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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2019  |  Volume : 37  |  Issue : 2  |  Page : 205-208

Maintenance of space by innovative three-dimensional-printed band and loop space maintainer

Private Clinical Practice Limited to Pediatric Dentistry; Department of Dentistry, Sir H N Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India

Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Bhaggyashri A Pawar
5/40, 6th Floor, BMC Staff Quarters, Kehavrao Khade Marg, Haji Ali, Mumbai - 400 034, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_9_19

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Preventive orthodontics is an aspect of pediatric dentistry, which requires a unique set of skills and understanding to aid the patient's treatment and properly align teeth. The safest way to prevent future malocclusions from tooth loss is to place a space maintainer (SM), which is advocated to hold the space until the eruption of permanent teeth. SM manufacturing is a laborious process that requires ample communication with the laboratory to properly complete and provide the patient with optimal results. Band and loop SM is mostly indicated for the premature loss of single primary molar, but this appliance has a number of limitations. Digital technology has resulted in decreasing human errors by automating the dental model fabricating process with three-dimensional printing. The current paper provides an insight of the use of this new technology in pediatric dentistry for manufacturing two types of SMs and a case report.

Keywords: Digital dentistry, pediatric dentistry, space maintainers, three-dimensional printing

How to cite this article:
Pawar BA. Maintenance of space by innovative three-dimensional-printed band and loop space maintainer. J Indian Soc Pedod Prev Dent 2019;37:205-8

How to cite this URL:
Pawar BA. Maintenance of space by innovative three-dimensional-printed band and loop space maintainer. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 Dec 6];37:205-8. Available from: http://www.jisppd.com/text.asp?2019/37/2/205/261360

   Introduction Top

The primary dentition plays a pivotal role in the child's growth as well as development. This targets toward not only in terms of speech, chewing, appearance, and the prevention of bad habits, but also in the guidance and eruption of permanent teeth.[1] Exfoliation of primary teeth for eruption of the formed permanent teeth beneath is a normal physiological process. When this process is disrupted, due to premature loss of primary teeth and proximal carious lesion, it may lead to mesial migration of following permanent teeth, resulting in malocclusion in the form of crowding, impaction of permanent teeth, and supraeruption of opposing teeth. The best way to avoid these problems is to preserve the primary teeth in the arch till their normal time of exfoliation is attained. Hence, it is rightly quoted that primary teeth serve as best space maintainers (SMs) for permanent dentition.[2]

Nevertheless, if premature extraction or loss of primary tooth is unavoidable, the safest option to maintain arch space is by placing a SM. The SMs maintain the space created by premature loss of primary teeth. Of the various fixed SMs, band and loop type of SMs are the most frequently used appliances.[3] In spite of good patient compliance, solder failure, caries formation along the margins of band, and long construction time are some of the disadvantages associated with them.[4]

Considering the demerits of conventional appliances, there are various pilot studies that explain the use of newer adhesive directly bonded splints, for example, glass fiber reinforced composite resins Ribbond and Everstick as fixed SMs.[5],[6],[7] Nevertheless, with these appliances, chances of polymerization shrinkage of the luting cement were not taken into consideration.

A new technology of three-dimensional (3D) printing also known as additive manufacturing or desktop fabrication has been recently introduced. It is a process of making 3D solid objects from a digital file. The digital 3D model is saved in STL format and then sent to the 3D printer where the layer by layer design of an entire 3D object is formed. This creation of the 3D-printed object is achieved using additive processes. Each of these layers can be observed as a thin sliced horizontal cross-section of the eventual object.[8] The present paper discusses about the use of this digital technology in manufacturing SMs. To the best of authors' knowledge, there is no evidence till date on the use of 3D printing for manufacturing a SM appliance in pediatric dentistry.

