1. Presenter: B.NEHA, MDS 2nd Year
Dept. of Pedodontics and Preventive
Dentistry
A.M.E’s Dental College and Hospital,
Raichur.

2. CONTENTS
• Definition
• Nolla’s Classification
• Causes of Premature loss of primary teeth.
• Space closure of Primary teeth after premature loss.
• Rate of Space Closure.

3. • Effects of Premature loss of Individual teeth
Effects of lower incisors
Effects of upper incisors
Effects of Canines
Effects of first molar
Effects of second molars
• Classification of Space Maintainers
• Treatment Considerations
• Band and Loop Appliance
• Fixed lingual arch space maintainer

4. • Nance Palatal Arch
• Trans Palatal Arch
• Distal Shoe space maintainer
• E Z space maintainer
• Tube and loop Space maintainer
• Removable Space maintainer
• Case Reports and studies.

5. DEFINITION
Space maintenance: J C Boucher 1941, It is defined as the
process of maintaining a space in a given arch previously
occupied by a tooth or a group of teeth.
Space Control: Gainsforth (1955) defined it as careful
supervision of the developing dentition; it reflects the
understanding nature of the dynamic occlusion.
Space Maintainer: Boucher, It is a fixed/ removable
appliance designed to preserve the space created by the
premature loss of a primary tooth or a group of teeth.

6. NOLLA’S CLASSIFICATION

7. IMPORTANT FUNCTIONS OF
SOUND PRIMARY TEETH:
• Normal facial appearance.
• Mastication
• Clear speech.
• Maintenance of a proper diet.
• Maintenance of space and arch continuity for the emergence of
permanent teeth.
• Flared root configuration of molars resists mesial migration and
space loss.
• Natural tooth is always a best space maintainer.

8. CAUSES OF PREMATURE LOSS OF
PRIMARY TEETH:
• Caries. (Brothwell DJ 1997 and Ngan 1999)
• Trauma.
• Ectopic eruption.
• Abnormal root resorption.
• Systemic disorders or hereditary
syndromes Eg.Hypophosphatasia, Rickets,
Acrodynia , Histocytosis X, Leukaemia,
Cherubism, Juvenile Periodontitis, Dentinal
Dysplasia, Cyclic Neutropenia, Papillon –
Lefevre Syndrome
• Brothwell DJ. Guidelines on the use of space maintainers following premature
loss of primary teeth. J Can Dent Assoc 1997;63:753,757-60,764-6.
• Ngan P, Alkire RG, Fields H Jr. Management of space problems in the
primary and mixed dentitions. J Am Dent Assoc 1999;130:1330-9.
• Owen DG. The incidence and nature of space closure following the premature
extraction of primary teeth: A literature review. Am J Orthod 1971;59:37-49.

9. Premature loss of primary
teeth
undesireable tooth movements of
primary and or permanent teeth
loss of arch length
increase the severity of malocclusions with
crowding, rotations, crossbite, excessive
overjet &overbite ,unfavorable molar
relationship & occlusal plane discrepancies

10. SPACE CLOSURE AFTER PREMATURE
LOSS OF PRIMARY TEETH
Seipel (1946)
Primary dentition,
space closure after
extractions was
progressive up to 28
months after the
extractions
Permanent
dentition space
closure proceeded
most rapidly for the
first 3 months
Primary dentition
space closure
occurred less in
the incisor region
than in the molar
region

11. RATE OF SPACE CLOSURE
MAXILLA MANDIBLE
SEIPEL D: 1.3mm/yr D: 1mm/yr
BREAKSPEAR (1951) D: 0.8mm/yr
E: 2mm/yr
D: 0.9mm/yr
E: 1.6mm/yr
1. Maxillary spaces close more rapidly than mandibular
spaces.(Davey 1967)
2. Early loss of the primary mandibular first molar
results primarily in distal movement of the primary
mandibular canine. (Owen DG 1971; Kisling E, Hoffding J
1979; Cuoghi OA 1998; Kumari BP, Kumari NR 2006)
3. In the maxilla, mesial drifting of the primary
second molar into the extraction site
predominates. (Owen DG 1971, Seward FS 1965, Kisling
E, Hoffding J 1979).

