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SPACE MAINTAINERS

INTRODUCTION TO SPACE MANAGEMENT
Pediatric Space Management
Introduction: Space Management
Space management is an important responsibility of the general dentist and the pediatric dentist.
Inadequate space management can cause problems which are long lasting and severe. The premature loss of
primary teeth may cause loss of arch length, resulting in crowding of the permanent dentition, impaction of
permanent teeth, esthetic difficulties, malocclusion, and other problems. We recommend prompt and
appropriate space management therapies to help insure optimal lifelong dental health.
The purpose of this chapter is to describe space management therapies. We will focus on the various types
of space maintainers, when and how they are used, and how they are made.

Our coverage will center on maintaining existing space once primary teeth have been lost prematurely,
rather than on tooth movement. For information concerning the movement of teeth, we refer you to
current textbooks of orthodontics or minor tooth movement.

The best space maintainer is a primary tooth, as you see
demonstrated in this radiograph. When nature's best space
maintainer is lost prematurely, we need to intervene and
maintain the space for normal development of the dental
arches.

For example, this panoramic
radiograph shows the premature loss of the
mandibular right second primary molar,
resulting in the tipping of the first
permanent molar and consequent loss of
space. This is an example of space loss
which could have been prevented if a space
maintainer had been placed after the
primary tooth was removed.


This patient also has a missing mandibular right second
primary molar, but a space maintainer will be placed here,
keeping the permanent molar from drifting mesially. The
critical importance of maintaining the space of a prematurely
lost primary molar will be emphasized throughout the chapter.




This photograph demonstrates a space maintainer placed on the
mandibular right first permanent molar using 0.036 stainless steel
wire soldered to an orthodontic band, with space being maintained
for the underlying bicuspid.
Space Maintainers: Types & Indications
Section Topics
Types Of Space Maintainers
Clinical Indications For Space Maintenance
Classification Of Space Maintainers
Space Maintainers: Types Of Space Maintainers
There are numerous types of space maintainers. They range from the very simple to those with numerous
bands and wires. They can be constructed differently and used in different parts of the mouth. As we will
cover later, some even have parts extending into the tissue.
We feel the best way to make sense of the numerous types and subtypes of space maintainers is to start by
classifying them broadly into four categories. They can be fixed or removable, and they can be unilateral or
bilateral.
A removable space maintainer, of course, can be removed. A fixed space maintainer is fixed (i.e., held) to a
tooth or to more than one tooth. Fixation usually is done by cementing the space maintenance appliance in
place.
Unilateral space maintainers are fixed to one side of the mouth and bilateral space maintainers are fixed to
both sides of the mouth. Fixed space maintainers can be unilateral or bilateral.
Space maintainers also can be placed on the mandibular or maxillary arch. Consequently, we could have a
maxillary removable bilateral space maintainer, or a mandibular fixed unilateral right side space maintainer,
and so forth. There are numerous variations on these basic themes. For example, some space maintainers
are used for missing anterior teeth and some are used to preserve space for posterior unerupted teeth. The
following pages will show the various types of space maintainers.
Fixed Bilateral Space Maintainers
Space Maintainers: Types Of Space Maintainers

This photograph shows an example of a fixed bilateral space
maintainer. The patient is four years of age. The appliance is
cemented on the two second primary molars. Fixed bilateral
space maintainers on the mandibular arch often are called
lingual arch space maintainers.
Mandibular fixed bilateral space appliances generally are
preferred by clinicians over removable space maintainers. Fixed
appliances are easier to maintain and they are less likely to be
removed, damaged, or lost by the child.
Another lingual arch appliance for mandibular bilateral space
maintenance is shown here. In this case, the appliance is attached to
permanent teeth.
The mandibular lingual arch space maintainer is used very commonly
in the primary dentition and the mixed dentition, where bands can be
cemented to primary or permanent molars respectively. This is one of
the most ubiquitously used space maintainers. It is even used on
occasion in the permanent dentition when bicuspids are missing and
maintaining space is necessary prior to orthodontic and/or prosthetic therapy.

Mandibular Removable Bilateral Space Maintainers
Space Maintainers: Types Of Space Maintainers

A mandibular removable bilateral space maintainer is shown on a six year-old. This youngster prematurely
lost the mandibular right and left first and second primary molars. The disadvantages of a removable
appliance are that it may not be worn by the patient and it is more
susceptible to breakage or loss by the patient. To reiterate, most
clinicians prefer to place fixed space maintainers if possible.

Mandibular Removable Bilateral Space Maintainers
Space Maintainers: Types Of Space Maintainers
The same mandibular removable bilateral space maintainer is shown outside
of the mouth. Note the wire attachments designed for the purpose of
improved appliance retention.




Fixed unilateral Appliance
Space Maintainers: Types Of Space Maintainers
This photograph shows an example of a fixed unilateral appliance on the
maxillary left side for a seven year-old patient. The photograph
demonstrates the appliance after cementation. This appliance is referred
to as a band and loop space maintainer and is a favorite among many
clinicians.

The photograph presents a variation on the band and loop space
maintainer; a mandibular left crown and loop space maintainer is
shown. Note how the stainless steel wire is soldered to the stainless
steel crown and the wire is bent so that it is adapted closely to the
tissue. The crown and loop space maintainer is a type of fixed unilateral
space maintainer where stainless steel crown therapy was necessary on
the abutment tooth.

Bilateral Band & Loop Space Maintainers
Space Maintainers: Types Of Space
Maintainers
This photograph shows two band and loop space
maintainers, an example of the bilateral use of fixed
unilateral band and loop space maintainers. These are
very common types of unilateral space maintainers, and
they often are used bilaterally.






Fixed Bilateral Space Maintainers
Space Maintainers: Types Of Space Maintainers
The photograph demonstrates another variation on the bilateral
use of fixed unilateral space maintainers. In this case, a fixed
unilateral band and loop space maintainer was used on one side
and a fixed unilateral crown and loop space maintainer was used
on the other side. Crown and loop space maintainers can be used
when a stainless steel crown is needed on a tooth which also is an abutment for a space maintainer.
However, often band and loop space maintainers are used over stainless steel crowns. The rationale for
using a band and loop space maintainer over a stainless steel crown is that if the band and loop appliance is
no longer needed or if it fails, replacing the stainless steel crown will not also be necessary.

