Clinical success of fixed space maintainers: Conventional band and loop versus fiber-reinforced composite loop space maintainer

Reena Rani; Sanjay Chachra; Abhishek Dhindsa; Manu Sharma

doi:10.4103/nnjcr.nnjcr_32_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 9 | Issue : 15 | Page : 1-6

Clinical success of fixed space maintainers: Conventional band and loop versus fiber-reinforced composite loop space maintainer

Reena Rani, Sanjay Chachra, Abhishek Dhindsa, Manu Sharma
Department of Pedodontics and Preventive Dentistry, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India

Date of Submission	24-May-2019
Date of Acceptance	16-Dec-2019
Date of Web Publication	11-May-2020

Correspondence Address:
Dr. Reena Rani
Department of Pedodontics and Preventive Dentistry, Swami Devi Dyal Hospital and Dental College, Barwala, Panchkula - 134 118, Haryana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/nnjcr.nnjcr_32_19

Abstract

Aim: The study aimed to compare the clinical efficacy of two fixed space maintainers and conventional band and loop and fiber-reinforced composite resin (FRCR) space maintainers. Subjects and Methods: Thirty healthy children, aged 6–8 years were selected having at least two deciduous molars in different quadrants indicated for extraction or lost previously. Band and loop space maintainer was cemented in one quadrant, and in the other quadrant, FRCR space maintainer was placed. All the patients were recalled at the 1^st, 3^rd, 6^th, and 9^th months, and retention of both the types of space maintainers was evaluated. Statistical Analysis Used: The observations thus obtained were subjected to the statistical analysis using the ANOVA test and post-hoc Tukey test. Results: The retention of the FRCR space maintainer was found to be superior to that of the band and loop space maintainer, and this difference was statistically significant. Conclusion: FRCR (Ribbond) space maintainers can be considered alternative to the conventional band and loop space maintainers.

Keywords: Band and loop, fiber-reinforced composite resin, retention, space loss, space maintainer

How to cite this article:
Rani R, Chachra S, Dhindsa A, Sharma M. Clinical success of fixed space maintainers: Conventional band and loop versus fiber-reinforced composite loop space maintainer. N Niger J Clin Res 2020;9:1-6

How to cite this URL:
Rani R, Chachra S, Dhindsa A, Sharma M. Clinical success of fixed space maintainers: Conventional band and loop versus fiber-reinforced composite loop space maintainer. N Niger J Clin Res [serial online] 2020 [cited 2023 May 29];9:1-6. Available from: https://www.mdcan-uath.org/text.asp?2020/9/15/1/284084

Introduction

When a primary tooth is extracted or is exfoliated prematurely, the teeth present mesial and distal to space tend to drift or be forced into that space. This may result in the impaction of the succedaneous tooth, over-eruption of the opposing tooth, and a shift of the midline of the dental arch to the affected side, resulting in the impairment of function. The maintenance of the space may eliminate or overcome these consequences.^[1]

The safest way to prevent above-mentioned consequences and future malocclusions pertaining to early loss of a primary tooth is to place a space maintainer that is effective, durable, and economical.^[2] The greatest amount of tooth displacement and space loss occur within 6 months following the loss of teeth, and hence, it is best to insert a space maintainer immediately after the loss of primary teeth.^[3]

It has been reported that a well-designed fixed space maintainer is more preferable than a removable appliance to both the patient and the dentist.^[4] Band and loop space maintainer is the most commonly used one. Because of potential disadvantages such as irritation to underlying tissue or breakage of this conventional type, space maintainer has led to the introduction of fiber-reinforced composite resin (FRCR) technology which includes polyethylene fiber.^[5]

This material is a translucent, semi-manufactured product made up of glass fibers. Although FRCRs have been developed for dental use, their application in pediatric dentistry for space maintainers is still limited. Hence, the aim of the present study was to evaluate the clinical success of FRCR space maintainer as an alternative to conventional band and loop space maintainer.

