Saudi Dental Journal (2019) 31, 165–172

King Saud University

Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

REVIEW ARTICLE

Survival rate of different fixed posterior space

maintainers used in Paediatric Dentistry – A
systematic review
Mahesh Ramakrishnan a,*, R. Dhanalakshmi a, E.M.G. Subramanian b

a
Department of Pediatric Dentistry, Saveetha Dental College, Saveetha University, Chennai, India
b
Department of Pedodontics and Preventive Dentistry, Saveetha Dental College, Chennai, India

Received 7 November 2018; revised 5 February 2019; accepted 7 February 2019

Available online 14 February 2019

KEYWORDS Abstract Purpose: Space Maintainers have long been used for the management of space loss in
Survival rate; primary and mixed dentition, but there is a need to have an evidence based approach when selecting
Longevity; the most appropriate space maintainer for space management in children. This systematic review
Fixed space Maintainer; aimed to assess the survival rate of space maintainers in children.
Band and loop Methods: A systematic literature search was conducted until October 2017 using PubMed, Sco-
pus, and The Cochrane Central Register of Controlled Trials databases to identify peer- reviewed
papers published in English. Search keywords and MeSH headings include ‘‘primary dentition” and
‘‘Fixed Space maintainers”. The inclusion criteria were clinical studies conducted in children less
than 12 years of age, who required unilateral or bilateral fixed space maintainer. Retrieved papers
were evaluated by four reviewers independently to assess suitability for inclusion in the systematic
review and the final decision was made by consensus. Qualities of the included studies were assessed
using Quality of Reporting of Observational Longitudinal Research by Oxford Academics and data
were extracted for analysis.
Results: The search identified a total of 39 papers for screening after removal of duplicate arti-
cles. Among the retrieved studies, 23 papers did not satisfy the study inclusion criteria. Conse-
quently, 16 full text articles were retrieved and reviewed. Finally, those 11 papers which fulfilled
all the inclusion criteria were selected and reviewed systematically. Most of the clinical trials were
assessed as having moderate and low risk of bias.
Conclusion: There is a wide variation in the survival rate of metal based and resin based space
maintainers and also within the metal based space maintainers. There is an inadequate evidence

* Corresponding author.
E-mail address: mahesh@saveetha.com (M. Ramakrishnan).
Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

https://doi.org/10.1016/j.sdentj.2019.02.037
1013-9052 Ó 2019 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
166 M. Ramakrishnan et al.

to recommend one best fixed space maintainer due to lack of properly designed studies. Hence, clin-
ical trial comparing different types of metal based space maintainer and resin based space main-
tainer with longer duration of follow-up must be performed to evaluate its survival rate.
Ó 2019 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.1. Inclusion criteria for considering studies for this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.2. Type of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.3. Types of participants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.4. Type of intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.5. Outcome measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.6. Exclusion criteria for considering studies for this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.7. Search Methods for identification of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.8. Manual printed copy search. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.9. Details of search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.9.1. PubMed-MeSH terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.10. Data collection and analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.10.1. Screening and selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
2.11. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
4.1. Assessment of individual space maintainers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
4.1.1. Band and loop space maintainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
4.1.2. Crown and loop space maintainer:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.1.3. Nance palatal arch space maintainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.1.4. Lower lingual arch space maintainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.1.5. Resin space maintainers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.1.6. Simple fixed space maintainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.1.7. Direct bonded space maintainer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
4.1.8. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Ethical statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

1. Introduction less tolerance by the child, high chances of appliance dislodge-

ment, the usage of fixed space maintainers would be more
One of the greatest challenges in Paediatric dentistry is the appropriate for longer periods of space maintenance. Though,
management of space loss due to untimely loss of primary fixed space maintainers are well tolerated and durable; they
teeth. An array of events occur, as the occlusion develops from should be removed once a year to allow inspection, cleaning,
the primary dentition through the transitional (or mixed) den- and application of fluoride to the teeth.
tition to the permanent dentition stage, these events play an Resin bonded space maintainers gained popularity due to
imperative role for a functional, esthetic and stable occlusion. ease of bondability, ease of fabrication, patient comfort; it
If this continuance is disrupted, it may eventually affect the eliminates the need of annual inspection as in case of other
ultimate occlusal status of the permanent dentition (Dean fixed space maintainers and can be used as a viable alternative
et al., 2004). These problems can be prevented or their severity to the conventional fixed space maintainers (Kargul et al.,
can be alleviated if the practitioner employs an adequate plan- 2005). Though resin space maintainers holds several advan-
ning and space maintenance during initial treatment in the tages, a study conducted by Saravanakumar et al. (2013) stated
mixed dentition (Choonara, 2005). that, resin fiber space maintainers can be accepted as a success-
Various appliances can be used for space maintenance ful space maintainer only for a short period of time.
based on patient’s age, growth and development of dental There are only a few studies on the Survival rate of various
arches and ability to co-operate. Since removable space fixed space maintainers (metal based and resin based). How-
maintainers have several disadvantages like poor retention, ever, as a Paediatric dentist or as a General Practitioner, it is
Survival rate of fixed Posterior Space maintainers 167

