THE FIRST PERMANENT MOLAR*
By W. D. N. MOORE, L.D.S., D.D.S., Chicago, Illinois
S U S T A IN E D interest in any subject
is the best evidence o f its importance,
and the application o f this truth
is most fitting to the topic o f our dis­
cussion this evening, the first perm anent
m olar. I t requires some degree o f
courage to prepare a paper today on a
subject th at has been so long and so
fu lly discussed as this. T h e tendency
o f the present day is to exploit some
new idea w hether or not it is fu n d a­
m entally sound, as long as it is capable
o f producing a th rill or furnishing
something o f a spectacular nature. In
spite o f all th at has been said o f the
first perm anent m olar, much still re­
mains to be said if this difficult problem
is to be most satisfactorily solved. T h e
loss o f the first perm anent m olar in ­
troduces one of%tthe most pow erful
forces fo r the detrim ent, and even dev­
astation, o f the hum an mouth.
T h ere is no gainsaying the fact that
no other tooth in the dental arch plays
so im portant a role as that o f the first
perm anent m olar. E rupting am ong the
earliest o f the second dentition and
w ithout any disturbance, as a rule, to the
deciduous teeth or the gums, it boldly
and definitely takes a position in the
arch, the significance o f which cannot
be too fu lly realized or appreciated
i f a w ell developed perm anent dentition
is to be m aintained. A study of
* R e ad b e fo re th e O d o n to g ra p h ic
o f C h ica g o , D ec. 13, 1926.
Jo u r. A . D . A ., J u ly , 1927
N atu re’s plan fo r the function this tooth
is to perform is most interesting and
fascinating, and, when thoroughly un­
derstood, it should awaken the keenest
sense o f responsibility, in view o f the
m any considerations that are likely to
be encountered if the tooth is to render
the m axim um service to its host.
A ll teeth are im portant organs o f
the hum an m outh and their conservation
is imperative. T h e lot to which the
first perm anent m olar is heir is in many
respects different from that o f any o f
the other teeth. Its eruption and pres­
ence in the arch are so frequently un­
known to the parent or guardian of the
child, and not being under the regular
observation o f a dentist as it should be,
it is frequently mistaken fo r a deciduous
tooth, and no attention is given it until
serious inroads o f decay occur. U ntil
the average parent is better enlightened
initial injury to this tooth can be ex­
pected. Frequently, faulty development
o f this m olar offers a predisposing cause
o f dental caries, and this liability isoften
enhanced by an offending neighbor in
the adjacent deciduous m olar whose sur­
faces do not present a clean and healthy
environm ent. W ith these handicaps,
more or less present, this tooth is born
to p erform its functions in the dental
arch, which are at least tw ofold, and
Society each equally im portant fo r the future
perm anent dentition.
1213
1214 T h e Journal o f the Am erican D ental Association
First, and naturally so, we think o f
its function in mastication, and realizing
at times certain prevailing conditions
under which it labors, the m arvel is its
survival and endurance. I t is not un-
Fig. 1.— Loss of first permanent molar,
before and after operation; showing method
for correction.
common, when the deciduous teeth have
been lost prem aturely, to observe that
the entire stress in the posterior part of
the arches is borne by the fo u r first
perm anent m olars and practically all the
mastication is done on these teeth.
Particularly in the transition period do
we find an extra burden placed on the
first perm anent m olar. I t undoubtedly
becomes the chief organ o f mastication
Fig. 2.—Loss of first permanent molar, right and left sides.
with a larger and more effective oc­
clusal area. B ut its function does not
end here: it m aintains the stability and
integrity o f the arches in a m anner
that no other tooth does. E rupting
norm ally before the loss o f the decidu­
ous molars, and in the proper position,
the first perm anent m olar becomes the
veritable cornerstone and central pillar
o f the human mouth. I t is the general­
issimo o f the dental organs.
Recognizing, then, the im portant
functions and valuable service the first
perm anent m olar perform s in the
hum an mouth, we as dentists should
readily realize that its loss cannot fail
to be productive o f the most u n fo rtu ­
nate results unless early treated and cor­
rected. Its effects are so far-reaching
that it is difficult to deal fully with all
o f them here. T h e age at time o f
loss o f the m olar, the duration o f its
absence, the m anner in which the teeth
occlude and articulate are all capable
o f producing an endless num ber o f
conditions, each one different from the
others, but all similar in their destructive
influence. From the very first day the
m olar is lost, there at once begins a
d riftin g and m igration o f some or all
o f the teeth on that side o f the mouth,
with the usual elongation o f the tooth
opposing the space. W ith this comes
the usual “ tipping” o f the teeth adjacent
to the space a condition that proves
ruinous if long perm itted to remain.
