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International Journal of Clinical Preventive Dentistry
Volume 7, Number 4, December 2011
Distal Shoe, an Effective Space Maintainer for Premature
Loss of Primary Mandibular Second Molar - A Case Report
Beena J.P.
AECS Maaruti College Of Dental Sciences and Research Centre, Bangalore, India
Mandibular permanent first molars have a mesiocclusal eruption pattern, guided by the distal surface of the primary second
molar. If the primary second molar is lost prematurely, the permanent first molar may erupt in a more anterior position leading to midline shifts, space loss and crowding. The distal shoe space maintainer remains an acceptable and effective with an
extension subgingivally which serves as a guide for the erupting first molar.
Keywords: distal shoe, space maintainer, subgingival
Introduction
prior to the eruption of the first permanent molar. In the absence
of the second primary molar mesial movement and migration
of the permanent molar may be expected to occur before and
during its eruption. An unerupted first permanent molar may
drift mesialy within the alveolar bone resulting in a loss of arch
length and possible impaction of the second premolar.
The distal shoe is indicated in cases where the second primary
molar is lost prematurely. This appliance guides the first permanent molar into place and prevents mesial drifting of the tooth.
The distal shoe has an extension going subgingivally to a location mesial to the unerupted first permanent molar. It is a successful appliance in guiding unerupted permanent teeth into the arch.
The distal shoe space maintainer, as introduced by Gerber (8)
and extended by Croll (9,10) is a valuable part of the pediatric
dentist’s armamentarium, because in those cases where the second primary molar is lost prematurely, it helps guide the first
permanent molar into place.
In 1973, Hicks outlined in detail the indications and contraindications for the distal shoe appliance, as well as the diagnostic and systemic considerations (11).
In 1887, Davenport (1) described the concept of space loss resulting from premature loss of primary teeth. Subsequent studies also emphasized the harmful effects of space loss, such as
tipping of the first permanent molar, crowding of the dental arch
and impaction of the permanent tooth (2-4).
Space maintenance has been thought to be important after premature loss of primary teeth to preserve the integrity of the dental arch (5). Choonara (6) reported that many orthodontic cases
involving crowding and lack of space in the permanent dentition
could have been prevented or the severity of the problems alleviated if the practitioner had maintained adequate space during
the initial treatment of the mixed dentition.
The safest way to prevent future malocclusions from tooth loss
is to place a space maintainer that is effective and durable. Factors
that influence the selection of fixed or removable space maintainer types are: 1) dentitional development stage; 2) the number
of lost teeth; 3) dental arch and occlusion; and 4) the patient’s
age, psychological condition, and cooperative ability (7).
One of the most frustrating problems of managing the developing dentition is the premature loss of the second primary molar
1. Indications
1) Premature loss or extraction of the second primary molar
prior to the eruption of the first permanent molar
2) Advanced root resorption and periapical bone destruction
of the second primary molar prior to eruption of the first
permanent molar
Corresponding author Beena J.P.
E-mail: [email protected]
Received September, 19, 2011, Revised October, 13, 2011,
Accepted November, 16, 2011
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International Journal of Clinical Preventive Dentistry
3) A primary second molar with advanced caries that is not
restorable
4) Ectopic eruption of the permanent first molar
5) Ankylosis of the primary second molar
2. Contraindications
Inadequate abutments due to multiple loss of teeth
Poor patient or parental cooperation
Missing permanent first molar
Systemic diseases that affect healing such as diabetes mellitus
5) Cardiac anomalies that require antibiotic prophylaxis prior
to dental treatment
1)
2)
3)
4)
Case Report
A four and half year old male child reported to the Department
of Pedodontics and Preventive Dentistry with the chief complaint of severe pain and difficulty in eating on both the sides
of his lower jaw. Patients medical history was non contributory.
Patient gave a history of previous restorations for his teeth 3
months ago.
Clinical examination:
Teeth present: 55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
84 and 75 was tender and mobile associated with periapical
abscesses.
Radiographic examination revealed perforation of the pulpal
floor and restorative material inter radicularly in relation to 84
and radiolucency beneath restoration with respect to 85. Inter
radicular radiolucency, widening of periodontal ligament space
and root resorption with respect to 75 The lower permanent first
molar on right and left side showed 7 stage of Nolla’s tooth
development.
