1

T h e s e p a p e r s a r e m e a n t t o b e a s e c o n d a r y r e f e r e n c e o n l y S l a s h e r X
Space Maintainers
|Q| what are the factors that after premature loss of primary Lower molars influence malocclusion?
- Abnormality in the oral musculature:
o An abnormal high tongue + Strong mentalis muscles + loss of mandibular primary molars = Very damaging to
occlusion leading to collapse of dental arch + drifting of the anterior segment
- Oral Habits. (thumb sucking, Finger sucking etc)
- Presence of existing malocclusion: an present malocclusion (Inadequate arch length, Class II Division 1) will become
progressively more sever after the loss of the mandibular primary molars.

|Q| what are the indications of Space maintainers?
- Time Factor:
o Space closure usually occurs 6 months after extraction and after Several years after premature extraction some unfavorable
changes may occur to occlusion.
o To reestablish the occlusion a space maintainer is required, and if the space is insufficient for the future eruption of the
permanent successor a space regainer is needed to regain the lost space.

- Age:
o The developmental age is more important than the chronological age.
o The average date of eruption must not effect and influence the construction of a space maintainer, why? because there is a
variation in the time of eruption, thus the doctor should depend on the X-ray to provide useful information to when the
eruption will occur instead of eruption tables.

- Amount of bone covering the un-erupted tooth:
o This can help provide the important information about the eruption time.
o The amount of bone covering the crown of the permanent incisors can indicate when eruption will occur, this means if there
is a large amount of bone covering the crown its still many months till eruption, but if there bone destruction (Alveolar
abscess related to the primary Molar) then the permanent successor will erupt before its eruption date.

- Degree of development of the permanent successors:
o Teeth dont move into its crypt till after complete calcification of the crown and beginning of root formation.
o If the deciduous tooth is extracted at the time the crown of the permanent successor isnt fully formed there is a chance that
there will be complete wound healing and bone formation thus delaying its eruption, while if the extraction occurred when
the permanent successors root formation begun than it may erupt 6 months earlier than the expected.

- Sequence of the eruption:
o Observation on the relationship between the developing/erupting teeth and the teeth adjacent to the space created due to
premature loss is very important.
E.g.: If the (E) is prematurely lost + the (7) is erupting early = the (7) during eruption will push the (6) Mesial Drifting into the
(E) space thus occupying the space required for the (5). all teeth are lower

- Delayed eruption of the permanent teeth:
o Sometimes individual teeth may be delayed in their development leading to delaying eruption.
E.g.: partially impacted teeth or deviation in the pathway of eruption will delay eruption,
In this case the primary teeth are extracted +Construction of space maintainer to allow the permanent teeth to erupt
and assume its normal position.



2
T h e s e p a p e r s a r e m e a n t t o b e a s e c o n d a r y r e f e r e n c e o n l y S l a s h e r X
|Q| how would you determine the arch length before construction of a space maintainer?
- The dentist should find out :
o The size of the permanent teeth that are going to erupt (specifically the teeth anterior to the lower 6)
o The amount of mesial drift that will occur to the lower 6 after extraction of the Lower D and Lower E.
- Nance Analysis:
o He said that the length of the dental arch from the mesial surface of the lower 6 to the mesial surface of the other lower 6,
always shorten during the transaction from mixed dentition to permanent dentitions.
o Leeway space = is the difference in mesial-distal width of the primary teeth (C, D, E) and permanent successors (3, 4, 5)
[Primary is always bigger than permanent]
Leeway space of the maxilla = 0.9 mm on each side Leeway Space on the mandibular = 1.7 mm on each side
o Tools needed:
Set of periapical radiographs, a millimeter ruler, a brass wire (0.65 mm), a 3X5 ruled card for measurement recording and
study cast.
o Measurements:
Space needed =
Width of the lower permanent incisors from the study cast.
Width of the unerupted lower canine, 1st premolar and 2
nd
premolar from the Periapical radiographs

Space Available = Length of the dental arch =
The brass wire is contoured to follow the arch form of the lower study cast and must pass over the buccal cusps of
the posterior teeth and incisal edge of the anterior teeth (from the mesial surface of the lower 6 till the mesial side of
the other lower 6.
Subtraction of the leeway space 3.4 mm (1.7 mm on each side)

- By Comparing the values of the space needed and space available, the dentist can predict with a fair degree of accuracy the
sufficiency of the arch.

|Q| what are the different designs for a space Maintainer for the first primary molar area?
- The effect of the premature loss of the primary first molar on occlusion depends on the stage of development of occlusion at
the time of loss. This means:
If the Lower D is lost during active eruption of the lower 6, the lower 6 will tip the Lower E into the space required for the
lower 4.
If the lower D is lost during active eruption of the Lower 2, the lower C will tip into the space of the space required for
lower 4 and there will also be a shift in the midline towards the affected area and increased overbite.
- Treatment:
1. Band and Loop Maintainer. The loop is made of 0.7 mm stainless steel wire.
Advantages Disadvantages
Easy to use, cheap cost of material
Appliance gives room for erupting permanent teeth
Will not restore mastication function
Will not prevent over eruption of the opposing tooth.


