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Original Article

Metal to resin: A comparative evaluation of


conventional band and loop space maintainer with the
ber reinforced composite resin space maintainer in
children
Garg A., Samadi F., Jaiswal J. N. , Saha S.
Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow,
Uttar Pradesh, India

ABSTRACT

Address for correspondence:

Aims: To compare the clinical efcacy of two


space maintainers namely, conventional band
and loop and Fiber Reinforced Composite
Resin (FRCR) space maintainers. Subjects and
Methods: Thirty healthy children, aged 5 to 8
years were selected having at least two deciduous
molars in different quadrants indicated for
extraction or lost previously. FRCR space
maintainer was placed in one quadrant and in the
other quadrant band and loop space maintainer
was cemented. All the patients were recalled
at 1st, 3rd, and 6th months for evaluation of both
types of space maintainer. Patient acceptability,
time taken, and clinical efcacy was recorded.
Statistical analysis used: The observations thus
obtained were subjected to statistical analysis
using Chi- square test and Mann-Whitney U test.
Results: Patient acceptability was greater in
Group I (FRCR) in comparison to Group II (band
and loop space maintainer). The time taken by
Group I was signicantly lower as compared to
that of Group II. In Group I, debonding of enamel,
composite was the most common complication
leading to failure followed by debonding of ber
composite. In Group II, cement loss was the most
common complication leading to failure followed
by slippage of band and fracture of loop. The
success rates of Groups I and Group II weares
63.3% and 36.7%, respectively. Conclusion: The
study concluded that FRCRFiber Reinforced
Composite Resin (Ribbond) space maintainers
can be considered as viable alternative to the
conventional band and loop space maintainers.

KEYWORDS: Band and loop, ber reinforced


composite resin, space loss, space maintainer

111

Dr. Aarti Garg, A-4 Ashok Nagar, Mandoli Road,


Shahdara, Delhi-110 093, India.
E-mail: artigarg7@gmail.com

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Website:
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DOI:
10.4103/0970-4388.130783
PMID:
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Introduction
The most effective way to prevent mesial drift after
early loss of primary molars is to insert a durable
space maintainer.[1] Band and loop space maintainer
is the most commonly used one. Potential
disadvantages of the conventional type have led to
the development of ber reinforced composite resin
(FRCR) technology which includes polyethylene
ber.[2]
Very few literature reports on use of polyethylene
FRCR (Ribbond) as space maintainers. Hence,
the present study has been taken up to develop a
clinically acceptable, less time consuming, and patient
friendly FRCR space maintainer as an alternative to
conventional band and loop space maintainer.

Subjects and Methods


Thirty healthy children, aged 5-8 years were selected
from Department of Pedodontics and Preventive
Dentistry, Sardar Patel Post Graduate Institute of
Dental and Medical Sciences, Lucknow.

Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2014 | Vol 32| Issue 2 |

Garg, et al.: A comparative evaluation of conventional band and loop space maintainer with the ber reinforced composite resin space
maintainer in children

The study design, objectives, potential benets,


and methodology were explained to both children
and their parents. Consent and ethical committee
clearance were obtained from institutional review
board prior to study.
Previously, a pilot study was carried out in the same
department, to overview the proper study design and
to take care of possible constraints during main study.

Inclusion criteria

A. Clinical criteria
Premature loss of primary rst molar in two
quadrants.
Sound and healthy abutment teeth.
Presence of Angles Class I molar relationship
and/or presence of ush terminal/mesial step
primary molar relationship.
Absence of abnormal dental conditions such as
cross bite, open bite, and deep bite.
B. Radiographic criteria
Absence of periapical pathology.
Presence of succedaneous tooth bud.
Presence of more than 1 mm bone overlying
the succedaneous tooth germ and/or less
than one-third of the root of the permanent
tooth formed.

Exclusion criteria

Carious buccal and lingual surfaces of abutment


teeth.
Absence of teeth on mesial and distal side of
edentulous area.