Design and fabrication procedure

Owing to no literature reports on the use of 3D printing in pediatric dentistry, initially, an ideal mixed dentition cast was poured of a standard dye, for a trial design of 3D-printed SM by digital scanning and designing. The cast was scanned using a 3D digital dental scanner (Medit T500, Medit Corp., Seongbuk-gu, South Korea) followed by the designing of the band and loop similar to the conventional SM, on the DentalCAD 2.2 Valletta (Exocad GmbH, Darmstadt, Germany) [Figure 1]. Two types of SMs were printed: (i) using a titanium-based powdered metal material (Ti64 Gd23; LPW Technology Ltd., Cheshire, UK) by Micro Laser Sintering Technology which offers all benefits of an additive manufacturing process [Figure 2]a and [Figure 2]b and (ii) using a clear photopolymer resin (Formlabs Inc., Massachusetts, USA) by Formlabs Form 2 (Formlabs Inc.) [Figure 2]c and [Figure 2]d.{Figure 1}
Figure 2: (a and b) Metallic three-dimensional-printed space maintainer of titanium-based powdered metal material and (c and d) using a clear photopolymer resin

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   Case Report Top

A 7-year-old male child reported to the Department of Dentistry with a chief complaint of pain in the lower left back region of the jaw for the past few days. Clinical examination revealed deep proximal caries with 74 and a fair oral hygiene (OHI-S score 2.4). An intraoral periapical radiovisiography X-ray was taken [Figure 3]a, which revealed coronal radiolucency involving the enamel, dentine, pulp, and extending to the furcal region. It also revealed the root resorption with loss of two-third of the root length suggesting for extraction due to poor prognosis. Nolla's Stage 6 of erupting 34 was noticed. Informed consent was obtained from the patient's parents followed by extraction of tooth #74.
Figure 3: (a) Preoperative X-ray of 74 revealing coronal radiolucency involving enamel, dentine, pulp, and extending to the furcal region, (b and c) three-dimensional-printed metallic space maintainer on the cast poured after recording impression, (d and e) cemented three-dimensional-printed appliance

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A study model of the mandibular arch was done and Tanaka Johnston mixed dentition space analysis was carried out which presented space deficit of 1.8 mm, hence indicating the need space maintenance. Based on this inference, it was decided to fabricate a band and loop SM using the most recent 3D printing technology.

Single-step rubber base impression was made using addition silicon and was poured to make a cast. The retrieved cast was sent to the 3D printing laboratory for scanning and printing a metal-based SM by the technique explained earlier [Figure 3]b and [Figure 3]c. The printed SM was tried in the patient's oral cavity and after confirming its adaptation, followed by cementation using glass ionomer cement (Type 2; GC Fuji; Tokyo, Japan) [Figure 3]d and e]. The patient was instructed not to eat or drink for 30 min and not to bite on any hard food. The patient was recalled after 3 months.

   Discussion Top

Premature loss of primary teeth in children is still very common despite technological and scientific advances in dentistry and oral health prevention measures.[9] Maintenance of arch length during primary, mixed, and early permanent dentition after premature loss is of great significance for the normal development of future permanent occlusion.[10] Failure in maintaining the space may lead to the collapse of vertical and horizontal occlusal relationships in primary and permanent dentitions. Hence, it is very important to maintain the space present due to loss of primary tooth/teeth before normal physiologic exfoliation, until eruption of succeeding permanent dentition.[11] The use of SMs should be advocated, as it prevents dental movements and loss of perimeter helping in avoiding such complications.[12],[13]

Various other disadvantages have been reported in the literature may lead to failure of the conventional appliance.[14],[15],[16],[17] The technology used in the current design of the SM was 3D printing, which involves the process of constructing a 3D solid object from a digital file. The whole process of taking impression of the patient, pouring cast, digitalizing it, designing the SM, and printing it by the help of 3D printer increases the precision of the appliance to the next level, minimizing human error. The extensive laboratory work, stabilizing the loop, and more importantly, soldering the loop on the band at two places and polishing, is also not required which saves time chair-side. Furthermore, the appliance is printed as one unit minimizing the breakage, thus reducing failure of the appliance. Compared to a conventional appliance, a 3D-printed model has a more complex structure with a higher level of detail.

The use of 3D printing and its advantages over conventional treatment procedure in dentistry has been reported in the literature. In oral surgery, it can be used for preparing surgical guides and conducting various blocks to augment bone defects, and for learning modules, to create the mandibles and jaws that can be easily showed to the students.[18],[19] The use of 3D printing technology has also gained popularity in dental implantology due to the introduction of guidelines of the surgical procedure to insert a dental implant.[20]

   Conclusion Top

Conventional band and loop has long been used for maintaining space, but certain disadvantages such as tendency for disintegration of cement and increased chairside and laboratory time make it a cumbersome procedure. The presented innovative digital design of 3D-printed SM is precise, quick, and easy. Development and perfection of 3D printing technology allow production of information in 3Ds with accuracy. There is a huge potential in the application of 3D printing for pediatric dentistry, yet to be explored.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


The author would like to thank Dr. Shibu John of Trinity Media and Marketing Solutions, for his help in designing and manufacturing the space maintainer, and Dr. Mayur Davda of The Dental Photography School, for professionally capturing space maintainers in [Figure 2].

