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Space Management In Pediatric

Dentistry

                                                           

                                                        

Space Maintainers: Types And Indications

Appliance Construction

Long-term Evaluation And Significance

Photo Bank: Space Management

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Introduction To Space Management

Space management is an important responsibility of


the general dentist and the pediatric dentist.
Inadequate space management can cause problems
which are long lasting and severe. The premature loss
of primary teeth may cause loss of arch length,
resulting in crowding of the permanent dentition,
impaction of permanent teeth, esthetic difficulties,
malocclusion, and other problems. We recommend
prompt and appropriate space management therapies
For example, this panoramic radiograph shows the
to help insure optimal lifelong dental health.
premature loss of the mandibular right second primary
The purpose of this chapter is to describe space molar, resulting in the tipping of the first permanent
management therapies. We will focus on the various molar and consequent loss of space. This is an
types of space maintainers, when and how they are example of space loss which could have been
used, and how they are made. prevented if a space maintainer had been placed after
the primary tooth was removed.
Our coverage will center on maintaining existing
space once primary teeth have been lost prematurely,
rather than on tooth movement. For information
concerning the movement of teeth, we refer you to
current textbooks of orthodontics or minor tooth
movement

The best space maintainer is a primary tooth, as you


see demonstrated in this radiograph. When nature's This patient also has a missing mandibular right
best space maintainer is lost prematurely, we need to second primary molar, but a space maintainer will be
intervene and maintain the space for normal placed here, keeping the permanent molar from
development of the dental arches. drifting mesially. The critical importance of
maintaining the space of a prematurely lost primary
molar will be emphasized throughout the chapter.

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This photograph demonstrates a space maintainer placed on the
mandibular right first permanent molar using 0.036 stainless steel wire
soldered to an orthodontic band, with space being maintained for the
underlying bicuspid.

Types Of Space Maintainers space maintainer, and so forth. There are numerous
variations on these basic themes. For example, some
There are numerous types of space maintainers. They space maintainers are used for missing anterior teeth
range from the very simple to those with numerous and some are used to preserve space for posterior
bands and wires. They can be constructed differently unerupted teeth.
and used in different parts of the mouth. As we will
cover later, some even have parts extending into the The following pages will show the various types of
tissue. space maintainers.

We feel the best way to make sense of the numerous Fixed Bilateral Space Maintainer
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. This photograph shows an example of a fixed bilateral
space maintainer. The patient is four years of age. The
Unilateral space maintainers are fixed to one side of appliance is cemented on the two second primary
the mouth and bilateral space maintainers are fixed to molars. Fixed bilateral space maintainers on the
both sides of the mouth. Fixed space maintainers can mandibular arch often are called lingual arch space
be unilateral or bilateral. maintainers.

Space maintainers also can be placed on the Mandibular fixed bilateral space appliances generally
mandibular or maxillary arch. Consequently, we could are preferred by clinicians over removable space
have a maxillary removable bilateral space maintainers. Fixed appliances are easier to maintain
maintainer, or a mandibular fixed unilateral right side and they are less likely to be removed, damaged, or
lost by the child.

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Another lingual arch appliance for mandibular
bilateral space maintenance is shown here. In this
case, the appliance is attached to permanent
teeth.The mandibular lingual arch space maintainer
is used very commonly in the primary dentition and
the mixed dentit

on, where bands can be cemented to primary or


permanent molars respectively. This is one of the
most ubiquitously used space maintainers. It is even The same mandibular removable bilateral space
used on occasion in the permanent dentition when maintainer is shown outside of the mouth. Note the wire
attachments designed for the purpose of improved
bicuspids are missing and maintaining space is appliance retention
necessary prior to orthodontic and/or prosthetic
therapy.

Mandibular Removable Bilateral Space Fixed Unilateral Appliance


Maintainer

A mandibular removable bilateral space maintainer


is shown on a six year-old. This youngster
prematurely lost the mandibular right and left first
and second primary molars. The disadvantages of a
removable appliance are that it may not be worn by
the patient and it is more susceptible to breakage or
loss by the patient. To reiterate, most clinicians
prefer to place fixed space maintainers if possible.
This photograph shows an example of a fixed
unilateral appliance on the maxillary left side for a
seven year-old patient. The photograph demonstrates
the appliance after cementation. This appliance is
referred to as a band and loop space maintainer and
is a favorite among many clinicians.

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Fixed Bilateral Space Maintenance

The photograph presents a variation on the band and


loop space maintainer; a mandibular left crown and
loop space maintainer is shown. Note how the The photograph demonstrates another variation on the
stainless steel wire is soldered to the stainless steel bilateral use of fixed unilateral space maintainers. In
crown and the wire is bent so that it is adapted closely this case, a fixed unilateral band and loop space
to the tissue. The crown and loop space maintainer is maintainer was used on one side and a fixed unilateral
a type of fixed unilateral space maintainer where crown and loop space maintainer was used on the
stainless steel crown therapy was necessary on the other side. Crown and loop space maintainers can be
abutment tooth. used when a stainless steel crown is needed on a tooth
which also is an abutment for a space maintainer.

However, often band and loop space maintainers are


Bilateral Band And Loop Space used over stainless steel crowns. The rationale for
Maintenance using a band and loop space maintainer over a
stainless steel crown is that if the band and loop
appliance is no longer needed or if it fails, replacing
the stainless steel crown will not also be necessary.

REMOVABLE UNILATERAL SPACE


MAINTAINERS(ARE DANGEROUS)

This photograph shows two band and loop space


maintainers, an example of the bilateral use of fixed
unilateral band and loop space maintainers. These are
very common types of unilateral space maintainers,
and they often are used bilaterally.

These are examples of dangerous space maintainers.


