A space maintainer is an intra-oral appliance used to preserve arch length following the premature loss of primary teeth/tooth.

1. Pediatric Space Management
Dr Alvi Fatima
Jr III
Dept. of Pedodontics and Preventive Dentistry 1

2. Contents
• Definition
• Objectives of space maintenance
• Requirements of space maintainers
• Loss of individual teeth
2

3. DEFINITIONS
Preventive Orthodontics
Graber (1966) has defined preventive
orthodontics as the action taken to preserve
the integrity of what appears to be normal
occlusion at a specific time
3

4. • Interceptive Orthodontics
American Association of Orthodontists (1969) defined it
as that phase of science and art of orthodontics
employed to recognize and eliminate the potential
irregularities and malposition’s in the developing
dentofacial complex.
4

5. • Space Maintenance
This term was coined by JC 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.
5

6. • Space Control
Gainsforth in 1955 defined it as careful supervision of the developing dentition; it reflects an
understanding of the dynamic nature of occlusal development.
6

7. Objectives of space maintenance
Preservation on of primate space.
Preservation of the integrity of the dental arches.
Preservation on of normal occlusal planes.
In case of anterior space maintenance, it should aid in esthetics
and phonetics.
7

8. Space Maintainers
“ A space maintainer is an intra-oral appliance
used to preserve arch length following the
premature loss of primary teeth/tooth. ”
8

9. • This allows the permanent teeth to erupt unhindered into
proper alignment and occlusion.
• A space maintainer is recommended after the untimely loss of
a primary tooth.
9

10. Aim:
• To maintain the total arch circumference of the dental
arch during the period of dental development, thus
controlling the process of exchange from primary to
permanent dentition.
10

11. Requirements of space
maintainers
• It should maintain the entire space created by the lost tooth
• It must restore function
• Prevent supraeruption of opposing tooth
• It should be simple in construction
• 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 it’s own.
11

12. Loss of individual teeth
• Loss of maxillary deciduous 1st molar
o The deciduous cuspid shifts distally in the first year only, if at
all. The 1st permanent molar and second deciduous molar
shift mesially, with the amount depending on the duration of
absence and age at loss
o An erupting first bicuspid is guided along the mesial surface
of the mesially migrating second deciduous molars,
eventually lying close to the lateral incisor
12

13. • Loss of maxillary deciduous 2nd molar
o If the maxillary second deciduous molar is lost early, the
second bicuspid is generally impacted
o The permanent molar shifts mesially
o The cuspid and first deciduous molar shift distally
o As the first bicuspid generally has an eruption timing
advantage over the second bicuspid, will erupt earlier into the
site, maintained by the first deciduous molar, often with distal
drift
o The resultant lack of space between the permanent molar
and first bicuspid causes impaction of the second bicuspid
13

14. • Loss of mandibular deciduous molar
o The effect of mandibular extractions tends to be similar for all three
situations, i.e. loss of primary 1st molar, 2nd molar or both
o Timing differentials between the cuspid, first bicuspid and second
bicuspid in the mandible appear to account most for the similarity among
groups
o In case of loss of first primary mandibular molar, the permanent molar
and second primary molar both tips forward
o In case of loss of second primary mandibular molar, the permanent molar
tips forward
o In case of loss of first and second primary mandibular molars, the
permanent molar will tip forward and primary canine will tip distally
leading to impaction of bicuspids and also causing midline shift
14

15. Space maintenance in the
primary dentition
Maxillary
incisor
No space
maintenance
required
No consequence.
Exception: If incisor(s)
is (are) lost prior to
primary canine
eruption, space closure
may be observed
15

16. Mandibular
incisor
No space
maintenance
required
No consequence. Exceptions:
• If incisor(s) is (are) lost prior
to primary canine eruption,
space closure may be observed
• Pre-existing incisor crowding
(tendency of incisors to tip
linqually)
16

