There are numerous types of space maintainers.

They range from the very simple to those with numerous

bands and wires. They can be constructed differently and used in different parts of the mouth. As we will
cover later, some even have parts extending into the tissue.

We feel the best way to make sense of the numerous types and subtypes of space maintainers is to start
by classifying them broadly into four categories. They can be fixed or removable, and they can be
unilateral or bilateral.

A removable space maintainer, of course, can be removed. A fixed space maintainer is fixed (i.e., held) to
a tooth or to more than one tooth. Fixation usually is done by cementing the space maintenance
appliance in place.

Unilateral space maintainers are fixed to one side of the mouth and bilateral space maintainers are fixed
to both sides of the mouth. Fixed space maintainers can be unilateral or bilateral.

Space maintainers also can be placed on the mandibular or maxillary arch. Consequently, we could have
a maxillary removable bilateral space maintainer, or a mandibular fixed unilateral right side space
maintainer, and so forth. There are numerous variations on these basic themes. For example, some
space maintainers are used for missing anterior teeth and some are used to preserve space for posterior
unerupted teeth.

The following pages will show the various types of space maintainers.

Page 10

This photograph shows an example of a fixed bilateral space

maintainer. The patient is four years of age. The appliance is cemented
on the two second primary molars. Fixed bilateral space maintainers on
the mandibular arch often are called lingual arch space maintainers.

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.

Distal shoe space maintainers are discussed in the chapter on pediatric pulp therapy, particularly in terms
of the importance of saving pulpally compromised second primary molars prior to the eruption of the first
permanent molars. This is principally because of the technical difficulties associated with the placement of
distal shoe space maintainers. The point we make repeatedly in discussions concerning pulp therapy is
that it is best to save second primary molars using primary endodontic therapy (i.e., pulpectomy) when
first permanent molars have not yet erupted. Most experienced clinicians prefer to avoid distal shoe space
maintainers.

However, one approach which may cause the process to be easier is to make distal shoe space
maintenance a one appointment procedure. Most space maintainer protocol involves two appointments:
the first appointment for extraction and impression taking, and the second appointment for placement and
cementation of the appliance. In the case of distal shoe space maintainers, this means an additional local
anesthetic experience for the child and a surgical incision immediately mesial to the first permanent molar
so the distal shoe can be imbedded in tissue.

The distal shoe space maintainer can be placed at the time of extraction of the second primary molar. If
this approach is used, the impression must be taken and the appliance constructed prior to extraction of
the primary tooth. The advantage is not having to go back at a later time and surgically make an incision
for insertion of the distal shoe into the tissue so the distal shoe segment can abut against the permanent
molar.

Preformed (i.e., prefabricated) distal shoe space maintainers also can be used. Of course, preformed
space maintainers are not customized (i.e., fitted) for the individual patient. They are placed at the time of
the extraction appointment (i.e., a one appointment procedure is involved). Although they are not
customized for the patient, using a preformed space maintainer is acceptable in many situations. Using a
preformed space maintainer certainly is preferable to not using a space maintainer at all. Unfortunately,
distal shoe space maintainers sometimes are not used when a child's behavior makes it unlikely that
placement of the appliance at a second appointment would be successful. Of course, when distal shoe
space maintainers are not used, the development of space problems results.

Consequently, placement of distal shoe space maintainers can be planned as one appointment or two
appointment procedures, and the choice of approach is left to the discretion of the clinician. As mentioned
earlier in the chapter, it also is desirable to replace the distal shoe space maintainer with an appliance
which is banded to the permanent molar once the permanent molar erupts. Consequently, using the distal
shoe space maintainer and a subsequent band and loop appliance really involves several appointments.