IJCPD

Shantanu S Deshpande et al. 10.5005/jp-journals-10005-1554

REVIEW ARTICLE

Survival of Bonded Space Maintainers: A Systematic Review

1
Shantanu S Deshpande, 2Vikas D Bendgude, 3Vivian V Kokkali

ABSTRACT children. Although they are used for mastication, speech,

growth of the jaws, esthetics, and guidance of normal
Aim: This systematic review was aimed at evaluating the
function; primary teeth most importantly serve as a
average survival time and the various factors which determine
the longevity of bonded space maintainers. natural space maintainer for their permanent successors.1
Pre-mature loss of primary teeth, especially the molars
Background: Although a meta-analysis could not be per-
formed from the available literature, this review emphasizes
could eventually lead to mesial drifting of the posterior
the various factors contributing to the success of bonded space teeth, crowding in the dental arches, changes in the arch
maintainers and its relevance during the planning of bonded circumference, which may eventually result in insufficient
space maintainers. space for the eruption ofthe permanent teeth.2-4 The use
Review results: The study selection criteria included in-vivo of space maintainers is the recommended treatment for
randomized and non-randomized clinical trials performed the protection of dental arch relations.
which was published in English. The databases searched Space maintainers can be broadly classified as removable
were Pubmed, EBSCOhost and Google scholar, wherein the or fixed space maintainers.1 Removable space maintainers
articles published from 1st January 1995 to 31st December
2015 were selected in the review.
are usually functional and are easy to clean which can help
in maintaining good oral hygiene. However, the success of
Conclusion: From the existing data, it can be concluded that
these removable appliances heavily weighs on the patient
the average survival period of bonded space maintainers is
11.2 months. However, there is a necessity for additional clini- compliance and considering that the patients are mostly
cal trials with strict protocols to better the level of evidence. children, compliance becomes a problem. Moreover, there
is always a chance for these appliances of being fractured
Clinical significance: From the various articles included in the
review, the longevity of bonded space maintainers was found or misplaced.5 On the other hand, fixed space maintainers
to be comparable to the banded space maintainers. Hence, reduce the need for patient compliance, require minimal care,
the bonded space maintainers can be a suitable alternative to and are relatively comfortable and acceptable to the patient.
the banded space maintainers in pediatric dentistry. The conventionally fixed space maintainersare mostly
Keywords: Bonded space maintainers, Longevity, Survival banded.6 It requires less chair-side time, easy to fabricate,
rate. adapts easily to the changing dentition and is extremely
How to cite this article: Deshpande SS, Bendgude VD, economical. Although the banded applianceis being used
Kokkali VV. Survival of Bonded Space Maintainers: A Syste­ successfully, they do have certain disadvantages like:4
matic Review Int J Clin Pediatr Dent. 2018;11(5):440-445. • Two visits are required, therefore cannot be planned
Source of support: Nil in patients under general anesthesia.
• May lead to tipping and rotation of the abutment teeth.
Conflict of interest: None
• Occasionally, requires some preparation in the abut-
ment teeth.
• Requires laboratory procedures.
BACKGROUND
• Dislodgment of the band due to loss of the luting cement
Space maintenance is an indispensable part of Pediatric • Impingement of the soft tissue because of slipping of the
Dentistry and is the primary preventive orthodontic care loop gingivally, as it is a cantilever type of an appliance.
that is provided to avoid future dental anomalies. Primary • Plaque accumulation at the band-tooth interface could lead
teeth play a critical role in the growth and development of to incipient carious lesions and gingival inflammation.
• There also have been cases of metal allergy.7-9
1
Postgraduate Student, 2Professor and HOD, 3Senior Lecturer These disadvantages have led clinicians to develop a
1-3
Department. of Pedodontics, Dr. D.Y Patil Dental College, more viable alternative to the traditional space maintainers.
Pimpri, Pune, Maharashtra, India Swaine et al.10 was the first to use bonded space maintain-
Corresponding Author: Shantanu S Deshpande, Department. ers and reporteda 70% success rate. Over the past few
of Pedodontics, Dr. D.Y Patil Dental College, Pimpri, Pune, decades, adhesive technology is being harnessed to replace
Maharashtra, India, Phone: 022 28186564, e-mail: drshantanu. the conventional space maintainer in the form of direct
[email protected]
bonded space maintainers (Ribbond®), fiber-reinforced