17. Maxillary/
Mandibular
canine
Band and
loop space
maintainer
Decreases
possibility of
midline shift
17

18. Maxillary/
Mandibular
1st molar
Band/crown
loop space
maintainer
Prevents loss
in arch
dimension
18

19. Maxillary/
mandibular 2nd
molar
Distal shoe space
maintainer
Guides 1st
permanent molar
into proper position
• Prevents loss in
arch dimension
19

20. INDICATIONS OF
SPACE MAINTAINERS:
If the space after premature loss of deciduous teeth shows signs of closing.
If the use of space maintainer will aid in or make the future orthodontic treatment
less complicated.
If the need for treatment of malocclusion at a later date is not indicated.
When the space for a permanent tooth should be maintained for two years or
longer.
To avoid supraeruption of a tooth from the opposing arch.
To improve the physiology of a child’s masticatory system and restore dental
health optimally.
20

21. CONTRAINDICATIONS
If the radiograph of extraction region shows that the
succedaneous tooth will erupt soon.
If the radiograph of extraction region shows one third
of the root of succedaneous tooth is already calcified.
When the space left by prematurely lost primary
tooth is greater than the space needed for the
permanent successor as indicated radiographically.
If the spcae shows no signs of closing.
When succedaneous tooth is absent.
21

22. Diagnostic steps
• Medical & Dental History
• Full mouth radiographs
• Missing teeth
• Over Retention
• Supernumerary tooth
• Diagnostic casts
• Space analysis
22

23. Failure to maintain space
results in Malocclusion
• Drifting / tipping of teeth
• Loss of arch length
• Midline shift
• Crowding of permanent teeth
• Impactions of succedaneous tooth
• Orthodontic intervention including extractions
23

24. FACTORS AFFECTING PLANNING
FOR SPACE MAINTAINERS
• Time Elapsed Since Tooth Loss
o 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.
24

25. • Amount of Space Loss
o Maxillary spaces close faster as compared to
mandibular spaces.
o Olsen, 1959 stated that greater loss occurs in
mandible owing to a mesial axial orientation of
1st molar.
o Cohen (1941), Seipel (1949), Richardson (1965)
stated that loss of 2nd deciduous molar will
cause greater space loss.
25

26. 26

27. • Rate of Space Closure
o 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
o 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
27

28. • Direction of Space Closure
o Stewart FS (1965) noted that, 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 2 mm were brought about mainly by a distal
movement of the teeth mesial to the space.
o Rose JS (1966) states that, space closure can occur in two
ways either through forward migration or rotation of teeth
distal to the site of extraction.
28

29. • Eruption Status of the Adjacent Teeth
• Amount of Bone Coverage Over the Tooth
o According to Mc Donald 1mm of bone resorbs in 4 to
5 months and so if the bone is present over the
succedaneous tooth it is an indication for space
maintainer.
• Eruption Status of the Succedaneous Tooth
o Tooth erupts in oral cavity after 2/3rd root
formation
29

30. • Dental Age of Patient
o It is the age calculated according to the last tooth
erupted in oral cavity in normal eruption sequence.
• Sequence of Eruption
• Delayed Eruption of Permanent Teeth
o Over-retained or ankylosed primary teeth, or impacted
permanent teeth, can result in a delay of the eruption
process.
30

31. ERUPTION TIME DIFFERENCES
• Eruption time of permanent teeth influenced by loss of
adjacent teeth
Eg., premature loss of 2nd primary molar → earlier
eruption of PFM.
• As age  → incidence of space closure ↓ (Linder &
Aronson, 1960; Breakspear, 1961)
• Extraction before 71/2 years → delayed eruption & vise
versa (Posen & Schleichter, 1965)
• Amount of bone covering & presence of inflammatory
process → early or late eruption of permanent successor.