12. FACTORS INFLUENCING THE
DEVELOPMENT OF MALOCCLUSION
AFTER PREMATURE LOSS OF
PRIMARY MOLAR
• Abnormality of oral musculature
• Presence of oral habits
• Existence of malocclusion
• Stage of developing dentition

13. EFFECTS OF PREMATURE LOSS OF
INDIVIDUAL TEETH
1. LOSS OF LOWER PRIMARY INCISORS:
• Individual circumstances may indicate extraction of the
antimere primary incisor to enhance incisor
positioning and midline symmetry.

14. 2. LOSS OF UPPER PRIMARY INCISORS
At the age of 2 years primary canines have
erupted
Loss of primary incisors during this stage
Does not necessarily cause loss of intercanine
width

15. • The support of the mandibular occlusion "holds" the
maxillary anterior intercanine width dimensions.
• The major consequence of early loss of maxillary
primary incisors is most likely delayed eruption timing
of the permanent successors as reparative bone and
dense connective tissue covers the site.
Contd..

16. 3. LOSS OF PRIMARY CANINES
Unilateral loss of a
lower primary canine
Shift in
the dental midline toward the side
of loss
Lingual collapse of the
incisor
segment
Possibly deepening
of the bite

17. • If one primary canine is lost during incisor eruption, it
may be desirable to extract the contralateral primary
canine to help maintain arch symmetry and prevent
midline spacing.
• Incase of ectopic loss of a maxillary primary canine
typically reflects a very distal eruptive displacement of
the permanent lateral incisor and not necessarily a
significant tooth mass problem.

18. 4. LOSS OF PRIMARY FIRST MOLARS
• The effect of premature loss of first primary
molars in both arches is mostly dependent on
the state of eruption of the first permanent
molars.
• This results in a loss of posterior arch length
within the quadrant that can lead to crowding
as the canines and premolars erupt in later
stages.

19. • Therefore loss of a first primary molar in either arch
approximating eruption of first permanent molars indicates
use of a space maintainer is generally desirable to stabilize
second primary molar and canine positioning

20. 5. LOSS OF PRIMARY SECOND MOLARS
Leads to complete bodily drifting of permanent molar
which is erupting along with mesiolingual rotation of
palatal root
Space loss of as much as 8 mm in a maxillary
quadrant has been documented
In lower molars space loss of 4-6mm is
observed
When permanent molar has not erupted

21. • If the loss of the second primary molar occurs after the
first permanent molars have fully erupted and normal
cuspal interdigitation has been established, the degree
of space loss should be less dramatic than earlier
during molar transition regardless of arch involved.

22. CLASSIFICATION OF SPACE MAINTAINERS
1) Acc. To Hitchcock(1973)
• Removable or fixed or semi-fixed.
• With bands or without bands.
• Functional or non-functional.
• Active or passive.
• Certain combinations of the above

23. 2) Acc. To Raymond C.Thurow (1978)
• Removable
• Complete arch
Lingual arch
Extra-oral anchorage
• Individual tooth

24. 3) Acc. To Hinrichsen (1962)
o Fixed space maintainers
CLASS I
(a) Non-functional types
• i. Bar type.
• ii. Loop type.
(b) Functional types
• i. Pontic type.
• ii. Lingual arch type.
CLASS II
Cantilever type (distal shoe)
o Removable space maintainers
Acrylic partial dentures

25. 4) There are four basic types of space maintainers
(Pedodontic Appliances, 1977):
• 1.The band (crown) and loop is used to maintain the loss of a
single primary first or second molar.
• 2.The Nance holding arch maintains the maxillary arch length
after the premature loss of more than one primary maxillary molar
in the same quadrant or after a bilateral loss of primary molars.
• 3.The fixed lingual arch is used to maintain mandibular arch
length and prevent mesial tipping and/or rotation of the permanent
first molars. The fixed lingual arch prevents lingual tipping of the
permanent incisors.
• 4.The intra-alveolar ("distal shoe") appliance is used to prevent
mesial migration of the unerupted permanent first molar after
premature loss of the primary second molar.

