LETS PRESERVE THE SPACE WE HAVE!!PRIMARY TEETH BEING THE BEST SPACE MAINTAINER. WHAT TO GIVE?HOW TO DECIDE? SPACE MAINTAINERS OR SPACE REGAINERS?

1. PREVENTIVE ORTHODONTICS
WITH SPECIAL REFERENCE TO
SPACE MANAGEMENT
GUIDED BY: PRESENTED BY:
DR. SANDEEP TANDON DR. RUCHIKA BAGARIA
SENIOR PROF & HOD 1ST YEAR POST GRADUATE
RUHS COLLEGE OF DENTAL SCIENCES PEDIATRIC & PREVENTIVE
JAIPUR DENTISTRY

2. CONTENTS
꙳ Introduction
꙳ Definition
꙳ Preventive Orthodontics
꙳ Space Maintenance
꙳ Removable Space Maintainers
꙳ Fixed Space Maintainers
꙳ Conclusion
꙳ References

3. INTRODUCTION
• Preventive orthodontics is that part of orthodontic practice which is concerned with
the patient and parent education, supervision of growth and development of
dentition and the cranio-facial structure which is largely the responsibility of a
general dentist.
• Many of the procedures are common in preventive and interceptive orthodontics but
the timings are different.
• Preventive procedures are undertaken in anticipation of development of a problem ,
whereas interceptive procedures are taken when the problem has already
manifested.

4. DEFINITION
Preventive Orthodontics - The action taken to preserve the integrity of what appears to
be normal occlusion at a specific time. – Graber (1966)
Proffit and Ackermann (1980) - has defined it as prevention of potential interference with
occlusal development.
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 in the developing dentofacial complex.

5. • Space Maintenance - This term was coined by JC Brauer
in 1941. According to Keith J Ryan, space maintenance
is the process of maintaining a space in a given arch
previously occupied by a tooth or a group of teeth.
• 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. Parent education
Management of
deeply locked first
permanent molars
Management of
abnormal frenal
attachments
Prevention of damage
to occlusion
Occlusal equilibration
Checkup for oral habits
and habit breaking
appliance if necessary
Maintenance of quadrant
wise tooth shedding time
table
Management of
ankylosed teeth
Care of deciduous
dentition
Caries control
Extraction of
supernumerary teeth
Space
maintenance

7. • Expecting mother - Nutrition, ideal environment for developing foetus, avoid certain
drugs.
• Soon after birth - Proper nursing and care of child.
• If bottle fed - Use physiologic teat and not conventional teat (do not permit suckling by
movement of tongue and lower jaw) leading to various orthodontic problems.
PARENT EDUCATION
CONVENTIONAL TEAT PHYSIOLOGIC TEAT CONVENTIONAL VS PHYSIOLOGIC TEAT

8. • Do not use pacifiers for a long time.
• Prevention of nursing bottle syndrome
• Proper nutrition of the child & proper nursing care of the infant.
• Correct method of brushing teeth

9. Proximal caries
Movement of adjacent
teeth into the space
Arch length and
tooth material discrepancy
Proper clinical and
radiographic examination
PREVENTED
CARIES CONTROL

10. CARE OF DECIDUOUS DENTITION
• Prevention and timely restoration of carious teeth.
• All efforts to prevent early loss of deciduous teeth (they are natural space
maintainers)
• Simple preventive procedures like: Application of topical fluorides, Pit & fissure
sealants etc.
TOPICAL FLUORIDES PIT & FISSURE SEALANTS

11. What is ankylosis???
What are the consequences???
Management???
MANAGEMENT OF ANKYLOSED TEETH

12. Supernumerary Tooth
Cysts and Tumours
Overhanging
restorations in
Deciduous teeth
Fibrosis of Gingiva
Presence of
unresorbed deciduous
root fragments
Presence of over-
retained deciduous
teeth roots
Ankylosis of Primary
Teeth
MAINTENANCE OF TOOTH
SHEDDING TIME TABLE

13. ORAL HABITS CHECK-UP AND EDUCATING
PATIENTS AND PARENTS
 Thumb sucking
 Nail biting
 Tongue thrusting
 Lip biting
 Mouth breathing

14. Habit breaking appliances can be used to stop these habits, they are of two kinds:
1. Fixed habit breaker
Example - Blue Grass Appliance
2. Removable habit breaker
Example - Palatal Crib
Both the appliances act as a reminder and
make the habit an unhappy experience.

