The transpalatal arch: an alternative to the Nance appliance for space maintenance.
ABSTRACT The loss of multiple primary molars in the primary or transitional dentition will, in many instances, lead to disturbances of the developing dentition. To prevent this, an appliance can be constructed to maintain the relationship of the remaining teeth and to guide the eruption of the developing teeth. Traditionally, the treatment of choice for maxillary loss is the placement of a Nance appliance. An alternative appliance that may be considered for use is the transpalatal arch or bar. The purpose of this clinical report was to describe the transpalatal arch appliance and present its advantages over the more common Nance appliance, thus encouraging clinicians to prescribe its use in certain clinical situations.
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ABSTRACT: Aim : This study evaluated assess the mechanical properties and forces produced by transpalatal bars made from low-nickel alloy. Methods: Using a template, a single operator made all transpalatal bars from 0.032" and 0.036" wires of two different alloys, thus originating four groups, namely: A8 (0.032" conventional stainless steel), B8 (0.032" low-nickel stainless steel), A9 (0.036" conventional stainless steel), and B9 (0.036" low-nickel stainless steel). The bars were then activated and mounted onto a device developed to serve as a support for mechanical assay in a universal testing machine (Emic DL 10.000). The values of resilience and ductility were obtained using the Origin 8 software. Results: No statistically significant differences (P > 0.05) were observed between Groups A8 and B8 neither between A9 and B9 for 0.5-, 1.0-, and 5-mm deformations. However, statistically significant differences (P < 0.05) were found in all groups for 15-mm deformation. Groups B8 and B9 showed greater ductility and resilience compared to groups A8 and A9, respectively. Conclusions : Low-nickel stainless steel transpalatal bars release the same amount of force for activations less than 10 mm compared to those made from conventional stainless steel. Mechanically, the low-nickel stainless steel bars are more ductile and resilient.Brazilian Journal of Oral Sciences (ISSN: 1677-3217) Vol 9 Num 1.
Article: Space maintenance.[Show abstract] [Hide abstract]
ABSTRACT: The use of a space maintainer appliance, or restoration of a carious primary tooth that can then act as a natural space maintainer, may potentially obviate the consequences of loss of arch length and the need for complex orthodontic treatment at a later stage. Nevertheless, all space maintainer appliances are plaque retentive and may predispose to dental caries and gingival inflammation. Space maintainer appliances may also impinge on the soft tissues, interfere with eruption of adjacent teeth, fracture, and become dislodged or lost. This review article provides a summary of the available evidence, and considers the indications for space maintenance. Medline and Ovid Medline were scanned, and additionally a hand-search of non-listed peer-reviewed papers written in English was performed. A total of 16 pertinent papers published between 1987 and 2007 that satisfied the inclusion criteria were selected for discussion. There is limited evidence to recommend either for or against the use of space maintainers to prevent or reduce the severity of malocclusion in the permanent dentition. Decisions regarding the use of space maintainers should be guided by balancing the occlusal disturbance that may result if one is not used against the potential plaque accumulation and caries that the appliance may cause.International Journal of Paediatric Dentistry 06/2009; 19(3):155-62. · 1.54 Impact Factor
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ABSTRACT: Premature loss of primary teeth can result in a loss of arch length and have a negative effect on occlusion and alignment, often increasing the need for orthodontic treatment. Use of space maintainers can reduce the severity of problems such as crowding, ectopic eruption, tooth impaction and poor molar relationship. This article presents a review of the consequences of premature tooth loss and discusses the appliances commonly used for space maintenance.Journal of the California Dental Association 08/2013; 41(8):612-8.