Subjects and Methods

Materials and methodology

Thirty healthy children, aged 6–8 years, who reported to the department with grossly carious primary molars indicated for extraction, were selected from the department of pedodontics and preventive dentistry. The study methodology was explained to both children and their parents and written informed consent was obtained. Ethical committee clearance was obtained from the Institutional Ethical Committee. The inclusion^[6] and exclusion^[6] criteria are given in [Table 1] and [Table 2].

Table 1: Inclusion criteria

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Table 2: Exclusion criteria

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After taking a history, the intraoral examination was done. Intraoral periapical radiographs were taken to confirm the diagnosis and treatment planning [Figure 1]. Impressions were made followed by study model preparation and space analysis. Total rehabilitation was done before the placement of space maintainers. Band and loop space maintainer was cemented, and in the opposite quadrant, FRCR space maintainer was placed.

Figure 1: (a-d) Intraoral periapical radiographs showing teeth indicative of extraction

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Technique for construction band and loop space maintainer

A conventional band and loop space maintainer was given as per the technique described by Graber^[7] and Finn.^[8] It was cemented using luting glass-ionomer cement (type I). Excess of cement was removed using dental floss interdentally [Figure 2].

Figure 2: (a and b) Band and loop space maintainers' insertion

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Technique for the construction of fiber-reinforced composite resin space maintainer

The initial framework of the FRC loop was constructed on to the preliminary study cast model using a commercially available polyethylene fiber system (Ribbond, Inc., Seattle, WA, USA). Ribbond fiber of 40-mm length and 2 mm in breadth was wetted with unfilled adhesive resin (Adper™, Single Bond, 3M-ESPE, St. Paul, MN, USA) to formulate the loop [Figure 3], leaving 5 mm of fiber on each end for attachment to the abutment tooth. A thin layer of restorative composite resin (Filtek Z 350, 3M-ESPE, St. Paul, MN, USA) was added to the outer portion of the fiber, leaving the 5 mm of fiber on each end to provide initial rigidity, handling and adaptability to the unetched middle third of the buccal and lingual surface of the preliminary study model. The fiber assembly was then light-cured for 40 s through its entire length. The loop was then detached from the cast; restorative composite resin (Filtek Z 350, 3M-ESPE, USA) was added to the inner portion of the loop except the 5 mm of the fiber on each end, and then, it was light cured for 40 s. The loop was finished and polished with finishing burs and polishing soflex discs. The buccal and lingual surfaces of the tooth were etched with phosphoric acid (Scotchbond™, 3M-ESPE, USA) for 15 s, rinsed with water, dried, and bonding agent (Adper™, Single Bond, 3M-ESPE, USA) was applied and cured for 40 s. The loop was finally attached to the tooth using restorative composite resin (Filtek Z 350, 3M-ESPE, USA) followed by finishing and polishing [Figure 4]a.

Figure 3: (a) Ribbond Fiber(Ribbond, Inc., Seattle, WA, USA), (b) Preliminary cast, (c) Measurement of the Ribbond Fiber-40mm, (d) Fabrication of fiber reinforced space maintainer, (e) Finished and Polished Space maintainer and (f) Final adaptation onto the working model

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Figure 4: (a and b) Final placement in the patient mouth

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Both the space maintainers were checked for gingival clearance and occlusal interference [Figure 4]b.

Instructions for oral hygiene and appliance maintenance were given to both children and parents/guardians. They were instructed to return if the appliance was loosened, dislodged, or broken. All the patients were recalled at the 1^st, 3^rd, 6^th, and 9^th months for the evaluation of both types of space maintainers.^[9],[10]

Evaluation criteria for space maintainers

Evaluation criteria for FRCR space maintainer^[9]

Debonding at the enamel-composite interface
>Debonding at the fiber-composite interface
>Fracture of the fiber frame
Caries or gingival inflammation.