We Feel Removable Unilateral Space Maintainers Are Dangerous
Space Maintainers: Types Of Space Maintainers

These are examples of dangerous space maintainers. They are
removable unilateral space maintainers. We believe removable
unilateral space maintainers should not be used. They are too small
and present swallowing and choking dangers for children.


Distal Shoe Space Maintainers
Space Maintainers: Types Of Space Maintainers
This appliance is called a distal shoe space maintainer or a
distal extension space maintainer. It is used to prevent first
permanent molars from moving mesially with the premature
loss of second primary molars. The example shown is a crown
with a distal extension segment soldered to the crown. The
distal segment is extended into the tissue against the unerupted first permanent molar. The distal extension,
also called a distal shoe, is used when the second primary molars are lost prior to the eruption of the first
permanent molars (i.e., very premature loss).




Maxillary Removable Bilateral Space
Maintainers
Space Maintainers: Types Of Space Maintainers
This photograph shows a maxillary removable appliance,
in this case a maxillary removable bilateral space
maintainer. As suggested previously, removable
appliances are not commonly used because of problems
with the appliance not being worn and the frequent
incidence of breakage and loss.


Maxillary Fixed Bilateral Space Maintainers
Space Maintainers: Types Of Space Maintainers
The photograph shows a maxillary fixed bilateral space
maintainer. This type of space maintainer also is known as a
Nance Holding Arch or a Nance Appliance. Note the small
acrylic button which will rest against the palatal tissue with
this appliance. Some clinicians object to the button since it
can create tissue irritation. Therefore, it is important that
patients and parents be instructed to make sure that the
patient meticulously flosses under the acrylic button. The Nance Holding Arch is used in situations where
premature bilateral loss of maxillary primary teeth has occurred.

Prosthetics For Maxillary Anterior Teeth
Space Maintainers: Types Of Space Maintainers
The appliance demonstrated in this photograph is used to
replace missing maxillary anterior primary teeth. Cases like
this are discussed at length later in the chapter and it is
part of pediatric restorative dentistry (it is an example of a
type of maxillary anterior prosthesis).









Using The Photo Bank For Demonstration To
Parents
Space Maintainers: Types Of Space Maintainers
Some clinicians like to have an example of the various
types of space maintainers used so they can show the
appliances to parents. Parents are almost always curious
about what space maintainers will look like, and it is hard
to describe the appearance of space maintainers verbally
to the parents. Examples of appliances like the ones shown are good educational tools for parents and
children. The Photo Bank section of the Electronic Atlas also can be used for parent education about space
maintainers.


The following section of the space maintainer chapter is focused on the various indications for space
maintenance therapy.
As you have gathered by now, there are numerous types of space maintainers. Each different space
maintainer is used in different clinical situations.
We will review an array of different clinical situations relating to space maintenance therapy and give our
recommendations for each of these situations. Hopefully, going through these clinical exercises will result in
an understanding of when space maintenance is indicated and what type or types of space maintainers
might be used. We will attempt to cover virtually every
generic type of clinical situation requiring space
maintenance therapy which clinicians will encounter in
the primary and mixed dentitions.

In this drawing, the mandibular right second primary
molar is missing on a four year-old child. In your
judgement, is this child in need of a space maintainer?








This is a radiograph of a similar situation showing the missing
mandibular right second primary molar. Again, is this a situation
requiring placement of a space maintainer?

Yes; a space maintainer is indicated in the situation described
in the previous pages for this four year-old child, as
demonstrated by the drawing in red.



This radiograph shows the placement of a distal shoe space
maintainer extending to the mesial surface of the unerupted
first permanent molar. The distal shoe space maintainer is
intended to prevent the first permanent molar from erupting in
a tipping manner over the underlying premolar.

This photograph demonstrates stainless steel crowns
on the cuspid and the first primary molar, with a
distal bar extending into the tissue, thereby
preventing the first permanent molar from tipping
mesially over the underlying premolar.



This is an example of a distal shoe space maintainer which
has been successful in directing the eruption of the first
permanent molar. However, since the first permanent molar
has now erupted, the existing distal shoe appliance should be
removed and a band and loop space maintainer can be
placed.

This photograph shows the band and loop space maintainer which has
been used to replace the distal shoe appliance. It is advantageous to
replace the distal shoe, which extends under the tissue and is less
hygienic than a band and loop space maintainer.
Distal shoe space maintainers are discussed on pediatric pulp therapy,
particularly in terms of the importance of saving pulpally compromised
second primary molars prior to the eruption of the first permanent
molars. This is principally because of the technical difficulties
associated with the placement of distal shoe space maintainers. The
point we make repeatedly in discussions concerning pulp therapy is
that it is best to save second primary molars using primary endodontic
therapy (i.e., pulpectomy) when first permanent molars have not yet erupted. Most experienced clinicians
prefer to avoid distal shoe space maintainers.
However, one approach which may cause the process to be easier is to make distal shoe space maintenance
a one appointment procedure. Most space maintainer protocol involves two appointments: the first
appointment for extraction and impression taking, and the second appointment for placement and
cementation of the appliance. In the case of distal shoe space maintainers, this means an additional local
anesthetic experience for the child and a surgical incision immediately mesial to the first permanent molar
so the distal shoe can be imbedded in tissue.
The distal shoe space maintainer can be placed at the time of extraction of the second primary molar. If this
approach is used, the impression must be taken and the appliance constructed prior to extraction of the
primary tooth. The advantage is not having to go back at a later time and surgically make an incision for
insertion of the distal shoe into the tissue so the distal shoe segment can abut against the permanent molar.
Preformed (i.e., prefabricated) distal shoe space maintainers also can be used. Of course, preformed space
maintainers are not customized (i.e., fitted) for the individual patient. They are placed at the time of the
extraction appointment (i.e., a one appointment procedure is involved). Although they are not customized
for the patient, using a preformed space maintainer is acceptable in many situations. Using a preformed
space maintainer certainly is preferable to not using a space maintainer at all. Unfortunately, distal shoe
space maintainers sometimes are not used when a child's behavior makes it unlikely that placement of the
appliance at a second appointment would be successful. Of course, when distal shoe space maintainers are
not used, the development of space problems results.
Consequently, placement of distal shoe space maintainers can be planned as one appointment or two
appointment procedures, and the choice of approach is left to the discretion of the clinician. As mentioned
earlier in the chapter, it also is desirable to replace the distal shoe space maintainer with an appliance which
is banded to the permanent molar once the permanent molar erupts. Consequently, using the distal shoe
space maintainer and a subsequent band and loop appliance really involves several appointments.
In this drawing, the mandibular right first primary molar is missing on a
six year-old child. In your judgement, is the child in need of a space
maintainer? If so, would you use a removable or a fixed space
maintainer?

