Source: AJO-DO on CD-ROM (Copyright © 1998 AJO-DO), Volume 1987 Oct (336 - 345): Management of

ectopically erupting first permanent molors - Kennedy and Turley

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The clincal management of ectopically erupting first permanent molars

David B. Kennedy, B.D.S., M.S.D., F.R.C.D.(Can.), and Patrick K. Turley, D.D.S., M.S.D., M.Ed.

Vancouver, British Columbia, Canada, and Los Angeles, Calif.

The literature on ectopically erupting first permanent molars is reviewed. The progression of the ectopic
condition is discussed along with factors that will affect the practitioner's decision on a mode of
treatment. The optimal treatment approach depends on the clinical eruption status of /6/, the change in
position of /6/, the amount of enamel ledge of /E/ entrapping /6/, the mobility of /E/, and the presence
of pain or infection. A variety of treatment approaches together with diagnostic rationale and clinical
guidelines are presented. Overall aspects of the malocclusion must be considered when planning the
management of ectopically erupting first permanent molars. (AM J ORTHOD DENTOFAC ORTHOP
1987;92:336-45.)

Ectopically erupting first permanent molars occur in 3% to 4% of the population.1 There is a higher
frequency (19.8%) of this anomaly in siblings2 and also in children with cleft lip and palate.3 The
frequency of occurrence has no sex or race variation and is unaffected by water fluoridation.4 Most
commonly, the maxillary arch is affected; in a study by Young,1 only three of 78 ectopically erupting first
permanent molars affected the mandibular arch. One of the first clinical signs of ectopically erupting
maxillary first permanent molars is a canting of the occlusal plane of the second primary molar.5 A bite-
wing or periapical radiograph may demonstrate the permanent molar to be both superiorly and mesially
positioned, and frequently the tooth is delayed in its eruption.5 Half of the patients present unilaterally,
the remainder bilaterally.1 Pulver6 noted that patients with ectopically erupting maxillary first
permanent molars often have a lack of arch length and a smaller maxilla, which is retropositioned
relative to the anterior cranial base. Frequently, there is a steeper angle of eruption of the first
permanent molar, which is also often larger than normal. The skeletal findings noted by Pulver were
confirmed in a recent European study.7 By contrast, Bjerklin and Kurol8 found only two factors— the
steeper angle of eruption and the larger molar width— that differentiated the ectopic eruption cases
from their normally erupted controls; no skeletal differences were noted.

Spontaneous self-correction or "jumping" of the impaction of the first permanent molar occurs in 66%
of cases.1 In persons with cleft lip and palate, the degree of self-correction is considerably less.3 In cases
that are self-correcting, the second primary molar exhibits resorption of the distobuccal root; despite
this resorption, all but two of 92 teeth studied longitudinally lasted until normal exfoliation.9 For those
ectopic molars that are not self-correcting, some type of intervention is warranted. Failure to do so will
result in continuing resorption of the second primary molar and its eventual loss.10 Surgical uncovering
of the unerupted impacted maxillary first permanent molar is reported to relieve the impaction,
although clinical trials of this method remain undocumented.5 In instances in which the impacted molar
is clinically accessible, some type of separation can be used for disimpaction. With reciprocal anchorage,
either a brass ligature,11 a spring-type deimpactor,12 or an elastic separator13 can be used.

