Space Management in Pediatric Dentistry
Space Management in Pediatric Dentistry
Space Management in Pediatric Dentistry
Dentistry
Appliance Construction
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Introduction To Space Management
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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 space maintainer, and so forth. There are numerous
variations on these basic themes. For example, some
There are numerous types of space maintainers. They space maintainers are used for missing anterior teeth
range from the very simple to those with numerous and some are used to preserve space for posterior
bands and wires. They can be constructed differently unerupted teeth.
and used in different parts of the mouth. As we will
cover later, some even have parts extending into the The following pages will show the various types of
tissue. space maintainers.
We feel the best way to make sense of the numerous Fixed Bilateral Space Maintainer
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.
Space maintainers also can be placed on the Mandibular fixed bilateral space appliances generally
mandibular or maxillary arch. Consequently, we could are preferred by clinicians over removable space
have a maxillary removable bilateral space maintainers. Fixed appliances are easier to maintain
maintainer, or a mandibular fixed unilateral right side and they are less likely to be removed, damaged, or
lost by the child.
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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
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Fixed Bilateral Space Maintenance
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Distal Shoe Space Maintenance
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Clinical Indications For Space
Maintenance
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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.
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The distal shoe space maintainer can be placed at the In this drawing, the mandibular right first primary
time of extraction of the second primary molar. If this molar is missing on a six year-old child. In your
approach is used, the impression must be taken and judgement, is the child in need of a space maintainer?
the appliance constructed prior to extraction of the
If so, would you use a removable or a fixed space
primary tooth. The advantage is not having to go back
at a later time and surgically make an incision for maintainer?
insertion of the distal shoe into the tissue so the distal
shoe segment can abut against the permanent molar.
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In this drawing, the mandibular right and left first The lingual arch appliance, as demonstrated in the
primary molars are missing on a four year-old child. photograph, would be the appliance of choice for
In your judgement, is the child in need of a space some clinicians in a situation where both primary first
maintainer? If so, would you use a removable or a molars have been lost in the primary dentition. The
fixed space maintainer? bilateral appliance is very stable since it is anchored to
two teeth.
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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.
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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.
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In this drawing, the maxillary primary central and
lateral incisors are missing in this four year-old child.
In your judgement, is the child in need of a space
The drawing demonstrates another approach, where maintainer? If so, would you use a removable or a
two fixed unilateral space maintainers are used (band fixed space maintainer?
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.
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Of course, many parents applaud the procedure
because of the improved esthetics.
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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 This is an example of the situation seen in the prior
child in need of a space maintainer? If so, would you drawing. The second primary molar has been lost and
use a removable or a fixed space maintainer? the first permanent molar is
present.
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This is a space maintainer which is similar to the one
shown previously. Please note the occlusal rest designed Space management is indicated in this patient to
on the loop wire. This is placed to prevent the mandibular prevent the mandibular first permanent molars from
right first permanent molar from tipping and causing the tipping or moving mesially. A fixed bilateral lingual
wire to imbed apically in the tissue distal to the first arch space maintainer could be used, as shown in the
primary molar. Thus, the occlusal rest helps prevent the drawing.
tipping motion of the first permanent molar.
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In this drawing, the maxillary right second primary In this drawing, the maxillary right and left second
molar is missing in this eight year-old patient. In your primary molars are missing on this ten year-old child.
judgement, is the child in need of a space maintainer? In your judgement, is the child in need of a space
If so, would you use a removable or a fixed space maintainer? If so, would you use a removable or a
maintainer? fixed space maintainer?
A space maintainer is indicated in this situation, as The patient needs bilateral fixed space maintenance to
shown in red in the drawing. A fixed unilateral band hold the permanent molars in place.
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.
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Appliance Construction be banded and selecting a band from the box of bands
which appears to be the appropriate size for that tooth.
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The first step in the placement process is carrying the The advantage of using a tongue depressor is that the band
band to the tooth and placing it on the tooth with is almost never crushed during placement. Please note that
finger pressure. Further placement of the band can be the authors are using a dentoform for this series of
done by pushing with a tongue depressor or the photographs, to make it easier for the viewer to see the
handle of a band seater. The patient can be asked to process.
bite on the tongue depressor or handle of the band
seater to push the band further apically.
