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SPACE REGAINERS-A REVIEW

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ejbps, 2018, Volume 5, Issue 7, 212-217. Review Article SJIF Impact Factor 4.918

European Journal ISSN 2349-8870

Rane et al. European of Biomedical
Journal of Biomedical and Pharmaceutical Sciences
Volume: 5
AND Pharmaceutical sciences Issue: 7
212-217
http://www.ejbps.com Year: 2018

SPACE REGAINERS – A REVIEW

Rane Jaai*1 and Winnier Jasmin2

1
Post Graduate, Department of Pedodontics and Preventive Dentistry, D Y Patil University – School of Dentistry,
Nerul, Navi Mumbai.
2
Associate Professor, Department of Pedodontics and Preventive Dentistry, D Y Patil University – School of Dentistry,
Nerul, Navi Mumbai, Maharashtra, India.

*Corresponding Author: Rane Jaai

Post Graduate, Department of Pedodontics and Preventive Dentistry, D Y Patil University – School of Dentistry, Nerul, Navi Mumbai.

Article Received on 02/05/2018 Article Revised on 23/05/2018 Article Accepted on 13/06/2018

ABSTRACT
The primary dentition provides a “mould” for the proper growth of jaws, so that the permanent teeth may have an
adequate space for aligning themselves. Whenever primary or permanent teeth are lost prematurely the arch
integrity is lost, leading to loss of arch length, arch perimeter and arch circumference which consequently results
in loss of space. As a result of space loss, the permanent tooth may remain impacted, or it may erupt buccally or
lingually. Premature loss of primary second molars leads to greater amount of space closure than premature loss of
primary first molar. When the space is progressively lost, the therapy should be considered to regain the space so
that additional disharmonies do not develop. Various appliances help for both regaining the lost space as well as
maintenance of the regained space for the eruption of succedeneous permanent teeth. Various fixed and removable
space regainers are available and there are continuous innovations in the quest for simpler and more effective
space regainers. The decision of using a particular appliance depends on the patient’s requirements and the
operator’s choice.

KEYWORDS: Space Loss, Regainers, Coil Springs

INTRODUCTION Space maintainers are appliances used to maintain space,

In the quest for providing optimal dental care, the age old so as to guide the un-erupted tooth into proper position in
maxim of “Prevention is better than cure” holds true. In the arch. It not only maintains function and preserve arch
this endeavour the Pedodontist is most evenly poised to length, but also maintain esthetics, prevent development
carry the mantle of providing the required services. For of deleterious oral habits and eliminate any potential
the preventive approach to be truly effective it needs to psychological damage a child could face. It also allows
be applied at its earliest, i.e. at the primary prevention the permanent tooth to erupt unhindered into proper
level. alignment and occlusion.[4]

The change from primary dentition to the permanent At the initial appointment, the appliance is activated to
dentition is a complex phenomenon which includes the regain the space and then it is kept passive till the tooth
exfoliation of the primary teeth, the eruption of is erupted into the oral cavity. Usually minimal space
permanent teeth and the establishment of occlusion loss can be regained better.[5]
though independent yet harmonious sequence.[1,2] There
are many morphogenetic and environmental influences, A pediatric dentist is often the first person to encounter
which guide the occlusal development and a disorder or the effects of premature loss of deciduous teeth. Thus, it
deviation in any of these elements may influence the is essential on the part of the pediatric dentist to take
occlusion. Among these elements, the primary teeth are early measures in preventing the profound effects on
of utmost importance since when there is physiologic future developing dentition, psychology and personality
exfoliation, there is also a favourable alveolar growth of child.
which often provide space for a better accommodation of
the successor permanent teeth.[1] When early loss of The purpose of the review is to discuss the various space
primary tooth occurs, corrective measures such as regainer appliances which may be used in the mixed
passive space maintenance, active tooth guidance with dentition. Space regainers can be fixed or removable.
space regaining, or a combination of both may be needed
to optimize normal process of occlusion development.[3]

