Space Maintainer Teaching Module and Competency

Basic Space MaintainersBasic Space MaintainersTeaching Module and Teaching Module and

CompetencyCompetencyPrepared by:Prepared by:

Cynthia K Christensen; DDS, MS Cynthia K Christensen; DDS, MS Sean Whalen, DDSSean Whalen, DDS

University of Iowa Department of Pediatric DentistryUniversity of Iowa Department of Pediatric Dentistry2008-20092008-2009

Basic Space MaintainersBasic Space Maintainers

• Are PASSIVE

– .036 wire is very heavy and should not be used to actively move teeth

Before Placing a Space Before Placing a Space MaintainerMaintainer

• 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 Space Maintainers are Simple!Simple!

Name the 4 most basic pediatric Name the 4 most basic pediatric space maintainersspace maintainers

Basic Space MaintainersBasic Space Maintainers

• NANCE (Transpalatal Arch with Acrylic Button Stop on Palate)• LOWER LINGUAL HOLDING ARCH

(LLHA)

• BAND/CROWN and LOOP

• DISTAL SHOE

Distal ShoeDistal Shoe

• MAXILLARY or MANDIBULAR

• Used when second primary molar requires extraction and first permanent molar has not erupted


• Should be evaluated with radiograph prior to cementation– Length– Position

• Will be replaced with another space maintainer when permanent teeth erupt.


• Example of use in partial eruption case.

Nance ApplianceNance Appliance

• MAXILLARY ONLY

• Bands on first permanent molars

Nance ApplianceNance 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)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 ArchLower Lingual Holding Arch

• MANDIBULAR ONLY

• Bands on first permanent molars

• Anterior Stop = Cinguli of #23-#26

Lower Lingual Holding ArchLower 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 #K and #T Extractions : LLHA Indicated?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 LoopsLLHA Omega Loops

• Omega Loops in area of premolars allow slight adjustment to fit appliance

• Should not be used to activate appliance

Appliance Activation FeaturesAppliance Activation Features

• Can be added by attaching light wire features

• This is beyond routine space maintenance

Band/Crown and LoopBand/Crown and Loop

• MAXILLARY or MANDIBULAR

• Unilateral most typical• Can be bilateral if

permanent teeth are not present

• Single tooth span

Crown and LoopCrown and Loop

• Stronger than band and loop

• Cementation failure or loss less likely

• Excellent choice if tooth needs a restoration

What About Removable What About Removable Appliances?Appliances?

• Yes, they are possible, however………..• High failure rate due to breakage and loss• Parent and patient compliance must be exceptional

Which Space Maintainer?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 Must I Plan to Replace a Band/Crown and Loop ?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 CompetencySpace Maintainer Competency

• The following cases require space The following cases require space maintainer consideration. Assume that maintainer consideration. Assume that radiographs have been taken, there is no radiographs have been taken, there is no abnormal pathology (other than dental abnormal pathology (other than dental caries), and a successor is developing. caries), and a successor is developing.

• Please answer the questions on your Please answer the questions on your worksheets.worksheets.

Question 1Question 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?


• 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



• Which teeth were extracted? How old is the patient?• What is the appropriate space maintainer?• When can the space maintainer be removed?


• Which teeth were extracted/• What is the appropriate space maintainer?


• Which teeth have been extracted? How old is the child?• What is the most appropriate space maintenance?

““Cheyenne” CaseCheyenne” Case

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

How old is Cheyenne assuming How old is Cheyenne assuming normal dental development?normal dental development?

Cheyenne’s Bite WingsCheyenne’s Bite Wings

Mandibular Arch Only:Mandibular Arch Only: Chart Chart Dentition on the OdontogramDentition on the Odontogram

CheyenneCheyenne

• Mandibular Arch OnlyMandibular Arch Only : Chart : Chart abnormalities and pathology (including abnormalities and pathology (including caries ) from the Panorex and Bite Wing caries ) from the Panorex and Bite Wing RadiographsRadiographs

CheyenneCheyenne

A Moyer’s space analysis predicted there A Moyer’s space analysis predicted there to be 2.3 mm of excess space in the to be 2.3 mm of excess space in the mandible.mandible.

