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SPACE MAINTAINERS
DR. (MRS) ESTHER UZAMERE (BDS, FWACS) 28/10/2024

LEARNING OBJECTIVES
1. Define space maintainer and space maintenance
2. State the objectives of space maintenance
3. State the ideal requirements of a space maintainer
4. List the indications and contra-indications of space maintenance
5. Classify space maintainers
6. Describe in details the design, indication, advantages and disadvantages of a
commonly used space maintainer

Definitions
A space maintainer (SM) is a temporary device/appliance that is used to maintain the
space created by the premature loss of deciduous tooth/teeth. The goal of space
maintenance is to prevent loss of arch length with its attendant sequelae of crowding,
ectopic eruptions and impactions. Therefore, Space maintenance can be defined as
measures put in place to prevent loss of arch development due to premature loss of
deciduous teeth. The term “space maintenance” was coined by JC Brauer in 1941.
Objectives of Space Maintenance
1. To preserve the primate space.
2. To maintain the integrity of the dental arches and the normal occlusal planes.
3. To aid in aesthetics and phonetics in case of anterior space maintainer.
4. To avoid future dental anomalies; thereby acting as a significant part of
primary preventive orthodontic care.
An ideal space maintainer will not only preserve arch length but maintain aesthetics,
function, prevent the development of deleterious oral habits and also allow the
unhindered eruption of the permanent tooth into proper alignment and occlusion.
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Ideal Requirements
1. An ideal space maintainer should maintain the desired mesio-distal width of
the space created by the loss of tooth.
2. It should be simple and easy to fabricate
3. It should be strong enough to withstand functional forces
4. Should be functional.
5. Should not interfere with the eruption of the occluding or replacing tooth
6. Should not interfere with oral functions
7. Should not exert excessive stress on adjacent tooth/teeth
8. Should not impede normal growth and arch development

Indications of space maintenance

1. Potential space inadequacy for succedaneous teeth
2. Developing malocclusion: distortion in eruption sequence, delayed eruption
of permanent tooth
3. Little time elapse since loss of tooth. Maximum closure occurs within
2weeks–6months after extraction; therefore, it is best to place a SM
immediately after extraction.
4. If the root of the succedaneous tooth is <3/4 formed or any other evidence that
succedaneous tooth is not ready for eruption.

Contra- Indications
1. Gross space discrepancy e.g. spacing in the arch or severe crowding that will
warrant future extractions for orthodontic treatment
2. Space created is in excess of the mesio-distal width of the replacing tooth
3. When space loss is not anticipated
4. When the succedaneous tooth is congenitally missing and space closure is
desired
5. Pre-extraction radiograph reveals that the succedaneous tooth will erupt soon
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Classification
1. According to Hitchcock
a. Removable, fixed or semi-fixed
b. With bands or without bands
c. Functional or non-functional
d. Active or passive
e. Certain combinations of the above
2. According to Heinrichsen
a. Fixed SM
Class I: (a) Non- functional
i. Bar type (no longer in use)
ii. Loop type
(b.) Functional
i. Pontic type

ii. Lingual arch type

Class II: Cantilever type (band and loop, distal shoe)

b. Removable SM e.g. acrylic partial denture
3. According to Prof. Shoba Tandon
a. Removable
1. Cast partial or wrought metal
2. Active or passive
3. Functional or non-functional
b. Fixed
1. Banded or bonded
2. Active or passive
3. Functional or non-functional
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BAND AND LOOP SM

It is a unilateral (fixed to one side of the mouth), fixed, non-functional and passive
SM. It is one of the commonly used.
Indications
1. Single posterior tooth loss
2. Bilateral loss of molars before the eruption of the permanent incisors
in the mandibular arch (a lingual arch may impede eruption of the incisors)
Contra-indications
1. High caries activity
2. More than one adjoining teeth missing
Advantages
1. Economical
2. Less chair side time
3. Less expertise

Disadvantages
1. It is non-functional
2. Does not prevent the supra eruption of opposing tooth
3. Difficult to maintain good oral hygiene
4. Loop may slip and impinge on the gingiva

Design
It has a cantilever design consisting of a stainless steel band (preformed or custom
made) which is cemented over a posterior/distal abutment and a loop (made of
0.9mm HSSW). The loop extends from the middle of the band from either side to
reach the distal surface of the anterior/mesial abutment just below the contact point
and above the gingiva margin (1mm). The loop is soldered to the band which should
extend 1mm sub-gingivally and not up to the occlusal surface as it may interfere
with occlusion.
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Modifications
1. Crown and Loop: A SS crown is cemented over the tooth instead of a band.
Indicated when the abutment requires a crown in cases such as gross caries,
hypoplasia, pulpally treated tooth; etc.
2. Reverse Band and Loop/Reverse Crown and Loop: The mesial/anterior
abutment is banded rather than the distal with the loop extending distally. Used
in cases of partially erupted 6
3. Band and bar: Both abutments are banded and a bar placed in between instead
of a loop. This is not ideal because although it is sturdy and stable, it may
interfere with eruption.

4. Bonded: No bands, just a loop bonded to either side of the tooth.

5. Mayne’s Space maintainer- It resembles the band and loop space maintainer,
with no buccal loop, only the lingual extensions.