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 IJCPD

Survival of Bonded Space Maintainers: A Systematic Review

composite space maintainers (Super Splint®), and prefab- Inclusion Criteria

ricated space maintainers (Splint-In®). Also, orthodontic
• Articles in English or those having a detailed
stainless steel wires have been used in the form of a loop
summary in English.
and directly bonded to the tooth.
• Studies published between 1st January 1995 and 31st
The bonded space maintainers have certain advantages
December 2015.
over the conventional banded space maintainers. They
• Studies that provided information for age groups
can be delivered to the patient in a single appointment,
< 18 from either sex.
eliminating the need for laboratory procedures. Moreover,
• Well defined information on the survival rate of
it also reduces the chances of plaque accumulation which
bonded space maintainers in maxillary and man-
helps maintain the health of hard and soft tissues in the oral
dibular arches.
cavity. The existing literature on bonded space maintainer,
evaluates the following parameters, namely, the survival Exclusion Criteria
period, gingival and periodontal health, condition of the
abutment tooth and the time required for fabrication of • Review
the appliance. Survival of the space maintainer until the • Case reports
eruption of the succedaneous tooth is the most important • Abstracts
factor in determining the success of the bonded appliance • Letters to editors
as it measures the primary function of space maintenance. • Editorials
Hitherto, no systematic reviews have been performed • In-vitro studies.
on the survival time of bonded space maintainers. Hence, All the studies identified by applying the inclusion
this systematic review was aimed at evaluating, the and exclusion criteria underwent assessment for data
average survival time andthe factors which determine extraction by a single reviewer. The data were extracted
the longevity of bonded space maintainers. using specifically designed data extraction forms. For
each included study, the qualitative and quantitative
DATA SOURCES information was extracted, including year of publication,
experimental and control treatments, numbers and ages
This systematic review was performed in accordance with of patients, treatment and follow-up durations, author’s
the Preferred Reporting Items for Systematic Reviews conclusions and all the information needed for methodo-
and Meta-Analyses (PRISMA) guidelines. A systematic logic quality evaluation.
computerized search was performed on three electronic
databases: PubMed, EBSCOhost and Google Scholar. The REVIEW RESULTS
various keywords used to search articles in the PubMed
The database search showed 18 articles on Pubmed,
and EBSCOhost databases were as follows:
21 articles on EBSCOhost and 13 articles on Google Scholar.
• “Space maintainers and survival rate."
Four articles were added after hand searches of the bib-
• "Space maintainers and longevity."
liographies of the selected articles. By using the PRISMA
• "Space maintainers and maxillary arch."
flow diagram (Fig. 1), an overview of the article selection
• "Space maintainers and mandibular arch."
process can be illustrated. After exclusion of the duplicate
• "Fixed space maintainers and survival rate."
articles 25 articles were finally selected for the study.
• "Fixed space maintainers and longevity."
In the first step of the screening process, further 14
• "Bonded space maintainers and survival rate."
articles were excluded because they were determined to
• "Bonded Space maintainers and longevity."
be irrelevant based on titles and abstracts. In the second
Hand searches were undertaken to find additional rele­
step of the screening process, further four articles were
vant published material that might have been missed in
excluded because they did not meet the inclusion and
electronic searches. The articles published from 1st January
exclusion criteria (Table 1). Thus, the selection process
1995 to 31st December 2015 were included in the study.
resulted in seven full-text articles (Table 2).
In the first step of the screening process, titles and
abstracts were used to identify full articles concerning
DISCUSSION
the survival times of bonded space maintainers used in
the pediatric populations. In spite of many studies investigating the survival rate of
In the second step of the screening process, the duplicates bonded space maintainers, only seven studies were con-
from the respective searches were removed, and one single sidered appropriate for inclusion in this systematic review.
article was selected. In the third step, these articles were sub- It was not possible to formulate a quantitative conclusion
jected to the inclusion and exclusion criteria of the review. since the study designs were very different from each other.

International Journal of Clinical Pediatric Dentistry, September-October 2018;11(5):440-445 441

Shantanu S Deshpande et al.

