A child has congenitally missing premolars. A band and loop is in place in the upper left, the primary molars are approaching exfoliation, and the permanent first molars have erupted. Which appliance is now indicated?

Correct answer: A. Nance holding arch

• A. CORRECT. The NANCE HOLDING ARCH is the maxillary appliance of choice for BILATERAL posterior space maintenance once the permanent first molars are present. Bands on the first molars are joined by a palatal wire carrying an acrylic button that rests against the anterior palate, resisting mesial molar drift without crossing the occlusion. With congenitally missing premolars and imminent loss of the primary molars, bilateral maxillary support is exactly what is required.
• B. A Hawley is a removable retainer for post-orthodontic retention, not a space maintainer for this situation.
• C. A distal shoe is used when a primary SECOND molar is lost BEFORE the permanent first molar has erupted, guiding that molar into position. Here the first molars have already erupted, so its indication has passed.
• D. A band and loop maintains a UNILATERAL single-tooth space. It cannot hold bilateral space and offers no anterior anchorage.

Note: Maxillary bilateral → Nance or transpalatal arch. Mandibular bilateral → lingual holding arch (only once the permanent incisors have erupted). Unilateral single space → band and loop.