to the guide wire in its passive occlusal rest added to the wire section to reduce cantilever effect.
position, or by filling in the edentulous region with additional An eyelet may be welded to a flattened part of the tube. Next
resin[2] [Figure 1b]. to the band weldable tube stops are soldered on wire portion
(lower right) and open coil spring sections are cut to fit over
Sling shot space regainer the wire between “stops” and ends of “U” tube. The length of
open coil spring is measured by establishing the assembly
Sling shot space regainer distalizes molar with a wire elastic
in desired position and the distance between mesial contact
holder with hooks as an alternative to spring which transmits a
or solder point to the entry of wire in the tube and add the
force against the tooth to be distalized. It is termed as sling shot
amount of space required or regained, plus additional 1-2 mm
appliance, as the forces to distalize tooth were produced by the
to ensure activation of spring. Load springs, tie floss or steel
elastic which was stretched on the middle of the lingual and the
ligature through eyelet and over “U” wire to hold stored force
buccal surface of the molar to be moved. The child places new
in compressed spring. Compress springs so that the assembly
elastic between the hooks while the appliance is outside the
should fit in the edentulous space and cement the assembly in
mouth. It is slipped into place then the child’s fingers can guide
place. After cementation, cut the ligature and remove to activate
the elastic into proper position. If the appliance is of a removable
regainer[2,3] [Figure 2a].
type, periodic checking should be done to evaluate whether
the patient is using it or not, whether there is any distortion
Hotz lingual arch
or breakage of the appliance or irritation of soft tissues. If the
teeth are emerging underneath the appliance, the portion Another method for moving molars distally utilizes the looped
of the acrylic is cut off to give way for the teeth to erupt into Hotz lingual (Hitchcock 1974). Hotz lingual arch is indicated
position. In case of fixed appliances, check for any breakage of in situations where the permanent tooth moves mesially rather
the appliance at the soldered joints or band material. It is also than distal movement of mesial teeth and also in cases where
checked that whether the appliance is loose due to dissolution sufficient space is present for eruption of permanent second
of cement which may result in food lodgement and caries. The molar. The lingual arch provides compound anchorage from
appliance is removed every 6 months or 1-year depending on all the other teeth which the lingual arch touches. A horizontal
the situation and the abutment tooth is checked for any caries spur can be soldered perpendicular to the arch wire contacting
or decalcification. Polishing of the abutment is done followed the distal surface of the premolar or canine. This compounds the
by fluoride application. Then the appliance is recemented anchorage additionally. The loop on the active side is adjusted
in position. Regular radiographic examination of developing periodically once a month. After adjustment, the wire is forced
permanent teeth is also necessary. The appliance can be removed forward and then slipped downward into appropriate space[2]
or discarded soon after the succedaneous teeth erupted into [Figure 2b].
proper position in the oral cavity[3] [Figure 1c].

Fixed Space Regainers

Jaffe appliance

An appliance for certain minor tooth movements was

described by Jaffe (1963), is useful when the presence of a b
ankylosed tooth, early loss of a deciduous molar or an extraction
result in filling of adjacent segments into proximal dental area.
Movement is obtained by the use of light spring pressure against
a sliding section or arch. The appliance consists of buccal and
lingual arms of molar bands and the sliding arch to move the
desired tooth or teeth.[3]

Gerber space maintainer c d

It is the type of appliance which may be fabricated chair side Figure 2: (a) Gerber’s space regainer, (b) hotz lingual arch, (c) lip
with relatively short duration of the appointment as it does not bumper, (d) king’s appliance

International Dental & Medical Journal of Advanced Research ● Vol. 1 ● 2015 3

Space regainers Chandak et al.

