brief description of how to perform the royal London space analysis

1. The Royal London Space Planning:
An integration of space analysis and
treatment planning
Robert H. Kirschen et. al.
‫الرحيم‬‫الرحمن‬‫هللا‬ ‫بسم‬
Mohanad Elsherif
BDS (U of K), MFD RCSI, MFDS RCPS(Glasg), MSc (Orthodontics), M.Orth. RCSEd
University of Khartoum
Faculty of Dentistry
Department of Orthodontics

2. Importance of space in
Ortho

3. Why do we need space?
 Correction of crowding.
 Retraction of proclined teeth.
 Reduction of increased overjet and
overbite.
 Leveling of steep curve of Spee .
 Derotaion of anterior teeth.
 Correction of unstable molar relations
(i.e. Cl II and Cl III molar relations).

4. Introduction
 The Royal London Space Planning has evolved
since 1985 as part of the postgraduate training
program at the Royal London Hospital.
 The purpose of the Royal London Space Planning
is to quantify the space required in each dental arch
to attain the treatment objectives in the permanent
or late mixed dentition and to quantify the space
implications of treatment mechanics.

5. introduction
 Specifically, the Royal London Space Planning will help the clinician:
 To ensure a disciplined approach to treatment planning.
 To define whether the objectives are attainable and modify them if necessary.
 To anticipate a shortage of anchorage or excess of space.
 To decide the need for extractions and choice of extractions.
 To plan the mechanics of anchorage control.
 To plan the mechanics of correction of arch relationship.
 To improve pretreatment patient information.
 To obtain valid informed consent.

6. Assessment of Space
Requirement
 Six specific aspects of the occlusion are considered for which
any change has an effect on the space required. These are:
 Crowding and Spacing.
 Leveling Occlusal Curves.
 Arch Expansion and Contraction.
 Incisor A/P Change.
 Angulation (Mesiodistal Tip).
 Inclination (Torque).

7. Assessment of Space
Requirement
 The measurements are taken and scores recorded
to the nearest millimeter or, at times, half
millimeter.
 The measurements are positive when space is
present or is created (eg, by arch expansion) and
negative when there is crowding or space is
required (e.g. for incisor retraction).

8. Assessment of Space
Requirement
1. Crowding and Spacing:
 The difficulty when quantifying
crowding is to decide “in relation to
what.”
 Clearly, crowding will be quantified
as less severe if the archform
selected passes through the most
prominent incisor and buccally
displaced canine, and more severe if
it passes through lingually displaced
teeth.

9. Assessment of Space
Requirement
1. Crowding and Spacing:
 Crowding and spacing should be quantified
in relation to the archform that reflects the
majority of teeth, not necessarily the
imaginary arch that passes through the incisal
edge of the most prominent central incisor in
each arch.
 The line of arch selected does not
necessarily represent a treatment objective,
as a separate assessment is made for arch
width and for the anteroposterior position of
the labial segments.

10. Assessment of Space
Requirement
 The method recommended for assessment is to use a clear ruler over the
occlusal or labial surface of study models to measure the mesiodistal width of
misaligned teeth and available space in the archform selected.

11. Assessment of Space
Requirement
 This technique has been found to be preferable to using calipers
to measure all the teeth and a brass wire to assess arch length; that
method is less reliable, probably because of cumulative error or
bias that arises from the need to measure every tooth rather than
just the misaligned ones.
 The assessment of crowding of 2 adjacent teeth can be
undertaken together by measuring the mesiodistal width of each
tooth and the combined space available. This method is not
recommended for 3 or more teeth as the difference between chord
and arc becomes significant.

12. Assessment of Space
Requirement
 Crowding and spacing are assessed anterior to the mesial
surface of the first molars. The permanent teeth are considered as
they present, regardless of size.
 When the second primary molars are present, up to 1 mm
spacing is allowed for upper E space (the size difference between
primary and permanent tooth) and up to 2 mm for lower E space.
 What If the patient is at an earlier stage in the mixed dentition?
 Estimations of the size of the permanent unerupted teeth can
be made with the aid of radiographs, proportionality tables, or
both.