32. • Arch Length Adequacy
o This will be estimated by position of incisors, Leeway
space and Incisor liability.
• Curve of Spee
o 1 mm of space is gained per 1mm of depth of curve of
Spee
• Abnormal Oral Habits
o They will exert abnormal pressure on dental arches and so
may influence the type and planning of space maintainer.
32

33. • Space discrepancy analysis
• Any space management measures should be carried
out only after a space discrepancy analysis is done for
which the two factors to be considered are:
1. Space required
2. Space available
• It can be done either by a radiographic method or on
study model or combination of both.
33

34. • Mixed dentition Analysis
• Huckaba’s analysis
• Hixon and old father’s method
• Moyers mixed dentition analysis
• Nance analysis
• Total space analysis
• Tanaka-Johnston analysis
34

35. • Huckaba’s Analysis
o He used both study casts and radiographs for
determining the width of unerupted tooth.
o This technique can be used both in maxillary and
mandibular arches in all ethnic groups.
35

36. • A simple proportional relationship can then be
established as follows:
• Actual width of primary molar (X1)
• Apparent width of primary molar (X2)
• Actual width of unerupted premolar (Y1)
• Apparent width of unerupted premolar (Y2)
• Y1 = X1 x Y2
36
X2

37. • Moyer’s Mixed Dentition Analysis
• There is high co-relation between sizes of
different teeth in same individual, thus making it
possible to predict the size of unerupted tooth by
looking at the teeth present in oral cavity
37

38. 38

39. 39

40. • Advantages
• It has minimal error and the range of possible error is precisely known
• It can be done with equal reliability either by a beginner or by an
expert
• It is not time consuming
• It requires no special equipment
• It can be done in the mouth as well on the cast
• It may be used on both the arches.
• Inference
• If the predicted value is greater than available arch length crowding of
teeth can be expected.
40

41. • Tanaka-Johnston Analysis (1974)
• Available arch length =
41
Total arch length – sum of
incisors + predicted width
+ value : space surplus
– value : space deficit

42. 42

43. • Inference
• If the result is positive, there is more space
available in the arch than is needed for the
unerupted teeth.
• If the result is negative, the unerupted teeth
require more space than is available to erupt
into ideal alignment.
43

44. • Advantages
• Improving on the Moyer’s analysis, it is relatively
accurate for children of European ancestry.
• The technique involves simple, easily repeated
procedures and minimal material needs.
• It does not use prediction charts.
• Limitations
• There may be error in the predicted size of the unerupted
teeth if patients are not of Northwestern European
descent.
44

45. GENERAL GUIDELINES FOR MANAGEMENT
OF SPACE MAINTENANCE (AAPD-2012)
• Adverse effects associated with space maintainers
include:
1. Dislodged, broken, and lost appliances;
2. Plaque accumulation;
3. Caries;
4. Interference with successor eruption;
5. Undesirable tooth movement;
6. Inhibition of alveolar growth;
7. Soft tissue impingement; and
8. Pain.
45

46. • Treatment considerations:
1. Specific tooth lost;
2. Time elapsed since tooth loss;
3. Pre-existing occlusion;
4. Favorable space analysis;
5. Presence and root development of permanent successor;
6. Amount of alveolar bone covering permanent successor;
7. Patient’s health status;
8. Patient’s cooperative ability;
9. Active oral habits; and
10.Oral hygiene.
46

47. Classification of space
maintainers
47

48. FIXED SPACE
MAINTAINERS
• Advantages of Fixed Space Maintainers
o Bands require no tooth preparation
o Do not interfere with eruption of abutment teeth
o Jaw growth is not hampered
o Succedaneous tooth is free to erupt
o Can be used in uncooperative patients.
48

49. • Disadvantages of Fixed Space Maintainers
o Elaborate instrumentation and skills required
o Banded tooth is more prone to caries and
decalcification
o Supraeruption of opposing tooth.
49

50. • Fabrication of Fixed Space Maintainers
o Band construction
o Taking the impression and cast preparation
o Loop fabrication
o Soldering
o Polishing
o Cementation.
50

51. Armamentarium
51
Band forming armamentarium

52. 52
Loop forming armamentarium

53. Band Construction
• The band forms can be classified as:
o According to Fabrication
• Loop bands
o Precious metal (first introduced by Johnson)
o Chrome alloy bands.
• Tailored bands
o Precious metal
o Chrome alloy.
53