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Barbería E, Lucavechi T, Cárdenas D, Maroto M. Free-end space maintainers: Design, utilization and advantages. J Clin Pediatr Dent 2006;31:5-8.  Back to cited text no. 1
Setia V, Pandit IK, Srivastava N, Gugnani N, Sekhon HK. Space maintainers in dentistry: Past to present. J Clin Diagn Res 2013;7:2402-5.  Back to cited text no. 2
Wright GZ, Kennedy DB. Space control in the primary and mixed dentitions. Dent Clin North Am 1978;22:579-601.  Back to cited text no. 3
Kirzioǧlu Z, Ertürk MS. Success of reinforced fiber material space maintainers. J Dent Child (Chic) 2004;71:158-62.  Back to cited text no. 4
Karaman AI, Kir N, Belli S. Four applications of reinforced polyethylene fiber material in orthodontic practice. Am J Orthod Dentofacial Orthop 2002;121:650-4.  Back to cited text no. 5
Kargul B, Caglar E, Kabalay U. Glass fibre reinforced composite resin as fixed space maintainer in children 12 month clinical follow up. J Dent Child. 2005;72:109-12.  Back to cited text no. 6
Kargul B, Caglar E, Kabalay U. Glass fiber reinforced composite resin space maintainer: Case reports. J Dent Child (Chic) 2003;70:258-61.  Back to cited text no. 7
Sharma S, Goel S. 3D printing and its future in medical world. J Med Res Innov 2019;3:e000141.  Back to cited text no. 8
Ahamed SS, Reddy VN, Krishnakumar R, Mohan MG, Sugumaran DK, Rao AP. Prevalence of early loss of primary teeth in 5-10-year-old school children in Chidambaram town. Contemp Clin Dent 2012;3:27-30.  Back to cited text no. 9
[PUBMED]  [Full text]  
Murshid SA, Al-Labani MA, Aldhorae KA, Rodis OM. Prevalence of prematurely lost primary teeth in 5-10-year-old children in Thamar city, Yemen: A cross-sectional study. J Int Soc Prev Community Dent 2016;6:S126-30.  Back to cited text no. 10
Horax S. Fixed space maintainer with molar band in premature loss of primary first molar teeth (case report). J Med Nurs 2006;27:174-6.  Back to cited text no. 11
Law CS. Management of premature primary tooth loss in the child patient. J Calif Dent Assoc 2013;41:612-8.  Back to cited text no. 12
Qudeimat MA, Sasa IS. Clinical success and longevity of band and loop compared to crown and loop space maintainers. Eur Arch Paediatr Dent 2015;16:391-6.  Back to cited text no. 13
Baroni C, Franchini A, Rimondini L. Survival of different types of space maintainers. Pediatr Dent 1994;16:360-1.  Back to cited text no. 14
Thornton JB. The space maintainer: Case reports of misuse and failures. Gen Dent 1982;30:64-7.  Back to cited text no. 15
Hill CJ, Sorenson HW, Mink JR. Space maintenance in a child dental care program. J Am Dent Assoc 1975;90:811-5.  Back to cited text no. 16
Srivastava N, Grover J, Panthri P. Space maintenance with an innovative “Tube and loop” space maintainer (Nikhil Appliance). Int J Clin Pediatr Dent 2016;9:86-9.  Back to cited text no. 17
Winder J, Bibb R. Medical rapid prototyping technologies: State of the art and current limitations for application in oral and maxillofacial surgery. J Oral Maxillofac Surg 2005;63:1006-15.  Back to cited text no. 18
Sykes LM, Parrott AM, Owen CP, Snaddon DR. Applications of rapid prototyping technology in maxillofacial prosthetics. Int J Prosthodont 2004;17:454-9.  Back to cited text no. 19
Lal K, White GS, Morea DN, Wright RF. Use of stereolithographic templates for surgical and prosthodontic implant planning and placement. Part I. The concept. J Prosthodont 2006;15:51-8.  Back to cited text no. 20


  [Figure 2], [Figure 2], [Figure 3]

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