Thelongevityof spacemaintainers:
a retrospective
study
Muawia
A.Qudeimat,
BDS,MDSc,
MRCD(C)
Stephen
A. Fayle,BDS,
MDSc,
FDSRCS,
MRCD(C)
Abstract
Methods:This retrospectivestudy investigatedthe lon-
gevity of 301 spacemaintainersfitted in 141patients aged
3.4-22.1 years in the Departmentof PediatricDentistryat
LeedsDentalInstitute between1991and 1995.
Results: Failure occurredin 190 space maintainers
(63%),of which36%weredue to cementloss, 24%break-
age, 10%design problems, and 9%were lost. Usingthe
life table method, the mediansurvival time (MST)for
space maintainers was found to be 7 months. Bandand
loop (B&L)applianceshad the highest MSTof l3 months,
while the lower lingual holding arch (LLHA)had the low-
est of 4 months. Unilateral space maintainerssurvived
longerthan bilateral spacemaintainers(MST of 13 months
vs. 5 months). Lefi B&Lshada MSTofl6months, com-
paredto only 4 monthsfor right B&Ls.Gender,age, arch
in whichthe appliancewasplaced, the operatorplanning
it, fixed vs. removable,and adequacyof pretreatmentas-
sessmentdid not havea significant effect on survivaltime.
(Pediatr Dent 20:267-72, 1998)
Vi rious appliances can be used ,for space main-
enance dependingon the child s stage of den-
al development,dental arch involved, primary
teeth missing, and whichteeth they are.~-5 Occlusion
may also be a factor in determining the type of
space maintainer. The patients age and ability to co-
operate and tolerate a removableappliance are also
majorconsiderations.2 4-6
Theclinical efficacy of space maintainers, and how
variablesin designandconstructionaffect survival time,
have gained little attention from researchers. Some
authors have anecdotally attempted to estimate the
most commoncauses of failure of space maintainers
and the longevity of these appliances, including a
high incidence of breakage in mandibular appliances
when compared with other appliances) Others
state that fixed space maintainers, if properly
designed,are less damagingto the oral tissues than re-
movablespace maintainers, and less of a nuisance to
the patient, thus moreappropriate for longer periods
4of space maintenance.
In a 4-year prospective study, 226 space maintainers
were fitted in 196 children, aged6-10 years.7 Problems
were encounteredin 43%of all the appliances, of which
PediatricDentistry-20.4, 1998
58%were LLHAs,31%band and loop and crown and
loop appliances, 6%transpalatal arches, and 4%re-
movable appliances. The most commonproblem was
appliance loss. This problem constituted 37%of the
total problems, while 27%were due to broken B&Ls,
14%due to failure of cementation,13%due to patients
failing to attend the follow-up appointments,and 11%
7due to distortion of the arch or loop.
Onlyone recent study has lookedobjectively at the
longevity of space maintainers, and variables that can
affect their survivaltime in children.Baroniet al.8 stud-
ied the longevity of 88 fixed space maintainers fitted
in 61 patients, aged 5-9 years, followed for a maximum
of 53 months.Survival wasevaluated utilizing the life
table method.Theoverall incidence of failure was31%.
Solder failures accountedfor 37%of the total failures,
33%were due to loss of cement, 19%involved soft-
tissue lesions, and 11%were caused by interference
with eruption of permanent teeth. Nanceappliances
and B&Lspace maintainers had a 70%survival rate,
while the LLHAshad a 40%survival rate after 36
months of cementation. The differences between the
survival time of different designs of space maintainers
8werenot statistically significantly different.
Theaim of the present study wasto investigate the
survival of space-maintenanceappliances fitted in the
Department of Pediatric Dentistry at a UKdental
school over a 5-year period.
Methods
Thestudy includedall patients whohad either fixed
or removable space maintenance appliances provided
in the Department of Pediatric Dentistry at Leeds
Dental Institute between January, 1991 and Decem-
ber, 1995. Data concerning the planning, fitting,
progress, and fate of each appliancewereextracted from
patient records. Patients were excludedif they had re-
ceived dental treatment from another dental service
during the study period or if the space-maintenance
