Dear Dr.

If necessary, to prevent rotten molars and bicuspids future not leave permanent position. Since the maxillary teeth tend to rotate and distalize. Follow the patient to place correctly in position 7.

Another option is to maintain and rehabilitate the space 6 because 8 springs too late.

Si es necesario, para evitar que los molares temporales roten y las futuras bicúspides permanentes no salgan en posición. Ya que los dientes maxilares tienden a rotar y deslizarse en especial los del sector anterior. Seguir el paciente para colocar correctamente el 7 en posición. 

Otra opción es mantener el espacio y rehabilitar el 6 porque el 8 brota muy tarde.  

It is my option, Cordially Dr Valdés General Dentist

Thank you dr Abu-Hussein Muhamad and dr Jose Manuel Valdes Reyes for ur valuable suggestions.

Usually maintenance of Dec. first molars' space is not indicated at 8yrs of age. However, intra-oral periapical X- ray should be the deciding factor. If the succeeding pre-molar is in normal position and showing good root development, with no bone covering the crown, a space maintainer may be avoided. Otherwise it may be indicated. Also any crowding of incisors in the arch can be another deciding factor.

Thank you dr Ashok Utreja sir for your expert comments. 

Better give a space maintainer and monitor the eruption and alignment of canine and premolar. 

There is no "one answer fits all", but there will be space lost in the aftermath of "D-loss." More worrisome than that is the mesial shift that takes place when the upper first premolar erupts prematurely, glancing off of the mesial incline of the upper second primary molar and consuming space needed for the normal eruption of the maxillary canine. Most of those who are not supervised will have labially displaced maxillary canines.

Please read "The not-so-harmless maxillary primary first molar extraction," JADA, Vol. 131, December, 2000, 1711-20.

Actually this case is not a straight forward decision, it needs to look for some factors; Is the extraction due to presence of infection (Bone covering has been resorbed): Does the lateral incisor erupted; Is the first molars are in good cuspation so mesial movement is not so easy ;Is the arch crowded Or spaced

Alexander S A., Askari M, Lewis P. (The premature loss of primary first molars: Space loss to molar occlusal relationships and facial patterns. Angle Orthod 2015; 85: 218–223.)

have  advised that space maintenance for the premature loss of primary first molars be revisited. The placement of a space maintainer in the maxilla or mandible is recommended when a patient presents with one of the following conditions: (1) a leptoprosopic facial form and end-on molar relationship and missing maxillary or mandibular primary first molars or (2) a mesoprosopic/euryprosopic facial form, end-on molar occlusion, and missing mandibular first primary molars. The occlusal relation- ship of the permanent first molar or its eruptive status is no longer the sole factor in this treatment planning decision, but should be a component in space management.

Other authors report that patients in the full primary dentition

and those in the mixed dentition with good intercuspation of permanent molars are less susceptible to space loss. Therefore, some authors question the need for space maintenance following early loss of primary first molars under these circumstances.

However, space maintenance is generally considered to be important for children during the mixed dentition stage.

Dear Naveen,

As per the chronology maxillary  first premolar erupts at the age of 10-11 years and i think need to give space maintainer. However, other factors like amount of bony coverage, Nolla's stage of premolar and other permanent teeth in the oral cavity also to be considered.

 I think that the best comment so far was done by Ashok Utreja and W. M. Northway: "There is no one answer that fits all". The patient should be evaluated by an experienced orthodontist (who eventually will be doing the orthodontic therapy later), prompting the necessary diagnostic measures and decide the future therapy. 

During my more than 40 years of orthodontic experience I never used a space maintainer for a lost upper first deciduous molar.

Hi Dr Naveen

Pls read the following paper. This is the best evidence we have for your question.

Int J Paediatr Dent. 2009 May;19(3):155-62. doi: 10.1111/j.1365-263X.2008.00951.x.

Space maintenance.

Laing E1, Ashley P, Naini FB, Gill DS.

Author information

Abstract

OBJECTIVE:

The use of a space maintainer appliance, or restoration of a carious primary tooth that can then act as a natural space maintainer, may potentially obviate the consequences of loss of arch length and the need for complex orthodontic treatment at a later stage. Nevertheless, all spacemaintainer appliances are plaque retentive and may predispose to dental caries and gingival inflammation. Space maintainer appliances may also impinge on the soft tissues, interfere with eruption of adjacent teeth, fracture, and become dislodged or lost. This review article provides a summary of the available evidence, and considers the indications for space maintenance.

METHODS:

Medline and Ovid Medline were scanned, and additionally a hand-search of non-listed peer-reviewed papers written in English was performed. A total of 16 pertinent papers published between 1987 and 2007 that satisfied the inclusion criteria were selected for discussion.