Lip bumper appliance a ‘U’ loop (21 gauges of wire). The ‘U’ loop or the canine retractor
Lip bumper appliance is used in the mandibular arch for gaining should be placed a little away from the band on either side of the
space or for distalization of molar and its counterpart in the tooth (buccal or lingual side) depending on space available, eruption
maxillary arch is Denholtz appliance. Molar bands are prepared on pattern of the tooth to avoid heating while soldering the appliance.
permanent first molar and molar tubes are welded on the buccal After soldering the appliance with band, appliance is cemented on
side of each molar band. Labial archwire is then engaged in both the teeth. The activation of the appliance comprises of opening the
buccal tube and acrylic button is prepared on the labial vestibule. ‘U’ loop or the coil spring of the canine retractor[7] [Figure 3]. It
It transfers forces from lips directly on to the buccal aspect of is indicated for space closure after the premature loss of one tooth.
first molar to distalize the molar[2] [Figure 2c]. It is used in early This appliance is effective for space regaining when space is present
primary dentition for minimum distalization of molar. Also useful mesial to the erupting or erupted tooth. Its limitation is in case of
in uprighting the mesially tipped molars to regain space in the arch. severe space loss with multiple unerupted teeth.

King appliance Recent Advances

King (1977) described an appliance for regaining of space in Unilateral spring space regainer
both maxillary and mandibular arch. The anchorage unit for the
mandibular arch is basically a fixed lingual arch with bands fitted The molar to be distalized and contralateral canine or premolar
on the first deciduous molar of the treatment side and the first is banded, and a lingual sheath (0.036” × 0.072”) is welded to
permanent molar on the opposite side. Then an edgewise bracket the band. Impression is taken, and a working cast is prepared by
is spot-welded to the buccal surface of the primary molar band, pouring with dental stone. Then adapt two 0.036” stainless steel
and the completed anchorage unit is cemented in place. A band wires on the model following the curvature of the gingival contour
with an angulated buccal tube is cemented on the malpositioned and solder them on the molar band and the bands on the opposite
molar, and a straight section of wire with an open coil spring is canine or premolar. A Ni-Ti spring is then fabricated and placed
introduced into the buccal tube and ligated into the bracket. in such a way that one end of the wire is inserted in the lingual
The anchorage unit must be modified for the treatment in the sheath. On the model, the spring is placed at a level 5-6 mm apical
maxillary arch. A millimeter a month is satisfactory progress in to the center of resistance of the molar. The Nance button is
the repositioning of first molar. When a Class I or cusp to cusp fabricated which covers the palate except the body of the spring
molar relation is achieved, a conventional space maintaining with the acrylic resin. Uncovered spring helps in the activation of
appliance should be given[3] [Figure 2d]. the appliance by opening of spring 3-4 mm extraorally and then
reinserts the sping palatally. This appliance moves the molar
Anterior space regainer
distally without any transverse movement when the force is
Two 0.018 × 0.025 standard labial tubes are adapted into the applied from the both buccal and palatal aspects. To counteract
mouth. A stainless steel mesh is spot welded and trimmed to rotational movement of teeth both in sagittal and transverse plane,
the tubes. The enamel of the labial surfaces of left central and a nickel-titanium open coil spring (0.010” × 0.030”), compressed
right lateral incisors is etched with 35% phosphoric acid, and 10 mm to its resting length should be ligated on the buccal aspect
each labial tube is individually bonded to each abutment tooth. of the molar. The force applied gingival to the center of resistance
When the composite is polymerized, a piece of 0.014” standard which results in palatal clockwise movement is counteracted by
round wire is introduced into the lateral incisor tube. The wire buccal force applied occlusal to the center of resistance, results in
is then inserted in a 0.036” × 0.009” open coil spring previously counter clockwise movement. This results in bodily movement of
selected and passed through the labial tube of the central incisor. molars without any rotation[8] [Figure 4].
A distal bend is made 2 mm from the distal ends of the tube. Advantages of USSR are it is easy to construct, cost-effective,
After 3 weeks, the coil spring is activated, and after the space produces steady and equivalent forces, allow bodily movement
is slightly over widened, 0.016” round wire is inserted with the with little or no tipping and efficient where second permanent
same coil spring. 3 weeks later the wire is changed to a 0.018” molar is fully erupted. Limitations of USSR are activation is
and finally to a 0.018” × 0.025” wire, leaving the coil spring only difficult and strict control of the appointments.
for retention. After that, an acrylic pontic is fixed over the wire
and coil spring, using the same type of composite already in the
patient’s mouth.[3]”

