SPACE

MAINTAINERS
SPACE MAINTENANCE IN THE
PRIMARY DENTITION

Space maintainers are appliances

used to maintain space or regain
minor amounts of space lost by
primary tooth or group of teeth,
So as to guide the unerupted tooth
into a proper position in the arch.
Objectives of space maintenance
Preservation of primate space
Preservation of integrity of dental arches
Preservation of normal occlusion
Esthetic and phonetic preservation in
anterior teeth
 IDEAL REQUIREMENTS of Sp.M

1. It should maintain the entire mesio-

distal space created by a lost tooth.

2. It’s preferred to restore the function

as far as possible &
3. prevent over-eruption of opposing
teeth.

4. It should be simple and strong.

5. It should be strong enough to withstand

the functional forces.
6. It should not exert excessive stress
on adjoining teeth.
7. It must permit maintenance of oral
hygiene.
8. It must not restrict normal growth
& development and natural
adjustments which take place during
the transition from deciduous to
permanent dentition.
9. It should not come in the way of
other functions.
 PLANNING FOR SPACE MAINTENANCE

The following factors are important to

the dentist when space maintenance is
considered after the untimely loss of
primary teeth-
1) Time elapsed since tooth loss.
If space closure occurs,it usually takes
place during the first 6 months after
the extraction.When a primary tooth is
removed & all factors indicate the need
for space maintenance,it is best to
insert an appliance as soon as possible
after the extraction.
2) Dental age of the patient-
The chronologic age of the patient is not so
important as the developmental age.
Gron studied the emergence of permanent
teeth based on the amount of root
development,as viewed on radiographs,at
the time of emergence.
She found that teeth erupt when three-
fourths of the root is developed,regardless
of the child’s chronologic age.
3) Amount of bone covering the
unerupted tooth-
if there is bone covering the crowns,it can be
readily predicted that eruption will not occur for
many months,a space-maintaining appliance is
indicated.

4) Sequence of eruption of teeth-

the dentist should observe the relationship
of developing & erupting teeth adjacent to the
space created by the untimely loss of a tooth.
5) Delayed eruption of the
permanent tooth-
 in case of impacted
permanent tooth,it is necessary to
extract the primary tooth,construct a
space maintainer & allow the permanent
tooth to erupt at its normal position.

If the permanent teeth in the same area

of the opposing dentition have erupted,it
is advisable to incorporate an occlusal
stop in the appliance to prevent
supraeruption in the opposing arch.
6) Congenital absence of the permanent
tooth-
if permanent teeth are
congenitally absent,the dentist must decide
whether it is wise to hold the space for many
years until a fixed replacement can be
provided or it is better to allow the space to
close.
If the decision is made to allow
the space to close,there will rarely if ever be
bodily movement of the teeth adjacent to the
space.Therefore,orthodontic treatment will be
needed to guide the teeth into a desirable
position.
7) Presentation of problems to
parents-
Take sufficient time to explain existing
conditions & discuss the possibility of the
development of a future malocclusion if
steps are not taken to maintain the space
or to guide the development of the
occlusion.
Also explain that the space-maintaining
appliance will not correct an existing
malocclusion but will only prevent an
undesirable condition from becoming worse
or more complicated.
8. Amount of Space Loss
a . Loss of maxillary second primary molars
results in the greatest amount of closure , up to
8 mm of space loss in a quadrant .
b . Loss of mandibular second primary molars
shows the next greatest amount , up to 4 mm in
a quadrant .
c . Loss of upper or lower first primary molars
shows almost equal amounts of space closure
when compared with one another , the amount
is most affected by timing of the first primary
molar loss .
d . Space loss potential is particularly high if the primary molar loss
occurs in approximation to first permanent molar eruption , irrespective
of which primary molar is lost and in which arch the loss occurs
e . After first permanent molars have erupted into occlusion , loss of
second primary molars may still result in significant space closure .
f Loss of a first primary molar with retention of the second primary
molar shows minimal amounts of space closure because the second
primary molar serves to buttress first permanent molar positions after
occlusion is established .