As you see demonstrated in red, a space maintainer is
indicated to prevent mesial movement of the second
primary molar. A band and loop space maintainer is the
best choice. It is especially important to start space
maintenance therapy prior to the eruption phase of the
first permanent molar, since the force of eruption of the
permanent molar will exert a lot of pressure to push the
second primary molar forward. The eruption phase of the
permanent molar is the time of greatest force exerted
against the primary molar.


For safety reasons, we recommend that you never use a
removable unilateral space maintainer. If they are dislodged,
they are so small that they can become a swallowing or
choking danger.




In this drawing, the mandibular right and left first primary
molars are missing on a four year-old child. In your
judgement, is the child in need of a space maintainer? If
so, would you use a removable or a fixed space
maintainer?




Space maintenance is necessary to hold the second primary
molars in position, especially as the first permanent molars
erupt and create forces which otherwise would move the
primary molars forward. Bilateral band and loop space
maintainers can be used, as outlined in red. The bilateral band
and loop strategy is our preferred approach, for reasons which
will be explained later.

The lingual arch appliance, as demonstrated in the
photograph, would be the appliance of choice for some
clinicians in a situation where both primary first molars
have been lost in the primary dentition. The bilateral
appliance is very stable since it is anchored to two teeth.




Another example of a lingual arch appliance designed
for the primary dentition is shown in the photograph.
The major disadvantage to the use of a lower fixed
bilateral lingual arch appliance in the primary
dentition is the potential for permanent incisors to
erupt later behind the lingual arch wire. In these
cases, the appliance must be remade or bilateral
fixed appliances can be placed. Some clinicians
anticipate this potential problem and place bilateral band and loop appliances in the first place, so that
interference with the eruption of mandibular incisors definitely can be avoided.
We believe that most experienced practitioners would select bilateral band and loop appliances in situations
where both lower first primary molars have been lost and before the eruption of the mandibular permanent
incisors has occurred. This approach will prevent later problems with permanent incisors erupting behind
the lingual wire.
Nevertheless, the fixed bilateral lingual arch has the advantage of being a very stable appliance because of
its two abutments. Many clinicians prefer it for that reason.
Both are very acceptable approaches, and the choice of a fixed lingual arch appliance or bilateral fixed band
and loop appliances is left to the preference of the individual clinician.
Removable bilateral appliances are not the best therapeutic choice, especially for children in the primary
dentition, although it is technically feasible to use them. The biggest problem is that children in the primary
dentition age group are very unreliable when it comes to taking care of removable appliances, and the
appliances are apt to become lost or damaged.
Of course, unlike the removable unilateral appliance, the removable bilateral appliance is too large to be a
serious swallowing or choking danger.

This is an example of a lingual arch wire which
was placed before eruption of the permanent
incisors, and a permanent incisor has erupted
behind the wire. This problem can be avoided
when band and loop space maintainers are used
before the eruption of the permanent incisors.



In this drawing, the maxillary right first primary molar is
missing in this six year-old child. In your judgement, is
the patient in need of a space maintainer? If so, would
you use a removable or a fixed space maintainer?


A unilateral space maintainer is needed, as shown in
red. Otherwise, the maxillary right second primary
molar will drift mesially, thereby losing space. Once
again, space loss will be especially severe if space
maintenance is not used during the active phase of
eruption of the maxillary right first permanent molar.
The time of active eruption is commonly referred to as
the dynamic phase of eruption.


This photograph shows the use of a band and loop space maintainer for this
type of situation. Note that the maxillary right first permanent molar has
not fully erupted. That is, it still is in the active phase of eruption. It is
especially necessary for a space maintainer to be used during this dynamic
phase of eruption.









This photograph demonstrates the same principle, when a unilateral fixed space
maintainer is needed on the maxillary right side. In this case, stainless steel
crown therapy was needed on the second primary molar. Therefore, a crown and
loop space maintainer was used. Please note that distal to the crown and loop
space maintainer is an erupting first permanent molar. The dynamic phase of
eruption is occurring, and this is when space maintenance is the most crucial.




Of course, we have emphasized that removable unilateral space maintainers
are not used because of swallowing and choking dangers.





In this drawing, the maxillary right and left first primary molars are
missing in this six year-old child. In your judgement, is the child in
need of a space maintainer? If so, would you use a removable or a
fixed space maintainer?

Space maintenance is indicated in the situation shown in
the drawing. As demonstrated in the drawing, one
solution is to use a Nance Appliance or a Nance-type
maxillary fixed bilateral appliance.



A Nance Appliance designed for the primary dentition
is shown in the photograph.

The drawing demonstrates another approach, where two
fixed unilateral space maintainers are used (band and loop
space maintainers). The choice of whether to use a maxillary
fixed bilateral appliance or two fixed unilateral appliances is
left to the preference of the clinician. As we have
emphasized, fixed space maintainers are almost always
preferred over removable appliances, although a removable
bilateral appliance could be used in a situation like the one
shown in the drawing.

This photograph demonstrates two maxillary fixed unilateral
space maintainers. A band and loop space maintainer is
shown on the patient's right side and a crown and loop
space maintainer is shown on the left. The choice of whether
to use a band and loop appliance or a crown and loop
appliance will depend partly on the restorative needs of the
underlying teeth. As mentioned earlier in the chapter, it also
is acceptable to use a band and loop space maintainer over a
stainless steel crown. Please note, once again, in this
photograph the maxillary left first permanent molar is in the
dynamic eruption phase.

In this drawing, the maxillary primary central and
lateral incisors are missing in this four year-old child.
In your judgement, is the child in need of a space
maintainer? If so, would you use a removable or a
fixed space maintainer?


