In the case where the first permanent molar has not erupted yet, and a second primary molar is removed, a distal shoe can be placed subgingivally to guide the eruption of the permanent molar. Radiographic imaging is required to confirm proper placement of the blade of the spacer adjacent to the mesial surface of the unerupted permanent molar. Ideally, the blade should contour and make contact with the mesial surface of the permanent molar. It is acceptable to place the blade in the most distal aspect of the distal root socket of the extracted tooth, if necessary.