Number: 033
(Update)

Subject: Space Maintenance in Primary Dentition

Reviewed: February 17, 2016

Important note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:

• Clinical outcome studies in the peer-reviewed published medical and dental literature
• Regulatory status of the technology
• Evidence-based guidelines of public health and health research agencies
• Evidence-based guidelines and positions of leading national health professional organizations
• Views of physicians and dentists practicing in relevant clinical areas
• Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

Space maintenance may be appropriate when one or more of the following conditions are present:

• A loss of one or more primary teeth
• Premature loss of primary molars
• Loss in arch perimeter
• A favorable prediction from the space analysis

It is considered esthetic with the early loss of a primary incisor or incisors.

Background

The premature loss of primary teeth from caries, trauma, ectopic eruption or other causes may lead to undesirable tooth movements of primary and/or permanent teeth including loss of arch length.¹ Not every tooth that is lost prematurely requires a space maintainer. If one of the four upper front teeth is lost early, the space will be maintained on its own until the permanent tooth comes in.²

Early loss of a primary incisor (teeth identified as D,E,F,G in the upper primary arch, and N,O,P,Q in the lower Primary arch³) usually results from dental caries or trauma. The early loss of a primary incisor results in very little change in the dentition. Premature loss of primary incisors does not require the placement of appliances for space maintenance because no forward movement of the adjacent teeth is expected when the primary canines have already erupted. Space maintenance is not necessary unless esthetic concerns warrant the replacement.³ The placement of either a removable or fixed partial denture (sometimes referred to as a ‘Kiddie Partial’) would be considered esthetic in nature when one or more primary anterior teeth are lost prematurely.

A premature loss of mandibular primary canines is usually a result of large permanent incisor and/or an ectopic eruption. A lateral shift of the incisor teeth can accompany the loss of the primary canine (or canines) and may result in a midline discrepancy. A fixed lingual holding arch may be used to maintain arch integrity and prevent lingual tipping of the mandibular incisors.

An early loss of primary first molars may cause distal drifting of the primary canine if the loss occurs during the active eruption of the permanent lateral incisors. An early loss of the primary second molars may be of concern as the primary second molar helps to guide the eruption of the permanent first molars, especially in the maxillary arch. Various space maintenance techniques may be appropriate for the treatment of the early loss of the primary first and/or primary second molars. Treatment modalities may include, but are not limited to fixed appliances (for example, band and loop, crown and loop, passive lingual arch, distal shoe, Nance appliance, transpalatal arch) or removable appliances (for example, partial denture, Hawley appliance).¹

Codes⁴

D1510 -- Space maintainer - fixed - unilateral
D1515 -- Space maintainer - fixed - bilateral
D1520 -- Space maintainer - removable - unilateral
D1525 -- Space maintainer - removable - bilateral
D1550 -- Re-cementation of space maintainer
D1555 -- Removal of fixed space maintainer - procedure delivered by dentist who did not originally place the appliance or by the practice where the appliance was originally delivered to the patient.

Revision dates

Original: November 22, 2005
Updated: November 28, 2007; March 29, 2010; March 14, 2011; July 12, 2012; August 12, 2013; June 9, 2014; June 22, 2015; February 17, 2016
Revised: November 20, 2006; October 13, 2008; February 24, 2009

The above policy is based on the following references:

¹American Academy of Pediatric Dentistry, Policies and Guidelines: Guideline of Management of the Developing Dentition and Occlusion in the Pediatric Dentistry, Clinical Affairs Committee-Developing Dentition Subcommittee, rev: 2005.

²Ngan, P, Alkire, RG, Fields, R. Management of space problems in the primary and mixed dentitions, Journal of the American Dental Association, 1999, Vol. 130, 1330-1339.

³American Dental Association. CDT 2016 Dental Procedure Codes: 16.*

*Copyright 2015 American Dental Association. All rights reserved.

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.