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Coil springs sliding loop regainer. However, in the “U” loop of the
Stainless steel orthodontic coil springs are inexpensive appliance enough solder is flown to make a stop at the
and were designed to provide sufficiently high applied junction of the straight part & curved part of the wire,
forces to move a patient's teeth, even posterior teeth like both buccally & lingually in contrast to the occlusal stop
molars. However, they are unable to maintain a high in the sliding loop appliance to prevent the rotation of the
applied force over a sufficient range of spring action. In first premolar.
addition, because the force being applied by these
springs typically diminishes very rapidly as the teeth The limitation of this appliance is that it is not possible to
start moving, they have to be replaced in order to obtain control the axial inclination of the tooth being moved and
proper realignment of the teeth. Another disadvantage is tipping may occur.[11]
that, stainless steel material quickly results in permanent
deformation of the spring and they contain elements such Gerber space regainer
as nickel, which have been known to cause adverse Gerber space regainer is similar in principle to open-coil
reactions in some patients.[6] and sliding loop regainer. In this appliance, weldable
tube stops are soldered on the U bend of the wire and
The concept of NiTi coil springs was suggested in open coil spring sections are cut to fit over the wire
1975.[7] A NiTi orthodontic coil spring is made of alloy between “stops” and ends of “U” loop. The springs are
wire which exhibits shape memory thus allowing loaded and floss is tied through eyelet and over “U” wire
excellent super-elastic and spring-back properties. Also, to hold stored force in compressed spring. The springs
coil spring can maintain a constant load value throughout are compressed so that the assembly should fit in the
a zone of deflection.[8] The open coil springs produce edentulous space. The assembly is cemented in place.
light, continuous forces through a long range of After cementation, the floss is cut and removed to
activation although the forces produced are slightly activate regainer.[12,13]
below the optimum 75-100 g range.[9] NiTi coil springs
deliver a constant force over a range of 7mm tooth Double banded space regainer
movement with one activation. They can be used In this appliance, both the teeth adjacent to edentulous
throughout the arch and require few activations, possibly area are banded so that the possibility of tipping is
only one to produce the desired tooth movement.[9] avoided as compared to when only one tooth is banded.
Chalakka P et al (2012) reported the use of „Double
If the coil spring is to be used as an open or compression banded space regainer‟ in maxillary arch as early
coil spring they are compressed from their initial length exfoliation of left second primary molar had resulted in
of 15mm to 6mm. The closed or tension coil spring are mesial migration of the permanent left first molar
distracted from their initial of 3mm to 6mm.[9] resulting in 3.5 mm of space between it and the primary
left first molar. Space regainers were fabricated for both
Fixed Space Regainers the arches. In maxillary arch, after 6 months, the space
Sliding loop regainer gained was 5.1 mm with the use of „Double banded
The sliding loop space regainer is recommended in cases space regainer‟ and in mandibular arch, after 5 months,
where space loss occurs due to premature loss of the space gained mesial to the first-left premolar was 4
mandibular second primary molar, when both the first mm, improving the canine space to 7 mm. [14]
molar and first premolar have tipped into the available
space. The setup applies a constant force to move the Gurin lock space regainer
first premolar mesially and, with some reciprocal distal Gurin lock space regainer is a unilateral fixed space
movement, move the permanent molar distally.[10] regainer. It is indicated when mesial movement of
bicuspid is required without distal movement of the other
It is designed with one band on the permanent molar and teeth. It consists of bands on the first premolar and molar
two 0.036 inch buccal tubes are welded to the molar and a sliding bar soldered to the premolar band. The bar
band. A loop, similar to the band and loop is fabricated slides into a buccal tube on the molar. This appliance
using a 0.036inch stainless steel wire. An open coil uses a nickel titanium coil spring which is activated by
spring of approximately 2mm in excess of the space to an adjustable Gurin Lock to regain space without tipping
be regained is cut
and inserted into the prepared loop. or rotating the teeth. The amount of reciprocal movement
The loop and coil spring component is placed and the of the molar distally and the bicuspid mesially will be
loop is slided into the buccal tubes. An occlusal stop is affected by the proximity of the adjacent teeth. In order
soldered to the loop component of the appliance, and to restrict the movement of one of the abutment teeth, it
placed in contact with the occlusal surface of the is necessary to add additional anchorage. This is done by
premolar to prevent rotation of the tooth. No further using a jackscrew with labial/lingual arch wires.
adjustment is usually necessary.[11] Activating the Gurin Lock is accomplished with a special
box wrench.[10]
Open coiled space regainer
Open coiled space regainer (OCSR) is a reciprocal active
space regainer. The Fabrication of OSCR is same as

