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[1]                                                                                                                                                                                                                                              AJDHS.COM 

 

 

Available online at ajdhs.com 

Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2024 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
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The Distal Pole-Alternative to Conventional Distal Shoe Space Maintainer: A 
Case Report 

Geeth Deepika Kottai Gandhi 1* , Jonathan Vasantha Rajan PT 2 , Dinesh Nandakumar Gopalan 3  

1 Reader, CSI College of Dental Sciences and Research, Madurai, India 

2 Private, Practitioner 

3 Reader, Best Dental College, Madurai, India 

Article Info: 
_____________________________________________ 
Article History: 

Received   29 March 2024     
Reviewed  23 April 2024 
Accepted   09 May 2024 
Published 15 June 2024 

_____________________________________________ 
Cite this article as:  

Kottai Gandhi GP, PT GVR, Gopalan DN, The Distal 
Pole-Alternative to Conventional Distal Shoe Space 
Maintainer: A Case Report, Asian Journal of Dental 
and Health Sciences. 2024; 4(2):1-4 

DOI: http://dx.doi.org/10.22270/ajdhs.v4i2.75   

_____________________________________________ 

*Address for Correspondence:   

Geeth Deepika Kottai Gandhi, Reader, CSI College of 
Dental Sciences and Research, Madurai, India 

Abstract 
_________________________________________________________________________________________________________________ 

Aim and Background: A major clinical challenge for pedodontist is space maintenance in primary 
dentition associated with the premature loss of primary teeth. When a primary second molar is lost 
prematurely, it is the distal shoe appliance (DSA) most widely used and proved to be the effective 
tool in guiding the permanent first molar into its proper place.  

Case Description: The sole purpose of this case report is to describe briefly the clinical management 
of unilateral extensively carious primary mandibular second molar with a modified distal shoe space 
maintainer which we named it as “distal pole” which is highly inevitable to prevent space loss and 
following malocclusion development in later stages. 

Clinical Significance: The prime importance in pediatric dentistry is preserving the primary teeth 
in the dental arch until their physiological exfoliation time however there are certain conditions 
which are challenging at times where extraction seems unavoidable. 

Keywords: distal shoe, space maintenance, E space, Deciduous Dentitions 

 

Introduction 

The prime importance in pediatric dentistry is preserving the 
primary teeth in the dental arch until their physiological 
exfoliation time however there are certain conditions which 
are challenging at times where extraction seems unavoidable 
due to extensive dental caries or trauma. When a primary 
second molar is lost prematurely, it is the distal shoe appliance 
(DSA) most widely used and proved to be the effective tool in 
guiding the permanent first molar into its proper place. The 
distal shoe space maintainer was first introduced by Gerber1 
and modified by Croll2,3 Indications and contra-indications of 
this space maintainer were discussed in detail by Hicks4 who 
chose fabrication of a cast gold appliance. Modifications like 
appliances with attachments which are soldered to stainless 
steel crowns or bands were also clinically acceptable. Brill5 in 
the year 2002 described chairside fabrication of a distal shoe 
space maintainer which can be delivered immediately after 
the extraction of the poor prognosed primary second molar 
showed a high success rate if the patient was cooperative. 

It has also been proved that early loss of primary second 
molars and the absence of eruption guidance for erupting 
permanent molars results in a higher reduction of arch length 
which is measured about 8mm in each maxillary quadrant and 
about 4-6 mm in each mandibular quadrant.6 Hence the use of 
distal shoe space maintainer in early loss of primary second 
molar is highly inevitable to prevent space loss and following 
malocclusion development in later stages. 

Based on the eruption pattern, upper arch molar teeth erupt 
distally and buccally whereas in lower arch, it is mesially and 
lingually which proved that special attention should be given 
while fabricating the design for this space maintainer.7 
However there are some contraindications which should also 
be taken into consideration. These include, absence of 
adequate number of abutments (loss of multiple teeth), highly 
uncooperative child and/or parents, congenital absence of 
permanent first molar, systemic conditions such as diabetes 
mellitus which interferes with wound healing and cardiac 
anomalies which require prophylactic antibiotics regime prior 
to dental procedure.4 In these conditions, the pediatric dentist 
is left with only two choices before considering giving this 
appliance that include: regaining the lost space after the 
eruption of permanent first molar and the usage of a fixed or 
removable appliance that neither penetrate the tissues but 
applies pressure on the ridge immediately mesial to the 
unerupted permanent first molar.6 