2. Chrome steel crown and Loop Maintainer.
Indicated if the posterior abutment teeth that needs a crown restoration, like: abutment with extensive caries or an abutment
that had vital pulp therapy. The loop may be cut once the need of the loop isnt required (No need for
maintain space) and the crown can continue as a separate restoration for the abutment. The loop is
made of 0.7 mm stainless steel wire.
Advantages Disadvantages
Easy to use, cheap cost of material
Appliance gives room for erupting permanent teeth
Will not restore mastication function
Will not prevent over eruption of the opposing tooth.



+
-
3
T h e s e p a p e r s a r e m e a n t t o b e a s e c o n d a r y r e f e r e n c e o n l y S l a s h e r X
Study without desirespoilsthememory, and it retainsnothingthat it takesin.
Leonardo Da
Vinci
|Q| what are the different designs for a space Maintainer for the second primary molar area?
- Its loss has less effect on the anterior teeth than the loss of the 1
st
primary molar.
- But it will affect the permanent molar relationship.
- The end result of losing the 2
nd
primary molar loss is mesial drifting of the first molar and impaction of the 2
nd

premolar.
- Treatment depends on the time of eruption of the first permanent molar:
1. After eruption of the first molar:
Band and loop or Chrome steel crown and loop.
2. Before eruption of the first molar:
Because of the mesial movement of the permanent first
molar that will occur after premature loss of the lower E.
Thus the need for a space maintainer that will guide
the permanent first molar into correct position, which
is a crown or band maintainer with a distal shoe extension, and the first
primary molar is the abutment.






|Q| what are the different designs for a space Maintainer for the second primary canine area?
- If the loss of the Primary canine occurs before the eruption of the permanent lateral incisors.
1. There will always be a shift of the midline and space closure.
2. But if the space isnt closed and there is no shift in the midline just yet. A band or crown with loop maintainer can
be used and the first primary molar is the abutment tooth.

|Q| what are the different designs for a space Maintainer for the second primary incisors area?
- If spacing between the anterior teeth is present when the primary tooth is lost little chance of drifting of the
adjacent teeth and loss of space needed for the permanent teeth
- If anterior teeth are in contact before primary tooth loss / evidence of insufficient arch length after the loss
collapse of the anterior arch after the loss of the primary tooth and in some cases drifting of the primary canine
anteriorly.
- Treatment:
1. Removable Partial dentures:
Gives good esthetics, reestablish function, prevent abnormal speech and tongue habits.
Acrylic dentures can be used for very young if the child is co-operative and interested.
Contraindicated if there is severe caries problem, no interest in oral hygiene, difficult oral
hygiene, and uncooperative child.

2. Modified Fixed Partial Dentures:
Bands are adapted on the last molars in the arch.
A wire arch is adapted on the bands touching the lingual surface of the posterior teeth
passively.
The wire arch continues over the edentulous ridge area and engulfed with acrylic base.

4
T h e s e p a p e r s a r e m e a n t t o b e a s e c o n d a r y r e f e r e n c e o n l y S l a s h e r X
|Q| what are the different designs for a space Maintainer for the permanent incisors area?
- It requires an immediate treatment, why? Because after the loss of the tooth, the adjacent teeth will drift and within a few
weeks the space would lose several millimeters. An alginate impression is taken and then construction of the temporary
appliance is made to prevent space closure.
- If any degree of closure occurs after loss of anterior tooth the space should be regained before the construction of the space
maintainer, and it depends if:
If there are no other irregularities in occlusion and no need for bodily movement of teeth a general practitioner can build it.
If there are other irregularities in occlusion or need for bodily movement of teeth a Professional orthodontist is needed.
- Treatment:
Cervical clasps are adapted on the first permanent molar to help in retention.
Contour the finger springs to the teeth that should be repositioned. The finger spring shouldnt be changed more than 0.5
mm each 2-3 weeks.
The wire should be placed Cervical as possible.
To improve esthetics a tooth replacement maybe used.
After the space is regained, use of a new partial denture can be used till the time of the fixed replacement.
An additional acrylic extension into the alveolus is needed to guide the unerupted tooth into normal position. E.g.: In case of
the loss an maxillary central incisor before the eruption of permanent lateral incisors, the lateral will drift mesially during its
eruption.

