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In the permanent dentition -- your teeth as they are after all permanent teeth are in -- it is easy to assess the amount of crowding by taking measurements directly from a study model. Treatment will depend on the severity of the problem and may involve arch lengthening or extractions. In the mixed dentition however -- when some but not all primary teeth are coming in -- it is necessary to be able to predict future crowding. Space management can minimize the development of crowding in the permanent dentition. It essentially involves:

The best space maintenance therapy is to preserve the primary molars until natural exfoliation. Although dental health education and improved caries prevention have lowered the number of children who develop malocclusion because of premature loss of primary teeth, it is still one of the most common controllable causes of malocclusion.

When a primary second molar is lost prematurely due to caries or to the ectopic eruption of the first permanent molar, the first permanent molar will drift mesially. This is most pronounced in the maxilla, with a more rapid shift of the molar and thereby causing a malocclusion, where the teeth do not meet and align properly when the jaw is closed. The earlier the loss of the second primary molar and the less the root development of the permanent molar, the greater the amount of bodily mesial shift of the permanent molar.

Placement of a space maintainer requires care of the appliance and maintenance of the oral hygiene: a child with poor oral hygiene and high caries risk is not the ideal case for such therapy. Before a decision is made to provide a space maintainer it is often essential to critically evaluate its merits, the need, and the benefit it would provide to the development of normal occlusion.

Anterior teeth

Loss of one or more primary incisors results in negligible space loss if canines and molars are present.
If the eruption of a permanent incisor is delayed, space loss may occur because of migration of adjacent teeth.

Posterior teeth

Whenever a primary second molar is lost prematurely, whether before or after the eruption of the first permanent molar, there will be some loss of arch length caused by the mesial drift of the permanent molar.
Space maintenance is critical in children who have a normal arch length and lose a primary molar. Any loss of space in these children will result in crowding of the permanent teeth.
Where space has already been lost it is necessary to regain space and then fit a space maintainer.

Types of Space Maintainers

Removable

Removable space maintainers have the shortcomings of all removable appliances.
They may be worn at the whim of the patient.
May be broken.
Easily lost when removed by the patient.

A removable space maintainer that is only worn at night is often sufficient to hold space and prevent the mesial drift of permanent molars. Night only wearing of the appliance also reduces the risk of loss or breakage by the patient. The appliance should be washed and inserted immediately before going to the bed, then removed, washed and place in a safe place when not worn. The Hawley appliance is a typical example.

Fixed space maintainers

Fixed appliance have the advantage that they are worn continuously and do not require patient cooperation in wearing them.

It should be noted that the placement of a fixed appliance in a child at high risk of caries may compromise teeth that are banded, or even adjacent teeth.

Band and loop appliance is typically used in cases of unilateral loss.

Nance appliance or lingual arch appliance can be used if the loss is bilateral.

Distal shoe appliance can be used if the first permanent molar is not yet erupted, but are not widely used because of risks of infection.

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