Space Management in Pediatric Dentistry

Space Management In Pediatric
Dentistry
Space Maintainers: Types And Indications

Appliance Construction
Long-term Evaluation And Significance
Photo Bank: Space Management
1|P a g e h t t p : / / d e n t a l b o o k s d r b a s s a m . b l o g s p o t . c o m /
Introduction To Space Management

Space management is an important responsibility of
the general dentist and the pediatric dentist.
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. We recommend
prompt and appropriate space management therapies
to help insure optimal lifelong dental health.
The purpose of this chapter is to describe space
management therapies. We will focus on the various
types of space maintainers, when and how they are
used, and how they are made.
Our coverage will center on maintaining existing
space once primary teeth have been lost prematurely,
rather than on tooth movement. For information
concerning the movement of teeth, we refer you to
current textbooks of orthodontics or minor tooth
movement
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.
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.
This patient also has a missing mandibular right

second primary molar, but a space maintainer will be
placed here, keeping the permanent molar from
drifting mesially. The critical importance of
maintaining the space of a prematurely lost primary
molar will be emphasized throughout the chapter.
This photograph demonstrates a space maintainer placed on the

mandibular right first permanent molar using 0.036 stainless steel wire
soldered to an orthodontic band, with space being maintained for the
underlying bicuspid.
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. As we will
cover later, some even have parts extending into the
tissue.
We feel the best way to make sense of the 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.
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.
Unilateral space maintainers are fixed to one side of
the mouth and bilateral space maintainers are fixed to
both sides of the mouth. Fixed space maintainers can
be unilateral or bilateral.
Space maintainers also can be placed on the
mandibular or maxillary arch. Consequently, we could
have a maxillary removable bilateral space
maintainer, or a mandibular fixed unilateral right side
space maintainer, and so forth. 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.
The following pages will show the various types of
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.
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 dentit
on, 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.
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.
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
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.
Fixed Bilateral Space Maintenance
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.
Bilateral Band And Loop Space

Maintenance
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.
REMOVABLE UNILATERAL SPACE

MAINTAINERS(ARE DANGEROUS)
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.
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.
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).
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.
Prosthetics For Maxillary Anterior Teeth

Maxillary Removable Bilateral Space
Maintenance
This photograph shows a maxillary removable

appliance, in this case a maxillary removable bilateral
space maintainer. As suggested previously, removable
appliances are not commonly used because of
problems with the appliance not being worn and the
frequent incidence of breakage and loss.
The appliance demonstrated in this photograph is used

to replace missing maxillary anterior primary teeth.
Cases like this are discussed at length later in the
chapter and in the chapter covering pediatric
restorative dentistry (it is an example of a type of
maxillary anterior prosthesis).
Clinical Indications For Space

Maintenance
Indications For Space Maintenance

Therapy
The following section of the space maintainer chapter

is focused on the various indications for space
maintenance therapy.
As you have gathered by now, there are numerous
types of space maintainers. Each different space
maintainer is used in different clinical situations.
We will review an array of different clinical situations
relating to space maintenance therapy and give our
recommendations for each of these situations.
Hopefully, going through these clinical exercises will
result in an understanding of when space maintenance
is indicated and what type or types of space
maintainers might be used. We will attempt to cover
virtually every generic type of clinical situation
requiring space maintenance therapy which clinicians
will encounter in the primary and mixed dentitions.
This is a radiograph of a similar situation showing the

missing mandibular right second primary molar.
Again, is this a situation requiring placement of a
space maintainer?
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Yes; a space maintainer is indicated in the situation

described in the previous pages for this four year-old
child, as demonstrated by the drawing in red.
In this drawing, the mandibular right second primary

molar is missing on a four year-old child. In your
judgement, is this child in need of a space maintainer?
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
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.
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.
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.
Distal shoe space maintainers are discussed in the

chapter on pediatric pulp therapy, particularly in terms
of the importance of saving pulpally compromised
second primary molars prior to the eruption of the
first permanent molars. This is principally because of
the technical difficulties associated with the
placement of distal shoe space maintainers. The point
we make repeatedly in discussions concerning pulp
therapy is that it is best to save second primary molars
using primary endodontic therapy (i.e., pulpectomy)
when first permanent molars have not yet erupted.
Most experienced clinicians prefer to avoid distal shoe
space maintainers.
However, one approach which may cause the process
to be easier is to make distal shoe space maintenance
a one appointment procedure. Most space maintainer
protocol involves two appointments: the first
appointment for extraction and impression taking, and
the second appointment for placement and
cementation of the appliance. In the case of distal
shoe space maintainers, this means an additional local
anesthetic experience for the child and a surgical
incision immediately mesial to the first permanent
molar so the distal shoe can be imbedded in tissue.
The distal shoe space maintainer can be placed at the

