ORIGINAL ARTICLE

SPACE MAINTAINERS UTILIZATION BY 6-7 YEARS OLD GIRLS

IN RIYADH SAUDI ARABIA

Nouf S. Al Hammad*,

BDS

OBJECTIVE: This cross-sectional study aimed to report utilization of space maintainers by first and second grade
female (6 & 7 year old) students in Riyadh Saudi Arabia.
METHODOLOGY: A total of 609 school girls were included in the study. The schools were randomly selected
from a list of all public elementary girls' schools to represent the five different educational zones of Riyadh city.
Dental examination was conducted in schools by one examiner visually using penlight, individually wrapped and
sterilized mouth mirrors and gloves.
RESULT: Out of the 609 children examined, {337 (55.3%) were 6 year old and 272 (44.7%) were 7 year old}, 156
(25.6%) had premature loss of teeth. All the prematurely missing teeth were primary molars and or canines except
for two children where each of them had one of the permanent incisors prematurely missing. Only 6 children (3.8%)
utilized space maintainers in the place of tooth loss. A total of 8 space maintainers were utilized by the 6 children
replacing missing primary molars. No space maintainer was utilized in place of missing primary canines or
permanent incisors. Fifty percent of the children (24) having primary canines prematurely missing had their
midline shifted to the affected side.
CONCLUSION: From the present study we can conclude that only very few (3.8%) of the examined children
utilized space maintainers after premature tooth loss. Increasing the parent's knowledge about the consequences of
premature loss of primary teeth, the importance of maintaining the space of a lost tooth, and encouraging dental
practitioners to use the space maintainers whenever indicated are all needed to reduce the expected malocclusion.
KEYWORDS: space maintainers, primary teeth.
J Pak Dent Assoc.2011; 20 (1): 23-28

in increased dental caries activity and gingival

3,4,6-11
inflammation.
Severe space loss may indicate the
subsequent need for extraction of permanent teeth and
probable comprehensive orthodontic care.3 Preservation
of the space can prevent or reduce the severity of
developing malocclusion and consequently eliminate or
reduce the need for prolonged orthodontic treatment.3,12
Miyamoto and coworkers(1976)13 studied the effect of the
premature loss of deciduous canines and molars on
malocclusion of the permanent dentition in 255
schoolchildren 11 years of age or older and concluded that
children who had a premature loss of one or more canines
or molars had a higher frequency of receiving orthodontic
treatment for the permanent dentition, and the likelihood
of need of treatment increased with the number of
prematurely lost teeth. Various kinds of space maintainers
(removable or fixed) are available and the techniques used
in the fabrication of these appliances are well documented
in a number of standard texts.4,14 The treating dentist

INTRODUCTION

rimary teeth are a determining factor in the

development of occlusion. Early loss of primary
teeth may result in drifting of both adjacent primary
and permanent teeth and loss of space needed for the
eruption of permanent successors, which will harm the
normal occlusal development.1-5 The effect of the
premature loss of primary teeth have been described by
many authors including a decreased arch length, increased
overbite, dental malposition, impaction, arch asymmetry,
crowding, alteration in eruption, midline discrepancy in
the permanent dentition, cross bite in the first permanent
molar area, reduced masticatory function and
accumulation of plaque material and food debris after the
loss of normal cleansing function which will often result
*

Assistant Professor, Department of Pediatric Dentistry and

Orthodontics, College of Dentistry, King Saud University P.O Box
5967 Riyadh 11432
Correspondence:Dr. Nouf S. Al Hammad <nhammad02@yahoo.com>

JPDA Vol. 20 No. 1 Jan-Mar 2011

23

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SPACE MAINTAINERS UTILIZATION BY 6-7 YEARS OLD GIRLS

IN RIYADH SAUDI ARABIA

decides which appliance to use, on the basis of general and

local factors related to the child. The decision for space
maintenance should be based on clinical experience, good
judgment, and knowledge of the principles of growth and
development.3 The purpose of this study was to assess the
utilization of space maintainers by 6-7 years old girls with
premature loss of primary teeth in Riyadh..

entered into a computer utilizing FOX PRO program.

Statistical Package for Social Science (SPSS version 16)
was used to analyze the obtained data. The association
between prematurely missing teeth and age and
educational zones were tested using Chi Square Test, with
consideration of P-value of 0.05 to be statistically
significant.

