Space Maintainers Part 2 - Which one to use, When and How

Following on from the last post, we will now go into some practical tips for the various methods of space maintenance.

Chairside Band and Loop (Denovo)

A Denovo (chair side) space maintainer

These are ideal to maintain the space for unilateral early loss of D’s. They can also be used for the early loss of E’s when the 6 is erupted, however the D is usually lost prior to the eruption of the second premolar, so the spacer loses its mesial contact point resulting in a risk of subsequent space loss. However, we know that most space is lost in the first 6-12 months after extraction of the tooth, so potentially with careful case selection and monitoring, this is still a feasible option and better than no space maintenance at all.

Practical tips for Chairside Band and Loop

You can find the official step by step guide on the Denovo website – this is a compilation of extra things we’ve picked up after using them a while now. https://denovodental.com/product-category/chairside-space-maintainer-system/

• Select appropriate band size for the tooth distal to the space. Almost always, once the band is fully seated, the arms will be angling downwards, digging into the extraction site. Use 3-beak pliers to tip the arms upwards towards the contact point. I’d say this is the most important part of your armamentarium for these,

• Use crimpers to make the band a more snug fit,

• Band seaters and band removers are great to have but not essential,

• Once you have trimmed the wire and are fitting it in, you may need to alter the way the band seats on the tooth, or adjust the angle of the arms to ensure the wing meets the mesial tooth roughly in the centre of the contact point as sometimes the arms will be pointing more buccally or lingually,

• Check the occlusion prior to cementing- you want to make sure it’s not greatly affected/ biting on the wing.

• Once happy with the length of the wire, use the Denovo tube crimpers to secure the wing in place, then cement with your choice of luting cement.

Lab Made Band and Loop

A lab made band and loop

These are used in similar cases to the chairside band and loop, and require an impression/scan to be sent to the lab and inserted at a separate appointment. The lab solders a wire onto a stainless steel band.

Practical tips for Lab Made band and loop
       

• If you have the luxury of forward planning and time, you can place dental separators mesial/distal of the tooth that will have the band (the tooth distal to the one being extracted). This will make it easier to fit the band at the impression appointment·       

• Remove seps (if placed), and select appropriate size metal band for the tooth distal to the one extracted. You can crimp and adjust the band to fit if you’d like, though the lab should also be able to do this for you. If you didn’t place seps, not to worry! Floss the contacts free of debris, and you can push the band on. Warn them there will be some pressure, but this is usually tolerated even without LA if not done at the time of the extraction.

• There are now two different ways you can go about it, and it can come down to operator and/or technician preference.

  • You can remove the band, place it in a labelled bag assigning which tooth it should go on (this is especially important if doing a bilateral appliance), take your impression as usual and the lab will seat the band on the model

  • You can leave the band on the tooth, take the impression, remove the band from the tooth and place it in the impression prior to pouring up. You need to be extremely careful that the band does not move when pouring up the model- some operaters use small wires or single staples to push into the alginate to stabilize the band prior to pouring up.

• Take an alginate impression or a scan – single arch is fine. This can be done before the extraction or on the day of the extraction (first up, otherwise you’re dealing with alginate in a fresh socket) – the lab will remove the tooth on the model. Or it can be taken a week or so after the extraction, though this is a less efficient plan.

• If you placed separators prior to the impression, you may like to replace them at the end of the session if necessary (Moreso for the case of bilateral appliances. For a unilateral appliance, the band will usually go on much easier following the extraction, so seps don’t provide much/any benefit here)

• Once received from the lab, check fit and cement in the usual fashion.

Bilateral Lab Made appliances – LLA (lower lingual arch), Nance Appliance, TPA (transpalatal arch)

Some bilateral space maintainers. LLA, Nance and TPA

These are ideal for spaces that span more than one tooth, or where teeth on both sides are lost.

·        Practical tips are pretty much the same as for band and loop appliances as above. You may just want to go 1/2 a size up on the bands to give youself a tad more ‘room’

Care Tips for Space Maintainers

We always stress to patients and their parents to come in at any time they notice the space maintainer becoming loose. Especially in the case of bilateral appliances, because if one side loosens, the appliance will not ‘just fall out’ as it is secured on the other side. It is explained to them that if they are loose, they run the risk of eventually breaking the appliance (which will be more costly to fix than just recementing), or worse, trapping food and bacteria under the band which could create a cavity in an adult molar.

Impeccable oral hygiene is required, as a fixed appliance always presents extra surface area for bacteria. Don’t be afraid to remove a space maintainer if the patient fails to demonstrate good home care- it’s more important to have a healthy oral environment.

Super floss can be hand to thread under cross arch wires as well

Monitoring

Regardless of who places the space maintainer, regular monitoring at recall appointments can be carried out by any general dentist, OHT or hygienist. It needs to be checked for any movement/loosening, ensure bands are not embedding into the gingiva, cleanliness, and when you see the adult tooth erupting into the space, that signals time for removal.

Removal

The appliance can be removed when the permanent molar is close to, or begining to erupt through.

We hope this post has been useful. The chairside space maintainers can be found at: KITS – The Paediatric Dental Company (tp-dc.com.au)

Tim, Erica and Sarah