time of extraction of the second primary molar. If this
approach is used, the impression must be taken and
the appliance constructed prior to extraction of the
primary tooth. The advantage is not having to go back
at a later time and surgically make an incision for
insertion of the distal shoe into the tissue so the distal
shoe segment can abut against the permanent molar.
Preformed (i.e., prefabricated) distal shoe space
maintainers also can be used. Of course, preformed
space maintainers are not customized (i.e., fitted) for
the individual patient. They are placed at the time of
the extraction appointment (i.e., a one appointment
procedure is involved). Although they are not
customized for the patient, using a preformed space
maintainer is acceptable in many situations. Using a
preformed space maintainer certainly is preferable to
not using a space maintainer at all. Unfortunately,
distal shoe space maintainers sometimes are not used
when a child's behavior makes it unlikely that
placement of the appliance at a second appointment
would be successful. Of course, when distal shoe
space maintainers are not used, the development of
space problems results.
Consequently, placement of distal shoe space
maintainers can be planned as one appointment or two
appointment procedures, and the choice of approach is
left to the discretion of the clinician. As mentioned
earlier in the chapter, it also is desirable to replace the
distal shoe space maintainer with an appliance which
is banded to the permanent molar once the permanent
molar erupts. Consequently, using the distal shoe
space maintainer and a subsequent band and loop
appliance really involves several appointments.
In this drawing, the mandibular right first primary

molar is missing on a six year-old child. In your
judgement, is the child in need of a space maintainer?
If so, would you use a removable or a fixed space
maintainer?
As you see demonstrated in red, 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 permanent molar is the time of greatest
force exerted against the primary molar.
For safety reasons, we recommend that you never use

a removable unilateral space maintainer. If they are
dislodged, they are so small that they can become a
swallowing or choking danger.
In this drawing, the mandibular right and left first

primary molars are missing on a four year-old child.
In your judgement, is the child in need of a space
maintainer? If so, would you use a removable or a
fixed space maintainer?
The lingual arch appliance, as demonstrated in the

photograph, would be the appliance of choice for
some clinicians in a situation where both primary first
molars have been lost in the primary dentition. The
bilateral appliance is very stable since it is anchored to
two teeth.
Another example of a lingual arch appliance designed
for the primary dentition is shown in the photograph.

Space maintenance is necessary to hold the second
primary molars in position, especially as the first
permanent molars erupt and create forces which
otherwise would move the primary molars forward.
Bilateral band and loop space maintainers can be
used, as outlined in red. The bilateral band and loop
strategy is our preferred approach, for reasons which
will be explained later.
The major disadvantage to the use of a lower fixed

bilateral lingual arch appliance in the primary
dentition is the potential for permanent incisors to
erupt later behind the lingual arch wire. In these cases,
the appliance must be remade or bilateral fixed
appliances can be placed. Some clinicians anticipate
this potential problem and place bilateral band and
loop appliances in the first place, so that interference
with the eruption of mandibular incisors definitely can
be avoided.
We believe that most experienced practitioners would
select bilateral band and loop appliances in situations
where both lower first primary molars have been lost
and before the eruption of the mandibular permanent
incisors has occurred. This approach will prevent later
problems with permanent incisors erupting behind the
lingual wire.
Nevertheless, the fixed bilateral lingual arch has the

advantage of being a very stable appliance because of
its two abutments. Many clinicians prefer it for that
reason.
Both are very acceptable approaches, and the choice
of a fixed lingual arch appliance or bilateral fixed
band and loop appliances is left to the preference of
the individual clinician.
Removable bilateral appliances are not the best
therapeutic choice, especially for children in the
primary dentition, although it is technically feasible to
use them. The biggest problem is that children in the
primary dentition age group are very unreliable when
it comes to taking care of removable appliances, and
the appliances are apt to become lost or damaged.
In this drawing, the maxillary right first primary

molar is missing in this six year-old child. In your
judgement, is the patient in need of a space
Of course, unlike the removable unilateral appliance,

the removable bilateral appliance is too large to be a
serious swallowing or choking danger.
This is an example of a lingual arch wire which was

placed before eruption of the permanent incisors, and
a permanent incisor has erupted behind the wire. This
problem can be avoided when band and loop space
maintainers are used before the eruption of the
permanent incisors.
A unilateral space maintainer is needed, as shown in

red. Otherwise, the maxillary right second primary
molar will drift mesially, thereby losing space. Once
again, space loss will be especially severe if space
maintenance is not used during the active phase of
eruption of the maxillary right first permanent molar.
The time of active eruption is commonly referred to as
the dynamic phase of eruption
space maintainer is an erupting first permanent molar.

The dynamic phase of eruption is occurring, and this
is when space maintenance is the most crucial.
This photograph shows the use of a band and loop

space maintainer for this type of situation. Note that
the maxillary right first permanent molar has not fully
erupted. That is, it still is in the active phase of
eruption. It is especially necessary for a space
maintainer to be used during this dynamic phase of
eruption.
In this drawing, the maxillary right and left first

primary molars are missing in this six year-old child.
Space maintenance is indicated in the situation shown

in the drawing. As demonstrated in the drawing, one
solution is to use a Nance Appliance or a Nance-type
maxillary fixed bilateral appliance.
This photograph demonstrates the same principle,

when a unilateral fixed space maintainer is needed on
the maxillary right side. In this case, stainless steel
crown therapy was needed on the second primary
molar. Therefore, a crown and loop space maintainer
was used. Please note that distal to the crown and loop
A Nance Appliance designed for the primary dentition

is shown in the photograph.
The drawing demonstrates another approach, where

two fixed unilateral space maintainers are used (band
and loop space maintainers). The choice of whether to
use a maxillary fixed bilateral appliance or two fixed
unilateral appliances is left to the preference of the
clinician. As we have emphasized, fixed space
maintainers are almost always preferred over
removable appliances, although a removable bilateral
appliance could be used in a situation like the one
shown in the drawing.
In this drawing, the maxillary primary central and

lateral incisors are missing in this four year-old child.
What is your recommendation for a case like this?