They are removable unilateral space maintainers. We
believe removable unilateral space maintainers should
not be used. They are too small and present
swallowing and choking dangers for children.

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Distal Shoe Space Maintenance

The photograph shows a maxillary fixed bilateral


space maintainer. This type of space maintainer also is
This appliance is called a distal shoe space maintainer known as a Nance Holding Arch or a Nance
or a distal extension space maintainer. It is used to Appliance. Note the small acrylic button which will
prevent first permanent molars from moving mesially rest against the palatal tissue with this appliance.
with the premature loss of second primary molars. Some clinicians object to the button since it can create
The example shown is a crown with a distal extension tissue irritation. Therefore, it is important that patients
segment soldered to the crown. The distal segment is and parents be instructed to make sure that the patient
extended into the tissue against the unerupted first meticulously flosses under the acrylic button. The
permanent molar. The distal extension, also called a Nance Holding Arch is used in situations where
distal shoe, is used when the second primary molars premature bilateral loss of maxillary primary teeth has
are lost prior to the eruption of the first permanent occurred.
molars (i.e., very premature loss).
Prosthetics For Maxillary Anterior Teeth
Maxillary Removable Bilateral Space
Maintenance

The appliance demonstrated in this photograph is used


to replace missing maxillary anterior primary teeth.
Cases like this are discussed at length later in the
chapter and in the chapter covering pediatric
This photograph shows a maxillary removable
restorative dentistry (it is an example of a type of
appliance, in this case a maxillary removable bilateral
maxillary anterior prosthesis).
space maintainer. As suggested previously, removable
appliances are not commonly used because of
problems with the appliance not being worn and the
frequent incidence of breakage and loss.

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Clinical Indications For Space
Maintenance

Indications For Space Maintenance


Therapy

The following section of the space maintainer chapter


is focused on the various indications for space
maintenance therapy. This is a radiograph of a similar situation showing the
missing mandibular right second primary molar.
As you have gathered by now, there are numerous Again, is this a situation requiring placement of a
types of space maintainers. Each different space
space maintainer?
maintainer is used in different clinical situations.
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We will review an array of different clinical situations
relating to space maintenance therapy and give our
recommendations for each of these situations.
Hopefully, going through these clinical exercises will
result in an understanding of when space maintenance
is indicated and what type or types of space
maintainers might be used. We will attempt to cover
virtually every generic type of clinical situation
requiring space maintenance therapy which clinicians
will encounter in the primary and mixed dentitions.

Yes; a space maintainer is indicated in the situation


described in the previous pages for this four year-old
child, as demonstrated by the drawing in red.

In this drawing, the mandibular right second primary


molar is missing on a four year-old child. In your
judgement, is this child in need of a space maintainer?

This radiograph shows the placement of a distal shoe


space maintainer extending to the mesial surface of
the unerupted first permanent molar. The distal shoe
space maintainer is intended to prevent the first
permanent molar from erupting in a tipping manner
over the underlying premolar

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This photograph demonstrates stainless steel crowns
on the cuspid and the first primary molar, with a distal
bar extending into the tissue, thereby preventing the
first permanent molar from tipping mesially over the
underlying premolar.
This photograph shows the band and loop space
maintainer which has been used to replace the distal
shoe appliance. It is advantageous to replace the distal
shoe, which extends under the tissue and is less
hygienic than a band and loop space maintainer.

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
This is an example of a distal shoe space maintainer the technical difficulties associated with the
which has been successful in directing the eruption of placement of distal shoe space maintainers. The point
we make repeatedly in discussions concerning pulp
the first permanent molar. However, since the first
therapy is that it is best to save second primary molars
permanent molar has now erupted, the existing distal using primary endodontic therapy (i.e., pulpectomy)
shoe appliance should be removed and a band and when first permanent molars have not yet erupted.
loop space maintainer can be placed. 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.

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The distal shoe space maintainer can be placed at the In this drawing, the mandibular right first primary
time of extraction of the second primary molar. If this molar is missing on a six year-old child. In your
approach is used, the impression must be taken and judgement, is the child in need of a space maintainer?
the appliance constructed prior to extraction of the
If so, would you use a removable or a fixed space
primary tooth. The advantage is not having to go back
at a later time and surgically make an incision for maintainer?
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 As you see demonstrated in red, a space maintainer is
not using a space maintainer at all. Unfortunately, indicated to prevent mesial movement of the second
distal shoe space maintainers sometimes are not used primary molar. A band and loop space maintainer is
when a child's behavior makes it unlikely that
placement of the appliance at a second appointment the best choice. It is especially important to start space
would be successful. Of course, when distal shoe maintenance therapy prior to the eruption phase of the
space maintainers are not used, the development of first permanent molar, since the force of eruption of
space problems results. the permanent molar will exert a lot of pressure to
push the second primary molar forward. The eruption
Consequently, placement of distal shoe space phase of the permanent molar is the time of greatest
maintainers can be planned as one appointment or two
force exerted against the primary molar.
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.

For safety reasons, we recommend that you never use


a removable unilateral space maintainer. If they are
dislodged, they are so small that they can become a
swallowing or choking danger.

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In this drawing, the mandibular right and left first The lingual arch appliance, as demonstrated in the
primary molars are missing on a four year-old child. photograph, would be the appliance of choice for
In your judgement, is the child in need of a space some clinicians in a situation where both primary first
maintainer? If so, would you use a removable or a molars have been lost in the primary dentition. The
fixed space maintainer? bilateral appliance is very stable since it is anchored to
two teeth.

