extraction of the first permanent molar

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EXTRACTION OF THE FIRST PERMANENT MOLARS (FPM)

DR.SASHI KUMAR MANOHARDENTAL OFFICER

CONTENTS

INTRODUCTION

IMPORTANCE OF FPM

OVERVIEW

GUIDELINES FOR EXTRACTIONS OF FPM TREATMENT PLANING BALANCING & COMPENSATING EXTRACTIONS IDEAL TIMING FOR EXTRACTION CONSEQUENCES

ORTHO-PAEDO MANAGEMENT

INTRODUCTION

Morphological evidence of permanent first molar formation is usually present in the human embryo by week 17 of gestation

Calcification is initiated by birth

Coronal development completed by the 3rd year of life

Eruption into the dental arch occurs around the age of 6-7 years

Root formation is completed by the age of 9-10 years

IMPORTANCE OF FPM

Largest and strongest teeth in the dental arch

Mainly plays a major role in mastication (grinding & chewing of food)

Important in maintaining the vertical dimension of the face

Vital role in aesthetics by making the cheeks appear full and vibrant.

Important in maintaining continuity within dental arches (keeping other teeth in alignment)

OVERVIEW

The relative timing of the FPMs development & eruption ( 6-7 years ) makes them more susceptible to :1. Dental Caries2. Hypomineralization3. Hypoplasia

Children can present with a developing dentition affected by one or a combination of multiple conditions, which may necessitate their enforced extraction

OVERVIEW

In the right circumstances, FPM extraction can be followed by successful eruption of the second permanent molar to provide a suitable replacement

Ultimately, the third molar eruption to complete the molar dentition and balance the occlusion (although not guaranteed)

Therefore, treatment planing and questionable long term prognosis should be taken into consideration prior to extractions

TO EXTRACT !!!
OR
NOT TO EXTRACT !!!!

TREATMENT PLANING

Factors that affect treatment planing decisions include :1. Child's age & social background2. Occlusion of the developing dentition3. Prevention & oral hygiene practice within the family4. Child's ability to co-operate with treatment options5. Other oral habits & dietary intake of the child

TREATMENT PLANING

6. Degree of molar-incisor hypomineralization severity7. Restorability & pulpal involvement of the tooth8. Presence of second and third molar tooth germs9. The necessity for GA to allow extractions of FPM 10. Expected long term treatment cost

BALANCING & COMPENSATING EXTRACTIONS

Balancing extractions :Removal of the FPM from the contra-lateral side of the same dental arch

Compensating extractions :Removal of the FPM from the same side of the opposing dental arches


Generally, compensation of the upper FPM is recommended when the lower FPM requires extraction

Balancing extraction of healthy FPM's are not recommended in either arches


Principles of balancing & compensating extractions :1. Which molar requires enforced extractions2. Teeth present within the developing dentition (2nd and 3rd molars)3. Overall oral condition & long term prognosis4. The underlying malocclusion

IDEAL TIMING FOR EXTRACTIONS

UPPER ARCH- The developmental position of an unerupted permanent second molar generally ensures that this tooth will achive a good occlusal position following extraction of FPM

LOWER ARCH- Achieving a good occlusion is more dependent upon the timing of the FPM extraction

IDEAL TIMING FOR EXTRACTIONS

Lower FPM should only be extracted when bifurcations of the lower permanent second molar starts to calcify, usually at the age of 8 9 years

CONSEQUENCES

1. The loss of only a lower first permanent molar after the eruption of the lower second permanent molar (> 8 years) may result in :

(A) Severe mesial tipping of the lower second permanent molar (B) Supra-eruption / over eruption of the upper first permanent molar(C) Migration or distal tipping of the lower second premolar

CONSEQUENCES

2. The loss of only a upper first permanent molar after the eruption of the upper second permanent molar may result in :

(A) Migration of the upper second permanent molar (B) No change in movements of tooth in the lower arch

CONSEQUENCES

3. The loss of a lower & upper first permanent molar after the eruption of the lower & upper second permanent molar (>8 years) may result in :

(A) Mesial tipping of the upper & lower second permanent molar (B) Distal tipping of the upper & lower second premolars(C) Mesial migration of the upper & lower second permanent molar

CONSEQUENCES

4. The loss of a lower & upper first permanent molar when the bifurcations of the upper & lower permanent second molar starts to calcify, usually at the age of 8 9 years :

(A) Mesial movement & successful eruption of the upper & lower second permanent molar (B) Suitable replacement for the lost molar in form, function & aesthetics

ORTHO-PAEDO MANAGEMENTS

Treatment planing decisions and management of extractions should be ideally made following input from both the paediatric dentist & the orthodontist

