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Passive Space Management in Children

An essential part of pediatric dental care, understanding the concept of space
management is critical in managing the developing dentition.

By Brent Pen-Jen Lin, DMD On Jul 11, 2018

An essential part of pediatric dental care, understanding the concept of space

management is critical in managing the developing dentition
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one study, it was reported that more than 40% of parents/caregivers felt it was
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unnecessary to spend time and money on a tooth that is going to shed. The impact
of loss of deciduous teeth would not be realized until later, and could lead to costly
and complicated orthodontic and/or surgical treatment. Therefore, the importance
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of preserving the primary dentition should be emphasized by dental professionals.
The concept of space management is critical in managing the developing dentition
and is essential knowledge for any dental provider who cares for children.

One of the functions of the primary

dentition is to preserve space for the
succedaneous teeth. Teeth have a
tendency to drift into edentulous space.
Without intervention, premature loss or
reduction in tooth mass (due to factors
such as interproximal dental caries in
deciduous teeth) could lead to
inadequate space for erupting
permanent teeth. Hence, maintenance of
FIGURE 1. Severe malocclusion and
ectopic eruption due to crowding and a healthy primary dentition and its
space loss.
existing space is paramount in preserving
arch length and space for the erupting
permanent dentition, and preventing complications leading to malocclusion,
ectopic eruption, crowding, impaction, super-eruption, and tipping and drifting of
teeth (Figure 1).

Spacing between primary teeth is generally bene7cial and doesn’t need to be

closed. It not only provides ease of cleansing and reduces caries incidence, but, most
importantly, provides leverage to accommodate and offset the tooth size
discrepancy between primary and permanent dentitions. It also alleviates minor
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crowding of permanent teeth. Baume described two distinct types of arch form in
primary dentition, and approximately two-thirds of the primary dentition exhibited
generalized spacing known as Baume Type I. Those without spacing or with closed
proximal contacts were termed Baume Type II. Studies have shown a correlation
between amount of spacing in the primary dentition and severity of crowding in the
3,4
permanent dentition. If the child has more than 6 mm of spacing, crowding is less
likely to be observed in permanent dentition. If the spacing is between 3 to 6 mm,
there would be approximately a 20% chance that crowding will occur in the
permanent dentition. For those with less than 3 mm of spacing, the possibility of
crowding increased to 50%. If a child has no space in the deciduous teeth, crowding
of the permanent dentition would be highly likely (more than a 66% chance). With
existing crowding in the primary dentition, it would be almost certain that the child
will have crowding in the succedaneous dentition.
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To predict space availability, various space
analysis methods have been utilized —
such as Tanaka and Johnston, Nance,
Hixon and Oldfather Mixed Dentition
Analyses, and the Moyer’s method — that
are based on prediction tables, dental
casts and/or radiographs. Determinants
and variables that may affect available
arch space and lead to space issues
FIGURE 2. Naturally occurring spacing
include tooth size discrepancy, between primary teeth.
supernumerary teeth, ectopic eruption of
teeth, congenitally missing teeth, sequence and timing of tooth eruption,
premature loss of teeth, arch development, and interproximal dental caries.

Developmental spaces have been identi7ed in developing dentitions of children,

and were distinctive and categorized based on the anatomical position in the arch
(Figure 2). Primate space is a naturally occurring spacing between deciduous teeth.
In the mandibular arch, the primate space is observed between primary canine and
7rst molar. The primate space in the maxillary arch is located between primary
lateral incisor and canine. Other generalized spacing mesial to the primary canine
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and in between incisors is termed physiological space. The leeway space involves
posterior primary teeth and accounts for tooth size difference between primary and
permanent dentitions. It is the space to be preserved when primary teeth are lost
prematurely. The realization of leeway space occurs during the process of exfoliation
and eruption of succedaneous teeth in the mixed dentition and may relieve some
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crowding in the permanent dentition. The amount of available space is calculated
based on the difference between the sum of width of primary canine, primary 7rst
molar, and primary second molar and the sum of widths of their succedaneous
teeth; or (C+D+E) – (3+4+5) = leeway space. The leeway space derives from larger
mesial-distal anatomical dimension of primary molars compared to their
permanent successors or premolars (Figure 3), and stays the same from time of
eruption of the second deciduous molars until that tooth is lost. It is either saved via
space maintenance or lost due to mesial drifting of the 7rst permanent molar.  The
leeway space serves as the basis in the concept of passive space management in the
developing occlusion.
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 FIGURE 3. Space maintainer to preserve
leeway space.