Another example of a lingual arch appliance designed


for the primary dentition is shown in the photograph.
Space maintenance is necessary to hold the second
The major disadvantage to the use of a lower fixed
primary molars in position, especially as the first
bilateral lingual arch appliance in the primary
permanent molars erupt and create forces which dentition is the potential for permanent incisors to
otherwise would move the primary molars forward. erupt later behind the lingual arch wire. In these cases,
Bilateral band and loop space maintainers can be the appliance must be remade or bilateral fixed
used, as outlined in red. The bilateral band and loop appliances can be placed. Some clinicians anticipate
strategy is our preferred approach, for reasons which this potential problem and place bilateral band and
will be explained later. loop appliances in the first place, so that interference
with the eruption of mandibular incisors definitely can
be avoided.

We believe that most experienced practitioners would


select bilateral band and loop appliances in situations
where both lower first primary molars have been lost
and before the eruption of the mandibular permanent
incisors has occurred. This approach will prevent later
problems with permanent incisors erupting behind the
lingual wire.

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Nevertheless, the fixed bilateral lingual arch has the
advantage of being a very stable appliance because of
its two abutments. Many clinicians prefer it for that
reason.

Both are very acceptable approaches, and the choice


of a fixed lingual arch appliance or bilateral fixed
band and loop appliances is left to the preference of
the individual clinician.

Removable bilateral appliances are not the best


therapeutic choice, especially for children in the
primary dentition, although it is technically feasible to
In this drawing, the maxillary right first primary
use them. The biggest problem is that children in the
primary dentition age group are very unreliable when molar is missing in this six year-old child. In your
it comes to taking care of removable appliances, and judgement, is the patient in need of a space
the appliances are apt to become lost or damaged. maintainer? If so, would you use a removable or a
fixed space maintainer?
Of course, unlike the removable unilateral appliance,
the removable bilateral appliance is too large to be a
serious swallowing or choking danger.

A unilateral space maintainer is needed, as shown in


red. Otherwise, the maxillary right second primary
molar will drift mesially, thereby losing space. Once
This is an example of a lingual arch wire which was again, space loss will be especially severe if space
placed before eruption of the permanent incisors, and maintenance is not used during the active phase of
a permanent incisor has erupted behind the wire. This eruption of the maxillary right first permanent molar.
problem can be avoided when band and loop space The time of active eruption is commonly referred to as
maintainers are used before the eruption of the the dynamic phase of eruption
permanent incisors.

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space maintainer is an erupting first permanent molar.
The dynamic phase of eruption is occurring, and this
is when space maintenance is the most crucial.

In this drawing, the maxillary right and left first


This photograph shows the use of a band and loop primary molars are missing in this six year-old child.
space maintainer for this type of situation. Note that In your judgement, is the child in need of a space
the maxillary right first permanent molar has not fully maintainer? If so, would you use a removable or a
erupted. That is, it still is in the active phase of fixed space maintainer?
eruption. It is especially necessary for a space
maintainer to be used during this dynamic phase of
eruption.

Space maintenance is indicated in the situation shown


in the drawing. As demonstrated in the drawing, one
solution is to use a Nance Appliance or a Nance-type
maxillary fixed bilateral appliance.

This photograph demonstrates the same principle,


when a unilateral fixed space maintainer is needed on
the maxillary right side. In this case, stainless steel
crown therapy was needed on the second primary
molar. Therefore, a crown and loop space maintainer
A Nance Appliance designed for the primary dentition
was used. Please note that distal to the crown and loop
is shown in the photograph.

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In this drawing, the maxillary primary central and
lateral incisors are missing in this four year-old child.
In your judgement, is the child in need of a space
The drawing demonstrates another approach, where maintainer? If so, would you use a removable or a
two fixed unilateral space maintainers are used (band fixed space maintainer?
and loop space maintainers). The choice of whether to
use a maxillary fixed bilateral appliance or two fixed
unilateral appliances is left to the preference of the
clinician. As we have emphasized, fixed space
maintainers are almost always preferred over
removable appliances, although a removable bilateral
appliance could be used in a situation like the one
shown in the drawing.

What is your recommendation for a case like this?


The patient is age three and has multiple missing
maxillary teeth.

A decision of whether or not to replace multiple missing


maxillary primary teeth involves some potential
controversy. Some clinicians prefer to replace maxillary
anterior primary teeth in patients when more than one tooth
is missing, and when it will be more than six months
before eruption of permanent central incisors. This
assumes the child's behavior is acceptable.
This photograph demonstrates two maxillary fixed
unilateral space maintainers. A band and loop space Their reasoning is that the presence of replacement teeth
maintainer is shown on the patient's right side and a will hold the tongue in a better position. In this way, the
development of a tongue thrust is less likely. We are aware
crown and loop space maintainer is shown on the left. of no well validated empirical research which actually
The choice of whether to use a band and loop demonstrates an association between missing primary
appliance or a crown and loop appliance will depend anterior teeth and the development of tongue thrust.
partly on the restorative needs of the underlying teeth. Nevertheless, replacement of multiple missing primary
maxillary incisors is standard practice for some
As mentioned earlier in the chapter, it also is practitioners as a precaution. We cannot identify any
acceptable to use a band and loop space maintainer serious risks to this approach, and it may indeed turn out
over a stainless steel crown. Please note, once again, to be a useful strategy as research provides more
in this photograph the maxillary left first permanent information on the topic of tongue thrust
molar is in the dynamic eruption phase. development.

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Of course, many parents applaud the procedure
because of the improved esthetics.

There also are many pediatric dental offices and many


dental schools where multiple missing primary
anterior teeth are not replaced, at least routinely.
Space loss usually is not a consideration, and
monitoring for that problem can be used to insure that
it does not occur. Most third party carriers also will
not cover the prosthetics procedure (i.e., insurers will
not reimburse you for the procedure and it will be an
out-of-pocket cost for the parents). A palatal view of the same appliance is shown in this
photograph. As you can see, the appliance is based on
the principle of banding posterior teeth and attaching
prosthetic teeth to a wire running between the bands.
It is a maxillary fixed bilateral appliance

As you can see demonstrated in red, a prosthetic


appliance could be placed in this situation.