When the degree of impaction or inaccessibility of the first permanent molar prevents separation, active
appliance therapy can be used to disimpact the tooth. Most appliances consist of a band cemented to
the second primary molar with an active spring or arm soldered to the band. The spring extends distally
to apply a force to disimpact the permanent molar. The distally extending arm of such appliances can be
attached to the first permanent molar through an occlusal cavity preparation as described by
Humphrey.14 Recently, Harrison and Michal5 described a modification of the Humphrey appliance. A
sheath is welded on the band of the second primary molar; a preformed removable spring attaches to
the sheath and engages an occlusal preparation in the permanent molar. Alternatively, pressure can be
applied to the mesiobuccal surface15 or to the mesiobuccal and mesiolingual surfaces of the permanent
molar.16 Since the advent of enamel bonding, the occlusal preparation is no longer necessary to retain
the wire on the occlusal surface of the first permanent molar.17 A stainless steel button can also be
bonded to the occlusal surface of the permanent molar and a reverse band and loop made on the
second primary molar. An elastic chain stretching from the button to a distally placed spur on the loop
portion of the appliance disimpacts the molar.18 Pulver and Croft19 describe the application of light-
cured resin to the occlusal surface of the permanent molar, providing a shelf for the retention of the
active arm of the appliance; buccal and lingual helical springs are soldered to the band on the primary
molar. Recently, a totally bonded appliance that permits activation in three planes of space has been
described by Kennedy.20 Once the molar has been repositioned, the potential for premature exfoliation
of the resorbed second primary molar and the need for space management must be monitored.5

When the second primary molar is so extensively resorbed that it exfoliates, the clinician is faced with
either space regaining or permitting space closure. When space regaining is considered, a removable
appliance is often the preferred-treatment. Because of the frequent finding of a smaller retropositioned
maxilla,7 the skeletal effects of extraoral traction may be contraindicated. However, Kurol and
Bjerklin21 used cervical headgear for both unilateral and bilateral cases with excellent results in 70% of
the 46 children treated. Poor cooperation was the main reason for failure to regain space. Although
there was some decreased sagittal maxillary growth resulting from the headgear, it was limited.

Deliberate extraction of the resorbed second primary molar and planned space closure are indicated in
selected circumstances.22 Indications and treatment concepts regarding this approach will be discussed
in the next section.

DIAGNOSTIC AND TREATMENT CONCEPTS

Space regaining

In the majority of cases, the treatment of choice for ectopic eruption is distalization of the molar to its
normal position. The main objectives of treatment are (1) to prevent loss of the second deciduous molar
so it can continue to serve as a space maintainer and (2) to regain lost arch length, allowing the second
premolar to erupt into normal position. The UCLA flowchart (Fig. 1) illustrates the progression of the
ectopic condition and discusses the factors that will affect the practitioner's decision on a mode of
treatment. The optimal treatment approach depends on a number of factors including the clinical
eruption status of /6/, the change in position of /6/, the amount of enamel ledge of /E/ entrapping /6/,
the mobility of /E/, and the presence of pain or infection.

Because two thirds of cases identified will spontaneously self-correct, the practitioner should reexamine
the area clinically and, if necessary, radiographically in 3 to 6 months. If no improvement is noted, active
intervention is warranted; the approach to treatment depends on the eruption status of the first
permanent molar. If the tooth is unerupted clinically, simple excision of the overlying soft tissue may be
the initial treatment of choice.5 If this procedure does not result in spontaneous self-correction, active
intervention is necessary. If the amount of entrapment is 1.0 mm or less, simple separation with either a
brass wire, a commercial separating spring, or an elastic may be adequate to remedy the problem. The
use of topical anesthetic permits more comfortable placement of the separator. Often, the separator
must be placed with waxed dental floss rather than pliers to minimize gingival damage. Our experience
has been that elastic separation is easier to perform and better tolerated by the patient than either
brass wire or commercial separating springs. The separator is replaced every 7 to 14 days until the
impaction is overcorrected. Spontaneous loss of the separator gives evidence of this overcorrection.

If the amount of entrapment is greater than 2.0 mm, the use of a Humphrey-type appliance is probably
warranted. The design of such an appliance depends on the stability of /E/ and the desired movement of
/6/. If /E/ is not mobile, it can be banded or bonded. Fig. 2 demonstrates a banded modified Humphrey
appliance. A bonded button is placed on the first permanent molar at the same time the appliance is
cemented on the second primary molar. The free arm engages on the mesial side of the button using
reciprocal anchorage to distalize the permanent molar. Activation at 3 to 4-week intervals is made with
three-prong pliers until overcorrection occurs. In the design shown, only anteroposterior movement is
possible. Vertical as well as buccal and lingual movements can be obtained by incorporating various
loops in the arm of the appliance and activating it in the desired direction. A totally bonded unilateral
appliance20 is shown in Fig. 3. Helical loops are placed in an 0.018-inch round wire to aid in retention at
the buccal surface of the first and second primary molars, and the occlusal surface of the permanent
molar. Activation is also by three-pronged pliers.

