|Year : 2014 | Volume
| Issue : 2 | Page : 111-116
'Metal to resin': A comparative evaluation of conventional band and loop space maintainer with the fiber reinforced composite resin space maintainer in children
A Garg, F Samadi, JN Jaiswal, S Saha
Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||17-Apr-2014|
A-4 Ashok Nagar, Mandoli Road,Shahdara, Delhi-110 093
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: To compare the clinical efficacy 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 1 st , 3 rd , and 6 th months for evaluation of both types of space maintainer. Patient acceptability, time taken, and clinical efficacy 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 significantly 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 fiber 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, fiber reinforced composite resin, space loss, space maintainer
|How to cite this article:|
Garg A, Samadi F, Jaiswal J N, Saha S. 'Metal to resin': A comparative evaluation of conventional band and loop space maintainer with the fiber reinforced composite resin space maintainer in children. J Indian Soc Pedod Prev Dent 2014;32:111-6
|How to cite this URL:|
Garg A, Samadi F, Jaiswal J N, Saha S. 'Metal to resin': A comparative evaluation of conventional band and loop space maintainer with the fiber reinforced composite resin space maintainer in children. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2020 Feb 18];32:111-6. Available from: http://www.jisppd.com/text.asp?2014/32/2/111/130783
| Introduction|| |
The most effective way to prevent mesial drift after early loss of primary molars is to insert a durable space maintainer.  Band and loop space maintainer is the most commonly used one. Potential disadvantages of the conventional type have led to the development of fiber reinforced composite resin (FRCR) technology which includes polyethylene fiber. 
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.
The study design, objectives, potential benefits, 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.
A. Clinical criteria
- Premature loss of primary first molar in two quadrants.
- Sound and healthy abutment teeth.
- Presence of Angle's Class I molar relationship and/or presence of flush 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.
- 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 1]a. Intraoral periapical radiographs were taken in the areas of tooth loss [Figure 1]b 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.
|Figure 1: (a) Preoperative intraoral view. (b and c) Preopertaive intraoral periapical radiographs|
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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 fiber were adapted to tooth surface with a plastic instrument. Preliminary curing for 40 s was done individually at each end of the fiber framework. An additional layer of flowable composite was applied over the area where the fiber 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 2]a. Any uncovered fiber was further covered with flowable composite. The space maintainer was checked for gingival clearance and occlusal interference. Finishing was done using composite finishing burs. Finally, bonding agent was applied over the fiber frame and light cured at multiple points for the purpose of reactivation.
|Figure 2: (a) Fiber reinforced composite space maintainer. (b) Band and loop space maintainer|
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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. , It was cemented using luting glass ionomer cement (type II), mixed according to manufacturer's instructions. Excess of cement was removed with floss interdentally [Figure 2]b.
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 1 st , 3 rd , and 6 th months for evaluation of both types of space maintainers. Patient acceptability towards treatment was checked using visual analogue scale (six point facial Wong-Baker Scale)  [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.
The observations thus obtained were subjected to statistical analysis using chi-square test and Mann-Whitney U test to know the effect of each variable and to reveal the statistical significance. The confidence level of study was proposed to be 95% Hence, P-value < 0.05 has been considered significant, P-value < 0.01 has been considered highly significant and P-value < 0.001 has been considered very highly significant.
| Results|| |
[Table 1] shows the patient acceptance after completion of treatment.
Patient acceptability was greater in Group I compared to Group II and the difference was found to be statistically significant (P < 0.001).
[Table 2] shows time taken for completion of the treatment.
The time taken by Group I was significantly 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 fiber 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 significant.
|Table 4: Comparison of two groups for cumulative success rate up to 6 months of evaluation|
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| 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. 
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.  This may result in problems like reduction of arch space, blocked or deflected 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.  One of the approaches to control this space discrepancy is by the provision of space maintainer appliances. 
Ideally, space maintainers should not interfere with masticatory function or inhibit or deflect 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. , Owen (1971) revealed various factors to be considered in assessment of the need for a space maintainer. , Space maintainers may be removable or semifixed or fixed, with bands or without bands, functional or nonfunctional, active or passive or combinations of above; of which fixed appliances are the most advantageous. 
Of all the fixed space maintainers used in pediatric dentistry, the band and loop ones are the most prevalent. , They adjust easily to accommodate changing dentition. But due to its varied disadvantages, attempts have been made to utilize newer materials in its fabrication. , Development of FRC technology has brought a new material into the realm of metal-free, adhesive esthetic dentistry.  Various commonly used bondable reinforced fibers in clinical practice are: Fibers impregnated with resin (Vivadent, StickTech, Pentron), glass fiber (GlasSpan and Polydentia), and ultrahigh molecular weight polyethylene fiber (Ribbond). 
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 a high resistance to traction allowing them to easily adapt to tooth morphology and dental arch contour.  The key to Ribbond's 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. ,
Recent literature reports very few studies evaluating clinical efficacy, 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 first 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 benefits 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. 
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.  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.  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 Ribbond's biocompatibility which meets patient's esthetic expectations.  According to Tuloglu et al., (2009) FRCR used as fixed space maintainers had an esthetic appearance and possessed no risk of damage to abutment teeth and was easy to clean. 
As regards the time taken to complete the procedure, time taken by Group I was significantly lower compared to Group II and results were statistically significant. 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 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 finishing; 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.  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. , They concluded that this procedure was time taking and labor intensive, therefore expensive. Also, impression making was difficult in young and uncooperative children.
Clinical efficacy of both types of space maintainers were evaluated by various criteria's at 1 st , 3 rd , and 6 th 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 fiber-composite interface and fracture of fiber frame in descending order [Figure 5]a and b. The failure due to debonding of enamel-composite interface continued till 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 which had negative influence on the resin retention. , The results of the present study were in accordance with Subramaniam et al., (2008) using glass FRCR space maintainer.  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 1 st month of placement. They attributed this failure to be due to lack of rubber dam isolation.  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.  Two cases showed the failure due to fracture of fiber 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 fiber frame, resulting in increased concentration of mechanical stresses on the fiber frames and its subsequent fracture. ,
|Figure 5: Failures associated with band and loop and fi ber reinforced space maintainers: (a) Debonding at enamel-composite interface, (b) debonding at fi ber-composite interface, (c) failure of band and loop due to cement loss, and (d) slippage of band gingivally|
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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 [Figure 5]c and d]. Failure due to cement loss may be due to nonapplication of rubber dam during cementation. This was consistent with the findings of Moore et al., (2006) 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. , Croll (1982) concluded that when unilateral fixed stainless steel appliances were employed, the solder wire loop loses proper contact with the nonattached abutment tooth and becomes submerged in the gingival. 
Fathian et al., (2007) reported that patient's 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 fit band placement. ,
When comparing the overall success rate of both the types of space maintainers it was 63.3 and 36.7%, respectively and statistically significant.
As inferred by Yeluri and Munshi (2012), FRCR space maintainer may be clinically acceptable and expedient alternative to the conventional band and loop appliance. 
| Conclusions|| |
- Patient acceptance of FRCR space maintainers was found to be better than that of band and loop space maintainers.
- The time taken to carry out the procedure for FRCR space maintainers was significantly lower as compared to that taken by band and loop space maintainers.
- FRCR space maintainers were found to be superior to that of band and loop space maintainers in terms of clinical efficacy.
- 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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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]