The photograph demonstrates another example of a


maxillary fixed bilateral anterior prosthesis.

For those who opt to provide treatment in these


situations, an excellent final result can be obtained, as
shown in the photograph.

Although we almost always prefer fixed appliances,


removable appliances can be used in situations where
maxillary primary anterior teeth are prematurely lost.
In this case, a removable appliance is shown where
the primary central incisors are replaced.

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Prior to this juncture, our clinical situations have
involved the primary dentition. Now we are going to
move into the mixed dentition. In this drawing, the
mandibular right second primary molar is missing on
a nine year-old patient. The first permanent molar is
present and fully erupted. In your judgement, is the This is an example of the situation seen in the prior
child in need of a space maintainer? If so, would you drawing. The second primary molar has been lost and
use a removable or a fixed space maintainer? the first permanent molar is

present.

As shown in the drawing, a space maintainer is


needed in this situation to prevent the bodily mesial
This photograph demonstrates the same case shown
migration and/or tipping of the first permanent molar.
earlier. A fixed unilateral band and loop space
A removable unilateral appliance would be an unwise
maintainer has been placed. You will note also that
choice.
the amalgam was removed from the permanent molar
and a composite restoration was placed, and a
stainless steel crown was placed on the first primary
molar (in place of a very large amalgam).

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This is a space maintainer which is similar to the one
shown previously. Please note the occlusal rest designed Space management is indicated in this patient to
on the loop wire. This is placed to prevent the mandibular prevent the mandibular first permanent molars from
right first permanent molar from tipping and causing the tipping or moving mesially. A fixed bilateral lingual
wire to imbed apically in the tissue distal to the first arch space maintainer could be used, as shown in the
primary molar. Thus, the occlusal rest helps prevent the drawing.
tipping motion of the first permanent molar.

Right and left side fixed unilateral band and loop


A closer view of the same occlusal rest is shown in space maintainers also could be used, as shown in the
this photograph. drawing. Nevertheless, we believe most clinicians
would select the fixed bilateral lingual arch
appliance since the permanent lower incisors
already are fully erupted. However, both the fixed
bilateral and the fixed unilateral approaches are
acceptable. Removable appliances can be used more
successfully as children grow older. Nevertheless,
even with older children, the loss and damage rate for
removable appliances is high.
In this drawing, the mandibular right and left second
primary molars are missing in this nine year year-old
patient. In your judgement, is the patient in need of
space management? If so, would you use a fixed or
removable appliance?

A lingual holding arch designed for the mixed


dentition is shown in the photograph.

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In this drawing, the maxillary right second primary In this drawing, the maxillary right and left second
molar is missing in this eight year-old patient. In your primary molars are missing on this ten year-old child.
judgement, is the child in need of a space maintainer? In your judgement, is the child in need of a space
If so, would you use a removable or a fixed space maintainer? If so, would you use a removable or a
maintainer? fixed space maintainer?

A space maintainer is indicated in this situation, as The patient needs bilateral fixed space maintenance to
shown in red in the drawing. A fixed unilateral band hold the permanent molars in place.
and loop space maintainer is an appropriate choice. It
will prevent the maxillary right first permanent molar
from moving forward, which would result in a loss of
space for the unerupted bicuspid. A removable
unilateral appliance would not be used because of
swallowing and choking risks, even for older children.

An example of a maxillary removable appliance


designed to hold the first permanent molars in place is
shown in the photograph.

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Appliance Construction be banded and selecting a band from the box of bands
which appears to be the appropriate size for that tooth.

Once a decision is made regarding what type of


appliance is needed and how it is to be used, the next
phase of the space maintenance protocol involves
creating the appliance. Four steps are involved in
fixed appliance therapy: 1. Fitting the bands, 2.
Impression taking, 3. Appliance fabrication, 4.
Cementation.

In the case of removable appliances, impression


taking is the first step since bands will not be used.

Occasionally we discover that the contacts between


the teeth are so tight that separating elastics are
Fitting The Bands necessary before the bands can be placed.

Selecting And Fitting Bands

The separating elastic is situated between the teeth


where the band will be placed. One of the easiest
methods of elastic placement is to use two threads of
dental floss in order to hold the elastic. Next, gently
"saw" the elastic between the teeth. Ideally, the elastic
can be placed a few days before the band fitting
The first step in the process of appliance fabrication is appointment. If that were not possible, elastics could
selecting and fitting the bands. A trial and error be placed at the same appointment. When both steps
method is used by most clinicians when selecting are planned for the same appointment, better
bands for an appliance. This is accomplished by separation will result if at least fifteen or twenty
estimating the proper size of band needed. The minutes is scheduled between elastic placement and
estimation is done by examining the tooth which will the band try-in.

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The first step in the placement process is carrying the The advantage of using a tongue depressor is that the band
band to the tooth and placing it on the tooth with is almost never crushed during placement. Please note that
finger pressure. Further placement of the band can be the authors are using a dentoform for this series of
done by pushing with a tongue depressor or the photographs, to make it easier for the viewer to see the
handle of a band seater. The patient can be asked to process.
bite on the tongue depressor or handle of the band
seater to push the band further apically.

The handle of a band seater also is a convenient instrument


to use to push the band into place.

Some clinicians use a tongue depressor to aid in


pushing the band down over the tooth. You can ask
the patient to bite gently on the tongue depressor and
the band is pushed down. HELPFUL HINT: As
shown in the photograph, sometimes a tongue
depressor which has been broken in half can be used
more effectively than an unbroken tongue depressor,
since the broken tongue depressor is smaller and
easier for the child to bite on.
If the band is too large, it will be too loose a fit. If it is too
small, the band will not go down over the tooth. We
usually consider a nicely adapted band to be one that is
placed on the tooth with some resistance and one which
cannot be lifted off with finger pressure. We remove and
place various bands until we obtain one which has a good
fit.

