Extraction of first permanent molars

1. EXTRACTION OF THE FIRST PERMANENTEXTRACTION OF THE FIRST PERMANENT
MOLARS (FPM)MOLARS (FPM)
DR.SASHI KUMAR MANOHARDR.SASHI KUMAR MANOHAR
DENTAL OFFICERDENTAL OFFICER

2. CONTENTS
● INTRODUCTION
● IMPORTANCE OF FPM
● OVERVIEW
● GUIDELINES FOR EXTRACTIONS OF FPM
° TREATMENT PLANING
° BALANCING & COMPENSATING EXTRACTIONS
° IDEAL TIMING FOR EXTRACTION
° CONSEQUENCES
●
ORTHO-PAEDO MANAGEMENT

3. 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

5. 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)

6. OVERVIEW
● The relative timing of the FPMs
development & eruption ( 6-7 years ) makes
them more susceptible to :
1. Dental Caries
2. Hypomineralization
3. Hypoplasia
● Children can present with a developing
dentition affected by one or a combination of
multiple conditions, which may necessitate
their enforced extraction

7. 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

8. TO EXTRACT !!!
OR
NOT TO EXTRACT !!!!

9. TREATMENT PLANING
● Factors that affect treatment planing decisions
include :
1. Child's age & social background
2. Occlusion of the developing dentition
3. Prevention & oral hygiene practice within
the family
4. Child's ability to co-operate with treatment
options
5. Other oral habits & dietary intake of the
child

10. TREATMENT PLANING
6. Degree of molar-incisor hypomineralization
severity
7. Restorability & pulpal involvement of the
tooth
8. Presence of second and third molar tooth
germs
9. The necessity for GA to allow extractions of
FPM
10. Expected long term treatment cost

11. 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

12. BALANCING &
COMPENSATING
EXTRACTIONS
● 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

13. BALANCING &
COMPENSATING
EXTRACTIONS
● Principles of balancing & compensating
extractions :
1. Which molar requires enforced extractions
2. Teeth present within the developing
dentition (2nd
and 3rd
molars)
3. Overall oral condition & long term prognosis
4. The underlying malocclusion

14. 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

15. 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 8½ – 9½
years

16. 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

18. 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

21. 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

24. 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 8½ – 9½ years :
(A) Mesial movement & successful eruption of the
upper & lower second permanent molar
(B) Suitable replacement for the lost molar in form,
function & aesthetics

26. 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
FPM
2. To guide the eruption of the second
permanent molar to proper position
3. To prevent crowding & other malocclusion

27. ORTHO-PAEDO
MANAGEMENTS
● 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

28. ORTHO-PAEDO
MANAGEMENTS
● 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 eruption
UNLESS, the lower second molar has erupted
and the upper first molar is in occlusal contact
with it

29. ORTHO-PAEDO
MANAGEMENTS
● CLASS 1 CASES WITH CROWDING (> 3MM)
(A) BUCCAL SEGMENT CROWDING
(B) LABIAL SEGMENT CROWDING

30. ORTHO-PAEDO
MANAGEMENTS
● (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

31. ORTHO-PAEDO
MANAGEMENTS
● (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

32. ORTHO-PAEDO
MANAGEMENTS
● 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

33. ORTHO-PAEDO
MANAGEMENTS
● CLASS 2 CASES WITH MINIMAL
CROWDING (< 3MM)
● CLASS 2 CASES WITH CROWDING (> 3MM)

34. ORTHO-PAEDO
MANAGEMENTS
● 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.

35. ORTHO-PAEDO
MANAGEMENTS
● 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.

36. ORTHO-PAEDO
MANAGEMENTS
● 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

37. ORTHO-PAEDO
MANAGEMENTS
● 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

38. ORTHO-PAEDO
MANAGEMENTS
● 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.

39. ORTHO-PAEDO
MANAGEMENTS
● CLASS 2 CASES WITH MINIMAL
CROWDING (< 3MM)
- 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

40. ORTHO-PAEDO
MANAGEMENTS
● 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.

41. ORTHO-PAEDO
MANAGEMENTS
● 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

42. ORTHO-PAEDO
MANAGEMENTS
● 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

43. ORTHO-PAEDO
MANAGEMENTS
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

44. 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

45. THANK YOU FOR
YOUR TIME