SPACE MANAGEMENT

IN PEDODONTICS
Social
distance !

I need
my space
GUIDED BY

Dr.T.H.Kotaiah MDS
Head of the department
of pedodontics

Dr.M.Suneetha MDS
Assistant professor of
pedodontics

Dr.B.Sushma MDS
Assistant professor of
pedodontics Presented by
D.Lakshmi Prasanna
Internee
CONTENTS
⦿Introduction
⦿Definitions
⦿Objectives of space maintenance
⦿Indications
⦿Contraindications
⦿Factors contributing for space closure
⦿Classification of space maintainers
⦿Space regainers
Introduction
Space maintenance is done by providing an
appliance which only checks space loss and
is not concerned with development of
dentition.

Premature loss of primary teeth can

cause drifting of teeth which may lead to
loss of space, to prevent this space
maintainers are used.
Definitions :
SPACE MAINTENANCE
⦿This term was coined by J C Brauer in
1941
⦿It is defined as the process of maintaining a
space in a given arch previously occupied by a
tooth or a group of teeth.
 SPACE CONTROL
Grainsforth
it as careful (1955) defined
supervision ofit
the developing
reflects dentition;
an understanding of
the dynamic nature
occlusal development. of
 SPACE MAINTAINER
According to Boucher- It is a fixed or
removable appliance designed to preserve the
space created by the premature loss of a
primary tooth or a group of teeth.

Too
early
 SPACE REGAINER
Space regainer is a fixed or removable
appliance capable of moving a displaced
permanent tooth into its proper position in
dental arch
WHY DO WE NEED SPACE
MAINTENANCE?
⦿ The dentition is designed to function as a single unit,
retained spatially by sum of forces exerted upon
each individual member.
⦿ Three distinct forces ; occlusal , muscular and
eruptive forces contribute to space closure.
Need for space maintenance in different
regions
First Primary Molar Area : The potential for
space loss when first primary molar is lost
depends on the different stages of eruption of
first molar teeth
Second primary molar area : The potential for space loss is
even greater when the second primary molars are lost
prematurely because they normally serve as a buttress for
permanent molar eruption.
Anterior segment-primary canine area : Early loss
of deciduous canine is more common due to
erupting lateral incisors rather than caries

Early loss of cuspid may results in

 Closure of space by mesial movement of

posterior teeth
 Lingual displacement of the anteriors
 Eruption of permanent laterals into the space
intended for permanent cuspid
Primary Incisor Area : Primary Incisors are lost
prematurely due to ECC & Traumas