54. o Preformed seamless bands
• A range of preformed bands from 1 to 32
depending on the mesiodistal width of
the tooth for the maxillary and
mandibular arch are available
commercially.
54

55. o According to Band Material
• Anterior teeth: 0.003 × 0.125 × 2 inches
• Bicuspids: 0.004 × 0.150 × 2 inches
• Primary molars: 0.005 × 0.180 × 2 inches
• Permanent molars: 0.006 × 0.180 × 2 inches.
55

56. o Impression Taking and Cast Preparation
• 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.
56

57. o Loop Fabrication
o This is formed using round stainless steel wire.
(0.036” wire)
o Loop should be in close approximation to the ridge
without impinging soft tissue (1 mm of gingival tissue).
o Loop portion should be wide enough faciolingually
(approx. 8 mm) to allow eruption of premolars.
57

58. o Soldering
• Quick set plaster is used to position the adapted wire on
the working model
• A generous amount of flux should be applied above and
below the point where wire contacts band
• The flame is redirected toward the cast and the joint is
heated till it is red hot and the solder flows evenly.
• Immediately dip this in water and remove appliance.
58

59. o Finishing and Polishing
• A finished solder joint should be smooth
and free of porosity.
• A green stone is used to contour the
soldered joint to a smooth
59

60. 60
Initial spot weld

61. 61
Rounding off margins

62. 62
Buccal grove adaptation

63. 63
Pinching with hoe pliers

64. 64
Festooning

65. 65
Final pinching with peak pliers

66. 66
Spot welding after final adaption

67. 67
Presentation of band

68. 68
Seating of band

69. 69
Infolding of seam

70. 70
Final spot welding of band seam

71. 71
Completely adapted band

72. 72
Initial loop fabrication

73. 73
Curve formation with three prong plier

74. 74
Adaption according to mucosa

75. 75
Marginal adaption of loop

76. 76
Retentive band of loop

77. 77
Complete loop placement

78. 78
Final loop presentation

79. 79
Stabilization

80. 80
Application of flux

81. 81
Soldering

82. 82
Finishing and polishing

83. 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
83

84. • Indications
• It is usually indicated for preserving the space
created by the premature loss of single primary
molar.
84

85. • Advantages
• Construction is easy and faster
• Few appointments by patient
• 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 2nd molar (E) is lost before eruption
of premolar.
85

86. 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.
86

87. • Crown-band and loop: Stainless steel crown is first
placed on abutment tooth and then it is banded.
• Meyne’s space maintainer: Band and loop but the loop
is halved.
87

88. • Reverse band and loop: Given 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.
88

89. • Band and bar:
• Bonded band and loop • Long band and loop
89

90. • Band and loop with NIMS modification: Prajapati et
al. (2013) proposed that in some case like long-standing
loss of upper first primary molars, the primary canine
occludes with primary molar of opposite arch such that
cusps of molar impede in the space created by loss of
tooth. In such cases, the loop has to be modified and
one arm has to be removed to create space and allow
proper occlusion
90

91. • Band and loop space maintainer with unilateral band and
bent wire design was presented by Pushpalatha et al.
2016 in cases with space loss.
91

92. LINGUAL ARCH SPACE
MAINTAINER
• It is a bilateral,
nonfunctional,
passive/active, mandibular
fixed appliance.
• It is the most effective
appliance of space
maintenance and minor
tooth movement in lower
arch.
92

93. • Indication
• The appliance is usually indicated to preserve the
space
• It helps in maintaining the arch perimeter by
preventing both mesial drifting and lingual
movement of the molar teeth and also lingual
collapse of the anterior teeth.
• Bilateral loss of primary molars after eruption of
lower lateral incisors.
• Minor space regaining
93

94. • Contraindication
• It is not used before eruption of permanent incisors
because the permanent incisor tooth buds develop
and erupt somewhat lingual to their primary
precursors and the design of conventional
mandibular lingual arch might interfere with their
eruption.
94