The patient is age three and has multiple missing
maxillary teeth.
A decision of whether or not to replace multiple missing
maxillary primary teeth involves some potential
controversy. Some clinicians prefer to replace maxillary
anterior primary teeth in patients when more than one tooth
is missing, and when it will be more than six months
before eruption of permanent central incisors. This
assumes the child's behavior is acceptable.
This photograph demonstrates two maxillary fixed

unilateral space maintainers. A band and loop space
maintainer is shown on the patient's right side and a
crown and loop space maintainer is shown on the left.
The choice of whether to use a band and loop
appliance or a crown and loop appliance will depend
partly on the restorative needs of the underlying teeth.
As mentioned earlier in the chapter, it also is
acceptable to use a band and loop space maintainer
over a stainless steel crown. Please note, once again,
in this photograph the maxillary left first permanent
molar is in the dynamic eruption phase.
Their reasoning is that the presence of replacement teeth

will hold the tongue in a better position. In this way, the
development of a tongue thrust is less likely. We are aware
of no well validated empirical research which actually
demonstrates an association between missing primary
anterior teeth and the development of tongue thrust.
Nevertheless, replacement of multiple missing primary
maxillary incisors is standard practice for some
practitioners as a precaution. We cannot identify any
serious risks to this approach, and it may indeed turn out
to be a useful strategy as research provides more

information on the topic of tongue thrust
development.
Of course, many parents applaud the procedure

because of the improved esthetics.
There also are many pediatric dental offices and many
dental schools where multiple missing primary
anterior teeth are not replaced, at least routinely.
Space loss usually is not a consideration, and
monitoring for that problem can be used to insure that
it does not occur. Most third party carriers also will
not cover the prosthetics procedure (i.e., insurers will
not reimburse you for the procedure and it will be an
out-of-pocket cost for the parents).
A palatal view of the same appliance is shown in this

photograph. As you can see, the appliance is based on
the principle of banding posterior teeth and attaching
prosthetic teeth to a wire running between the bands.
It is a maxillary fixed bilateral appliance
As you can see demonstrated in red, a prosthetic

appliance could be placed in this situation.
The photograph demonstrates another example of a

maxillary fixed bilateral anterior prosthesis.
For those who opt to provide treatment in these

situations, an excellent final result can be obtained, as
shown in the photograph.
Although we almost always prefer fixed appliances,

removable appliances can be used in situations where
maxillary primary anterior teeth are prematurely lost.
In this case, a removable appliance is shown where
the primary central incisors are replaced.
Prior to this juncture, our clinical situations have

involved the primary dentition. Now we are going to
move into the mixed dentition. In this drawing, the
mandibular right second primary molar is missing on
a nine year-old patient. The first permanent molar is
present and fully erupted. In your judgement, is the
child in need of a space maintainer? If so, would you
use a removable or a fixed space maintainer?
This is an example of the situation seen in the prior

drawing. The second primary molar has been lost and
the first permanent molar is
present.
As shown in the drawing, a space maintainer is

needed in this situation to prevent the bodily mesial
migration and/or tipping of the first permanent molar.
A removable unilateral appliance would be an unwise
choice.
This photograph demonstrates the same case shown

earlier. A fixed unilateral band and loop space
maintainer has been placed. You will note also that
the amalgam was removed from the permanent molar
and a composite restoration was placed, and a
stainless steel crown was placed on the first primary
molar (in place of a very large amalgam).
This is a space maintainer which is similar to the one

shown previously. Please note the occlusal rest designed
on the loop wire. This is placed to prevent the mandibular
right first permanent molar from tipping and causing the
wire to imbed apically in the tissue distal to the first
primary molar. Thus, the occlusal rest helps prevent the
tipping motion of the first permanent molar.
A closer view of the same occlusal rest is shown in

this photograph.
Space management is indicated in this patient to

prevent the mandibular first permanent molars from
tipping or moving mesially. A fixed bilateral lingual
arch space maintainer could be used, as shown in the
drawing.
Right and left side fixed unilateral band and loop

space maintainers also could be used, as shown in the
drawing. Nevertheless, we believe most clinicians
would select the fixed bilateral lingual arch
appliance since the permanent lower incisors
already are fully erupted. However, both the fixed
bilateral and the fixed unilateral approaches are
acceptable. Removable appliances can be used more
successfully as children grow older. Nevertheless,
even with older children, the loss and damage rate for
removable appliances is high.
In this drawing, the mandibular right and left second

primary molars are missing in this nine year year-old
patient. In your judgement, is the patient in need of
space management? If so, would you use a fixed or
removable appliance?
A lingual holding arch designed for the mixed

dentition is shown in the photograph.
In this drawing, the maxillary right second primary

molar is missing in this eight year-old patient. In your
judgement, is the child in need of a space maintainer?
If so, would you use a removable or a fixed space
maintainer?
In this drawing, the maxillary right and left second

primary molars are missing on this ten year-old child.
A space maintainer is indicated in this situation, as