For every selected child, a brief history was taken


followed by clinical examination [Figure 1a]. Intraoral
periapical radiographs were taken in the areas of
tooth loss [Figures 1b and c]. Impressions were made
followed by study model preparation and space
analysis. Oral prophylaxis and other restorative
treatments were done prior to the placement of space
maintainers. FRCR space maintainer was placed in
one quadrant and in the other quadrant band and loop
space maintainer was cemented.

Technique for construction of FRCR space


maintainer

The distance between the mesiobuccal line angle


of primary canine and the distobuccal line angle of
second primary molar was measured to determine
the length of FRCR required and adequate amount of
FRCR was cut. After administration of adequate topical
anesthesia, isolation was done using rubber dam and
suction. Both the abutment teeth (primary canine and
second primary molar) were cleaned and air dried.
Adhesive was applied and light cured for 20 s. A thin
layer of composite was applied to the buccal surfaces of
abutment tooth and required length of FRCR (Ribbond)
was placed on this composite, extending from the
buccal aspect of the primary second molar to primary
canine. The ends of the ber were adapted to tooth
surface with a plastic instrument. Preliminary curing
for 40 s was done individually at each end of the ber
framework. An additional layer of owable composite
was applied over the area where the ber abutted
the tooth surface and this was light cured for 40 s. A
similar procedure was repeated on the lingual aspect
of the abutment teeth [Figure 2a]. Any uncovered ber
was further covered with owable composite. The
space maintainer was checked for gingival clearance
and occlusal interference. Finishing was done using
composite nishing burs. Finally, bonding agent was
applied over the ber frame and light cured at multiple
points for the purpose of reactivation.

Technique for construction band and loop space


maintainer

In the other quadrant, a conventional band and loop


space maintainer was given as per the technique
described by Graber and Finn.[3,4] It was cemented using
luting glass ionomer cement (type II), mixed according
to manufacturers instructions. Excess of cement was
removed with oss interdentally [Figure 2b].
Both the space maintainers were checked for gingival
clearance and occlusal interference [Figure 3].
Instructions on oral hygiene and appliance maintenance
were given to both children and parents. They were
instructed to return if the appliance was loosened,
dislodged, or broken. All the patients were recalled at 1st,
3rd, and 6th months for evaluation of both types of space
maintainers. Patient acceptability towards treatment was

Figure 1: (a) Preoperative intraoral view. (b and c) Preopertaive


intraoral periapical radiographs

Figure 2: (a) Fiber reinforced composite space maintainer. (b) Band


and loop space maintainer

Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2014 | Vol 32| Issue 2 |

112

Garg, et al.: A comparative evaluation of conventional band and loop space maintainer with the ber reinforced composite resin space
maintainer in children

checked using visual analogue scale (six point facial WongBaker Scale)[5] [Figure 4] after the treatment completion.
Time taken was recorded in minutes for both the
procedures and measured with the help of a stop watch.

Results

Statistical analysis

Patient acceptability was greater in Group I compared


to Group II and the difference was found to be
statistically signicant (P < 0.001).

The observations thus obtained were subjected to


statistical analysis using chi-square test and MannWhitney U test to know the effect of each variable and
to reveal the statistical signicance. The condence
level of study was proposed to be 95% Hence, P-value
< 0.05 has been considered signicant, P-value < 0.01
has been considered highly signicant and P-value <
0.001 has been considered very highly signicant.

Table 1 shows the patient acceptance after completion


of treatment.

Table 2 shows time taken for completion of the


treatment.
The time taken by Group I was signicantly lower as
compared to that of Group II.
Table 3 shows the complications leading to failure of
space maintainer. In Group I, debonding of enamel,
composite was the most common complication
followed by debonding of ber composite. In Group
II, cement loss was the most common complication
followed by slippage of band and fracture of loop.
Table 4 shows the comparison of two groups for
cumulative success rate up to 6 months evaluation.
The success rates of Groups I and II were 63.3 and
36.7%, respectively and the difference was statistically
signicant.