 M uore— T h e First Perm anent M olar 1215
T h e arch becomes less in dimensions in T h e loss o f contact point o f several
all directions. T h e loss o f the first teeth, dependent in extent on the age o f
perm anent m olar before the fu ll erup­ the patient and the time space has existed,
tion o f the bicuspids will lead to a is a common sequence to the loss o f the
dropping together o f the m axilla and first perm anent molar. T here is always
mandible and result in too much over­ some loss o f the bony structure, and
bite o f the anterior teeth, in terferin g w hen pronounced inclination and elon­
w ith the contour o f the face and de- gation o f the teeth occur, an involvement

Fig. 3.— Result of delayed treatment after extraction: Above, left: right side; above,
right: left side. Postoperative treatment: Below, left: right side; below, right: left side.
tracting from the character o f the o f soft and hard tissues is usually pres­
countenance. T h e loss o f this tooth at ent; and when this condition is long al­
any age results in abnorm al occlusion. lowed to rem ain, complete loss o f the
Even when the occlusion appears to be second and third m olar has resulted.
restored by a d riftin g together o f the Im paired function is the aggravating
second bicuspid and second m olar, a cause o f this loss follow ing the m al­
model made o f the upper and lower position o f the teeth. Associated with
w ill show a faulty occlusion on the teeth that are malposed is impaired func­
lingual aspect. Invariably, there is an tion, and wherever these are to be
elongation o f a tooth or teeth opposite found a lack o f hygienics can be ex­
the space follow ing the loss o f this pected and usually prevails.
molar. I f we have a fu ll and definite per-
1216 T h e Journal o f the Am erican D ental Association
ception o f all the functions intended by
N ature fo r the first perm anent m olar to
perform , together with the m isfortune
that follow s its loss, we cannot fail to
be forcibly impressed w ith the impor-
Fig. 4.— Case presented by a young patient.
tance that must be attached to this tooth,
and our responsibility fo r its w elfare
cannot be too earnestly assumed if the
greatest good is our goal o f service and
accomplishment in professional practice.
O u r first efforts, then, should be di­
rected against initial injury to this tooth,
which is, and can be, best obtained by
frequent observation and prophylaxis.
T h e importance o f this is a m atter that
Fig. 5.— Model of case shown in Figure 4, sition. second molar restored to correct po­
showing
after extraction.
cannot be too strongly impressed on the
parent’s m ind at the tim e o f the tooth’s
first appearance in the mouth. W hen
the first break in the continuity o f any
o f its surfaces appears, no delay or
tem porizing should be tolerated. T h e
idea that has prevailed in m any minds
that temporary fillings should be em ­
ployed in filling teeth fo r young pa­
tients is a fallacy, a contention without
any good foundation. T h ere is no place
Fig. 6.—Appliance used in correcting the
position of the second molar.
in dentistry where w ork o f a perm anent
nature is more clearly indicated than in
the treatm ent and care o f these teeth.
T h e more extensive the decay, the more
imperative the dem and fo r permanency,
fo r the reason that contour and contact
are so essential to all that pertains to the
future w elfare o f the first perm anent
m olar in the perform ance o f its fu ll
function. I t is not uncommon to see
large proximal fillings in these molars
Fig. 7.— Model of case shown in Figure 5,
that are soon a fte r insertion so badly
disintegrated that a ll contact with
adjacent teeth and contour is totally lost,
a shifting o f its own position resulting,
as well as that of those adjacent to it.
 M oore— T h e First Permanent M olar
In such cases as these, it is impossible to
maintain the norm al position o f the
other teeth in the arch. N o small am ount
o f trouble has resulted from a lack o f
Fig. 8.— Second molar in correct position.
observance o f these details in first fill­
ings that have been placed in the first
perm anent molars. Pulp involvement
should be strenuously combated in con­
nection w ith these teeth.
T h e belief in the minds o f some
operators th at the cavity preparation
necessary fo r perm anent fillings in these
teeth should not be borne by the child
accounts, and rig h tfu lly so in certain
cases, fo r much o f the temporary work
to be seen in the teeth o f young patients.
I t seems that this has often been used
Fig. 9.—Appliance in position on model.
as an excuse rather than a sound reason,
and we have allow ed ourselves to resort
to temporary work fo r convenience and
sometimes economy when it was not
truly justified. A great deal o f this
1217
tem porary w ork has been only a kind­
ness in disguise. T h e gold inlay has
long proved its value and usefulness in
operative dentistry and in no place has
it been shown to be o f greater impor­
tance than in restoring perm anently,
the first perm anent m olar, within the
tolerance o f the average young patient.
I t offers almost ideal advantages, partic­
ularly in regard to contour and contact
point, both o f which are essential in
these cases.
