REVIEW PAPER

SPACE MAINTENANCE OF PREMATURE PRIMARY

TOOTH LOSS - AN OVERVIEW
Andrija Nedeljkovic1, Marijana Petrovic1 and Bojan Andjelic2
1
University of Kragujevac, Faculty of Medical Sciences, Kragujevac, Serbia
2
University of Pristina, Faculty of Medicine, Kosovska Mitrovica, Serbia

Received: 25.02.2022.
Accepted: 07.03.2022.

ABSTRACT

Corresponding author: Replacement of deciduous teeth with permanent teeth is a physio-

Andrija Nedeljkovic
University of Kragujevac, Faculty of Medical Sciences,
Svetozara Markovica 69, 34 000 Kragujevac, Serbia
E-mail: nedeljkovicandrija96@gmail.com
logical process, and as a consequence of early tooth loss in decid-
uous or mixed dentition, loss of space may occur. There is no
doubt that the loss of space after the premature extraction of de-
ciduous molars occurs, however, the width of the lost space and
the need for their clinical use are still a topic that is up for discus-
sion. This period is an indication for the designing and installa-
tion of space maintainers. The goal of therapy in such situations
is to maintain the position of the deciduous dentition in the arch
until the eruption of permanent teeth takes place and those teeth
take their natural and correct positions. Depending on the method
of fixation, space keepers can be fixed, cemented and mobile.
These devices are divided by the way they function into active (en-
able the increase of space by their action) and passive. Space
maintainers are a bit neglected, and they represent a very im-
portant clinical treatment whose use can bring a lot of benefits,
both prophylactic and therapeutic. The development of biomateri-
als and digitalization in dental practice can direct us to modify
and improve this therapeutic method.

Keywords: Pediatric dentistry, space maintainers, tooth loss.

DOI: 10.2478/sjecr-2022-0009
INTRODUCTION
Replacement of deciduous teeth with permanent teeth is
a physiological process, and as a consequence of early tooth
loss in deciduous or mixed dentition, loss of space may occur
(1,2). Loss of space usually results in mesial migration of
posterior teeth, and often distal movement of anterior teeth.
In general, there is an idea that early loss of a deciduous mo-
lar in the lower jaw mainly results in distal canine displace-
ment, while early loss of the first deciduous molar in the up-
per jaw results in mesial migration of the second deciduous
molar (3,4). There is no doubt that the loss of space after the
premature extraction of deciduous molars occurs, however,
the width of the lost space and the need for their clinical use
are still a topic that is up for discussion (5-11). In the process
of active eruption of the constant first molar between 5 and 7
years of age there is the highest probability of deciduous
tooth migration and the occurrence of loss of space. It is for
these reasons that this period is an indication for the design-
ing and installation of space maintainers.
The Clinical Efficacy Committee of the Faculty of Dental
Surgery in England was the first to publish guidelines for the
extraction of deciduous teeth and application of space main-
tainers in 2001, which was supplemented in 2006 (7).
Their guidelines say that space maintainers are most use-
ful in the following situations:
- Loss of a deciduous molar with an problematic arrange-
ment in the jaw
- Loss of the second deciduous molar except for arches
with sufficient space width.
From this method until today, the consensus about the use
and design of space maintainers has changed a lot. In time it
was proposed and established that the application of space
maintainers after the premature loss of a primary molar can
prevent unwanted migration of deciduous or permanent teeth
and prevents loss of space or the shortening of the length of
the dental arch and of the space for the positioning of perma-
nent teeth (American Academy of Pediatrics dentistry 2014).
this period is an indication for the designing and installation
of space maintainers.Different types of devices are used for
the application of space maintainers as a therapeutic method,
depending on the stage of development of the teeth, dental
arch, and the number of missing teeth (2).
The key moment is maintaining the position of the decid-
uous molar, whose position is crucial for guiding the eruption
of the first permanent molar, otherwise mesial migration, loss
of space and reduction in arch length can occur as a result of
their loss. Unilateral loss of deciduous second molars can free
up space which can be maintained with various preparations.
The choice of the type of preparation used depends on the
clinical conditions, age of the patient, state of their oral hy-
giene and other parameters.
Depending on the method of fixation, space keepers can
be fixed, cemented and mobile. These devices are divided by
the way they function into active (enable the increase of
space by their action) and passive (retain existing space)
(Table 1).
FIXED SPACE MAINTAINERS
Generally speaking, space keepers are semi-permanent
holders whose function is to maintain the space properly until
the eruption of permanent substitute teeth. After the eruption
of permanent teeth, the maintainer of space is removed.
Crown and loop (C&L)
These devices include a crown placed over one tooth and
a stainless-steel wire loop. Usually are used when the distal
tooth is carious, so we solve this problem with the crown as
an integral element and at the same time it represents a fixed
part of the space maintainer to which the loop connects. The
loop is tied to the crown on one end of the space while at the
other end it presses on the tooth and keeps the void constant
after the loss of a deciduous tooth. The high level of patient
cooperation is the main advantage of using this type of space
maintainer and disintegration of cement, cracking of a solder,
the forming of caries and long construction time are their
shortcomings.
Band and loop (B&L)
It has been used most often in the past due to its easy con-
struction. However, the precision of setting and adapting the
tape as a noose around the abutment tooth is a problem. Dur-
ing the production trauma of soft tissues can occur during
tape adaptation, and infiltration anesthesia is necessary. In
addition, an additional problem is plaque accumulation, gin-
gival inflammation, bacterial colonization, and damage to the
surrounding soft tissues (13-20). Making it takes a lot of ef-
fort and time and requires a few materials which bring with
them additional costs (18). Breakage, bending or displace-
ment of the space maintainer cannot be corrected on the spot,
and for that reason in these situations this type of maintainer
must be removed and a new one must be made, which re-
quires more time and additional finances (16,17). Another in
a series of shortcomings is the poor aesthetic effect that is
because they are made of stainless steel and the possibility of
allergic reactions is present. This type of space maintainer is
commercialized in the form of a ready-made system for the
production of space maintainers that bypasses the laboratory
phase.
However, they are not suitable for all clinical situations,
and the above-mentioned problems can be seen in this com-
mercial type of maintainer as well (18). The apparent pres-
ence of shortcomings justifies constant research and devel-
opment of new materials and products designed to maintain
the space of premature loss of a deciduous tooth (21).
 Table 1. Types of space maintainers – clinical indications, advantages and disadvantages

