However, one approach which may cause the process to be easier is to make distal shoe space maintenance a one appointment procedure. Most space maintainer protocol involves two appointments: the first appointment for extraction and impression taking, and the second appointment for placement and cementation of the appliance. In the case of distal shoe space maintainers, this means an additional local anesthetic experience for the child and a surgical incision immediately mesial to the first permanent molar so the distal shoe can be imbedded in tissue.

The distal shoe space maintainer can be placed at the time of extraction of the second primary molar. If this approach is used, the impression must be taken and the appliance constructed prior to extraction of the primary tooth. The advantage is not having to go back at a later time and surgically make an incision for insertion of the distal shoe into the tissue so the distal shoe segment can abut against the permanent molar.

Preformed (i.e., prefabricated) distal shoe space maintainers also can be used. Of course, preformed space maintainers are not customized (i.e., fitted) for the individual patient. They are placed at the time of the extraction appointment (i.e., a one appointment procedure is involved). Although they are not customized for the patient, using a preformed space maintainer is acceptable in many situations. Using a preformed space maintainer certainly is preferable to not using a space maintainer at all. Unfortunately, distal shoe space maintainers sometimes are not used when a child's behavior makes it unlikely that placement of the appliance at a second appointment would be successful. Of course, when distal shoe space maintainers are not used, the development of space problems results.

Consequently, placement of distal shoe space maintainers can be planned as one appointment or two appointment procedures, and the choice of approach is left to the discretion of the clinician. As mentioned earlier in the chapter, it also is desirable to replace the distal shoe space maintainer with an appliance which is banded to the permanent molar once the permanent molar erupts. Consequently, using the distal shoe space maintainer and a subsequent band and loop appliance really involves several appointments.