CONCLUSIONS:

There is limited evidence to recommend either for or against the use of space maintainers to prevent or reduce the severity of malocclusion in the permanent dentition. Decisions regarding the use of space maintainers should be guided by balancing the occlusal disturbance that may result if one is not used against the potential plaque accumulation and caries that the appliance may cause.

PMID:

19385999

[PubMed - indexed for MEDLINE]

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Hi 

I think we can be brief for this question, space maintaining is only needed for lost of the second deciduous molar, after a well done investigation.

Hi Dears!

Unfortunately, due to some circumstances there is no space for the subject of  "Space Maintainer" in postgraduate orthodontic programs.  However, in our field, there are basic premises that are not negotiable. In this context, conceptually, "early" loss of primary tooth has 4 serious consequences on dental arch.

There is compiling evidence that proves that ideal occlusion/ intercuspation can not prevent tooth drifting! Thus, I consider this as an effective interceptive treatment. According to Gianelly, the success rate of SM is 3 out of 4 cases.

It is not professionally acceptable to underestimate the preventive role of SM just due to food impaction problem that the appliance may causes. After all, it is our duty to educate our patients regarding every oral health care we provides for them.

Good Luck !! 

Dear Colleagues

In regards to your question dear Naveen,

The age of the child is not a good parameter to assess whether or not to do space maintainer although there is a believe that for children  8 years and above there is no need to do space maintainer.

The decision to perform a space maintainer depends on careful  evaluation of the  chronological age of the child which can best be evaluated from an x- ray that shows the developmental stage of the succedaneous permanent tooth.  if more than half of the root of the permanent tooth has developed that means the tooth is near to erupt or if the  bone covering the permanent tooth bud is lost due to infected predecessor, more likely no need for space maintainer. However there are many factors should be considered that will accelerate the degree of space loss such as the presence of active occlusion, susceptibility of fast space loss,etc.which necessitate the use of space maintainer. 

 I agree that an orthodontic opinion is also useful for the overall evaluation of the  case.

I totally support Dr. Zafarmand in not to underestimate the preventive role of space maintainers & provide oral health education to our patients.

Dear Naveen Manuja

Please, You can communicate what was your final decision?

Cordially Dr JM

The discussion about the best therapeutic alternative for the case in question was very rich!

Thank you Navenn for the question.

Thank you all for the answers and thoughts!

Thanks Dr Muthu MS for your expert comments.

Thank you all for the answers and suggestions.

This was a very fruitful discussion.

I do agree that before planning a space maintainer we should keep in mind all the factors like dental age, bone coverage, amount of root formation etc. Also we should consider the sequence of the erupting permanent lateral incisor.

Patient educatoon regrding oral hygiene maintance is also very importance.

I am perplexed by the thought promoted by Lainge, et al (as put forward above by Muthu) that “there is limited evidence to recommend either for or against the use of space maintainers to prevent or reduce the severity of malocclusion in the permanent dentition”. The article “Effects of premature loss of deciduous molars,” Angle Orthodontist, 1984 (3), 295-329, demonstrates that devastating amounts of arch length are lost in both jaws. It depicts that space can be lost from the mesial or distal, that the age of exfoliation has an impact, that space is not regained with subsequent eruption of the permanent teeth and that the interdigitation with the opposing arch might not be an effective deterrent to space loss – especially depending upon how much destruction is happening in the opposite arch.

The idea that space maintainers might cause food impaction and further decay, and that “space maintainer appliances may also impinge on the soft tissues, interfere with eruption of adjacent teeth, fracture, and become dislodged or lost” has much more to say about faulty appliance design and a lack of attention to oral hygiene than it is a condemnation of use of appropriate space maintenance.

The issue promoted by Farah regarding the timing of the implementation of space maintenance is very well taken. Each case should be thoroughly evaluated, certainly taking into consideration the occlusion as Dr. Zafarmand reminds us that Gianelli promoted. The orthodontic needs of the case might beg further loss of space followed by extraction. The need for space maintenance is a multi-factoral phenomenon requiring a thorough knowledge of the development of the occlusion, both normal and aberrant.

I should have added that the real treasure in the data from the referenced article:  “Effects of premature loss of deciduous molars,” Angle Orthodontist, 1984 (3), 295-329, is that it is all longitudinal and the sample sizes provide very meaningful statistics. The idea the no further space is lost and space maintainers are not beneficial is ludicrous.

The original question which initiated this wonderful discussion was "Is a space maintainer required in an 8 year old child where primary maxillary first molar has been extracted?. The questions was NOT " Is a space maintainer required where primary maxillary first molar has been extracted?". 

The paper by Lainge et al posted by me was NEITHER to Support NOR to contradict the idea of space maintainer in the above mentioned situation. It has not concluded anything but QUESTIONED the ROUTINE use of space maintainer in that region. 