Figure 3: Postoperative intraoral view

Table 1: Evaluation for patient acceptance in two


study groups
Acceptance level

Group I (n = 30)

Group II (n = 30)

No hurt
Hurts little bit
Hurts little more
Hurts even more
Hurts whole lot
Hurts worst

No.
%
14
46.7
13
43.3
2
6.7
1
3.3
0
0.0
0
0.0
1.331.52

No.
%
0
0.0
0
0.0
4
13.3
17
56.7
8
26.7
1
3.3
6.401.43

No hurt

Hurts even more

Table 3: Nature of complications leading to failure


in two groups
Nature of complication
Group I
Debonding of enamel-composite
Fracture of ber-frame
Debonding of ber-composite
Group II
Cement loss
Distortion of band
Slippage of band gingivally
Fracture of loop

113

No. of cases

Percentage

5
2
4

16.67
6.7
13.3

14
1
2
2

46.7
3.3
6.7
6.7

Figure 4: Wong-Baker FACES Pain Rating Scale

Table 2: Comparison for time taken to carry out the


procedure
Time taken
(min)
1-15 min
15-30 min
>30 min
Median

Group I (n = 30)

Group II (n = 30)

No.
21
8
1

No.
0
13
17

%
70.0
26.7
3.3
1-15 min

%
0.0
43.3
56.7
>30 min

Table 4: Comparison of two groups for cumulative


success rate up to 6 months of evaluation
Outcome

Group I (n = 23)

Group II (n = 19)

Successful
Failure

No.
19
11

No.
11
19

%
63.3
36.7

%
36.7
63.3

Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2014 | Vol 32| Issue 2 |

Garg, et al.: A comparative evaluation of conventional band and loop space maintainer with the ber reinforced composite resin space
maintainer in children

Discussion
In the quest for providing optimal dental care, the age
old maxim of prevention is better than cure holds
true. In this endeavor the pedodontist is more evenly
poised to carry the mantle of providing the required
services. For the preventive approach to be truly
effective it needs to be applied at its earliest, that is, at
the primary prevention level.[6]
When a primary tooth is extracted or is exfoliated
prematurely, the teeth mesial and distal to the space
tend to drift or be forced into it.[7] This may result
in problems like reduction of arch space, blocked or
deected 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.[8] One of
the approaches to control this space discrepancy is by
the provision of space maintainer appliances.[9]
Ideally, space maintainers should not interfere with
masticatory function or inhibit or deect normal
growth changes; should be simple to construct and
maintain; durable, strong, and stable; passive in not
imposing pressure on remaining teeth that might affect
orthodontic movements; and easily cleanable without
enhancing dental caries or soft tissue pathology.[1,10]
Owen (1971) revealed various factors to be considered
in assessment of the need for a space maintainer.[10,11]
Space maintainers may be removable or semixed
or xed, with bands or without bands, functional
or nonfunctional, active or passive or combinations
of above; of which xed appliances are the most
advantageous.[3]
Of all the xed space maintainers used in pediatric
dentistry, the band and loop ones are the most
prevalent.[12,13] They adjust easily to accommodate
changing dentition. But due to its varied disadvantages,
attempts have been made to utilize newer materials in
its fabrication.[7,14] Development of FRC technology
has brought a new material into the realm of metalfree, adhesive esthetic dentistry.[2] Various commonly
used bondable reinforced bers in clinical practice are:
Fibers impregnated with resin (Vivadent, StickTech,
Pentron), glass ber (GlasSpan and Polydentia),
and ultrahigh molecular weight polyethylene ber
(Ribbond).[15]
Ribbond consists of bondable, reinforced ultra-highstrength polyethylene bers with a high elasticity
coefcient (117 GPa) and molecular weight that makes
them resistant to stretch and distortion and a high
resistance to traction allowing them to easily adapt to
tooth morphology and dental arch contour.[3] The key
to Ribbonds success is its lock-stitch feature design
that transfers forces throughout the weave without
stress transfer back into the resin. It is biocompatible,
esthetic, translucent, and an easy-to-use reinforced

