Modified Distal Shoe Appliance for Multiple Loss of First and Second Primary Molars.

Abstract

A 4.5-year-old boy reported to the Department of Pedodontics and Preventive Dentistry complaining of pain and recurrent swelling in lower right back region of the jaw since five days. The patient was well oriented and did not have any contributory medical history. No abnormality was detected in the general and extra-oral examinations. Intra-oral examination revealed that both the mandibular first and second primary molars on the right side (FDI teeth No. 84,85) and the mandibular second primary molar on the left side (FDI tooth No. 75) had deep carious lesions and were judged to be non-restorable. The teeth were tender to palpation. The mandibular first primary molar on the left side (FDI tooth No. 74) had a multi-surface carious lesion not involving the pulp [Table/Fig-1]. The gingival tissue surrounding the first and second primary molars on the right side (FDI teeth No. 84,85) was inflamed and the buccal vestibule slightly obliterated. Radiographic examination revealed a radiolucency involving the furcation of both the mandibular first and second primary molars of the right side (84,85) and the mandibular second primary molar of the left side (75) along with external root resorption. A multi-surface carious lesion, not approaching pulp, was seen on mandibular left primary first molar (74). The mandibular first permanent molars on both sides showed Nolla’s Stage V of tooth development [Table/Fig-2]. In addition, smooth surface caries were seen on upper and lower anteriors. Based on clinical and radiographic examination a diagnosis of apical periodontitis was made and extraction of mandibular left second molar (75) and mandibular right first and second molar (84,85) followed by fabrication of a space maintainer was planned. Parental consent for the same was taken. Study models were obtained and a space analysis (using Huckaba’s method) revealed approximately 2mm of space available per side. The mandibular left primary first molar (74) was restored using a pre-formed stainless steel crown. A 125X0.04mm band was adapted around the mandibular right primary canine. Impressions were made in alginate and models obtained along with the crown and the band on the respective teeth. A 1mm (19 G) Hard Round Stainless Steel (HRSS) wire was used for fabrication of the appliance. The extension of the horizontal and vertical arms was determined using radiographs (after adjusting for the radiographic error). A vertical slit of the desired depth was made on the model and the wire was adapted accordingly. Following adaptation, the wire was soldered to the crown and the band respectively. The mandibular molars indicated for extraction were extracted under local anaesthesia and the appliance was seated in place. Radiographs were taken to check the horizontal and vertical extension of the appliance [Table/Fig-3] and the appliance was then cemented using Type I Glass Ionomer Cement on the same appointment following haemostasis [Table/Fig-4]. The patient was recalled after three days to assess wound repair and stability of appliance. Subsequently the patient was placed on a monthly recall. The recall after 10 months showed erupted permanent first molars [Table/Fig-5,​,6];6]; the space maintainer was well accepted by the child and we were satisfied and optimistic about the future of his dentition. This appliance would be eventually replaced with a bilateral fixed space maintainer like lingual arch following complete eruption of the permanent first molars and incisors.