This document discusses various types of space maintainers used to prevent premature loss of space after primary teeth are lost. It describes fixed unilateral appliances like band and loop and crown and loop space maintainers. Bilateral fixed appliances discussed include Nance palatal holding arch and lower lingual arch. Removable appliances like Hawley retainers are also mentioned. Indications, advantages, and disadvantages of different space maintainers are provided. The steps of construction including fitting bands and fabricating the appliance are outlined.

1. Space Maintainer
Prof. Dr. Jebun Nessa
Pedodontics Department

2. Space maintainers
 We recommend prompt and appropriate space
management therapies (using space maintainer) to
help insure optimal lifelong dental health.
 Space maintainers are defined as the appliances
that prevent loss of arch length and which in turn
guide the permanent tooth into a correct position,
in the dental arch.

3. *Importance of Baby Tooth
 Baby teeth aren't just for chewing.
 Each one also acts as a guide for the eruption of the
permanent tooth that replaces it.
 If a baby tooth is lost too early, the permanent tooth
loses its guide.
 It can drift or erupt into the wrong position in the
mouth. Neighboring teeth also can move or tilt into
the space. This means that there may not be enough
space for the permanent tooth to come in.

4. Causes of Premature Tooth Loss
 They can be knocked out in a fall or other accident.
 They may need to be extracted because of severe decay
that causes infection.
 They may be missing at birth.
 Some diseases or conditions can lead to early tooth
loss.

5. *Space Management
Space management is an important responsibility of
the general dentist and the pedodontist.
Inadequate space management can cause problems
which are long lasting and severe.
The premature loss of primary teeth may cause loss
of arch length, resulting in crowding of the
permanent dentition, impaction of permanent
teeth, esthetic difficulties, malocclusion, and
other problems.

6. The "Best" Space Maintainer

7. Natural Space Maintainer
 The best space maintainer is a primary tooth, as
you see demonstrated in this radiograph. When
nature's best space maintainer is lost prematurely,
we need to intervene and maintain the space for
normal development of the dental arches.

8. Pediatric Space Management
Introduction: Space Management
 For example, this panoramic
radiograph shows the premature loss
of the mandibular right second
primary molar, resulting in the
tipping of the first permanent
molar and consequent loss of space.
 This is an example of space loss
which could have been prevented if a
space maintainer had been placed
after the primary tooth was removed
(earlier).

10. Eruption times of primary teeth
 Upper
 Central incisor 7.5 mths
 Lateral incisor 8 mths
 Canine 16-20 mths
 First molar 12-16 mths
 Second molar 21-30 mths
 Lower
 Central incisor 61/2 mths
 Lateral incisor 7 mths
 Canine 16-20 mths
 First molar 12-16 mths
 Second molar 21-30 mths

11. Eruption times of permanent teeth
 Upper
 Central incisor 7 - 8 yrs
 Lateral incisor 8 - 9 yrs
 Canine 11 - 12 yrs
 First premolar 10 - 11 yrs
 Second premolar 10 - 12
yrs
 First molar 6 - 7 yrs
 Second molar 12 - 13 yrs
 Third molar 17 - 21 yrs
 Lower
 Central incisor 6 - 7 yrs
 Lateral incisor 7 - 8 yrs
 Canine 9 - 10
 First premolar 10 - 12 yrs
 Second premolar 11 - 12
yrs
 First molar 6 - 7 yrs
 Second molar 12 - 13 yrs
 Third molar 17 - 21 yrs

12. Various Types Of Space Maintainers
There are numerous types of space maintainers. They
range from the very simple to those with numerous
bands and wires. They can be constructed differently
and used in different parts of the mouth. Some even
have parts extending into the tissue.

13. Examples Of Various Types Of Space
Maintainers

14. Variations on Space Maintainer
There are numerous variations on these
basic themes.
For example, some space maintainers
are used for missing anterior teeth
and
some are used to preserve space for
posterior unerupted teeth.

15. Classification Of Space Maintainers
There are numerous types and subtypes of space
maintainers is to start by classifying them
broadly into four categories.
They can be fixed or removable,
and they can be unilateral or bilateral.

16. Removable and Fixed
• A removable space maintainer, of course, can be
removed.
• A fixed space maintainer is fixed (i.e., held) to a tooth
or to more than one tooth. Fixation usually is done by
cementing the space maintenance appliance in place.