Space maintainers Indications Advantages Disadvantages

Premature loss of either the first or
Can be used with Two visits required for
second
permanent and fabrication, laboratory
Band and loop primary molar, with a distal
primary expenses, frequent
abutment tooth
molar banding cementation failures.
available.
Premature loss of primary first
Good survival rates
molar with a Two visits required for
and lengths
Crown and loop carious primary second molar in fabrication, laboratory
compared to other
need of a crown expenses.
space maintainers.
to restore.
Single visit Technique sensitive, good
Non-carious/restored surface for placement, easy to isolation and
Glass fiber reinforced
bonding either repair/ cooperation is required,
composite space
side of a primary molar space. replace and risk of bonding
maintainer
eliminates failures.
laboratory expenses.
Premature loss of a primary molar
with an unerupted
Lengthy and technically
tooth distal to the primary molar Potential for use
complex procedure,
space. Crown fitted before first
Distal end shoe requires soldering
on first primary molar and L-shaped permanent
equipment and excellent
bar with an intra-alveolar extension molar eruptions.
patient compliance.
soldered to crowns distal surface to
guide first permanent molar.
Stainless steel wire attached to Can impede eruption of
First permanent
bands and mandibular incisors
Lingual arch molars must be
adapted to lingual aspect of so contraindicated before
erupted.
mandibular arch. their eruption
Useful when loss of Need to await first
Multiple loss of primary (maxillary) multiple adjacent permanent molar
teeth, failed fixed unilateral SMs. teeth, preserves eruption, potential risk of
Transpalatal arch
Stainless steel wire attached to transverse soft tissue irritation
molar bands intermolar to tongue.
distance
Two visits required for
Easy to maintain
Removable appliances Multiple loss of primary teeth fabrication, laboratory
oral hygiene.
Expenses.

