JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 191-194

Modified Nance Palatal Arch: A Novel Appliance

1 Department of Pedodontics and Preventive Dentistry, DY Patil Dental School, Pune, Maharashtra, India
2 Director and Professor, DY Patil Dental School, Pune, Maharashtra, India

Date of Submission06-Jun-2019
Date of Decision10-Sep-2019
Date of Acceptance19-Oct-2019
Date of Web Publication14-Dec-2020

Correspondence Address:
Dr. Pritesh N Gawali
Department of Pedodontics and Preventive Dentistry, DY Patil Dental School, Lohegaon, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_16_19

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The following case report presents a new and innovative technique for the preservation of space due to tooth loss as well as the interception of anterior cross-bite. The novel appliance fabricated fully satisfies the demand of the adolescent patient, while fulfilling the esthetic and functional requirements presented by the case.

Keywords: Cross-bite, modified Nance palatal arch, space maintainer

How to cite this article:
Gawali PN, Jadahav GJ, Shigli AB, Hegde RJ, Garje PK. Modified Nance Palatal Arch: A Novel Appliance. J Int Clin Dent Res Organ 2020;12:191-4

How to cite this URL:
Gawali PN, Jadahav GJ, Shigli AB, Hegde RJ, Garje PK. Modified Nance Palatal Arch: A Novel Appliance. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Apr 21];12:191-4. Available from: https://www.jicdro.org/text.asp?2020/12/2/191/303397

   Introduction Top

The primary dentition plays a very important role not only in the child’s growth and development but also in the guidance and eruption of permanent teeth. Root resorption of primary teeth followed by eruption of permanent teeth is a normal physiological process. Teeth provide a mold for the proper growth of the jaws so that the permanent teeth may have adequate space for aligning themselves. Premature loss of a deciduous tooth or a group of teeth will lead to a wide range of implications such as loss of arch length which may manifest as malocclusion in permanent dentition in the form of anterior and posterior cross-bite, crowding, impaction of permanent teeth, and supraeruption of opposing teeth.[1] The best way to avoid these problems is to preserve the primary teeth in the arch until their normal time of exfoliation. However, in cases where extraction of teeth is unavoidable due to extensive caries, the safest option to maintain arch space is by placing a space maintainer.

The present case report introduces a newer appliance that can intercept a malocclusion and can also act as a space maintainer.

   Case Report Top

A 10-year-old boy reported to the Department of Pediatric Dentistry, DY Patil Dental School, with a chief complaint of malaligned teeth. On intraoral examination, missing upper right and left deciduous canine were missing, thus requiring a need of placement of a space maintainer. On questioning, the patient gave a history of extraction of decidicous canines. Lower arch was otherwise noncarious. Single-tooth cross-bite in relation to upper right central incisor was noticed [Figure 1]. A Nance palatal arch (NPA) space maintainer was thus planned to maintain the space until the eruption of both the permanent canines.
Figure 1: preoperative image

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As the patient was more concerned about the malaligned teeth, the treatment for anterior cross-bite was also to be planned. Thus, the treatment of anterior cross-bite along with maintenance of extraction space was carried out with a newer modification of NPA. Patient’s parents were explained about the need for an appliance and a through consent was obtained.

Anterior dental cross-bites originate from abnormal axial inclination of the maxillary anterior teeth, whereas anterior skeletal cross-bite is often associated with a skeletal problem, such as mandibular prognathism and mid-face deficiency.

Design of the appliance

Preformed stainless steel molar bands (3M Unitek) were placed on the upper right and left first permanent molars, and an impression was registered using C-silicon impression material. Bands were then transferred onto the impression and were stabilized by two bobby pins which were placed diagonally to stabilize the band and the cast was poured.

Under laboratory procedures, stone models were cast from the impressions. With 19-gauge stainless steel wire, an NPA was made and the wire lay passively against the anteroinferior aspect of the palate. The distal end of the wire rested in contact with the palatal surface of the maxillary molar bands and was soldered. The fabrication of an acrylic button on the rugae area was done later with a “Z” spring fabricated with a 23-gauge wire embedded in the acrylic button for the correction of the cross-bite [Figure 2]. Posterior bite was then raised using posterior bite block (BLUEBITE) and the appliance was then cemented using zinc polycarboxylate cement and activation of “Z” spring was done every 2 weeks by opening the helices 2 mm each time[2] [Figure 3].
Figure 2: appliance design

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Figure 3: cementation of the appliance

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The child was motivated to maintain good oral hygiene. He was instructed not to eat hard foodstuff to prevent separation or breakage of the Z spring from the acrylic button.