What is your recommendation for a case like this? The
patient is age three and has multiple missing maxillary
teeth.
A decision of whether or not to replace multiple
missing maxillary primary teeth involves some
potential controversy. Some clinicians prefer to
replace maxillary anterior primary teeth in patients
when more than one tooth is missing, and when it will
be more than six months before eruption of
permanent central incisors. This assumes the child's
behavior is acceptable.

Their reasoning is that the presence of replacement teeth will hold the tongue in a better position. In this
way, the development of a tongue thrust is less likely. We are aware of no well validated empirical research
which actually demonstrates an association between missing primary anterior teeth and the development of
tongue thrust. Nevertheless, replacement of multiple missing primary maxillary incisors is standard practice
for some practitioners as a precaution. We cannot identify any serious risks to this approach, and it may
indeed turn out to be a useful strategy as research provides more information on the topic of tongue thrust
development.
Of course, many parents applaud the procedure because of the improved esthetics.
There also are many pediatric dental offices and many dental schools where multiple missing primary
anterior teeth are not replaced, at least routinely. Space loss usually is not a consideration, and monitoring
for that problem can be used to insure that it does not occur. Most third party carriers also will not cover the
prosthetics procedure (i.e., insurers will not reimburse you for the procedure and it will be an out-of-pocket
cost for the parents).
The authors prefer to leave the decision to the individual clinician, based on particular circumstances.

The figure shows an intraoral view of the same patient.










As you can see demonstrated in red, a prosthetic
appliance could be placed in this situation.




For those who opt to provide treatment in these situations, an
excellent final result can be obtained, as shown in the photograph.


A palatal view of the same appliance is shown in this
photograph. As you can see, the appliance is based on
the principle of banding posterior teeth and attaching
prosthetic teeth to a wire running between the bands. It
is a maxillary fixed bilateral appliance.





The photograph demonstrates another example of a
maxillary fixed bilateral anterior prosthesis.




Although we almost always prefer fixed appliances, removable
appliances can be used in situations where maxillary primary
anterior teeth are prematurely lost. In this case, a removable
appliance is shown where the primary central incisors are
replaced.



Prior to this juncture, our clinical situations have involved the
primary dentition. Now we are going to move into the mixed
dentition. In this drawing, the mandibular right second primary
molar is missing on a nine year-old patient. The first permanent
molar is present and fully erupted. In your judgement, is the child
in need of a space maintainer? If so, would you use a removable
or a fixed space maintainer?







This is an example of the situation seen in the prior drawing. The
second primary molar has been lost and the first permanent molar is
present.





As shown in the drawing, a space maintainer is needed in this
situation to prevent the bodily mesial migration and/or tipping of
the first permanent molar. A removable unilateral appliance
would be an unwise choice.



This photograph demonstrates the same case shown earlier. A fixed
unilateral band and loop space maintainer has been placed. You will
note also that the amalgam was removed from the permanent molar
and a composite restoration was placed, and a stainless steel crown
was placed on the first primary molar (in place of a very large
amalgam).


This is a space maintainer which is similar to the one
shown previously. Please note the occlusal rest designed
on the loop wire. This is placed to prevent the mandibular
right first permanent molar from tipping and causing the
wire to imbed apically in the tissue distal to the first
primary molar. Thus, the occlusal rest helps prevent the
tipping motion of the first permanent molar.


A closer view of the same occlusal rest is shown in this photograph.





In this drawing, the mandibular right and left second primary molars are missing
in this nine year year-old patient. In your judgement, is the patient in need of
space management? If so, would you use a fixed or removable appliance?


Space management is indicated in this patient to prevent the mandibular first
permanent molars from tipping or moving mesially. A fixed bilateral lingual arch
space maintainer could be used, as shown in the drawing.

Right and left side fixed unilateral band and loop space maintainers
also could be used, as shown in the drawing. Nevertheless, we
believe most clinicians would select the fixed bilateral lingual arch
appliance since the permanent lower incisors already are fully
erupted. However, both the fixed bilateral and the fixed unilateral
approaches are acceptable. Removable appliances can be used more
successfully as children grow older. Nevertheless, even with older
children, the loss and damage rate for removable appliances is high.

A lingual holding arch designed for the mixed
dentition is shown in the photograph.







In this drawing, the maxillary right second primary molar is
missing in this eight year-old patient. In your judgement, is the
child in need of a space maintainer? If so, would you use a
removable or a fixed space maintainer?








A space maintainer is indicated in this situation, as shown in red in
the drawing. A fixed unilateral band and loop space maintainer is an
appropriate choice. It will prevent the maxillary right first
permanent molar from moving forward, which would result in a
loss of space for the unerupted bicuspid. A removable unilateral
appliance would not be used because of swallowing and choking
risks, even for older children.

In this drawing, the maxillary right and left second primary
molars are missing on this ten year-old child. In your judgment,
is the child in need of a space maintainer? If so, would you use
a removable or a fixed space maintainer?





The patient needs bilateral fixed space maintenance to hold the
permanent molars in place.




The patient is in need of a space maintainer to
prevent mesial movement or tipping of the first
permanent molars. A Nance Holding Arch usually is
the appliance of choice in this situation. A
removable appliance could be used, but is not
recommended for the usual reasons mentioned
throughout the chapter. A Nance Appliance
designed for the mixed and permanent dentitions
is shown in the photograph.


An example of a maxillary removable appliance designed to hold the first
permanent molars in place is shown in the photograph.

Introduction

Fitting The Bands

Impression Taking

Appliance Fabrication

Cementation


Once a decision is made regarding what type of appliance is needed and how it is to be used, the next phase
of the space maintenance protocol involves creating the appliance. Four steps are involved in fixed appliance
therapy:
1. Fitting the bands
2. Impression taking
3. Appliance fabrication
4. Cementation.

In the case of removable appliances, impression taking is the first step since bands will not be used.










The first step in the process of appliance fabrication is
selecting and fitting the bands. A trial and error method is
used by most clinicians when selecting bands for an
appliance. This is accomplished by estimating
the proper size of band needed. The estimation is
done by examining the tooth which will be banded and
selecting a band from the box of bands which appears to be the appropriate size for that tooth.

Occasionally we discover that the contacts between the teeth
are so tight that separating elastics are necessary before the
bands can be placed.