METHODOLOGY

RESULT

A total of 609 primary school female students (6&7

This cross-sectional study included first and second
year old) were included in the study.
Subject's
grade girls attending elementary schools at Riyadh city.
distribution among the five educational zones is presented
These schools were randomly selected from a list of on Figure 1, while the age, type of dentition, number of
all public elementary girls schools obtained from the subjects with prematurely missing teeth is presented on
Ministry of Education to represent the five different Table 1.
educational zones of Riyadh city (Central, Northern, Fig 1. Subjects distribution in the five educational zones
Southern, Eastern and Western). Approval of the study
Subjects distribution in the five educational zones
was obtained from the ethical committee of King Saud
University College of Dentistry Research Center and
Central
Western
President General for Girls Education Office in Riyadh,
19%
20%
Saudi Arabia. Permission was obtained to visit schools
and carry out clinical examination. The Ministry of
Northern
Education sent an official letter to the selected schools
Eastern
22%
informing them about the aim of the study in order to
19%
facilitate the implementation of the study protocol.
Southern
20%
Letters were sent to the parents explaining the nature and
purpose of the study and to seek consent. Dental
Table 1. Age, type of dentition, and premature loss status
examination of the subjects was conducted in schools by (Number and Percentage)
one examiner (author) visually after seating the child
Age (Years)
Dentition
Premature Loss
comfortably in an ordinary chair using penlight,
6
7
Primary
Mixed Yes
No
individually wrapped and sterilized mouth mirrors and
337
272
37
572
156
453
gloves.
(55.3%) (44.7%)

The following information was collected: name, age

from the school records, type of dentition, teeth present,
prematurely missing teeth (missing primary incisors were
not included as the age of the subjects examined is the
normal exfoliation age of primary incisors), presence of
space maintainer, quality of space maintainer, abutment
teeth, teeth replaced by space maintainer, as well as
presence of proximal caries that resulted in broken
proximal contact with clear proximal cavitations
clinically. The quality of space maintainers was assessed
by direct examination with the help of mouth mirror for
the following: if the space maintainer in place or only
band(s) in place, if it is broken, impinging on the soft
tissues, interfering with the eruption of adjacent and/or
underlying teeth, had design problem or needs to be
replaced, then the child was asked if she is having any
problem with the space maintainer. The data collected
were recorded on a special form designed for the study and

609 (100%)

(6.1%)

(93.9%) (25.6%)

609 (100%)

(74.4%)

609 (100%)

Out of the 609 subjects examined, 156 (25.6%) had

prematurely missing teeth, 152 (96.8%) of them were in
mixed dentition stage (Table 2). All the prematurely
missing teeth were primary molars and or canines except
for two children where each of them had one of the
permanent incisors missing due to trauma (maxillary left
central incisor and mandibular left central incisor).
Table 2. Distribution of Prematurely Missing Teeth
Tooth
Primary molar
Primary canines
Primary molar &
canines
Permanent incisors
Total
24

Number of Subjects
130 (83.3%)
9 (5.8%)
15 (9.6%)
2 (1.3%)

Number of teeth
239
10
22 canines &
30 molars
2

156 (100%)

303

SPACE MAINTAINERS UTILIZATION BY 6-7 YEARS OLD GIRLS

IN RIYADH SAUDI ARABIA

AL-HAMMAD NS

Using Chi-Square test at degree of freedom = 4 , there

was no association found between the educational zone
2
and the premature loss of teeth ( (4)= 7.371, P-value =
0.118 ) while the same test at a degree of freedom = 1,
showed a statistically significant difference in number of
subjects with prematurely missing teeth between the
subjects at 6 year of age and 7 years of age, as more
children with prematurely missing teeth are at the age of
7 [88(56.4%)] compared to [68(43.6%)] age 6 ( 2(1) = 11.7
, P-value = 0.001). Among the 37 children having primary
dentition, there was 5 (13.5%) having premature loss of
teeth, while for the mixed dentition 151 (26.4%) out of the
572 had premature loss of teeth. The most common
prematurely missing primary molar (30.1%) was the
upper first primary molar, followed by the lower first
primary molar (28.2%), while the least affected was the
upper second primary molar (13.7%). For the primary
canines the lower canines were more affected (65.7%)
than the upper (Table 3).

prematurely lost than the second (41.6%), P-value =

0.000. The range of prematurely missing teeth was 1-8
teeth per child, with 136 children having at least one tooth
missing and 20 children having at least 4 teeth missing.
Out of the 156 subjects having premature loss of teeth,
only 6 had space maintainers in the place of tooth loss. A
total of 8 space maintainers were utilized by the 6 subjects
(Table 4).
Table 4. Type and distribution of space maintainers
Space
Abutment
N
Uni
Bi
Maxilla Mandible
maintainer
Lateral Lateral
Band & Loop