17. Unilateral and Bilateral
• Fixed space maintainers can be unilateral or
bilateral.
• Unilateral space maintainers are fixed to one side of
the mouth and
• Bilateral space maintainers are fixed to both sides of
the mouth.

18. Indications:
Premature loss of primary molar
 The premature loss of primary molars may
require the placement of a space maintainer
to prevent the migration of the adjacent
teeth, depending upon the teeth present
and the arch length.

19. Premature loss of primary canine
 When loss of primary canine occurs, the dental arch
midline may be compromised and the arch length
also may be reduced. The premature loss of primary
canines may therefore require the placement of a
space maintaining appliance to prevent midline
deviation and/or loss of arch length, perimeter
and/or circumference.

20. Premature loss of primary incisors
 The premature loss of primary incisors does
not usually require the placement of a
dental appliance for the maintenance of
space because mesial movement of the
adjacent teeth is not generally expected.

21. *Contraindications :
 A space maintainer is usually not necessary if there is
a sufficient amount of space present to allow for
eruption of permanent tooth/teeth.
 A space maintainer may not be recommended if
severe crowding exists, such that space
maintenance is of minimal effect and subsequent
orthodontic intervention is indicated.
 A space maintainer may not be necessary if the
succedaneous tooth will be erupting soon.

22. Types of space Maintainers
 The treatment modalities may include, but are not
necessarily limited to the following types of appliances
 Fixed appliances
 Band and Loop/Crown and Loop
 Distal Shoe
 Lower Lingual Arch (For mandible)
 Nance Appliance (For Maxilla)
 Removable appliances
 Hawley appliance/Removable dentures

23. In case of unilateral loss
 Fixed appliances
 Band and Loop/Crown and Loop
 Distal Shoe
 Removable appliances
 Hawley appliance/Removable dentures

24. In case of bilateral loss
For maxilla :
 Nance palatal holding arch.
 Bilaterally placed band and loop space maintainers
For mandible :
 Lingual arch.
 Bilaterally placed band and loop space maintainers

25. Space maintenance for premature loss of
deciduous first molar
In case of unilateral loss :
 Band and loop-nonfunctional passive space
maintainer or Crown and loop space maintainer.
 Deciduous second molar is used for abutment
tooth.

26. Indications For Space Maintenance Therapy
 A space maintainer is indicated to prevent
mesial movement of the second primary
molar.
 A band and loop space maintainer is the best
choice.
 It is especially important to start space
maintenance therapy prior to the eruption
phase of the first permanent molar, since
the force of eruption of the permanent molar
will exert a lot of pressure to push the
second primary molar forward.
 The eruption phase of the 1st permanent
molar is the time of greatest force exerted
against the primary molar.

27. Fixed Unilateral Appliance
 This photograph shows an
example of a fixed unilateral
appliance on the maxillary
left side for a seven year-old
patient.
 The photograph
demonstrates the appliance
after cementation.
 This appliance is referred to
as a band and loop space
maintainer and is a favorite
among many clinicians.

28. Band And Loop Space Maintainer

29. Band and loop space maintainer

30. Band and Loop space maintainer
Indication :
 Loss of first primary molar tooth.
Advantage :
 Easy of fabrication for the clinician
 Requires less chair time
 Easy of maintenance for the patient.
Disadvantage
 Opposing tooth may over-erupted.
 Nonfunctional passive space maintainer, so
 It does not helps in mastication.

31. Steps of Construction of Space Maintainer
 Once a decision is made regarding what type of
appliance is needed and how it is to be used, the next
phase of the space maintenance protocol involves
creating the appliance.
 Four steps are involved in fixed appliance therapy: 1.
Fitting the bands, 2. Impression taking, 3.
Appliance fabrication, 4. Cementation.
 In the case of removable appliances, impression
taking is the first step since bands will not be used.

32. Selecting And Fitting Bands
 The first step in the process of
appliance fabrication is selecting
and fitting the bands
accomplished by estimating the
proper size of band needed. A trial
and error method is used by most
clinicians when selecting bands for
an appliance.