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are desired, so that washout of the cement is less
likely to occur.
A band pusher may be used for the final step in Note that the top jaw of the pliers is placed on the
adaptation of the band. It is used to push the band occlusal surface of the tooth and the bottom jaw rests
against the tooth if a space remains between the band under the gingival margin of the band. When the
and the tooth. Tightly placed and well adapted bands pliers are squeezed the band moves occlusally off the
tooth.
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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.
Although we like compound when taking impressions The first step is softening the compound in the hot
for space maintainers, we are fully aware that many water bath.
clinicians prefer alginate because of their familiarity
with this material. Consequently, the impression
material of choice is left to the preference of the
individual.
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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.
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The major potential problem with this appliance
This prosthetic appliance is discussed earlier in the involves eruption of the maxillary anterior permanent
chapter and in the restorative chapter, so let's go ahead teeth, since the appliance obviously will interfere with
and review how it is completed. After the impression, their eruption.
it is important to remind the laboratory to leave some
spaces between the anterior primary teeth if the It is very important to stress with the parents that
patient presents with that appearance, as was done bringing the child in for regular recall appointments is
with this patient. 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.
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This photograph shows an impression after it has been
We will discuss the nontray technique in detail, since removed. Please look carefully at the quality of definition
it is a viable approach and has the advantage of of the impression of the band in the compound. Do you
eliminating the paraphernalia of the tray. It also may feel that the impression is of satisfactory quality? It is not.
be interesting to some readers since the technique is It could be difficult to place the band in the impression
not taught or used in many dental schools and hospital accurately. In these cases, it is important to take another
centers. impression
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This frame demonstrates the band in place, prior to The impression is poured with stone. Once the stone
pouring-up with the stone or plaster. Notice how is set, the poured impression is placed in the hot water
nicely the band fits into the registration of the band in bath and the cast is retrieved from the warmed
the compound. The accuracy of the compound makes compound. When the cast is retrieved, you will want
this possible. to trim any excess stone from the cast and especially
around the band
.
The next step in the process is appliance fabrication. We will continue with the fixed unilateral space
maintainer as our instructional example of appliance
Many family dentists and pediatric dentists employ a construction.
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.
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This photograph shows the pencil adaptation where This photograph demonstrates the wire as it has been
we want the wire to be bent to the cast. Please note adapted to the cast. It should be emphasized that the
how the outline of the drawing is wide enough so the wire needs to be adapted close to the tissue so that it
wire loop will be large enough bucco-lingually to will be comfortable for the child. The wire should be
allow the bicuspid to erupt between the buccal and adapted in close approximation to the tissue, but not
lingual segments of the wire. 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.
Allowing space for the eruption of a bicuspid, as
represented on this case, reinforces a very important At this point, the adapted wire can be anchored to the
point. cast so that it can be soldered to the band. We use
compound or sticky wax to heat tack the wire to the
WHATEVER APPLIANCE YOU ARE cast; and then we follow-up by pouring a thin mix of
PLANNING, ALWAYS MAKE SURE THAT fast-set stone to the wire and the cast as the final
YOU ANTICIPATE HOW THE PERMANENT anchorage step. It is important to keep both the sticky
TEETH WILL BE ERUPTING AND MAKE wax and fast-set stone clear of the areas of the solder
ALLOWANCES FOR THOSE joints, so that those materials do not interfere with the
DEVELOPMENTS. joints. Once the wire is anchored to the cast, check to
make sure that its placement is satisfactory. At this
It is essential to construct the space maintainer so that point, the wire is soldered to the band using either an
it does not interfere with the normal eruption of electric soldering technique or a flame soldering
permanent teeth. technique
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Fabrication Of The Single Appointment determined and adjusted. Once the wires from the
Preformed Space Maintainer loop are placed in the tubes, the loop and tubes can be
crimped together.
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swallowing danger. In this photograph, note that the
buccal tube and wire have been soldered together for
more secure retention.
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Cementation The traditional choice, zinc phosphate cement, has
been used for decades and still is used by many
Cementing The Appliance In Place practitioners. It is a satisfactory material. It stores
well, is easy to mix, and is well tolerated by patients.