15. ELIMINATING OCCLUSAL
INTERFERENCES
• Functional prematurity should be eliminated as they can lead to
deviations in the mandibular path of closure and also predispose to
bruxism.
• Detected by using articulating paper & premature contact is removed by
selective grinding.
• Sometimes abnormal anatomical features like enamel pearls, may cause
premature contact.
• Presence of an abnormally large cingulum on a maxillary incisor prevents
establishment of normal overbite and overjet.

16. PREVENTING MILWAUKEE BRACE DAMAGE
• Orthopaedic appliance used for correction of scoliosis.
• It applies tremendous force on the mandible and the developing occlusion
leading to retardation of mandibular growth and possible deformities.

17. EXTRACTION OF
SUPERNUMERARY TEETH

18. DEEPLY LOCKED FIRST PERMANENT MOLARS
• Occasionally the deciduous second molar have a prominent distal bulge
which prevents the eruption of the first permanent molars.
• Slicing these distal surface helps in guiding the eruption of first permanent
molars.

19. HIGH LABIAL FRENUM
ANKYLOGLOSSIA
MANAGEMENT OF ABNORMAL FRENAL ATTACHMENTS

20. SPACE MAINTENANCE
 Premature loss of deciduous teeth can cause drifting of the adjacent teeth into the space
 Causes abnormal axial inclination of teeth, spacing and shift in the midline.
 Premature loss of anteriors only minimal orthodontic changes
 Premature loss of deciduous first molars lateral shift of anteriors
 Premature loss of deciduous second molars mesial migration of first permanent molars
impaction of second premolars or deflection in eruption pathway

21. 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

22. 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
OBJECTIVES OF SPACE MAINTENANCE

23. SPACE CLOSURE FOLLOWING PREMATURE LOSS OF TEETH
INCIDENCE OF CLOSURE
David G Owen (1971) in a literature survey of incidence and nature of space
closure following premature extraction of primary teeth showed that the
incidence of closure increases with time from premature extraction.
RATE AND AMOUNT OF CLOSURE
Maxillary spaces have a higher average rate of closure than mandibular extraction
spaces. Space loss in the maxilla is more than the mandible in terms of amount of
space.
DIRECTION OF CLOSURE

24. FORCES EXERTED ON TEETH
• Three distinct forces, i.e. occlusal, muscular and
eruptive forces contribute to space closure.
• Occlusal forces - opposing forces of passive eruption exerted
by individual teeth to maintain a constant vertical relation.
• Muscular forces - cheek, lip and tongue muscles which tend
to limit buccal, labial and lingual movements & contribute to
dental arch form by maintaining tooth contact &
establishing a stable intermolar and intercanine width.
• Eruptive forces - powerful mesial forces during eruption of
permanent molar as arches continue to develop.

25. SPACE MAINTENANCE IN THE DIFFERENT REGIONS
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
MANDIBULAR
INCISOR
No space
maintenance
required
No consequence.
Exception: 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)

26. MAXILLARY/
MANDIBULAR
CANINE
Band and loop
space maintainer
Decreases
possibility of
midline shift
MAXILLARY/
MANDIBULAR 1ST
MOLAR
Band/crown loop
space maintainer
Prevents loss in
arch dimension
MAXILLARY/
MANDIBULAR 2ND
MOLAR
Distal shoe space
maintainer
Guides 1st permanent
molar into proper
position
Prevents loss in arch
dimension

27. DIAGNOSTIC STEPS
• Medical & Dental History
• Full mouth radiographs
• Missing teeth
• Over Retention
• Supernumerary tooth
• Diagnostic casts
• Space analysis