shown in red in the drawing. A fixed unilateral band
and loop space maintainer is an appropriate choice. It
will prevent the maxillary right first permanent molar
from moving forward, which would result in a loss of
space for the unerupted bicuspid. A removable
unilateral appliance would not be used because of
swallowing and choking risks, even for older children.
The patient needs bilateral fixed space maintenance to

hold the permanent molars in place.
An example of a maxillary removable appliance

designed to hold the first permanent molars in place is
shown in the photograph.
Appliance Construction
be banded and selecting a band from the box of bands

which appears to be the appropriate size for that tooth.
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.
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.
Selecting And Fitting Bands
The first step in the process of appliance fabrication is
selecting and fitting the bands. A trial and error

method is used by most clinicians when selecting
bands for an appliance. This is accomplished by
estimating the proper size of band needed. The
estimation is done by examining the tooth which will
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.
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.
The advantage of using a tongue depressor is that the band

is almost never crushed during placement. Please note that
the authors are using a dentoform for this series of
photographs, to make it easier for the viewer to see the
process.
The handle of a band seater also is a convenient instrument

to use to push the band into place.
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.
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.
are desired, so that washout of the cement is less

likely to occur.
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.
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
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.
Note that the top jaw of the pliers is placed on the

occlusal surface of the tooth and the bottom jaw rests
under the gingival margin of the band. When the
pliers are squeezed the band moves occlusally off the
tooth.
Impression Taking
however, trays can be used or a "free-hand" (trayless)

technique can be used.
Our purpose in this subsection is to cover impression

taking techniques involved with space maintainer
appliances. Once the bands have been fitted to the
teeth, an impression is taken.
The two impression materials most commonly used in
pediatric dentistry for space maintainers are alginate
and compound.
Alginate is indicated primarily when removable
appliances are being made. And as you know very
well by now, removable space maintainers are rarely
indicated and seldom used in pediatric dentistry.
We will focus on impression taking with compound.
Compound is an excellent impression material,
especially for fixed appliances. In particular, it is
accurate and stable, and you will see how these
qualities make it highly suitable for taking
impressions for space maintainers as we proceed
through the chapter.
We will start with a demonstration of impression

taking for fixed bilateral space maintainers, using a
full arch tray technique. The following series of
photographs, taken by using a typodont, show the
compound impression technique used in our practices.
Please notice the necessary armamentaria, a hot water
bath, full arch tray, and compound.
Of course, alternative materials can be used. If you

use other materials successfully and/or if your office
routine is set up for other materials, by all means
continue to use them. The most critical feature for an
impression taking material for space maintainers is
accuracy in obtaining the band registration around the
tooth.
Although we like compound when taking impressions
for space maintainers, we are fully aware that many
clinicians prefer alginate because of their familiarity
with this material. Consequently, the impression
material of choice is left to the preference of the
individual.
For purposes of this presentation, we will cover
compound impression taking techniques for
impression taking for both fixed bilateral and fixed
unilateral appliances. We also emphasize these two
techniques since they provide an opportunity to
demonstrate two alternative impression taking
procedures: taking impressions with and without
impression trays. For bilateral impression taking, trays
are always used. For unilateral impression taking,
The first step is softening the compound in the hot

water bath.
The warm, pliable compound is placed in a child's

size tray and warmed again if necessary.
registration in the compound material. This is one of

the significant advantages of compound material - the
bands can be placed back into the impression material
in exactly the correct place before pouring with stone.
After heating, the impression tray material can be

cooled until it reaches the correct consistency and
temperature. The essential consideration is to insure
that the material is warm enough to flow but is
sufficiently cool so not to burn the child. Having the
patient stick out their tongue and touch the material is
one method of insuring that the material has cooled
satisfactorily.
The tray can then be placed in the child's mouth.
Individuals who are new to compound may believe
that it might be difficult to remove the compound
impression from the teeth because of hard compound
setting in the undercut areas. This is not a problem,
and experience with the material will bear this out for
individuals who use compound for the first time.
The compound material needs to be pliable, but not
runny or it will take too long to set up. Ideally, the
impression should be withdrawn after ten to fifteen
seconds because children tolerate short impression
times much better. A steady stream of air accelerates
the set of the compound once it is inserted.
A photographic enlargement of the impression area

around one of the banded teeth is shown to
demonstrate that it is possible to see clearly the band
Compound is the impression material of choice

because of its ease of use, its accuracy, stability, and
tolerance by the child. Many dentists simply send the
compound impression to the laboratory with no worry
about dimensional changes in the impression. The
bands can be placed nicely and easily in the
impression. Usually, a highly identifiable ring can be
seen in the impression material around the teeth where
the occlusal aspect of the band has registered in the
compound, and the bands are placed in the
indentations made by the bands from the mouth.
This photograph demonstrates the bands placed in the

compound impression. Because the compound
material is firm the bands are mounted on a stable
base. Nevertheless, it is often useful to heat tack the
bands into the impression material before pouring.
HELPFUL HINT: Keep the heat tack area away from
the area where you will be placing the solder joints.
The photograph shows the cast with bands in the

correct position waiting for construction of the space
maintainer, in this case an anterior fixed bilateral
prosthetic appliance
This prosthetic appliance is discussed earlier in the