The separating elastic is situated between the teeth
where the band will be placed. One of the easiest
methods of elastic placement is to use two threads of
dental floss in order to hold the elastic. Next, gently
"saw" the elastic between the teeth. Ideally, the
elastic can be placed a few days before the band
fitting appointment. If that were not possible, elastics
could be placed at the same appointment. When both steps are planned for the same appointment,
better separation will result if at least fifteen or twenty minutes is scheduled between elastic
placement and the band try-in.
The first step in the placement process is carrying the
band to the tooth and placing it on the tooth with
finger pressure. Further placement of the band can
be done by pushing with a tongue depressor or the
handle of a band seater. The patient can be asked to
bite on the tongue depressor or handle of the band
seater to push the band further apically.

Some clinicians use a tongue depressor to aid in pushing the
band down over the tooth. You can ask the patient to bite gently
on the tongue depressor and the band is pushed down. HELPFUL
HINT: As shown in the photograph, sometimes a tongue
depressor which has been broken in half can be used more
effectively than an unbroken tongue depressor, since the broken
tongue depressor is smaller and easier for the child to bite on.



The advantage of using a tongue depressor is
that the band is almost never crushed during
placement. Please note that the authors are
using a dentoform for this series of photographs,
to make it easier for the viewer to see the
process.

The handle of a band seater also is a convenient
instrument to use to push the band into place.





If the band is too large, it will be too loose a fit. If it is too small, the
band will not go down over the tooth. We usually consider a nicely
adapted band to be one that is placed on the tooth with some
resistance and one which cannot be lifted off with finger pressure.
We remove and place various bands until we obtain one which has
a good fit.

Usually a band seater is used for further
adaptation after initial placement. Please note
how the band seater is placed on the tooth prior
to having the patient bite down on the seater.
Band seaters come in circular and triangular
shapes. CAUTION: If you use the triangular
seater, it is important not to place it next to the
band in such a way that the patient can
inadvertently drive the triangular piece into the
cusp of the tooth. This may fracture the cusp.

A band pusher may be used for the final step in
adaptation of the band. It is used to push the
band against the tooth if a space remains
between the band and the tooth. Tightly placed
and well adapted bands are desired, so that
washout of the cement is less likely to occur.

Note the use of band removal pliers. These
are used during the placement and fitting
process to remove bands. Of course, the same
band removers are used to remove space
maintainers when necessary in other clinical
situations, for example when they are no
longer needed due to eruption of permanent
teeth.

Note that the top jaw of the pliers is placed on
the occlusal surface of the tooth and the
bottom jaw rests under the gingival margin of
the band. When the pliers are squeezed the
band moves occlusally off the tooth.




Taking Impressions
Appliance Construction- Impression Taking
Our purpose in this subsection is to cover impression taking techniques involved with space
maintainer appliances. Once the bands have been fitted to the teeth, an impression is taken.
The two impression materials most commonly used in pediatric dentistry for space maintainers are
alginate and compound.
Alginate is indicated primarily when removable appliances are being made. And as you know very
well by now, removable space maintainers are rarely indicated and seldom used in pediatric
dentistry.
We will focus on impression taking with compound. Compound is an excellent impression material,
especially for fixed appliances. In particular, it is accurate and stable, and you will see how these
qualities make it highly suitable for taking impressions for space maintainers as we proceed through
the chapter.
Of course, alternative materials can be used. If you use other materials successfully and/or if your
office routine is set up for other materials, by all means continue to use them. The most critical
feature for an impression taking material for space maintainers is accuracy in obtaining the band
registration around the tooth.
Although we like compound when taking impressions for space maintainers, we are fully aware that
many clinicians prefer alginate because of their familiarity with this material. Consequently, the
impression material of choice is left to the preference of the individual.
For purposes of this presentation, we will cover compound impression taking techniques for
impression taking for both fixed bilateral and fixed unilateral appliances. We also emphasize these
two techniques since they provide an opportunity to demonstrate two alternative impression
taking procedures: taking impressions with and without impression trays. For bilateral impression
taking, trays are always used. For unilateral impression taking, however, trays can be used or a
"free-hand" (trayless) technique can be used.
We will start with a demonstration of impression
taking for fixed bilateral space maintainers, using a
full arch tray technique. The following series of
photographs, taken by using a typodont, show the
compound impression technique used in our
practices. Please notice the necessary armamentaria,
a hot water bath, full arch tray, and compound.

The first step is softening the compound in the
hot water bath.


The warm, pliable compound is placed in a child's
size tray and warmed again if necessary.

After heating, the impression tray material can be
cooled until it reaches the correct consistency and
temperature. The essential consideration is to
insure that the material is warm enough to flow
but is sufficiently cool so not to burn the child.
Having the patient stick out their tongue and
touch the material is one method of insuring that the material has cooled satisfactorily.
The tray can then be placed in the child's mouth. Individuals who are new to compound may
believe that it might be difficult to remove the compound impression from the teeth because of
hard compound setting in the undercut areas. This is not a problem, and experience with the
material will bear this out for individuals who use compound for the first time.
The compound material needs to be pliable, but not runny or it will take too long to set up. Ideally,
the impression should be withdrawn after ten to fifteen seconds because children tolerate short
impression times much better. A steady stream of air accelerates the set of the compound once it is
inserted.

A photographic enlargement of the impression area around
one of the banded teeth is shown to demonstrate that it is
possible to see clearly the band registration in the compound
material. This is one of the significant advantages of compound
material - the bands can be placed back into the impression
material in exactly the correct place before pouring with stone.
Compound is the impression material of choice because of its ease of use, its accuracy, stability, and
tolerance by the child. Many dentists simply send the compound impression to the laboratory with no worry
about dimensional changes in the impression. The bands can be placed nicely and easily in the impression.
Usually, a highly identifiable ring can be seen in the impression material around the teeth where the occlusal
aspect of the band has registered in the compound, and the bands are placed in the indentations made by
the bands from the mouth.

This photograph demonstrates the bands
placed in the compound impression.
Because the compound material is firm
the bands are mounted on a stable base.
Nevertheless, it is often useful to heat
tack the bands into the impression
material before pouring. HELPFUL HINT:
Keep the heat tack area away from the
area where you will be placing the solder
joints.

The photograph shows the cast with bands in the
correct position waiting for construction of the
space maintainer, in this case an anterior fixed
bilateral prosthetic appliance.

