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Longevity of band and loop space maintainers using glass ionomer cement: a prospective study.

Introduction

Loss of dental arch circumference due to premature loss of primary molars is a common presentation in the primary and mixed dentitions. This reduction in arch length circumference may compromise the eruption of succedaneous teeth. One approach is to control the space created from the premature loss of primary teeth by the provision of a space maintainer (SM) appliance [Qudeimat and Fayle, 1998; Christensen and Fields, 2005]. A commonly used unilateral space maintainer is the band and loop (Fig. 1).

In recent years, the use of SM in the paediatric population has gained increasing attention from researchers. It has been shown that the success rate of different SM appliances varies widely [Hill et al., 1975; Santos et al., 1993; Baroni et al., 1994; Qudeimat and Fayle, 1998; Rajab, 2002; Kirzioglu and Ozay, 2004; Tulunogu et al., 2005; Moore and Kennedy, 2006; Fathian et al., 2007]. Some studies reported the success rate to be as high as 91.5% [Santos et al., 1993] while others reported it to be as low as 27% [Kirzioglu and Ozay, 2004]. The most commonly reported reason for failure of band and loop SM is breaking of the cement lute or simply by loss of cement.

[FIGURE 1 OMITTED]

Croll [1983] over 25 years ago recommended the use of either zinc phosphate or polycarboxylate cements to attach SM. Using polycarboxylate cement, Baroni et al. [1994] reported a 40% failure rate due to partial or complete decementation of band and loop appliances. Nowadays, glass ionomer cements are more widely accepted for SM band cementation [Rajab, 2002; Moore and Kennedy, 2006; Fathian et al., 2007]. These have among other properties the advantage of adherence to both enamel and metal [Hotz et al., 1977], and release and uptake of fluoride [Creanor et al., 1994]. However, glass ionomer cements have not eliminated the problem of failure of the attachment of the stainless steel band to the tooth [Millett et al., 1995]. Fathian et al. [2007] using Ketac-Cement, reported cement loss to account for over 70% of band and loop appliance's failures.

Although there are many retrospective studies in the literature on the clinical longevity of SMs, no study has so far prospectively investigated the survival rate of band and loop SM appliances using glass ionomer for cementation. It was therefore the aim of the present study to prospectively investigate the success rate and longevity of band and loop SM appliances fitted at Tawam Hospital- Dental Centre, Al-Ain, UAE using glass ionomer luting cement.

Materials and methods

Subjects. This prospective study was conducted at Tawam Hospital-Dental Centre, Al-Ain, United Arab Emirates from January 2000 until January 2004 (total follow up period of 40 months). A special data capture form for collecting each subject's information regarding the band and loop SM was designed at the beginning of the study. Ethical approval was obtained from Faculty of Dentistry, Kuwait University and parents gave an informed consent to their children's' participation in the study. A total of 40 subjects between the ages of 3.4 and 7.3 years participated and hence 40 band and loop SMs were constructed for the participants. Subjects were excluded from this study if they received dental treatment from another dental service outside the Tawam Hospital-Dental Centre during the study period.

Space maintainer construction. Band selection, seating, and impression taking for each patient, were always performed by the same clinician (IS). The smallest stainless steel band (3M Co., St. Paul, MN), that seats approximately 1 millimetre below the mesial and distal marginal ridges, was selected. Impressions were taken with alginate impression material. Each band was then gently removed with a band remover and stabilized with a drop of super glue in the impression material in the correct position. The impression was then cast using dental stone with the band in place within 30 minutes of impression taking. The same dental technician performed construction of all band and loop SMs. Flux was used (Dentaurum Universal Dentaflux) for all loop and band soldering (Dentaurum Hartlot Hard solder).

Cementation. Subjects were given an appointment for the cementation of their appliance 7-10 days after the impression taking appointment. All band and loop SMs were cemented onto a clean, dry abutment tooth with glass ionomer cement. The cement used was 3M[TM] ESPE[TM] Ketac[TM]-Cem Maxicap[TM] mixed for 10 seconds as per manufacturer's recommendation. Low-volume suction and cotton rolls isolation were used to maintain a dry field during cementation. Children were instructed not to eat for 30 minutes following cementation. In addition, parents were instructed to notify the clinician immediately if the band and loop space maintainer became loose, or if any discomfort was encountered. Regular follow up appointments were scheduled at 4-6 months.

