PEDIATRIC DENTISTRY

SPACE MAINTAINERS
Dr.Ban ali salih

Definition: A device used to preserve arch length following the premature loss of a
primary tooth or teeth.
The best space maintenance treatment is the preservation of the primary teeth until
natural exfoliation.
The premature loss of primary teeth is still one of the most common controllable
causes of malocclusion.

Types of S.M:
1-Fixed appliances.
2-Removable appliances (Partial Denture)

There are four basic type space maintainers (S.M.) fixed types:
-The band and loop (crown and loop) space maintainer:
Used to maintain the space loss of a single primary first or second molar.
-The Nance holding arch:
Maintains the maxillary arch length after the premature loss of more than primary
maxillary molar in the same quadrant or after a bilateral loss of primary molars.
-The fixed lingual arch:
Used to maintain the mandibular arch length and prevent mesial tipping and /or
rotation of the permanent first molars.
The fixed lingual arch prevents lingual tipping of the permanent incisors.
-The intra- alveolar space maintainer (distal shoe appliance):
Used to prevent mesial migration of the unerupt permanent first molar after
premature loss of primary second molar.

Loss of Primary Incisors

Early loss of lower primary incisors: is generally due to ectopic eruption of

the permanent incisors in reflecting excessive incisor liability. Given the potential for
increased intra canine width during permanent incisor eruption, the clinician should
monitor development in the lower incisor area and generally not intervene.
Individual circumstances may indicate extraction of the antimere primary incisor to
‫اذا ﺻﺎر ﻋﻧدي‬and
enhance incisor positioning ‫ اﻧو‬midline
‫ﻻزم ﺗﻌرﻓون‬ ‫ھﺎي ﺑس اﻧو‬The loss of lower incisors in other
symmetry.
Early loss in the lower primary incisor of a neonatal tooth may
circumstances such as trauma, advanced caries, or extraction
result in anterior space loss if it occurs before primary canine stabilization is realized.
‫ﺑس اﻧو اﺳوي‬ ‫ﺑس اﻧو اﺳوي‬
Monitor development ‫ﻣراﻗﺑﺔ اﻟﺗﻧﻣﯾﺔ‬
& not intervene & ‫ﻋدم اﻟﺗدﺧل‬

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 ‫ھﺳﮫ ھذا ال‬
Upper
‫ﻧﺳوﯾﻠﮫ ﻋﻼج ﺣﺗﻰ ﻧرﺟﻊ ال‬
Esthetic & phonetics
‫ ﻣو ﻋﻠﻣود ال‬space ‫ ﻻن ال‬space ‫ ﻣﻣﻛن ﯾﻛون ﻣﺣﻔوظ ﺑواﺳطﺔ ال‬canine ‫ﻣن اﻟﺟﮭﺗﯾن‬
Premature loss of maxillary primary incisors: does not generally result in
decreased upper intracanine dimensions if the incisor loss occurs after the primary
canines have erupted into occlusion at approximately 2 years of age.
If the anterior primary teeth were in contact before the loss or there is evidence of an
arch-length inadequacy in the anterior region, space adjustments in alignment after the
loss of one of the primary incisors is a potential factor in space maintenance
The major consequence of early loss of maxillary primary incisors is most likely:
-Delayed eruption timing of the permanent successors as reparative bone and dense
connective tissue covers the site. ‫اﻟﻧﻘﺎط اﻟﺟوه ھﯾﮫ اﻟﻣﺷﺎﻛل وره ﻣﺎ اﻟطﻔل ﯾﺧﺳر‬
-Unattractive appearance ‫ﻣظﮭر ﻏﯾر ﺟذاب‬
-Potential development of deleterious habits (e.g., tongue-thrust swallow, forward
resting posture of the tongue,
-Improper pronunciation of fricative sounds—”s,” “f”) may be of concern following
premature loss of primary maxillary incisors.
An anterior appliance incorporating artificial primary teeth may be considered to
satisfy esthetic and functional needs. ‫ال‬
Upper anterior
Acrylic partial dentures have been successful in the replacement of single and primary
multiple maxillary primary incisors. ‫اذا ﺻﺎر ﺑﯾﮭﺎ‬
Premature loss
Disadvantages:
Given the demands of cooperation in wear. ‫اﻣﺎ ﻧﺳوﯾﻠﮫ‬
And frequent appliance loss or damage, such removable appliances can be Partial denture ‫ﻣﺗﺣرك‬
problematic in preschool-age children. ‫ﻣﺛل ﻣﺎﻟﺗﻧﮫ ﻣﺎل ﺑروس‬
‫ او ﻧﺳوﯾﻠﮫ‬fixed