26. TREATMENT CONSIDERATIONS
A) Time elapsed since loss:
• Space closure occurs within first 6 months. Therfore,
space maintainers should be given as soon as possible
after extraction.-McDonald and Avery,1994
B) Dental age of the patient:
• The chronologic age of the patient is not so important
as the developmental age.
• Teeth erupt when three-fourths of the root is
developed, regardless of the child’s chronologic age.
(Gron, 1962)
Gron Am. Prediction of tooth emergence. J Dent Res 1962;41:573-85.

27. C) Amount of bone covering the unerupted tooth:
• If due to infection bone is destroyed then regardless of
root formation status tooth eruption is accelerated.
D) Delayed eruption of the permanent tooth:
• If the permanent teeth in the same area of the opposing
dentition have erupted, it is advisable to incorporate an
occlusal stop in the appliance to prevent supra eruption
in the opposing arch.
1mm of bone resorbs in 4-5 months

28. E) Amount of space closure :
• A/C to Oslen(1959), greater loss occurs in mandible, as
it has permanent molars which have mesial inclination.
D mm E
mm
D mm Emm
First Year 1.3mm 2.8 1.8 2.4
Second Year 1.8mm 4.5 2.7 3.1
Third Year 3.2mm 8.0 3.3 4.5
MAXILLA MANDIBLE

29. F) Interdigitation:
• Cuspal height is believed to contribute to the stability
of the dentition.
• Gould(1965) and Devey (1967) mentioned that cuspal
interlocking acts as physical barrier for migration of
teeth after extraction.

30. SPACE MAINTAINER
APPLIANCES

31. BAND AND LOOP APPLIANCES
FIXED
NON- FUNCTIONAL
PASSIVE

32. INDICATIONS: (MOYERS,1988)
• Premature loss of any primary first molar in the
primary dentition.
• Premature loss of a primary second molar as the
permanent first molar is erupting clinically.
• Bilateral loss of primary molars before the eruption of
the permanent incisors.

33. CONTRAINDICATIONS
1. An occlusion that is extremely crowded or already
exhibits marked space loss.
2. High dental caries activity.
3. Replacement of primary anterior teeth.
4. Replacement of primary second molars in the
primary dentition without partial clinical eruption of
the permanent first molar.

34. CHECKLIST
• The loop should be parallel to the edentulous ridge
1mm off the gingival tissue and should rest against the
adjacent tooth at the contact area. The faciolingual
dimension of the loop should be approximately 8mm.
• The distal free end of the loop should lie on both sides
and in the middle of band. This allows occlusal
clearance and adequate strength of the soldered joints.

35. MODIFICATIONS:
• Use of Stoppers: To prevent buccolingual movement of loop
• Crown and Loop
• Crown – Band and Loop

36. • Mayne’s Space Maintainer: Band and loop but the loop is
halved with buccal loop eliminated and only lingual
extension given.
Nayak UA, Louis J, Sajeev R, Peter J. Band and Loop space maintainer- made
easy.J Indian Soc Ped Prev Dent.2004;22:134-6

37. • Reverse Band and Loop:
When there is premature loss of primary
second molar
Permanent molars have not erupted
completely.
Therefore, primary first molar is banded and
reverse loop is given

38. • Bonded band & loop space maintainer

39. • Band and Loop with NIMS modification:
In some cases, the primary canine occludes with opposite arch first
primary molar, such that the mesio-buccal cusp and marginal ridge
of first primary molar almost touches the ridge in space created by
loss of the tooth.
Therefore, the loop has to be modified to allow proper occlusion.
Prajapati et al, Unique J Med Dent Sci 2013;1:46-7