Glass fiber reinforced composite space maintainer
The emergence and application of fiber-reinforced com-
posites in dentistry has brought a great revolution in numer-
ous procedures. One of the places of their application is in
pediatric dentistry during production of space maintainers
(26, 27). There are a number of advantages over Band and
loop (21,22,15,16):
- Better aesthetics
- Minimally invasive (saves surrounding soft tissues)
- Easily removable
- Better accepted by patients themselves
This material also shows exceptional strength, it can even
be compared to stainless steel (21). Production and
installation is more economical, easier to manipulate and use.
Costs have also been reduced by circumventing the labora-
tory phase and requiring only taking an impression. The de-
sign is simple and extremely easy and quick to set up due to
light-curable composite (16,17,18,19,20,21).
With its strength and plasticity, it does not allow a nega-
tive impact on soft tissues and them being damaged (19). The
main drawback is more difficult manipulation and manifes-
tation of negative properties of the composite in the presence
of moisture, as well as the fact that it does not prevent exces-
sive eruption of the antagonist tooth, and does not restore the
function of the missing tooth (18,19)
Distal end shoe
This type of therapeutic procedure was introduced into
clinical practice by Gerber (23), which was perfected and re-
fined by Krol (24,25). This is a very valuable and important
device that helps in case of loss of the second deciduous mo-
lar since it aids the positioning of the first permanent molar
in its place. In 1973, Hicks detailed the indications and con-
traindications for this device, as well as diagnostic and sys-
tematic considerations. Indications for its application are
premature loss or extraction of the second deciduous molar
before the eruption of the first permanent molar, advanced
root resorption and periapical bone destruction of the second
deciduous molar before eruption of the first permanent mo-
lar.
After Hicks, Gegenheimer and Donly describe the labor-
atory production of the distal apparatus, which consists of the
crown and a distal element whose apex is incised into the gin-
gival line at the site of extraction of the second deciduous
molar as a guide for proper growth of the first permanent mo-
lar (27). During the first visit, a tooth was prepared, which
served as a support for crowns and an impression was taken
to make the apparatus, while another visit is planned for ce-
mentation and installation of the apparatus itself. During the
first visit, X-ray diagnostics was performed in order to notice
the position of the first permanent molar. Before cementa-
tion, another deciduous molar was extracted, after which the
device was cemented. The main disadvantage is aesthetics,
very difficult conditions for maintaining oral hygiene as well
accumulation of plaque which causes damage to other struc-
tures as well as a large number of controls in order to control
the efficiency and function of the device itself.
Lingual arch
Bilateral fixed passive non - functional devices that con-
trol the anteroposterior position of the tooth and maintain a
constant length of the dental arch. Indications for their use
are bilateral loss of the first deciduous molars after the emer-
gence of permanent lower incisors, minimal forward move-
ment of the anterior teeth and space maintenance (28). It is a
contraindication before the emergence of permanent incisors.
The advantages of this device are:
- Unobstructed eruption of permanent teeth
- Space maintenance
- Easy maintenance of oral hygiene
- Comfortable for the patient
- The disadvantages of this device are:
- Inability to prevent tooth antagonist extrusion
- High possibility of inclination due to forces caused
by the tongue
- May have adverse effects on surrounding structures
with poor oral hygiene habits
The devices are made in a combination of an office and
in a lab. The loops are applied around the teeth in the office,
after which the technician performs additional adaptation of
the loops on the model, bends and adapts the wire and solders
the structures themselves (29). The wire should be in contact
with the cingulum of the incisor near the tip of the papilla
(30). It should also rest on the gingival third of the permanent
molars or in in the case of placing bands on other deciduous
molars on the gingival third, where it is soldered to the loop.
It can have certain modifications, i.e. the application of cer-
tain orthodontic elements in the area of the incisors for their
minimal displacement.
Transpalatal arch
It differs from the lingual one only by the fact that the
place of the leaning arch is on the palate, and it does not in-
clude the anterior teeth as a place of support. It relies on the
palate indirectly through acrylic to prevent it from forming
mucosal damage.
REMOVABLE APPLIANCES
Mobile maintainers are similar to orthodontic mobile den-
tures. They are made of acrylic and many of them have
acrylic teeth built-in that compensate for the lost tooth and
represent a functional apparatus whose carrier are metal rings
adapted around the distal teeth in relation to space and situa-
tion on a case-by-case basis (15,31).
There are a number of benefits to using mobile space
maintainers (32). This applies in addition to maintaining
proximal, distal and mesial lengths of the space itself also to
maintaining the vertical height thus returning aesthetics (33),
it prevents speech disorders (34,35) and eliminates bad habits
such as one-sided chewing. However, the method of their
production has many shortcomings (36), mostly in the form