important to have a clear knowledge on the survival rate of  Cochrane central (Upto June 2017)
different space maintainers. Love and Adams (1971) had  SIGLE (Upto 2017)
reported that a significant amount of space loss occurs due
to mesial migration of the posterior teeth. So, it is more impor- Articles in English were only applied during the electronic
tant to assess the survival rate of posterior space maintainers, search to include all the possible clinical trials in the potential
as it preserves arch length and circumference. relevant article search phase of the systematic review.
The survival rate of space maintainers used in the primary
and mixed dentition was not reviewed and reported. There is a 2.8. Manual printed copy search
need for a systematic review to critically appraise and summarise
the results of clinical trials evaluating the survival rate of various  Journal of Clinical Paediatric Dentistry (JCPD)
fixed posterior (metal based and resin based) space maintainers.  Pediatric Dentistry
This systematic review aimed to assess the survival rate of differ-  International Journal of Paediatric Dentistry (IJPD)
ent types of space maintainers indicated in children.  Journal of Dentistry for Children
 Journal of Indian Society of Pedodontics and Preventive
2. Materials and methods
Dentistry(ISPPD)

2.1. Inclusion criteria for considering studies for this review

2.9. Details of search
Inclusion criteria for considering studies for this review were
set prior to the search. They were as follows 2.9.1. PubMed-MeSH terms
((((((((((((((((((((((((((child) OR children) OR Paediatric) OR
2.2. Type of studies Paediatric patients) OR primary dentition) OR deciduous den-
tition) OR mixed dentition) OR transition dentition) OR child
 Randomized controlled trial with extracted primary molars) AND ((((((((((((((((((((space
 Prospective longitudinal study maintainer) OR space maintainers) OR fixed space maintain-
ers) OR fixed posterior space maintainers) OR unilateral space
maintainer) OR bilateral space maintainer) space maintain-
2.3. Types of participants ers))AND ((((((longevity) OR durability) OR failure rate)
OR success rate) OR survival period) OR survival rate).
 Children less than 12 years of age
 Children who require space maintainer 2.10. Data collection and analysis
 Children with unilateral or bilateral missing primary molars
2.10.1. Screening and selection
Three review authors (DR), (EMG) and (MR) independently
2.4. Type of intervention assessed the titles and abstracts of studies resulting from the
searches. Full articles of those studies which met the inclusion
 Fixed posterior space maintainers (metal based and resin criteria, or for which there were insufficient data in the title
based space maintainers)

2.5. Outcome measures

 Survival/longevity of space maintainers

 Success rate of space maintainers
 Failure rate of space maintainers

2.6. Exclusion criteria for considering studies for this review

 Studies on removable space maintainers

 Studies on method of fabrication
 Literature review
 Retrospective studies

2.7. Search Methods for identification of studies

The following search engines were used:

 PubMed (Upto June 2017)