40. MODIFIED MINK REVERSE BAND
AND LOOP WITH INTRA
ALVEOLAR PROJECTIONPrimary second molar served as a
guide on the working
model for calculating the length of
distal extension loops
The vertical
depth of intra-alveolar projection
was calculated radiographically
Buccolingual width of the
appliance was calculated in
accordance with the buccolingual
width of the primary maxillary left
second molar.
a cut should be
made in the cast

41. After extraction under
antibiotic coverage, the intra
alveolar projection of the
modified appliance was placed
in the socket
Periapical radiographs should
be taken to check the passive
contact between the mesial
end of the permanent first
molar and the appliance before
cementation

42. • Christensen and Fields advised that the crown and loop
is not a recommended technique as it precludes the
simple appliance removal and replacement. Therefore
it was recommended that even crown should be
banded like natural teeth.

43. FIXED LINGUAL ARCH
• It is a bilateral fixed space maintainer.
• Most effective in space maintenance and minor tooth
movement.
• Classical mandibular arch wire consists of two bands
cemented to the first permanent molars or sometimes
2nd deciduous molars, which are joined by a stainless
steel wire butting against four incisors.

44. • Controls:
1) Anterio posterior tooth movement
2) Prevents distortion of arch perimeter.

45. INDICATIONS:
1. Maintainence of arch perimeter , because of premature loss of
1°ry teeth after permanent incisor eruption
2. Maintainence of leeway space.
3. Retention of position of mandibular incisors after tooth
movement to prevent relapse in mand. Ant. Crowding and changes
in bite depth.
4. Base for aesthetic restoration in loss of anterior teeth(hollywood
appliance) and as a base for habit appliance.

46. CONTRAINDICATIONS:
1. Absence of lower permanent anteriors
2. Rampant caries
3. Excessive crowding
4. Anterior or Posterior Cross bite.

47. CONSTRUCTION:
• Band:
Stainless steel material 0.005 inches in thickness (ortho
bands)
• Lingual arch wire:
Stainless steel round wire 0.036 inches in thickness
• The arch wire should contact the erupted permanent
incisors at the cingulum.

48. • PASSIVATION the lingual arch wire should be completely
passive. This is done by heating the wire to a dull brownish
appearance, while keeping the wire gently in place on the
cingula with an old instrument.
• Anterior portion of arch wire should contact the mandibular
lower permanent incisors at the cingulum area.
• In the posterior regions it should be located 2mm below the
gingival margin/ edentulous ridge.

49. MODIFICATIONS:
• HOTZ LINGUAL ARCH
With U-Loop for space regaining.
• Lingual arch with canine stopper.
• Omega bends in Canine region to prevent interference,
Suggested by Konstantinos et al.

50. • Functional Lingual Arch with Hinge-type Lockable
Dentulous Component
Int J Clin Pediatr Dent. 2017 Jul-Sep; 10(3): 302–308

52. • Leeway space represents the difference between the sum of
the mesiodistal diameter of the primary canine and molars
and the sum of the mesiodistal diameter of the permanent
canine and premolars and can measure up to 4.3 mm.
• Normally, the first molars move mesially into the leeway
space, decreasing the arch length. This space can be
preserved by maintaining the arch length with passive
appliances, such as the lingual arch.

53. A fixed option using primary incisor denture teeth secured
from a rigid steel wire (0.036 or 0.040) extended to bands
or stainless steel crowns on the primary molars, a so-called
"Hollywood" bridge, may be a more predictable option.

54. NANCE PALATAL ARCH SPACE
MAINTAINER
(H.N. NANCE IN1947)
• Use of the maxillary lingual arch is feasible in the
primary and mixed dentition because it can be
constructed to rest away from the incisors.
• The Nance appliance is designed to retain maxillary
molar position, serving as a "brace" against the anterior
wall of the palatal vault

55. • INDICATIONS :
To maintain the maxillary first permanent molar position
when there is bilateral premature loss of primary teeth with
no loss of space in arch.