 When loss of teeth occurs at age close to

normal exfoliation, space maintenance is not
needed
OBJECTIVES OF SPACE
MAINTENANCE
⦿Preservation of primate space
⦿Preservation of the integrity of the
dental arches
⦿Preservation of normal occlusal planes
⦿In case of anterior space maintenance,
it should aid in esthetics and phonetics.
IDEAL REQUIREMENTS OF SPACE
MAINTAINER
 It should maintain the entire space
created by the tooth
 It must restore the function
 Prevent supraeruption of opposing tooth
 It should be simple in construction
 It should be strong enough to withstand
occlusal forces
 Should permit maintenance of oral
hygiene
 Must not restrict the growth of jaws
 It should not exert undue forces of its
INDICATIONS
 If the space shows signs of closing.
 If the use of space maintainer will make
the future orthodontics less complicated.
 If the need for treatment of malocclusion at
a later date is not indicated.
 When the space should be maintained for
two years or more.
 To avoid supra eruption of opposing teeth
 To improve the masticatory system amd
restore dental health
CONTRAINDICATION
S If the radiograph shows that the succeeding
 tooth
will erupt soon.
 If the radiograph shows one third or more of the
root is already resorbed or calcified.
 If the space shows no sign of closing.
 When the space left is greater than that is needed
for a permanent tooth
 When the succedaneous tooth is lost
FACTORS CONTRIBUTING SPACE
CLOSURE
⦿Inclination of long axis permanent molars – tendency of
molars to shift mesially because their long axis is
mesially inclined.
⦿Premature loss of deciduous teeth.
⦿Influence of buccal musculature – buccinators exerts
forces that can derange occlusion.
⦿Path of least resistance – this is created following loss of
support because of extraction or missing tooth.
⦿Effect of position of center of rotation of mandible:
Smyd pointed out that more the axis of mandibular
rotation is lowered in respect to occlusal plane less is
the amount of horizontal thrust transmitted to teeth in
occlusion
Factors affecting Planning for Space Maintainers :
 Time elapsed since tooth loss
It was stated by Mc Donald and Avery that if space
closure is going to occur, it will usually take place within
six months after the loss of tooth. Therefore, the
appliance must be placed as soon as possible, following
the extraction of tooth.
 Rate of Space closure
Younger the patient, more is the
space loss.
Maximum space is lost during
first 6 months of extraction and
most immediate loss is within
76hrs.
• According to Breakspear:
– Space loss after loss of 1st maxillary molar is 0.8 mm
– Space loss after loss of 1st mandibular molar is 0.9 mm
– Space loss after loss of 2nd maxillary molar is 2.2 mm
– Space loss after loss of 2nd mandibular molar is 1.7 mm
• According to Clinch and Healy:
– Space loss before eruption of permanent molar is 6.1 mm
– Space loss after eruption of permanent molar is 3.7 mm
• Direction of space closure :
Stewart FS(1965) – in maxilla all except one of 12
extraction spaces closed by mesial migration of teeth
distal to the extraction space.

In mandible all space losses greater than 2mm

were bought about mainly by a distal movement of
teeth mesial to the space.
Rose JS(1966) - space closure can occur in two
ways - through forward migration / rotation of
teeth distal to the site of extraction.
• Eruption status of adjacent teeth :
Helps us ascertain Mesial shift for molars and
distal tipping for canines.
• Amount of bone covering unerupted tooth
:
According to Mc Donald 1mm of bone resorbs
in 4-5 months and so if the bone is present
over the succedaneous tooth,space maintainer
is indicated
• Eruption status of Succedaneous Tooth:
It is estimated by the amount of root
completion
• Dental age of patient :
It is the age calculated according to the last tooth erupted
in the oral cavity in normal eruption sequence
It can be calculated according to the methods of gustafson
and koch or gron and moorees
• Sequence of eruption :
Knowledge of usual eruption sequence is important
• Delayed eruption of permanent tooth :
over retained or ankylosed primary teeth or impacted
permanent teeth, can result in a delay of the eruption
process
Available Space evaluation of the available space should
be performed to determine whether the deficiency is
developmental or a result of the pre-existing condition

Arch Length Adequacy This will be estimated by position

of incisors, Leeway space and Incisor liability.

Curve of Spee According to Andrews, ideal occlusion will

have a near flat curve of Spee thus additional space can
be gained (1 mm of space is gained per 1mm of depth of
curve of Spee).

Abnormal Oral Habits They will exert abnormal pressure

on dental arches and so may influence the type and
planning of space maintainer.
 CLASSIFICATION OF SPACE
MAINTAINERS
According to Hitchcock

 Removable/fixed/semi fixed
 with bands/without bands
 Functional/non-functional
 Active/passive
 certain combinations of the
above
 According to Raymond C Thurow

 Removable
 Complete Arch
• Lingual arch
• Extra oral anchorage
 Individual tooth
 According to Hinrichsen

Removable
Fixed Space space
maintainer maintainer

Functional
Pontic type Acrylic
Lingual Arch Partial
Class I
Dentures
Non-Functional Bar type
Loop Type

Class II
Distal Shoe
Cantilever Type
Type
 FIXED SPACE MAINTAINERS
Fixed space maintainers are the appliances,
which are fixed onto the teeth and
utilize bands or crowns for their
construction
FABRICATION OF FIXED SPACE MAINTAINERS

Steps in fabrication of fixed space maintainers:

1.Band construction
2.Taking the impression and cast preparation
3.Loop fabrication
4.Soldering
5.Polishing
6.Cementation
1.Band construction
2.Taking impression and
cast pouring
An alginate impression of the banded tooth and
appropriate abutment is made. Full arch impression
is taken for lingual arch and Nance appliance
whereas a sectioned impression can be taken when
planning a band and loop space maintainer. After
taking the impression band remover pliers is used to
remove the band and place it into the impression in
the same position that it occupied on the tooth.
Stabilize and pour the cast.
3.Loop Fabrication
4.Soldering
5.Polishing 6.Cementation
 Band and loop space maintainer

⦿ It is a unilateral ,nonfunctional,passive,fixed
appliance indicated for space maintenance
in the posterior segments when single tooth
is lost.
 INDICATIONS
⦿For preserving the space created by
the premature loss of single primary
molar
⦿Bilateral loss of single primary molar
before eruption of permanent incisors.

Bilateral loss
Design of the wire loop:
1.Arms should be placed in the junction of
middle and cervical third, not interfering
with occlusion.
2.Contour of loop should be similar and
as close as possible to the gingival
contour.
3.Width of loop should be wide enough to allow
eruption of premolar inside the loop.

1
3
2
Advantages
⦿Construction is easy
⦿Few appointments
⦿Many modifications are possible

Disadvantages
⦿Cannot stabilize the arch
⦿Nonfunctional
⦿Slippage of loop by masticatory forces
⦿Cannot be used for multiple loss of teeth
⦿Most of the time primary second molar is
lost before eruption of premolar
MODIFICATIONS
⦿Robert Rapp and Isik Demiroz(1983): Stoppers can be
used to prevent gingival as well as buccal movements of
loop.

⦿Crown and loop: same as band and loop but a

stainless steel crown is used on abutment tooth
instead of a band.
⦿ Meyne’s space maintainer: loop is halved

⦿ Reverse band and loop: when there is premature loss of

primary 2nd molar and the permanent molars have not
erupted fully to support a band.In such cases primary 1st
molar is banded and a loop is made that touches just
below the marginal ridge of permanent molars.
⦿Band and bar: Prevents eruption of premolar
⦿Long band and loop
⦿Bonded band and loop

Bonded band and loop

 Lingual arch space maintainer

⦿It is a bilateral, non functional, passive/

active, Mandibular fixed appliance
⦿Bands on first permanent molars
⦿Mandibular incisors often erupt lingually and are
pushed forward by the tongue
⦿It should not be placed with primary incisors
INDICATIONS
⦿To preserve the space created by multiple
loss of primary molars when there is no loss
of space in the arch
⦿Bilateral loss of primary molar teeth
after eruption of lower lateral incisors
⦿Minor space regaining
⦿To prevent lingual collapse of the teeth
Contraindication
⦿Before the eruption of mandibular
incisors
Design of the wire loop
⦿Arch wire should contact the erupted permanent incisors
at the cingulum.
⦿Should be located 2mm below the gingival margin or
edentulous ridge in the posterior regions to prevent
distortion under process of mastication
⦿Should be located 1-2mm lingual to the posterior teeth to
permit satisfactory eruption of bicuspids in a
buccolingual plane
⦿Should meet the band at mesiobuccal cusp
⦿Soldered joint should be placed in the middle third of the
band to avoid occlusal interference.
Design of the wire loop

Lingual arch space maintainer

Advantages
⦿Many modifications are possible
⦿Can also be used to regain space
⦿Arch holding space maintainer
⦿Excellent source of Anchorage, because it
incorporates resistance of several teeth
⦿Less conspicuous & causes little or no inconvenience
to patient
⦿Less bulky than acrylic space maintainers
Disadvantages
⦿Construction is difficult
⦿More chances of distortion of appliance
by tongue pressure
⦿May cause unwanted
movement
MODIFICATIONS
Hotz lingual arch
Removable lingual arch
Omega bands
Removable lingual arch

