Dr. Jeff’s Approach

Have your burning questions answered by Dr. Jeff himself in this Q & A section.

Philosophy

  • My space maintenance approach began as a culmination of my undergraduate and specialty training. Over the years, it has evolved as I have critically evaluated the success of procedures in my practice, watching what worked and what didn’t. At this point, I’ve settled on an approach that I believe is predictable, efficient, and cost-effective for families. I also never hesitate to ask an orthodontic colleague for their input when in doubt.

  • I believe that forgoing space maintenance often leads to more time consuming and costly treatment (and extractions of permanent teeth) down the road. Pursuing space maintenance when indicated is ultimately the choice of the child’s parent/guardian, but it is my job to at least inform the family of this option at the appropriate time.

    It should also be kept in mind that not everyone can afford orthodontic treatment in the future. Placing a space maintainer may not solve all orthodontic issues, but it will likely prevent the development of a severe malocclusion that could have a negative impact on a child’s quality of life and confidence. How could you not want that as a child’s dentist or parent?

  • I feel that as the dentist, we have the obligation to thoroughly explain the benefits of space maintenance when indicated. If you don’t spend time having the conversation with the family, not everyone will truly appreciate the potential negative consequences of doing nothing. Without space maintenance, life can become far more burdensome both financially and in terms of treatment complexity. I want to know that I have done everything possible to help families understand the long-term implications of their decision.

  • Generally, as the number of teeth to be extracted increases, my threshold for placing a space maintainer decreases. This is because as more teeth are lost, the potential to develop a severe malocclusion increases and the benefits of space maintenance become unquestionable. This notion has been accounted for in the Space Maintenance Calculator.

Appliances

  • It depends on the clinical situation, but generally, I find there are good reasons to place a bilateral SM when possible. In the mandible, due to the typical sequence of eruption, placing a bilateral SM when possible means you avoid having an abutment tooth exfoliate and shouldn’t have to switch to another appliance in the future. Same for the maxillary Es–the D falls out before the second premolar erupts. So this means that placing a bilateral SM right off the bat is often more efficient and cost effective. It also allows you to take advantage of leeway space, allowing for some spontaneous resolution of crowding and giving the orthodontist more room to work with in the future.

    These advantages need to be weighed against the risks. Using a bilateral space maintainer often means you are banding permanent teeth. This increases the risk of decalcification and caries, so oral hygiene and maintenance appointments become even more important. If there are questions about a oral hygiene, behaviour, or parent/guardian cooperation, a bilateral space maintainer resting on permanent teeth may not be the best option.

  • With fixed space maintainers, there are less concerns about compliance. Removable appliances are prone to breakage and loss, which can lead to space loss and increased costs for families.

  • The impact of NOT placing a distal shoe appliance is predictable and dramatic in a negative way. I view it as a disservice to the patient. As Daniel’s literature review has shown, mesialization of the first permanent molar can have a great impact on the occlusion and increase the likelihood of permanent tooth extractions in the future. After 30 years, I can count on one hand the number of distal shoes that didn’t do exactly what I expected them to.

  • There’s always concern about soft tissue irritation or embedding of the appliance, but as long as you are aware of these risks and stress the importance of regular re-evaluation to the family, then the concern is relatively low. If you have a patient with inflammation of the palate, which I find doesn't happen very often, you could leave the appliance out for a few weeks to give things time to heal.

  • Chairside appliances are a convenient and efficient option, especially when a patient is already sedated or under general anesthesia. I often place chairside distal shoes immediately after extracting an E when a child is asleep.

Patient Management

  • I am reluctant to place space maintainers if oral hygiene is poor. I might share my concerns with the family and say “let’s take 2 weeks to improve the oral hygiene, or else we would recommend not inserting the appliance because of the risk to the permanent teeth.” Although I am a strong advocate for space maintenance when indicated, issues can be corrected in the future with orthodontics when oral hygiene is better. But if a permanent molar becomes badly decayed during childhood, the chance of long-term survival is relatively low.

  • You have to make sure parents understand the risks and benefits of pursuing the recommended care. Take your time to ensure families fully appreciate the risks involved with non-compliance and make sure your informed consent is thorough. As long as you cover your bases, I think parents/guardians should always make the final decision.

  • If a primary molar is lost at a very young age, it may not be practical to place a space maintainer at that time. For example, if a 3 year old loses an E and the permanent tooth is still deep within the bone, I would prefer to monitor the space / tooth over time. Placing an appliance at that age is an incredible responsibility for both the child and family and you, as a dentist. The chance of the appliance not becoming an issue - especially a distal shoe appliance - over time, and well before the permanent molar emerges, is rather small.

    I would prefer instead to inform the family as to when the tooth is likely to erupt and make plans accordingly. That is, I would remind the family that an appliance is indicated and that there is always a chance that the tooth will migrate even before it erupts. Therefore, radiographic evaluation over time is warranted and that should allow one to place an appliance prior to any pre-eruptive space loss and prior to the actual eruption of the tooth.

  • Let’s think about this in the context of space maintenance. If a child is under 8 years old, you can assume the root of the permanent successors (premolars) is quite low and the tooth will not be erupting soon. If the child is 8 year old or more, you should be assessing root development using a radiograph. A periapical radiograph works well, but if the child has not had a pan yet, now would be an appropriate time to take one. It will allow you to assess root development in multiple quadrants and assess the overall growth and development of the child.

Orthodontics

  • I personally do not, but I do think it can be a valuable service for patients. A lower lingual arch or Nance could preserve leeway space, anchorage, and be an important step in space supervision. If I think a child might benefit from a LLA or Nance for orthodontic reasons, I would make a referral to an orthodontic colleague to ask for their input. If they agree it is indicated, I am happy to let them place the appliance or place it myself–whatever works best for the family.

  • It becomes quite clear that space maintenance is far more complex than focusing only on the space left behind by the loss of a primary tooth. If we strive to provide the highest standard of care for our patients based on the literature that’s available, there are many factors we should be considering for each unique patient. I think it also reinforces collaboration with our orthodontic colleagues.

  • As a paediatric dentist, I choose to focus purely on space maintenance. I prefer to leave space regaining and comprehensive orthodontic plans to the orthodontists–the people who do it more often. That said, if I see a situation where it looks like space regaining may be beneficial, I’ll happily make a referral to an orthodontist for their input.

  • We programmed the calculator to recommend “consider referral” whenever the situation becomes more complex for my liking. When I believe something is beyond my level of expertise, I am a big believer in getting an opinion from an orthodontist to avoid missing out on an opportunity to intervene at the most appropriate time. This includes cases with pre-existing space loss, missing permanent teeth, a lack of abutments for space maintainers, severe crowding (i.e. extractions of premolars may be needed anyway), etc.

    In short, I refer cases to orthodontists when I am not certain that placing a space maintainer will be of benefit to my patient. This of course is affected by my choice not to undertake any active orthodontic treatment. If you are someone with a greater understanding of orthodontics and would like to treat the case comprehensively, then a referral may not be necessary for you.

Other questions?

Feel free to reach out!