Basic Space Maintainers
Teaching Module and
Competency
Prepared by:
Cynthia K Christensen; DDS, MS
Sean Whalen, DDS
University of Iowa Department of Pediatric Dentistry
2008-2009
Basic Space Maintainers
• Are PASSIVE
– .036 wire is very heavy and should not be
used to actively move teeth
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
Space Maintainers are
Simple!
Name the 4 most basic pediatric
space maintainers
Basic Space Maintainers
• NANCE (Transpalatal Arch with Acrylic
Button Stop on Palate)
• LOWER LINGUAL HOLDING ARCH
(LLHA)
• BAND/CROWN and LOOP
• DISTAL SHOE
Distal Shoe
• MAXILLARY or
MANDIBULAR
• Used when second
primary molar
requires extraction
and first permanent
molar has not erupted
Distal Shoe
• Should be evaluated with
radiograph prior to
cementation
– Length
– Position
• Will be replaced with
another space maintainer
when permanent teeth
erupt.
Distal Shoe
• Example of use in
partial eruption case.
Nance Appliance
• MAXILLARY ONLY
• Bands on first
permanent molars
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
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 (?)
Lower Lingual Holding Arch
• MANDIBULAR
ONLY
• Bands on first
permanent molars
• Anterior Stop =
Cinguli of #23-#26
Lower Lingual Holding Arch
• Mandibular incisors
often erupt lingually
and are pushed
forward by the tongue
• LLHA should not be
placed with primary
incisors
#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.
LLHA Omega Loops
• Omega Loops in area
of premolars allow
slight adjustment to fit
appliance
• Should not be used
to activate appliance
Appliance Activation Features
• Can be added by
attaching light wire
features
• This is beyond routine
space maintenance
Band/Crown and Loop
• MAXILLARY or
MANDIBULAR
• Unilateral most typical
• Can be bilateral if
permanent teeth are
not present
• Single tooth span
Crown and Loop
• Stronger than band
and loop
• Cementation failure or
loss less likely
• Excellent choice if
tooth needs a
restoration
What About Removable
Appliances?
• Yes, they are possible, however………..
• High failure rate due to breakage and loss
• Parent and patient compliance must be exceptional
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
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.
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.
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?
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?
Question 3
• Which teeth were extracted? How old is the patient?
• What is the appropriate space maintainer?
• When can the space maintainer be removed?
Question 4
• Which teeth were extracted/
• What is the appropriate space maintainer?
Question 5
• Which teeth have been extracted? How old is the child?
• What is the most appropriate space maintenance?
“Cheyenne” Case
• Cheyenne 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.”
How old is Cheyenne assuming
normal dental development?
Cheyenne’s Bite Wings
Mandibular Arch Only: Chart
Dentition on the Odontogram
Cheyenne
• Mandibular Arch Only : Chart
abnormalities and pathology (including
caries ) from the Panorex and Bite Wing
Radiographs
Cheyenne
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.
Cheyenne
• Assuming normal dental development, at
what age will the space maintainer you
placed no longer be needed?
“Justin” Case
• Justin 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.”
Justin: Chart Maxillary Dentition
Only on the Odontogram
Justin’s Bite Wings
• Chart any pathology or abnormal findings
(including caries) for the maxillary arch only on
the odontogram.
Justin
Justin
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
Justin
Discussion
Question 1
• 5 or 6 y.o. child. Tooth #I extracted.
Question 1
• Band/Crown and Loop #J-H
• Will not need replacement. #12 should erupt
before #H or J exfoliate
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?
Question 2
• Band/Crown Loop #K-M
• May need to be replaced by LLHA later. Tooth
#M should exfoliate prior to eruption #21.
Question 3
• Teeth #A and #J extracted. Patient 8-9 y.o.
Question 3
• Nance #3-#14
• Can be removed when #4 and #13 erupt-around age 12
Question 4
• Teeth #K and L extracted
Question 4
• Lower Lingual Holding Arch (LLHA) #19-#30
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.
“Cheyenne”
• Cheyenne 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.”
Assuming normal dental development,
Cheyenne is 8 years old.
Cheyenne
• Mandibular Arch Only : Chart
abnormalities and pathology (including
caries ) from the Panorex and Bite Wing
Radiographs
Cheyenne
• 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.
Cheyenne
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.
Cheyenne 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
Cheyenne
• 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
“Justin” Case
• Justin 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.”
Justin
Justin
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
Justin
• 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.
Justin
Justin 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.
Justin Tx Sequence
• Appt 1
– 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
Please Evaluate This
Teaching Module
Thank You!