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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 209 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 IJCPD 211 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. References 1. Davenport IB. 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