This prosthetic appliance is discussed earlier in the
chapter and in the restorative chapter, so let's go
ahead and review how it is completed. After the
impression, it is important to remind the laboratory
to leave some spaces between the anterior primary
teeth if the patient presents with that appearance,
as was done with this patient.
Of course, children frequently exhibit a good deal of
spacing in the primary anterior dentition.

A larger view of the final result is shown in the photograph. Most
parents are very appreciative of the improvement.

Let's look at the appliance again. The teeth are
banded with the wire running anteriorly. The teeth
are acrylic. There are other designs which are
acceptable; but this is one of the more common.
Can you think of any potential problems with this
appliance?

The major potential problem with this
appliance involves eruption of the
maxillary anterior permanent teeth,
since the appliance obviously will
interfere with their eruption.

It is very important to stress with the parents that bringing the
child in for regular recall appointments is absolutely necessary so
that the appliance can be removed before it interferes with the
normal eruption of permanent teeth. Of course, the dentist must be aware of the timing when the different
teeth can be expected to erupt. An anterior radiograph also can be used for more accurate prediction of
when the permanent teeth can be expected to erupt.
The previous impression taking technique involved the process used for a fixed bilateral space maintainer,
and an impression tray was used. What was described is the standard compound impression technique for
fixed bilateral space maintainers, whether they are lingual arch appliances, Nance Appliances, or anterior
prosthetic appliances.
The next procedure we will describe is a technique for taking impressions for unilateral space maintainers,
which we will call the nontray technique, where the impression is taken without an impression tray.
Naturally, it is possible to use impression trays for impressions for unilateral appliances, and many clinicians
take this approach using half-arch impression trays. The impression taking process using the half arch tray is
the same as for taking a full arch impression which we just described. The choice of whether to use a half
arch tray or the alternative technique without a tray is left to the preference of the practitioner.
We will discuss the nontray technique in detail, since it is a
viable approach and has the advantage of eliminating the
paraphernalia of the tray. It also may be interesting to some
readers since the technique is not taught or used in many
dental schools and hospital centers.
For the nontray technique, of course, no tray is used. You
merely use the same compound material and the same
technique for warming the compound. However, the amount
of material used is approximately the size of a large thumb. It
is taken to the patient's mouth, molded with the fingers, and
held in place for ten to fifteen seconds. Just like the tray
technique discussed earlier, the impression can be air dried
and removed. This photograph shows the amount of warmed
compound material to be used prior to placement in the
mouth.

This photograph shows an impression after it has been
removed. Please look carefully at the quality of
definition of the impression of the band in the
compound. Do you feel that the impression is of
satisfactory quality? It is not. It could be difficult to
place the band in the impression accurately. In these
cases, it is important to take another impression.

Do you believe that the definition in this impression is
satisfactory? Yes; it is. This photograph demonstrates an
impression with excellent definition, where the stainless
steel band can be placed in the compound securely and
accurately.



It is important to have good definition of the impression
in order to properly place and adapt the band so it will
not move when the impression is poured with a stone or
plaster material. Still, we usually heat tack the band to
the compound material once it is placed, which makes it
very unlikely that the band will become dislodged or
float during the pouring process.

This frame demonstrates the band in place, prior to pouring-up
with the stone or plaster. Notice how nicely the band fits into the
registration of the band in the compound. The accuracy of the
compound makes this possible.

The next step in the process is appliance fabrication.
Many family dentists and pediatric dentists employ a dental laboratory to fabricate their space maintainers.
This is a completely satisfactory approach, assuming the dental laboratory is able to follow your instructions
appropriately and produces appliances of good quality.
It is even possible to have the laboratory come into the picture at various stages during the space
management process. For example, you could send the laboratory the compound impression. One of the
major advantages of compound impression material is that it is stable. It does not undergo distortion before
the pouring process. In this way, the laboratory will do the pouring and the appliance construction.
You could also send the cast to the laboratory and they can construct the appliance using the cast that you
have poured.
Whether you use a laboratory or make the appliance yourself is a matter of personal preference. We have
included instructions regarding how we construct appliances for those of you who will be involved in
appliance construction.
We will continue with the fixed unilateral space maintainer as our instructional example of appliance
construction.

This photograph demonstrates using a pencil to sketch the
outline where the wire will be adapted to the stone model.




This photograph shows the pencil adaptation where we
want the wire to be bent to the cast. Please note how
the outline of the drawing is wide enough so the wire
loop will be large enough bucco-lingually to allow the
bicuspid to erupt between the buccal and lingual
segments of the wire.
Allowing space for the eruption of a bicuspid, as represented on this case, reinforces a very important point.
WHATEVER APPLIANCE YOU ARE PLANNING, ALWAYS MAKE SURE THAT YOU ANTICIPATE HOW THE
PERMANENT TEETH WILL BE ERUPTING AND MAKE ALLOWANCES FOR THOSE DEVELOPMENTS.
It is essential to construct the space maintainer so that it does not interfere with the normal eruption of
permanent teeth.
Of course, it goes without saying that space maintainers should be constructed so they do not interfere with
normal functions, or at least as little as possible. Wires and any other parts of space maintainers should be
planned so that they do not interfere with eating and speech. HELPFUL HINT: Always to check to make sure
that the child can close his or her mouth normally after placement of an appliance.

This photograph demonstrates the wire as it has been adapted
to the cast. It should be emphasized that the wire needs to be
adapted close to the tissue so that it will be comfortable for the
child. The wire should be adapted in close approximation to the
tissue, but not touching the tissue, so that the tongue can not
get under the wire and cause irritation. It is necessary for the
wire to be adapted closely to the band to produce a strong but
not too bulky solder joint.

Instrumentation
Needed:
Wire cutters
Band adaptor
Band remover
Band seater
3-prong plier
Birdbeak plier
Cast







At this point, the adapted wire can be anchored to the cast so that it can be soldered to the band. We use
compound or sticky wax to heat tack the wire to the cast; and then we follow-up by pouring a thin mix of
fast-set stone to the wire and the cast as the final anchorage step. It is important to keep both the sticky wax
and fast-set stone clear of the areas of the solder joints, so that those materials do not interfere with the
joints. Once the wire is anchored to the cast, check to make sure that its placement is satisfactory. At this
point, the wire is soldered to the band using either an electric soldering technique or a flame soldering
technique.


Various wheels are used for polishing bands,
wires, and solder joints. The particular
choice of polishing vehicle is a matter of
individual preference.