Make a treatment plan and appointment Make a treatment plan and appointment sequence for the mandibular arch only.sequence for the mandibular arch only.

CheyenneCheyenne

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

““Justin” CaseJustin” Case

• Justin was referred by his general dentist Justin was referred by his general dentist for ‘ tooth decay and crowding.’for ‘ tooth decay and crowding.’

• The family does not believe they can The family does not believe they can afford comprehensive orthodontic care, afford comprehensive orthodontic care, but does have dental insurance for but does have dental insurance for “routine dental care.”“routine dental care.”

Justin: Justin: Chart Chart Maxillary DentitionMaxillary Dentition OnlyOnly on the Odontogram on the Odontogram

Justin’s Bite WingsJustin’s Bite Wings

• Chart any pathology or abnormal findings (including caries) for the maxillary arch only on the odontogram.

JustinJustin

JustinJustin

A Moyer’s space analysis predicts 1.2 mm A Moyer’s space analysis predicts 1.2 mm of space shortage in the maxillaof space shortage in the maxilla

Treatment plan and sequence appointments Treatment plan and sequence appointments for the for the Maxillary Arch OnlyMaxillary Arch Only

JustinJustin

DiscussionDiscussion


• 5 or 6 y.o. child. Tooth #I extracted.


• Band/Crown and Loop #J-H• Will not need replacement. #12 should erupt

before #H or J exfoliate


• Tooth #L extracted. 3-5 y.o. child.• What is the appropriate space maintainer?• Will it have to be replaced with a different space



• Band/Crown Loop #K-M• May need to be replaced by LLHA later. Tooth

#M should exfoliate prior to eruption #21.


• Teeth #A and #J extracted. Patient 8-9 y.o.


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


• Teeth #K and L extracted


• Lower Lingual Holding Arch (LLHA) #19-#30


• 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”

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

Assuming normal dental development, Assuming normal dental development, Cheyenne is 8 years old.Cheyenne is 8 years old.

CheyenneCheyenne

• Mandibular Arch OnlyMandibular Arch Only : Chart : Chart abnormalities and pathology (including abnormalities and pathology (including caries ) from the Panorex and Bite Wing caries ) from the Panorex and Bite Wing RadiographsRadiographs

CheyenneCheyenne

• 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.

CheyenneCheyenne

A Moyer’s space analysis predicted there A Moyer’s space analysis predicted there to be 2.3 mm of excess space in the to be 2.3 mm of excess space in the mandible.mandible.

Make a treatment plan and appointment Make a treatment plan and appointment sequence for the mandibular arch only.sequence for the mandibular arch only.

Cheyenne Tx PlanCheyenne 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

CheyenneCheyenne

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

• Answer: When #21,28 and 29 erupt. Answer: When #21,28 and 29 erupt.

• Around age 12 yearsAround age 12 years

““Justin” CaseJustin” Case

• Justin was referred by his general dentist Justin was referred by his general dentist for ‘ tooth decay and crowding.’for ‘ tooth decay and crowding.’

• The family does not believe they can The family does not believe they can afford comprehensive orthodontic care , afford comprehensive orthodontic care , but does have dental insurance for but does have dental insurance for “routine dental care.”“routine dental care.”

JustinJustin

JustinJustin

A Moyer’s space analysis predicts 1.2 mm A Moyer’s space analysis predicts 1.2 mm of space shortage in the maxillaof space shortage in the maxilla

Treatment plan and sequence appointments Treatment plan and sequence appointments for the for the Maxillary Arch OnlyMaxillary Arch Only

JustinJustin

• 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.

JustinJustin

Justin Tx PlanJustin 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 SequenceJustin 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

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Space Maintainer Teaching Module and Competency