PEDIATRIC DENTISTRYV 29 /NO 3MAY/JUNE 07
The Transpalatal Arch: An Alternative to the Nance Appliance for Space Maintenance
Ari Kupietzky, DMD MSc1 • Eli Tal, DMD2
The loss of multiple primary molars in the primary or mixed
dentition will, in many instances, lead to disturbances of
the developing dentition unless an appliance is constructed
to maintain the relationship of the remaining teeth and to
guide the eruption of the developing teeth.1 Sequelae of non-
intervention following loss of the primary maxillary molars
may include drifting of the permanent molars and a resultant
posterior crossbite. Due to space loss, premolars may erupt
ectopically and—in extreme situations—may become im-
pacted. Traditionally, the treatment of choice for maxillary
loss is the placement of a Nance appliance. An alternative
appliance which may be considered for use is the transpala-
tal arch (TPA) or bar. The purpose of this report was to de-
scribe the transpalatal arch appliance and present its ad-
vantages over the more common Nance appliance, thus en-
couraging clinicians to prescribe its use in certain clinical
The maxillary lingual arch
Historically, a maxillary lingual arch with adjustment loops
has been described for use in the upper jaw. The wire is
soldered to molar bands and contacts the cingula of the ma-
xillary incisors.2 Maxillary lingual arches of this type are not
commonly used and are not familiar to many clinicians, but
theoretically are contraindicated only in patients whose bite
depth causes the lower incisors to contact the archwire on
the lingual side of the maxillary incisors.
The Nance appliance
A modifi ed maxillary lingual arch was described by Nance in
1947 and has since been commonly known as the Nance ap-
pliance (NA).3 The NA is simply a maxillary lingual arch that
does not contact the anterior teeth, but approximates the
anterior palate. The palatal portion incorporates an acrylic
button that contacts the palatal tissue, which, in theory, pro-
vides resistance to anterior movement of the posterior teeth
(Figures 1). The appliance is an eff ective space maintainer,
but soft tissue irritation can be a problem. The accumulation
of bacteria and food debris will often result in palatal infl am-
mation and, in many cases, pain (Figure 2). The acrylic por-
tion can become embedded in the soft tissue if the palatal
tissue hypertrophies because of poor oral hygiene or if the
appliance is distorted (Figure 1b).
The issue of palatal soft tissue irritation and infl ammation
is avoided when using a TPA. The TPA is soldered to molar
bands and runs across the palatal vault, avoiding contact with
the soft tissue (Figure 3). The wire follows the vault of the
palate, is comfortable, and does not interfere with normal
speech. Diff erent designs of TPAs exist. The original design
included a straight bar extending across the palate. It should
1Dr. Kupietzky is a pediatric dentist in private practice, Jerusalem, Israel, and visiting pro-
fessor, Department of Pediatric Dentistry, New Jersey Dental School, University of Medicine
and Dentistry of New Jersey, Newark, NJ; 2Dr. Tal is in private pediatric dental practice in
Correspond with Dr. Kupietzky at email@example.com
Abstract: The loss of multiple primary molars in the primary or transitional dentition will, in many instances, lead to disturbances of the developing dentition. To
prevent this, an appliance can be constructed to maintain the relationship of the remaining teeth and to guide the eruption of the developing teeth. Traditionally,
the treatment of choice for maxillary loss is the placement of a Nance appliance. An alternative appliance that may be considered for use is the transpalatal arch
or bar. The purpose of this clinical report was to describe the transpalatal arch appliance and present its advantages over the more common Nance appliance, thus
encouraging clinicians to prescribe its use in certain clinical situations. (Pediatr Dent 2007;29:235-8)
KEYWORDS: SPACE MAINTENANCE, NANCE, INTERCEPTIVE ORTHODONTICS, TRANSPALATAL ARCH
PEDIATRIC DENTISTRYV 29 /NO 3MAY/JUNE 07
be referred to as the transpalatal bar. A variation of the bar
and the type most frequently used is called the Goshgarian
appliance or, more commonly, the transpalatal arch (Figure
4). The TPA off ers the option of expansion, rotation, con-
traction, and torque of the molars due to an omega loop in
the center of the vault. It is constructed from a 0.036-inch
(0.9 mm) stainless steel wire. The central loop is oriented
either mesially or distally. This traditional form can be bent
by a technician, or the clinician can directly use prefabri-
cated arch forms available in diff erent lengths. When used
as a space maintainer, the arch is most commonly soldered
directly onto the bands. Another method uses prefabricated
lingual attachments welded to the molar bands, into which
the arch form is inserted and may also be removed. Care must
be taken to ensure that the TPA is passive when cemented. If
the appliance is not passive, unexpected vertical and trans-
verse movements of the permanent molars may occur.2
When permanent maxillary molars move anteriorly, they ro-
tate mesiolingually around the large lingual root. The space
between the buccal and lingual cortical plates becomes nar-
row anterior to the fi rst molar roots, preventing the molar
from advancing directly and limiting its movement to a ro-
tation.4 The large lingual root contacts the lingual plate and
acts as a pivot, allowing the 2 buccal roots to rotate mesio-
lingually. The TPA reduces anterior molar movement by cou-
pling the right and left permanent molars together and, thus,
preventing any possibility of rotations.