ribbon. Apart from its various applications in clinical


dentistry, it is also used as a space maintainer.[2,16]
Recent literature reports very few studies evaluating
clinical efcacy, patient acceptability, and time taken
for a construction using polyethylene FRCR (Ribbond)
as a space maintainer. Hence, the present study has
been taken up to develop a clinically acceptable, less
time consuming, and patient friendly space maintainer
using Ribbond as an alternative to the stainless steel
band and loop space maintainer over a period of 6
months.
The age group of 5-8 years was selected in the present
study as in this age; the rst permanent molars had not
yet completely erupted and hence could not be banded.
Additionally, children did not have all their mandibular
permanent incisors erupted. Both for ethical reasons as
well as for the purpose of comparison, both types of
space maintainers were given in each child. Thus, no
child was denied the benets of either type of space
maintainer. Also, as both types of space maintainers
were in the same oral cavity, they would both be
exposed to the same environment, for example, diet,
oral hygiene, and occlusal forces.[7]
Precautions were taken for proper isolation for
placement of both types of space maintainers including
rubber dam isolation and use of high volume suction.
Patient acceptability towards the treatment was
checked with the help of a Wong-Bakers Scale.[5] This
scale was quick, inexpensive, and easy to use having
adequate psychometric properties together with its
wide acceptability. It was the most preferred of all
other faces pain scales by children of all ages and
parents.[5] No previous studies have reported the use
of this scale to measure patient acceptability for either
band and loop or FRCR space maintainers. No prior
instructions were given to the participating subjects
regarding the procedure or use of VAS to avoid bias
due to anticipated pain.
Results of the present study revealed that, patient
acceptability was greater in Group I (FRCR space
maintainer) as compared to that of Group II (band
and loop space maintainer). According to Karaman
et al., (2002) this may be attributed to Ribbonds
biocompatibility which meets patients esthetic
expectations.[16] According to Tuloglu et al., (2009)
FRCR used as xed space maintainers had an esthetic
appearance and possessed no risk of damage to
abutment teeth and was easy to clean.[2]
As regards the time taken to complete the procedure,
time taken by Group I was signicantly lower compared
to Group II and results were statistically signicant.
No study earlier had been conducted measuring time
taken for fabrication of band and loop and bonding
of FRCR space maintainers. Hence, the present study

Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2014 | Vol 32| Issue 2 |

114

Garg, et al.: A comparative evaluation of conventional band and loop space maintainer with the ber reinforced composite resin space
maintainer in children

had been taken up to measure time taken for their


fabrication. The time taken was measured with a
stop watch in minutes. For FRCR space maintainers,
the time taken was measured from the beginning of
the procedure till its nishing; and for band and loop
space maintainers, from beginning of the banding
till the impression taking and the cementation of the
prepared band and loop.
Ganesh et al., (2006) inferred that Ribbond as a
material for space maintainer could often make the
technique relatively easy, fast, and the procedure
could be completed in single appointment which
required no laboratory services.[15] Nayak et al., (2004)
and Kulkarni et al., (2009) inferred that fabrication of
conventional band and loop space maintainer required
more laboratory time and needed minimum of two
appointments.[12,13] They concluded that this procedure
was time taking and labor intensive, therefore
expensive. Also, impression making was difcult in
young and uncooperative children.
Clinical efcacy of both types of space maintainers
were evaluated by various criterias at 1st, 3rd, and 6th
month. During this time period, space maintainers were
removed if failures had occurred and were either repaired
or replaced; these cases were not considered further
in the study. Initially, both types of space maintainers
showed no failures. This may be because patients were
more careful in the immediate postappliance placement
period. It was also possible that parents were more
vigilant and more strictly complaint with posttreatment
instructions during this period.
Failures observed in Group I was maximum due to
debonding of enamel-composite interface followed by
debonding of ber-composite interface and fracture of
ber frame in descending order [Figures 5a and b]. The
failure due to debonding of enamel-composite interface