28. HUCKABA ANALYSIS (1964)
Width of primary tooth on IOPA—Y 1
Width of its underlying successor on IOPA—X 1
Width of primary tooth on the cast—Y
Width of the unerupted permanent tooth—X
Formula , X = YX1/Y1
SPACE ANALYSIS IN MIXED DENTITION

29. MOYERS MIXED DENTITION ANALYSIS
The combined width of the mandibular permanent central and lateral incisors is measured.
This value is used in the probability chart (75% of the value) and a value obtained.
TANAKA – JOHNSON ANALYSIS
It requires no additional radiographs or tables to predict tooth size

31. 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
INDICATIONS
OF
SPACE
MAINTAINERS

32. 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.
If the space shows no signs of closing.
When succedaneous tooth is absent
When the space left by prematurely lost primary tooth is greater than
the space needed for the permanent successor as indicated
radiographically.
CONTRAINDICATIONS
OF
SPACE
MAINTAINERS

33. Maintain
the entire
space
Restore
function and
prevent
over
eruption
Simple in
construction
Strong to
withstand
occlusal
forces
No excessive
stress
Oral hygiene
maintenance
Should not
restrict
growth
Not interfere
with functions
IDEAL REQUIREMENTS

34. FACTORS TO BE CONSIDERED
WHEN PLANNING OF SPACE
MAINTENANCE
A
B
C
D
E
Time elapsed since loss of tooth
Dental age of the patient
Thickness of the bone covering
Sequence of eruption of teeth
Congenital absence of permanent tooth

35. With or without
bands
Complete arch
• Lingual arch
• Extra-oral anchorage
Individual tooth
HITCHCOCK RAYMOND
C THUROW
Removable or
fixed or semi-
fixed
Functional or Non-
functional
Active or passive
Combinations of
the above
Removable
CLASSIFICATION
OF
SPACE
MAINTAINERS
Fixed space
Maintainers
Class I
1.Non-functional
I. Bar type
II. Loop type
2. Functional
I. Pontic type
II. Lingual arch
type
Class II
- Cantilever type
Removable space
maintainers
HINRICHSEN

36. REMOVABLE SPACE MAINTAINERS
Brauer classified removable dentures for children as follows:
1. Class 1: Unilateral maxillary posterior
2. Class 2: Unilateral mandibular posterior
3. Class 3: Bilateral maxillary posterior
4. Class 4: Bilateral mandibular posterior
5. Class 5: Bilateral maxillary anterior posterior
6. Class 6: Bilateral mandibular anterior posterior
7. Class 7: One or more primary or permanent anterior
8. Class 8: Complete primary

38. Advantages Disadvantages
Easy maintenance Lost or broken
Maintain the vertical dimension Uncooperative patients
Worn part time Restriction of lateral jaw growth
Aid in functions Irritation of soft tissues
Dental checkup can be done easily
Room can be made for the eruption
Stimulate eruption
No band construction
Prevents tongue thrust habit

39. Indications Contraindications
Aesthetics Uncooperative patients
No support from abutment teeth Allergic to acrylic materials
Cleft palate patients Epileptic patients
More than 5 months for eruption
of permanent teeth
Partially erupted permanent teeth
Multiple loss of deciduous teeth

40. ACRYLIC PARTIAL DENTURES
FULL OR COMPLETE DENTURES
REMOVABLE SPACE MAINTAINERS

41. FIXED
SPACE MAINTAINERS

42. Advantages Disadvantages
Minimum or no tooth preparation Instrumentation & skill
Do not interfere with passive
eruption of abutment teeth
Tooth decalcification
Jaw growth is not hampered Supra-eruption of opposing tooth
Permanent teeth are free to erupt Prevention of eruption of abutment
tooth
Uncooperative patients
Masticatory function is restored if
pontics are placed

43. Band construction
Taking the
impression and
cast preparation
Loop fabrication
Soldering Polishing Cementation
FABRICATION OF FIXED SPACE MAINTAINERS