of design and the production of the devices themselves. Their
production is complicated because it requires the work of an
experienced therapist and technician and the appearance of
the product itself shows a large degree of variation. Constitu-
tive elements of these maintainers (rings, wire, acrylate)
show great variability in their definitive appearance from
work to work. and the biggest problem is the contraction of
acrylates during polymerization (37), which negatively af-
fects the intimate fitting between the surface of the tissue and
the surface of the maintainer. For these reasons, patients
themselves find it difficult to accept the maintainer. Another
problem in making the device is the unavailability of baby
tooth sets, so it is necessary to adapt and modify the adult
teeth sets according to the morphology of deciduous teeth,
however, absolute precision can never be achieved. These de-
vices enable good maintenance of oral hygiene, but their ef-
ficiency is not at a high level precisely because of the mobil-
ity and irresponsibility of children at that age. Mobile space
maintainers can be unilateral and bilateral. Unilateral mobile
space maintainers are very small in size so during childhood
they represent a very great danger of swallowing and suffo-
cation, which are the main contraindications due to which
these preparations are very rarely made. Bilateral devices are
similar to mobile partial denture ones that do not maintain
mesiodistal stability and tooth position, vertical dimension
and function in the area in which the teeth were lost in func-
tional mobile devices. In addition to this with these devices
better aesthetics as well as phonation are observed.
Dentistry adopted the digital workflow in the 1980s and
has been using it ever since. The use of CAD-CAM technol-
ogy in dentistry has shown tremendous success in recent
years. Improved patient compliance and acceptance of treat-
ments are two main advantages (34). By using the CAD-
CAM method, restorations can be virtually designed and then
milled on an automated milling machine. One more modern
method of making progress in the therapeutic approach is
3D- printing. Additive manufacturing, layered manufactur-
ing, and solid freeform fabrication are other terms for 3D
printing. The basic notion behind this new technology is that
a digital file may be used to construct a layer-by-layer design
for a 3D object of any shape or geometry. A cross-section of
the final object is represented by each of these layers.
In the long run, these technologies that are quick, precise,
and do not require a lot of time may be the best option for
pediatric patients. However, despite the great advantages,
they have not been widely used in pediatric dentistry today.
DISCUSSION
The purpose of this article is to summarize evidence from
previously published papers as a basis for future research
(1,2). One of the most commonly used space maintainers is a
maintainer with a band and a loop (B & amp; L). Less used
is a maintainer in the form of a crown and a loop (C & amp;
L). The reason for this is the ease and time needed to make
them as well as adaptability (2). According to the recommen-
dations, the space maintainer should be present until the erup-
tion of the substitute teeth (2).
It is from this fact that the problem in the use of the space
maintainers arises, that is in their duration and successful-
ness. In the literature, the success of the band and loop varies
greatly. In certain studies, the failure rate is 10% (39), while
in others 63 % (40). The durability of a space maintainer can
be affected by a number of factors which are the systemic
health of the patient, diet, meal times and teeth brushing hab-
its and the type of space maintainer.
Despite the many benefits of this type of therapy, there is
limited evidence and insufficient controlled and quality stud-
ies on their use (37). All space maintainers have the potential
to cause gingival diseases characterized by bleeding, ery-
thema and ulceration and all as a result of the compression of
the space maintainer.
On the other hand, mobile space maintainers show a num-
ber of benefits in the form of maintaining the proximal, distal
and mesial lengths of the space itself and the maintenance of
vertical height thus returning aesthetics (43), preventing
speech disorders (34), and elimination of bad habits such as
one-sided chewing. However, their production has many
shortcomings (35), mostly in the form of design and the
construction of the devices themselves. Production is com-
plicated because it requires the work of an experienced ther-
apist and technician and the appearance of the product itself
shows a large degree of variation. The constitutive elements
of these maintainers (rings, wire, acrylate) show great varia-
bility of their definitive appearance varies from work to
work. Perhaps the biggest problem is contracting acrylate
during polymerization (36), which negatively affects the in-
timate adhesion between the tissue surface and maintainer
surfaces. For these reasons, patients find it difficult to accept
the device. Another problem in the production is unavailabil-
ity of sets of deciduous teeth, so it is necessary to modify the
teeth from the set of permanent teeth and to adapt them to the
morphology of deciduous teeth, however, absolute precision
can never be achieved.
CONCLUSION
Space maintainers are a bit neglected, and they represent
a very important clinical treatment whose use can bring a lot
of benefits, both prophylactic and therapeutic. The develop-
ment of biomaterials and digitalization in dental practice can
direct us to modify and improve this therapeutic method.
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