33. Selecting And Fitting Bands
 The estimation is done
by examining the tooth
which will be banded
and selecting a band
from the box of bands
which appears to be
the appropriate size for
that tooth.

34. Appliance Construction - Fitting The Bands
 Occasionally we discover
that the contacts
between the teeth are so
tight that separating
elastics are necessary
before the bands can be
placed.

35. Selecting And Fitting Bands
 The separating elastic is situated between the
teeth where the band will be placed. One of the
easiest methods of elastic placement is to use two
threads of dental floss in order to hold the elastic.
Next, gently "saw" the elastic between the teeth.
Ideally, the elastic can be placed a few days
before the band fitting appointment. If that
were not possible, elastics could be placed at the
same appointment. When both steps are planned
for the same appointment, better separation
will result if at least fifteen or twenty minutes
is scheduled between elastic placement and
the band try-in.

36. Selecting And Fitting Bands
 The first step in the placement process
is carrying the band to the tooth and
placing it on the tooth with finger
pressure. Further placement of the
band can be done by pushing with a
tongue depressor or the handle of a
band seater. The patient can be asked
to bite on the tongue depressor or
handle of the band seater to push the
band further apically.

37. Selecting And Fitting Bands
 Some clinicians use a tongue depressor to aid
in pushing the band down over the tooth.
You can ask the patient to bite gently on the
tongue depressor and the band is pushed
down.
 HELPFUL HINT: As shown in the
photograph, sometimes a tongue depressor
which has been broken in half can be used
more effectively than an unbroken tongue
depressor, since the broken tongue depressor
is smaller and easier for the child to bite on.

38. Selecting And Fitting Bands
 The advantage of using a
tongue depressor is that the
band is almost never crushed
during placement.

39. Selecting And Fitting Bands
 The handle of a band seater
also is a convenient
instrument to use to push the
band into place.

40.  If the band is too large, it will be too
loose a fit. If it is too small, the band
will not go down over the tooth. We
usually consider a nicely adapted
band to be one that is placed on the
tooth with some resistance and one
which cannot be lifted off with finger
pressure. We remove and place
various bands until we obtain one
which has a good fit.

41. Usually a band seater is used for further adaptation
after initial placement. Please note how the band
seater is placed on the tooth prior to having the
patient bite down on the seater. Band seaters come
in circular and triangular shapes.
CAUTION: If you use the triangular seater, it is
important not to place it next to the band in such a way
that the patient can inadvertently drive the triangular
piece into the cusp of the tooth. This may fracture
the cusp.

42. A Nicely Fitted And Adapted Band

43. Band Pusher

 A band pusher may be used
for the final step in
adaptation of the band. It is
used to push the band against
the tooth if a space remains
between the band and the
tooth. Tightly placed and well
adapted bands are desired, so
that washout of the cement is
less likely to occur.

44. Compound Impression With Band In Place

45. Fabricating The Appliance

46. Nicely Cemented Band (Using
Glass Ionomer Cement)

47. Time To Remove Space
Maintainer

48. Time To Remove Space Maintainer

49. Time To Remove Space Maintainer

50. Band Removal Pliers.
 Note the use of band removal
pliers. These are used during the
placement and fitting process to
remove bands. Of course, the same
band removers are used to remove
space maintainers when necessary
in other clinical situations, for
example when they are no longer
needed due to eruption of
permanent teeth

51. Crown and loop space maintainer
Indication :
 Loss of First primary molar with significant loss of
abutment tooth.
Advantage :
 Easy of fabrication for the clinician
 Easy of maintenance for the patient.
Disadvantage :
 More difficult to fabricate than band and loop

52. Crown and loop space maintainer

53. Crown And Loop Space Maintainer

54. Fixed Unilateral Appliance
 The photograph presents a variation
on the band and loop space
maintainer; a mandibular left crown
and loop space maintainer is shown.
 Note how the stainless steel wire is
soldered to the stainless steel
crown and the wire is bent so that
it is adapted closely to the tissue.
 The crown and loop space maintainer
is a type of fixed unilateral space
maintainer where stainless steel
crown therapy was necessary on
the abutment tooth.