44. BAND FORMING ARMAMENTARIUM LOOP FORMING ARMAMENTARIUM
ARMAMENTARIUM FOR
SPOT WELDING

45. • Stainless steel band material or preformed bands
• Pliers—contouring pliers, band forming pliers, band seater or pusher, band adapter, hoe
pliers straight and curved, band cutting scissors, bird beak pliers, crimping pliers, three-
pronged pliers, universal pliers
• Stainless steel wires (round)
• Spot welding unit, soldering unit, silver solder, flux
• Wire cutter
• Finishing burs, polishing stones

46. BAND CONSTRUCTION
• According to fabrication,
1. Loop bands
• Precious metal (first introduced by Johnson)
• Chrome alloy bands
2. Tailored bands
• Precious metal
• Chrome alloy
3. Preformed seamless bands
Chrome alloy or precious metal, which are adapted, festooned, and stretched to fit. 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.

47. 4. According to band material
• Anterior teeth: 0.003 × 0.125 × 2 inch
• Bicuspids: 0.004 × 0.150 × 2 inch
• Primary molars: 0.005 × 0.180 × 2 inch
• Permanent molars: 0.006 × 0.180 × 2 inch
PREFORMED SEAMLESS BANDS BAND MATERIAL

48. BAND
FABRICATION

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

50. LOOP
FABRICATION

51. 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.

52. SOLDERING
STABILIZATION

53. FINISHING & 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 transition with
the band. Rubber wheels are relied upon to reduce surface roughness, and gold
rouge or rag wheel is used for final polishing
FINISHING POLISHING

54. FINAL PRESENTATION OF POLISHED SPACE MAINTAINER

55. BAND AND LOOP
• It is a fixed, nonfunctional, passive space maintainer
• MAXILLARY or MANDIBULAR
• Unilateral most typical
• Single tooth span
• INDICATION: is usually indicated for preserving the
space created by the premature loss of single
primary molar.

56. INDICATIONS
(MATHEWSON)
Premature loss of any
primary first molar in the
primary dentition or the
primary maxillary first molar
in the transitional dentition.
Premature loss of a primary
second molar as the
permanent molar is erupting
clinically
CONTRAINDICATIONS
An occlusion that is extremely
crowded or already exhibits
marked space loss.
High dental caries activity.
Replacement of primary anterior
teeth.
Replacement of primary second
molar in the primary dentition
without partial clinical eruption
of the permanent 1st molar
Cases that need guidance of
eruption

57. DESIGN OF BAND & LOOP
BAND: stainless steel material 0.005 inches in
thickness
CRIB: portion of the wire spanning the
edentulous space
LOOP: portion of the wire contacting the
abutting tooth 0.032 inches in diameter

58. • Mesial end of the loop contacts the distal surface of the first primary molar at a point just
below the height of contour.
• Distal ends – Use simple bends to contour the wire so it contacts the band near the mesial
line angle and remains in contact for the full length of the band - Cut away any excess wire or
plaster that interferes with fitting
• The wire should be above the gingiva at the point of contact with the abutment tooth.
• The central portion of the loop is shaped wide enough
to allow the full eruption of the permanent tooth.

59. • The facio-lingual dimension should be approximately 8mm.
• The loop should be contoured to follow the edentulous ridge, but 1mm off the tissue.
• The anterior curve of the loop is shaped to approximate the shape of the distal surface of
the abutment tooth and to match its width.
• Purpose of S-bend - Allows transition of wire from
the ridge to band without impinging on the gingival
tissues

60. MODIFICATIONS
CROWN AND LOOP
Same as band and loop but a stainless steel crown is used on
abutment tooth instead of a band
Robert Rapp and Isik Demiroz (1983) used stoppers to
prevent gingival as well as buccal movements of loop
BAND AND LOOP WITH STOPPERS

61. 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
LONG BAND AND LOOP
Multiple loss of teeth in one segment and an arch stabilizing space
maintainer like lingual arch cannot be given due to eruption status or if
removable appliance is contraindicated

62. REVERSE BAND & LOOP
BAND & BAR
Abutment teeth on either side of the extraction space are
banded and connected to each other by bar
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

63. BONDED BAND & LOOP
• Advantages are ease of adhesion to the dental
contours, fast technique of application, good strength
• Gerald Z Wright (1976) preformed loop of 0.81 mm
wire designed
• Simsonsen RJ (1978) used a metal bar (3M company)

64. • A new technology of three-dimensional (3D) printing
also known as additive manufacturing or desktop
fabrication has been recently introduced.
• It is a process of making 3D solid objects from a
digital file
Pawar BA. Maintenance of space by innovative three-dimensional-printed band and loop space maintainer.
J Indian Soc Pedod Prev Dent 2019;37:205-8.