Hotz lingual arch Omega lingual arch

 Nance Palatal Arch Space Maintainer

⦿ It is a Bilateral, non functional, passive, Maxillary

fixed appliance that does not contact the anterior
teeth, but approximates the anterior palate via an
acrylic button that contacts the palatal tissue, which
provides resistance to the anterior movement of
posterior teeth in a horizontal direction.
⦿ Bands on first permanent molars
 INDICATI
⦿ONS
when there is bilateral premature loss of primary
tooth with no loss in arch and a favourable mixed
dentition analysis
⦿Combined with habit breaking appliance by
incorporating spurs in the acrylic button
DESIGN OF THE WIRE LOOP
⦿Arch wire extends anteriorly without touching against
the surface of the primary molars.
⦿A small U shaped bend should be incorporated in the
wire at the rugae area which is 1-2mm away from soft
tissue.
⦿1-2mm below the incisive papilla on the descending
portion of palatal vault an acrylic button of 0.5 inch is
placed
1-2mm
Advantage
Arch stabilization

Disadvantages
⦿May cause tissue hyperplasia
⦿Irritation to palatal tissues
⦿Pressure effects
⦿Cannot be used in patient allergic to
acrylic
MODIFICATIONS
⦿ Modified nance appliance for unilateral
molar distalization
 Transpalatal arch

⦿Can be used like a Nance.

⦿First described and designed by Robert
Goshgarian in 1972.
⦿it is an unilateral, non-functional, passive,
maxillary fixed appliance.
INDICATIO
NS
⦿When teeth on side of the arch are intact
and several primary teeth on the other side
are missing..
⦿Loss of primary molars bilaterally.
⦿Arch expansion
⦿Designed to prevent molars from rotation.
DESIGN OF THE WIRE LOOP
⦿Runs across palatal vault avoiding the contact with
soft tissue.
⦿If any manipulation is required an U shaped bend
must be placed at the mid-palatal region
⦿The mesial part of palatal surface of the band,the
wire should be bent to the distal part of the band
to assure a better joint
Advantages
⦿Lack of acrylic button so less tissue
irritation and more cleansible.
⦿Arch expansion.
⦿Multiple unilateral loss.

Disadvantages
⦿Rotation of molars.
⦿Both molars may tip together.
 Distal shoe space maintainer

⦿Also known as intra-alveolar appliance

⦿Early design of distal shoe space maintainer was
Willets’s and appliance in use now is Roche’s distal
shoe or its modification.
INDICATION
S
when the second primary molar is extracted
or lost before the eruption of 1st permanent
molar.
CONTRAINDICA
TIONS
⦿Inadequate abutments due to multiple loss
of teeth.
⦿poor oral hygiene.
⦿lack of parent and patient cooperation.
⦿medically compromised patients.
⦿congenitally missing 1st permanent molar.
Advantages
Only space maintainer,which can be used if there is
premature loss of primary second molar before
eruption of permanent molars.
Disadvantages
⦿Can cause deviation of permanent tooth bud
⦿May permit tipping if not placed properly
⦿Interfere with epithelialization of socket
 DESIGN OF THE WIRE LOOP
 Using 1st primary molar as abutment the stainless steel band
is adapted
 If the morphology of tooth does not permit easy placement
and adaptation of band then the tooth is prepared for
stainless steel crown and on that band is fitted
 In the lower arch, the contact area of distal extension of the
appliance should have a slight lingual position over the crest
of the alveolar ridge in order to engage the mesial contact
area of the 1st permanent molar as it begins its mesial and
lingual movements.
 By contrast the contact area of distal extension of the
maxillary appliance should be slightly facial to the crest of
the alveolar ridge.
MODIFICATIONS
⦿ Lingual arch and distal shoe appliance was suggested
where both primary molars are lost and patients strong gag
reflex prevented the use of removable appliance.
⦿Loops are placed in horizontal arm of space maintainer.
⦿It is placed after signs of eruption of 1st molar are seen,
vertical extension –short, not placed vertically, just
touches the mesial surface of erupting molar.
⦿Gingival saddle appliance.