55. Fixed Bilateral Space Maintenance:
Space Maintainers: Types Of Space Maintainers
 The photograph demonstrates another
variation on the bilateral use of fixed
unilateral space maintainers.
 In this case, a fixed unilateral band and loop
space maintainer was used on one side and
a fixed unilateral crown and loop space
maintainer was used on the other side.
 Crown and loop space maintainers can be
used when a stainless steel crown is needed
on a tooth which also is an abutment for a
space maintainer.
 However, often band and loop space
maintainers are used over stainless steel
crowns. The rationale for using a band and
loop space maintainer over a stainless steel
crown is that if the band and loop appliance
is no longer needed or if it fails, replacing
the stainless steel crown will not also be
necessary.

56. Nance palatal holding arch
Indication :
 Bilateral loss of upper first primary molar.
 Bilateral loss of upper second primary molar.
Advantage :
 Maintain the tooth space and leeway space
 Allows growth transversely in the inter canine area.
Disadvantage :
 Palatal acrylic button may cause food accumulation
leading to an inflammatory soft tissue response in the
palate.

57. Nance palatal holding arch

58. Nance palatal holding arch

59. Maxillary Fixed Bilateral Space
Maintainer (Nance Appliance)

60. Maxillary Fixed Bilateral Space
Maintainer (Nance Appliance) Maintenance
 The photograph shows a maxillary fixed
bilateral space maintainer. This type of
space maintainer also is known as a Nance
Holding Arch or a Nance Appliance. Note
the small acrylic button which will rest
against the palatal tissue with this
appliance. Some clinicians object to the
button since it can create tissue
irritation. Therefore, it is important that
patients and parents be instructed to
make sure that the patient meticulously
flosses under the acrylic button. The
Nance Holding Arch is used in situations
where premature bilateral loss of maxillary
primary teeth has occurred.

61. Bilateral Band And Loop
Space Maintenance
 This photograph shows two
band and loop space
maintainers, an example of
the bilateral use of fixed
unilateral band and loop
space maintainers.
 These are very common types
of unilateral space
maintainers, and they often
are used bilaterally.

62. Lower lingual arch
Indication :
 Bilateral loss of lower second primary molar
 Bilateral loss of first lower primary molar
Advantage
 Maintain the tooth space and leeway space.
Disadvantage
 First permanent molars may be susceptible to
decalcification, may be prone to breakage unless the
patient is well informed on maintenance.

63. ***Mandibular Fixed Bilateral
Space Maintainer (Lower Holding
Arch)

64. Lingual arch space maintainers:
Fixed Bilateral Space Maintainer
 This photograph shows an example
of a fixed bilateral space maintainer.
The patient is four years of age.
 The appliance is cemented on the
two second primary molars. Fixed
bilateral space maintainers on the
mandibular arch often are called
lingual arch space maintainers.
 Mandibular fixed bilateral space
appliances generally are preferred by
clinicians over removable space
maintainers.
 Fixed appliances are easier to
maintain and they are less likely to
be removed, damaged, or lost by the
child.

65. Lingual arch space maintainers:
Fixed Bilateral Space Maintainer
 Another lingual arch appliance for
mandibular bilateral space maintenance is
shown here. In this case, the appliance is
attached to permanent teeth. The
mandibular lingual arch space maintainer
is used very commonly in the primary
dentition and the mixed dentition, where
bands can be cemented to primary or
permanent molars respectively. This is one
of the most ubiquitously used space
maintainers. It is even used on occasion in
the permanent dentition when bicuspids
are missing and maintaining space is
necessary prior to orthodontic and/or
prosthetic therapy.

66. Mandibular Removable Bilateral Space
Maintainer A mandibular removable bilateral
space maintainer is shown on a six
year-old. This youngster
prematurely lost the mandibular
right and left first and second
primary molars. The
disadvantages of a removable
appliance are that it may not be
worn by the patient and it is
more susceptible to breakage
or loss by the patient. To
reiterate, most clinicians prefer to
place fixed space maintainers if
possible.

67. Prosthetics For Maxillary Anterior Teeth
 The appliance
demonstrated in this
photograph is used to
replace missing maxillary
anterior primary teeth
(it is an example of a
type of maxillary
anterior prosthesis).

68. Mandibular Removable Bilateral Space
Maintainer
 The same mandibular
removable bilateral
space maintainer is
shown outside of the
mouth. Note the wire
attachments designed for
the purpose of improved
appliance retention.