95. • Design of the Wire Loop
• The arch wire should contact the erupted
permanent incisors at the cingulum.
• Arch wire should be located 2 mm below the
gingival margin or edentulous ridge in the
posterior regions to prevent distortion under
process of mastication
• should be located 1 to 2 mm lingual to the
posterior teeth to permit satisfactory eruption of
the bicuspids in a buccolingual plane.
95

96. 96
Design of the wire loop

97. • Advantages
• Many modifications are possible
• Can also be used to regain space
• Arch holding space maintainer.
• Disadvantages
• Construction is difficult
• More chances of distortion of appliance by tongue
pressure
• May cause unwanted movements.
97

98. • Modifications
• Hotz lingual arch — with U-loop used for space
regaining
98

99. 99

100. NANCE PALATAL ARCH
SPACE MAINTAINER
• Bilateral, nonfunctional, 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.
• It provides resistance to the
anterior movement of posterior
teeth in a horizontal direction.
100

101. • Indications
• Nance palatal arch may be used in maintaining the
maxillary 1st permanent molar positioning when
there is bilateral premature loss of primary teeth
with no loss of space in arch
101

102. • Design of the Wire Loop
• The arch extends anteriorly without touching against the
surface of the primary molars; as the successor bicuspids
usually are broader buccolingually, and the wire could deflect
them from their natural position.
• At the rugae area, a small U-shaped bend should be
incorporated in the wire, which is approximately 1 to 2 mm
away from the soft tissue. The bend will enhance the retention
of acrylic to the wire
• The acrylic button, 0.5 inch in diameter is placed usually on the
descending portion of the palatal vault 1 to 2 mm below the
incisive papilla.
102

103. • Advantages
• Arch stabilizing.
• Disadvantages
• May cause tissue hyperplasia
• Irritation to palatal tissues
• Pressure effects
• Cannot be used in patients allergic to acrylic.
103

104. • Modifications
• Modified Nance appliance for unilateral molar distalization
• Esthetic Nance palatal arch: Appliance modified with the
attachment of teeth in anterior region to serve as space
maintainer and also for anterior esthetics.
104

105. TRANSPALATAL ARCH
• Unilateral, nonfunctional,
passive, maxillary fixed
appliance that has been
recommended for stabilizing
the maxillary 1st permanent
molars when primary molars
require extraction
105

106. • Indications
• The best indication for transpalatal arch is when one side
of arch is intact and several primary teeth on the other
side are missing.
• It is also indicated when primary molars are lost
bilaterally.
• The appliance is designed to prevent the molars from
rotation.
• In arch expansion.
106

107. • Design of the Wire Loop
• The transpalatal arch runs directly across the palatal vault
avoiding contact with the soft tissues.
• U-shaped bend must be given to the wire in middle of
palate if any manipulation is required.
• As it approaches the mesial part of the palatal surface of
the band, the wire should be bent to the distal part of the
band to assure a better joint.
107

108. • Advantages
• Used in multiple unilateral loss
• Can be used for expansion.
• Disadvantages
• Rotation of molars
• Both molars may tip together.
108

109. DISTAL SHOE SPACE
MAINTAINER
• Distal shoe appliance is
otherwise known as the
intraalveolar appliance
• The appliance, which is in
practice, is Roche’s distal
shoe or modifications of it
using crown and band
appliances with a distal intra
gingival extension
109
• Distal surface of the 2nd primary molar provides a
guide for unerupted 1st permanent molar.