65. Advantages
• 3D-printed SM is precise, quick, and easy.
• Development and perfection of 3D printing
technology allow production of information in 3Ds
with accuracy
• Single-step impression addition silicon and make a
cast.
• The cast -3D printing laboratory for scanning and
printing a metal-based SM .
• Cementation by using glass ionomer cement (Type 2;
GC Fuji; Tokyo, Japan)

66. Khanna S, Rao D, Panwar S, Pawar BA, Ameen S. 3D printed band and loop space maintainer: A digital game
changer in preventive orthodontics. Journal of Clinical Pediatric Dentistry. 2021 Jul 1;45(3):147-51.

67. Vinothini V, Sanguida A, Selvabalaji A, Prathima GS, Kavitha M. Functional band and loop space
maintainers in children. Case Reports in Dentistry. 2019 Apr 24;2019.

68. Aids in mastication.
Prevents supra eruption of the opposing
tooth.
Distribution of occlusal forces on the pontic
and hence less chance of loop distortion/
slippage and impingement in gingiva.
Prevents the development of abnormal
tongue habit
Direct visualization of the eruption of
the successor is not possible.
Cement loss and solder failure can be
possible reasons for failure of this
appliance. Hence, quality designing of
the appliance, close supervision, and
frequent follow-ups at 2-4 month
interval are imperative.

69. Prajapati D, Nayak R, Kashyap N, Kappadi D. Band and loop redefined—the NIMS modification.
Unique J Med Dent Sci. 2013;1:46–7
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
opposite arch first primary molar such that the mesio-buccal cusp
and mesial marginal ridge of first primary molar almost touches the
ridge in the space created by loss of the tooth. In such cases, the
loop has to be modified and one arm has to be removed to create
space and allow proper occlusion

70. Pushpalatha C, Mala Devi M, Punitha K, Shwetha G. Custom modified band and loop space
maintainer—a case report. J Dent Orofacial Res. 2016;12.
BAND & LOOP SPACE MAINTAINER WITH UNILATERAL BAND AND BENT WIRE DESIGN

71. LOWER LINGUAL HOLDING ARCH
• Bilateral, fixed or semi-fixed, non- functional passive arch appliance
• Holds molar position distally & incisor segment anteriorly
• Advantages:
– Prevents lingual collapse of anterior teeth
– Prevents space loss from deep bite or from lingual pressures
from oral habits
– Preserves primary canine space - maintaining arch length
– Arch holding space maintainer

72. Maintenance of arch perimeter (not just quadrant
perimeter) – mainly in mandibular arch
Maintenance or prevention of mandibular changes
in arch length, over jet or over bite from incisor
repositioning in transitional dentition
Retention or stabilization of mandibular anterior
teeth after correction
Anything that requires frequent adjustments
Rampant caries, high plaque scores, poor patient
cooperation
Anterior or posterior cross bite
Extreme mandibular crowding
INDICATIONS CONTRAINDICATIONS

73. DESIGN OF THE WIRE LOOP
• The arch wire should contact the erupted permanent incisors at the cingulum.
• Arch wire located 2 mm below the gingival margin to prevent distortion under
process of mastication .
• The arch wire should meet the band at the mesiolingual cusp, and at the same
time, place the soldered joint in the middle third of the band to avoid occlusal
interference.