69. Mandibular Removable Bilateral
Space Maintainer

70. Space maintenance for premature loss of
deciduous second molars
In case of unilateral loss
 Band and loop space maintainer.
In case of bilateral loss
For maxilla :
 Nance palatal holding arch.
 Bilateral band and loops are indicated
For mandible
 Lower lingual arch.
 Bilateral band and loops are indicated

71. Indications For Space Maintenance Therapy
This is a
radiograph of a
similar situation
showing the
missing
mandibular right
second primary
molar.

72. Space maintenance on premature loss of deciduous
second molars but before the eruption permanent
first molars.
Methods of space maintenance in such condition are
 Distal shoe
Advantage :
 Maintain the second primary molar space.
Disadvantage :
 Difficult to fabrication.
 It is contraindicated in some medically compromised patients eg.
 Blood dyscrasias
 Congenital heart defects
 Diabetes mellitus
 Poor oral hygiene.

73. Distal Shoe Space Maintenance
This appliance is called a distal shoe space maintainer or
a distal extension space maintainer.
It is used to prevent first permanent molars from moving
mesially with the premature loss of second primary
molars.
The example shown is a crown with a distal extension
segment soldered to the crown.
The distal segment is extended into the tissue against
the unerupted first permanent molar.
The distal extension, also called a distal shoe, is used
when the second primary molars are lost prior to the
eruption of the first permanent molars (i.e., very
premature loss).

74. Distal shoe space maintainer

75. Indications For Space Maintenance
Therapy
 This photograph
demonstrates stainless steel
crowns on the cuspid and the
first primary molar, with a
distal bar extending into the
tissue, thereby preventing
the first permanent molar
from tipping mesially over
the underlying premolar.

76. Maintenance Therapy
 This radiograph shows the
placement of a distal shoe space
maintainer extending to the
mesial surface of the
unerupted first permanent
molar.
 The distal shoe space maintainer
is intended to prevent the first
permanent molar from
erupting in a tipping manner
over the underlying premolar.

77. Indications For Space Maintenance Therapy
 This is an example of a distal
shoe space maintainer which
has been successful in
directing the eruption of the
first permanent molar.
However, since the first
permanent molar has now
erupted, the existing
distal shoe appliance
should be removed and a
band and loop space
maintainer can be placed.

78. Time To Replace The Distal
Shoe (With A Band And Loop)

79. Indications For Space Maintenance Therapy
 This photograph shows the band
and loop space maintainer which
has been used to replace the distal
shoe appliance.
 It is advantageous to replace the
distal shoe, which extends under
the tissue and is less hygienic than
a band and loop space
maintainer.

80. Space maintenance for premature loss
of deciduous incisor
 The premature loss of primary incisors does not
usually require the placement of a dental appliance for
the maintenance of space because mesial movement of
the adjacent teeth is not generally expected.
 Appliance may require use removable partial
denture.

81. Hawley appliance/Removable acrylic
Indication :
 When multiple teeth are lost and space maintenance
and mastication are of concern.
Advantage :
 Can maintain space as well as aid in mastication.
 Helps in speech development.
Disadvantage :
 Susceptible to fracture or loss.
 Discomfort for the child.

82. Maxillary Removable Bilateral
Space Maintainer

83. Removable Unilateral Space
Maintainer (NOT USED)

84. WE FEEL REMOVABLE UNILATERAL SPACE
MAINTAINERS ARE DANGEROUS
 These are examples of dangerous
space maintainers.
 They are removable unilateral space
maintainers.
 We believe removable unilateral space
maintainers should not be used.
 They are too small and present
swallowing and choking dangers
for children.

85.  For safety reasons, we recommend not to
use a removable unilateral space
maintainer.
 If they are dislodged, they are so small
that they can become a swallowing or
choking danger.

86. Conclusion
 Space maintainers help “hold space” for permanent
teeth. The child may need one if he or she loses a
baby tooth prematurely, before the permanent
tooth is ready to erupt.
 If a primary tooth is lost too early, adult teeth can
erupt into the empty space instead of where they
should be.
 When more adult teeth are ready to come into the
mouth, there may not be enough room for them
because of the lost space.
 To prevent this from happening, the dentist may
recommend a space maintainer to hold open the
space left by the missing tooth.