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A Guideline for First Permanent Molar Extraction in Children.

Balancing extraction is removal of the first molar on the other side of the same arch2 Compensating extraction is removal of the first molar on the same side in the opposing arch2 Extraction of the first permanent molar is rarely the orthodontic extraction of choice. It doubles the treatment time and halves the prognosis Mills (1968) 1 As a general rule first permanent molars should be restored2 . This quote from Mills was made at a time when most orthodontic treatment was undertaken using removable appliances. It is now possible to achieve good results following removal of 6s using fixed appliances, although there is some evidence that the overbite may deepen in some cases3,4,5 and treatment times tend to be increased.6,7 . It is not advisable to extract a healthy premolar for orthodontic purposes if the first permanent molar in the same quadrant is heavily restored8 . [SIGN Grade B] Ideally an orthodontic opinion should be obtained before extraction of any permanent tooth, preferably from the orthodontist who will be responsible for future treatment. Temporise or restore and refer 2,9,10,11 This is not always possible if there is sepsis or pain or practical if the patient is unlikely to attend an orthodontist. If use of LA is practical, then extract only the tooth affected and refer. If GA is only option, try to obtain advice beforehand to prevent multiple anaesthetics. Before any decision is made, an orthopantomogram of good quality i s needed to show that all teeth are present, in good condition i.e. not hypoplastic, and are well placed for eruption. If any of the permanent dentition is missing or in a poor eruptive position, then temporise/restore the tooth and seek an orthodontic opinion. [SIGN Grade C] Class 1 case with no crowding, extraction may be unavoidable but will lead to spacing. Do not balance the extraction with one from the other side of the mouth either in the upper or the lower arch. If the first molar on the lower is to be lost and the upper first molar has a poor prognosis, consider extraction of the opposing upper 6. If the first molar on the lower is to be lost and the upper first molar is healthy, extract the opposing upper 6 to avoid overeruption10, 11 unless the lower second molar has already erupted and the upper 6 is in occlusal contact with it. If the upper first molar is to be lost, do not compensate with extraction of the lower first molar if it is healthy. [SIGN Grade C] Class 1 case with crowding. This is the classical case for balancing and opposing extractions. First permanent molars with a poor prognosis, dental age 9-112,3,11, all teeth present on radiograph with no hypoplasia, and well placed for eruption. Works best if there is premola r crowding3 . Do not balance9 unless the 6 on other side has poor prognosis or premolars are impacted due to early loss of deciduous molars and 8s are present12 Beware if there is incisor crowding, temporise or restore and refer. [SIGN Grade B]

In Class 11 case, with no crowding. Extraction of the first permanent molar in the lower will lead to spacing, uncontrolled eruption of teeth and may compromise future orthodontic treatment. Temporise or restore if possible, refer and do not carry out any balancing extractions. In the upper temporise/restore and refer. It is sensible to delay extraction of 6s until 7s have erupted sufficiently to be controlled orthodontically, and the extraction space can be used to treat the malocclusion2,11. If the upper first molar is unopposed and at risk of over-erupting and third molars are present radiographically, then extraction of the upper first molar may be indicated 10,11. The patient should be counselled however, that additional premolar extractions in the upper arch might be required in the future to create sufficient space for overjet correction. [SIGN Grade C]

Class 11 case with crowding. Consider balancing9 extraction in the lower only if the first molar is of poor prognosis or premolars are impacted due to early loss of deciduous molars and 8s are present12 Temporise or restore the upper and refer2, 11. If the upper first molar is unopposed and at risk of over-erupting and third molars are present radiographically, then extraction of the upper first molar may be indicated 10,11. The patient should be counselled however, that additional premolar extractions in the upper arch might be required in the future to create sufficient space for overjet correction and treatment of crowding. [SIGN Grade C]

Class 111 case Temporise or restore and refer 2, 11 [SIGN Grade C] IF IN DOUBT, GET PATIENT OUT OF PAIN, TRY AND MAINTAIN TEETH AND REFER2,9,10. [SIGN Grade C] References 1. Mills JR (1968). The stability of the lower labial segment. A cephalometric survey. Dent Pract Dent Rec 18 : 293-306. 2. Houston, Stephens & Tulley. Local factors and early treatment. Chpt 9 in A Textbook of Orthodontics. Wright, Oxford 1992. 3. Hallett GEM and Burke PH (1961). Symmetrical extraction of first permanent molars. Factors controlling results in the lower arch. Europ Orthodont Soc Trans 238-253. 4. Richardson A (1979). Spontaneous changes in the incisor relationship following extraction of lower first permanent molars. Br J Orthod 6 85-90. 5. Abu Aihaija ES, McSheny PF and Richardson A (2000). A cephalometric study of the effect of extraction of lower first permanent molars. J Clin Paediatr Dent 24 195198. 6. Taylor PJS & Kerr WJS (1996). Factors associated with the standard and duration of orthodontic treatment. Br J Orthod 23 : 335-341. 7. Sandler PJ, Atkinson R & Murray AM (2000). For four sixes. Am J Orthod 117: 418-435.

8. Daugaard-Jensen I (1973). Extraction of first molars in discrepancy cases. Am J Orthod 64: 115-36. 9. Crabb JJ & Rock WP (1971). Treatment planning in relation to the first permanent molar. Br Dent J 131: 396-401. 10. Penchas J et al (1994). The dilemma of treating severely decayed first permanent molars in children: to restore or to extract. ASDC J Dent Child 61: 199-205. 11. Gill DS, Lee RT & Tredwin CJ (2001). Treatment planning for the loss of First Permanent Molars. Dental Update 28 304-308. 12. Plint DA (1970). The effect on the occlusion of the loss of one or more first permanent molar. Trans.Eur Orthod Soc 329-336.

SIGN Classification The Scottish Intercollegiate Guideline Network (SIGN) classification system indicates whether a guidelines recommendations are based on proven scientific evidence or currently accepted good clinical practice with limited scientific evidence. Level Ia Ib IIa IIb III IV Type of evidence Evidence obtained from meta-analysis or randomised control trials. Evidence from at least one randomised control trial. Evidence obtained from at least one well-designed control study without randomisation. Evidence obtained from at least one other type of well-designed quasiexperimental study without randomisation. Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case control studies. Evidence from expert committee reports or opinions and/or clinical evidence of respected authorities.

Grade A> (Evidence levels 1a,1b) B> (Evidence levels IIa,IIb,III C> (Evidence level IV)

Recommendations Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendations Requires availability of well conducted trials but no randomised clinical trials on the topic of recommendation Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

Professor Alison Williams Dr Roslyn McMullan May 2004