October 1, 2011

Space Maintenance in the Pedodontic Patient: May Save You Money in the Long Run

“Doctor, is that a baby tooth you want to fix on my little Katie?  It is?! Then just pull it out.”

Unfortunately, the general population of parents today have little knowledge about how to take care of their children’s teeth. Parental care of children’s teeth should start shortly after teeth begin to erupt into the mouth.  Habits that are established between the parents and the child will form how the child perceives their teeth for the rest of their lives.


Mothers (and I’m saying fathers and all other relatives, too) who use xylitol sugar during and after pregnancy have children with less cavities. This is because children eventually get the majority of their cavity causing bacteria from their parents, siblings and relatives through touching and kissing.  Xylitol is a natural sugar that taste very similar to table sugar, but doesn’t cause cavities.  I have written extensively throughout my blogs about the blessing of xylitol and at this time I’d like to direct you to those articles.

Brushing and Flossing:

Parents who have extensive dental work or dentures have problems taking care of their own mouths, let alone their childrens.  I call this a “low dental IQ”. It follows that the best way to become obese is to have obese parents because they are the ones who taught you how and what to eat.  So the best way to have dentures is to have parents with denture.  They never took care of their own teeth properly so they have little information on how to teach their children how to take care of teeth. At some point the “family dental IQ” level will have to increase or the child may follow down the same path of decay and periodontal disease the parents went down. Regular dental check-ups/cleanings, xylitol, fluoride, and brushing/flossing the teeth properly goes a long way towards better long term dental health.


Tooth decay can be devastating to the health and well being of a developing child. Whether it be a small incipient lesion or a mouth full of nursing caries, going to the dentist at such an impressionable age to have dental work should be kept to a minimum. This may mean going to the pedodontist and having sedation for big cases or going to the general dentist for small problems including cleanings.  If a baby tooth has to be extracted before its time, then depending on where it is in the arch, there may be a problem.  Think of baby teeth as space maintainers for the adult teeth that will take their place in the future.  They hold open a space so that when the face grows from a child’s small rounded profile into an adult, there will be enough space in the arches for the tongue and lips to push the adult teeth into their proper places.

The baby teeth (deciduous teeth) start coming into the mouth at around 6-12 months and start falling out at around 6-8 years old.  The last baby teeth to fall out around 10-13 years old are the baby molars. If these baby molars  get cavities before they are ready to come out naturally, then the adult teeth underneath can have crowding problems.

Space Maintenance:

Teeth in an arch support each other like the keystone in a Roman arch.

If a keystone is removed all the arch blocks will cave in and collapse the archway.  If a tooth is lost in the dental arch, the teeth behind the one lost will fall forward, closing the space.  This would not be bad except that under a baby tooth there is an adult tooth waiting to use that baby tooth’s space when it is time to erupt into the mouth.  If the baby tooth is lost and the space closes, there is no space for the adult tooth and you will have an orthodontic nightmare. To solve this problem, when a baby tooth has to be removed prematurely, a space maintenance device can be placed into the mouth to keep open the space for the adult tooth.  These space maintenance devices come in different forms.  The simplest form is called the band and loop.  It is simply an orthodontic band with a wire loop soldered onto the band to hold the teeth apart.

The band and loop is left in the mouth until the first signs of the adult tooth coming in and then it is removed.

If teeth are missing on both sides of the mouth then a bilateral space maintenance device called a fixed lingual arch is used.

When teeth are missing on the upper arch a Nance Holding Arch can be placed.

Undoubtedly, the most challenging space maintenance device is one that has to be placed to hold a space for a lost baby 2nd year molar when the patient has not erupted the permanent first molar (before 6 years old).  This device is called a Distal Shoe or a Free-End space maintenance device.  Since the permanent first molar is still below the gum line and one tooth back a specially designed metal piece is fixed to the baby first molar and extended back to under the gum line to hold the permanent molar from erupting forward and crowding out the second premolar waiting to erupt into the lost second baby molars place.

Without these devices being placed in the mouth after prematurely loosing a baby tooth, crowding can occur.

If the child already has a need for future orthodontics because of other developmental crowding reasons then it may not be that important.  If the premature loss of a baby tooth is the only problem the child has, then not putting in the proper space maintenance can cost you from a couple a hundred to as much as $5000 for braces.


1. Am J Orthod Dentofacial Orthop. 2010 Oct;138(4):382.e1-4; discussion 382-3. Effects of lingual arch used as space maintainer on mandibular arch dimension: a systematic review. Viglianisi A. Department of Orthodontics, Faculty of Dentistry, University of Catania, Catania, Italy. azzurravi_9@hotmail.com

2. J Indian Soc Pedod Prev Dent. 2010 Apr-Jun;28(2):113-5. NiTi bonded space regainer/maintainer. Negi KS. Department of Orthodontics, H. P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India. docksnortho@yahoo.com

3. Int J Paediatr Dent. 2009 Nov;19(6):383-9. Epub 2009 Apr 16. Three-dimensional space changes after premature loss of a maxillary primary first molar. Park KJung DWKim JY. Department of Pediatric Dentistry, The Institute of Oral Health Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea 135-710.

4. Int J Paediatr Dent. 2009 May;19(3):155-62. Space maintenance. Laing EAshley PNaini FBGill DS. Department of Orthodontics, Eastman Dental Hospital, University College London Hospitals NHS Trust, London, UK.

5. Eur Arch Paediatr Dent. 2009 Jan;10(1):6-10. Longevity of band and loop space maintainers using glass ionomer cement: a prospective study. Sasa ISHasan AAQudeimat MA. Dept of Paediatric Dentistry, University of Texas Health Science Center, San Antonio, TX, USA.

6. J Indian Soc Pedod Prev Dent. 2008 Sep;26(3):132-5. Modified Willet’s appliance for bilateral loss of multiple deciduous molars: a case report. Dhindsa APandit IK. Department of Pedodontics and Preventive Dentistry, M.M. College of Dental Sciences and Research, Mullana, Ambala (Haryana), India. abhishekdhindsa@yahoo.co.in

7. J Am Dent Assoc. 2007 Mar;138(3):362-8. Immediate and six-month space changes after premature loss of a primary maxillary first molar. Lin YTLin WHLin YT. Pediatric Dentistry, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

8. J Clin Pediatr Dent. 2006 Fall;31(1):5-8. Free-end space maintainers: design, utilization and advantages. Barbería ELucavechi TCárdenas DMaroto M. Department of Prophylaxis, Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Madrid Complutense University, Spain. barberia@odon.ucm.es

9. J Indian Soc Pedod Prev Dent. 2004 Sep;22(3):134-6. Band and loop space maintainer–made easy. Nayak UALoius JSajeev RPeter J. Department of Pedodontics and Preventive Dentistry, Rajah Muthiah Dental College & Hospital, Annamalai University.

10. Pediatr Dent. 2002 Nov-Dec;24(6):561-5. The distal shoe space maintainer chairside fabrication and clinical performance. Brill WA. School of Dentistry, University of Maryland, Baltimore, MD, USA. wbrill@erols.com