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Space maintenance
Blackwell Publishing Ltd
International Journal of Paediatric Dentistry 2009; 19: 155–162 Methods. Medline and Ovid Medline were scanned,
and additionally a hand-search of non-listed peer-
Objective. The use of a space maintainer appliance, reviewed papers written in English was performed.
or restoration of a carious primary tooth that can A total of 16 pertinent papers published between
then act as a natural space maintainer, may poten- 1987 and 2007 that satisfied the inclusion criteria
tially obviate the consequences of loss of arch length were selected for discussion.
and the need for complex orthodontic treatment Conclusions. There is limited evidence to recom-
at a later stage. Nevertheless, all space maintainer mend either for or against the use of space
appliances are plaque retentive and may predispose maintainers to prevent or reduce the severity of
to dental caries and gingival inflammation. Space malocclusion in the permanent dentition. Decisions
maintainer appliances may also impinge on the soft regarding the use of space maintainers should be
tissues, interfere with eruption of adjacent teeth, guided by balancing the occlusal disturbance that
fracture, and become dislodged or lost. This review may result if one is not used against the potential
article provides a summary of the available evidence, plaque accumulation and caries that the appliance
and considers the indications for space maintenance. may cause.
Table 1. Summary of longitudinal studies investigating the effects of premature loss of primary molars.
Follow-up
Author Sample size period (months) Teeth lost Main findings
Lin et al. (2007)5 19 children 6 Maxillary primary first molar (unilateral) Distal drift of primary canines
Palatal migration of incisors
1 mm D space lost
Padma Kumari and 40 children 8 Mandibular primary first molar Space loss on extraction side
Retnakumari (2006)6 (unilateral) (P < 0.01).
No significant space loss on non-
extraction side (P > 0.05)
Lin and Chang (1998)7 21 children 8 Mandibular primary first molar Distal drift of primary canines
(unilateral)
At 8 months post-extraction,
D + E space is significantly shorter
than control side (P = 0.025)
Type of space
maintainer Space maintainer Description Advantages Disadvantages
Fixed, unilateral Band and loop A loop of heavy gauge wire is soldered • Can be used bilaterally • Single span
to a band on an abutment tooth • Simple to fabricate • Plaque retentive
adjacent to the edentulous space and • Well-tolerated by patients • Increased risk of caries
closely adapted to the edentulous space
Crown and loop A variation on the band and loop, • As for band and loop • As for band and loop
whereby the wire is soldered to a crown • Useful if abutment tooth also needs a • If the space maintainer part (loop) is no longer
rather than a band crown required or fails, a new crown may be necessary
Distal shoe Typically, a crown on the primary first • Effective at guiding eruption of FPM • Technically difficult
molar with a distal segment extension • Can use preformed distal shoes, although • Requires excellent oral hygiene
soldered to the crown. The distal as they are not customized to an • Requires local anaesthetic and a surgical incision
segment (distal shoe) is extended into individual, they cannot be used in all • Once the FPM has erupted, it often needs to be
the tissue mesial to the unerupted first cases swapped for a band and loop until the second
permanent molar (FPM) premolar erupts, entailing several appointments
Journal compilation © 2009 BSPD, IAPD and Blackwell Publishing Ltd
Removable, unilateral Removable unilateral Acrylic base carrying 1–4 pontics • Can be removed for cleaning • Dangerous as easily swallowed/inhaled due to
space maintainer supported by clasps at either end small size. Now an archaic method
Fixed, bilateral Transpalatal arch (TPA) Comprises a heavy gauge wire soldered • Good where bilateral premature loss of • FPM’s may move forwards simultaneously
to molar bands on each side of the maxillary primary molars has occurred. approximately 1 mm
mouth with a central ‘U’ loop • Stable as anchored to two teeth
Nance palatal arch As for TPA, but has a central acrylic • As for TPA but more stable as additional • Button can cause palatal tissue irritation
appliance button resting against palatal tissue anchorage gained from palatal vault
anteriorly instead of the ‘U’ loop
Lingual arch Consists of a heavy gauge wire soldered • Very stable, because two abutments • If used in the primary dentition, the wire may
to molar bands on each side of the • Can be used in primary/mixed dentition obstruct the eruption of the lower incisors
mouth, extending anteriorly to contact as bands can be cemented to primary/ • Some clinicians favour bilateral band and loop
the lingual surfaces of the incisors permanent molars appliances in the primary dentition
• Can use in hypodontia cases where
premolars are absent, prior to prosthetic
treatment
Removable, bilateral Upper or lower Acrylic baseplate with pontic teeth filling • Good for multiple spaces • Compliance
removable appliance the exact dimensions of the edentulous • Appliance can also be used for active • Susceptible to breakage/loss by the patient
© 2009 The Authors
indicated when a second primary molar (com- a fixed unilateral space maintainer as previously
monly mandibular) is lost early, prior to the described.
eruption of the first permanent molar. In an
early study regarding space maintenance, Fixed space maintainers: bilateral. Lingual arch.