Molar

N (%)

Canines

52 (19.3%) Upper left canine

6 (18.7%)

29 (10.8%) Lower left canine

7 (21.9%)

Upper left second molar

17 ( 6.3%) Lower right canine 14 (43.8%)

Lower left second molar

37 (13.8%)

Lower left first molar

38 (14.1%)

Lower right first molar

38 (14.1%)

Lower right second mola

Total

Reverse Crown
& Loop

74

85,83

One child utilized a unilateral space maintainer while

having a bilateral tooth loss. All space maintainers were
in place, one band & loop was mentioned to be sharp by
the child while other two space maintainers need to be
replaced (fixed bridge and reverse band & loop) as both
were impinging on the soft tissues and the fixed bridge
was interfering with the eruption of underlying tooth and
had design problem. No space maintainer was utilized in
a place of missing primary canine or permanent incisor.
Fifty percent of subjects (24) having a primary canine
missing prematurely had their midline shifted to the
affected side. Around 69% (419) of the subjects had
proximal caries (mesial, distal, and or mesial & distal)
causing broken contact (Figure2), with a range of 1-12
proximal lesions.

38 (14.1%)
269(100%)

Total

N (%)

Upper left first molar

84

Fixed bridge

20 (7.4 %) Upper right canine 5 (15.6%)

Upper right first molar

Reverse Band
& Loop

Table 3. Distribution of Prematurely missing primary molars &

canines
Upper right second molar

55,55,65,85,75 5

303(100%)

Using proportions t-test lower primary molars were

found to be significantly more prematurely lost (56.1%)
than the upper (43.9%), P-value = 0.002, and the first
primary molars to be significantly more (58.4%)

Fig II: Proximal caries distribution in molars and canines

Proximal caries distribution in molar and canines
Mesial

Distal

Mesial & Distal

Total

802
557

508

311
111 104

166

150

79
15

Second primary molar (2318)

First primary molar (2255)

25

99

36

primary canines (2380)

Permanent molar (1960)

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the midline toward the space, retrusion of the anterior

segment on the affected side and an increased overbite
1,4,9
may result.

DISCUSSION
The goal of every dental practitioner who examine
and treat children's teeth should be to properly assess and
protect the developing dental occlusion of their patients.
Protection of dental arch relations in the premature loss of
teeth can only be ensured with placement of space
4,11
maintainers.
In this cross sectional study, 25.6% of the
examined children had premature loss of teeth, and only
very few of them (3.8%) utilized space maintainers.
Davies and King 196115 found a slightly less number
(22%) of children with premature loss of teeth and
reported that 10% of the sample required orthodontic
treatment as a result of these premature extractions. There
are a large number of factors that influence the magnitude
of the alterations caused by the premature loss of primary
molars, among them dental age, eruption pattern, the
amount of bone covering the succedaneous tooth, and the
type of tooth lost.4,16

Early loss of mandibular primary canines in a

complete primary dentition may result in space closure by
mesial movement of the primary molars, especially if the
canines are lost near the time of eruption of the permanent
first molars,9 while in mixed dentition premature loss of
primary canines, if space maintainer is not placed in the
maxilla a midline shift to the affected side should be
anticipated when the permanent incisors erupt. In the
mandible, lingual movement of the incisors and
movement of the midline to the affected side will occur
with subsequent increased overbite.4,5,9 In the present
study, 50%of the subjects having a primary canine
missing prematurely had their midline shifted to the
affected side. Only 3.8% of the subjects with premature
missing teeth utilized space maintainers. No studies with
similar objective to our study were found in the literature
as most of the previous studies were focused on the
longevity, success or failure rate of the space maintainer.1923
The appropriate design and application of space
maintenance appliance is of paramount importance in the
primary, mixed, and early permanent dentitions. The
appliance should not impair function, should not interfere
with alveolar growth or eruption of teeth, and should be
cost-effective and not cause damage such as caries due to
poorly fitted bands and loose appliances.3,21,24 Several new
types of space maintainers have been introduced recently,
such as Glass fiber reinforced composite space
25,26
maintainer.
simple fixed space maintainers bonded
with flow composite11, and free-end space maintainers.16
In the present study only 8 space maintainers were utilized
by 6 subjects. All the space maintainers were used to
maintain the space of missing primary molars; no one was
used to maintain the space of missing primary canines or
permanent incisors, regardless of the importance of
maintaining the space of such teeth that was discussed by
4,9,24
several authors.

