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Primary dentition plays an important role in child’s growth and development not only in terms of mastication, esthetics, and phonetics but also in the guidance and eruption of permanent teeth. In cases of premature loss of primary teeth, correct planning and choice of a space maintainer are required to avoid future space loss. A 5-year-old female patient reported to the department of pediatric and preventive dentistry with a chief complaint of grossly decayed teeth in her mandibular right back teeth region since 6 months. Clinical examination revealed grossly decayed tooth wrt 85, radiographic examination revealed radiolucency approaching root and furcation area. Diagnosis was made as chronic irreversible pulpitis wrt 85 and extraction wrt 85 followed by Starkey’s modification of distal shoe space maintainer was planned. Space maintainers are the appliances which guide the eruption of permanent teeth. In the present case, the first permanent molar had already pierced the bone but was inside the gingiva therefore a modification of distal shoe – Starkey’s space maintainer was fabricated with an acrylic extension that aids in mastication. The Starkey’s modification of distal shoe with an acrylic extension is the most appropriate appliance to be given in cases where there is premature loss of second primary molar before eruption of first permanent molar.

Effectiveness of Starkey's appliance as space maintainer; a 21 months clinical follow-up