MECHANISMS FOR PRESERVING SPACE

The best space maintenance is the one provided by natural teeth and is one of the
many functions of the primary dentition. Good oral hygiene practices, dietary habits,
and an effective caries prevention protocol are the fundamental and most ef7cient,
cost-effective methods of preserving the arch length and space. Hence, parental
education about the critical role that primary dentition plays and its effect on
permanent dentition should serve as a priority and basic element in space
management.

Early recognition and timely intervention

of dental disease and interproximal
dental caries can prevent space loss, as
teeth have a tendency to drift into
edentulous spaces and into damaged,
lost dental structure. Previous studies
have reported that the arch length could
be reduced due to carious breakdown of
dental structure, even in absence of
6,7 FIGURE 4. Space maintainer placement
premature loss of teeth. It was evident
immediately following tooth extraction.
that the mesial-distal width of teeth is
reduced due to extensive proximal caries and compromised by drifting of adjacent
teeth, and subsequent restorative procedures would be altered and modi7ed. The
placement of a stainless steel crown, for example, in such a situation may require
signi7cant adjustment, such as squeezing the mesial-distal dimension of the
prefabricated crown and reducing the mesial-distal width of the crown, which
otherwise would have 7t nicely on a prepared tooth without signi7cant adjustment.
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Shape of the restored interproximal surface of an intracoronal restoration may not
follow the physiological contour and may be concave due to chronic drifting of
adjacent teeth into the previous caries lesions. Restoring a primary tooth with dental
caries not only serves to restore the esthetic and physiologic form, it also prevents
space loss and preserves arch length.

The relationship between premature loss of primary teeth and space loss with
6,8
reduction in arch length has been well documented in the literature. The amount
of space loss accelerated and increased during the active eruption phase of
permanent 7rst molars. If the deciduous tooth is extracted before 6 years of age, the
loss is more signi7cant than those extracted after the eruption of the 7rst
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permanent molar, with the effect more signi7cant in the maxillary arch. Therefore,
an appliance to maintain space for the extracted primary teeth is crucial and should
be placed in a timely manner. If the leeway space is not preserved promptly, the
consequence could be costly and require orthodontic treatment to open and create
space for succedaneous teeth to erupt.

Management and preservation of space can be easily

accomplished with a passive appliance. For children, a
7xed appliance is preferred due to treatment
compliance. A variety of space maintainers is available,
and each appliance comes with speci7c indications
(Table 1) and limitations. A space maintainer should be
placed as soon as a tooth is lost or extracted (Figure 4).
A lengthy wait between tooth extraction and 7nal
cementation of the appliance may lead to tipping and
drifting of adjacent teeth, space loss, poor 7t, and
remaking of the appliance.  If feasible, consideration
should be given to fabrication of the appliance prior to
tooth extraction. The tooth to be extracted, if
FIGURE 5. 
5. Band and
asymptomatic, could serve as a natural space loop appliance.
maintainer until the extraction can be performed. With
the space maintainer available, the extraction could be performed immediately prior
to cementation of the space maintainer with glass ionomer cement. As a precaution
for the cementation of the appliance (especially when working with children), a
piece of dental koss should be attached to the space maintainer to prevent possible
aspiration of the appliance.
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COMMON SPACE MAINTAINERS
The most common space maintainer is the band and loop appliance, which held
space for single extracted tooth (Figure 5). Custom fabrication of a band and loop
appliance is a durable and precise means of preventing adjacent teeth from drifting
and tipping into the space. The band should 7t tightly, present some degree of
dif7culty to remove with digital pressure, and the occlusal portion of the band
should be placed below the marginal ridge of the anchor tooth to prevent
interference with occlusion. The loop is made with 0.036-inch orthodontic wire bent
into shape with three-prong plier and is extended and in direct contact with the
proximal surface of tooth adjacent to the space. The anchor tooth with band is
usually the 7rst permanent molar or the tooth distal to the empty space. However, if
the permanent molar is partially erupted and a band cannot be 7tted, a reverse
band and loop appliance could be an alternative option, with the band placed on
the primary 7rst molar and the loop extended distally. The band and loop appliance
is also available in a prefabricated form (Figure 6).