appliance had an orthodontically active component.
The following information was collected from the
patients record card:
Pretreatmeatassessment
1. Thedate and type of radiographsexposedbefore the
space-maintenanceappliance fitting date. In cases
AmericanAcademyof Pediatric Dentistry 267
 in whicha periapical or a bite-wingradiographwas
exposed,the quadrantwas also recorded.
2. Anypreliminary assessment of space needs was
recorded,i.e.: Space Maintainers(%)
a. Primary molars relation
9(Baumesclassification) Removablepartial denture 82 (31%)
b. Presence or absence of crowdingor Band and loop 81 (27%)
spacing in the primary dentition
Lowerlingual holding arch 71 (24%)
3. Whetheror not a set of study modelswas taken
Nanceappliance 30 (10%)
4. Whetheror not a mixed dentition analysis was
carried out. Fixedpartial denture 20 (7%)
Adequacy of pretreatment
assessment Distal shoe 6 (2%)
Patients were deemedto have had adequatepretreat- Crownand loop 1 (0.3%)
ment assessment if all the following pretreatment
surveys were recorded as carried out before they were Total 301 (100%)
fitted with a space maintainer:
1. For all study grouppatients
a. Full radiographic survey showingall the
primary and permanent teeth
b. A set of study models
Operator SpaceMaintainers(%)
2. For patients with established mixed dentitions
(i.e., all permanentfirst molarsand incisors fully Postgraduate student 206 (67%)
erupted) prior to being fitted with a space main- Undergraduate student 47 (16%)
tainer or during the course of treatment (other
than those whereanterior tooth was lost due to Hospital and/or University staff 44 (15%)
trauma): space analysis results wererecorded ei- Not recorded 4 (1.3%)
ther on mixeddentition analysis sheet or in the
clinical notes Total 301 (100%)
3. For patients with loss of an anterior tooth: clini-
cal records of space measurement. After applying the exclusion criteria, 18 patients with
Fate andlongevityofspace-maintenance
appliances 25 space maintainers were excluded.
The age range of patients in the study group was 3.4
Each appliance could have one of three possible to 22.1 years (mean8.8, SD= 13.3). Nineteenpatients
fates: 1) withdrawn,either due to successful space man- in the 13-22-year age group had 40 upper, removable
agement(i.e., the records demonstratedthat the space space maintainersfitted to keepthe space of a traumati-
maintainer was removedbecause it accomplished the cally lost anterior tooth or teeth.
original purposeof its fitting) or lasted until the end Of the 141 patients, 74 were female and 67 were
of the study period (i.e., the space maintainersurvived male. In these patients, 301 space maintainers had been
intact until the studyclosing date); 2) failed if the pa- fitted (Table 1). Of these, 155 were newlyconstructed
tients records demonstrated that the appliance was and fitted for the first time and 146 were either a
recorded as lost or removeddue to inadequatepretreato recementation,a repair, or replacementof the original
mentdiagnosis, poordesign, faulty construction, failure space maintainer. Postgraduate students fitted 69%of
of cementation, failure of a space maintainer due to the space maintainers (Table 2).
caries, pulpal/periodontal pathology of an abutment
tooth, poor follow-up care, or poor patient coopera- Pretreatment assessment
tion or attendance;or 3) lost to follow-upif the patient The radiographic assessmentcarried out before fit-
failed to attend the follow-upappointmentand the fate ting a space maintainer is presented in Table 3. Full
of the appliance was unknown,or the operator failed radiographic surveys were exposedprior to fitting 87%
to record the presence or absence of the appliance in of the space maintainers. A set of pretreatment diag-
the clinical narrative and there wasno sign of the apo nostic models were madefor 78%of the appliances
pliance on subsequent chartings or radiographs. prior to fitting.
Whenmixed dentition analysis was considered
Results appropriate, either initially or subsequentlyduring the
The clinical records of 159 patients in whom326 course of space management,it was carried out and
space maintainerswerefitted wereoriginally identified. recorded for only 34%of space maintainers (Table 3).