74. • BAND: Stainless steel material 0.005 inches in
thickness (ortho bands)
• LINGUAL ARCH WIRE: Stainless steel round wire
0.036 inches in thickness

75. TYPES
• Fixed – soldering wire to band
• Semi-fixed – ends of arch wire fitted into tubes attached to lingual surfaces
MODIFICATIONS
CHAWLA MODIFICATION
soldering of wire on the lingual
side of the band and also use
canine spurs to prevent midline
shift

76. WITH CANINE STOPPERS HOTZ MODIFICATION
with U-loop used for
space regaining
MODIFIED FOR ERUPTING INCISORS
Wire bent to create space for
lingually erupting incisors

77. Bilateral, fixed, passive & non-functional space maintainer
At rugae area, a small U-shaped bend is given which approximates 1 cm
distal to the lingual surfaces of incisors
Bend enhances the retention of acrylic button (0.5” in diameter)
Indications Bilateral loss of multiple primary teeth
Also serves as habit breaking appliance (tongue thrusting) –
using spurs
NANCE HOLDING ARCH APPLIANCE

78. DESIGN OF THE WIRE LOOP
• The arch wire 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.
• The acrylic button, is placed usually on the descending portion of the palatal vault 1–
2 mm below the incisive papilla.

79. 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

80. TRANSPALATAL ARCH
Bilateral, fixed, passive & non-functional space maintainer
INDICATION: unilateral loss of multiple primary teeth, while the other
side is intact
Effective in preventing molars from rotating around palatal roots
Prevents anchorage loss
Transpalatal arch runs across the palatal vault avoiding contact with soft
tissue
In arch expansion

81. 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 (can be given mesially or
distally) 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

82. INTRA-ALVEOLAR (DISTAL SHOE) APPLIANCE
OBJECTIVE
To retain & guide the PFM into normal eruptive occlusion
INDICATION
Maintain space of primary 2nd molar that has been lost before the eruption of PFM
CONTRAINDICATION
• If several teeth are missing (abutment to support the cemented appliance may be missing)
• Poor oral hygiene
• Certain medical conditions like SABE, Blood dyscrasias, etc.
• Congenitally missing PFM (rare)

83. Made of Cast gold –
increased cost & difficulties
in tooth preparation
Bar type of extension into
the soft tissues & bony
alveolus to guide the
erupting PFM
DISADVANTAGE:
• Injure the permanent unerupted
tooth
• Erupting PFM is guided by the
distal primary crown (not root)
surface – use of tissue inserted
distal shoe is ill-advised
WILLET DISTAL GUIDING SHOE (1932)

84. Advocated crown or band
appliance with distal
intragingival extension
V-shaped extension – broader
surface → prevents rotations
Greater chances of success
even if unerupted tooth lies
buccal or lingual in arch
DISADVANTAGES:
• Cantilever design → anchored
on occlusally convergent crown
of 1ST primary molar
• Can replace only one tooth
• No occlusal function is restore
ROACHE DISTAL GUIDING SHOE (1942)

85. • MEASURING THE 2ND PRIMARY MOLAR
• If not removed before
• MEASURED FROM THE RADIOGRAPH
• distance between distal surface of primary 1st molar
& unerupted PFM (if already missing)
• May force the tooth to erupt too far distally (if
fabricated at 3 to 4 years of age) → disto-occlusion
of molars
LENGTH OF DISTAL EXTENSION (HORIZONTAL BAR)

86. • 1mm below the MMR of unerupted PFM (Hicks)
• V shaped edge should be sharp if inserted into extraction site after healing
• Can be polished & smooth if inserted on day of extraction
• Too long → injures the developing 2nd premolar
• Too short → unerupted PFM might slip under the extension
DEPTH OF EXTENSION (VERTICAL BAR)

87. Should be evaluated with radiograph prior to cementation
• Length
• Position
Will be replaced with another space maintainer when permanent teeth
erupt

89. MODIFICATIONS
GINGIVAL SADDLE APPLIANCE
This is a combination of reverse band and loop and distal
shoe where the loop is placed on gingiva and the molar
on eruption contact this loop

90. Chanchala et al. (2014) modified the design of distal shoe space maintainer in bilateral loss of molars to
add circular distal extension with bands on canine and an added functional component

91. Bhat et al. 2014 modified the design of distal shoe space maintainer
and fused it with lingual arch in case of early loss of both primary first
and second molars unilaterally.
Bhat PK, Navin HK, Idris M, Christopher P, Rai N. Modified distal shoe appliance for premature loss of
multiple deciduous molars : a case report. J Clin Diagn Res. 2014;8:ZD43–ZD45.