PRISMA 2009 Flow Diagram

Fig. 1: Prisma flow diagram

Table 1: Excluded articles with reasons Table 2: Selected articles

Sr Year of Sr no Study Year of publication
No Study publication Reason for exclusion 1 Simsek et al. 2004
1 Yilmaz et al. 1999 Only abstract in 2 Kirzioglu et al. 2004
English
3 Subramaniam P et al. 2008
2 Negi KS 2010 Descriptive study 4 Emine Sen Tunc et al. 2012
3 Bhasin et al. 2011 Case report 5 Setia et al. 2014
4 Yeluri et al. 2012 Descriptive study 6 Garg et al. 2014
7 Serkan Gulec et al. 2014

Relative to the study designs included in this review, two bonded appliance was fabricated using orthodontic
were non-randomized clinical trials,4,11 four studies were stainless steel wire, in which the loop was bonded to
randomized clinical trials,12-15 and one was an experimen- permanent molars using a Single Bond® system and
tal study16 evaluating the survival rate of bonded space Tetric Flow® composite resin. The study was carried
maintainers. The summary of all the included articles has out in children with an average age of 7.3 years which
been described in Table 3. The advantage of a selection of is ideal because the chronological age of eruption of
randomized clinical trials over cohort and non-randomized premolars is 10 to 12 years.
trails is the random allocation and avoidance of bias. The parameters that determine the longevity include
There are different criteria to evaluate the success the type of isolation technique used, arch in which space
of bonded space maintainers. These include the lon- maintainers were given, the bonding systems used, com-
gevity of space maintainers, gingival health, plaque posite kind of resin used and the abutment tooth (primary
accumulation, the condition of the abutment tooth and or permanent tooth) being bonded.
the ease to fabricate the appliance. The most important The various methods of isolation like cotton rolls
being their longevity and their ability to maintain space and saliva ejectors have been used,16 but the rubber dam
which is their primary function. From the selected provides optimum isolation. The rubber dam when used
studies, the patients were being followed-up from makes moisture contamination negligible.12,15 This, in
9 to 18 months. On an average, the survival time of turn, enhances the bonding of the space maintainers
bonded space maintainers was 11.2 months depend- to the abutment tooth. Hence, the use of rubber dam
ing upon the type of space maintainer placed and the should be encouraged during placement of bonded
age of the patient at the time of placement. However, space maintainers. Similarly, moisture control is better in
the maximum period a bonded space maintainer that the maxillary arch as compared to the mandibular arch.
sustained in the oral cavity was 15.3 months.4 This Therefore, it has been observed in few studies; survival
442
 Table 3: Summary of the included studies in terms of study design and results
Study ID Author Participants Intervention Comparison Outcomes Study design Follow up Main findings
1 Simsek 74 space maintainers in 51 children Fixed space None Space Non- Till the Out of 64 space maintainers,
et al.4 (19 girls and 32 boys) Avg age = 7.3 maintainer bonded Maintenance randomized permanent 34 space maintainers were
years. maintainers in 51 children with a composite clinical trial tooth placed in mandible and 30 in
(19 girls and 32 boys) Avg age = 7.3 resin erupts maxilla with a mean survival
years. time of 12 to 18 months.
(average time being 15.3
months). This study showed
a moderate risk of bias.

2 Kirzioglu et al.11 40 space maintainers in 29 children Fixed space None Space Non- Till the Out of the 40 space
(14 girls,15 boys) Aged 7–14 years maintainer bonded maintenance randomized permanent maintainers, 24 space
Avg age = 10 years and 1 month with Sprint- In clinical trial tooth erupts maintainers were placed in
mandible and 16 in maxilla
with a mean survival time of
5.7 months. This study has a
moderate risk of bias
3 Subramaniam 60 space maintainers in 30 children Fibre reinforced the Band and Longevity Randomized 12 months Out of the 60 space
et al.12 (7 girls and 23 boys) aged 6–8 years composite resin loop space of space clinical trial maintainers placed on 26
maintainer maintainers survived at the end of 12
months. This study has a
moderate risk of bias.

International Journal of Clinical Pediatric Dentistry, September-October 2018;11(5):440-445

4 Tunc et al.13 30 space maintainers in 30 children Fibre reinforced the Band and Longevity Randomized 12 months The mean survival time of
(15 girls and 15 boys) aged 4–10 composite resin loop space of space clinical trial fixed space maintainers
years. maintainers maintainers was 9.03 months with
and directly band and loop for 11.2
bonded months followed by 9.2
space months for directly bonded
maintainers. space maintainers and 6.7
months for fiber reinforced
composite resin.
This study has a moderate
risk of bias.