We will use this opportunity to discuss fabrication of the preformed (i.e., prefabricated) band and loop space
maintainer. The preformed band and loop space
maintainer is used by many clinicians since the appliance
can be completed and placed in a single appointment.
The tooth is extracted and the preformed space
maintainer is cemented in place at the same visit, after
fitting and fabrication of the appliance at chairside.
Using preformed space maintainer appliances eliminates
all laboratory work and allows placement of appliances
at the same appointment when the surgery is done.
Note that the preformed band and loop space
maintainer has female and male units. The
tubes attached to the orthodontic band
receive the wire loop which will abut to the
adjacent tooth. The wire loop can be cut so
the mesiodistal space requirement can be
determined and adjusted. Once the wires
from the loop are placed in the tubes, the
loop and tubes can be crimped together.



The crimping pliers for the preformed band and loop space maintainer
are shown in the photograph.








The photograph demonstrates how the crimping is
accomplished using the crimping pliers to crush the
tube and wire together. Please note that some
clinicians also solder one arm of the preformed
appliance to obtain a stronger attachment of the tube
and wire. This additional safety measure makes it more unlikely that the preformed appliance will come
apart in the mouth and present a swallowing danger.

The completed preformed band and loop space
maintainer is shown. Note where the female and male
units come together. The tube is crimped to secure
the male unit to the female unit. It is a tube and wire
appliance.

Preformed band and loop space maintainers also are
configured with occlusal rests, which can be adapted
at chairside.

Please note that some clinicians also solder one arm
of the preformed appliance to obtain a stronger
joining of the tube and wire. This additional safety
measure makes it more unlikely that the preformed
appliance will come apart in the mouth and present a
swallowing danger. In this photograph, note that the buccal tube and wire have been soldered together for
more secure retention.
A preformed distal shoe space maintainer is shown in the
photograph. Many clinicians prefer to use a customized
band and loop appliance for most cases. However, many
of these same clinicians prefer to use a preformed distal
shoe appliance because of its relative ease of fabrication
and the fact that a one appointment procedure is
involved. Opting for a one appointment procedure will
avoid a second local anesthetic administration and the
difficulty of seating a customized appliance so it fits
securely against the unerupted first permanent molar.

The photograph shows an example of a
customized distal shoe space maintainer,
which is attached to a stainless steel crown. An
appliance such as this obviously is much more
difficult to fabricate and place than a
preformed distal shoe space maintainer. It also
represents the absolute highest standard of
customized care. Nevertheless, if the
customized approach is not practical given all
the circumstances, a preformed appliance certainly is better than no appliance.




The next phase in the process is cementation of the appliance. There are several important fine points
related to the cementation phase of space management therapy.
First of all, place the space maintainer in the mouth for a trial fit before you attempt cementation. It should
fit like it does on the cast. Check to make sure that the wire of a band and loop space maintainer is in light
contact with the tooth which is mesial to the edentulous space. With the wire in contact, you are sure
tipping will not occur. In the case of a Nance Appliance, check to make sure that the acrylic button is in very
gentle contact with the palatal tissue.
Also check for large voids or spaces between the band and the tooth. If any are present, carefully use an
instrument to push (burnish) the band to the surface of the tooth. In some cases, this step can be
accomplished on the cast.
Finally, make sure the child can occlude normally before you cement the space maintainer. It is a major
interruption to be forced to remove a space maintainer after it has been cemented because it interferes with
chewing.
In the case of unilateral space maintainers and children who have extremely vigorous gag reflexes, you will
want to consider running floss through the wire loop so that the space maintainer cannot be swallowed. A
unilateral space maintainer possibly could be lost down the throat of a gagging, choking child without the
protection of the floss.
The next step is the actual cementation of the appliance. Probably the most interesting issues related to
cementation of space maintainers concern the continuing development of new cements.
The traditional choice, zinc phosphate cement, has been used for decades and still is used by many
practitioners. It is a satisfactory material. It stores well, is easy to mix, and is well tolerated by patients.
The glass ionomer cements, however, have gained huge popularity over the last decade. They also are easy
to mix and are well tolerated by patients. In addition, glass ionomers release fluoride, are technique
forgiving if isolation from oral fluids is less than perfect, and are very insoluble. Their lack of solubility is
perhaps their most important advantage, since practitioners encounter less recurrent decay around and
underneath bands. Bands rarely come off when glass ionomer cements are used, especially if the bands are
tight fitting to begin with.
You will start cementation phase of the procedure by isolating the tooth to be banded. Isolation can be
obtained with cotton rolls. The tooth then is air dried. The tooth should be slightly moist (not desiccated).
The cement can be mixed according to the manufacturers instructions. However, if you mix the cement so
that it is sufficiently viscous, it will adhere to the inside of the band during placement and cementation and
not cause difficulty by "running all over." Some clinicians stick a small section of masking tape over the band
to prevent escape (i.e., "running") of the cement. This technique is fine if it works well for you. However, a
slightly thicker mix of cement will prevent escape of the material in the first place.
Once the appliance is cemented in place, remove the excess cement. One other advantage of the newer
generation cements is that they are much handier when it comes to cement removal than the older
generation cements.
Have the patient bite together one last time to insure that the appliance is not interfering with the occlusion.
It also is a good idea to show the appliance to the parent. Emphasize the importance of keeping the area
clean. At this time, you can mention any potential issues about the space maintainer that you choose, in
addition to re-emphasizing the importance of hygiene. For example, soreness for approximately twenty-four
hours can occur. The child should avoid "playing" with the appliance with the tongue, which also can cause
soreness (of the tongue). Temporary speech changes can occur with some appliances (especially Nance
Appliances), but it is important to emphasize that the changes are temporary. In very unusual cases, short-
lived sleep changes can occur, but once again these problems are transitional (and indeed very rare).
Many clinicians appoint patients who have had space maintainers placed for a quick check-up visit after
approximately two-four weeks.

This photograph demonstrates the cementation of a band
and loop space maintainer with zinc phosphate cement.
Although this cementing material is still commonly used,
more and more dentists now are using glass ionomer
cements. Glass ionomer cements have the advantages of
fluoride release, excellent handling characteristics, low
solubility, and good adhesion.



This frame shows the cementation of a band and loop space maintainer
with glass ionomer cement.