 PubMed Advanced Search Fig. 1 PRISMA flow diagram.
 168
Table 1 General information of selected articles.
S. Author and year Study design Sample size Follow up Age Intervention Variables evaluated
No. duraTION
1 Baroni et al. Prospective 61 patients 36 Months 5– Lingual arch -36 Cement loss, Solder failure, Soft tissue lesion,
(1994) clinical trial 9 years Band and loop-33 Eruption interference.
Nance palatal arch-19
2 Simsek et al. Prospective 51 patients 18 Months 7.3 years Simple fixed space maintainer-64 Broken wire ends, loss of composite resin, angular
(2004) clinical trial (Male-32 changes in the abutment tooth
Female-19)
3 Kargul et al. Prospective 19 patients 12 Months 8.4 years Glass Fiber Reinforced Compoite Resin Bonding failures
(2005) clinical trial (Male-14 Space maintainer-23
Female-5)
4 Subramaniam Prospective 30 patients (Male-23 12 Months 6– Conventional band and loop-30 Cement loss, Solder failure, Soft tissue lesion,
et al. (2008) clinical trial Female-7) 8 years GFRCR space maintainer-30 Distortion, Debonding, fracture of fibre frame.
5 Sasa et al (2009) Prospective 40 patients(Male- 40 Months 3.4– Band and loop-40 Cement loss, Solder failure, Soft tissue lesion
clinical trial 18Female-22) 7.3 years
6 Tunc et al. (2012) Randomized 30 patients 12 Months 6.9 years Band and loop-10 Distortion, cement loss, Loop fracture, Caries or
clinical trial (Male-13 Direct bonded-10 gingival inflammation, broken wire, bond failure,
Female-17) Fibre-reinforced-10 debonding, fracture f fibre frame
7 Saravanakumar Prospective 30 patients 18 Months 6– Fibre- reinforced composire resin Debonding, fracture of fibre frame, gingival
et al. (2013) clinical trial (Male-12 9 years (FRCR) space maintainer -30 inflammation
Female-18)
8 Setia et al. (2014) Randomized 30 patients 9 Months 4– Conventional band and loop-15 Survival rate (successful, failed, loss of follow up,
clinical trial (Male-13 9 years Prefabricated band with custom made censored at the end of study), caries, gingival health,
Female-17) loop-15 Debonding, fracture of fibre frame.
Ribbond-15
Super splint-15
9 Garg et al. (2014) Prospective 30 patients 6 Months 5– Conventional band and loop-15 Patient acceptance, Debonding, fracture of fibre
clinical trial 8 years FRCR space maintainer-15 frame, cement loss, Distortion of band, Slippage of
band gingivally, Fracture of loop
10 Qudeimat and Prospective 36 patients 52 Months 3.4– Band and loop 18 Decementation, solder breakage, soft tissue lesion
Sasa (2015) clinical trial (Male-16 6.3 years Crown and loop 18
Female-20)
11 Kirzioglu et al. Prospective 44 Patients (Male-11, 24 Months 6– Fibre reinforced composite resin space Debonding and dislodgement of space maintainers,

M. Ramakrishnan et al.
(2017) clinical trial Female-33) 10 years maintainer status of abutment teeth, and oral hygiene
Survival rate of fixed Posterior Space maintainers 169

and abstract to make a clear decision, were retrieved. DR,

et al. (2017)
Kirzioglu EMG and MR assessed the full text papers independently to
establish whether the studies met the inclusion criteria or

Yes

Yes
Yes
Yes

Yes

Yes

Yes
not. Studies fulfilling the inclusion criteria then underwent

No

No

No
quality assessment and data extraction.
(2014)

2.11. Data extraction

Garg
et al.

Yes

Yes
Yes
Yes

Yes

Yes

Yes
No

No

No
Data were extracted independently and in duplicate by three
review authors (DR, EMG and MR). Titles of articles relevant
Qudeimat
and Sasa

to the review were selected by discussion. Forty titles were

(2015)

identified from the electronic and Seventeen from manual

Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes
No

No
printed copy search. Abstracts and full texts of the articles
were reviewed independently. After reviewing the articles inde-
pendently, eleven articles were selected.
(2014)
et al.
Setia

Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes
No

No
3. Results
Saravanakumar

A total of 11 studies were identified for inclusion in the review.

et al. (2013)

The search of PubMed and MesH data bases provided a total

of 32 articles. Cochrane library search provided 8 articles. Of
Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes
No

No

these 40 articles, 29 articles were excluded after reading the title

and abstracts, as these papers did not meet the inclusion crite-
ria. The full texts of the included 11 articles were reviewed in
(2012)
Tunc
et al.

detail. Fig. 1 depicted the flow chart of complete data collec-

Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes

Yes

No

tion search process.

There were 4 studies which directly compared Metal and
Resin space maintainers (Subramaniam et al., 2008; Tunc
(2009)
et al.
Sasa
Quality assessment based on quality of reporting of observational longitudinal research.