A fixed option using primary incisor denture teeth secured from a rigid steel wire
(0.036 or 0.040) extended to bands or stainless steel crowns on the primary molars, an
obtain additional stabilization in keeping the wire from flexing by placing an occlusal
rest on the first primary molar, using a Nance button, or by covering the ridge with
acrylic resin. Use of such an appliance incorporating artificial primary anterior teeth is
elective to primarily address esthetic demands rather than specific space management
concerns.

Space Maintenance for the First and Second Primary Molar

and the Primary Canine Area

Premature loss of first primary molar

Band and loop S.M.

A Band and loop sm. is a fixed unilateral appliance used to maintain arch length in the
primary or mixed dentitions following the premature loss of a primary molar.
Parts of a band and loop:
-A molar band adapted to a primary molar.
-A wire loop which is soldered to the molar band and which extends over the
edentulous area to contact the neighboring tooth, there by preventing migration of
teeth (loss of arch length).

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Advantages
1. easy and economical to make,
2. takes little chair time,
3. and adjusts easily to accommodate
Disadvantages
1. it does not restore chewing function
2. Will not prevent the continued eruption of the opposing teeth

Technique:
1. a stainless steel band must fitted on tooth
2. Impression of dentition and band, the band is removed from the tooth and seated in
the impression
3. On the model of the impression, a piece of 0.036-inch steel wire is used to prepare
the loop and soldered to the band.
4. Band and loop appliance cemented intraorally

Contraindications:
1-An occlusion that is extremely crowded or already exhibits marked space loss.
2-High dental caries activity.
3-Replacement of primary anterior teeth.

This appliance should be removed each year so that the abutment tooth can be
inspected and polished, fluoride is then applied and the appliance recemented.
‫ھذا ال‬
Band and loop
‫ ﻣﻧﻛدر ﻧﺳﺗﺧدﻣﮫ ﺑﺎﻻ‬anterior
‫ﻧﺳﺗﺧدﻣﮫ ﻋﻧد اﻟﻲ ﻋدھم‬
3 ‫وﻻ ﻧﻛدر‬
High caries activity
‫ﻻن ﯾﺟﻣﻊ اﻛل‬

‫ واذا ﻋﻧدي‬space loss ‫ھم ﻣﺎﻛدر اﺳﺗﺧدﻣﮫ ﻻن اﺣﺗﺎج ﺑﮭﯾﺞ ﺣﺎﻟﺔ‬

Space regainer
The stainless steel crown and loop maintainer
May be used if the posterior abutment tooth has extensive caries and requires a
crown restoration or if the abutment tooth has had vital pulp therapy, in which case it
is desirable to protect the crown with full coverage

‫اﻟﻠﮫ وﻛﯾﻠﻛم اﻟﻣﮭم ﻣن ھذا ﯾﺷﺑﮫ اﺑو ال‬

Band and loop
‫ ﺑس ھذا اﻟﺑﺎﻧد ﻧﺑدﻟﮫ ﺑﻛراون ﻻﻧو اﻟﺳن ال‬abutment ‫ﻣﺗﺳوس‬
Extensive caries
‫او ﻣﺣﺗﺎج‬
Vital pulp therapy

‫ﻓﺣﺗﻰ اﺳوي‬
Protection to abutment
+ space maintainer

The technique
The steel crown should be prepared before cementation, a compound impression is
made the crown is removed from the tooth and seated in the impression and the stone
working model is prepared. A piece of 0.036-inch steel wire is used to prepare the
loop. Because it is difficult to remove the crown to make adjustments in the loop,
some dentists prefer to adapt a band over a cemented crown restoration and construct
a conventional band and loop appliance