Richardson (1965) observed that there is This custom-made appliance, popularized by
significant mesial movement of the first Burstone, consists of a single heavy-gauge
permanent molars in these cases, if space [0.036 inch (0.9 mm) or higher] stainless steel
maintainers are not used12. The distal shoe wire adapted to the lingual aspect of the man-
consists of a plastic or metal guide plane that dibular arch, attached to bands on the first
guides permanent molar eruption. The loop permanent molars14. The appliance is stable as
carrying the intra-alveolar distal shoe is soldered it is anchored to two teeth, and the design can
onto a band or crown on the first primary incorporate two U-loops bent into the wire
molar. To be effective, the distal shoe must mesial to the first molars, which permit adjust-
extend into the alveolar process so that it con- ment in the sagittal direction. Lingual arches
tacts the first permanent molar approximately are commonly used in the primary and mixed
1 mm below its mesial marginal ridge, or at its dentitions where there has been premature
emergence from the bone. Once the molar loss of multiple posterior primary teeth. The
erupts, the distal shoe should be replaced for a appliance is cemented onto either the lower
band and loop as the distal shoe is less hygienic, primary second molars or first permanent
due to its extension under the gingival tissues. molars, and can be of fixed (soldered) design
Consequently, meticulous oral hygiene must or removable design. A conventional lingual
be maintained, and it should be borne in mind arch, contacting the cingulae of the mandibular
that the use of a distal shoe space maintainer incisors while staying approximately 1–1.5 mm
entails several appointments and is contrain- away from the soft tissue laterally, can prevent
dicated in patients with infective endocarditis. anterior movement of the posterior teeth and
Given the disadvantages of distal shoes, most posterior movement of the anterior teeth. The
clinicians prefer to try to save the primary evidence demonstrates that it is effective at
second molar with a pulpectomy prior to the maintaining the arch perimeter in the transition
eruption of the adjacent first permanent molar, from the mixed to the permanent dentition,
or use a removable appliance13. but at the expense of slight (mean 0.44 mm,
The procedure for distal shoe placement SD 0.31) lower incisor proclination15,16.
involves a first appointment for extraction of The lingual arch is commonly placed once
the primary second molar and impression the mandibular incisors have erupted, as other-
taking. At the second appointment, an incision wise the appliance may obstruct eruption of
is made in the gingival tissues immediately the lower incisors. If a bilateral space maintainer
mesial to the first permanent molar so that the is required prior to the eruption of the man-
distal shoe can be embedded in tissue, and the dibular incisors, some clinicians prefer to place
appliance is then cemented into place. Some bilateral band-and-loop appliances instead of a
clinicians combine the extraction and placement lingual arch. Either of these options is preferable
procedure to reduce patient discomfort from to a lower removable appliance, due to diffi-
local anaesthetic administration at both appoint- culties with compliance and the limited retention
ments. Alternatively, prefabricated distal shoes provided by mandibular molars.