13. Assessment of Space
Requirement
2. Leveling Occlusal Curves
 Space is required to level a curve of Spee, but accurately quantifying this space is very
difficult.
 It is incorrect to assume that the process is equivalent to the 2-dimensional
straightening of a curved line, or that the space required is the difference between an arc
of a circle and its chord.
 An increased occlusal curve is due to a series of slipped contact points in the vertical
dimension.
 it is the restoration of the contact point relationships between neighboring teeth that
demands increased space within the dental arch.
 This slippage is usually too slight at any one contact point to be recorded as a form of
crowding, but when an arch is taken overall, space is required for leveling.
 If teeth were parallel-sided (cylindrical), no space would be required when leveling an
occlusal curve. Where the teeth are bulbous, the space implications are greater.

15. Assessment of Space
Requirement
 The Royal London Space Planning assesses occlusal curves in relation to a plane from
the distal cusps of the first molars to the incisal edges.
 Two other considerations are relevant:
 First, the space implication should be recorded only if the premolars have not been
assessed as crowded; it would be another example of double counting for premolars to be
assessed both as crowded and as needing space from leveling the occlusal curve.
 Second, clinical judgment is necessary as occlusal curves need not be leveled in all
cases.
 Assess the depth of curve from premolar cusps to a flat plane on distal cusps of first
molars and incisors. Only one value is given for the arch, and only if the premolars have
not been assessed separately as crowded. Allow 1 mm space for 3 mm depth of curve, 1.5
mm for 4 mm depth, and 2 mm space for a 5 mm curve.

17. Assessment of Space
Requirement
3. Arch Expansion and Contraction
 It seems logical there should be a direct one-to-one relationship
between arch expansion and the creation of space.
 For the purpose of space planning, each millimeter expansion of the
intermolar width will create approximately 0.5 mm space within the
arch.
 The space created may be greater when overall arch expansion is
achieved by splitting the palatal suture.
 The buccal or lingual movement of an individual tooth does not
constitute a change in arch width, as this would be assessed in the
analysis of crowding.

18. Assessment of Space
Requirement
4. Incisor A/P Change
 It may be desirable to alter the anteroposterior position of the lower
incisors, in either direction, depending on the specifics of the malocclusion as
assessed clinically and cephalometrically.
 The upper incisors are then corrected in the analysis to an overjet of 2 to 3
mm in relation to the position selected for the lower incisors.
 It is essential that the incisors selected for the measurement of overjet and
cephalometric tracing correspond to those used to define the archform in
relation to which crowding and spacing are assessed.
 For the purpose of space planning, each millimeter of incisor advancement
or retraction will create or consume 2 mm of space within the dental arch.

20. Assessment of Space
Requirement
5. Angulation (Mesiodistal Tip):
 If upper incisors are too vertical, they
take up less space in the arch than if
correctly angulated.
 Very occasionally, teeth are over
angulated, and space is gained by
correction to normal angulation.
 Applies only to maxillary incisors.
Allow 0.5 mm space for correction of
each parallel sided vertical tooth
(usually no allowance is necessary).

21. Assessment of Space
Requirement
6. Inclination (Torque)
 Andrews pointed out the importance of the
inclination of upper incisors if they are to
occupy the correct amount of space, and that
failure in this respect would lead either to
incorrect buccal occlusion or to spacing. Correct
inclination is also important to ensure optimum
esthetics.
 Applies only to maxillary incisors. Allow 1 mm
space for every 5° change affecting all 4 incisors,
and 0.5 mm space if only 2 teeth are affected.

22. Integration of space requirement
component
 Among the 6 factors considered, only crowding and spacing, arch width
change, and incisor anteroposterior change can have substantial space
implications. The other factors—occlusal curves, angulation, and inclination of
teeth—are associated with only small amounts of space.
 The difference in the total space required for the upper and lower arches
requires clarification:
 Class I molars are associated with a space requirement that is equal in both
upper and lower arches, unless there is a disproportion in the size or number
of teeth between the arches (eg, small or absent maxillary lateral incisors).
 Assuming 7 mm premolars, bilateral full unit Class II occlusions are
associated with an upper space requirement 14 mm greater (more negative)
than the lower; a 7 mm discrepancy would imply one half unit Class II molars.