92. Somwanshi et al. 2016 modified the design of distal shoe appliance in case of multiple bilateral loss
of teeth by banding and adding lingual component with rectangular distal extensions.

93. NEWER MODIFICATIONS
IN SPACE MAINTAINER

94. E Z SPACE MAINTAINER
• Developed by Dr Enis Guray in 2008
• Adjustable bondable space maintainer, directly bonded during single office
visit
• It can be modified by including a NiTi coil to regain space

95. TUBE AND LOOP SPACE MAINTAINER
 Designed by Srivastava et al. in 2017 and termed as “Nikhil appliance”
 Can be given in a single sitting without any laboratory work
 Consists of wire component with helix which is fitted on to the buccal tubes in
molars
 It is an innovative modification of band and loop space maintainer which can be
used in single, unilateral tooth loss
Srivastava N, Grover J, Panthri P. Space Maintenance with an Innovative “Tube and Loop” Space Maintainer
(Nikhil Appliance). Int J Clin Pediatr Dent 2016;9(1):86-89.

96. CEMENTED APPLIANCE ERUPTING 25

97. Zameer M, Dawood T, Basheer SN, Peeran SW, Peeran SA, Birajdar SB, et al. Clinical technique: Space maintenance
Following the Premature Loss of Primary Molars using Innovative Fixed Unilateral Space Maintainers (Smart
Appliances). Int J Dentistry Oral Sci. 2020;7(12):968-71

98. PREFORMED SPACE MAINTAINER
e – Space Maintainer (Kids-E-Dental)
ADVANTAGES:
•Single appointment
•No impression and model pouring
•Precise and no laboratory errors involved
•Universal bands decreases inventory
•Cost effective
•Very useful in sedation cases

99. FUNCTIONAL SPACE MAINTAINER
INDIRECT TECHNIQUE

101. DIRECT TECHNIQUE : DOUBLE ATTACHMET

103. DIRECT TECHNIQUE : CANTILEVER

105. ANTERIOR ESTHETIC FUNCTIONAL SPACE MAINTAINER

106. BONDED SPACE MAINTAINER
• Overcome problems of
Multiple visit
Loosening of bands
Decalcification of abutment tooth

107. SIMPLE FIXED SPACE MAINTAINER
• Introduced by Swaine & Wright, 1976.
• Fixed space maintainer bonded to the abutment tooth
• Advantages: Eliminates problem of rotation of abutment tooth
• Modification: Fixed space maintainer combined with open-faced SSC

108. 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

109. In order to determine the length of GFRCR, the distance
from MB line angle of C to DB line angle of E was measured

110. • C&L SMs have the best longevity and GFRCR SMs may be a longer lasting and
safer alternative to B&L SMs. C&L SMs are recommended for loss of a primary
first molar and GFRCR SMs (placed under rubber dam) are recommended for
loss of a primary second molar.
Ahmad AJ, Parekh S, Ashley PF. Methods of space maintenance for premature loss of a primary
molar: a review. European Archives of Paediatric Dentistry. 2018 Oct;19:311-20.