W h en destruction has gone beyond
repair and the first perm anent m olar is
to be lost, it is then that the real problem
Fig. 10.— Finished case.
confronts us. Its importance in the
dental arch has been emphasized and
its loss described and it is therefore not
difficult fo r us to conclude w hat should
be done if we are to conserve the
original plan that N ature so w ell de­
signed fo r the best w elfare o f a useful
dentition. T h e greater difficulty lies in
how it can best be done. T h e first
thought should be to m aintain, as early
as possible, the space occupied by the
first perm anent m olar, and this can best
be accomplished by the use o f a w ell-
made fixed bridge. I f the extraction
is made when the second permanent
biscuspid and second perm anent molar
are in position, no ordinary responsibility
rests on the operator fo r immediate
1218 T h e Journal o f the Am erican D ental Association
means fo r retaining its space, and this
should have been fu lly planned previ­
ously to the operation. I t is directly
a fte r the extraction that the most rapid
Fig. 11.— Results of early loss of the lower first permanent molar.
movement o f the adjacent teeth is made,
particularly if the occlusion is such as
to favor their m igration. Unless con­
siderable movem ent o f these adjacent
teeth has taken place previously to ex­
traction, and this is common, owing to
cavities or faulty restorations o f the
first perm anent m olar, it is good practice
Fig. 12.— Results of early loss of the
lower first permanent molar.
to construct the bridge, or at least its
greater part, before the first perm anent
m olar is extracted, and place it in posi­
tion alm ost imm ediately on extraction.
T h is precludes the possibility o f the
slightest movement. But if the
adjacent teeth have already lost their
norm al position owing to faulty res-
torations, this is not necessary; fo r their
correction o f position should first be
obtained. M ore often than otherwise,
these cases come to us a considerable
time a fte r this m olar has been lost, and
with various conditions of derangem ent
o f the teeth already established; all o f
Fig. 13.-—Results of loss of the upper first
permanent molar.
which adds to the complexity o f the
task.
“ T ipping” o f the teeth on one or both
 M oore— T h e First Permanent M olar
sides o f the space is a condition not to
be overlooked w hether it has happened
before or a fte r extraction. Before any
replacement is considered, particularly
in the younger class o f patients, their
contact with adjacent teeth and their
proper occlusion w ith opposing teeth
should be reestablished. I n addition to
this, bridging inclined teeth fo r these
patients is employing teeth to bear an
extra strain at a disadvantage, and w ill,
when done, prove a detrim ent to them.
T h e more vertical position is the one
most suitable and toleran t to the sur-
Fig. 14.— Results of loss of the upper first permanent molar.
rounding tissues o f a tooth. T h erefo re,
it is only a logical conclusion th at those
teeth whose positions have in any way
been changed by reason o f the loss o f
the first perm anent m olar should, pre­
viously to the use o f a bridge fo r service
and m aintenance o f its space, be placed
in a norm al position in the arch, even
if this is not, strictly speaking, a correct
position.
T h e methods to be used fo r moving
these teeth into norm al position, and
the age lim it advisable fo r such pro­
cedure, as w ell as m any other particulars
incident to this operation, can be much
more ably covered by D r. Lourie in his
discussion o f this paper, since this partic-
1219
ular aspect o f the subject comes within
the field o f the orthodontist. I look
w ith much interest fo r his enlighten­
m ent on this side o f the subject.
W hile the treatm ent follow ing the
loss o f the first perm anent m olar in the
young patient may extend over a con­
siderable period o f time, i f properly car­
ried out through its entire procedure it
can supply intense interest and a grati­
fication to both patient and operator
that is most genuine in character.
T his is particularly so w hen compared
w ith cases o f long standing in the
m ouths o f patients who are somewhat
advanced in years and where correction
o f position o f the teeth is not to be
considered. In these cases, the move­
m ent o f bicuspids and molars toward
each other has been so m arked that their
surfaces often are w ithin a m illim eter
or tw o o f contact. In m any mouths,
this is a most aggravating condition, and
even w hen no cavities or fillings are
present in the teeth, the only correction
can be an operative one, preferably made
by the use o f the gold inlay in one or
both teeth.
Probably the most discouraging
condition that we are called on to treat
is that in m iddle-aged patients in which
1220 T h e Journal o f the Am erican D ental A ssociation
the bicuspids, and particularly the second
and third molars, have not moved so
much bodily but “ tipped” extensively,
w ith a marked elongation o f the upper
first m olar, and w ith a history o f pain
in masticating. T h e second and third
molars may be slightly loosened and no
cavities or fillings present. W h a t we
accomplished in the younger patient by
correcting the position can be only par­
tially gained by operative methods in re­
storing occlusion by preparing cavities
on the proximal and occlusal surfaces
Fig. IS.— Results of loss of the lower first permanent molars.
o f the molars and so shaping inlays that
occlusion is corrected w ith a more up­
right position given to the natural
crowns. T h e n , by assembling these in ­
lays, which w ill greatly stabilize the tw o
m olars as w ell as serve as an abutm ent
to carry a substitute fo r the lost m olar,
a reinforcem ent is gained that is o f
m uch value. T h e second bicuspid
treated in a m anner sim ilar to the molars
w ill supply the anterior abutm ent. T h e
upper first m olar should be shortened
and inlayed. Cases o f this kind have
been made com fortable and serviceable
to the patient fo r m any years.