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are desired, so that washout of the cement is less
likely to occur.

Usually a band seater is used for further adaptation


after initial placement. Please note how the band
seater is placed on the tooth prior to having the patient
bite down on the seater. Band seaters come in circular Note the use of band removal pliers. These are used
and triangular shapes. CAUTION: If you use the during the placement and fitting process to remove
triangular seater, it is important not to place it next to bands. Of course, the same band removers are used to
the band in such a way that the patient can remove space maintainers when necessary in other
inadvertently drive the triangular piece into the cusp clinical situations, for example when they are no
of the tooth. This may fracture the cusp. longer needed due to eruption of permanent teeth.

A band pusher may be used for the final step in Note that the top jaw of the pliers is placed on the
adaptation of the band. It is used to push the band occlusal surface of the tooth and the bottom jaw rests
against the tooth if a space remains between the band under the gingival margin of the band. When the
and the tooth. Tightly placed and well adapted bands pliers are squeezed the band moves occlusally off the
tooth.

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Impression Taking however, trays can be used or a "free-hand" (trayless)
technique can be used.
Our purpose in this subsection is to cover impression
taking techniques involved with space maintainer
appliances. Once the bands have been fitted to the
teeth, an impression is taken.

The two impression materials most commonly used in


pediatric dentistry for space maintainers are alginate
and compound.

Alginate is indicated primarily when removable


appliances are being made. And as you know very
well by now, removable space maintainers are rarely We will start with a demonstration of impression
indicated and seldom used in pediatric dentistry. taking for fixed bilateral space maintainers, using a
full arch tray technique. The following series of
We will focus on impression taking with compound. photographs, taken by using a typodont, show the
Compound is an excellent impression material, compound impression technique used in our practices.
especially for fixed appliances. In particular, it is Please notice the necessary armamentaria, a hot water
accurate and stable, and you will see how these bath, full arch tray, and compound.
qualities make it highly suitable for taking
impressions for space maintainers as we proceed
through the chapter.

Of course, alternative materials can be used. If you


use other materials successfully and/or if your office
routine is set up for other materials, by all means
continue to use them. The most critical feature for an
impression taking material for space maintainers is
accuracy in obtaining the band registration around the
tooth.

Although we like compound when taking impressions The first step is softening the compound in the hot
for space maintainers, we are fully aware that many water bath.
clinicians prefer alginate because of their familiarity
with this material. Consequently, the impression
material of choice is left to the preference of the
individual.

For purposes of this presentation, we will cover


compound impression taking techniques for
impression taking for both fixed bilateral and fixed
unilateral appliances. We also emphasize these two
techniques since they provide an opportunity to
demonstrate two alternative impression taking
procedures: taking impressions with and without
impression trays. For bilateral impression taking, trays The warm, pliable compound is placed in a child's
are always used. For unilateral impression taking, size tray and warmed again if necessary.

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registration in the compound material. This is one of
the significant advantages of compound material - the
bands can be placed back into the impression material
in exactly the correct place before pouring with stone.

Compound is the impression material of choice


because of its ease of use, its accuracy, stability, and
tolerance by the child. Many dentists simply send the
compound impression to the laboratory with no worry
about dimensional changes in the impression. The
bands can be placed nicely and easily in the
After heating, the impression tray material can be impression. Usually, a highly identifiable ring can be
cooled until it reaches the correct consistency and seen in the impression material around the teeth where
temperature. The essential consideration is to insure the occlusal aspect of the band has registered in the
that the material is warm enough to flow but is compound, and the bands are placed in the
sufficiently cool so not to burn the child. Having the indentations made by the bands from the mouth.
patient stick out their tongue and touch the material is
one method of insuring that the material has cooled
satisfactorily.

The tray can then be placed in the child's mouth.


Individuals who are new to compound may believe
that it might be difficult to remove the compound
impression from the teeth because of hard compound
setting in the undercut areas. This is not a problem,
and experience with the material will bear this out for
individuals who use compound for the first time. This photograph demonstrates the bands placed in the
compound impression. Because the compound
The compound material needs to be pliable, but not material is firm the bands are mounted on a stable
runny or it will take too long to set up. Ideally, the base. Nevertheless, it is often useful to heat tack the
impression should be withdrawn after ten to fifteen bands into the impression material before pouring.
seconds because children tolerate short impression HELPFUL HINT: Keep the heat tack area away from
times much better. A steady stream of air accelerates the area where you will be placing the solder joints.
the set of the compound once it is inserted.

The photograph shows the cast with bands in the


A photographic enlargement of the impression area
correct position waiting for construction of the space
around one of the banded teeth is shown to
maintainer, in this case an anterior fixed bilateral
demonstrate that it is possible to see clearly the band
prosthetic appliance
.

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The major potential problem with this appliance
This prosthetic appliance is discussed earlier in the involves eruption of the maxillary anterior permanent
chapter and in the restorative chapter, so let's go ahead teeth, since the appliance obviously will interfere with
and review how it is completed. After the impression, their eruption.
it is important to remind the laboratory to leave some
spaces between the anterior primary teeth if the It is very important to stress with the parents that
patient presents with that appearance, as was done bringing the child in for regular recall appointments is
with this patient. absolutely necessary so that the appliance can be
removed before it interferes with the normal eruption
of permanent teeth. Of course, the dentist must be
aware of the timing when the different teeth can be
expected to erupt. An anterior radiograph also can be
used for more accurate prediction of when the
permanent teeth can be expected to erupt.