may be used, although as they are not cust-
omized to the patient, they are unlikely to be TPA. Originally described by Robert Goshgarian
acceptable in every situation. in 1972, the Transpalatal arch is a maxillary fixed
or removable appliance consisting of a heavy-
Removable space maintainers: unilateral. These gauge [0.036 inch (0.9 mm) or higher] stainless
appliances present swallowing and choking steel wire that extends from one maxillary first
hazards for children due to their small size. They permanent molar, along the contour of the
are rarely used and are considered dangerous palate, to the contralateral first molar (Fig. 2). It
appliances. A preferable alternative would be is adapted to the curvature of the palatal vault,
so that it lies 2–3 mm away from the palatal H.N. Nance in 1947, consisting of a heavy-gauge
mucosa, and an omega loop is usually incor- [0.036 inch (0.9 mm) or higher] stainless steel
porated midway across the span. A TPA would wire soldered to the palatal aspect of the first
theoretically bring the roots of the upper permanent molar bands (Fig. 3). The wire is
molars into contact with cortical bone if they directed from the molars anteriorly and is
were forced to move mesially, which would attached to an acrylic button that rests against
supplement their anchorage. Cortical bone the most superior and anterior aspects of the
provides greater resistance to tooth movement palatal vault. It is used as a space maintainer,
than cancellous bone due to its reduced vas- such as in cases where bilateral loss of maxillary
cularity and increased density. primary teeth has occurred, or as a means to
The TPA can be adapted to produce a range reinforce anchorage, and it has some scope for
of forces and couples to move and/or rotate acting as a habit breaker. The advantage over
maxillary molars in all three planes of spaces17. the TPA is that additional anchorage is gained
Changing the palatal arch form can produce from the palatal vault, which helps to resist
expansion or constriction of the intermolar mesial movement of the terminal molars. It
width, and activation of the inserts of the TPA follows that the Nance arch is more suited to
will produce couples at the molar sheaths. patients in whom the palatal vault is deeper;
Following early loss of second primary molars, however, if excessive anchorage demands are
mesial rotation of the maxillary first permanent placed on the Nance, then it can become
molars around their palatal roots commonly embedded into the palatal mucosa and can be
occurs and the TPA can be activated to derotate difficult to remove. Kupietzky and Tal (2007)
them such that the mesiobuccal cusps move compared the use of the TPA and the Nance
distofacially18. Due to their rhomboidal shape, appliance, and found that the TPA can be just
maxillary molar derotation is an efficient way as effective as the Nance for space maintenance,
of gaining arch length as it opens up space and advocated its use 19. The advantage of
mesial to the molars (mean 0.4 mm, SD 2.0)18. the TPA over the Nance is that there is less
Alternative space maintainers in the maxillary potential for irritation of the palatal mucosa.
arch following premature loss of primary The Nance arch is useful in the case of missing
molars are bilateral band-and-loop appliances, maxillary anterior teeth, as an additional wire
a Nance palatal arch appliance, or an upper can be soldered onto the palatal aspect of the
removable appliance. first molar bands extending anteriorly to support
acrylic pontic teeth20. This can give acceptable
Nance palatal arch appliance. This is a maxillary aesthetics, although the patient must also
custom-made fixed appliance developed by clean meticulously under the pontics.
primary molar: a longitudinal study. J Indian Soc Pedod 13 Kupietzky A. Clinical technique: removable appliance
Prev Dent 2006; 24: 90–96. therapy for space maintenance following early loss of
7 Lin YT, Chang LC. Space changes after premature loss primary molars. Eur Arch Paediatr Dent 2007; 8 (Suppl.
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study. J Clin Pediatr Dent 1998; 22: 311–316. 14 Burstone CJ. Precision lingual arches. Active applica-
8 Rao AK, Sarkar S. Changes in the arch length follow- tions. J Clin Orthod 1989; 23: 101–109.
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Pedod Prev Dent 1999; 17: 29–32. dentition. Br Dent J 1969; 126: 76–79.
9 Northway W. The not-so-harmless maxillary primary 16 Rebellato J, Lindauer SJ, Rubenstein LK, Isaacson RJ,
first molar extraction. J Am Dent Assoc 2000; 131: Davidovitch M, Vroom K. Lower arch perimeter
1711–1720. preservation using the lingual arch. Am J Orthod Den-
10 Roberts JF. Treatment of vital and non-vital primary tofacial Orthop 1997; 112: 449–456.
molar teeth by one stage formocresol pulpotomy. 17 Rebellato J. Two-couple orthodontic appliance systems:
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Int J Paediatr Dent 1996; 6: 111–116. 18 Dahlquist A, Gebauer U, Ingervall B. The effect of a
11 Qudeimat MA, Fayle SA. The longevity of space transpalatal arch for correction of first molar rotation.
maintainers: a retrospective study. Pediatr Dent 1998; Eur J Orthod 1996; 18: 257–267.
20: 267–272. 19 Kupietzky A, Tal E. The transpalatal arch: an alter-
12 Richardson ME. The relationship between the relative native to the Nance appliance for space maintenance.
amount of space present in the deciduous dental arch Pediatr Dent 2007; 29: 235–238.
and the rate and degree of space closure subsequent 20 Evans RD, Jones AG. Modified Nance appliance for
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