FIGURE 6. Prefabricated band and loop

appliance. COURTESY HELEN MO, DMD,
UNIVERSITY OF SAN FRANCISCO

In a situation in which the primary second molar is extracted and permanent 7rst
molar has not erupted adequately to serve as the anchor tooth, a distal shoe is
indicated for space maintenance and guidance of the unerupted permanent 7rst
molar into proper position in the arch (Figure 7). The blade of distal shoe would
extend through the gingiva to engage the mesial surface of the unerupted
permanent 7rst molar. The distal shoe appliance is also available in a prefabricated
form; however, the wire attachment may easily be dislodged upon mastication. A
chairside modi7cation with an electric spot welder has been shown to improve the
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clinical performance of the prefabricated distal shoe appliance. A radiograph
should be taken to verify the position and proper engagement of the distal shoe
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blade prior to 7nal cementation (Figure 8). The distal shoe appliance may not be
appropriate and is contraindicated in children who are medically compromised or
have systemic diseases, such as diabetes mellitus, hemophilia, a compromised
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immune system, or cardiac anomalies requiring antibiotic prophylaxis.

When multiple primary teeth are extracted or lost

prematurely, a bilateral 7xed appliance is the treatment
of choice and provides arch stability and space
preservation. A lower lingual holding arch appliance can
maintain arch length in the mandible (Figure 9). The
design consists of bands placed on the permanent 7rst
molars bilaterally and connected by a heavy lingual wire
circumferentially, resting on the cingulae of incisors
above the gingival margin. Omega loops near the
posterior section of the lingual wire are frequently
incorporated bilaterally into the appliance design for
adjustment and minor activation, if needed. One
criterion that should be met prior to fabrication of a
FIGURE 7. 
7. Distal shoe
appliance.
lower lingual holding arch appliance is that the
permanent incisors and permanent 7rst molars must
be adequately erupted. As the mandibular permanent incisors erupted lingual to
the deciduous teeth, an inappropriately placed appliance may hinder the eruption
of permanent incisors, trap the incisors ectopically, and pose as a potential obstacle
if it is placed prior to the eruption of permanent incisors. In this case, two band and
loop appliances may be the most appropriate treatment option.

For the maxillary arch, a Nance appliance and transpalatal arch appliance present
two options for bilateral 7xed appliances in children. The clinical indications for a
Nance appliance is similar to that of the lower lingual holding arch appliance, but
the eruption of incisors is not a factor to consider with a Nance appliance (Figure 10).
An acrylic button is incorporated anteriorly to provide contact with palate and
stabilization, as opposed to resting on the teeth. Although hygiene and cleansing
may be an issue, the Nance appliance is most effective in case of tooth loss
bilaterally in the maxillary arch. The transpalatal arch appliance presents a hygienic
alternative. Bands cemented to the maxillary 7rst permanent molars are connected
by a single heavy wire across the posterior palate (sometimes with an omega loop
incorporated into the midline portion of the wire) without contacting soft tissue The
appliance can prevent mesio-palatal rotation of the maxillary permanent 7rst molar.
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However, it has limited ef7cacy in preventing mesial tipping of molars. Therefore, a
transpalatal arch appliance should not be considered as the 7rst option for patients
with bilateral tooth loss in the maxilla.

Not all the cases of premature loss of primary tooth require placement of an
appliance to preserve arch length. Space maintainers may not be indicated when
imminent eruption of a succedaneous tooth is preceded by primary tooth
exfoliation. When the primary incisors are lost prematurely, no space maintainer is
indicated, and any appliance fabricated to replace deciduous anterior teeth is
mainly for esthetics. If the 7rst permanent molar is completely erupted and in stable
occlusion, the loss of deciduous 7rst molar may not warrant placement of a space
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maintainer. Park et al reported minimal change in available space for erupting
succedaneous premolars after premature loss of primary 7rst molars, provided the
permanent 7rst molars have already erupted and are in Class I molar relationship.
Conversely, if a deciduous second molar is lost prematurely, a space maintainer
appliance should be placed, regardless the state of permanent 7rst molars.

FIGURE 8. Con7rmation of proper

position and engagement of distal shoe
blade prior to 7nal cementation.
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 FIGURE 9. Lower lingual holding
arch appliance.

FIGURE 10. Nance appliance.

FOLLOW-UP MANAGEMENT
Once a space maintainer is placed, continuous follow-up and monitoring are
required. Detailed instructions should be presented to the parent/caregiver at the
insertion visit in order to avoid miscommunication and noncompliance. The need to
return for periodic evaluation and assessment of treatment should be emphasized.
If the appliance is defective or lost, a decision must be made to either repair or
replace it, or discontinue the appliance based on assessment and the state of dental
development and eruption of the permanent dentition. It is critical to inform
parents/caregivers that space maintainers should be evaluated at routine intervals,
and that appliance removal is necessary upon eruption of the appropriate
permanent tooth or teeth. The consequence of prolonged retention of space
maintainers may lead to undesirable complications, such as ectopic eruption of
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permanent teeth. Finally, if a space has been held by a distal shoe appliance,
replacement with a band and loop appliance may be indicated in the future,
following the eruption of permanent molars.