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Rane et al. European Journal of Biomedical and Pharmaceutical Sciences

Anterior space regainer Nance button allowing space gaining and arch
For regaining space in anterior region two 0.018 × 0.025 coordination.[16]
standard labial tubes are selected. The enamel of the
labial surfaces of right central and left lateral incisors is Nappee MM et al (2014),[18] presented a new Pendulum
etched with 35% phosphoric acid. The labial tube is variant using a mini-screw, the "Pendulis". It follows the
individually bonded to each abutment tooth. When the original concept (titanium-molybdenum alloy
composite is polymerized, a piece of 0.014” standard distalization springs and polymethyl-methacrylate pellet)
round wire is introduced into the lateral incisor tube. The but dental support is replaced by a single palatal mini-
wire is then inserted in a 0.036” × 0.009” open coil screw (median in adults, para-median in children) to
spring which is previously selected and passed through which the device is fixed by means of a metal welded
the labial tube of the central incisor. A distal bend is cap which can be easily positioned and removed by the
made 2 mm from the distal ends of the tube. 3 weeks practitioner. This appliance allows for better control of
later the wire is changed to a 0.018” and finally to a the oral hygiene and completely controlled extra-oral
0.018” × 0.025” wire, leaving the coil spring only for activation.
retention. After that, an acrylic pontic is fixed over the
wire and coil spring, using the same type of composite Distal jet appliance
already in the patient‟s mouth.[13] Carano and Testa (1996),[19] designed an appliance that
can be used for either unilateral or bilateral Class II
Pendulum appliance correction.
The pendulum appliance may be used for unilateral or
bilateral distalization of maxillary first molar teeth when The Distal Jet consists of a bilateral piston and tube
mesial drift of upper first molars is present due to early arrangement, with the tube embedded in an acrylic
loss of primary molars. It can also be used in non- Nance button in the palate, supported by attachments on
extraction treatment of mild to moderate crowding.[15] the first or second premolars. A bayonet wire is inserted
into the lingual sheath of each first molar band and the
The pendulum appliance contains an acrylic plate that is free end is inserted into the tubes, much like a piston. A
retained in place either by clasps to the first premolars or nickel-titanium open-coil spring and an activation collar
the acrylic is integrated with a metal frame that is are placed around each tube. Compressing the coil spring
soldered to bands on the first premolars. Distalization generates a distally directed force. The activation collar
arms or springs are constructed from 0.6 mm stainless is retracted and the mesial setscrew in each collar is
steel round-wire that consists of a closed helix and a U- locked onto the tube to maintain the force. The active
loop. The purpose of the closed helix is to allow for components have to be placed palatally. Ideally, they
activation of the distalization arms. The U-loops are result in lines of force running close to the center of
incorporated mesial to the molars to allow for adjustment resistance of the molars.[19]
of the axial inclination during distalization. This wire is
soldered to molar bands. Typically, an initial activation NiTi coil springs exerting a force of 150 grams for
of 60° to 70° (around the width of one molar) will children and 250 grams for adults is recommended. The
generate 250g of force per side. The appliance is springs are clamped on the tube to exert a distal force,
activated extra-orally and is cemented in place. The bodily movement is achieved as the force passes close to
appliance is monitored at monthly intervals where it is the center of resistance. Reactivation is done by sliding
removed for reactivation and re-cementation is done with the clamp closer to first molar once a month. Once
luting GIC.[16] distalization is completed the appliance can be converted
to a Nance retainer or passive Nance appliance.
The advantage of this appliance is that it is less Movement of 2-3mm is seen in 4 months.[19]
dependent on patient compliance. It is easy to fabricate
and allows correction of minor transverse and vertical Band and U loop space regainer
molar positions by adjustment of the springs. The Band and U loop regainer is type of fixed unilateral
appliance is well accepted by the patients.[17] expander. This appliance can serve dual purposes of
space regainer and space maintainer at the same time.
The pendulum appliance as reported by Hilgers in 1992 Initially, the appliance is activated for regaining the lost
can lead to a favorable mesio-buccal rotation as well as space and then it is kept passive as a space maintainer in
bodily movement of the first molars with the the same place till the tooth is erupted into the oral
incorporation of a U-loop in the spring. This could be of cavity. It is indicated in premature loss of single tooth
use to improve the Class I molar relationship and to yield and space closure. This appliance is most effective when
additional space.[16] Hilgers (1992) proposed variation in there is space present mesially to the erupting or erupted
design of pendulum appliance including a lingual sheath tooth (usually first premolar) which can be moved into
on the molar bands allowing intra-oral adjustment of the it.[20]
springs, a Nance holding arch or utility arch wires
inserted for stabilization while allowing the premolars to A suitable pre-formed stainless steel band is selected or a
drift distally and an expansion screw incorporating in the molar band is constructed over the first permanent molar