So m any and varied are the conditions
follow ing the loss o f the first perm anent
m olar that there must be several differ­
ent methods employed if all conditions
are to be successfully cared for. T h e
technical detail is m itself a sufficient
topic fo r an evening and one which
could better be treated from a clinical
standpoint. I should, however, feel
disappointed if I could not at this time
express my appreciation fo r the help
and cooperation I have received from
the orthodontic branch of our profession
and D r. Lourie in particular. F o r sev­
eral years, I have been deeply interested
in this subject, and the help and interest
given me by D r. Lourie has strength­
ened my convictions o f its importance
and stim ulated my determination to treat
the cases along the lines I have here
endeavored to indicate. I wish to ex­
press my appreciation to the program
committee fo r enlisting his support to­
night on this subject fo r I feel certain
that the greatest good can only come
where a close cooperation o f all the
branches o f our profession prevails.
DISCUSSION
What im­
Lloyd. S. L o u rie, C hicago, III.:
portance do you place upon the loss of the
first permanent molar in young children, and
what should be done in such cases? Dr.
 M oore— T h e First Perm anent M olar
Moore has answered the first question so ably
that I shall simply indorse his statements and
show a few cases illustrating the damage re­
sulting from early loss of this tooth. Cases
1 (Fig. l l ) and 2 (Fig. 12) show results of
early loss of lower first permanent molars,
while Cases 3 (Fig. 13) and 4 (courtesy of
Dr. J. W. Ford) (Fig. 14) show results
of the loss of upper first permanent molars.
In Case 1, there was at least 50 per cent
reduction in masticating efficiency on the side
where the tooth was lost. In Cases 3 and 4,
the spaces have more nearly closed, but with
considerable malocclusion and just as much
as or greater facial deformity than in Cases
1 and 2, in which lower molars were lost.
Cases 5 and 6 (Fig. 15) show different re­
sults after loss of the lower first permanent
molars. Possibly in Case 5, the loss occurred
earlier, before the bicuspids were in occlusion,
allowing them to drift toward the space as
well as the second permanent molar, while
in Case 6, only the second molar moved. I
agree with Dr. Moore that if the loss occurs
after the eruption of the second permanent
molar, the best procedure, in most cases, is to
place a fixed bridge as soon as possible, and
if delay should seem advisable, a space re­
tainer should be used. The space retainer
should also prevent the overeruption of the
tooth in the opposing arch, and probably a
plate would best fulfil all requirements. If
the first permanent molar has been lost before
the eruption of the second, a more difficult
problem is presented. This problem may be
prosthetic or orthodontic or both, and must
first be considered by the general practitioner
who first has the opportunity of seeing the.
great majority of these cases. The specialist
seldom sees them until after the time for do­
ing the greatest good has passed. The correc­
tion, which all orthodontists can accomplish, is
but “a drop in a bucket” compared to the pre­
ventive orthodontia which the general practi­
1221
tioners might practice successfully here if only
they did their best as early as possible. Pend­
ing the eruption of the second permanent
molar, little can be done except to maintain
the positions of the other erupted teeth; but
at that time, a decision should be made be­
tween closing or opening the space previously
occupied by the lost tooth. Certainly, the
adjoining teeth must not be allowed to drift
without supervision, for they usually require
assistance one way or the other if malocclu­
sion and facial deformity are to be avoided.
Various things must be considered in making
this decision. The difficulty of the proposed
tooth movement under the two plans must be
estimated, and in this, attention should be
given to the distance the teeth would have to
be moved, the character of the alveolar
process and the amount of tipping or root in­
clination, it being easier, of course, to move
the crown than the root, to improve the axis
of the tooth for occlusal strain. Radiograms
would, of course, help here. Orthodontic
opinion seems to be against extensive bodily
movement of molars, and probably, in most
cases, greater good will result from prosthetic
than from orthodontic treatment, though or­
thodontic assistance may often make possible
better prosthetic work, as explained by Dr.
Moore. Plate and spring appliances such as
he has described seem particularly suited to
these cases, combining as they do space reten­
tion and the means for improving tooth
positions, preparatory to prosthetic restora­
tions. It does not seem advisable nor is there
time to discuss extensive orthodontic correc­
tion. That is often out of the question be­
cause of limitations of the patient’s time or
finances. It must be remembered, too, that
ideal results are not to be expected by any
plan of handling these cases; consequently,
conservatism should be a controlling influence
in efforts to give the patient the greatest
benefits in a practical way.