Early Tooth Loss and Space Maintenance

Anterior Tooth Loss

Early tooth loss in the anterior region can be a result of traumatic avulsion or extraction of carious or infected teeth. Unlike tooth loss in the posterior region, anterior tooth loss does not result in space loss if the primary cuspids are erupted. The lack of teeth does not interfere with the child’s ability to eat. However it may interfere with speech if teeth loss occurs before speech development is complete. The most valid reason to replace anterior teeth is for aesthetics as lack of teeth may harm the patient’s self image. Teeth replacement can be accomplished with cemented or removable appliances. The “pedo partial” is a simple yet effective replacement for extracted anterior teeth. Orthodontic bands are fitted on the posterior molars. An impression is taken and sent to the lab with the fitted bands. Primary denture teeth, which are smaller and whiter than adult denture teeth are available to fabricate a natural looking appliance.

Image: Teeth replacement appliance
Image: Teeth replacement appliance
Image: Picture of teeth that have been replaced with an appliance.

Posterior Tooth Loss

Premature loss of a posterior primary tooth results in mesial tilting of the tooth distal to the extraction space due to the mesial direction of eruption of the first permanent molar. The lack of space prevents eruption of the permanent tooth into its proper position. To maintain the space and allow normal eruption of the permanent tooth a space maintainer is placed. Depending on the location of the extraction site there are a variety of space maintainers from which to choose. Space maintainers are left in place until eruption of the permanent teeth.

Image: Variety of space maintainers
Image: Variety of space maintainers

Band and Loop Space Maintainer

The indication for placement of a band and loop space maintainer is for loss of a first primary molar. A band is placed on the second primary molar and a wire loop extends to the distal of the primary cuspid. It is contraindicated to maintain the space for a missing second primary molar. The band and loop would extend from the first permanent molar to the first primary molar to maintain space for the second premolar. However, the first primary molar exfoliates before the second premolar erupts and the band and loop would lose its source of anchorage. Therefore a lingual or palatal holding arch should be placed. An exception to the rule is if the permanent mandibular anterior incisors are unerupted. There is a possibility that the lingual arch wire will interfere with the eruption of the incisor. In this case a band and loop space maintainer is placed temporarily. When the mandibular incisors erupt a bilateral space maintainer is inserted.

A bilateral space maintainer is indicated for loss of more than one tooth in a quadrant or loss of a second primary molar. Three examples of bilateral space maintainers are the Lingual Arch space maintainer, the Nance appliance, and the Trans Palatal Arch space maintainer.

Lingual Arch Space Maintainer

The indications for a lingual arch space maintainer are:

  • Bilateral loss of the mandibular primary molars after eruption of the permanent incisors
  • Unilateral loss of more than one tooth in the mandibular arch

Its design is of bilateral bands on molars that are connected by a heavy wire that rests on the cingulums of the anterior incisors.

Image: Lingual Arch Space Maintainer

Nance Appliance

The indications for a Nance appliance are bilateral loss of the maxillary primary molars or unilateral loss of more than one tooth in the maxillary arch. Its design is of bilateral bands on molars that are connected by a heavy wire. Connecting the bands with a heavy arch wire that rests on the cingulums of the anterior incisors, in a manner similar to the lingual arch, would interfere with the occlusion of the mandibular incisors into the maxillary incisors. Instead, the arch wire is directed toward the palatal rugae and is embedded in an acrylic button resting on the soft tissue.

Image: Nance Appliance

Transpalatal Arch Appliance

The indications for a Transpalatal Arch appliance is bilateral loss of the maxillary primary molars or unilateral loss of more than one tooth in the maxillary arch. Its design is of bilateral bands on molars that are connected by a heavy wire that transverses the hard palate without touching soft tissue. Although it is easier to clean than the Nance appliance it is not as stable, especially when bilateral second primary molars are missing.

Image: Transpalatal Arch Appliance