Cont...
Survival of Bonded Space Maintainers: A Systematic Review

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 Shantanu S Deshpande et al.

time of bonded space maintainers in the maxillary arch

and band and loop is 73.3%.

end of 9 months was 84.6%,

analyzed at 18 months, fiber

Out of 42 space maintainers
was better as compared to the opposing lower arch.4,11

33.33%, ribbond is 45.4 %,

220 days. This study has a

reinforced composite resin
custom-made loops at the

63.3% and band and loop

This study has a high risk

showed a success rate of

showed a success rate of

of EZ space maintainer is
whereas super splint was

36.7%. This study has a

The resin to tooth bond strength also plays a vital
The success rate of the
prefabricated band with

The mean survival time

moderate risk of bias.

moderate risk of bias.

role in determining the longevity of the bonded space
maintainer. The bond strength of primary tooth enamel
Main Findings

is considerably lower than the permanent tooth enamel.

This can be attributed to the presence of prismless zones
of bias.

in the enamel of primary teeth, that tend to have an

adverse effect on the bond strength thereby, affecting
resin retention.17 The bond strength of the resin can
18 months
Follow up

appliance
9 months

be positively modified by grinding the outer enamel

Till the
failure
of the
layer and increasing the etching time.18-20 The bonding,
however, is better in permanent teeth than in primary
teeth. However, in cases of permanent first molars in
Study Design

Experimental
Randomized

Randomized

the mandible, Artun stated that occlusal trauma might

clinical trial

clinical trial

be more of a problem in cases of newly erupted teeth

study

where area available for bonding is inadequate. The main

reasons for failure in the enamel-composite bond are the
improper surface preparation, moisture contamination,
maintainers

maintainers

maintainers

and disturbances during the adhesive setting process.21

Survival of
Outcomes
Longevity

Longevity

EZ space
of space

of space

In the majority of the studies, a fifth-generation bonding

agent was used along with a flow composite resin. Fifth
generation bonding system has better bonding abilities
prefabricated

and fewer steps required. Flow composite resin, which is

Comparison

maintainers

made loops

maintainers
loop space

loop space
Band and

band with

Band and

low in filler particles have low viscosity and better flow

custom-

None

leading to the emergence of lower air bubbles during

and

application. This helps in better penetration in the tooth

surfacewhich aids in bonding. Adequate bond strength
Fibre reinforced the
Ribbond and Super

was also achieved when bonded with the packable form

composite resin

of composites (Transbond®).16
Intervention

maintainer
EZ space

The studies in which the space maintainers were fabri-

Splint

cated with an orthodontic stainless steel wire, the survival

time was higher (15.3 months) as compared to the fiber-
reinforced composite resin (FRCR) material (9–12 months)
60 space maintainers in 60 children

60 space maintainers in 30 children

41 space maintainers in 27 children

(11 girls and 16 boys) aged 6 to 12

This can be attributed to the fact that the orthodontic stain-

less steel wire was fabricated following the contours of the
ridge and hence, the tooth of the opposing arch did not
impinge on the loop during occlusion. The FRCRs and the
NiTi wires were bonded directly on to the abutment teeth in
aged 4-9 years

aged 5-8 years

a horizontal fashion which did not follow the contours of the

Participants

ridge. This design, therefore, exposed the loop to the occlusal

forces which was an important reason for the fracture of the
years.

fiber frame. With longer time-interval, there is a possibility

of supra-eruption of the opposing tooth which eventu-
ally impinges on the fiber frame. This also could result in
Gulec et al.16
14

Garg et al.15

increased concentration of mechanical stresses on the fiber

Setia et al.

frame and its subsequent fracture.12 Another type of failure

Author

observed was debonding at the composite-fiber interface.

This type of failure occurs due to overzealous finishing that
caused the excess removal of the resin overlying the fiber.12
Study ID

The factors like the bonding systems, the type of abut-

Cont...

ment tooth used, the material used for fabrication and the

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Survival of Bonded Space Maintainers: A Systematic Review

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International Journal of Clinical Pediatric Dentistry, September-October 2018;11(5):440-445 445