Yes

Yes

Yes

Yes

Yes

Yes

Yes

et al., 2012; Setia et al., 2014; Garg et al., 2014). All these 4
No

No

No

studies compared only Band and Loop space maintainers with

different resin space maintainers. Two studies had compared
Subramaniam
et al. (2008)

the survival rate of fixed metal space maintainers, namely,

Band and loop, Lingual arch space maintainer, Nance palatal
arch space maintainer and crown and loop space maintainer
Yes

Yes
Yes
Yes

Yes

Yes

Yes

Yes
No

No

(Baroni et al., 1994; Qudeimat and Sasa, 2015). Two studies

reported only the survival rate of a particular fixed metal space
maintainer (Simsek et al., 2004; Sasa et al., 2009) and 3 studies
Kargul

(2005)
et al.

had evaluated the survival rate of a solitary resin space main-

Yes

Yes

Yes

Yes

Yes

Yes

Yes
No

No

No

tainer (Kargul et al., 2005; Saravanakumar et al., 2013;

Kirzioglu et al., 2017).
Information regarding the study characteristics of the
Simsek

(2004)
et al.

included studies such as study design, setting, population, sam-

Yes

Yes
Yes
Yes

Yes

Yes
No

No

No

No

ple size, interventions, outcome measures, follow-up intervals

was depicted in Table 1. Quality assessment of each article
with the risk of bias was done based on Quality of Reporting
Baroni

(1994)
et al.

of Observational Longitudinal Research. (Table 2) Risk of

Yes

Yes

Yes

Yes
No

No

No

No

No

No

bias was considered as low, if 8 or more than 8 criteria were

satisfied. Risk of bias was considered as moderate if more than
Was the type of analyses conducted
Were confounders accounted for in
Are the objectives or hypotheses of

Were reasons for loss to follow-up

Was the number of participants at

Was the number of participants at

5 criteria but less than 7 criteria were satisfied and considered

the beginning of the study stated?

Was loss to follow-up taken into

Is the study population defined?

as high if 5 or less than 5 criteria were satisfied (Fig. 2).

Is the number of participants
Are eligibility criteria stated?

Among the 11 included studies, all the studies had stated

each stage/wave specified?

the hypothesis/objective of the study, defined the study popu-

account in the analysis?

lation and mentioned the number of participants at the begin-

Quality assessment

ning of the clinical trial. Two studies did not account on the
the study stated?

eligibility criteria of the participants (Baroni et al., 1994;

Kargul et al., 2005) and four studies did not address the num-
quantified?

analyses?

justified?

ber of participants available at each stage of the follow-up

stated?

(Baroni et al., 1994; Simsek et al., 2004; Qudeimat and Sasa,

2015; Garg et al., 2014). In addition, 2 studies did not specify
Table 2

the reasons for loss of follow-up (Baroni et al., 1994; Kirzioglu

No.

10.

et al., 2017). Only 3 studies evaluated the confounding

S.

1.

2.
3.
4.

5.

6.

7.

8.

9.
170 M. Ramakrishnan et al.

Table 3 Interpretation of results.