9. Rate of Space Closure

a . The younger the patient , more is the space loss .
b . Maximum space is lost during first 6 months of extraction and most
immediate loss is within 76 hours .
10. Direction of Space Closure
 Maxillary posterior spaces close predominantly by mesial
bodily movement and mesiolingual rotation around the
palatal root of the first permanent molars .
 Only minimal mesial crown tipping of the first molar is
usually noted . In contrast , mandibular spaces close
primarily by mesial tipping of the first permanent molars ,
along with distal movement and retroclination of teeth
anterior to the space .
 Bodily movement of first molars is not typically notable
in the lower arch as seen in the upper arch . Lower molars
also tend to roll lingually in conjunction with their mesial
crown - tipping during space loss movements . 5. Eruntion
Status of the Adiacent Teeth
11. Eruption Status of the Adjacent
Teeth
It helps us ascertain mesial shift for molars and
distal tipping for canines . For example , if the first
primary molar is lost during the time of active
eruption of the first permanent molar , a strong
forward force will be exerted on the second primary
molar , causing it to tip into the space required for
the eruption of the first premolar . In addition , if the
loss of the second primary molar occurs after the
first permanent molars have fully erupted and
normal cuspal interdigitation has been established ,
the degree of space loss should be less dramatic than
earlier during molar transition
12. Eruption Status of the Succedaneous

Tooth It is estimated by the amount of root

completion ( tooth erupts in oral cavity after 2 / 3rd
root formation ) . Teeth normally erupt when three
fourths of the root is developed , regardless of the
child's chronologic age . However , the eruption
timing of a permanent successor may be delayed or
accelerated after premature loss of a primary tooth ,
depending on the developmental status , bone
density of the area , and nature of the primary tooth
loss . Very early loss before significant root
formation of the permanent successor usually results
in delayed eruption timing .
13. Abnormal oral musculature
( Abnormal Oral Habits )
They will exert abnormal pressure on dental
arches and so may influence the type and planning
of space maintainer .
Strong mentalis muscle patterns may have a
pronounced negative effect after loss of
mandibular primary molars or canines , with
collapse of the arch and the distal drifting of the
anterior segment that is often exhibited .
Thumb or finger habits may similarly produce
abnormal forces in initiating collapse of the dental
arches after untimely loss of primary teeth .
14. Arch Length Adequacy
 This will be estimated by position of incisors , Leeway space
and incisor liability :
 a . If analysis indicates a positive arch length or deficiency of
less than 1 to 2 mm per quadrant , a space maintainer may be
beneficial in holding tooth position . If the pace is not held ,
the total arch length may be further decreased and lead to
possible premolar extraction requirements . Holding the
space may allow the permanent premolars and canines to
erupt and utilize leeway space to alleviate anterior crowding .
 b . If the arch length deficiency is 2 to 3 mm or more per
quadrant , a significant discrepancy exists where space
regaining , serial extraction , and / or comprehensive
orthodontic treatment may be indicated
c . If there is no question that permanent
teeth will have to be removed to obtain a
favorable occlusion , space maintenance
may not be desirable because the space
would need to be closed during
orthodontic treatment anyway . In less
obvious extraction cases , holding the
space to allow teeth to erupt and prevent
impactions can be a valuable service .
15. Miscellaneous Factors
These factors influence planning because
they may be associated with either space
gain or space loss . Some of these factors
are growth of jaws , proximal caries ,
wear and attrition .
Types of space maintainers
 APPLIANCE THERAPY
Fixed space Removable space
maintainers- maintainers-
Band & loop space
maintainer. Acrylic partial
Crown & loop dentures.
appliance. Full or complete
Lingual arch. dentures.
Palatal arch
appliance. Removable distal shoe
Transpalatal arch. space maintainer.
Distal shoe.
Esthetic anterior
space maintainer.
Band & Bar type
space maintainer.
Four appliances generally used to
maintain space in the primary
dentition are-
The Band & Loop
The Lingual Arch
The Distal Shoe
The Removable Appliance
 Fixed Space Maintainers