24. Exercise One
A 13 years old female patient with a chief complain of sticking-out upper
front teeth. Clinically she presented with a class II Div 1 malocclusion on
a class II skeletal base and average lower vertical facial proportion. Her
malocclusion was complicated by:
 Moderate upper arch crowding (-7 mm)
 Mild lower arch crowding (-3 mm)
 Increased overjet (6 mm)
 Proclined upper inciosrs (UIMP = 120)
 Increased lower curve of spee (4 mm)

25. Exercise Two
A 15 years old male patient with a chief complain of crooked upper front
teeth. Clinically he presented with a class II Div 2 malocclusion on a mild
class II skeletal base and decreased lower vertical facial proportion. His
malocclusion was complicated by:
 Upper arch crowding (-8 mm)
 Palataly displaced upper lateral incisors and are in crossbite
 Mild lower arch crowding (-3 mm)
 Overjet (3 mm)
 Bilateral Scissor bite (4 mm wider maxilla)
 Retroclined upper incisors (UIMP = 95)

26. Exercise Three
A 14 years old female patient with a chief complain of Front to back bite.
Clinically she presented with a class III malocclusion on a class I skeletal
base and average lower vertical facial proportion. Her malocclusion was
complicated by:
 Moderate upper arch crowding (-5 mm)
 Lower arch spacing (2 mm)
 Reversed overjet (-1 mm)
 Unilateral posterior corssbite ( maxilla in narrow by 3 mm)
 Proclined upper incisors (UIMP = 130)
 Mesially angulated upper central incisors (10°) {normal value is 4°}

27. Declaration
 The author wish to declare that; these presentations are his original work, all
materials and pictures collection, typing and slide design has been done by the
author.
 Most of these materials has been done for undergraduate students, although
postgraduate students may find some useful basic and advanced information.
 The universities title at the front page indicate where the lecture was first
presented. The author was working as a lecturer of orthodontics at Ibn Sina
University, Sudan International University, and as a Master student in Orthodontics at
University of Khartoum.
 The author declare that all materials and photos in these presentations has been
collected from different textbooks, papers and online websites. These pictures are
presented here for education and demonstration purposes only. The author are not
attempting to plagiarize or reproduced unauthorized material, and the intellectual
properties of these photos belong to their original authors.

28. Declaration
 As the authors reviews several textbooks, papers and other references during
preparation of these materials, it was impossible to cite every textbook and journal
article, the main textbooks that has been reviewed during preparation of these
presentations were:
Contemporary Orthodontics 5th edition; Proffit, William R, Henry W. Fields, and
David M. Sarver.
Handbook of Orthodontics. 1st edition; Cobourne, Martyn T, and Andrew T. DiBiase.
Clinical cases in orthodontics; Martyn T. Cobourne, Padhraig S. Fleming, Andrew T.
DiBiase, Sofia Ahmad
Essentials of orthodontics: Diagnosis and Treatment; Robert N. Staley, Neil T. Reske
Orthodontics: Current Principles & Techniques 5th edition; Graber, Lee W, Robert L.
Vanarsdall, and Katherine W. L. Vig
Evidence based Orthodontics; Greg J. Huang, Stephen Richmond, Katherine W.L. Vig.

29. Declaration
 For the purposes of dissemination and sharing of knowledge, these
lectures were given to several colleagues and students. It were also
uploaded to SlideShare website by the author. Colleagues and students
may download, use, and modify these materials as they see fit for non-
profit purposes. The author retain the copyright of the original work.
 The author wish to thank his family, teachers, colleagues and students
for their love and support throughout his career. I also wish to express
my sincere gratitude to all orthodontic pillars for their tremendous
contribution to our specialty.
 Finally, the author welcome any advices and enquires through his
email address: Mohanad-07@hotmail.com

30. Thank You