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Rane et al. European Journal of Biomedical and Pharmaceutical Sciences

with stock band material of 0.180x0.005inch diameter. Molar bands are prepared on permanent first molar and
After the band is made or selected, an alginate molar tubes are welded on the buccal side of each molar
impression of the both arches are taken keeping the band band. Labial arch wire is then engaged in both the buccal
in place. The wire bending for the space regainer tube and acrylic sheath is prepared on the labial
comprises of either a canine retractor or a „U‟ loop. The vestibule. It transfers forces from lips directly on to the
„U‟ loop appliance should be made of 21 gauge of wire, buccal aspect of first molar to distalize the molar.[21]
whereas the canine retractor can be made with 22 or 23
gauge of wire. When we give two „U‟ loops, one on NiTi bonded space regainer
lingual side and the other one on the buccal side, the wire NiTi bonded space regainer was introduced by K.S Negi
should be of 23 gauge. The position of the 'U' loop or the in 2007. It is a simple appliance which can be used chair-
canine retractor should be placed a little away from the side in a single visit.
band to avoid heating while soldering the appliance. The
„U‟ loop or reverse canine retractor can be soldered on A composite dimple is bonded on the buccal side of
both side of the tooth (buccal or lingual side) depending permanent first molar and with the help of an explorer
on space available and eruption pattern of the tooth (for burrow a tunnel into the mesial of dimple, creating a
example, the canine retractor can be soldered with a composite tunnel that is open only on the mesial end. A
lingual arch space maintainer). The spring or the „U‟ piece of 0.016 inch NiTi wire is then bonded on the
loop should be covered properly (boxing) with plaster to buccal side of primary molar/first premolar and extended
prevent heating while soldering the spring with the band. beyond the dimple. After the composite sets on both the
The activation of the appliance comprises of opening the teeth with the help of birdbeak plier, the free end of wire
„U‟ loop or the coil spring of the canine retractor.[20] is directed into the tunnel made in the dimple of first
molar. This will give a form of activated loop of NiTi
The advantages of this appliance are that it is simple and wire. A small amount of bonding material is placed in
the patient compliance is good. After regaining the the opening of the tunnel to make the attachment more
space, it can be kept passive as a space maintainer till the permanent. Over time, loop returns to its original shape
tooth is erupted into the oral cavity. When severe space due to unique shape memory property of NiTi wire,
loss has been taken place, it can be used for mesial distalizing and up-righting the first molar. Once the
movement of the mesial tooth followed by distal tooth active correction is completed, the wire segment is left in
movement of the permanent first molars with extra- oral place as a passive space maintainer till the eruption of
head gear if required.[20] second premolar.[22]