chapter and in the restorative chapter, so let's go ahead
and review how it is completed. After the impression,
it is important to remind the laboratory to leave some
spaces between the anterior primary teeth if the
patient presents with that appearance, as was done
with this patient.
A larger view of the final result is shown in the

photograph. Most parents are very appreciative of the
improvement.
Let's look at the appliance again. The teeth are banded

with the wire running anteriorly. The teeth are acrylic.
There are other designs which are acceptable; but this
is one of the more common.
The major potential problem with this appliance

involves eruption of the maxillary anterior permanent
teeth, since the appliance obviously will interfere with
their eruption.
It is very important to stress with the parents that
bringing the child in for regular recall appointments is
absolutely necessary so that the appliance can be
removed before it interferes with the normal eruption
of permanent teeth. Of course, the dentist must be
aware of the timing when the different teeth can be
expected to erupt. An anterior radiograph also can be
used for more accurate prediction of when the
permanent teeth can be expected to erupt.
The previous impression taking technique involved
the process used for a fixed bilateral space maintainer,
and an impression tray was used. What was described
is the standard compound impression technique for
fixed bilateral space maintainers, whether they are
lingual arch appliances, Nance Appliances, or anterior
prosthetic appliances.
The next procedure we will describe is a technique for
taking impressions for unilateral space maintainers,
which we will call the nontray technique, where the
impression is taken without an impression tray.
Naturally, it is possible to use impression trays for
impressions for unilateral appliances, and many
clinicians take this approach using half-arch
impression trays. The impression taking process using
the half arch tray is the same as for taking a full arch
impression which we just described. The choice of
whether to use a half arch tray or the alternative
technique without a tray is left to the preference of the
practitioner.
Can you think of any potential problems with this

appliance?
We will discuss the nontray technique in detail, since

it is a viable approach and has the advantage of
eliminating the paraphernalia of the tray. It also may
be interesting to some readers since the technique is
not taught or used in many dental schools and hospital
centers.
For the nontray technique, of course, no tray is used.

You merely use the same compound material and the
same technique for warming the compound. However,
the amount of material used is approximately the size
of a large thumb. It is taken to the patient's mouth,
molded with the fingers, and held in place for ten to
fifteen seconds. Just like the tray technique discussed
earlier, the impression can be air dried and removed.
This photograph shows the amount of warmed
compound material to be used prior to placement in
the mouth.
This photograph shows an impression after it has been

removed. Please look carefully at the quality of definition
of the impression of the band in the compound. Do you
feel that the impression is of satisfactory quality? It is not.
It could be difficult to place the band in the impression
accurately. In these cases, it is important to take another
impression
Do you believe that the definition in this impression is

satisfactory? Yes; it is. This photograph demonstrates an
impression with excellent definition, where the stainless
steel band can be placed in the compound securely and
accurately.
It is important to have good definition of the impression in

order to properly place and adapt the band so it will not
move when the impression is poured with a stone or plaster
material. Still, we usually heat tack the band to the
compound material once it is placed, which makes it
very unlikely that the band will become dislodged or

float during the pouring process.
This frame demonstrates the band in place, prior to

pouring-up with the stone or plaster. Notice how
nicely the band fits into the registration of the band in
the compound. The accuracy of the compound makes
this possible.
The impression is poured with stone. Once the stone

is set, the poured impression is placed in the hot water
bath and the cast is retrieved from the warmed
compound. When the cast is retrieved, you will want
to trim any excess stone from the cast and especially
around the band
Appliance Fabrication
Laboratory Fabrication Of The
Appliance
The next step in the process is appliance fabrication.
Many family dentists and pediatric dentists employ a
dental laboratory to fabricate their space maintainers.
This is a completely satisfactory approach, assuming
the dental laboratory is able to follow your
instructions appropriately and produces appliances of
good quality.
It is even possible to have the laboratory come into
the picture at various stages during the space
management process. For example, you could send
the laboratory the compound impression. One of the
major advantages of compound impression material is
that it is stable. It does not undergo distortion before
the pouring process. In this way, the laboratory will
do the pouring and the appliance construction.
Whether you use a laboratory or make the appliance

yourself is a matter of personal preference. We have
included instructions regarding how we construct
appliances for those of you who will be involved in
appliance construction.
We will continue with the fixed unilateral space
maintainer as our instructional example of appliance
construction.
This photograph demonstrates using a pencil to sketch

the outline where the wire will be adapted to the stone
model
You could also send the cast to the laboratory and

they can construct the appliance using the cast that
you have poured.
This photograph shows the pencil adaptation where

we want the wire to be bent to the cast. Please note
how the outline of the drawing is wide enough so the
wire loop will be large enough bucco-lingually to
allow the bicuspid to erupt between the buccal and
lingual segments of the wire.
Allowing space for the eruption of a bicuspid, as

represented on this case, reinforces a very important
point.
WHATEVER APPLIANCE YOU ARE
PLANNING, ALWAYS MAKE SURE THAT
YOU ANTICIPATE HOW THE PERMANENT
TEETH WILL BE ERUPTING AND MAKE
ALLOWANCES FOR THOSE
DEVELOPMENTS.
It is essential to construct the space maintainer so that
it does not interfere with the normal eruption of
permanent teeth.
This photograph demonstrates the wire as it has been