The sole purpose of this case report is to describe briefly the 
clinical management of unilateral extensively carious primary 
mandibular second molar with a modified distal shoe space 
maintainer which we named it as “distal pole” 

Appliance Fabrication 

The first step in the appliance fabrication is the appropriate 
selection of band which can be done directly from the mouth 
or indirectly after taking an impression followed by cast 
pouring. In this case we had plans to place the loop component 

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Geeth Deepika Kottai Gandhi et al.                                                                                            Asian Journal of Dental and Health Sciences. 2024; 4(2):1-4 

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to the stainless steel crown since the adjacent tooth was 
pulpally treated. The loop component in this design consisted 
of two parts namely horizontal and vertical. Horizontal part 
maintains the mesio-distal dimension of the extracted primary 
second molar and the vertical part actually serves as a pole of 
guidance for the erupting permanent first molar.  

Horizontal part of the loop follows the residual alveolar ridge 
and the vertical part extends into the extracted socket till it 
reaches 1 mm beyond the mesial marginal ridge of the 
erupting permanent first molar. The free ends of the loop were 
then approximated and soldered to the stainless steel crown 
of adjacent tooth. 

Case Report 

A 5 years old boy reported to my clinic in the month of  
December 2022 with a chief compliant of pain and frequent 
swelling in the lower left back region for a brief period of time. 
He has non-contributory medical history. Clinical examination 
revealed a grossly decayed primary mandibular left second 
molar and pulpally involved mandibular left first molar. A 

radiovisiography of the same teeth had been taken which 
showed the extensively decayed and mesial root resorption in 
primary second molar and dental caries involving the mesial 
pulp horn of primary mandibular first molar. (Figure 1) 

We planned to proceed with pulpectomy for primary first 
molar followed by stainless steel placement and extraction of 
primary second molar followed by modified DSA which is 
soldered with SSC of primary first molar. Before cementation, 
a RVG was taken to determine the relationship of intra-
gingival extension with mesial surface of the permanent 
molar. (Figure 2) Final cementation is done with type – 1 glass 
ionomer luting cement (GC Fuji, Tokyo, Japan). (Figure 3) Post 
extraction, post cementation and oral hygiene maintenance 
instructions were given to the patient as well as his parents.  

Recalling and reviewing visits has been given every 3 months 
to check the integrity of the appliance and the eruption status 
of permanent molar. Follow up after one year showing the 
ideal eruption of lower left permanent first molar without any 
clinical signs of mesial drift (Figure 4)  

 

 
Figure 1: Pre-operative radiovisiograph 

 
Figure 2: Immediate post cementation radiovisiography showing the tip of the distal pole just reaching beyond the mesial marginal 

ridge of unerupted lower left permanent first molar 



Geeth Deepika Kottai Gandhi et al.                                                                                            Asian Journal of Dental and Health Sciences. 2024; 4(2):1-4 

[3]                                                                                                                                                                                                                                              AJDHS.COM 

 

Figure 3: Immediate post cementation image 

 

Figure 4: Follow up after one year showing the ideal eruption of lower left permanent first molar without any clinical signs of mesial 
drift 

Discussion 

Premature loss of multiple primary molars is a potential 
challenge for the pedodontists to manage and preserve the 
arch integrity. In this case of premature loss of primary second 
molar before the eruption of permanent first molar, it is 
mandatory to provide a distal shoe appliance which serves as 
a space maintainer as well as guides the eruption. Since the 
conventional distal shoe has its own disadvantages, modified 
distal shoe has been adopted in this case which favours simple 
design with minimal adjustment, high stability & strength and 

patient acceptance. This unilateral modified distal shoe 
appliance is considered as a short-term appliance for eruption 
guidance.8 

In such situations, if they left untreated, the first permanent 
molar would definitely migrate mesially and proficient space 
loss would occur evidently which could possibly result in a 
need for active therapy. Active appliances also have some 
complications and patients and their parents should have full 
cooperation. However, it is desirable to have an affordable 
method that requires a moderate level of patient cooperation 