The major factor for space loss when primary maxillary first molar is prematurely lost is the ERUPTING first permanent molar. In the above question there is a possibility that the first molar might have completed its eruption. It is also been possible the forces exerted by the erupted first permanent molar could be buttressed by the well placed maxillary second primary molar ( There is no evidence for this). There could have been no bone covering the unerupted first premolar. Hence a space maintainer MIGHT become redundant. We have to evaluate the " Status of eruption of first permanent molar" ( major factor), bone covering the unerupted premolar ( second major determinant), the root development of the erupting first premolar ( third determinant) for the decision in this region. I will go in this order. Infact the first and second determinant might need equal importance too. I am enclsoing the chapter with a pic at the end of this discussion where the premolar has erupted even before the first permanent molar is erupted. It is published in my Textbook - Pediatric Dentistry - Principles and Practice  2nd edition published by Elsevier. Pls see Page No 40 in the chapter.

We were not looking for evidences in 1980's. It all started in early 90's. Now the "Standard of Care" will be good if we have concrete evidence for our decisions. However, as clinicians we know, most of the decisions what we take daily and what we practice DO NOT have strong evidence but EMPIRICAL and but we still practice them in our department and in our practice settings. But if we believe something strongly probably the opportunity to QUESTION the KNOWN could become difficult. In the present evidence based world, it is better to look for evidences and make clinical decisions. Also keeping the ability to question the methodology by which evidence was generated is also important. 

The discussion is NOT against space maintainers. It has a very important role to play in dentistry. But the bottomline is " IS IT NECESSARY ALWAYS" ?

Thank you Dr. Northway for your very clear explanations. There are much benefit in all "interceptive treatments" protocols than we have discussed in this tight contact tool. (Jan 24, 2016)

The image (Figure 4.6 on page 40 of the chapter Dr. Muthu has attached) shown is what’s known as an anomaly, not something that might be anticipated as a function of typical premature loss of the first primary molar. In fact, rather than calling it a “Premolar erupted at the age of 6 years even before the eruption of first permanent molar”, this might be better described as the aberrant development of a supernumerary tooth with crown formation resembling a lower premolar and presenting a potentially threatening lesion at the apex. While we have only a periapical from which to judge, it looks as though both of the actual premolars are developing in that quadrant albeit with a very unusual sequence of development:  canine-ahead-of- premolar.

I am much more persuaded by the quote from the attached chapter, “Be sure you positively identify your target before you pull the trigger.”  Dental development and eruption is a highly varied and dynamic process. There are very few absolutes, and the process should be flexible but well designed; that includes making space maintainers that are hygienic and using them appropriately. That is a very different message from the one reflected in Dr. Muthu's first response and very different from the article by Lainge.

I guess this discussion is going in a different direction now losing its focus. Anyway i would like to clarify Dr Northway that it was a premolar and there was no aberrant development there and the tooth underneath was the developing canine. There were no aberrations in the xrays and there are no supernumeraries in this patient. Infact my Graduate student presented a series of three cases in 2007, this is the only one ahead of first permanent molar and the other two were around 7 years with first permanent molar in different eruptive stages. Will try to retrieve if i could locate her and retrieve old records. Anyway it will be superfluous if the possibility of first premolar erupting at this age is neglected and considered as an anomaly. Whenever there is NO bone covering the unerupted tooth ( developing successor) the successor erupts pretty quick into the mouth irrespective of the root development. Space maintainer will be redundant there. That is the point i would like to bring. If the periapical infection associated with a primary molar is left untreated and managed with medications ( patient does not report back for further pulp treatment ) and every time the infections occurs, part of the bone covering the unerupted tooth is destroyed. The above case is also a similar one. However, i would like to stop here.

The message and my initial answer is ONLY pertaining to premature loss of first primary molar and a RELATED recent systematic review. It was posted NOT to follow exactly as it is. Only to think and ACT. At times we tend to make certain things default.

Again i would like to clarify USE OF SPACE MAINTAINERS is NOT QUESTIONED and the NEED at different circumstances.

If the “premolar” shown in Figure 4.6 does survive, then the case falls far more into the category of the type that comprises the situation that inspired the article, “That not-so-harmless maxillary primary first molar extraction.” Bear in mind that eleven of the thirteen cases with premature loss of the primary first molar ended up with blocked-out upper canines. As it is presented, the case from your text will be one more.

In keeping with the concept that I am trying to under-score about the varied and dynamic nature of development, the concept of “Space Maintenance” really should be replaced with “Space Management.” What is needed for the case from your text might be the removal of the aberrant premolar with precocious eruption (please note the lack of root development and/or rarefaction at the apex). Or you might want to move the premolar to the distal – to make space for the canine.