The previous impression taking technique involved


the process used for a fixed bilateral space maintainer,
A larger view of the final result is shown in the and an impression tray was used. What was described
photograph. Most parents are very appreciative of the is the standard compound impression technique for
improvement. fixed bilateral space maintainers, whether they are
lingual arch appliances, Nance Appliances, or anterior
prosthetic appliances.

The next procedure we will describe is a technique for


taking impressions for unilateral space maintainers,
which we will call the nontray technique, where the
impression is taken without an impression tray.
Naturally, it is possible to use impression trays for
impressions for unilateral appliances, and many
clinicians take this approach using half-arch
impression trays. The impression taking process using
the half arch tray is the same as for taking a full arch
Let's look at the appliance again. The teeth are banded impression which we just described. The choice of
with the wire running anteriorly. The teeth are acrylic. whether to use a half arch tray or the alternative
There are other designs which are acceptable; but this technique without a tray is left to the preference of the
is one of the more common. practitioner.

Can you think of any potential problems with this


appliance?

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This photograph shows an impression after it has been
We will discuss the nontray technique in detail, since removed. Please look carefully at the quality of definition
it is a viable approach and has the advantage of of the impression of the band in the compound. Do you
eliminating the paraphernalia of the tray. It also may feel that the impression is of satisfactory quality? It is not.
be interesting to some readers since the technique is It could be difficult to place the band in the impression
not taught or used in many dental schools and hospital accurately. In these cases, it is important to take another
centers. impression

Do you believe that the definition in this impression is


satisfactory? Yes; it is. This photograph demonstrates an
impression with excellent definition, where the stainless
steel band can be placed in the compound securely and
For the nontray technique, of course, no tray is used.
accurately.
You merely use the same compound material and the
same technique for warming the compound. However,
the amount of material used is approximately the size
of a large thumb. It is taken to the patient's mouth,
molded with the fingers, and held in place for ten to
fifteen seconds. Just like the tray technique discussed
earlier, the impression can be air dried and removed.
This photograph shows the amount of warmed
compound material to be used prior to placement in
the mouth.

It is important to have good definition of the impression in


order to properly place and adapt the band so it will not
move when the impression is poured with a stone or plaster
material. Still, we usually heat tack the band to the
compound material once it is placed, which makes it
very unlikely that the band will become dislodged or
float during the pouring process.

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This frame demonstrates the band in place, prior to The impression is poured with stone. Once the stone
pouring-up with the stone or plaster. Notice how is set, the poured impression is placed in the hot water
nicely the band fits into the registration of the band in bath and the cast is retrieved from the warmed
the compound. The accuracy of the compound makes compound. When the cast is retrieved, you will want
this possible. to trim any excess stone from the cast and especially
around the band
.

Appliance Fabrication Whether you use a laboratory or make the appliance


yourself is a matter of personal preference. We have
included instructions regarding how we construct
Laboratory Fabrication Of The appliances for those of you who will be involved in
Appliance appliance construction.

The next step in the process is appliance fabrication. We will continue with the fixed unilateral space
maintainer as our instructional example of appliance
Many family dentists and pediatric dentists employ a construction.
dental laboratory to fabricate their space maintainers.
This is a completely satisfactory approach, assuming
the dental laboratory is able to follow your
instructions appropriately and produces appliances of
good quality.

It is even possible to have the laboratory come into


the picture at various stages during the space
management process. For example, you could send
the laboratory the compound impression. One of the
major advantages of compound impression material is
that it is stable. It does not undergo distortion before
the pouring process. In this way, the laboratory will This photograph demonstrates using a pencil to sketch
do the pouring and the appliance construction. the outline where the wire will be adapted to the stone
model
You could also send the cast to the laboratory and
they can construct the appliance using the cast that
you have poured.

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This photograph shows the pencil adaptation where This photograph demonstrates the wire as it has been
we want the wire to be bent to the cast. Please note adapted to the cast. It should be emphasized that the
how the outline of the drawing is wide enough so the wire needs to be adapted close to the tissue so that it
wire loop will be large enough bucco-lingually to will be comfortable for the child. The wire should be
allow the bicuspid to erupt between the buccal and adapted in close approximation to the tissue, but not
lingual segments of the wire. touching the tissue, so that the tongue can not get
under the wire and cause irritation. It is necessary for
the wire to be adapted closely to the band to produce a
strong but not too bulky solder joint.
Allowing space for the eruption of a bicuspid, as
represented on this case, reinforces a very important At this point, the adapted wire can be anchored to the
point. cast so that it can be soldered to the band. We use
compound or sticky wax to heat tack the wire to the
WHATEVER APPLIANCE YOU ARE cast; and then we follow-up by pouring a thin mix of
PLANNING, ALWAYS MAKE SURE THAT fast-set stone to the wire and the cast as the final
YOU ANTICIPATE HOW THE PERMANENT anchorage step. It is important to keep both the sticky
TEETH WILL BE ERUPTING AND MAKE wax and fast-set stone clear of the areas of the solder
ALLOWANCES FOR THOSE joints, so that those materials do not interfere with the
DEVELOPMENTS. joints. Once the wire is anchored to the cast, check to
make sure that its placement is satisfactory. At this
It is essential to construct the space maintainer so that point, the wire is soldered to the band using either an
it does not interfere with the normal eruption of electric soldering technique or a flame soldering
permanent teeth. technique

Of course, it goes without saying that space


maintainers should be constructed so they do not
interfere with normal functions, or at least as little as
possible. Wires and any other parts of space
maintainers should be planned so that they do not
interfere with eating and speech. HELPFUL HINT:
Always to check to make sure that the child can close
his or her mouth normally after placement of an
appliance.