Gingival saddle appliance

 Fixed Functional space maintainer

⦿when the space for a permanent tooth

should be maintained for 2 years or longer, a
unilateral fixed space maintainer should be
placed.
⦿there are two methods of constructing a
fixed functional space maintainer : indirect
technique and direct technique.
 Anterior aesthetic functional space
maintainer
⦿ when the anterior primary tooth is lost prematurely, the teeth present
both mesial and distal to the created space tend to drift leads to
unesthetic smile and difficulty in biting.
⦿ an aesthetic functional space maintainer is fabricated.
REMOVABLE SPACE
MAINTAINERS
⦿they are space maintainers which can be removed and
inserted into the oral cavity by the patient.
⦿the partial denture is the most useful for bilateral
posterior space maintenance when more than one tooth
has been lost per segment and the permanent incisors
have not yet erupted.
⦿They are of two types ; functional and non functional
Classification of Removable Space Maintainers
Brauer classified removable dentures for children as follows:

Class 1: Unilateral maxillary posterior.

Class 2: Unilateral mandibular posterior.
Class 3: Bilateral maxillary posterior.
Class 4: Bilateral mandibular posterior.
Class 5: Bilateral maxillary anterior posterior.
Class 6: Bilateral mandibular anterior posterior.
Class 7: One or more primary of permanent anterior.
Class 8: Complete primary
Bilateral non functional removable Unilateral non functional
space maintainer removable space maintainer

Unilateral functional removable Bilateral functional

space maintainer removable space maintainer
INDICATIONS
⦿when aesthetics is important.
⦿abutment teeth can not support a fixed appliance.
⦿cleft palate patient
⦿ Child has reached a mental age of 2½ years.
⦿Permanent teeth are not fully erupted for adaptation of
bands.
⦿ Multiple loss of deciduous tooth.
CONTRAINDICATIONS
⦿lack of patient co-operation.
⦿patients who are allergic to acrylic
material.
⦿Epileptic patients
⦿Children with possible caries activity.
⦿the child has not attained a mental age of
2½ years
Advantages
⦿easy to clean and permit maintenance
of proper oral hygiene.
⦿maintain and restore the vertical
dimension.
⦿can be worn part time allowing circulation
⦿of the bloodcan
alterations to be
themade
soft tissues.
without changing the
appliance.
⦿stimulate eruption of permanent teeth.
⦿helps in mastication
Disadvantages
⦿may be broken by the patient.
⦿un co-operative patients may not wear
the appliance.
⦿lateral jaw growth may be restricted,
if clasps are incorporated.
⦿may cause irritation of the underlying
soft tissues.
 REMOVABLE DISTAL SHOE
SPACE MAINTAINER
⦿This was revised by Starkey.
⦿Indicated in premature loss of primary 2nd
molar before the eruption of permanent 1st
molar.
⦿It is an immediate acrylic partial denture
with an acrylic distal shoe extension.
⦿The acrylic will extend knot alveolus after
the removal of primary tooth
⦿The extension may be removed after the
eruption of the permanent tooth
SPACE REGAINERS
 Space maintenance is necessary in early loss of posterior
primary teeth because early loss contributes to occlusal
disharmonies.
 For regaining of space or to prevent further disharmonies the
most important procedure is diagnosis.The attention is
not limited to segment in which tooth is not missing.
 Considerations for treatment include the alignment and space
needs for other teeth in the arch,relationship of teeth to
denture base ,the transverse and sagittal relationships,the
vertical denture relationship,profile of soft tissue
 Classification
Fixed Removable
Open coil Free end loop
Gerber Split saddle
Hotz Jack screw
Sectional Sling shot
Lip bumper

New types
CONCLUSION

The space maintainer is a good alternative to

other fixed appliances.
Time saving.
Ease of application.
Long term success and durability.
CONCLUSION

The Best Space

Maintainer is
“PRIMARY TOOTH”
REFERENCES

Nikhil Marwah
Muthu. shiva kumar
Gowri shankar : text book
of orthodontics
Net sources.
This Photo by Unknown Author is licensed under CC BY-NC