56. • MODIFICATIONS:
Modified Nance palatal arch appliance for anterior
tooth replacement Ntasha sethi et al.

57. • The utilisation of extracted teeth as pontic created an
outstanding match of colour and surface texture, an
ideal contour and position and an excellent support of
the soft tissue architecture.
• The addition of a Nance palatal arch button, carried out
in the current case, presented the benefit of moving the
fulcrum of the appliance posteriorly. This permitted
some amount of microresilience which facilitates
stimulation of the underlying tissue and thereby,
prevents ridge resorption, which frequently occurs
after extraction.

58. TRANSPALATAL ARCH
• Construction of transpalatal arch was
described by Hill et al (1975) and
Tsamtsouries and George E. White (1977).
When permanent maxillary
molars move anteriorly
They rotate mesiolingually
around the large palatal
root
Transpalatal arch reduces
ant. Molar movement by
preventing this rotation.

59. • INDICATION:
 When one side of the arch is intact, and several primary teeth on
the other side are missing.
Bilateral loss of primary molars.
In arch expansion.
• DISADVANTAGE:
 Failure of the appliance to remain passive.
 If appliance is not passive , unexpected vertical & transverse
movement of the permanent molars can occur.

60. • Introduced by Willets (1932) with bar type gingival
extension and modified by Roche (1942) with a V shaped
gingival extension.
• Used to maintain the space of a primary second molar that
has been lost before the eruption of the permanent first
molar.

61. APPLIANCE DESIGN
• Using first primary molar as abutment, the band is
adapted.
• Impression taken and cast poured
• Tissue bearing loop is constructed with 0.0004” wire
extending distally into the prepared opening in the
model.
• Main function is to guide the path of eruption of the first
molars…..

62. • Normal paths of eruption
In lower arch, Contact
area of distal extension
should be slightly
lingual over the crest of
the ridge so as to
engage the mesial
contact area of the first
permanent molar.
In maxillary the
appliance should
be facial to the
crest of the alveolar
ridge.

63. • Length of distal extension (Horizontal bar):
Distal surface of first primary molar and mesial surface
of unerupted first permanent molar can be used as a
guide.
• Depth of Gingival Extensions:
If left too long it can harm the permanent first molar
If too short, the permanent molar might erupt below
the appliance.

64. • ADVANTAGES:
 Only space maintainer that can be used if there is
premature loss of primary second molar before
eruption of permanent molars.
• DISADVANTAGES:
May cause tipping if not placed correctly.
Higher chances of infection
Interferes with epithelisation of socket.

65. MODIFICATIONS AFTER
CONTROVERSY
• Firstly, there have been reports of trauma and damage
to the unerupted teeth by the appliance.
• Secondly, it is seen that normally erupting first
permanent molar does not contact the root of primary
second molar but uses the distal surface of the primary
second molar which leads to buttressing for uprighting
and establishing a mesial position.

66. • Loops in horizontal arm of space maintainer, as they
can permit the precise adjustments for accurate
placement of molar.
• No intra-alveolar involvement, vertical extension only
till it touches the mesial surface of the permanent first
molar.

67. • Levit (1971),
After extraction of second deciduous
molar
The mesial root is ground off
The remaining tooth is placed on the
impression and cast is poured
The tooth is removed from cast.
And the distal extension is placed.

68. • Bhat et al, 2014. Distal shoe space maintainer fused with
lingual arch incase of early loss of both primary first and
second molars unilaterally.

69. • Somwanshi et al, 2016. incase of multiple bilateral loss of teeth by
banding and adding lingual component with rectangular distal
extensions.

70. E Z SPACE MAINTAINER:
• Developed by Dr. Enis Guray, 2008.
• Can be directly bonded during single visit.
• Can be modified by incorporating a Ni-Ti coil to regain space.