Various wheels are used for polishing bands, wires,


and solder joints. The particular choice of polishing
vehicle is a matter of individual preferenc

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Fabrication Of The Single Appointment determined and adjusted. Once the wires from the
Preformed Space Maintainer loop are placed in the tubes, the loop and tubes can be
crimped together.

We will use this opportunity to discuss fabrication of


the preformed (i.e., prefabricated) band and loop
space maintainer. The preformed band and loop space
maintainer is used by many clinicians since the
appliance can be completed and placed in a single
appointment. The tooth is extracted and the preformed
space maintainer is cemented in place at the same The crimping pliers for the preformed band and loop
visit, after fitting and fabrication of the appliance at space maintainer are shown in the photograph.
chairside. Using preformed space maintainer
appliances eliminates all laboratory work and allows
placement of appliances at the same appointment
when the surgery is done.

The photograph demonstrates how the crimping is


accomplished using the crimping pliers to crush the
tube and wire together. Please note that some
clinicians also solder one arm of the preformed
Note that the preformed band and loop space appliance to obtain a stronger attachment of the tube
maintainer has female and male units. The tubes and wire. This additional safety measure makes it
attached to the orthodontic band receive the wire loop more unlikely that the preformed appliance will come
which will abut to the adjacent tooth. The wire loop apart in the mouth and present a swallowing danger.
can be cut so the mesiodistal space requirement can be

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swallowing danger. In this photograph, note that the
buccal tube and wire have been soldered together for
more secure retention.

The completed preformed band and loop space


maintainer is shown. Note where the female and male
units come together. The tube is crimped to secure the A preformed distal shoe space maintainer is shown in
male unit to the female unit. It is a tube and wire the photograph. Many clinicians prefer to use a
appliance. customized band and loop appliance for most cases.
However, many of these same clinicians prefer to use
a preformed distal shoe appliance because of its
relative ease of fabrication and the fact that a one
appointment procedure is involved. Opting for a one
appointment procedure will avoid a second local
anesthetic administration and the difficulty of seating
a customized appliance so it fits securely against the
unerupted first permanent molar.

Preformed band and loop space maintainers also are


configured with occlusal rests, which can be adapted
at chairside.

The photograph shows an example of a customized


distal shoe space maintainer, which is attached to a
stainless steel crown. An appliance such as this
obviously is much more difficult to fabricate and
place than a preformed distal shoe space maintainer. It
Please note that some clinicians also solder one arm also represents the absolute highest standard of
of the preformed appliance to obtain a stronger customized care. Nevertheless, if the customized
joining of the tube and wire. This additional safety approach is not practical given all the circumstances, a
measure makes it more unlikely that the preformed preformed appliance certainly is better than no
appliance will come apart in the mouth and present a appliance

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Cementation The traditional choice, zinc phosphate cement, has
been used for decades and still is used by many
Cementing The Appliance In Place practitioners. It is a satisfactory material. It stores
well, is easy to mix, and is well tolerated by patients.
The next phase in the process is cementation of the
appliance. There are several important fine points The glass ionomer cements, however, have gained
related to the cementation phase of space management huge popularity over the last decade. They also are
therapy. easy to mix and are well tolerated by patients. In
addition, glass ionomers release fluoride, are
First of all, place the space maintainer in the mouth technique forgiving if isolation from oral fluids is less
for a trial fit before you attempt cementation. It should than perfect, and are very insoluble. Their lack of
fit like it does on the cast. Check to make sure that the solubility is perhaps their most important advantage,
wire of a band and loop space maintainer is in light since practitioners encounter less recurrent decay
contact with the tooth which is mesial to the around and underneath bands. Bands rarely come off
edentulous space. With the wire in contact, you are when glass ionomer cements are used, especially if
sure tipping will not occur. In the case of a Nance the bands are tight fitting to begin with.
Appliance, check to make sure that the acrylic button
is in very gentle contact with the palatal tissue. You will start cementation phase of the procedure by
isolating the tooth to be banded. Isolation can be
Also check for large voids or spaces between the band obtained with cotton rolls. The tooth then is air dried.
and the tooth. If any are present, carefully use an The tooth should be slightly moist (not desiccated).
instrument to push (burnish) the band to the surface of
the tooth. In some cases, this step can be The cement can be mixed according to the
accomplished on the cast. manufacturers instructions. However, if you mix the
cement so that it is sufficiently viscous, it will adhere
Finally, make sure the child can occlude normally to the inside of the band during placement and
before you cement the space maintainer. It is a major cementation and not cause difficulty by "running all
interruption to be forced to remove a space maintainer over." Some clinicians stick a small section of
after it has been cemented because it interferes with masking tape over the band to prevent escape (i.e.,
chewing. "running") of the cement. This technique is fine if it
works well for you. However, a slightly thicker mix
In the case of unilateral space maintainers and of cement will prevent escape of the material in the
children who have extremely vigorous gag reflexes, first place.
you will want to consider running floss through the
wire loop so that the space maintainer cannot be Once the appliance is cemented in place, remove the
swallowed. A unilateral space maintainer possibly excess cement. One other advantage of the newer
could be lost down the throat of a gagging, choking generation cements is that they are much handier
child without the protection of the floss. when it comes to cement removal than the older
generation cements.

Have the patient bite together one last time to insure


The next step is the actual cementation of the that the appliance is not interfering with the occlusion.
appliance. Probably the most interesting issues related
to cementation of space maintainers concern the It also is a good idea to show the appliance to the
continuing development of new cements. parent. Emphasize the importance of keeping the area
clean. At this time, you can mention any potential
issues about the space maintainer that you choose, in

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addition to re-emphasizing the importance of hygiene. Although this cementing material is still commonly
For example, soreness for approximately twenty-four used, more and more dentists now are using glass
hours can occur. The child should avoid "playing" ionomer cements. Glass ionomer cements have the
with the appliance with the tongue, which also can advantages of fluoride release, excellent handling
cause soreness (of the tongue). Temporary speech characteristics, low solubility, and good adhesion.
changes can occur with some appliances (especially
Nance Appliances), but it is important to emphasize
that the changes are temporary. In very unusual cases,
short-lived sleep changes can occur, but once again
these problems are transitional (and indeed very rare).