Daily oral hygiene practice may present a signi7cant challenge at times, as cleaning
is dif7cult around the bands and wires — but it is absolutely essential to maintain
good oral hygiene and healthy hard and soft tissues. Risks and bene7ts, potential
complications, and alternative treatment options should be discussed with
parents/caregivers prior to fabrication and placement of an appliance, especially if
the child has a debilitating medical condition, combative or cognitive issue, or
special needs.
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SUMMARY
The primary dentition maintains arch length and space for permanent teeth.
Restoration of carious primary teeth can prevent drifting and tipping of adjacent
teeth and space loss. Premature loss of a deciduous tooth may warrant placement
of a space maintainer appliance. Once the appliance is placed, clinical management
is not 7nished, and periodic evaluation and assessment are required until the
eruption of the permanent succedaneous tooth and removal of the appliance.

KEY TAKEAWAYS
One of the functions of the primary dentition is to preserve space for the
succedaneous teeth.
Leeway space involves posterior primary teeth and accounts for tooth size
difference between primary and permanent dentitions. It is the space to be
preserved when primary teeth are lost prematurely.
Good oral hygiene practices, dietary habits, and an effective caries prevention
protocol are the fundamental and most ef7cient methods of preserving the
arch length and space.
Space preservation can be easily accomplished through the use of passive
appliances.
Parental education about the critical role that primary dentition plays and its
effect on permanent dentition should serve as a priority and basic element in
space management.

REFERENCES
o. Setty JV, Srinivasan I. Knowledge and awareness of primary teeth and their
importance among parents in Bengaluru City, India. Int J Clin Pediatr Dent.
2016;9:56–61.
q. Vinay S, Keshav V, Sankalecha S. Prevalence of spaced and closed dentition and
its relation to malocclusion in primary and permanent dentition. Int  J Clin
Pediatr Dent. 2012;5:98–100.
r. Leighton BC. The early signs of malocclusion. Eur J Orthod. 2007;29:i89–i95.
s. Baume LJ. Physiological tooth migration and its signi7cance for the
development of occlusion. I. The biogenetic course of the deciduous dentition.
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 J Dent  Res. 1950;29:123–132.
t. Gianelly AA. Leeway space and the resolution of crowding in the mixed
dentition. Semin Orthod. 1995;1:188–194.
u. Northway WM, Wainright RL, Demirjian A. Effects of premature loss of
deciduous molars. Angle Orthod. 1984;54:295-329.
v. Northway WM, Wainright RW. D E Space–a realistic measure of changes in arch
morphology: space loss due to unattended caries. J Dental Res. 1980;59:1577–
1580.
w. Seward FS. Natural closure of the deciduous molar extraction spaces. Angle
Orthod. 1965;35:85–94.
x. Luzzi V, Fabbrizi M, Coloni C, et al. Experience of dental caries and its effects on
early dental occlusion: a descriptive study. Ann Stomatol (Roma). 2011;2:13–18.
oy. Brill WA. The distal shoe space maintainer chairside fabrication and clinical
performance. Pediatr Dent. 2002;24:561–565.
oo. Hicks EP. Treatment planning for the distal shoe space mainitainer. Dent Clin
North Am. 1973;17:135–150.
oq. Park K, Jung DW, Kim JY. Three-dimensional space changes after premature
loss of a maxillary primary 7rst molar. Int J Paediatr Dent. 2009;19:383–389.

Featured image by REANAS/ISTOCK/GETTY IMAGES PLUS

From Decisions in Dentistry. July 2018;4(7):13–14,17–18.

Brent Pen-Jen Lin, DMD

Brent Pen-Jin Lin, DMD, is a clinical professor in the Division of Pediatric Dentistry
and director for the predoctoral pediatric dentistry program at the University of
California, San Francisco (UCSF) School of Dentistry. Founder and director of the
Oral Health Alliance at UCSF, Lin’s awards and honors include the Pierre Fauchard
Excellence in Education Award in 2006 and the Mentor of the Year Awards at UCSF School of
Dentistry in 2009 and 2013. He can be reached at Brent.Lin@ucsf.edu.

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