1. Basic Space Maintainers lecture one
Prepared by:
Dr Seyed Ebrahim Jabbarifar Associate professor
University of Isfahan Department of Pediatric Dentistry2009

2. Basic Space Maintainers
Are PASSIVE
.036 wire is very heavy and should not be used to actively move teeth

3. Before Placing a Space Maintainer
Evaluate Arch Length
Has the space already been lost?
Is there excess space?
Appropriate Radiographs
Succedaneous tooth?
Time to Eruption?
Patient/Family Compliance

4. Space Maintainers are Simple!
Name the 4 most basic pediatric space maintainers

5. Basic Space Maintainers
NANCE (Transpalatal Arch with Acrylic
Button Stop on Palate)
LOWER LINGUAL HOLDING ARCH (LLHA)
BAND/CROWN and LOOP
DISTAL SHOE

6. Distal Shoe MAXILLARY or MANDIBULAR
Used when second primary molar requires extraction and first permanent molar has not erupted

7. Distal Shoe Should be evaluated with radiograph prior to cementation
Length
Position
Will be replaced with another space maintainer when permanent teeth erupt.

8. Distal Shoe
Example of use in partial eruption case.

9. Nance Appliance
MAXILLARY ONLY
Bands on first permanent molars

10. Nance Appliance
Cross Palatal Bracing prevents rotation #3 and #14 around palatal root- this starts mesial migration of #3 and #14
Acrylic Button provides additional stop

11. Transpalatal Holding Arch (TPA)
Can be used like a Nance.
Advantage
Lack of acrylic button so less tissue irritation and more cleansible
Disadvantage
Lack of anterior stop = possible tooth shift (?)

12. Lower Lingual Holding Arch
MANDIBULAR ONLY
Bands on first permanent molars
Anterior Stop = Cinguli of #23-#26

13. Lower Lingual Holding Arch
Mandibular incisors often erupt lingually and are pushed forward by the tongue
LLHA should not be placed with primary incisors

14. #K and #T Extractions : LLHA Indicated?
NO- note lingual eruption #23 and #26
Option: Reverse Crown and Loops
#L-19 and #S-30.
**LLHA will be placed 2-3 years later, prior to loss of #L and #S. Simply cut off loop and leave SSCs.

15. LLHA Omega Loops
Omega Loops in area of premolars allow slight adjustment to fit appliance
Should not be used to activate appliance

16. Appliance Activation Features
Can be added by attaching light wire features
This is beyond routine space maintenance

17. Band/Crown and Loop MAXILLARY or MANDIBULAR Unilateral most typical
Can be bilateral if permanent teeth are not present
Single tooth span

18. Crown and Loop Stronger than band and loop
Cementation failure or loss less likely
Excellent choice if tooth needs a restoration

19. What About Removable Appliances?
Yes, they are possible, however………..
High failure rate due to breakage and loss
Parent and patient compliance must be exceptional

20. Which Space Maintainer?
Distal Shoe = 2nd Primary Molar Extraction with unerupted 1st Permanent Molar
Nance or Band/Crown Loop = Maxillary problem with 1st Permanent Molars present
Lower Lingual Holding Arch = Mandibular Problem with 1st Permanent Molars and Permanent Incisors present
Band/Crown and Loop= Primary 1st Molar Extraction

21. Must I Plan to Replace a Band/Crown and Loop ?
All depends on ERUPTION SEQUENCE
No, in maxillary arch
Yes, in mandibular arch- may need LLHA later
Why? Canine should exfoliate prior to eruption of 1st premolar, making space maintainer defunct.

22. Space Maintainer Competency
The following cases require space maintainer consideration. Assume that radiographs have been taken, there is no abnormal pathology (other than dental caries), and a successor is developing.
Please answer the questions on your worksheets.

23. Question 1 What tooth was extracted? How old is this child?
What is the appropriate space maintainer?
Will it have to be replaced with a different space maintainer in the future? If so, with what?

24. Question 2 What tooth was extracted? How old is the child?
What is the appropriate space maintainer?
Will it have to be replaced with a different space maintainer in the future? If so, with what?

25. Question 3 Which teeth were extracted? How old is the patient?
What is the appropriate space maintainer?
When can the space maintainer be removed?

26. Question 4 Which teeth were extracted/
What is the appropriate space maintainer?

27. Question 5 Which teeth have been extracted? How old is the child?
What is the most appropriate space maintenance?

28. “Somieh” Case
Somieh presented for an initial visit at the COD. She has had dental treatment on and off throughout life. She is in no pain, but mom reports that “we know she has dental problems.”