Many clinicians appoint patients who have had space


maintainers placed for a quick check-up visit after
approximately two-four weeks

This frame shows the cementation of a band and loop


space maintainer with glass ionomer cement.

This photograph demonstrates the cementation of a


band and loop space maintainer with zinc phosphate
cement.

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Long-term Evaluation And Significance
Monitoring And Removal

Ongoing Monitoring And Evaluation Of In Place


Appliances

This photograph shows a lingual arch space


maintainer with the teeth erupted. The appliance
should be removed.
This photograph demonstrates a tooth partially
erupting between the wires of a space maintainer.

A radiograph of a band and loop space maintainer is


shown here. The space maintainer can be removed at
this point.
This photograph demonstrates substantial eruption of
a tooth between the wires of a space maintainer.

This photograph demonstrates a situation where a


crown and loop space maintainer had been resting
This photograph shows a case where the tooth is against the primary cuspid. The primary cuspid has
almost completely erupted in a space maintainer. The exfoliated. It is time to remove this space maintaine
space maintainer can be removed at this time.

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Conclusions And Significance

The best space maintainer is a well maintained primary tooth. But when these important natural space maintainers
are lost, it is essential to implement a space management strategy. Appropriate space management therapy can save
a child from esthetic disfigurement and save a family thousands of dollars in later orthodontic costs.

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A Quick Self Check
This is a quiz at the end of chapter designed to give you a barometer of how well you understand the concepts
covered in this chapter

1- The patient is a five year-old child with acute pain associated with tooth #K. What is your preferred
choice of therapy for tooth #K? The patient is very cooperative and is able to tolerate long appointments.

A. Pulpotomy
B. Primary endodontics (pulpectomy)
C. . Incision and drainage
D. . Extraction

2- Regarding the patient in the previous question, if tooth #K were extracted, what type of
space maintainer would be needed?
A. Band and loop space maintainor
B. Distal shoe space maintainer (fixed)
C. Distal shoe space maintainor (removable)
D. Crown and loop space maintainor

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3- What type of space maintainer would you choose for the patient shown in the radiograph?
The patient is a male, age nine. Your examination shows that all teeth normally present on
the patient's right side are present.

A. Nance Appliance
B. Bilateral fixed lower holding arch
C. Bilateral removable lower space maintainor
D. Band and loop space maintainor

4- Regarding the patient in the previous question, what best choice for cementing the
appliance in place?
A. Zinc phosphate cemenl
B. Zinc oxide eugenol cemenl
C. IRM
D. glass mnomer cemenl

5- Regarding the patient in the previous question, when would you decide to remove the
space maintainer?
A. When Ihe bicuspids erupt
B. When Ihe patient is ten years-old
C. When the patient is ready to begin orthodontic therapy
D. None of the above

6- The patient shown in the radiograph is a six year-old male and his mother reports that he
has complained of severe spontaneous pain associated with tooth #B. Your examination
indicates a lesion of moderate size on the mesial aspect of tooth #A and a large lesion on
the distal aspect of tooth #B, which extends toward the pulp. All other maxillary teeth are
present and are noncarious. You decide that extraction of tooth #B is warranted. What
type of space maintainer will you advise for the patient?

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A. Nance Appliance, cemented lo teeth #'s 3 and 14
B. Upper right removable unilateral appliance
C. Upper removable bilateral appliance
D. Upper right band and loop appliance (or crown and loop appliance)

7- The patient shown in the photograph is a four year-old male who lost tooth #E in an accident.
The child's father is concerned about his son's appearance. What advice would you give the
father regarding space maintenance and/or a prosthetic replacement?

A. . You recommend a maxillary fixed bilateral appliance with a prosthetic replacement for tooth #E.
B. . You recommend a maxillary removable bilateral appliance with a prosthetic replacement for tooth #E (i.e.,
a flipper).
C. . You recommend a prosthetic tooth to replace #E which can be bonded to teeth #'s D and F.
D. . You recommend that no space maintainer or prosthetic replacement be used in this case.

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8- Your examination of the patient shown in the photograph indicates that teeth #'s A and J will
be restored and teeth #'s B and I will be extracted. What type of space maintainer will you plan
in this case?

A. . Fixed bilateral space maintainer with prosthetic replacement teeth for#'s E and F
B. . Fixed bilateral band and loop space maintainers
C. . Nance Appliance
D. . Removable bilateral partial denture with prosthetic replacement teeth forf's E and F and acrylic space
holders forf's B and I

99- Your examination of the patient shown in the photograph indicates that teeth #'s L and S will
be removed. All other mandibular teeth will be restored. How will you plan for space
maintenance?

A. Right and left fixed band and loop appliances (or crown and loop appliances)
B. Right and left removable space maintainors
C. Fixed bilateral lingual holding arch
D. Removable bilateral space maintainer

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10 A 6.0 year-old female patient is shown in the photograph. Based on your examination, you
determine that tooth #J must be extracted. However, you also find that tooth #1 can be restored.
You decide to place a distal shoe space maintainer to maintain space in the place of tooth #J.
Once tooth #14 fully erupts, what is your plan regarding the distal shoe space maintainer?

A. . Leave the distal shoe space maintainer in place.


B. . Remove the distal shoe space maintainer and do nothing else.
C. . Remove the distal shoe space maintainer and replace it with a space maintainer which is not imbedded in
tissue.
D. . Remove the distal shoe space maintainer and place a removable unilateral space maintainer.

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