Analysis of data. Each appliance could have one of three possible fates:

* Withdrawn: either due to successful space management (i.e. the band and loop was removed because it accomplished the original purpose of its fitting) or lasted until the end of the study (i.e. the SM survived intact until the study closing date);

* Failed: if the appliance was lost or removed due to poor design (soft tissue irritation), faulty construction (breakage), failure of the cementation, failure of a space maintainer due to caries, pulpal/ periodontal pathology of the abutment tooth, or poor patient attendance;

* Lost to follow up: if the patient failed to attend the follow up appointment and the fate of the appliance was unknown.

The variables that might have affected the median survival time for all SMs were tested using Log Rank and Chi-square tests [Brown and Swanson Beck, 1995]. All data were processed by SPSS (16.0, SPSS, Chicago, Ill, USA). The level of significance was set at p value less than or equal to 0.05.

Results

Data capture forms for 40 children with 40 band and loop appliances were available for analysis at the end of the study period (40 months). The age range of subjects in the study was 3.4-7.3 years at the time of inclusion in the study (Mean 5.4 years, SD [+ or -] 0.91). Of the 40 children, 22 (55%) were females and 18 (45%) were males. The fate of SMs is presented in Table 1; 23 (57.5%) were considered as failures, 4 (10 %) as successful and removed by the clinician after serving the fitting purpose, 1 (2.5%) reported as lost due to failure to attend the follow up appointment and 12 (30%) lasted successfully until the study period ended. The causes of failure of SM are presented in Table (2). The most common cause of failure of SM in this study was decementation, which was recorded in 82% of all failures. A typical example is shown in Fig 2.

[FIGURE 2 OMITTED]

The overall median survival time of band and loop SMs in this study was 19.9 months (SE= 8.1, CI= 4.1-35.7) (Fig. 3). The median survival times by fate are presented in Table 3 and were 13 months for decemented band and loop SMs, 21 months for the solder breakage, 14.5 months for soft tissue lesion and 38 months for all other appliances (successful and those which lasted until the end of the study period). Variables included in this study that might have affected the median survival time for band and loop appliances were: gender, quadrant, arch and the tooth the band was cemented on (primary/permanent) Table (4). The quadrant in which a SM was cemented had a statistically significant effect on their survival, maxillary left and lower left quadrants having the highest median survival rate (34.6 and 28.1 months respectively). Gender, the dental arch and the tooth on which the SM was cemented had no significant effect on longevity.

Discussion

It has been previously documented that the failure rate of band and loop SM appliances varies between 29%-37% [Baroni et al., 1994; Rajab, 2002; Fathian et al., 2007]. In this prospective study, the failure rate was 57.5% (23/40 appliances) during the study period that is a relatively high failure rate. The reason for this could be due to differences in research design and total number and characteristics of the sample included. Unlike previous retrospective studies [Hill et al., 1975; Baroni et al., 1994; Rajab, 2002; Fathian et al., 2007], in the current prospective study, the decision to provide or remove the SM, the band selection, the impression taking and the cementation of SM were all made by the same paediatric dentist. Also, this study is unique with respect to the follow up visits, where examination of each SM was carried out by the same clinician and over a known recall interval. Thus, the main investigator was the only clinician involved in the decision of withdrawing SM from the study according to previously determined criteria.

[FIGURE 3 OMITTED]

In the investigation by Fathian et al. [2007], they included in their total sample 32 (29.5%) were remade or recemented band and loop SMs. This could have influenced the success\ failure rate and the median survival rate as shown in a previous study [Qudeimat and Fayle, 1998]. In this latter study band and loop SMs that failed during the study period were recorded as a failure and then removed from the study.

Fathian at al. [2007] reported that among other factors possibly responsible for the failure of SM, patients' young age was an important reason. Those authors suggested that younger patients in their study might have exhibited a lesser cooperation level; increased intake of sticky foods, lesser crown length available for banding and anatomy of the primary molars that precluded a tight fit band placement. In this study the mean age of subjects included in the final sample was 5 years, 5 months. This could have contributed to the increased failure rate in comparison to previous studies where the mean age for the study sample was higher [Baroni et al., 1994; Qudeimat and Fayle, 1998; Rajab, 2002; Fathian et al., 2007].

Although band and loop SMs in this study demonstrated a high failure rate (57.5%), they also showed a relatively satisfactory median survival time. The overall median survival time for the band and loop appliances in this study was 19.9 months (38 months for successful and "still in service" appliances) which is higher than that of an earlier study [Tulunogu et al., 2005] and comparable to other retrospective studies, where the authors reported a survival time of 20-26 months for band and loop SM [Rajab, 2002; Fathian et al., 2007]. The relatively high survival time could be due to many factors:

* The type of space maintainers used (band and loop) which encounter lesser stresses than longer span appliances [Qudeimat and Fayle, 1998];

* The design and methodology followed in this study;

* The long study period (4 years).