268 AmericanAcademyof Pediatric Dentistry PediatricDentistry- 20.4, 1998

 10

Pretreatment Space
Assessment Maintainers (%) Patients (%)
Radiographs
Full survey 261 (87%) 119 (85%)
Someradiographs 36 (12%) 20 (14%)
No radiographs 4 (1%) 2 (1%) Fig.Survival
rateoffour
different
designs.
Study Models
then removablepartial dentures (9 months), and B&L
Yes 234 (78%) 109 (77) space maintainers, which showedthe highest median
No 32 (23%) survival time of 13 months.
67 (22%)
Whena space maintainer was considered failed,
MDA postfailure action wasundertakenin certain instances,
Completed 67 (34%) 31 (32) and these space maintainers re-entered the study with
a new data-capture entry. Of the 190 failed space
Not Completed 129 (66%) 66 (68%) maintainers, 64 were remade, 60 recemented, 18 re-
paired, and for 48 space maintainers a decision was
madeby the operator to discontinue space manage-
Fateof space
ment. The mediansurvival time for recementedspace
maintainers maintainers was the lowest (4.5 months), followed
Thefate of all newlyfitted space maintainers (7 months),then remade
study space main- space maintainers (10 months), and then repaired space
Maintainer N (%) tainers is pre- maintainers, in whichthe highest mediansurvival time
Failed 190 (63%) sented in Table4. was encountered(13.5 months). These differences were
One-hundred statistically significant (P < 0.0005).
Lost to Follow-up 64 (21%) and ninety were Twenty-seven patients had more than one space
Successful 25 (8%) considered maintainer simultaneously. Of those, 26 had two and
failed(141 fixed, only onehad three. Nostatistically significant differ-
Endof Srudy 22 (7%) 49 removable) ence was found betweenthose and patients whohad only
Total 301 (100%) and 25 success- one space maintainer in terms of mediansurvival time.
ful.The causes Unilateral appliances (i.e., B&Ls,distal shoe, and
of failure as re- crownand loop space maintainers) survived morethan
cordedin the dinical notes are presentedin Table5. The twice as long as the bilateral appliances (i.e., LLHAs,
most commoncause of failure in this study was and Nanceappliances) at the 50%level (P <0.0005).
failure of cementation(either partial or complete), Left B&Lappliances had a mediansurvival time of 16
whichwasrecorded in 36%of all failures. months, while the right B&Lappliances had a median
Longevityof space
maintainers survival time of only 4 months(P < 0.01).
Whenpatients whohad a similarly situated space
Themediansurvival time of space maintainersin this maintainerfitted two times or less during the study pe-
study was 7 months. Whenboth new and all study riod were compared with those who had comparable
group space maintainers were considered independently, space maintainersfitted morethan two times, the first
there wasno statistically significant difference between group had a mediansurvival time of 10 months, while
survival time for space maintainersin both groups, sug- the second group had a median survival time of 3.5
gesting that newspace maintainers behavedin a similar months,a statistically significant difference(P < 0.0005).
fashion to all study groupspace maintainers. Gender,age, arch in whichthe appliance wasplaced,
Variables whichmighthave affected the mediansur- adequacy of pretreatment assessment, and operator
vival time for all space maintainers were tested using whoplannedor placed the space maintainer had no sig-
the log-rankandchi-squaretests. * Theresults are pre- nificant effect on longevity.
sented in Table6. A statistically significant difference
(P < 0.005) was found between the median survival Discussion
rimes of the four commonlyused space maintainers Theuseoflifetable methodindental
research
(Fig). The LLHA had the lowest median survival time In general, the relative gain in utilizing survival in-
(4 months), followed by Nanceappliance (6 months), formation on space maintainer cohorts with partial

