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Space management of the permanent dentition

Meticulous care of primary dentition plays an important role in the proper eruption of permanent dentition.

Mandibular space maintainersFixed bilateral SM Removable bilateral SM fixed unilateral SMRemovable unilateral SMDistal shoe



Maxillary space maintainersFixed bilateral SMFixed unilateral SMRemovable bilateral SM

Space management is an important responsibility of the general dentist, the pediatric dentist and the orthodontist. The premature loss of primary teeth may cause loss of arch length, resulting in crowding of the permanent dentition, impaction of permanent teeth, esthetic difficulties, malocclusion, and other problems. We recommend prompt and appropriate space management therapies to help insure optimal lifelong dental health.

We will focus on the various types of space maintainers, when and how they are used, and how they are made. Our coverage will center on maintaining existing space once primary teeth have been lost prematurely, rather than on tooth movement.

space management of the permanent dentition




A primary tooth is the best space maintainer

The best space maintainer is a primary tooth, as you see demonstrated in this radiograph. When nature's best space maintainer is lost prematurely, we need to intervene and maintain the space for normal development of the dental arches.

 

For example, this panoramic radiograph shows the premature loss of the mandibular right second primary molar, resulting in the tipping of the first permanent molar and consequent loss of space. This is an example of space loss which could have been prevented if a space maintainer had been placed after the primary tooth was removed.


premature loss of the mandibular right second primary molar





mandibular fixed bilateral space maintainer

Classification of space maintainers


Mandibular space maintainers
Fixed bilaeral SM

Mandibular fixed bilateral space appliances generally are preferred by clinicians over removable space maintainers. Fixed appliances are easier to maintain and they are less likely to be removed, damaged, or lost by the child. In other words, they need less patient compliance.

 


Removable bilateral SM

Removable appliance must be worn at least 14 hours per day. Hence, it is highly dependent on patient compliance. However, oral hygiene would be easier owing to its removable nature.



Mandibular removable bilateral space maintainer





Mandibular fixed unilateral space maintainer

Fixed unilateral SM

This photograph shows an example of a fixed unilateral appliance on the mandibular first molar using stainless steel wire soldered to an orthodontic band, with space being maintained for the underlying bicuspid. This appliance is referred to as a band and loop space maintainer and is a favorite among many pediatricians and general dentists. However, orthodontists usually prefer to use bilateral appliances due to their versatility following loss of other primary teeth and being less prone to removal and swallow with the child.

 


Removable unilateral SM

These are examples of dangerous space maintainers. They are removable unilateral space maintainers. We believe removable unilateral space maintainers should not be used. They are too small and present swallowing and choking dangers for children.


Mandibular removable unilateral space maintainer





distal shoe space maintainer distal shoe space maintainer

Distal shoe

Distal shoe space maintainer or distal extension space maintainer is used to prevent first permanent molars from moving mesially with the premature loss of second primary molars. The example shown is a crown with a distal extension segment soldered to the crown. The distal segment is extended into the tissue against the unerupted first permanent molar.

This appliance is mostly used with pediatricians, but orthodontists are usually afraid of making problem for the first permanent molar instead of guiding its eruption via this appliance due to the common error in precise positioning of the distal extension part.

 


Maxillary space maintainers

Fixed bilateral SM

This type of space maintainer also is known as a Nance Holding Arch or a Nance Appliance. Note the small acrylic button which will rest against the palatal tissue with this appliance. Some clinicians object to the button since it can create tissue irritation. Therefore, it is important that patients and parents be instructed to make sure that the patient meticulously flosses under the acrylic button. The Nance Holding Arch is used in situations where premature bilateral loss of maxillary primary teeth has occurred.



Maxillary fixed bilateral space maintainer





Maxillary fixed unilateral space maintainer

Fixed unilateral SM

This photograph shows an example of a fixed unilateral appliance constructed by a stainless steel wire soldered to an orthodontic band, with space being maintained for the underlying bicuspid. This appliance is referred to as a band and loop space maintainer.

 


Removable bilateral SM

As suggested previously, removable appliances are more dependent on patient compliance so prone to problems with the appliance not being worn and the frequent incidence of breakage and loss. However, they make oral hygiene more comfortable.


Maxillary removable bilateral space maintainer Maxillary removable bilateral space maintainer




Maxillary space maintainer replacing missing teeth
Maxillary space maintainer replacing missing teeth

The appliances demonstrated in this photographs are used to replace missing maxillary anterior or posterior primary teeth. In other words, these space maintainers also serve as maxillary anterior or posterior prosthesis and provide better function and esthetic situation for the child.


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