Although it is been reported that using glass ionomer cements for attaching stainless steel bands have many advantages [Hotz et al., 1977; Creanor et al., 1994], it seems that glass ionomer luting cements have not completely eliminated the problem of failure of the attachment of the appliance to the tooth [Millett et al., 1995]. It has been shown in the literature that loss of cement around a SM band and later decementation of an appliance, constitute a major cause of failure of SMs [Hill et al., 1975; Baroni et al., 1994; Qudeimat and Fayle, 1998; Fathian et al., 2007]. In this study, decementation accounted for 82% of the 23 failed cases. The median survival time for decemented band and loops was 13 months using the glass ionomer luting cement. This can probably be attributed to the fact that stainless steel bands are usually subjected to a large number of forces in the mouth resulting in a complex distribution of stresses within the luting cement and its junctions with the enamel and the band interior [Millett and Gordon, 1992; Durning et al., 1994]. However, in a recent Cochrane review, Millett et al. [2007] concluded that there is insufficient evidence in the dental literature to support the use of one band cement over another.

Other causes of failure of SMs in this study were breakage of the appliance and soft tissue irritation (inflammation and/ or soft tissue overgrowth). The breakage of band and loop maintainers in this study was relatively low (9%) compared with other studies [Hill et al., 1975; Baroni et al., 1994; Rajab, 2002]. This could be because this study examined only band and loop SMs that are known to have a shorter span than other appliances (such as lower lingual holding arches) rendering them less susceptible to breakage. These appliances also have minimal contact with the soft tissues (if any) that also reduces the risk of soft tissue irritation. In this study, only two cases (9%) showed evidence of soft tissue irritation that could be due to poor band/wire adaptation. Another possibility would be children playing/fiddling with the SM leading to distortion of the wire.

Surprisingly, the only variable that seemed to have influenced the survival time of band and loop SMs in this study was the quadrant in which the appliance was cemented; those cemented in the maxilla and mandibular lower left quadrant seemed to have a higher survival time compared with those cemented in the right quadrants. This is in agreement with a previous study where the authors reported a statistically significant higher survival rate for SMs cemented on the left side of the oral cavity compared with those on the right side [Qudeimat and Fayle, 1998]. The reason for this remains obscure, although one possible explanation might be that access and isolation might have been easier to control by a right-handed clinician, as in this study, when band and loop appliances were fitted in the maxilla and madnibular quadrants of the left side of the oral cavity. Another possible explanation might be the preference of the right side of the mouth as a chewing side by the children in this study.

It should be noted that when applying the life table method, factors affecting the reliability of results include:

* The size of the sample;

* The length of the study compared with median life;

* The proportion of data that is censored and the quality of information on censored data [Cutler and Ederer, 1958].

In addition, in dental restoration studies, both retrospective and prospective, the normal dental visits are commonly used for the collection of data. There can be wide gaps between these visits so that the latest data on a restoration can often be seriously out of date [Cutler and Ederer, 1958]. Furthermore, future studies are required to investigate the influence of mastication forces, the subject's oral habits and durability of more recent resin luting cements on the survival of SMs.

Conclusion

Although the overall median survival time was clinically acceptable (19.9 months), the failure rate of the band and loop space maintainers in general was high (57.5%). The main reason for failure was decementation of the band. Further studies are required to compare glass ionomer cements with more recent resin modified luting cements.

References:

Baroni C, Franchini A, Rimondini L. Survival of different types of space maintainers. Pediatr Dent 1994;16:360-361.

Brown RA, Swanson Beck J. Survival analysis. In: Brown RA, Swanson Beck J (eds). Medical statistics on personal computers. London: BMJ Publishing Group, 1995:99-118.

Christensen JR, Fields HW Jr. Space maintenance in the primary dentition. In: Pinkham JR, Casamassimo PS, Fields HW Jr, McTigue DJ, Nowak AJ (eds). Pediatric Dentistry: infancy through adolescence. Missouri: Elsevier Saunders, 2005:419-448.

Creanor SL, Carruthers LM, Saunders WP, Strang R, Foye RH. Fluoride uptake and release characteristics of glass ionomer cements. Caries Res 1994;28:322-328.

Croll TP. Cementation of stainless steel space maintainers. J Pedod 1983;7:120-126.

Cutler SJ, Ederer F. Maximum utilization of the life table method in analyzing survival. J Chron Dis 1958;8:699-712.