110. • Indications
o When the second primary molar is extracted or lost
before the eruption of 1st permanent molar.
110

111. • Contraindications
o Inadequate abutments due to multiple losses of teeth.
o Poor oral hygiene
o Lack of parent and patient cooperation.
o Medically compromized patients like patients with
congenital heart disease, kidney problems, juvenile
diabetes, history of rheumatic fever, generalized
debilitation and hemophiliacs.
o Congenitally missing 1st permanent molar.
111

112. • If distal shoe is contraindicated, either allow the tooth to
erupt and regain space later or use removable or fixed
appliance that does not penetrate the tissue but places
pressure on the ridge mesial to unerupted molar.
• Faulty positioning is most common problem so before
cementation checked by x-Ray
112

113. • Construction of loop :
• The tissue bearing loop is then contoured with a
0.040 inch wire extending distally and into the
prepared opening on the model. The free ends of
the loop are soldered to the band or directly to the
crown in some cases.
113

114. In The Lower Arch:
o should have slight lingual position over the crest of the
alveolar ridge
In the upper arch:
o should be slightly facial to the crest of the alveolar ridge.
o The width should closely approximate the normal contact
area of the distal surface of the second primary molar being
replaced.
Position and width of the distal extension :

115. • Length of the distal extension (horizontal bar) :
Second primary molar is still present, should be
maintained if possible until the appliance is ready to
be sealed
If the second primary molar is already missing.
• Record the mesiodistal width of the opposite second
primary molar if present and compare that with the
radiographic measurement.

116. • Depth of the gingival extension (vertical bar) :
o If the extension is left too long, possible harm to
the developing second premolar may result.
o If the extension is too short, the first permanent
molar could erupt underneath the appliance.

117. • For indirect construction techniques, a good preoperative
radiograph that is slightly under exposed to show the
thickness of the overlying soft tissues will aid in
determining the depth of the groove to be cut in the
working model for constructing the gingival extension.
• The gingival extension of the appliance should be
constructed to extend about 1mm (Hicks) below the
mesial marginal ridge of the first permanent molar or just
sufficient to “capture” its mesial surface on the tooth
erupts and moves forward.

118. • Appliance placement :
o The appliance is removed from the model and the V of the
tissue extension is filled in and soldered with pieces of 0.040
inch wire.
o A knife edge is formed at the apex of the V if the second primary
molar has previously been extracted and the extraction site has
healed. The sharpened distal shoe may be passed through a
sterilized and anaesthetized area of the ridge.
o If the appliance is delivered at the time of extraction, the
intragingival extension is just polished and not sharpened.

120. • Before final placement of the maintainer in the mouth,
a radiograph is taken to determine whether the tissue
extension of the appliance is in proper relationship
with the unerupted first permanent molar.
• Final adjustments in length and contour of the distal
shoe can be made at this time.

121. • According to Barber the appliance has become
controversial in recent years.
• Trauma and damage to the unerupted permanent teeth.
• Normal eruption of the lower first permanent molar rarely
contacts the root surface of the second deciduous molar
and does not use the root for eruption guidance at all.
• Instead, the lower first permanent molar normally erupts
occlusal ward to contact first the distal crown surface of
the deciduous molar and uses that to buttress for up
righting and establishing a mesial position.
121

122. Space maintenance in the mixed dentition
.
MISSING PRIMARY
TOOTH
TREATMENT SUGGESTION REASON
Maxillary lateral incisor Extract antimere Decreases possibility of mid-
line shift
Maxillary canine Prior of eruption of permanent
lateral incisor(s) : removable space
maintainer
Guides permanent lateral
incisor into proper position
Decreases possibility of mid-
line shift
After eruption of permanent lateral
incisor(s): extract antimere
Decreases possibility of mid-
line shift
Maxillary first molar
B/L loss Nance appliance Prevents loss in arch
dimension,mesial tipping of
molars
U/L,>1 tooth missing
Transpalatal arch rigid attachment to intact side
provides stability

123. MISSING
PRIMARY TOOTH
TREATMENT
SUGGESTION
REASON
Maxillary second
molar
B/L loss Nance appliance Prevents loss in arch
dimension,mesial tipping of
molars
U/L,>1 tooth mising
Transpalatal arch rigid attachment to intact
side provides stability