Space Regainer Cum Space Maintainer

A band is made or selected for an abutment tooth, alginate
impressions of the both arches are taken keeping the band in
place and models are prepared. The wire component for the space a b
regainer comprised of a canine retractor (22 or 23 gauge of wire) or Figure 3: (a and b) Space regainer cum space maintainer

4 International Dental & Medical Journal of Advanced Research ● Vol. 1 ● 2015

 Chandak et al Space regainers

Lingual arch crossbow and double-banded space regainer Conclusion

The appliance is used for space closure of the primary canines Management of space problems in the mixed dentition
and also missing primary second molar and space is regained by plays an important role in pediatric dental practice. An
the moving distal teeth distally. A lingual arch space maintainer is understanding of the development in the primary and mixed
prepared to avoid mesial drifting of permanent first molar. Molar dentitions can help in deciding when and how to intercept
tubes (1.1 mm diameter, 10 mm length) are welded to molar the malocclusion due to premature loss of deciduous teeth.
bands buccally and lingually. A curved stainless steel wire (0.9 mm Proximal stripping and serial extraction are irreversible and
width) is constructed angled medially forward, and posteriorly invasive techniques for treating a malocclusion while space
its free ends passing through molar tubes and contains NiTi regaining with removable and fixed space regainer appliances
open coil springs distal to the permanent first molar. Medially are noninvasive techniques and helps in interception of
angulated wire facilitates distalization of premolar without any malocclusion.
transverse movement. Lingal arch crossbow is cemented, and the
curved wire is engage the mesio-cervical margin of first premolar
by dragging it forward. This forward pull results in compression References
of the open coil spring to half of their original lengths. These 1. Proffit W. Contemprorary Orthodontics. 2nd  Edition, Mosby
compressed spring exert force between molar tube and posterior Year Book: 380-383.
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that leads to distalization of premolar simultaneously. As the Brothers; 470- 500.
required space is regained, a spring is deactivated by adding self- 3. Muthu. Paediatric dentistry: principles and practice. 2nd Edition,
cure acrylic. This prevents further gain of space, and it works as a 2011; Elsevier: 360-364.
space maintainer till the eruption of permanent teeth in its normal 4. Hoffding J, Kisling E. Premature loss of primary teeth; Part 1, its
occlusal position[9] [Figure 5]. overall effect on occlusion and space in the permanent dentition.
J Dent Child 1978;45:279-83.
5. Kisling E, Hoffding J. Premature loss of primary teeth: Part 111,
drifting patterns for different types of teeth after loss of adjoining
teeth. J Dent Child 1979;46:34-8.
6. Bishara Textbook of Orthodontics. 2nd  Edition, Elsevier:
410-412.
7. Kirtaniya BC, Singla A, Gupta KK, Khanna A, Kaur G.
Space Regainer Cum Space Maintainer – A New Appliance
a b For Paediatric Dentistry. Indian Journal of Dental Sciences.
September 2014;6:20-24.
Figure 4: (a and b) Unilateral spring space regainer
8. Roy AS, Chandna AK, Puri A. Unilateral spring space
regainer: A smart way to drive molar distally. APOS Trends in
Orthodontics. September 2013; 3: 163-167.
9. Chalakka P, Thomas AM, Akkara,F. Pavaskar R New design
space regainers: ‘Lingual arch crossbow’ and ‘Double banded
space regainer’. Journal Of Indian Society Of Pedodontics And
Preventive Dentistry. 2012; 30:

a b How to cite this article: Chandak P, Baliga S, Thosar N.

Space regainers in pediatric dentistry. Int Dent Med J Adv Res
Figure 5: (a and b) Lingual arch crossbow and double-banded space
regainer
2015;1:1-5.

International Dental & Medical Journal of Advanced Research ● Vol. 1 ● 2015 5

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