71. TUBE AND LOOP SPACE MAINTAINER:
• By Srivastava et al, 2017 termed as Nikhil Appliance.
• Can be given in single sitting.
• Can be used in single unilateral loss of tooth.

72. REMOVABLE SPACE MAINTAINER
• Brauer’s Classification:
 Class 1: Unilateral maxillary posterior
 Class 2: Unilateral mandibular posterior
Class 3: Bilateral maxillary posterior
Class 4: Bilateral mandibular posterior
Class 5: Bilateral maxillary anterior posterior
Class 6: Bilateral mandibular anterior and posterior
Class 7: One or more primary or permanent anterior
Class 8: Complete primary.

73. • INDICATIONS:
A cleft palate patient.
Permanent teeth are not fully erupted for adaptation of bands.
Multiple loss of deciduous teeth.
• CONTRAINDICATIONS:
Lack of patient cooperation
Epileptic patients
Children with possible caries activity.

74. CASE REPORTS
AND STUDIES

75. Loss of space and dental arch length after the loss of the lower
first primary molar: a longitudinal study.
The sample consisted of 4 lower arch plaster models of 31
patients, within the period of pre-extraction, 6, 12 and 18 months
after the lower first primary molar extraction.
 A reduction of space was of noted with the cuspid dislocation and
the permanent incisors moving toward the space of the extraction
site.
 It was concluded that the lower first molar primary premature
loss, during the mixed dentition, implicates an immediate
placement of a space maintainer.
J Clin Pediatr Dent. 1998 Winter;22(2):117-20, Coughi et al.

76. • Thirteen children, five girls and eight boys, expecting premature
extraction of a maxillary primary first molar because of caries
and/or failed pulp therapy, were selected.
• Spatial changes were investigated using a three-dimensional laser
scanner by comparing the primary molar space, arch width, arch
length, and arch perimeter before and after the extraction of a
maxillary primary first molar.
• There was no statistically significant space loss on the extraction
side compared to the control side (P ¼ 0.33). No consistent findings
were seen on the inclination and angulation changes on the
extraction side.
Park K1, Jung DW, Kim JY.
Int J Paediatr Dent. 2009 Nov;19(6):383-9. doi: 10.1111/j.1365-263X.2009.00990.x. Epub
2009 Apr 16
Three-dimensional space changes after premature
loss of a maxillary primary first molar.

77. Space changes after premature loss of deciduous molars
among Brazilian children.
• A sample of 55 children between 6 and 9 years of age with
unilateral loss of either first or second molars was followed for 10
months by clinical examination, cast analysis, and radiographic
analysis. The space in the extraction site, arch length, and hemi-
perimeter of the extraction and control sides were measured.
• Only the group of children with premature loss of the mandibular
second deciduous molars exhibited significant dimensional
alterations during the follow-up.
Macena et al, AJOD, 140(6),, 771-778

78. • Uddanwadiker et al, 2016. Compared Band & loop,
Nance palatal arch and transpalatal arch for
deformations in the jaw bone after placement. Nance
showed less deformation compared to band and loop
and TPA.
• Dincer et al, conducted a study to evaluate effect of
removable space maintainers on intercanine width, it
showed that they ceased the increase in intercanine
width.

79. Biodegradation of nickel and chromium from space
maintainers: An in vitro study
• Observed release of Ni-Cr which reached maximum
level by 7th day but continued to release until 28th day
of placement of the appliance and also increased based
on number of space maintainers inserted.
Bhaskar V, Subba Reddy V V. Biodegradation of nickel and chromium
from space maintainers: An in vitro study. J Indian Soc Pedod Prev
Dent 2010;28:6-12

80. • Anterior esthetic fixed appliances for the preschooler:
considerations and a technique for placement

81. Esthetic rehabilitation of anterior primary teeth using
polyethylene fiber.
Jain M, Singla S, Bhushan B, Kumar S, Bhushan A. Esthetic rehabilitation of
anterior primary teeth using polyethylene fiber with two different approaches. J
Indian Soc Pedod Prev Dent 2011;29:327-32