124. MISSING
PRIMARY
TOOTH
TREATMENT
SUGGESTION
REASON
Mandibular lateral
incisor
Extract antimere Decreases possibility of mid-
line shift
Mandibular canine Prior of eruption of permanent
lateral incisor(s) : removable space
maintainer
Requires only minor
adjustment to afford normal
positioning of permanent
incisors
Decreases possibility of mid-
line shift
After eruption of permanent lateral
incisor(s): stopped lingual arch
space maintainer
Decreases possibility of mid-
line shift
Prevents lingual tipping of
permanent incisors

125. MISSING
PRIMARY
TOOTH
TREATMENT
SUGGESTION
REASON
Mandibular 1st molar Prior to eruption of permanent lateral
incisor(s) : Band/Crown loop space
maintainer
Prevents loss in arch dimension
Does not interfere with
eruption of permanent teeth
After eruption of permanent lateral
incisor(s) : lingual arch space
maintainer
Prevents loss in arch dimension
Permits distolateral
repositioning of primary canine

126. MISSING
PRIMARY
TOOTH
TREATMENT
SUGGESTION
REASON
Mandibular 2nd
molar
Prior to eruption of permanent
lateral incisor(s) : Band/Crown loop
space maintainer
Prevents loss in arch
dimension
Does not interfere with
eruption of permanent
insicors
After eruption of permanent lateral
incisor(s) : lingual arch space
maintainer
Prevents mesial tipping of
PFM
Prevents loss in arch
dimension

127. BONDED
SPACE MAINTAINER

128. •Overcome problems of
―Multiple visit
―Loosening of bands
―Decalcification of abutment tooth

129. NiTi BONDED SPACE
REGAINER/MAINTAINER
•NiTi space regainer/maintainer is simple appliance, can be used
chairside in a single visit.
•A composite dimple is bonded on the buccal side of permanent
first molar and with the help of an explorer burrow a tunnel into
the mesial of dimple, creating a composite tunnel that is open
only on the mesial end.
•A piece of 0.016 inch NiTi wire is then bonded on the buccal
side of primary molar/first premolar and extended beyond the
dimple

130. •After the composite has set on both the teeth with the help
of birdbeak plier, the free end of wire is directed into the
tunnel made in the dimple of first molar.
•This will give a form of activated loop of NiTi wire.
•A small amount of bonding material is placed in the
opening of the tunnel to make the attachment more
permanent

131. •Over time the loop returns to its original shape due to unique
shape memory property of NiTi wire, distalizing and uprighting
the first molar.
•Once the active correction completes, the wire segment is left in
place as a passive space maintainer till the eruption of second
premolar .
•ADVANTAGES:
―The whole procedure can be completed in a single visit at the
chair side,
―No need of procedures like impression taking, fitting of
bands and soldering,
―Better oral hygiene can be maintained as the appliance is
self-cleansing
―Improved patient compliance.

132. Glass fiber-reinforced composite resin –
EverStick
•Translucent colored
•Matrix contains poly methylmethacrylate
• Advantages:
―Easy to apply & require only one visit
―No need of impression making
―No contact with soft tissues – good oral hygiene
―Esthetic, less bulky & occupy less space in oral
cavity
•Disadvantages:
―Technique sensitive
―Fracture at enamel-composite interface
―Framework fracture

133. PROCEDURE:
•In order to determine the length of GFRCR, the distance from MB
line angle of C to DB line angle of E was measured
•LA & RD isolation
•Both abutment teeth cleaned with pumice slurry & etched with
37% orthophosphoric acid for 40 S
•Then rinsed, air-dried, & wetted with adhesive (light cured for 20
S)
•Reapplication for 4 to 5 times (to avoid contraction gap
formation)

134. •Thin layer of flowable composite on buccal surfaces of
abutment teeth without light-curing it
•Cut length of GFRCR is placed from mesial surface of C to
distal surface of E
•Ends of fiber adapted to tooth surfaces with plastic
instrument
•Preliminary curing for 40 S & flowable CR was placed
over the GFRCR

135. •Final curing done for another 40 S
•Repeated on lingual surface
•Occlusion checked
•Final polishing done