Space maintainers which are fixed or fitted onto the

teeth are called fixed space maintainers.
ADVANTAGES:
1. Bands and crowns are used which require minimum or
no tooth preparation.
2. They do not interfere with passive eruption of
abutment teeth.
3. Jaw growth is not hampered.
4. The Succedaneous permanent teeth are free to erupt
into the oral cavity.
5. They can be used in un-co-operative patients.
6. Masticatory functions is restored if pontics are
placed.
DISADVANTAGES:
1. Elaborate instrumentation with expert
skill is needed.
2. They may result in decalcification of
tooth material under the bands.
3. Supra eruption of opposing teeth can
take place if pontics are not used.
4. If pontics are used it can interfere
with vertical eruption of the abutment
tooth & may prevent eruption of replacing
permanent teeth if patient fails to report.
 CONSTRUCTION-
The fixed space maintainer generally are
constituted of the following components-
a) Band
b) Loop / arch wire
c) Solder joint
d) Auxiliaries
 BAND-
The band forms an important part of
the constructions of the various fixed
appliances several bands are employed such
as-
1) Loop bands
2) Tailored bands
3) Preformed seamless bands
made of precious metal or chrome alloy.
Every band should possess a few ideal
criteria such that-

It should fit the contours of the tooth as

closely as possible,thereby enhancing the
placement of the attachment in relationship
to the tooth.
Should not extend subgingivally any more
than necessary.
Band material should resist deformation
under stresses in the mouth.
Resist tarnish.
Inherent springiness.
Cause no occlusal interference.
STEPS IN BAND FORMATION-
A) Separation of teeth
By (i) Brass wire
(ii) Elastic threads
B) Band formation
By (i) Direct formation
-Band pinching
-Festooning
-Trimming
-Folded flap
(ii) Preformed bands
(iii) Indirect band technique
C) Welding
D) Soldering
WELDING-
It is the process during which a
portion of the metal being joined is
melted & flowed together.
Bands are generally joined by
welding.
SOLDERING-
It is the process by which the
two metals are joined together by
an intermediary metal of a lower
fusion temperature.

The most common solder used is

the silver solder containing
silver,zinc,copper & tin.
REMOVABLE APPLIANCE
The appliance is typically used when more than
one tooth has been lost in a quadrant.
It is often the only alternative because there
are no suitable abutment teeth and because the
cantilever design of the distal shoe or the band
and loop is too weak to withstand occlusal
forces over a two-tooth span.
Not only can the partial denture replace more
than one tooth, it also can replace occlusal
function.
Two drawbacks of the appliance are retention
and compliance.
Advantages:

1. Easy to clean and permit maintainance of

proper oral hygiene.
2. Maintain or restore the vertical dimension.
3. Can be worn part time allowing circulation of
the blood to the soft tissues.
4. Room can be made for permanent teeth to
erupt without changing the appliance.
5. Stimulate eruption of permanent teeth.
6. Help in preventing development of tongue
thrust habit into the extraction space.
DISADVANTAGES:
1. May be lost or broken by the patient.
2. Un-co-operative patients may not
wear the appliance.
3. Lateral jaw growth may be
restricted, if clasps are incorporated.
4. May cause irritation of the undrelying
soft tissues.
 Indication:
1.When aesthetics is of importance.
2.In case the abutment teeth cannot support a
fixed appliance.
3.In cleft palate patients who require obturation
of the palatal defect.
4.In case the radiograph reveals that the
unerupted permanent tooth is not going to erupt
in less than five months time.
5.If the permanent teeth have not fully erupted
it may be difficult to adapt bands.
6.Multiple loss of deciduous teeth which may
require functional replacement in the form of
either partial or complete dentures.
 CONTRAINDICATIONS-
1.Lack of patient co-operation.
2.patients who are allergic to acrylic
material.
3.Epileptic patients.
BAND & LOOP APPLIANCE
(Fixed,Non functional,Passive space maintainer)

It is used to maintain the space of a single

tooth.
Inexpensive & easy to fabricate.
It does not restore the occlusal function
of the missing tooth.
Indications
Unilateral loss of the primary first
molar before or after eruption of the
permanent first molar.
Bilateral loss of a primary molar
before the eruption of the permanent
incisors.
 LINGUAL ARCH
(Fixed,Non functional,Passive Mandibular arch
appliance)

Used to maintain the posterior space in the

primary dentition.