The limitations are severe space loss with multiple The whole procedure can be completed in a single visit.
impacted or unerupted teeth require comprehensive There is no need of procedures like impression making,
analysis and fixed orthodontic treatment. If a permanent fitting of bands and soldering. Better oral hygiene can be
first molar is to be distalized to regain lost space, extra- maintained as appliance is self-cleansing. There is also
oral force with headgear may be considered.[20] improved patient compliance.[23]

Hotz lingual arch space regainer Removable Space Regainers

Hitchcock in 1974 introduced a modification of lingual C-space regainer
arch – “Hotz lingual arch” with U loops which is used C-space regainer is a removable appliance used to
for moving molars distally. Hotz lingual arch is indicated achieve bodily molar movement without significant
in situations where the permanent tooth moves mesially incisor flaring. This appliance can be used to intrude
rather than distal movement of mesial teeth and also in teeth as well as to move them distally or sagitally,[24] in
cases where sufficient space is present for eruption of cases with mild arch length discrepancy treated by
permanent second molar. The lingual arch provides extraction of second or third molars, and in open bite
compound anchorage from all the other teeth which the cases.[24]
lingual arch touches. A horizontal spur can be soldered
perpendicular to the arch wire contacting the distal The C-space regainer consists of a labial framework,
surface of the premolar or canine. This compounds the formed from 0.036” stainless steel wire and an acrylic
anchorage additionally. The loop on the active side is splint. A closed helix is bent into the framework in each
adjusted periodically once a month. canine region. The labial framework is extended distally
to lie as close to the buccal molar tubes as possible. This
Lip bumper allows easy insertion into the headgear tubes. The distal
Lip bumper appliance is used in the mandibular arch for ends of the framework should be polished down for a
gaining space or for distalization of molar and its loose fit in molar tubes. An 0.010” x 0.040” open coil
counterpart in the maxillary arch is Denholtz appliance. spring is soldered distal to the helix and 0.028” ball
It is used in early mixed dentition for minimum clasps are used to retain the appliance. The working cast
distalization of molar. It is also useful in up righting the is placed on a large glass slab for construction of the
mesially tipped molars to regain space in the arch. acrylic splint.[24] After the labial frame and ball clasps
have been stabilized, a separating medium is applied.

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Rane et al. European Journal of Biomedical and Pharmaceutical Sciences