adapted to the cast. It should be emphasized that the
wire needs to be adapted close to the tissue so that it
will be comfortable for the child. The wire should be
adapted in close approximation to the tissue, but not
touching the tissue, so that the tongue can not get
under the wire and cause irritation. It is necessary for
the wire to be adapted closely to the band to produce a
strong but not too bulky solder joint.
At this point, the adapted wire can be anchored to the
cast so that it can be soldered to the band. We use
compound or sticky wax to heat tack the wire to the
cast; and then we follow-up by pouring a thin mix of
fast-set stone to the wire and the cast as the final
anchorage step. It is important to keep both the sticky
wax and fast-set stone clear of the areas of the solder
joints, so that those materials do not interfere with the
joints. Once the wire is anchored to the cast, check to
make sure that its placement is satisfactory. At this
point, the wire is soldered to the band using either an
electric soldering technique or a flame soldering
technique
Of course, it goes without saying that space

maintainers should be constructed so they do not
interfere with normal functions, or at least as little as
possible. Wires and any other parts of space
maintainers should be planned so that they do not
interfere with eating and speech. HELPFUL HINT:
Always to check to make sure that the child can close
his or her mouth normally after placement of an
appliance.
Various wheels are used for polishing bands, wires,

and solder joints. The particular choice of polishing
vehicle is a matter of individual preferenc
Fabrication Of The Single Appointment

Preformed Space Maintainer
We will use this opportunity to discuss fabrication of

the preformed (i.e., prefabricated) band and loop
space maintainer. The preformed band and loop space
maintainer is used by many clinicians since the
appliance can be completed and placed in a single
appointment. The tooth is extracted and the preformed
space maintainer is cemented in place at the same
visit, after fitting and fabrication of the appliance at
chairside. Using preformed space maintainer
appliances eliminates all laboratory work and allows
placement of appliances at the same appointment
when the surgery is done.
Note that the preformed band and loop space

maintainer has female and male units. The tubes
attached to the orthodontic band receive the wire loop
which will abut to the adjacent tooth. The wire loop
can be cut so the mesiodistal space requirement can be
determined and adjusted. Once the wires from the

loop are placed in the tubes, the loop and tubes can be
crimped together.
The crimping pliers for the preformed band and loop

space maintainer are shown in the photograph.
The photograph demonstrates how the crimping is

accomplished using the crimping pliers to crush the
tube and wire together. Please note that some
clinicians also solder one arm of the preformed
appliance to obtain a stronger attachment of the tube
and wire. This additional safety measure makes it
more unlikely that the preformed appliance will come
apart in the mouth and present a swallowing danger.
swallowing danger. In this photograph, note that the

buccal tube and wire have been soldered together for
more secure retention.
The completed preformed band and loop space

maintainer is shown. Note where the female and male
units come together. The tube is crimped to secure the
male unit to the female unit. It is a tube and wire
appliance.
A preformed distal shoe space maintainer is shown in

the photograph. Many clinicians prefer to use a
customized band and loop appliance for most cases.
However, many of these same clinicians prefer to use
a preformed distal shoe appliance because of its
relative ease of fabrication and the fact that a one
appointment procedure is involved. Opting for a one
appointment procedure will avoid a second local
anesthetic administration and the difficulty of seating
a customized appliance so it fits securely against the
unerupted first permanent molar.
Preformed band and loop space maintainers also are

configured with occlusal rests, which can be adapted
at chairside.
Please note that some clinicians also solder one arm

of the preformed appliance to obtain a stronger
joining of the tube and wire. This additional safety
measure makes it more unlikely that the preformed
appliance will come apart in the mouth and present a
The photograph shows an example of a customized

distal shoe space maintainer, which is attached to a
stainless steel crown. An appliance such as this
obviously is much more difficult to fabricate and
place than a preformed distal shoe space maintainer. It
also represents the absolute highest standard of
customized care. Nevertheless, if the customized
approach is not practical given all the circumstances, a
preformed appliance certainly is better than no
appliance
Cementation
Cementing The Appliance In Place
The next phase in the process is cementation of the
appliance. There are several important fine points
related to the cementation phase of space management
therapy.
First of all, place the space maintainer in the mouth
for a trial fit before you attempt cementation. It should
fit like it does on the cast. Check to make sure that the
wire of a band and loop space maintainer is in light
contact with the tooth which is mesial to the
edentulous space. With the wire in contact, you are
sure tipping will not occur. In the case of a Nance
Appliance, check to make sure that the acrylic button
is in very gentle contact with the palatal tissue.
Also check for large voids or spaces between the band
and the tooth. If any are present, carefully use an
instrument to push (burnish) the band to the surface of
the tooth. In some cases, this step can be
accomplished on the cast.
Finally, make sure the child can occlude normally
before you cement the space maintainer. It is a major
interruption to be forced to remove a space maintainer
after it has been cemented because it interferes with
chewing.
In the case of unilateral space maintainers and
children who have extremely vigorous gag reflexes,
you will want to consider running floss through the
wire loop so that the space maintainer cannot be
swallowed. A unilateral space maintainer possibly
could be lost down the throat of a gagging, choking
child without the protection of the floss.
The next step is the actual cementation of the