111. SPACE REGAINERS
Active space maintainers – brings about active tooth movement Removable or fixed; unilateral or
bilateral
Indication: need to re-establish about 3mm or less of space
Easy to regain space in maxilla than in mandible
o Increased anchorage provided by palatal vault
o Maxilla – cancellous bone; Mandible – cortical bone
Types:
o Removable – Hawleys appliance; Head gear
o Fixed - Gerber space regainer; Jackscrew space regainer

112. GERBER SPACE REGAINER
• Consists of band adapted on tooth & open coil inserted into U shaped
wire
• Wire is inserted into molar tubes welded on band
• Whole assembly is inserted onto the tooth
HOTZ LINGUAL ARCH
• U loops in fixed lingual arch (Hitchcock, 1974)

113. JACKSCREW SPACE REGAINER
• Used to recover loss of space caused by drifting of tooth into
edentulous area
• Consists of 2 banded adjacent teeth & a threaded shaft with
screw and a locknut

114. REMOVABLE SPACE REGAINER
SLING-SHOT TYPE
• From distal end of appliance, hooks are attached on buccal & lingual sides of PFM → distal
movement
• Elastic band is slung between the hooks
• 1-2 mm of distance to be moved
• So named as it resembles “ Sling-shot

115. SCREW TYPE
• Expansion screw embedded in removable appliance
• Expansion of screw → distal movement
• Expansion is performed once a week
• 3mm (width of screw) of movement can be achieved

116. SPRING TYPE
Distal movement of PFM is achieved throu’ force produced by spring using
0.7mm spring

117. GROPER’S APPLIANCE
• Attach the anterior replacement teeth to 0.040” SS wire framework retained
with bands or crowns on 2nd primary molar
• If primary 1st molars are present – place indirect retainers (occlusal rest) to
prevent flexing of wire Additional stabilization with Nance button

118. CONCLUSION
• The first step in maintaining good dentition is to maintain good oral hygiene and
control abnormal oral habits which itself will reduce the requirement of
orthodontic treatment by a substantial amount.
• The best treatment is PREVENTION, so if at the preventive stage itself we can
evade malocclusion it is less traumatic and also cost effective to the patient. If
incase we are unable to prevent the malocclusion we must intervene to avoid
adverse occlusal and dental consequences.

119. REFERENCES
o Koch G. Poulsen S. Paediatric Dentistry A clinical approach. 2nd ed. UK: Wiley Blackwell; 2009.
o Paediatric Dentistry (Infancy through Adolescences) Jimmy R. Pinkham, Paul S. Casamassimo, Dennis J. McTigue,
Henry W.Fields, Arthur J. Nowak,.- 4th ed.
o Muthu MS. Sivakumar N. Paediatric Dentistry Principles & Practice. 2nd ed. Elsevier, Mosby; 2009.
o McDonald RE, Avery DR. Dentistry for the child and adolescent. 8TH Edition, Lea & Febiger, Elsevier, Mosby;
2004.
o Marwah N. Textbook of Paediatric Dentistry. 4th Ed. New Delhi: Jaypee Brothers Medical Publishers; 2018.
o Tandon S. Textbook of Pedodontics. 2nd Ed. Hyderabad: Paras Medical Publisher; 2009.
o Richard J. Mathewson, Robert E. Fundamentals of Pediatric Dentistry : Primosch; illustrations, Jack T.
Morrison.—3rd ed.

120. • Pawar BA. Maintenance of space by innovative three-dimensional-printed band and loop space maintainer. J
Indian Soc Pedod Prev Dent 2019;37:205-8.
• Khanna S, Rao D, Panwar S, Pawar BA, Ameen S. 3D printed band and loop space maintainer: A digital game
changer in preventive orthodontics. Journal of Clinical Pediatric Dentistry. 2021 Jul 1;45(3):147-51.
• Vinothini V, Sanguida A, Selvabalaji A, Prathima GS, Kavitha M. Functional band and loop space maintainers
in children. Case Reports in Dentistry. 2019 Apr 24;2019.
• Prajapati D, Nayak R, Kashyap N, Kappadi D. Band and loop redefined—the NIMS modification. Unique J Med
Dent Sci. 2013;1:46–7
• Pushpalatha C, Mala Devi M, Punitha K, Shwetha G. Custom modified band and loop space maintainer—a
case report. J Dent Orofacial Res. 2016;12.
• Srivastava N, Grover J, Panthri P. Space Maintenance with an Innovative “Tube and Loop” Space Maintainer
(Nikhil Appliance). Int J Clin Pediatr Dent 2016;9(1):86-89.