The acrylic is normally applied to cover the crowns of all Elgiloy or 0.020 Australian wire. The helical spring for
anterior teeth. The cast is immediately inverted on glass the lower Hawley appliance may be made in two
slab and the acrylic is extended labially according to the configurations. The double helical spring requires
amount of anchorage needed. After the acrylic is cured, slightly more time to bend but is compatible to the
the plate is scalloped around the cervical margins, periodontium of the tooth being repositioned. These
leaving it thick enough to contact the mandibular helical springs should be adjusted with little or no
incisors. In order to avoid anterior protrusion, 0.028” ball pressure exerted distally against the molar during the
clasps are added facially, between the lateral incisors and first week of treatment. At the second visit and thereafter
canines to serve as hooks for Class II elastics or J hook at intervals of 2 weeks, the springs should be adjusted to
headgear traction.[24] produce a slight distal pressure against the 6-year molar.
It takes 2 to 4 months to move a lower molar a distance
The patient should be checked every three weeks for the of 2mm distally.[25]
constant application of coil spring pressure. When re-
activation is required, the helix is squeezed with a heavy Lower Hawley appliance with split-acrylic spring
wire or three prong-plier, moving the labial wire In the lower arch a Hawley appliance constructed with a
extension and the coil spring distally. A molar split-acrylic dumbbell spring may be used to regain up to
overcorrection of at least 2mm distal to the normal Class 2mm of lost space by tipping one of the 6-year molars
I position will be needed because of the mesial relapse. A distally. The dumbbell spring allows easy adjustment to
Nance button should be placed immediately after add a distalizing force to the lower molar. The spring
removal of C-space regainer to hold the molars in should be adjusted twice a month, creating an increment
position. However, there is relatively insufficient of opening in the split-acrylic area of about 0.5mm at a
literature on the use of C-Space regainer and time. Any larger adjustment may not allow the appliance
recommendations on its removal and maintenance.[24] to be seated firmly into the area mesial to the molar
being moved distally.[25]
Upper Hawley appliance with helical spring
To move an upper 6-year molar distally with a Hawley Lower Hawley appliance with sling-shot elastic
appliance, a compressed helical spring is formed at a Instead of a specially contoured wire spring that
right angle to the alveolar ridge immediately adjacent to transmits a force against the molar to be distalized, a
the mesial surface of the 6-year molar to be moved. The wire elastic holder with hooks may be used. This is
spring is arranged so that it can be adjusted to maintain a called a slingshot appliance, since the distalizing force is
distally directed pressure over a distance of 3 to 4mm. A produced by the elastic stretched between the two hooks.
spring made of 0.028 yellow Elgiloy or 0.020 Australian One hook is located on the middle of the lingual surface
wire produces the desired movement if it is positioned of the molar to be moved. The other is arranged in the
properly on the appliance and adjusted at intervals of 2 same position on the buccal surface of the molar. The
weeks.[25] child places a new elastic between the hooks while the
appliance is outside the mouth. It is slipped into place,
Fixed-removable Hawley appliance then the child’s finger can guide the elastic into place
A more efficient upper Hawley appliance is fabricated by smugly against the gingiva on the mesial margin of the
fitting two orthodontic bands to the primary first or molar to be distalized. The elastic can be changed once
second molars with 0.028 wire loops soldered on the each day.[25]
lingual surfaces of the bands to incorporate the latter into
acrylic appliance. This converts the removable Hawley Maintenance and Recall
appliance to a fixed-removable device, with improved If the appliance is of a removable type, periodic checking
anchorage capability and better retention stability during should be done to evaluate whether the patient is using it
wear by the child. The single requirement is that there or not, whether there is any distortion or breakage of the
must be a primary molar tooth for banding, and the roots appliance or irritation of soft tissues. If the teeth are
of which have not been resorbed enough to create emerging underneath the appliance, the portion of the
excessive mobility, on each side of the arch.[25] acrylic is cut off to give way for the teeth to erupt into
position.
Lower Hawley appliance with helical spring
The lower Hawley appliance have a labial bow with In case of fixed appliances, the appliance is checked for
adjustment loops built into it labial to the cuspids. The any breakage at the soldered joints or band material. It is
wire passes distal to the cuspids over the ridge and is also checked that whether the appliance is loose due to
embedded in the body of the appliance on the lingual dissolution of cement which may result in food
side of the alveolar ridge. This helps utilize the lower lodgement and caries. The appliance is removed every 6
anterior teeth and so assists the whole lower arch in months or 1-year depending on the situation and the
acting as a total anchorage unit. The wire for the labial abutment tooth is checked for any caries or
bow is made of 0.025 or 0.028 yellow Elgiloy. The decalcification. Polishing of the abutment is done
helical spring positioned against the mesial surface of the followed by fluoride application. Then the appliance is
molar to be moved distally is made of either 0.028 re-cemented in position. Regular radiographic

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 Rane et al. European Journal of Biomedical and Pharmaceutical Sciences

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