|Q| what are the different designs for a space Maintainer for the first permanent molar area?
- Loss of the first permanent molar after the eruption of the second permanent molar.
Discussion is made weather the space should be kept for a bridge or the 2
nd
molar placed in its position by bodily movement
Bodily movement is satisfactory and the opposing arch will have the 3
rd
molar removed.
IF the space is kept ,
o Use of a band or chrome steel crown and loop to maintain the space.
o A modified bridge can be used but it will cause gingival recession.
o The space maintainer can be replaced once growth is complete and with a bridge.
- Loss of the first permanent molar before the eruption of the second permanent molar:
If no treatment Is done, the 2
nd
molar will drift mesially after eruption and repositioning this tooth can be done
orthodontically, but the child will have to wear the space maintainer for a long time until when its possible to build a fixed
bridge. The opposing first permanent molar is often recommended to be removed (Even though its healthy and sound), to
prevent it from supra-erupting during the long period of wearing the space maintainer.
If the first permanent molar is extracted years before the eruption of the first permanent molar, there is an excellent chance
that the 2
nd
molar will erupt in an acceptable position with an axial inclination slightly greater than normal.
- The decision to let the 2
nd
molar to drift or stay in position is influence by the presence of a 3
rd
molar in normal size, if there is
possible questioning in the condition of the development of the 3
rd
molar repositioning the drifted molar to normal location
and using it as the distal abutment for the fixed bridge.
- If the decision is to maintain the space, use of band and loop/chrome steel crown with loop with distal shoe extension is the
best choice.


|Q| classify the space maintainer and give examples?
According to function According to activity According to retention means
Functional Non-functional Active Passive Removable Semi fixed Fixed
Partial denture
Complete denture
Spoon denture
Modified Fixed
Partial Dentures
Band with loop
Crown with loop
Passive Lingual Bar
Passive trans-palatal bar
Active lingual bar
Active trans-palatal bar
Space regainer

Active lingual bar
Active trans
palatal bar
Space regainer
Band with loop
Crown with loop
Passive Lingual Bar
Passive trans-palatal bar
Partial denture
Complete denture
Spoon denture
Modified Fixed Partial Dentures
Partial denture
Complete denture
Spoon denture
Active lingual bar
Active trans palatal bar
Space regainer
Crown with loop
Passive Lingual Bar
Passive trans-
palatal bar
Modified Fixed
Partial Dentures
Band with loop




5
T h e s e p a p e r s a r e m e a n t t o b e a s e c o n d a r y r e f e r e n c e o n l y S l a s h e r X
|Q| what are the different designs for a space Maintainer for an area with multiple loss teeth?
- Acrylic Partial Denture:
Indication: when there is bilateral loss of more than a single tooth.
Advantages: easily adjusted to allow for eruption of teeth, artificial dentures teeth restore esthetics and mastication.
Disadvantages: Easily broken, if denture is removed from the mouth for a few days drifting of teeth will occur, possible of
development of new carious lesions unless proper cleaning of the teeth and denture.
Retention: stainless steel wire clasps on the canines (if present) and stainless steel wire rests for the molars.
Claps are advised to be removed in case of active eruption of permanent incisors and child is used to the denture, why?
To allow distal drifting and lateral movement of the canines and alignment of the permanent incisors.
If the primary molar (one of both) are lost a short time before the eruption of the first molars. The acrylic denture is preferable
over the distal shoe. The distal boarder of the acrylic denture is placed close to the mesial surface of the un-erupted first
permanent molar. Also to influence the molar eruption more favorably scrapping the model in this area to get an accentuated
post dam.

- Passive Lingual Bar:
The best choice sometimes for multiple teeth loss.
Advantages: eliminates the need for patient cooperation, there is no breakage problem, no concern about if the child is
wearing it or not (because its fixed) and less caries possibility.
Disadvantages: no restoring of function.
Design:
Orthodontic bands are adapted on the first permanent molars or most posterior.
An alginate impression is taken, bands are removed and the build the stone model.
0.8 mm stainless steel wire should be contoured to the arch extending forward and making contact
with the cingulim of the anterior teeth at the gingival margin, why? so that it wont interfere with
the anterior teeth.
The arch wire should extend posteriorly along the middle 1/3 of the lingual surfaces of the molars
bands and solder in position in an inactive state.
Polish and cement. The appliance should be completely passive to prevent undesirable movement.

- Active lingual Bar:
In case of multiple loss of teeth + loss of space in older children + fully eruption of first molars and permanent incisors.
Active lingual arch (with U loops) will be constructed with bands and will be cemented to the first permanent molar.
Before insertion the U loop is activated to distalize the molars.


- Trans-palatal bar:
Bands will be adapted to the maxillary first permanent molar and a bar is adapted to the palate and
soldered to the bands, thus preventing the mesial movement of the molars as it rotates around its
palatal root.

- Active Trans-palatal Bar:
When there is mesial movement of the maxillary first permanent molar with rotation.
Use of a U loop to distalize and regain the original position of the first permanent molar.

- Full denture:
Indications: loss of all teeth due to wide spread of oral dieses and infection, extensive decay or cases of complete anodontia.
Advantages: esthetics, restore function and effective to some degree in guiding the first permenet molar into correct position.
Its made the same way any complete denture is made, except:
The posterior margin of the denture can contoured at the mesial surface of the un-erupted first permanent molar to guide it.
Adjustments can be made to accompany the eruption of the permanent incisors.
A partial denture space maintainer or a lingual arch can be made to serve after the complete denture until the remaining
teeth are erupted.