Evaluation criteria for band and loop space maintainer^[10]

Distortion
>Cement loss
>Fracture of the loop
Caries or gingival inflammation/trauma due to slippage of the appliance.

Statistical analysis

The obtained data were then subjected to the statistical analysis using ANOVA and post-hoc Tukey test to evaluate the success of conventional band and loop space maintainer and fiber-reinforced space maintainer to reveal the statistical significance and to compare intergroup at individual time period. P < 0.05 was considered statistically significant, P <0.01 was considered highly significant, and P <0.001 was considered very highly significant.

Results

At the 1^st-month follow-up [Table 3], there were no failures in FRCR space maintainers group while 6.67% of band and loop space maintainers [Table 4] showed fracture of the loop. In the 3^rd month, 93.3% success was observed with FRCR space maintainers. The 6.67% failure was mainly due to debonding at the fiber-composite interface. Nearly 26.67% of band and loop space maintainers showed cement loss at 3 months. In the 6^th month, 92.31% success was observed with the FRCR space maintainer. Failures were due to debonding at the enamel-composite interface (3.84%) and fracture of the fiber frame (3.84%). The band and loop space maintainer showed 60% success; 15% showed cement loss; 10% showed fracture of loop; and 15% showed gingival inflammation due to the slippage of band gingivally. In the 9^th month, the overall success was 85% for FRCR and 60% for band and loop space maintainers. On analysis, the intergroup comparison of failure rate between both the space maintainers at various time intervals was found to be statistically significant [Table 5] and [Graph 1].

Table 3: Evaluation of fiber.reinforced composite resin space maintainer

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Table 4: Evaluation of glass band and loop space maintainer

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Table 5: Intergroup comparison for failures between both the groups

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Discussion

The normal process of exfoliation of the primary teeth and eruption of permanent teeth is hampered due to the premature loss of primary teeth and the teeth mesial and distal to space tend to drift or be forced into it.^[11],[12] This may result in reduction of arch space, blocked or ectopic eruption of permanent teeth, supraeruption of opposing teeth, interference in occlusion, unattractive appearance, food impaction areas, and an increased incidence of caries and periodontal diseases.^[13] To combat these problems, a number of space maintainers have been advocated, which can either be a removable or a fixed, functional or nonfunctional, and unilateral or bilateral. The selection of a space maintainer can be made depending on the area of tooth/teeth loss to be maintained.^[14]

Of all the fixed space maintainers used in pediatric dentistry, band and loop ones are the most prevalent.^[15],[16] These appliances adjust easily to accommodate changing dentition. However, they have disadvantages, such as a tendency for disintegration of the cement, inability to prevent the rotation and tipping movement of abutment teeth, a tendency to get embedded in gingival tissues and causing periodontal diseases or for initiation of caries formation, the need for a second visit, and the possibility of metal allergy.^[1],[7]

Fixed spaced maintainers have seen certain changes ever since the process of acid etching was reported by Buonocore^[17] stating that the process could increase the rate at which resin holds on to the surface of the enamel. In an era, where dental esthetics on the minds of adolescents and children, pediatric dentists aim to incorporate esthetics while delivering space maintainers by giving esthetic space maintainers to children.^[18] Various commonly used bondable reinforced fibers in clinical practice include fibers impregnated with resin (Vivadent, StickTech, Pentron), glass fiber (GlasSpan and Polydentia), and ultrahigh-molecular-weight polyethylene fiber (Ribbond).^[19]

Ribbond consists of bondable, reinforced ultra-high strength polyethylene fibers with a high elasticity coefficient (117 GPa) and molecular weight that makes them resistant to stretch and distortion and high resistance to traction allowing them to easily adapt to tooth morphology and dental arch contour.^[20]

Very few studies have been reported for the evaluation of clinical efficacy of polyethylene FRCR (Ribbond) as a space maintainer. Hence, the present study has been taken up to evaluate a clinical success of patient-friendly space maintainer using Ribbond as an alternative to the stainless steel band and loop space maintainer over a period of 1, 3, 6, and 9 months.