After 2 months, the central incisor in cross-bite was corrected [Figure 4]a and [Figure 4]b. Posterior bite that was raised using BLUEBITE was then removed. The “Z” spring was also removed from the acrylic button.
Figure 4: (a and b) correction of the cross-bite

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   Discussion Top

Anterior cross-bite is a condition in which one or more maxillary anterior teeth are in lingual relation to the mandibular teeth. Anterior cross-bite has reported an incidence of 4%–5% and the results from palatal malposition of the maxillary incisors. Other etiological factors include trauma to primary maxillary incisors, resulting in lingual displacement of permanent tooth buds, presence supernumerary anterior teeth, crowding in the incisor region, habit of biting the upper lip, odontoma, and delayed eruption of permanent teeth.[3] Anterior cross-bites should be intercepted and treated at an early stage because it is a self-perpetuating condition which if not treated early has the potential of growing into skeletal malocclusion and might at a later stage require major orthodontic treatment combined with surgical procedures.[2],[4] In the present case report, the child presented with dentoalveolar cross-bite which is often manifested as a single tooth cross-bite due to over-retained deciduous teeth. Either skeletal or dentoalveolar, the treatment of anterior cross-bite is recommended in primary and early mixed dentition. The aim of early treatment of this type of malocclusion is to correct anterior cross-bite, as otherwise often can lead to very serious Class III malocclusion which would be possible to treat only with combined orthodontic and orthognathic method.

Premature disappearance of primary dentition has received greater attention due to its negative consequences, i.e., the loss of further space for the eruption and accommodation of permanent teeth.[5]

In the present case, the child had premature exfoliation of the upper right and left first primary molar along with anterior single tooth cross-bite. Many types of space maintainers have been developed so far to maintain the space in the current case; however, their selection depends on child dental development There are several choices of space maintainers for each clinical situation, but longevity should be the standard and first element to consider when selecting the most appropriate maintainer.[6] Anterior dental cross-bites originate from abnormal axial inclination of the maxillary anterior teeth, whereas anterior skeletal cross-bites are often associated with a skeletal problem, such as mandibular prognathism and midface deficiency.[7]

Therefore, in the current case of dental cross-bite, along with maintaining the space, the correction of cross-bite was also attempted using a modification of NPA with “Z spring” was fabricated.

The advantages of this modified NPA are as follows.

  1. The developing anterior cross-bite can be intercepted
  2. The button can be used as a reminder in case of tongue thrusting habit
  3. Additional button can be added on the other side if rotation correction is required bilaterally
  4. Patient compliance is of crucial importance for successful outcomes in orthodontic treatment, especially when removable appliances are used. A great number of internal and external factors that potentially influence compliance
  5. Simple in fabrication, ease of activation, and regular oral hygiene can be maintained.

Many types of space maintainers have been developed so far, and their selection depends on child dental development, as well as on the involved tooth.

The variety of space maintainers available in the market shows advantages and disadvantages. It is important that they should neither interfere with the patient’s masticatory function nor inhibit or impair dentoalveolar maturation and growth.[7] They should be simply manufactured, easily maintained, resistant, durable, stable, and of straightforward sanitization.

Accordingly, the use of this device prevents dental movements of both deciduous and permanent teeth and the fact that it avoids loss of the arch perimeter and ectopic eruptions.

During the 3-month consultation period, the patient and the family were reminded about the importance of proper hygiene in the oral cavity and in the space maintainer region, as well as about the need of regular consultations with the dentist for case evaluation. Radiographs were also requested to follow-up in the permanent tooth eruption, as described by Amal I Linjawi AI et al. in their study.[8]

   Conclusion Top

This newer modification of an NPA, as proposed here, is a viable option for the preservation of space as well as to intercept anterior cross-bite. This modified device was successful at achieving the goals expected in this case, i.e., easy to fabricate and place, and it can be used by orthodontists, pediatric dentists, and general dentists.

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.

Financial support and sponsorship

The study was supported by DY Patil Dental School.

Conflicts of interest

There are no conflicts of interest.

   References Top

Brothwell DJ. Guidelines on the use of space maintainers following premature loss of primary teeth. J Can Dent Assoc 1997;63:753, 757-60, 764-6.  Back to cited text no. 1
Correction of Anterior Crossbite with Different Approaches: A series of three cases. Int J Oral Health Med Res 2016;3:41-3.  Back to cited text no. 2
Garg A, Samadi F, Jaiswal JN, 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.  Back to cited text no. 3
[PUBMED]  [Full text]  
Linjawi AI, Alajlan SA, Bahammam HA, Alabbadi AM, Bahammam MA. Space maintainers: Knowledge and awareness among Saudi adult population. J Int Oral Health 2016;8:733-8.  Back to cited text no. 4
  [Full text]  
Marwah N. Textbook of Pediatric Dentistry. 4th ed. Daryaganj, New Delhi: Jaypee Publishers; 2015.  Back to cited text no. 5
Bell RA, Dean JA, McDonald RE, Avery DR. Management of the developing occlusion. In: Dean JA, Avery DR, McDonald RE. editors. McDonald and Avery’s Dentistry for the Child and Adolescent. 9th ed. Maryland Heights, Mo: Mosby Elsevier; 2011:550-613.  Back to cited text no. 6
Ulusoy AT, Bodrumlu EH. Management of anterior dental crossbite with removable appliances. Contemp Clin Dent 2013;4:223-6.  Back to cited text no. 7
[PUBMED]  [Full text]  
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. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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