Pediatric Dentistry -20:4, 1998 AmericanAcademyof Pediatric Dentistry 269

 3.4 to 22.1 years, and the space
maintainers were followed for 5
years, in contrast to the only two
comparable previous studies where
of Fixed Removable Space 191 children 6-10 years old were
Failure Appliances Appliances Maintainers followed for 4 years 7 and61 children
5-9 years old were followed for a
Failure of cement 68 0 68 (36%) 8maximumof 53 months.
Breakage 15 30 45 (23%) The most commoncause of fail-
ure was loss of cement, which
Design represented 36%of the failed space
Soft-tissue lesions 13 0 13 (7%) maintainers (Table 5). This paral-
leled the 33%cement failure rate
Interfering with reported in fixed space maintainers
erupting teeth 5 0 5 (3%) in an earlier study.8 However,in an-
other prospective study, failure of
Improperselection 1 0 1 (0.5%) cement accounted for only 14%of
Lost 12 5 17 (9%) the total causesof failure. 7 Previous
authors have reported cement loss
Lost tooth from the denture 2 5 7 (4%) due to poorly adapted bands as one
Inadequate evaluation 5 0 5 (3%) of the main causes of fixed space
maintainer failure. 6-8 However,
Deteriorationof fit 0 3 3 (2%) failure couldalso reflect difficulties
Poor patient cooperation 1 1 2 (1%) in keepinga dry field during cemen-
Unacceptableaesthetic 0 2 2 (1%) tation, especially in the case of
bilateral appliances.
Distorted 1 0 1 (0.5%) Breakage ranked as the second
Combination" 14 3 17 (9%) most commonlyrecorded cause of
space-maintainer failure (24%, N
Not recorded 4 0 4 (2%) 45) in our study. A similar rate of
Total 141 49 190 (100%) breakage(27%, N = 26) has been re-
ported by Hill et al. 7 They found
that breakage was most commonly
"A combination of two or more reasons.
encountered in the LLHAfollowed
follow-up information will vary directly with 1) the by B&Lspace maintainers. In our
increase in the initial size of the cohort; 2) the com- study, breakage was encountered more in removable
pleteness of the addedsurvival information; and 3) the partial dentures followed by LLHA space maintainers.
magnitudeof failure rates during the first few follow- However,in the Hill et al. study,7 there wereonly four
up intervals. .1 Manylater texts ignored the potential removable partial denture space maintainers (2%)
impactof these factors and merelystated that the life which were all removedby the patients at homeand
2table methodis useful in determiningsurvival rates) then were lost, while we used 92 removablepartial-
Factorsaffectingthe reliability of results include:the size denture space maintainers. Ahigher solder failure rate
of the sample, the length of the study comparedwith of 37%(N = 10) of total failures in fixed space
medianlife, the proportionof data that is censored,and maintainers has been reported previously,8 in compari-
~2
the quality of informationon censoreddata. son to 11%(N = 15) of total failures in this study. The
Longitudinal studies of dental treatment have usu- former investigators concludedthat the relevance of
ally been carried out retrospectively, and those who mechanicalstress in long-termspace maintainers seemed
have attemptedthemwill agree that lack of record con- to be more important than appliance design. 8 Others
1~
tinuity presents a majordifficulty. have suggested that most mechanicalfailures are due
Fateofspace maintainers to poor construction quality, i.e., incomplete solder
joint, 6-14 overheatingof the wire duringsoldering,6 7,14
One-hundredand ninety (630/0) space maintainers
suffered failure during the study period (Table4). This wire thinnedby polishing,3 3remnantsof flux on the wire,
3andfailure to encasethe wire in the solder.
was a high failure rate in comparison with previous
studies, wherefailure rates of 437 and 31%have been It has been anecdotally stated that removablespace
reported. However,in this study the space maintainers maintainers are more frequently lost than fixed space
maintainers.15 Althoughthe difference was not clini-
were fitted in 141 children with a wider age range of

270 AmericanAcademyof Pediatric Dentistry Pediatric Dentistry- 20:4, 1998

 failed space maintainers in this study (mostly
premolars). The difference between the two studies
RELATED
TOTHEMEDIAN
SURVIVAL
TIMEFORALLSPACE mayhave arisen from the extensive use of LLHAs in
the primary dentition by investigators in the first
study.8 In our study, no LLHAs
were fitted in the pri-
50%Survival mary dentition.
Variables Rate (too.)
Survival
timeof space
maintainers
Lowerlingual holding arch 4
Nanceappliance 6 < 0.005 tweendifferent types of space maintainers in terms of
Removableappliances 9 survival time. Conversely,the results of the present
study indicate that the median survival time maybe
Band and loop 13 related to the design of the space maintainer with B&L
appliances lasting longer than LLHAs.A possible ex-
planation is that the LLHA and Nanceappliances are
Bilateral fixed space maintainers 5 more subject to occlusal stress than B&Lappliances,
Unilateral fixed space maintainers 13 < 0.0005 although this cannot be confirmed from our study.
It has also been anecdotally stated that removable
space maintainers maynot last as long as fixed space
Recemented 4.5 maintainers, and hence fixed space maintainers should
be preferred over removabledesigns. 4 However,when
New 7 < 0.0005 the longevity of fixed space maintainers was compared
Replacement 10 to removablepartial-denture space maintainers in this
Repaired 13.5 study, no statistically significant difference betweenthe
two groups was found.
In the current study, unilateral space maintainers
Right band and loops 4 showeda median survival time more than twice that
of the bilateral appliances.Baroniet al. 8 failed to dem-
Left band and loops 16 < 0.01 onstrate such a difference. The reason for this is
unknown,but could be related to bilateral appliances
being subjected to greater occlusal stress than unilat-
Fitted morethan two times 3.5 eral space maintainers.
Fitted two times or fewer 10 <0.0005 Surprisingly, whenmediansurvival times for left-
and right-fitted B&Lspace maintainers were investi-
gated, a statistical and clinical difference wasfound
cally or statistically significant, this last point was betweenthe two groups. Again, the reason for this re-
slightly evident in the present study, wherelost appli- mains obscure, although one possible explanation
ances represented 10%(N = 5) of recorded causes might be that access and isolation might have been
failure in removablepartial-denture space maintainers easier to control by a right-handed operator whena
and 9%(rq = 12) of those in fixed space maintainers. B&L wasfitted to the left side of the oral cavity. An-
Soft-tissue pathology resulting from space other possible--but uninvestigated--explanation
maintainers is often attributed to impingement. 2, 6 In mightbe the preference of the right side of the mouth
this study, soft-tissue pathologyled to the failure of 9% as a chewingside by the children in this study.
(N = 13) of failed fixed space maintainers in compari- Nostatistically significant difference wasfound in
son to 19%(N = 5) in fixed appliances in a previous this study in terms of space maintainer survival time
investigation, 8 in whichthe authors concluded,with- betweenthe different age groups. The seniority of the
out statistical analysis, that soft-tissue lesions were operator showedno statistical significance in the median
mainly related to unilateral space maintainers. In our survival time of the space maintainer. These findings
study, soft-tissue lesions were encountered more in could suggest that poor design and construction may
bilateral (7%of total failures recordedfor bilateral ap- play a greater role in space maintainerfailure than pa-
pliances) than in unilateral space maintainers (6% tient cooperation or degree of mental development.
total failures recordedfor unilateral appliances),but this Remadespace maintainers survived longer than a
difference wasnot statistically significant. newly fitted space maintainer. This could have been
While Baroni et al. 8 found that 10%of the space due to a more careful assessment in terms of the de-
maintainers in their study failed due to interferences sign selection andother considerationsprior to refitting
with eruption of the permanentteeth (all were lower the remade space maintainer. The fact that the
permanent incisors), this accounted for only 3%of recemented space maintainers had a 50%chance of