appliance. Probably the most interesting issues related
to cementation of space maintainers concern the
continuing development of new cements.
The traditional choice, zinc phosphate cement, has

been used for decades and still is used by many
practitioners. It is a satisfactory material. It stores
well, is easy to mix, and is well tolerated by patients.
The glass ionomer cements, however, have gained
huge popularity over the last decade. They also are
easy to mix and are well tolerated by patients. In
addition, glass ionomers release fluoride, are
technique forgiving if isolation from oral fluids is less
than perfect, and are very insoluble. Their lack of
solubility is perhaps their most important advantage,
since practitioners encounter less recurrent decay
around and underneath bands. Bands rarely come off
when glass ionomer cements are used, especially if
the bands are tight fitting to begin with.
You will start cementation phase of the procedure by
isolating the tooth to be banded. Isolation can be
obtained with cotton rolls. The tooth then is air dried.
The tooth should be slightly moist (not desiccated).
The cement can be mixed according to the
manufacturers instructions. However, if you mix the
cement so that it is sufficiently viscous, it will adhere
to the inside of the band during placement and
cementation and not cause difficulty by "running all
over." Some clinicians stick a small section of
masking tape over the band to prevent escape (i.e.,
"running") of the cement. This technique is fine if it
works well for you. However, a slightly thicker mix
of cement will prevent escape of the material in the
first place.
Once the appliance is cemented in place, remove the
excess cement. One other advantage of the newer
generation cements is that they are much handier
when it comes to cement removal than the older
generation cements.
Have the patient bite together one last time to insure
that the appliance is not interfering with the occlusion.
It also is a good idea to show the appliance to the
parent. Emphasize the importance of keeping the area
clean. At this time, you can mention any potential
issues about the space maintainer that you choose, in
addition to re-emphasizing the importance of hygiene.

For example, soreness for approximately twenty-four
hours can occur. The child should avoid "playing"
with the appliance with the tongue, which also can
cause soreness (of the tongue). Temporary speech
changes can occur with some appliances (especially
Nance Appliances), but it is important to emphasize
that the changes are temporary. In very unusual cases,
short-lived sleep changes can occur, but once again
these problems are transitional (and indeed very rare).
Although this cementing material is still commonly

used, more and more dentists now are using glass
ionomer cements. Glass ionomer cements have the
advantages of fluoride release, excellent handling
characteristics, low solubility, and good adhesion.
Many clinicians appoint patients who have had space

maintainers placed for a quick check-up visit after
approximately two-four weeks
This frame shows the cementation of a band and loop

space maintainer with glass ionomer cement.
This photograph demonstrates the cementation of a
band and loop space maintainer with zinc phosphate
cement.
Long-term Evaluation And Significance

Monitoring And Removal
Ongoing Monitoring And Evaluation Of In Place
Appliances
This photograph shows a lingual arch space

maintainer with the teeth erupted. The appliance
should be removed.
This photograph demonstrates a tooth partially
erupting between the wires of a space maintainer.
This photograph demonstrates substantial eruption of

a tooth between the wires of a space maintainer.
This photograph shows a case where the tooth is

almost completely erupted in a space maintainer. The
space maintainer can be removed at this time.
A radiograph of a band and loop space maintainer is

shown here. The space maintainer can be removed at
this point.
This photograph demonstrates a situation where a

crown and loop space maintainer had been resting
against the primary cuspid. The primary cuspid has
exfoliated. It is time to remove this space maintaine
Conclusions And Significance
The best space maintainer is a well maintained primary tooth. But when these important natural space maintainers
are lost, it is essential to implement a space management strategy. Appropriate space management therapy can save
a child from esthetic disfigurement and save a family thousands of dollars in later orthodontic costs.
A Quick Self Check

This is a quiz at the end of chapter designed to give you a barometer of how well you understand the concepts
covered in this chapter
1- The patient is a five year-old child with acute pain associated with tooth #K. What is your preferred
choice of therapy for tooth #K? The patient is very cooperative and is able to tolerate long appointments.
A.
B.
C.
D.
Pulpotomy
Primary endodontics (pulpectomy)
. Incision and drainage
. Extraction
2- Regarding the patient in the previous question, if tooth #K were extracted, what type of
space maintainer would be needed?
A.
B.
C.
D.
Band and loop space maintainor

Distal shoe space maintainer (fixed)
Distal shoe space maintainor (removable)
Crown and loop space maintainor
3- What type of space maintainer would you choose for the patient shown in the radiograph?
The patient is a male, age nine. Your examination shows that all teeth normally present on
the patient's right side are present.
A.
B.
C.
D.
Nance Appliance
Bilateral fixed lower holding arch
Bilateral removable lower space maintainor
Band and loop space maintainor
4- Regarding the patient in the previous question, what best choice for cementing the
appliance in place?
A.
B.
C.
D.
Zinc phosphate cemenl

Zinc oxide eugenol cemenl
IRM
glass mnomer cemenl
5- Regarding the patient in the previous question, when would you decide to remove the
space maintainer?
A.
B.
C.
D.
When Ihe bicuspids erupt