Premature loss of second primary molar

Have less effect on the teeth in the anterior segment than the loss of a first primary
molar. However, an irregularity may develop in the permanent molar relationship.
‫ال‬
Early loss of the second primary molar is invariably followed by mesial drifting of the
first permanent molar. And possibleBand and loop
impaction of the second premolar also a
‫ال‬ ‫ﺑﺣﺎﻟﺔ‬
maxillary molar often will rotate mesially ‫اﺳﺗﺧدﻣﮫ‬ ‫اﻛدر‬
The space-maintaining appliancesPremature loss ofadvocated
that are generally first and are
second primary molar
The band and loop with the band placed on the first permanent molar If the first
primary molar is the abutment tooth, it may be lost before the time when the space
maintaining appliance can be discarded.

The passive lingual arch.

The soldered lingual arch may be the space maintainer of choice after the multiple
loss of primary teeth in the mandibular arch
Also, the upper lingual arch (Nance appliance) arch
is the appliance of choice when bilateral space loss is present or when leeway space
must be preserved.

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Disadvantage:
it does not restore function.
Advantages: ‫ﯾزﯾل اﺳﺗﺧدام اﻟﻘوس اﻟﻠﻐوي ﺑﺷﻛل أﺳﺎﺳﻲ ﻣﺷﻛﻠﺔ ﺗﻌﺎون اﻟﻣرﯾض‬.
The use of the lingual arch essentially eliminates the problem of patient
cooperation.
With properly fitted bands and a well-made appliance, there should be no
problems with breakage or retention and no concern about whether the child is
wearing it.

Technique:
1. a stainless steel band must fitted on tooth
2. Impression of dentition and band, the band is removed from the tooth and seated in
the impression
3. On the working model a 0.036- or 0.040-inch steel wire is contoured to the arch,
extending forward to make contact with the cingulum area of the incisors
4. In contouring the arch wire, one should allow for the path of eruption of the
premolar and canines so that the arch wire will not interfere.
5. Where possible, an ideal anterior arch form should be constructed so that the
incisors have an opportunity for alignment.
6. The arch wire should be extended posteriorly along the middle third of the lingual
surface of the molar band and soldered firmly, but passively, in this position.
7. A ‘ U’ shaped arch wire extends from the lingual surface of the molar bands to the
lingual surface of the anterior teeth. They are placed above the cingulum of the lower
incisors. It prevents the mesial movement of the posterior teeth and collapse of the
anterior segment.

A transpalatal arch
indicated when one side of the arch is intact and several primary teeth are missing on
the other side. In this case, the rigid attachment to the intact side usually provides
enough stability for space maintenance. However, when primary molars have been
lost bilaterally, both permanent molars may tip mesially with a transpalatal arch. A
conventional lingual arch or Nance appliance ‫ ﺻﺎﯾر‬is‫اﻟﺟﮭﺗﯾن‬ ‫ﻛﺎل ﻣن‬in‫اذا‬this
preferred ‫ اﻣﺎ‬loss of primary molars
situation
‫ ﻣن ﻓﺗﺳﺗﺗﺧدم اﻣﺎ‬6 ‫وﺑﺎﻗﻲ ﺑس ال‬
Nance for upper
‫او ﺗﺳﺗﺧدم‬
Loss of the Second Primary Molar before
Lingual archEruption
for lowerof the First
Permanent Molar
Mesial movement and migration of the first permanent molar often occurs before
eruption in instances of premature loss of the second primary molar.

The Distal Shoe Appliance.

A crown and band appliance with a distal intragingival extension used to maintain
space or, in some instances, to influence the active eruption of the first permanent
molar in a distal direction.
Using the first primary molar as the abutment, stainless steel Crown or a well
adapted band on a noncrowned tooth may be satisfactory.
If the second primary molar has not yet been removed, it is cut off the model. A
hole that simulates the position of the distal root of the tooth is made in the model

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https://telesco.pe/dentistry679/29051
using a bur .
If the second primary molar has been removed previously, the positioning of the
tissue extension may be determined with dividers and a bite-wing radiograph
Before final placement of the maintainer in the mouth, a radiograph of the
appliance should be made to determine whether the tissue extension is in proper
relationship with the unerupted first permanent molar.
It is not necessary for the distal extension to be in direct contact with the
permanent molar unless the tooth has already moved mesially.
The depth of the intragingival extension should be about 1.0 to 1.5 mm below the
mesial marginal ridge of the molar
After the molar has erupted, the intragingival extension is removed.
If the appliance is to be used as a reverse band and loop space maintainer, it may
be necessary to add a supragingival extension to prevent the molar from tipping
over the wire.

