Abstract
Complications with the formation and eruption of first permanent molars can result in patients in the mixed dentition stage of development seeking orthodontic advice. The prognosis of first permanent molars can also be compromised by dental decay, and this can mean decisions have to be made with regard to the optimum timing of extractions in relation to the developing occlusion.
A structured assessment includes consideration of patient compliance with dental treatment, prognosis of the teeth, presence or absence of crowding and the underlying skeletal pattern.
Advice provided regarding the timing of the extraction of first permanent molars will reflect any future need for orthodontic treatment, and the impact first permanent molar extractions will have on the anchorage management during future orthodontic treatment.
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Summary
When assessing young patients presenting with FPMs of poor prognosis, a number of considerations have to be taken into account. These include the prognosis of the individual teeth, the developing occlusion and the likely mechanics of possible future orthodontic treatment.
In summary the key principles that can be applied to individual cases include:
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In young patients, FPMs may have to be extracted even if this complicates future orthodontic treatment. This can be due to the individual teeth being unrestorable or the patient not being compliant with the restorative treatment required to stabilise the teeth.
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In young patients with developing, significant malocclusions that are likely to require permanent tooth extractions as part of their future orthodontic treatment, delaying the extraction of the FPMs until the second permanent molars erupt can complicate the anchorage management of the future orthodontic treatment but will reduce the need for the additional extraction of permanent teeth.
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After the extraction of an upper FPM, space closure through the mesial migration of the upper second permanent molar is relatively predictable. If the upper FPM extraction space is required to correct a malocclusion, then anchorage reinforcement is required.
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After the extraction of a lower FPM, space closure through the mesial migration of the lower SPM is less predictable. If the relief of anterior crowding or the retraction of the lower labial segment is not required during future orthodontic treatment, it is advisable to extract the lower FPM at an optimum stage of dental development to allow for spontaneous closure of the extraction space.
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The optimum stage of dental development to allow spontaneous space closure to occur has been associated with the onset of the calcification of the bifurcation of the lower second permanent molar. However, this can be considered as a guide, and other factors such as the angulation of the lower Second permanent molar and the presence of the developing third molar are also useful indicators of the likelihood of spontaneous space closure occurring.
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The compensating extraction of a sound upper FPM can allow for more predictable space closure in the lower arch when a poor prognosis lower FPM requires extraction and spontaneous space closure is desirable. The compensating extraction of an unrestored lower FPM is not recommended to facilitate space closure if an upper FPM is extracted.
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The balancing extraction of unrestored FPMs to maintain arch symmetry is not routinely recommended.
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With appropriate orthodontic advice provided in the mixed dentition and contemporary orthodontic treatment with fixed appliances and planned anchorage reinforcement in the permanent dentition, the need to extract permanent teeth in addition to the extraction of poor prognosis FPMs can be avoided in the majority of clinical cases.
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Mack, G.J. (2017). First Permanent Molars. In: Cobourne, M. (eds) Orthodontic Management of the Developing Dentition. Springer, Cham. https://doi.org/10.1007/978-3-319-54637-7_3
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DOI: https://doi.org/10.1007/978-3-319-54637-7_3
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