When Ihe patient is ten years-old
When the patient is ready to begin orthodontic therapy
None of the above
6- The patient shown in the radiograph is a six year-old male and his mother reports that he
has complained of severe spontaneous pain associated with tooth #B. Your examination
indicates a lesion of moderate size on the mesial aspect of tooth #A and a large lesion on
the distal aspect of tooth #B, which extends toward the pulp. All other maxillary teeth are
present and are noncarious. You decide that extraction of tooth #B is warranted. What
type of space maintainer will you advise for the patient?
A.
B.
C.
D.
Nance Appliance, cemented lo teeth #'s 3 and 14

Upper right removable unilateral appliance
Upper removable bilateral appliance
Upper right band and loop appliance (or crown and loop appliance)
7- The patient shown in the photograph is a four year-old male who lost tooth #E in an accident.
The child's father is concerned about his son's appearance. What advice would you give the
father regarding space maintenance and/or a prosthetic replacement?
A. . You recommend a maxillary fixed bilateral appliance with a prosthetic replacement for tooth #E.
B. . You recommend a maxillary removable bilateral appliance with a prosthetic replacement for tooth #E (i.e.,
a flipper).
C. . You recommend a prosthetic tooth to replace #E which can be bonded to teeth #'s D and F.
D. . You recommend that no space maintainer or prosthetic replacement be used in this case.
8- Your examination of the patient shown in the photograph indicates that teeth #'s A and J will
be restored and teeth #'s B and I will be extracted. What type of space maintainer will you plan
in this case?
A.
B.
C.
D.
. Fixed bilateral space maintainer with prosthetic replacement teeth for#'s E and F
. Fixed bilateral band and loop space maintainers
. Nance Appliance
. Removable bilateral partial denture with prosthetic replacement teeth forf's E and F and acrylic space
holders forf's B and I
99- Your examination of the patient shown in the photograph indicates that teeth #'s L and S will
be removed. All other mandibular teeth will be restored. How will you plan for space
maintenance?
A.
B.
C.
D.
Right and left fixed band and loop appliances (or crown and loop appliances)
Right and left removable space maintainors
Fixed bilateral lingual holding arch
Removable bilateral space maintainer
10 A 6.0 year-old female patient is shown in the photograph. Based on your examination, you
determine that tooth #J must be extracted. However, you also find that tooth #1 can be restored.
You decide to place a distal shoe space maintainer to maintain space in the place of tooth #J.
Once tooth #14 fully erupts, what is your plan regarding the distal shoe space maintainer?
A. . Leave the distal shoe space maintainer in place.

B. . Remove the distal shoe space maintainer and do nothing else.
C. . Remove the distal shoe space maintainer and replace it with a space maintainer which is not imbedded in
tissue.
D. . Remove the distal shoe space maintainer and place a removable unilateral space maintainer.

Space Management in Pediatric Dentistry

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Space Management In Pediatric

Space Maintainers: Types And Indications

Introduction To Space Management

The best space maintainer is a primary tooth, as you

For example, this panoramic radiograph shows the

This patient also has a missing mandibular right

This photograph demonstrates a space maintainer placed on the

Types Of Space Maintainers

space maintainer, and so forth. There are numerous

Fixed Bilateral Space Maintainer

This photograph shows an example of a fixed bilateral

Another lingual arch appliance for mandibular

Mandibular Removable Bilateral Space

A mandibular removable bilateral space maintainer

The same mandibular removable bilateral space

Fixed Unilateral Appliance

This photograph shows an example of a fixed

Fixed Bilateral Space Maintenance

The photograph presents a variation on the band and

Bilateral Band And Loop Space

The photograph demonstrates another variation on the

REMOVABLE UNILATERAL SPACE

This photograph shows two band and loop space

Distal Shoe Space Maintenance

This appliance is called a distal shoe space maintainer

The photograph shows a maxillary fixed bilateral

Prosthetics For Maxillary Anterior Teeth

This photograph shows a maxillary removable

The appliance demonstrated in this photograph is used

Clinical Indications For Space

Indications For Space Maintenance

The following section of the space maintainer chapter

This is a radiograph of a similar situation showing the

Yes; a space maintainer is indicated in the situation

In this drawing, the mandibular right second primary

This photograph demonstrates stainless steel crowns

This is an example of a distal shoe space maintainer

Distal shoe space maintainers are discussed in the

The distal shoe space maintainer can be placed at the

In this drawing, the mandibular right first primary

As you see demonstrated in red, a space maintainer is

For safety reasons, we recommend that you never use

In this drawing, the mandibular right and left first

The lingual arch appliance, as demonstrated in the

Another example of a lingual arch appliance designed

for the primary dentition is shown in the photograph.

The major disadvantage to the use of a lower fixed

Nevertheless, the fixed bilateral lingual arch has the

In this drawing, the maxillary right first primary

Of course, unlike the removable unilateral appliance,

This is an example of a lingual arch wire which was

A unilateral space maintainer is needed, as shown in

space maintainer is an erupting first permanent molar.

This photograph shows the use of a band and loop

In this drawing, the maxillary right and left first

Space maintenance is indicated in the situation shown

This photograph demonstrates the same principle,

A Nance Appliance designed for the primary dentition

The drawing demonstrates another approach, where

In this drawing, the maxillary primary central and

What is your recommendation for a case like this?

This photograph demonstrates two maxillary fixed

Their reasoning is that the presence of replacement teeth

to be a useful strategy as research provides more