The next phase in the process is cementation of the
appliance. There are several important fine points The glass ionomer cements, however, have gained
related to the cementation phase of space management huge popularity over the last decade. They also are
therapy. easy to mix and are well tolerated by patients. In
addition, glass ionomers release fluoride, are
First of all, place the space maintainer in the mouth technique forgiving if isolation from oral fluids is less
for a trial fit before you attempt cementation. It should than perfect, and are very insoluble. Their lack of
fit like it does on the cast. Check to make sure that the solubility is perhaps their most important advantage,
wire of a band and loop space maintainer is in light since practitioners encounter less recurrent decay
contact with the tooth which is mesial to the around and underneath bands. Bands rarely come off
edentulous space. With the wire in contact, you are when glass ionomer cements are used, especially if
sure tipping will not occur. In the case of a Nance the bands are tight fitting to begin with.
Appliance, check to make sure that the acrylic button
is in very gentle contact with the palatal tissue. You will start cementation phase of the procedure by
isolating the tooth to be banded. Isolation can be
Also check for large voids or spaces between the band obtained with cotton rolls. The tooth then is air dried.
and the tooth. If any are present, carefully use an The tooth should be slightly moist (not desiccated).
instrument to push (burnish) the band to the surface of
the tooth. In some cases, this step can be The cement can be mixed according to the
accomplished on the cast. manufacturers instructions. However, if you mix the
cement so that it is sufficiently viscous, it will adhere
Finally, make sure the child can occlude normally to the inside of the band during placement and
before you cement the space maintainer. It is a major cementation and not cause difficulty by "running all
interruption to be forced to remove a space maintainer over." Some clinicians stick a small section of
after it has been cemented because it interferes with masking tape over the band to prevent escape (i.e.,
chewing. "running") of the cement. This technique is fine if it
works well for you. However, a slightly thicker mix
In the case of unilateral space maintainers and of cement will prevent escape of the material in the
children who have extremely vigorous gag reflexes, first place.
you will want to consider running floss through the
wire loop so that the space maintainer cannot be Once the appliance is cemented in place, remove the
swallowed. A unilateral space maintainer possibly excess cement. One other advantage of the newer
could be lost down the throat of a gagging, choking generation cements is that they are much handier
child without the protection of the floss. when it comes to cement removal than the older
generation cements.
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addition to re-emphasizing the importance of hygiene. Although this cementing material is still commonly
For example, soreness for approximately twenty-four used, more and more dentists now are using glass
hours can occur. The child should avoid "playing" ionomer cements. Glass ionomer cements have the
with the appliance with the tongue, which also can advantages of fluoride release, excellent handling
cause soreness (of the tongue). Temporary speech characteristics, low solubility, and good adhesion.
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).
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Long-term Evaluation And Significance
Monitoring And Removal
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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.
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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. Pulpotomy
B. Primary endodontics (pulpectomy)
C. . Incision and drainage
D. . Extraction
2- Regarding the patient in the previous question, if tooth #K were extracted, what type of
space maintainer would be needed?
A. Band and loop space maintainor
B. Distal shoe space maintainer (fixed)
C. Distal shoe space maintainor (removable)
D. Crown and loop space maintainor
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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. Nance Appliance
B. Bilateral fixed lower holding arch
C. Bilateral removable lower space maintainor
D. Band and loop space maintainor
4- Regarding the patient in the previous question, what best choice for cementing the
appliance in place?
A. Zinc phosphate cemenl
B. Zinc oxide eugenol cemenl
C. IRM
D. glass mnomer cemenl
5- Regarding the patient in the previous question, when would you decide to remove the
space maintainer?
A. When Ihe bicuspids erupt
B. When Ihe patient is ten years-old
C. When the patient is ready to begin orthodontic therapy
D. 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?
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A. Nance Appliance, cemented lo teeth #'s 3 and 14
B. Upper right removable unilateral appliance
C. Upper removable bilateral appliance
D. 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.
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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. . Fixed bilateral space maintainer with prosthetic replacement teeth for#'s E and F
B. . Fixed bilateral band and loop space maintainers
C. . Nance Appliance
D. . 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. Right and left fixed band and loop appliances (or crown and loop appliances)
B. Right and left removable space maintainors
C. Fixed bilateral lingual holding arch
D. Removable bilateral space maintainer
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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?
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