Contraindications:
1. If several teeth are missing, abutments to support a cemented appliance may be
absent.
2. Poor oral hygiene
3. lack of patient and parental cooperation.
4. Certain medical conditions, such as blood dyscrasias, immunosuppression,
congenital heart disease because it is associated with a chronic inflammatory
response.
https://t.me/dentistry679/29057
In cases in which use of the distal shoe is contraindicated, two possibilities for
treatment ‫اﻟﺑدﯾل‬
(1) allow the tooth to erupt and regain space later or
(2.) use a removable or fixed appliance that does not penetrate the tissue but places
pressure on the ridge mesial to the unerupted permanent molar

Areas of Multiple Primary Molar Loss

1-Removable acrylic partial dentures have been used successfully in either arch after
the loss of multiple teeth.
2- The passive lingual arch or (Nance appliance)
3- transpalatal arch.
4- It is occasionally necessary to recommend extraction of all the primary teeth in a
preschool child and wear complete dentures before the eruption of permanent teeth

Loss of First Permanent Molars

The first permanent molar is unquestionably the most important unit of mastication
and is essential in the development of a functionally desirable occlusion.
A caries lesion may develop rapidly in the first permanent molar and occasionally
progress from an incipient
lesion to a pulp exposure in a 6-month period. The loss of a first permanent molar in a
child can lead to changes in the dental arches that can be traced throughout the child’s
life.

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Unless appropriate corrective measures are instituted, these changes include
1. diminished local function,
2. drifting of teeth,
3. and continued eruption of opposing teeth.
The second molars, even if unerupted, start to drift mesially after the loss of the
first permanent molar.
A greater degree of forward bodily movement will occur with loss of the first
permanent molar in 8- to 12-year-old children.
In older children, if the loss occurs after eruption of the second permanent molar,
more exaggerated mesial tipping of the second molar can be the expected outcome.
Although the premolars undergo the greatest amount of distal drifting, all the teeth
anterior to the space, including the central and lateral incisors on the side where the
loss occurred, may show evidence of movement.
Contacts open and the premolars, in particular, rotate as they fall distally. There is a
tendency for the maxillary premolars to move distally in union, whereas those in
the lower arch may move separately.
When the maxillary first permanent molar loses its opponent, it erupts at a faster
rate than the adjacent teeth. The alveolar process is also carried along with the
molars and causes problems when prosthetic replacements are needed.
The treatment of patients with the loss of first permanent molars must be approached
on an individual basis.
1-If the first permanent molars are removed several years before eruption of the
second permanent molars, there is an excellent chance that the second molars will
erupt in an acceptable position. However, the axial inclination of the second
molars, particularly in the lower arch, may be greater than normal. The decision
whether to allow the second molar to drift mesially or to guide it forward in an
upright position may be influenced by the presence of a third molar of normal size.
2-When the first permanent molar is lost after the eruption of the second permanent
molar, orthodontic evaluation is indicated, and the following points should be
considered: Is the child in need of corrective treatment other than in the first
permanent molar area? Should the space be maintained for a replacement
prosthesis? Should the second molar be moved forward into the area formerly
occupied by the first molar? The latter choice is often the more satisfactory, even
though there will be a difference in the number of molars in the opposing arch. A
third molar can often be removed to compensate for the difference. Without
treatment, the second molar will tip forward within a matter of weeks
3- Another option to consider is autotransplantation of a third molar into the first
molar position

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Nance holding arch appliance

Fixed appliance as partial denture for missing anterior teeth

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Passive lingual arch

Transpalatal arch

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Distal shoe appliance

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