DISTAL SHOE SM (AKA Intra-alveolar, Eruption guidance SM)

It is a unilateral, fixed, passive and non-functional SM. Designed to maintain space

and guide the first permanent molar into eruption.
Indications:
1. Single loss of the 2nd deciduous tooth before the eruption of the first permanent
molar
2. Single tooth space maintenance
Contra-indications
1. Multiple loss of teeth on same side
2. Medically compromised children such as those with immunosuppression,
blood dyscrasias, congenital heart defects, diabetes, etc.
3. Poor oral hygiene
4. Lack of parental/child’s compliance
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Design
It is made of a crown or band with a distal intra-gingival extension. The distal
extension has 2 components, the horizontal component which spans the mesiodistal
width and the vertical component (intra-alveolar extension). The length of the
horizontal component is determined by measuring the mesio-distal width of the
primary 2nd molar (prior to extraction) or from IOPA by measuring between the distal
surface of the primary 1st molar and the unerupted permanent first molar. The vertical
bar extends 1-1.5mm below the mesial marginal ridge of the permanent first molar
(guided by IOPA). If it is too short, the permanent first molar will slip below it and
if too long, may cause injuries to the developing second premolar.
LINGUAL ARCH SM
It is a bilateral (fixed to both sides of the mouth), fixed/semi-fixed, non-functional
and passive SM.

Indications:
1. Bilateral loss of deciduous molars on the lower arch after the eruption of the
permanent lower incisors.
2. Multiple loss of teeth on same side or both sides of the lower arch
Contra-indications
1. Anterior or posterior cross bite
2. Significant mandibular crowding
Advantages:
1. More economical than two bilaterally placed band and loop
2. Has the ability to prevent the lingual collapse of the lower anterior teeth.
Disadvantage: wire distortion
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Design
It consists of bands on both ends with a U shaped arch wire (0.9mmHSSW) that runs
from the middle part of the lingual surface of the bands to the lingual surface of the
anterior teeth just above their cingula.
Modifications
1. It can be semi-fixed (Mershon arch) in which the U loop arch wire is passed
into tubes on the bands instead of being soldered.
2. Active Lingual arch/ Hotz Lingual Arch: a U loop is incorporated on one side
or both sides and can be activated for molar distalization and space regaining

NANCE’S PALATAL ARCH (AKA Nance’s holding arch)

It is a bilateral, fixed, passive and non-functional SM. Its design is similar to that of
the lingual arch but the anterior end does not contact the anterior teeth rather is
extended to the ruggae area and embedded in an acrylic button. This button provides
good anchorage for the appliance.

Indications:
1. Bilateral loss of deciduous molars in the upper arch
2. Multiple loss of teeth on same or both sides of the upper arch
Advantages:
1. The button provides good anchorage
2. More economical compared to two bilaterally placed band and loops
3. Allows transverse growth
Disadvantages:
1. More expertise required
2. Tissue irritation from acrylic button
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TRANS-PALATAL ARCH (TPA)

It is a bilateral, fixed, passive and non-functional SM. It consists of two bands and
an arch that runs across the palatal surface. Indicated in unilateral multiple loss of
deciduous molars in the upper arch and contra-indicated in bilateral loss of molars
as both anchor teeth will simultaneously move mesially. It is more hygienic than the
Nance appliance. Was reported and described by Goshgarian in 1972 thus named the
“Goshgarian” appliance.

NB: The preferred abutment for all bilateral SMs (Nance, TPA and the lingual arch)
is the first permanent molar. Using the second deciduous molars may result in the
premature loss of the SM even before the need to discontinue its use following their
exfoliation.

Choice of space maintainers for premature loss of teeth

1. Anterior teeth (both maxillary and mandibular)
a. Removable functional SM
b. Fixed cantilever prosthesis
2. Unilateral loss of deciduous 1st molar
a. Band and loop
b. Trans-palatal arch (TPA)
3. Bilateral loss of deciduous 1st molar
a. Two band and loop
b. Nance
c. Lingual arch
4. Unilateral loss of deciduous 2nd molar
a. Band and loop
b. TPA
c. Distal shoe (before the eruption of permanent 1st molar)
5. Bilateral loss of deciduous 2nd molar
a. Two Band and loop
b. Nance
c. Lingual arch (after the eruption of the permanent 1st molar)
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d. Two distal shoe (before the eruption of the permanent 1st molar)
6. Unilateral multiple loss
a. TPA
b. Lingual arch
7. Bilateral multiple loss
a. Nance
b. Lingual arch
NB: Removable functional SM is indicated in all of these. The best space
maintainer is the primary tooth

Modern designs of space maintainers

Modern designs of space maintainers aim to eliminate the laboratory steps saving
time and cost. No impression making or model fabrication is required. Examples of
these are:
1. Ribbond space maintainer: fiber reinforced composite resin; a biocompatible
aesthetic material, well tolerated by the patient and less time consuming.
2. EZ space maintainer: Cost effective, less time consuming than the traditional
band and loop SM
3. Nikhil appliance: It is a tube and loop space maintainer
4. H-Appliance: It is a simple bracket and hook space maintainer
5. Indirect bonded space maintainer: One of the commonest modern space
maintainers presenting a new design with brilliant properties
6. Digital Space maintainers (Digitainers): these are space maintainers using
CAD-CAM or 3D print technology with modern and biocompatible materials. The
examples include metal-based e.g titanium SM; and the metal free SMs which
include BRUXZIR and TRILOR.

ACTIVE SM (SPACE REGAINERS)

The goal of these is to recover loss space/arch length/perimeter and/or improve the
eruptive position of succedaneous teeth by maintaining the space regained. Indicated
when space loss is less or up to 3mm.

1. Removable e.g. free end loop space regainer, C-space regainer, Hawley’s with
a helical spring
2. Fixed e.g. Gerber (open coil), Jackscrew, Jaffe appliance, distal jet, pendulum
appliance