The first molar is the biggest tooth in the mouth, carries the most occlusal load, and affects the occlusal height, the vertical distance between the mandible and maxilla, and aesthetic proportions. They are also regarded as the greatest source of anchoring for shifting the teeth since they have the largest root surface area (Mostafa Rezaie et al. 2018). [1-2] Early space maintenance and function restoration are required when a teenage patient loses a permanent first molar.[2]

Primary dentition plays a very important role in a child’s development and growth, in terms of speech, chewing, esthetics, but most importantly guiding the eruption of permanent teeth. However.[3] Early loss of primary teeth is inevitable in case of extensive dental caries and trauma. The premature loss of primary molars causes loss of arch length, increased overbite, dental malposition, impaction, arch symmetry, and alteration in eruption. For this preservation of the dental arch’s length plays an important role.[4]

The FPM erupt early, making it more likely that it may develop dental cavities and require extraction before the age of 15. Early FPM loss can cause the dental arches to shift, with the local function being affected, teeth drifting, and opposing teeth continuing to erupt. [3-4]

Therefore, in such cases, we must prevent space loss. Preservation of the space can eliminate or reduce the need for prolonged orthodontic treatment. When the first premolar has not yet erupted or extracted, it possesses the greatest complications related to the choice of treatment option for the space maintainer [4-5]. Distal shoe appliance was first introduced by Garber to guide the eruption of the FPM in the dental arch. In the case of early loss of FPM and several primary molar teeth, the conventional distal shoe cannot be used. The modified distal shoe has recently been the focus of several studies.[6]

This case report describes a conservative, interim appliance design by combining 3 space maintainers: lingual arch (Gandhi JM. et al 2023) [7], modified band n loop (Zaidan SM. Et al. 2022) [8] and Intra-alveolar appliance (Dadpe MV. Et al 2023) [9] after the loss of permanent first molar in an adolescent dentition.

Primary dentition plays a very important role in a child’s development and growth, in terms of speech, chewing, esthetic, and most importantly guiding the eruption of permanent teeth. However early loss of primary teeth is inevitable in case of extensive dental caries and trauma. The premature loss of primary molars causes decreased arch length, increased overbite, dental malposition, impaction, arch symmetry, and alteration in eruption. For this preservation dental arches play an important role.[10] The FPM emerges early, making it more vulnerable to dental decay and maybe needing extraction before the age of 15. The early loss of FPM can lead to changes in the dental arches which include diminished local function, drifting of teeth and continuous eruption of opposing teeth (Supraeruption). [11]

However, in specific cases i.e., loss of several primary and permanent molars, the usual space maintainer cannot be used. In such type of cases if left untreated there will be mesial drift of teeth in space. Therefore, it is desirable to have an affordable method that requires a minimum level of patient cooperation and can maintain the space till further treatment. For this, the use of a modified distal shoe space maintainer was planned for treatment. [12] Thus, by taking the anchorage from the remaining teeth, a fixed bilateral appliance with an intra-alveolar appliance on one side and a band a loop space maintainer on the other side and connecting lingual arch was made as an appliance, named “Sonal appliance”.

By putting this appliance space loss due to mesial drifting of the permanent 2^nd molar could be prevented. However, in this appliance, we have incorporated a distal shoe, modified band and loop and lingual arch as space maintainers.