Long-Term Evaluation & Significance
Section Topics
Monitoring And Removal
Conclusions And Significance


This photograph demonstrates a tooth partially erupting
between the wires of a space maintainer.







This photograph demonstrates substantial eruption of a
tooth between the wires of a space maintainer.



This photograph shows a case where the tooth is
almost completely erupted in a space maintainer. The
space maintainer can be removed at this time.

This photograph shows a lingual arch space maintainer
with the teeth erupted. The appliance should be
removed.

A radiograph of a band and loop space
maintainer is shown here. The space maintainer
can be removed at this point.

This photograph demonstrates a situation where a crown
and loop space maintainer had been resting against the
primary cuspid. The primary cuspid has exfoliated. It is time
to remove this space maintainer.

The best space maintainer is a well maintained primary
tooth. But when these important natural space maintainers
are lost, it is essential to implement a space management
strategy. Appropriate space management therapy can save a
child from esthetic disfigurement and save a family
thousands of dollars in later orthodontic costs.

Missing primary incisors are usually repleased fo four reasons:
spase management: this does not seem to be true in most clinical situations
masticatory function : feeding is not problem , and when given a proper diet , the child continues to grow
normally
speech development : if the child has alredy acquired speech skills , the logs of an incisoris not particularly
important
Esthetic concerns : are voiced by some parents (fixed or removable)
Loss of a primary canine
rare: there is some debate a bout whether space loss will occur if the tooth is not replaced
-B & L or removable partial denture but : they will need to be remade when the permanent lateral incisor
erupts because it will require more space than primary lateral incisor and will interfere with space
maintenance
if a (space maintainer) is not placed : anticipated
in maxilla : shift to the affected side when permanent incisors erupt
in mandible : lingual movement of incisors and movement of the midline to affected side

Loss of primary molars
Reasons of loss primary molars
- loss of inter proximal contact as result of decay :
- extraction :
- ankylosis:
natural tooth is still superior to the best space miantainer :
functional - correct size - exfoliates appropriately
So : ideal restoration of all interproximal contours , and pulpal therapy as possible
Ankelosis : the tooth should be maintained until space loss is imminent (Ankylosed teeth usually show
limited vertical change in the primary dentition years )
It is then extracted and space maintained .
Band and loop :
To maintain the space of single tooth Inexpensive , easy fabrication ,
Requires continuous supervision and care In the primary and mixed dentition
INDICATED:
- Unilateral loss of the primary first molar before or after eruption of the permanent first molar
- Bilateral loss of the primary before the eruption of the permanent incisors
The loop should not restrict any physiologic tooth movement , such as the increase in intercanine width
Tow modification of the B&L appliance are not recommended for use in space maintainance therapy
Bonded band and loop : 1- shearing force 2- difficult to adjust
Crown and loop : if the soldered Joint fails and the wire breaks loose , there is no way to repair the crown
Lingual Arch
It is suggested when teeth are lost in both qudrants of the same arch
A conventional mandibular lingual arch is not recommended in primary dentition , because the incisor tooth
buds develop and erupt some what lingual to the primary precursors so instead bilateral band and loop in
this situation
The maxillary lingual arch is feasible in primary dentition because it is far from incisors . Tow types of lingual
arch in maxilla :
Nance appliance : incorporate an acrylic button that rest directly on palatal rugae .
Transpalatal arch : has wire that traverses the palat directly without touching it . It is cleaner easier to
construct BUT allows the tooth to move and tip mesialy in space loss .
Distal shoe
To maintain the space of primary second molar that has been lost before the eruption the permanent first
molar .
Impression can be taken after removal of primary second molar or before the tooth is extracted
In the former situation the gingiva needs to be incised when appliance is placed because of the healing of
the extraction site
The stainless steel should be positioned 1mm below the mesial marginal ridge of unerupted molar in the
alveolar bone
Removable Appliance
To maintain space when more than one tooth has been lost in a same quadrant
There are no abutment teeth
When distal shoe or B&L is too weak to withstand occlusal force over a two tooth span
It replace occlusal function
Mixed Dentition
Loss of posterior teeth in the primary dentition is a nearly universal indication for space
maintainance therapy
In the mixed dentition :
-Timing of permanent tooth eruption
-Timing of tooth loss
-Presence of succedaneous teeth
-Extent of crowding
must be accounted
Premature loss of primary molar : ( 8 age)
- At a very early age : delays the eruption of the permanent tooth : space maintianer and follow up
- At a later age : accelerate the eruption of the permanenet tooth : space maintainance unnecessary
The succedaneous tooth begins to actively erupt when root development is a proximately one half
to two thirds completed
6 months should be anticipated for every 1mm of bone that covers the permanent tooth
The premature loss of primary molar : space maintainer should be undertaken unless:
- tooth is expected to erupt within 6 months or there is enough space in the arch that a 1or 2 mm space
reduction will not compromise the eruption of the permanent tooth
Primary molar scheduled for extraction : SM is certainly indicated
Primary molar already missing for 6 months or longer : space analysis :
1 (excess space or much space has been lost the extraction of permanent teeth is inevitable) : SM is
contraindicated
2 (space remaining is marginally adequate to allow the permanent tooth to erupt) : SM is indicated
Absence of a permanent successor
1-Space maintainance and a fixed prosthesis or an implant : class I ,no crowding , good interarch
occlusion , minor crowding incisor position is normal and there is adequate space
2-Close space : crowding within the arch , protrusive incisors and lips , bilateral missing premolars ,
possibly other missing teeth
- Early loss of a primary molar in an arch with substantial crowding must be considered carefully .
However , SM alone will not solve the problem :
Permanent teeth will need to be extracted
OR
Arches will need to be expanded
If no space maintainance is implemented and tooth movement results from drifting prior to first
premolar extractions , less space remains to be closed later
If the crowding approaches 10mm/arch , SM may need to be placed even though permanent tooth
extraction is inevitably required
In the mixed dentition , the lingual arch is prefered if all lower incisors have erupted . Primary
second molar or permanent first molar may be used as abutment teeth oral hygiene is a problem , it
is recommended that primary second molar be banded . So decalcification occurs on teeth that will
eventually exfoliate .
When primary abutment teeth exfoliate , an appliance may need to be remade , using permanent
teeth as abutments .