Diagnosis: Chronic irreversible pulpitis with respect to 84
and 75 , Chronic pulpitis with respect to 74, 85 (Figure 1, 2).
Treatment done: Extraction of 84 and 75, Pulpotomy with
respect to 85, 74, Crown and loop space maintainer with respect
to 85, Distal shoe space maintainer with respect to 74.
1. Procedure
The primary mandibular left first molar that is 74 was prepared
for stainless steel crown after pulpotomy. Following preparation, a stainless steel crown was adapted to the 74 and a mandibular impression was made. The crown was removed, placed,
and stabilized into the impression, and the impression was poured in dental stone. A stainless steel crown of the same size is cemented temporarily, and the patient was discharged. The gingival extension was calculated radiographically, spanning
from the distal surface of the stainless steel crown, over the distal
extension of the crown and loop, then gingivally to seat at the
mesial surface of the permanent first molar just 1mm below the
mesial marginal ridge. The loop was fabricated as a modification of Willets appliance instead of a bar to provide wider
Figure 1. Chronic pulpitis with respect to 75.
Figure 2. Chronic pulpitis with respect to 84.
210 Vol. 7, No. 4, December 2011
Figure 3. Distal shoe appliance.
Beena J.P.：Distal Shoe - an Effective Space Maintainer
Figure 4. Placement of appliance post extraction of 75.
Figure 6. Eruption of 36 guided by distal shoe.
Figure 5. Radiograph before cementation of the distal shoe.
Figure 7. Distal shoe converted to crown and loop space maintainer.
contact area for the erupting permanent molar using a 21 gauge
for the Stainless Steel wire. The wire components were soldered
to the crown (Figure 3-5).
2. The next appointment
The procedure was explained to the parent and the patient and
informed consent was obtained for extraction of 75 under antibiotic coverage and local anesthesia. The bleeding was controlled and then the distal shoe appliance was seated on 74 with
the subgingival extension placed in the socket and the appropriate position confirmed with the radiograph and then was cemented permanently with glass ionomer cement. Recall was
one day, one week, after one month and then every three months.
After 14 months permanent first molar erupted Figure 6. Upon
eruption of the permanent first molar, the subgingival extension
was severed from the stainless steel crown at the solder joint on
the distal crown surface. The extension was removed and converted to crown and loop as a space maintainer　(Figure 6, 7).
An alternative space maintainer is a bilateral acrylic "saddle"
appliance by Carrol and Jones (12). Because of poor retention
and patient compliance, these appliances usually are used only
for multiple tooth loss. The distal shoe appliance is time efficient, meets all the criteria for proper space maintenance, and
can be fabricated easily.
Discussion
Mandibular permanent first molars have a mesiocclusal eruption pattern, guided by the distal surface of the primary second
molar. The extraction of a primary second molar prior to the
eruption of the first permanent molar should only be performed
as a last resort. If the second primary molar is extracted at a
young age, loss of mandibular arch circumference might require complex orthodontic treatment. Hoffding and Kisling reported that an increase in Class II molar occlusion and Class III
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International Journal of Clinical Preventive Dentistry
molar occlusion in patients with premature mandibular second
primary molar loss (13). There was a statistically significant increase in crowding with premature primary tooth loss (14).
Midline shifts occurred towards the extraction side, with greater
discrepancies in the mandible v/s the maxilla (15). Space maintainers are recommended after early loss of primary teeth to prevent these side effects (16).
The success criterion of a distal shoe space maintainer, as defined by Baroni et al and Qudeimat et al, is the successful guidance of the unerupted permanent tooth into the arch with no
problems associated with the appliance (17,18).
Conclusion
Failure to maintain the space will result in severe space loss,
and subsequently the clinician will need to regain space with
a future orthodontic appliance and cost implications.
Since the treatment of a child by a pediatric dentist is a dynamic
rather than a static relationship, it is the end point of therapy that
should be used as the marker for success. Accepting this dynamic definition rather than a static one, distal shoe appliance with
a stainless steel crown as the retainer can be considered a successful appliance, albeit one that needs careful supervision and
occasional service. The distal shoe appliance is cost and time
effective, meets all the criteria for proper space maintenance,
and can be fabricated easily.
We advocate the use of distal shoe space maintainer appliance
during this most crucial time to guide the erupting first molar
in cases where there is premature loss of second mandibular
molar.
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