Durning P, McCabe JF, Gordon PH. A laboratory investigation into cements used to retain orthodontic bands. Br J Orthod 1994;21:27-32.

Fathian M, Kennedy DB, Nouri MR. Laboratory-made space maintainers: a 7-year retrospective study from private pediatric dental practice. Pediatr Dent 2007;29:500-506.

Hill CJ, Sorenson HW, Mink JR. Space maintenance in a child dental care program. J Am Dent Assoc 1975;90:811-815.

Hotz P, McLean JW, Sced I, Wilson AD. The bonding of glass ionomer cements to metal and tooth substrates. Br Dent J 1977;142:41-47.

Kirzioglu Z, Ozay MS. Success of reinforced fiber material space maintainers. J Dent Child 2004;71:158-162.

Millett DT, Glenny AM, Mattick CR, Hickman J, Mandall NA. Adhesives for fixed orthodontic bands. Cochrane Database Syst Rev 2007;18:CD004485. DOI: 10.1002/14651858.

Millett DT, Gordon PH. The performance of first molar orthodontic bands cemented with glass ionomer cement--a retrospective analysis. Br J Orthod 1992;19:215-220.

Millett DT, McCabe JF, Bennett TG, Carter NE, Gordon PH. The effect of sandblasting on the retention of first molar orthodontic bands cemented with glass ionomer cement. Br J Orthod 1995;22:161-169.

Moore TR, Kennedy DB. Bilateral space maintainers: A 7-year retrospective study from private practice. Pediatr Dent 2006;28:499-505.

Qudeimat MA, Fayle SA. The longevity of space maintainers: a retrospective study. Pediatr Dent 1998;20:267-272.

Rajab LD. Clinical performance and survival of space maintainers: Evaluation over a period of 5 years. J Dent Child 2002;69:156-160.

Santos VL, Almeida MA, Mello HS, Keith O. Direct bonded space maintainers. J Clin Pediatr Dent 1993;17:221-225.

Tulunogu O, Ulusu T, Genc Y. An evaluation of survival of space maintainers: a six-year follow up study. J Contemp Dent Pract 2005;6:74-84.

I. S. Sasa *, A. A. Hasan **, M. A. Qudeimat **

* Dept. Paediatric Dentistry, University of Texas Health Science Centre, San Antonio, Texas, USA;

** Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, Kuwait

Postal address: Dr. M. A. Qudeimat. Dept. of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923, Safat- 13110, Kuwait. Email: mqudeimat@hsc.edu.kw
Table 1. Fate of band and loop space maintainers at the
closing date of a prospective study.

Fate of Space No. of Space
Maintainers Maintainers (%)

Failed 23 (57.5)
Lost to Follow 1 (2.5)
Successful 4 (10)
End of Study 12 (30)
Total 40 (100)

Table 2. The causes of failure for 23 out of 40 band and loop
space maintainers

Cause of Failure No. of Appliances (%)

Decementation 19 (82)
Solder Breakage 2 (9)
Soft tissue lesions 2 (9)
Total 23 (100)

Table 3. Median survival time (n months) and fate of 40 band and
loop space maintainer appliances.

 Median
 Number of Survival
Fate appliances (months)

Decementation 19 13.0

Solder Breakage 2 21.0

Soft Tissue Lesions 2 14.5

Successful appliances 17 38.0
and those still in service

Total 40 19.9

Table 4. Variables that might have affected the median survival
time for failed band and loop space maintainers in a prospective
study

Variable Number (%) Median Survival Standard
 Time (months) Error

Gender

Girls 22 (55) 16 1.5
Boys 18 (45) 34.5 11.0

Quadrant

UR 5 (12.5) 13.5 7.4
UL 4 (10) 34.6 0.0
LL 19 (47.5) 28.1 5.4
LR 12 (30) 15.9 2.3

Dental Arch

Maxillary 31 (77.5) 28.1 6.9
Mandibular 9 (22.5) 15.4 1.3

Tooth used for Cementation

Primary 26 (65) 15.8 0.4
Permanent 14 (35) 34.6 5.5

Variable Confidence P
 Interval

Gender

Girls 12.8-18.8 0.18
Boys 13.1-56.1

Quadrant

UR 0-28 0.008
UL 0
LL 17.6-38.7
LR 11.5-20.3

Dental Arch

Maxillary 14.5-41.7 0.30
Mandibular 12.8-17.9

Tooth used for Cementation

Primary 15-16.6 0.18
Permanent 23.9-45.3
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Article Details
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Author:Sasa, I.S.; Hasan, A.A.; Qudeimat, M.A.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:7KUWA
Date:Mar 1, 2009
Words:3303
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