Figure 5: Failures associated with band and loop and ber reinforced
space maintainers: (a) Debonding at enamel-composite interface, (b)
debonding at ber-composite interface, (c) failure of band and loop
due to cement loss, and (d) slippage of band gingivally

115

continued till 6th 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 which had negative inuence on the resin
retention.[1,3] The results of the present study were in
accordance with Subramaniam et al., (2008) using glass
FRCR space maintainer.[7] Kirzioglu and Erturk (2004),
in their study showed relatively high percentage
of failures of glass FRCR space maintainers due to
debonding at the enamel-composite interface during
1st month of placement. They attributed this failure to
be due to lack of rubber dam isolation.[17] Failures due
to debonding of ber-composite interface may be due
to overzealous nishing of the FRCR space maintainers
and wearing away of the thin layer of composite
during mastication from the ber frame.[7] Two cases
showed the failure due to fracture of ber frame. Such
type of failures may be attributed to chewing of hard
foods. With longer intervals of time, there may be a
possibility of supraeruption of the opposing tooth
and its impingement on the ber frame, resulting in
increased concentration of mechanical stresses on the
ber frames and its subsequent fracture.[7,18]
In the present study, the failures in Group II were
highest due to cement loss followed by slippage of
band gingivally, fracture of loop (solder breakage),
and distortion of band in decreasing order [Figures
5c and d]. Failure due to cement loss may be due to
nonapplication of rubber dam during cementation.
This was consistent with the ndings of Moore et al.,
(2006) who reported cement loss to be the most common
cause of failure of xed space maintainers. Although
glass ionomer cement has low oral solubility, cement
loss could be due to difculty 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 ux on the
wire, over thinning the wire during polishing, or
failure to encase the wire in the solder.[19,20] Croll (1982)
concluded that when unilateral xed stainless steel
appliances were employed, the solder wire loop loses
proper contact with the nonattached abutment tooth
and becomes submerged in the gingival.[21]
Fathian et al., (2007) reported that patients young
age was an important factor responsible for failures
of space maintainer. Authors suggested that young
patients exhibited a lesser cooperation level, increased
sticky food intake, lesser crown length available for
banding, and anatomy of the primary molars that
precluded a tight t band placement.[9,22]
When comparing the overall success rate of both the
types of space maintainers it was 63.3 and 36.7%,
respectively and statistically signicant.

Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2014 | Vol 32| Issue 2 |

Garg, et al.: A comparative evaluation of conventional band and loop space maintainer with the ber reinforced composite resin space
maintainer in children

As inferred by Yeluri and Munshi (2012), FRCR


space maintainer may be clinically acceptable and
expedient alternative to the conventional band and
loop appliance.[23]

Conclusions
1.

Patient acceptance of FRCR space maintainers was found


to be better than that of band and loop space maintainers.
2. The time taken to carry out the procedure for
FRCR space maintainers was signicantly lower
as compared to that taken by band and loop space
maintainers.
3. FRCR space maintainers were found to be superior
to that of band and loop space maintainers in terms
of clinical efcacy.
4. Thus, it was concluded from the study that
FRCR (Ribbond) space maintainers could be an
alternative to conventional band and loop space
maintainers.

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How to cite this article: Garg A, Samadi F, Jaiswal JN, Saha


S. 'Metal to resin': A comparative evaluation of conventional
band and loop space maintainer with the ber reinforced
composite resin space maintainer in children. J Indian! Soc
Pedod Prev Dent 2014;32:111-6.
Source of Support: Nil, Conflict of Interest: Nil

Journal of Indian Society of Pedodontics and Preventive Dentistry | Apr-Jun 2014 | Vol 32| Issue 2 |

116

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