S. Author and year Interpretation of results
No.
1. Baroni et al. At the 24–36 month interval, Nance
(1994) palatal arch and band and loop space
maintainer maintained a 70% constant
survival, while the lingual arch rapidly
declined to 40%
2. Simsek et al. 95% of Simple Fixed space maintainer
(2004) survived at the end of 18 months
3. Kargul et al. The success rate was found to be 43% at
(2005) the end of 12 months and failures were
mainly due to debonding. Fibre-
reinforced may be a alternative to
conventional space maintainers used in
pediatric dentistry
4. Subramaniam The overall success rate was 55% for
et al. (2008) GFRCR and 33.3% for band and loop
space maintainers for a follow up time
period of 12 months
5. Sasa et al. (2009) The 40 months failure rate of the band
Fig. 2 Risk of bias of the selected article.
and loop space maintainer was found to
be high (57.5%). The main reason for
failure was decementation of the space
variables (Tunc et al., 2012; Qudeimat and Sasa, 2015;
maintainer
Kirzioglu et al., 2017), one study did not interpret the type
6. Tunc et al. The survival rate was higher for band and
of statistical analysis used (Simsek et al., 2004) and only one (2012) loop (11.2 months), followed by direct
study did not account the loss of follow-up in the statistical bonded (9.2 months) and fibre reinforced
analysis (Baroni et al., 1994). Moreover, none of the included space maintainer (6.7 months)
studies have justified the sample size. The results of each 7. Saravanakumar The failure rate was higher for ribbond
included article according to their survival rate, success and et al. (2013) space maintainer (53%) at the end of
failure rate was presented in Table 3. 18 months. Ribbond space maintainer
can be used as a successful space
maintainer only for short periods
4. Discussion
8. Setia et al. Prefabricated band with custom made lop
(2014) exhibited maximum success rate (84.6%),
This systematic review was undertaken to evaluate the survival followed by conventional band and loop
rate of different fixed space maintainers (metal based and resin (73.3%) and ribbond space maintainer
based) used in Paediatric dentistry. It has shown that there is (45.4%) for the time duration of
an inadequate scientific evidence to provide a definitive infer- 9 months
ence on the survival rate of fixed space maintainers, as there 9. Garg et al. For the time frame of 6 months fibre
(2014) reinforced space maintainer exhibited
was no direct comparison of all the fixed space maintainers
higher success rate (63.3%) compared to
in a solitary study and also due to variation in the follow-up band and loop space maintainer (36.7%)
period in each study. Importantly, there were only 4 clinical 10. Qudeimat and Band and loop exhibited higher failure
trials on comparing metal and resin space maintainers and Sasa (2015) rate (83%) compared to crown and loop
those 4 studies compared only band and loop space maintain- space maintainer (22%) at the end of
ers with resin space maintainer. There was no meaningful com- 52 months follow up
parison to arrive at a decision on which space maintainer 11. Kirzioglu et al. Fibre Reinforced composite resin space
serves its best. The included studies were all prospective longi- (2017) maintainer exhibited 52.2% of success
tudinal clinical trials. This systematic review did not include rate at the end of 24 months follow up
other type of studies such as fabrication techniques, case
reports and reviews in order to maintain the homogeneity with
it is possible to conduct a randomized clinical trial in future by
the study design.
addressing all the drawbacks of the available studies.
Quality assessment of the selected articles was done using
Quality of Reporting of Observational Longitudinal Research
4.1. Assessment of individual space maintainers
and the risk of bias was evaluated based on the articles fulfill-
ing these criteria. Out of 11 included studies, providentially,
only one study carried a high risk of bias. (Table 2) This sys- 4.1.1. Band and loop space maintainer
tematic review included only clinical trials as there were no Out of 11 included studies, 7 studies had evaluated the survival
randomized clinical trials conducted to evaluate the survival rate of band and loop space maintainers. Baroni et al. (1994)
rate of fixed space maintainers due to general problems, such had stated that, there was no significant difference in the sur-
as ensuring equal dental treatment in both study arms, blind- vival rate of band and loop, Lingual arch and Nance palatal
ing and difficulty to allocate equal number of specific space arch space maintainer. Most of the included studies had stated
maintainers for all the treatment groups. Though it is difficult, that, band and loop space maintainer exhibited higher survival
Survival rate of fixed Posterior Space maintainers 171

rate and the most common reason stated for the failure of the clinician experience and selection of patients. Though the
appliance was cement failure and solder breakage author proved it as a successful appliance, no relevant compar-
(Subramaniam et al., 2008; Sasa et al., 2009; Tunc et al., ison was done with other fixed space maintainers. Hence, clin-
2012; Setia et al., 2014; Garg et al., 2014). Based on the above ical trials comparing simple fixed space maintainer with other
mentioned studies, it can be declared that, band and loop pro- space maintainers are required to ensure its success rate and
vided satisfactory results in terms of its survival rate. Unfortu- survival rate.
nately, a study conducted by Qudeimat and Sasa (2015) had
disclosed that, band and loop exhibited a lesser survival time 4.1.7. Direct bonded space maintainer
of 18.8 months as compared to that of crown and loop space Tunc et al. (2012) evaluated the survival rate of Direct bonded
maintainer (40.4 months). So, further clinical trials comparing space maintainer and compared with Band and loop space
band and loop and crown and loop with a larger sample size is maintainer and fibre reinforced space maintainer. The author
required to draw a definitive conclusion. had stated that the direct bonded space maintainer exhibited
a high failure rate of 60% with the survival period of
4.1.2. Crown and loop space maintainer: 9.2 months. A study conducted by Swaine and Wright (1976)
A study by Qudeimat and Sasa (2015) assessed the survival has stated a 70% success rate for Direct Bonded space main-
rate of crown and loop space maintainer and concluded that tainer. Debonding and swallowing of the broken wires are con-
it had higher survival rate as compared to band and loop space sidered as risk factors in fabrication of direct bonded space
maintainer. Hence, further clinical trials are needed to evaluate maintainer. Due to these conflicting results, further studies
the survival rate of crown and loop space maintainer and its are needed to obtain a better conclusion on its survival period
comparison with other types of fixed space maintainers. and success rate.