General Aim : 1. For space closure created by the loss of the FPM2. To guide the eruption of the second permanent molar to proper position3. To prevent crowding & other malocclusion


CLASS 1 CASES WITH MINIMAL CROWDING

CLASS 1 CASES WITH CROWDING (A) BUCCAL SEGMENT CROWDING(B) LABIAL SEGMENT CROWDING

CLASS 2 CASES WITH MINIMAL CROWDING (< 3MM)

CLASS 2 CASES WITH CROWDING

CLASS 3 CASES


CLASS 1 CASES WITH MINIMAL CROWDING (< 3MM)- Do not balance unilateral FPM extraction in either the upper or lower arches with healthy first molar- If the lower FPM is to be lost, compensating extraction of the upper first molar should be considered to avoid supra eruptionUNLESS, the lower second molar has erupted and the upper first molar is in occlusal contact with it


CLASS 1 CASES WITH CROWDING (> 3MM)(A) BUCCAL SEGMENT CROWDING(B) LABIAL SEGMENT CROWDING


(A) BUCCAL SEGMENT CROWDING

- If the buccal segment crowding is bilateral, consider balancing extraction to provide suitable relieve and maintain the center line

- Compensating extraction of upper FPMs should be considered to prevent over eruption or relieve premolar crowding


(B) LABIAL SEGMENT CROWDING- FPM extractions can be delayed until the second permanent molars erupt and then the space can be used for closure and alignment with a fixed appliance

- Alternatively, FPM can be extracted at the optimum time and the crowding can be treated when in permanent dentition. Third molars should be present If premolars are indicated for extraction


CLASS 2 CASES

-The extraction of FPMs in Class II cases can be more difficult to plan

-The main complicating factors often involve the upper arch because of the need for space to correct the incisor relationship



CLASS 2 CASES WITH CROWDING (> 3MM)


CLASS 2 CASES WITH MINIMAL CROWDING (< 3MM)In the upper arch, space will often be required to correct the incisor relationship- Lower FPM extractions should be carried out at the ideal time for successful eruption of the second permanent molar

- Compensating and balancing extraction of healthy lower first molars are not indicated.


CLASS 2 CASES WITH MINIMAL CROWDING (< 3MM)- Lower FPM extraction should be carried out at the ideal time for successful eruption of the second permanent molar

- Compensating and balancing extraction of healthy lower first molars are not indicated.


CLASS 2 CASES WITH MINIMAL CROWDING (< 3MM)- If the upper FPM require immediate extraction, orthodontic treatment may be instituted to correct the incisor relationship

- A functional appliance or removable appliance and headgear can be used to correct the buccal segment relationship, followed by fixed appliances if required


CLASS 2 CASES WITH MINIMAL CROWDING (< 3MM)- Alternatively, after extraction of the upper FPMs the second permanent molars can be allowed to erupt and the incisor relationship corrected once this has taken place. - In addition, if there is radiographic evidence of third molar development, then further space for incisor correction could be created by the extractions of upper premolars

-


CLASS 2 CASES WITH MINIMAL CROWDING (< 3MM)- If the upper FPM can be temporized or restored, then their extraction can be delayed until the second permanent molars have erupted. - The resultant extraction space can then be used to correct the malocclusion with fixed appliances.



- If the upper FPM is sound, elective extraction may be indicated if it is at risk of over-erupting

- However, the third molars should ideally be present radiographically


CLASS 2 CASES WITH MINIMAL CROWDING (< 3MM)- If there is no sign of upper third molar development, an appliance to prevent the over-eruption of sound upper FPM should be considered

- The malocclusion can be managed later following eruption of the second molars.


CLASS 2 CASES WITH CROWDING (> 3MM)

- If the third molars are present radiographically, lower FPM can be extracted at optimum time to allow eruption of permanent second molars. -Crowding can be corrected later by premolar extractions and fixed appliances


CLASS 2 CASES WITH CROWDING (> 3MM) - Alternatively, PFM can be extracted after second molar eruption where the space can be used to correct crowding with a fixed appliance

- Balancing and compensating extraction of lower FPM are not required


CLASS 3 CASES

- Often more difficult to manage, orthodontist specialist opinion is required prior to extractions

- Extraction of upper FPM should be avoided

- Balancing and compensating extractions are not recommended

CONCLUSION

The FPM Is a very vital tooth in the developing dentition of the oral cavity. Its functions varies from aesthetics to mastication

The loss of a PPM creates spacing, multiple malocclusion problems & mastication defects

Therefore, long term treatment planing and further consequences should be taken into consideration prior to any extraction procedures

THANK YOU FOR YOUR TIME

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extraction of the first permanent molar

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