Pediatric Dentistry -20:4, 1998 AmericanAcademyof Pediatric Dentistry 271

failing within 4.5 months comparedto 10 months for
replacement space maintainers strongly suggests the
space maintainersdesign and construction, rather than
the cementitself, could have been the primary cause
of failure.
Unexpectedly,space maintainers with adequate pre-
treatment assessment showedno difference in median
survival time whencomparedwith space maintainers
with inadequate pretreatment assessment. This possi-
bly reflects that adequate pretreatment assessmentmay
ensure that the use of a space maintainer is appropri-
ate, but does not influence appropriate design selection
and construction.
Interestingly, the mediansurvival time for space
maintainers that were fitted in similar situations two
times or less during the study period was highly sig-
nificantly longer than the median survival time for
space maintainers similarly fitted morethan two times.
This suggests that in cases wherespace maintainershave
failed in the same situation more than two times, any
subsequentreplacementis likely to have a poor median
survival time.
Twopossible explanations for this are that the lo-
cation maybe such that it could be unsuitable in some
wayfor a space maintaineror, alternatively, those pa-
tients in whomthese appliances were placed mayhave
tolerated thempoorly, leading to recurrent failure.
Conclusions
The following conclusions maybe drawn from this
study of a dental school population:
1. Overall, failure occurred in 63%of the study
space maintainers; 21%were lost to follow-up,
and only 8%were considered entirely successful.
2. Loss of cement was the most commonlyrecorded
cause of space maintainer failure, followed by
breakage, and then completeloss of the appliance.
3. Mediansurvival time was 7 months.
4. Of the commonlyused designs, B&Lmaintainers
had the highest mediansurvival time (13 months)
and LLHAsthe lowest (4 months).
5. Remadespace maintainers had a significantly
longer median survival time (10 months) than
new (7 months) and recemented space main-
tainers (4.5 months).
6. Gender, age, arch in which the appliance was
placed, adequacyofpretreatment assessment, and
operator whoplaced the space maintainer had no
significant effect on longevity.
Recommendations
i. A band and loop space maintainer design showed
a significantly higher mediansurvival time, and
272American
Academy
of PediatricDentistry
should be favored as a space maintainer design
wheneverpossible.
2. Whena space maintainer fails twice due to ce-
mentloss, careful reassessmentis required before
further replacementof the applianceis considered.
3. Close supervision and frequent follow-up ap-
pointmentsare necessaryfor all patients to check
the appliance, the integrity of the luting agent,
and to clean the abutmenttooth as required. In
the light of the current study, 2-monthfollow-
up appointments for bilateral fixed appliances
and 4-month follow-up appointments for re-
movableand unilateral fixed space maintainers
would be advisable.
Dr. Qudeimarwas a postgraduate student during the preparation
for this study, and is nowa clinical demonstrator, Departmentof
Child Dental Health, Leeds University. Dr. Fayle is a Consultant
in Pediatric Dentistry, Departmentof Child Dental Health, Leeds
University, UK.
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