Done by : Zainab Ahmed Habeb.

Supervised by : Dr.Ebtisam Abdullah.

| EARLY LOSS OF 1ST PERMANENT MOLAR IN |

• The first permanent molar is undeniably the most important unit of mastication and
is essential in the development of functionally desirable occlusion. The loss of a
first permanent molar in a child can lead to changes in the dental arches that can
be traced throughout the life of that person. Unless appropriate corrective
measures are instituted, these changes include diminished local function, drifting of
teeth, and continued eruption of opposing teeth.
• During the mixed-dentition stage of dental development, dentists may encounter
patients with first permanent molars considered to have a poor long-term
prognosis. In this situation, extraction of the tooth and space closure or use of the
extraction space for future orthodontic treatment should be considered.
• The first permanent molar (FPM) has been quoted as being the most caries-prone
tooth in the permanent dentition, probably as a result of its early exposure to the
oral environment. dentists may consider restoration of FPMs with extensive caries
and pulpal symptoms during the mixed-dentition stage. However, heavily restored
teeth will enter the restorative cycle and may need to be extracted in later life. Late
extraction has restorative implications and may lead to unfavourable occlusal
changes if spaces are left unrestored. In such cases,consideration should be given
to the extraction of these teeth during the mixed-dentition stage.
• It is commonly quoted that the FPM is not the ideal tooth to be extracted for
orthodontic reasons as space is provided away from the labial segments. Although
technically demanding, it is possible to use the extraction space orthodontically for
the relief of crowding and overjet reduction with favourable results.
FACTORS TO CONSIDER WHEN PLANNING EXTRACTION OF FIRST
PERMANENT MOLARS :

It is important to consider the following factors when planning extraction of

FPMs:
• ︎ the restorative state of the tooth;
• ︎ dental age of the patient
• ︎ degree of crowding in the buccal and labial segments
• ︎ the occlusal relationship .
• ︎ presence and condition of the other teeth.

RESTORATIVE STATE OF THE FIRST MOLAR

Extraction of a FPM during the mixed- dentition should be considered when these
teeth have, or are affected by:
• ︎large occlusal or approximal restorations.
• ︎irreversible pulpitis.
• ︎periradicular infection.
• ︎severe hypoplasia. In well kept mouths, where restorative treatment may have a
good long-term prognosis, conservation of hypoplastic molars may be a more
appropriate form of treatment. However, hypoplastic molars should always be
considered as candidates for extraction if space is required for the correction of
malocclusion.

DENTAL AGE OF THE PATIENT

To achieve spontaneous space closure, the ideal time for the extraction of FPMs is
before the eruption of the second molars. Timing is more critical in the mandible than
in the maxilla. Delayed extractions result in incomplete space closure and
establishment of poor contact point relationships.The results of delayed extraction in
the mandible are enhanced if mild crowding exists in the premolar region as distal
drift of the premolars reduces the amount the second molar must migrate mesially.

THE PRESENCE OF CROWDING

The presence of crowding has been shown to be one of the most important factors for
the establishment of a satisfactory occlusal result following the extraction of
FPMs .The extraction of FPMs cannot be expected to resolve significant crowding in
the labial segments spontaneously. In such cases, the FPM may be retained until the
second permanent molar erupts. Following this, the tooth can be extracted and the
space used to correct labial segment crowding orthodontically.
THE EFFECT OF THE EXTRACTION OF FIRST PERMANENT MOLAR ON
OCCLUSION:
The extraction does not create great problems in the upper jaw. However, in the lower
jaw, the effect of loss of PFMs on occlusion depends on the age of the extraction, and
the best results were found in the early age (8–10) years.
On the other hand, lower first molars can be extracted when all the following factors
are present:(Carious lesions with pulp involvement ,Crowding in the relevant quadrant
,Age 8–10 years ,No sagittal deviations ,No other tooth missing in the same
quadrant).
Moreover, the extraction in the lower jaw should be avoided in cases with distal
occlusion, deep bite, and increased overjet.
Early loss of deciduous first molar is different when compared to loss of PFM. In a
systematic review about the effect of early loss of primary first molars, little effect was
noted.However, loss of PFMs may affect the occlusion in a great deal. This difference
could be due to the fact that PFM at ages 5–14 plays an important role in arch
integrity and mastication as well. Furthermore, the locations of primary first molars
and PFMs are different which would lead to different effect on occlusion.

TREATMENT PLANNING FOR THE LOSS OF FIRST PERMANENT

MOLARS:
Suggested treatment for the loss of 1st permanent molar is include space closure or
use of the extraction space for future orthodontic treatment. Early space closure of
the extracted first molars although might appear to be a feasible option, the possible
downside of this approach is the relatively long time to be considered for closing such
spaces. On the other hand, leaving this space to be utilized for future orthodontic
treatment should be considered with care. An appropriate space maintainer and
careful evaluation of the patient's malocclusion are important in considering this
treatment modality. The use of space maintainers after premature loss of the second
upper temporary molar is a last solution in preventing tridimensional lesions in the
dental arch and occlusion.

References :
1. Hallett GEM, Burke PH. Symmetrical extraction of first permanent molars. Factors
controlling results in the lower arch. Trans Eur Orthod Soc 1961; 238–255.
2. Gill DS, Lee RT, Tredwin CJ. Treatment planning for the loss of first permanent
molars. Dent Update. 2001;28:304–8.
3. Tunison W, Flores-Mir C, ElBadrawy H, Nassar U, El-Bialy T. Dental arch space
changes following premature loss of primary first molars: A systematic review.