Geeth Deepika Kottai Gandhi et al.                                                                                            Asian Journal of Dental and Health Sciences. 2024; 4(2):1-4 

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that can guide the eruption of permanent first molars towards 
their correct position in the dental arch. For this purpose, the 
use of modified distal shoe appliance would be suggested as 
the treatment plan. Benefitting from the anchorage provided 
by the remaining teeth in the dental arch, a fixed, bilateral 
appliance with an intra-alveolar extension was fabricated, 
which was capable of guiding the eruption of the first 
permanent molar into its proper position. By placing this 
appliance, space loss due to mesial drifting of the permanent 
first molar could be prevented. Moreover, this appliance 
would be more easily tolerated by children due to its fixed 
nature, simplicity, and optimal stability compared to 
removable appliances. However, this design has some 
shortcomings as well, including its difficult fabrication, 
relatively high cost, and non-functionality.9 

In uncooperative children, this appliance is preferred to 
removable alternatives. Modified distal shoe space maintainer 
is considered a short-term appliance that will be replaced with 
other appliances depending on the eruption of the first 
permanent molars and permanent incisors. In contrast to our 
case, Gujjar et al9 & Dhindsa and Pindat10 used uniform 
appliances that did not have the potential of chairside 
adjustability and the whole appliance was fabricated in a 
laboratory. The current appliance was fabricated by soldering 
a part of the Gerber-type distal shoe to confer chair-side 
adjustability to the appliance. However, the appliance could be 
adjusted easier and more precise. Movement of the distal 
blade in the tube enables and ensures the correct position of 
the intra-alveolar extension of the appliance. Following the 
complete eruption of the first permanent molar or observing 
any interference with the eruption of permanent incisors, the 
appliance must be replaced with other types of space 
maintainers depending on the clinical conditions of patients. 

Research works conducted by Anegundi and his colleagues 
proposed that the horizontal U-loops space maintainers with 
an extended vertical arm length which can be easily adjustable 
against the mesial tipping movement of the first permanent 
molar.11 There are various other studies that have reported 
many designs of the conventional appliances effectively 
modified for premature loss of multiple primary molars with 
inadequate abutments.12,13,14 In our case study, we presented a 
simple method distal pole being soldered to the stainless steel 
crown (similar to crown and loop space maintainer) of 
pulpally treated first primary molar. Following which a 
custom-made stainless-steel wire was used for the horizontal 
and vertical parts of the distal shoe; moreover, SSCs have a 
perfect contour and shape easily adapts to the anatomy of first 
primary molars. Our case study also showed the healthy 
gingival tissue around distal shoe appliance and the 
abutments after more than a year; also the appliance did not 
intervene or impede the eruption of the first permanent 
molars. When considering the oral hygiene maintenance after 
the appliance insertion is of great importance to maintain 
healthy gingival conditions, especially of the fixed appliance 
whose vertical arm extends into the gingival tissue. 
Fluoridated toothpaste will greatly help with plaque removal 
and caries prevention in such kids. An interdental brush or 
end tuft brush will prove to clean underneath the wires as well 
as the abutments. Parents were equally advised to provide 
assistance in oral cleaning, especially for young children who 
are in their developmental stages where their fine motor skills 
are yet to develop. 

Also, this appliance has an added advantage of fabricating in 
the same visit as the extraction of the hopeless primary second 
molar and can be done in a very cost-effective manner 
compared to other appliances that included lab expenses and 

frequent visits subsequently. Moreover, after the eruption of 
permanent first molar, conversion of this distal shoe appliance 
to a band and loop maintainer is quite easy and simple which 
can be done without the need of local anaesthesia & 
cumbersome procedures. Hence this appliance serves as a 
valuable and effective asset to the paediatric dentist in space 
management and eruption guidance. 

Conclusion 

To conclude, the placement of modified distal shoe appliance 
preserves the integrity of dental arch and prevents space loss 
following the early loss of several primary molars in the cases 
that the use of conventional distal shoe appliance is not 
possible. However, regular patient follow-ups are critical for 
the success of this contemporary treatment plan. 

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https://doi.org/10.14219/jada.archive.1964.0387
https://doi.org/10.1016/S0011-8532(22)00765-0
https://doi.org/10.1016/B978-0-323-05724-0.50031-X
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https://doi.org/10.4103/0970-4388.43196
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