29. How old is Ali assuming normal dental development?

30. Ali’s Bite Wings

31. Mandibular Arch Only: Chart Dentition on the Odontogram

32. Ali
Mandibular Arch Only : Chart abnormalities and pathology (including caries ) from the Panorex and Bite Wing Radiographs

34. Ali
A Moyer’s space analysis predicted there to be 2.3 mm of excess space in the mandible.
Make a treatment plan and appointment sequence for the mandibular arch only.

36. Ali
Assuming normal dental development, at what age will the space maintainer you placed no longer be needed?

37. “Ali” Case
Ali was referred by his general dentist for ‘ tooth decay and crowding.’
The family does not believe they can afford comprehensive orthodontic care, but does have dental insurance for “routine dental care.”

38. Ali: Chart Maxillary Dentition Only on the Odontogram

39. Ali’s Bite Wings
Chart any pathology or abnormal findings (including caries) for the maxillary arch only on the odontogram.

40. Ali

41. Ali
A Moyer’s space analysis predicts 1.2 mm of space shortage in the maxilla
Treatment plan and sequence appointments for the Maxillary Arch Only

42. Ali

43. Discussion

44. Question 1
5 or 6 y.o. child. Tooth #I extracted.

45. Question 1 Band/Crown and Loop #J-H
Will not need replacement. #12 should erupt before #H or J exfoliate

46. Question 2 Tooth #L extracted. 3-5 y.o. child.
What is the appropriate space maintainer?
Will it have to be replaced with a different space maintainer in the future? If so, with what?

47. Question 2 Band/Crown Loop #K-M
May need to be replaced by LLHA later. Tooth #M should exfoliate prior to eruption #21.

48. Question 3
Teeth #A and #J extracted. Patient 8-9 y.o.

49. Question 3
Nance #3-#14
Can be removed when #4 and #13 erupt-around age 12

50. Question 4
Teeth #K and L extracted

51. Question 4
Lower Lingual Holding Arch (LLHA) #19-#30

52. Question 5 Teeth #K and #S extracted. 5-6 y.o. child.
Because permanent incisors are not erupted, LLHA not recommended. Options: Reverse band and loop #L-#19 and band and loop #T-#R.

53. “Ali”
Ali presented for an initial visit at the Afzal Clinic. He has had dental treatment on and off throughout life. He is in no pain, but mom reports that “we know she has dental problems.”

54. Assuming normal dental development, Ali is 8 years old.

55. Ali
Mandibular Arch Only : Chart abnormalities and pathology (including caries ) from the Panorex and Bite Wing Radiographs

57. Ali Teeth Present: 19, K,L,M,23,24,25,26,R,S,T,30 Restorations: SSC #L
Pathology/Caries: #L and #S abscessed,
#28 severely ectopic.

58. Ali
A Moyer’s space analysis predicted there to be 2.3 mm of excess space in the mandible.
Make a treatment plan and appointment sequence for the mandibular arch only.

60. Ali Tx Plan Extract #L,S and T and Place LLHA
#L and S due to abscess
#T due to ectopic #28
Appt #1: Fit bands and Impress for LLHA
Extract #L
Appt. #2: Seat LLHA
Extract #S, T

61. Ali
Assuming normal dental development, at what age will the space maintainer you placed no longer be needed?
Answer: When #21,28 and 29 erupt.
Around age 12 years

62. “Ali” Case
Ali was referred by his general dentist for ‘ tooth decay and crowding.’
The family does not believe they can afford comprehensive orthodontic care , but does have dental insurance for “routine dental care.”

63. Ali

64. Ali
A Moyer’s space analysis predicts 1.2 mm of space shortage in the maxilla
Treatment plan and sequence appointments for the Maxillary Arch Only

65. Ali Teeth Present: #3,A,B,C,7,8,9,10,H,12,J,14
Restorations: #A-MO, #B-DO.
Pathology/Caries: #3-M; #A-D; #B-M;
#H-D;#J-abscess, #14-MO
Note: #6 and #11 very advanced root development.

66. Ali

67. Ali Tx Plan Extract all maxillary primary teeth
#A,B,J- Multiple caries and near exfoliation
TE #C and #H due to root formation #6 and #11
Restore #3 with direct M composite
Restore #14-MO
Place Nance Space Maintainer- slight space deficiency, but this will be very beneficial.

68. Ali Tx Sequence Appt 1 Appt 2
Fit bands #3 and #14 and Impress for Nance
Restore #14
TE #H and #J
Appt 2
Restore #3
Seat Nance
TE # A,B,C

69. Thank You!