Ganesh and Tandon inferred that Ribbond as a material for space maintainer could often make the technique relatively easy, fast, and the procedure could be completed in a single appointment.^[19] Nayak et al. and Kulkarni et al. inferred that the fabrication of conventional band and loop space maintainer required more laboratory time and needed minimum of two appointments.^[15],[16]

The clinical efficacy of both types of space maintainers was evaluated by various criteria at 1^st, 3^rd, 6^th, and 9^th month. During this period, space maintainers were removed if failures observed and were either repaired or replaced; these cases were then excluded from the study.

Failures observed in Group I were maximum due to debonding of enamel-composite interface followed by debonding of fiber-composite interface and fracture of fiber frame in the descending order. The failure due to debonding of enamel-composite interface continued till the 6^th month. The cause to the debonding of enamel composite in FRCR space maintainers may be attributed to its placement on primary teeth (both abutment teeth) together with the presence of prismless enamel areas that had a negative influence on the resin retention.^[20],[21] The results of the present study were in accordance with Subramaniam et al. and Garg et al., using a glass FRCR (GFRCR) space maintainer.^[12],[13] Kirzioǧlu and Ertürk, in their study, showed relatively high percentage of failures of GFRCR space maintainers due to debonding at the enamel-composite interface during the 1^st month of placement. They attributed this failure to be due to the lack of rubber dam isolation. In one patient, failures due to debonding of fiber-composite interface may be due to overzealous finishing of the FRCR space maintainers and wearing away of the thin layer of composite during mastication from the fiber frame.^[12]

In the present study, the fiber frame fractured reason could be the patient chewed on hard foods. Setia et al.^[22] stated that the hanging fiber bridge is subjected to compressive and tangential forces from the fiber frame to the bonding margins between tooth and (FRCR) ribbond on either side of the framework might have weakened the bond and would have caused debonding of fiber composite interface or enamel cement interface.

The failures in Group II were the highest due to cement loss followed by the slippage of band gingivally and fracture of loop (solder breakage). Failure due to cement loss could be due to the nonapplication of rubber dam during the cementation of band and loop. This was consistent with the findings of Moore and Kennedy, who reported cement loss to be the most common cause of failure of fixed space maintainers. Although glass-ionomer cement has low oral solubility, cement loss could be due to difficulty in achieving complete isolation during cementation, especially in young patients. Failures due to solder breakage (fracture of loop) may be due to poor quality of construction, that is, either due to an incomplete solder joint, overheating of the wire during soldering, remnant of flux on the wire, over thinning the wire during polishing, or failure to encase the wire in the solder.^[23],[24] Moreover, also Croll (1982) concluded that when unilateral fixed stainless steel appliances were given, the solder wire loop loses proper contact with the nonattached abutment tooth and becomes submerged in the gingival tissue.^[25]

When comparing the overall success rate of both the types of space maintainers, it was 85% and 60%, respectively, and was statistically significant.

In pediatric dentistry, FRCR as a space maintainer is clinically acceptable, excellent esthetic choice, and expedient alternative to the conventional band and loop appliance.^[26] Saravanakumar et al., in their study, stated that FRCR can be successful space maintainer only for short periods, and its success depends on operator experience, choosing suitable patient group, and proper isolation.^[27] Garg et al. on the comparative evaluation of conventional band and loop space maintainer with the FRCR space maintainer concluded that the patient acceptance was better, time taken was significantly lower, superior in terms of clinical efficacy for FRCR space maintainer.^[13]

Further, long-term studies are required for its improve its longevity and to completely replace conventional space maintainers.

Conclusion

GFRCR space maintainers showed superior retention (85%) compared to band and loop space maintainers (60%), and the difference was statistically significant.

The findings of this study will enable the pediatric dentist to follow a simple method for the application of space maintainer, while making the appliance more acceptable, comfortable, and esthetically pleasing for young patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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