The TPA is not commonly used by pediatric dentists. Two
studies investigating success of diff erent types of space main-
tainers did not include any TPA appliances in their sample.5,6
The only bilateral fi xed appliances studied were the lingual
arch and NAs. A cursory review of a selection of popular pe-
diatric dentistry textbooks revealed that the TPA is far from
being recommended as being a fi rst-choice appliance for
space maintenance following loss of primary maxillary mo-
lars. Suggestions range from: (1) obligatory brief mention; to
(2) no mention; to (3) discouragement of its use.
One textbook states that, “although the TPA is a
cleaner appliance and is easier to construct, many clini-
cians think that it allows the teeth to move and tip mesi-
ally, resulting in space loss.”7 Another textbook states that
“considerable controversy exists regarding eff ectiveness
of the TPA as an alternative to NA theapy in maintaining
maxillary molar position. Theoretically, if maxillary molar
migration resulted exclusively in mesiolingual rotation, the
TPA would be as adequate an appliance in stabilizing molar
position. Clinical experience, however, does not support this
hypothesis; continued use should be discouraged.”8 No ref-
erences to scientifi c evidence, however, have been presented
that support this view. Regarding the Nance, on the other
hand, positive statements appear (also unsupported by ref-
erenced papers), such as “tissue irritation beneath the acry-
lic button is uncommon, for it appears to be self-cleansing.”9
However, it is unclear how the button can be self- cleansing.
If it is needed to prevent movement, it must be constructed
to touch the palate. Impingement of the button against the
palatal tissue can cause irritation, degeneration from the
pressure, and lack of hygiene in the area of the rugae.
The Nance anterior acrylic component may not contrib-
ute to the anchorage of the appliance as once thought. If it is
constructed a minimal distance away from the palate to allow
proper hygiene and yet it is crucial for space maintenance,
then it would be expected to allow space loss to occur accord-
1a. A NA placed following extraction of fi rst and second primary molars. The appliance has successfully allowed the erup-
tion of both premolars. Note, however, the unerupted, blocked-out canines.
1b. The acrylic portion has become partially embedded in the soft tissue. Inability to clean area underneath button may lead
to accumulation of bacteria and food debris, resulting in palatal tissue hypertrophy.
2. At a 6-month recall visit, a Nance appliance was removed due to the patient’s complaint of pain. The palatal tissue is red
and infl amed.
PEDIATRIC DENTISTRYV 29 /NO 3MAY/JUNE 07
ing to the gap between the button and the tissue no matter
how small this may be. Indeed, a study investigating the sur-
vival of various types of space maintainers reported that 11%
of the NAs failed due to soft tissue lesions.5 Another study
found that soft tissue lesions were encountered more in bi-
lateral (7% of total failures recorded for bilateral appliances)
than in unilateral space maintainers.6 Clinicians should be
aware of this problem when using the NA and should peri-
odically remove the appliance for cleaning.
Other uses. TPAs are regularly used in orthodontics in both
permanent and transitional dentition treatments to:
1. establish and maintain arch widths;
2. derotate unilaterally or bilaterally rotated molars;
3. control upper molar eruption;
4. correct unilateral crossbites for maxillary expansion
and buccal root torque of upper molars; and
5. correct mesiodistal asymmetries (Figure 5).4
Orthodontists routinely use the TPA to increase pos-
terior anchorage in maximum anchorage cases.10 The TPA,
resulting in an increase of posterior anchorage, will change
the ratio of anterior retraction to posterior protraction to ap-
proximately 2:1.10 Usually, in these cases an expansion loop
in the palatal section is not used, thereby allowing maximum
rigidity. In this capacity, the appliance may be referred to as a
maxillary stabilizing lingual arch.