The lingual arch is often suggested when teeth

are lost in both quadrants of the same arch.

Belong to those group of space control

appliances which not only control
anteroposterior movements but also are capable
of controlling & preventing an arch perimeter
distortion,by controlling the lingual collapse of
single tooth or segments of the arch.
It consist of a round stainless steel or
precious alloy wire closely adapted to the
lingual surfaces of the teeth & anchored to
bands on the first permanent molars.

The means used to anchor the archwire to

the bands will define whether the lingual
arch is of a removable or fixed type.

Because the permanent incisor tooth buds

develop & erupt somewhat lingual to their
primary precursors,a conventional
mandibular lingual arch is not recommended
in the primary dentition (bilateral band &
loop appliances are recommended in this
situation.)
PASSIVATION-
The lingual archwire should be
completely passive.This is done by
heating the wire to a dull brownish
appearance,while keeping the wire gently
in place on the cingula with an old
instrument.
The maxillary lingual arch is possible in the
primary dentition because it can be constructed to
rest away from the incisors.
Two types of lingual arch designs are used to
maintain maxillary space-
the Nance arch.
the Transpalatal arches.
These appliances use a large wire to connect the
banded primary teeth on both sides of the arch
that are distal to the extraction site.
The difference b/w the two appliances amounts
to where the wire is placed in the palate.
The Nance arch incorporates an acrylic button
that rests directly on the palatal rugae.
The Transpalatal arch(TPA) is made from a wire
that traverses the palate directly without touching
it.
 TPA Nance arch
NANCE ARCH or NANCE SPACE
HOLDING APPLIANCE
(Fixed,Non-functional,Passive,Maxillary
arch appliance)

Nance(1947) described the

“preventive lingual wire”.
It consists of bands on the upper
molars,with the arch wire extending
forward into the vault.
 CONSTRUCTION-
 The acrylic button is present on the
slope of the palate & provides an
excellent resistance against forward
movement(U loop).The wire should extend
from the lingual of bands to the deepest
& most anterior point in the middle of
hard palate.
 ‘U’ bend is given in the wire for the
retention of the acrylic 1-2mm away
from the soft tissue.
 TRANSPALATAL ARCH
(Fixed,Non-functional,Passive
appliance)
The arch is soldered to both sides,straight
without a button & without touching the
palate.
The basis of the appliance is that the
migration & rotation is caused by rotation
around the lingual root.By preventing
this,space loss is prevented by the
appliance.
Cross arch anchorage can be used if only
one of the primary molars is lost & both
the permanent molars are erupted.
 DISTAL SHOE
(Intra-alveolar,Eruption guidance
appliance)
o Used to maintain the space of a primary
second molar that has been lost before
the eruption of the permanent first
molar.
o An unerupted permanent first molar
drifts mesially within the alveolar bone if
the primary second molar is lost
prematurely.The result of the mesial
drifts is loss of arch length & possible
impaction of the second premolar.
 DISADVANTAGES-
o Because of its cantilever design & the fact
it is anchored on the occlusally convergent
crown of the primary first molar,the
appliance can replace only a single tooth &
is somewhat fragile.
o No occlusal function is restored because of
this lack of strength.
o Histologic examination shows that complete
epithelialization does not occur after
placement of the appliance.
 REFERENCES
 Dentistry for the child and adolescent; Ralph
E. Mc Donald; David R. Avery; eight edition
2019;C.V. Mosby Company.
 Paediatric Dentistry; Richard R. Welbury;
Second edition 2001; Oxford Medical
publications.
 Graber T.M.; Orthodontics principle and
practice; third edition; page no. 315 to 317
 William R. Proffit; Contemporay Orthodontics;
second edition; page no127
 Gurkreet Singh; Text book of Orthodontics;
first edition; 2004;Puublished by Jitendra P.
Vij; page no. 539 to 547