According to Owen (1971)2, 96% of the extraction

spaces present for one year or more result in space loss. In
the present study the majority (88.7%) of the prematurely
missing teeth were primary molars, and all the subjects
with premature tooth loss were in their primary or early
mixed dentition stage, which make them susceptible to
space loss as stated by Owen "the earlier the primary
molars are extracted, especially before eruption of the first
permanent molars, the greater the drifting into the
extraction space". In a more recent study using
longitudinal data in Canadian children, Northway and
coworkers (1984)17 studied the changes in the dental arch
following premature loss of primary molars compared to
changes in undisturbed arch and reported that "more space
was lost in the first year following an early extraction than
in successive years".
In the present study the most common prematurely
missing tooth was the upper first primary molar followed
by the lower first primary molar, and the least affected was
the upper second primary molar, Ronnerman (1974)18
found the reverse, where he reported the upper second
primary molar as the most commonly missing and the
least affected was the upper first primary molar. Different
studies of space loss after premature extraction of primary
molars have shown that premature extraction of primary
molars from the maxilla allow mesial drifting of the first
permanent molar teeth with subsequent blocking out of
the upper cuspids,1,10 while for premature loss of
mandibular primary molars, mesial drifting of the teeth
distal to the created space and distal drifting of teeth
mesial to it will occur, and crowding, impaction, a shift of

Loss of second primary molars and primary canines

seems to have the most negative consequences on the
24
dentoalveolar crowding in the permanent dentition and
loss of anterior permanent teeth requires immediate
treatment by the dentist if intra-arch changes are to be
prevented as within a few days after the loss of a
permanent incisor, the teeth adjacent to the space will
begin to drift, and often within a few weeks several
4
8
millimeters of space will be lost. Dearing (1981)
recommended the use of an acrylic tooth bonded to a
heavy palatal arch to provide an aesthetic semi-permanent
26

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IN RIYADH SAUDI ARABIA

bridge that will both hold the space and have a pleasing
appearance for the patient after loss of a permanent
incisor, other appliances can be employed as different
situations dictate.

ACKNOWLEDGMENT
The author gratefully acknowledges the help and
support of Professor Fouad Salama (University of
Nebraska) during the preparation of this manuscript. The
help of Mr. Nassr Al-maflehi during statistical analysis is
greatly appreciated. Special thanks go to the children and
their families for their cooperation during the study.The
study was registered with and granted by the college of
Dentistry Research Center, King Saud University.

The very few number of space maintainers utilized by

the subjects of this study could be attributed to parent's
lack of knowledge about the importance of maintaining
the space and the consequences of premature loss of
primary teeth, or to the inadequate knowledge and
practice in the use of space maintainers by the dental
practitioners. This might also be due to lack of
accessibility of these subjects to proper dental care as it
appears from the high number of carious teeth recorded.
Al-Dlaigan (2007)27 after questioning 236 dental
practitioners (general practitioners and pediatric dentists)
in Riyadh, reported that more than one third of the general
practitioners do not use space maintainers as a treatment
option for children. Most of them referred this to the cost
of the space maintainers or parent's refusal, while the other
few referred it to other reasons including that space
maintenance is a time consuming. Knowing the fact that
primary teeth with large proximal caries will not maintain
all the space required by their permanent successors, the
subjects were examined for presence of proximal caries
that caused broken contacts and around 69% of the
subjects were found to have such carious lesions. This
means some of these teeth will be extracted in the near
future and the number of subjects with premature missing
teeth will increase. Every effort to maintain the
mesiodistal dimension of the arches is important to
prevent malocclusion. Space maintenance begins with
good restorative dentistry, caries prevention and
appropriate caries restoration are of the greatest important
for occlusal development.3,5,24 Increasing the knowledge of
dental practitioners about space maintainers and their
implementation and increasing their ability to educate the
parents about the importance of space maintainer
whenever indicated by continuous education courses are
important aspects of improving the provided dental
services..

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CONCLUSION
From the present study we can conclude that only very
few (3.8%) of the examined children utilized space
maintainers after premature tooth loss. Increasing the
parent's knowledge about the consequences of premature
loss of primary teeth, the importance of maintaining the
space of a lost tooth, and encouraging dental practitioners
to use the space maintainers whenever indicated are all
needed to reduce the expected malocclusion.
27

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28