Another advantage of the TPA is its potential control of
the vertical dimension of the permanent molars. This feature
may also contribute to the TPA’s ability to hold the molars in
place and prevent overeruption or tipping. The vertical con-
trol that may prevent molar extrusion is produced by the
tongue during deglutition and mastication.11-13 The tongue af-
fects the dentition and the alveolar bone during mastication,
deglutition, speech, and at rest.14,15 The average frequency of
deglutition is between 1,60016 and about 2,40017 times a day.
The tongue, therefore, delivers orthodontic forces with con-
siderable frequency. The TPA may be able to control verti-
cal movement of the molars through tongue pressure on the
appliance’s loop, which occurs during deglutition when the
base of the tongue is moved forcibly upward and backward
toward the hard palate.12,18,19 The clinical signifi cance of this
force remains ambiguous, however, and confl icting evidence
may be found in the literature.20
Management of premature tooth loss in the primary and
transitional dentition requires careful thought by the clini-
cian. Choosing the appropriate appliance is crucial to a suc-
cessful outcome. No space maintainer—with the exception of
the primary tooth—can fulfi ll all the requirements of an ideal
appliance, including: (1) preservation of space; (2) eruption
of adjacent, succedaneous, and abutment teeth; (3) restora-
tion of masticatory function; (4) prevention of overeruption
of antagonists; (5) compatibility with soft tissues; (6) ef-
fective hindrance of torquing forces on abutment teeth; (7)
economy of construction and resistance to distortion; (8)
allowance for adjustment or minor repair; and (9) universal
The TPA off ers many advantages over the more common
NA, including: (1) better compatibility with soft tissues; and
(2) increased vertical control. Practitioners wishing to avoid
controversies—such as the TPA’s ability to hold the space fol-
lowing bilateral loss of primary molars—should consider its
use when one side of the arch is intact and several primary
3. The transpalatal arch is soldered to molar bands and runs directly across the palatal vault, avoiding contact with the soft
tissue. The wire follows the vault of the palate, is comfortable, and does not interfere with normal speech (photograph
courtesy of Space Maintainers Laboratory, Chatsworth, Calif).
4. This transpalatal arch has succeeded in maintaining the space in an 11-year-old patient who had undergone multiple
extractions of primary molars. The appliance has an omega-type central loop. The central loop may be oriented either
mesially or distally.
5. Transpalatal arches are regularly used in orthodontics in either permanent and mixed dentition treatments to: (1) es-
tablish and maintain arch widths; (2) derotate unilaterally or bilaterally rotated molars; (3) control upper molar eruption;
and (4) correct unilateral crossbites.
PEDIATRIC DENTISTRYV 29 /NO 3 MAY/JUNE 07
teeth are missing on the other side. In this situation, the rigid
attachment to the intact side may provide adequate stability
for space maintenance.2
Clinicians are encouraged to experience the transpalatal arch
appliance as an alternative to the Nance appliance. Further
research is needed to determine its effi cacy and success in
clinical situations involving bilateral loss of primary molars.
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developing occlusion. In: McDonald RE, Avery Dean JA,
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of functional tongue forces imparted on a palatal bar. J
Osaka Dent Univ 1993;27:51-66.
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illary molars during swallowing. J Osaka Dent Univ
14. Christiansen RL, Evans CA, Sue SK. Resting tongue
pressures. Angle Orthod 1979;49:92-7.
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palate during swallowing. J Am Dent Assoc 1962;65:319-30.
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relationship to overbite. Angle Orthod 1951;21:34-43.
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mal swallowing habit: Its causes, eff ects, and results in
relation to orthodontic treatment and speech therapy.
Am J Orthod 1961;47:596-617.
18. Chiba Y, Motoyoshi M, Namura S. Tongue pressure on
loop of transpalatal arch during deglutition. Am J Orthod
Dentofacial Orthop 2003;123:29-34.
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maxillary molars during swallowing. J Osaka Dent Univ
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Orthod Dentofacial Orthop 1994;106:403-8.