4.1.8. Limitations
4.1.3. Nance palatal arch space maintainer
Shortcomings of the included studies were, lacking a proper
Out of the 11 included studies, only one prospective longitudi-
study design and insufficient reporting of data, namely sample
nal study evaluated the survival rate of Nance palatal arch
selection, allocation, randomization, blinding and follow-up
space maintainer. The author had concluded that, the Nance
period. Sample size calculation and the power of the study
palatal arch maintained a constant survival rate of 70% at
were not mentioned in any of the included study. The conclu-
the end of 36 month interval (Baroni et al., 1994). Since Nance
sion would have been more meaningful if all these confounders
palatal arch exhibited a high survival rate, it is imperative to
were addressed. Though we maintained homogeneity in study
compare its survival rate with other fixed metal and resin space
selection, Meta analysis interpretation was not possible due to
maintainer.
lack of comparison of similar space maintainers in any of the
included studies.
4.1.4. Lower lingual arch space maintainer
The drawback of this systematic review is the effect of con-
Baroni et al. (1994) evaluated the survival rate of lingual arch founding factors (age, sex, dental arch, side of jaw) in each
space maintainer. The author had stated that lingual arch study variables which can directly influence the survival rate.
space maintainer had higher number of failures as compared Since there is no properly designed clinical trial which com-
to band and loop space maintainer and Nance palatal arch pared the different types of space maintainer, no definitive
space maintainer. The possible explanation for the failure of conclusion can be drawn. Hence, a properly designed clinical
lingual arch space maintainers were tongue interferences, high trial comparing different types of metal based space maintainer
occlusal load and long span arm (Qudeimat and Fayle, 1998; and resin based space maintainer with longer duration of
Moore and Kennedy, 2006). follow-up must be performed to evaluate its survival rate.

4.1.5. Resin space maintainers 5. Conclusion

Few studies have assessed the survival rate of resin space main-
tainers but none of the studies had proved that it is superior In the light of available evidences, following conclusion can be
over metal space metal maintainers (Kargul et al., 2005; drawn.
Saravanakumar et al., 2013; Subramaniam et al., 2008; Tunc
et al., 2012; Garg et al., 2014; Kirzioglu et al., 2017). Even  There is a wide variation in the survival rate of metal based
though, resin space maintainer has several advantages like ease and resin based space maintainers and within the metal
of fabrication, less bulky, patient compliance, still a well based space maintainers.
designed clinical trial with adequate follow up period is  There is an insufficiency of evidences to make any recom-
required to evaluate its longevity. mendation on which fixed space maintainer is appropriate
due to lack of properly designed studies.
4.1.6. Simple fixed space maintainer  Most of the included studies have assessed the survival rate
Simsek et al. (2004) assessed the clinical performance of simple of Band and loop space maintainer and direct comparison
fixed space maintainer and followed up longitudinally for a of Resin space maintainer was done only with band and
period of 12–18 months. This is the one of the first study to loop space maintainer. Meaningful comparison of survival
design and assess the survival rate of simple fixed space main- rate of metal and resin based space maintainers cannot be
tainer. The author had concluded that there was no loss of made from these studies, as there was no uniform distribu-
abutment space during the follow- up period and can be tion of types of space maintainers selected in the included
considered as a successful fixed space maintainer based on studies.
172 M. Ramakrishnan et al.

Ethical statement Kirzioglu, Z., Ciftci, Z.Z., Yetis, C.C., 2017. Clinical success of fiber-
reinforced composite resin as a space maintainer. J. Contemp.
Dent. Pract. 18 (3), 188–193.
We further confirm that any aspect of the work covered in this Love, W.D., Adams, B.L., 1971. Tooth movement into edentulous
manuscript that has involved either experimental animals or areas. J. Prosthet. Dent. 25 (3), 271–278.
human patients has been conducted with the ethical approval Moore, T.R., Kennedy, D.B., 2006. Bilateral space maintainers: a 7-year
of all relevant bodies and that such approvals are acknowl- retrospective study from private practice. Pediatr. Dent. 28 (6), 499–505.
edged within the manuscript. Qudeimat, M.A., Fayle, S.A., 1998. The longevity of space maintain-
ers: a retrospective study. Pediatr. Dent. 20 (4), 267–272.
Qudeimat, M.A., Sasa, I.S., 2015. Clinical success and longevity of
Conflict of interest
band and loop compared to crown and loop space maintainer. Eur.
Arch. Paediatr. Dent. 16 (5), 391–396.
The author declared that there is no conflict of interest. Saravanakumar, M.S., Siddaramayyal, J., Gugnanai, N., Gupta, M.,
2013. Fiber technology in space maintainer: a clinical follow-up
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