In cases where the /E/ is mobile, it may be necessary to increase the anchorage by including another
tooth in the appliance. One can include the /D/ adjacent to the /E/ via banding or bonding (Fig. 3) or go
across the arch and use the /6/ or /E/ on the contralateral side (Fig. 4). When designing a cross-arch
appliance in the maxillary arch, one may choose to add a Nance acrylic button as additional palatal
anchorage. All of these methods are an attempt to reduce stress to the /E/ and to increase its chance of
retention following correction of the ectopic condition. A reverse band and loop appliance (Halterman
appliance) with a distal spur can be cemented on the second primary molar ( Fig. 5). A chain elastic can
be stretched from the spur to a bonded button on the permanent molar and replaced at 1 to 2-week
intervals. This appliance design permits only anteroposterior movement, although selective placement
of the distal spur or bonded button will permit some mild rotational movement if required.

When space regaining is performed before the loss of the second primary molar, the treatment should
be accomplished within a 4-month period. The angulation of the impaction permits placement of an
occlusally bonded button without interference from the opposing tooth. However, when the impaction
is relieved early, the possibility of occlusal forces working against distal movement of the permanent
molar is reduced. Because reciprocal anchorage is used, some mesial movement of the primary molars is
expected; however, this result is not supported by clinical experience.

In cases in which the ectopic condition is more advanced, the amount of entrapment of the first
permanent molar may approach one half of the clinical crown. Resorption may extend into the pulp
chamber of /E/ and the tooth may be extremely mobile and often displaced. The patient may have pain
or discomfort and an abscess may be present. In these cases the /E/ is all but lost and the treatment of
choice is to extract the tooth and to regain space by moving the permanent molar distally. Space
regaining should be performed as early as possible after loss of the second primary molar to minimize
the following effects: rotation of the permanent molar into crossbite, displacement of the second
premolar palatally, development of molar asymmetry in unilateral cases, tipping of the molar such that
cuspal inclines drive the permanent molar further forward, drifting of the midline toward the side of
early loss, and mesial migration of the second permanent molar. For distalization of the permanent
molar to occur, there must be space distal to it.

Distalization of maxillary permanent molars may be done using removable appliances (Fig. 6), extraoral
traction, or a combination of the two (Fig. 7). Distalization with removable appliances can be done
unilaterally or bilaterally and is dependent on the availability of teeth for retention of the appliance.
Adams clasps are used for retention and can be attached to the first deciduous molar on the side of the
impaction and the opposing second deciduous molar in unilateral cases, or to both first deciduous
molars in bilateral cases. In cases in which additional anchorage is necessary, Adams clasps to the
central incisors or a Hawley bow can also be used. When there is extensive space loss, an anterior
biteplate may be needed to free up the occlusion to permit uprighting of the tilted permanent molar;
however, attempts to place headgear to severely tipped and rotated teeth can be equally frustrating for
both clinician and patient. The active arm of the uprihghting spring should contact the mesiolingual
curvature of the permanent molar as far gingivally as possible. This will permit both distal and slightly
buccal movements to offset the rotational aspects of mesial migration of the first permanent molar.

Extraoral traction in the form of a cervical headgear is an effective way to distalize molars, especially in
bilateral situations. As mentioned before, severe tipping of the permanent molar often precludes
comfortable placement of a face-bow and requires initial uprighting with a removable appliance. But
because of the potential orthopedic effect to the maxilla, cervical headgear should be avoided in
patients who show a Class III tendency. Because of the extrusive effect of cervical traction, cervical
headgear is also contraindicated in patients with skeletal open bite tendencies. To maximize distal tooth
movement and to minimize orthopedic restraint to the maxilla, the practitioner should encourage
maximum daily headgear wear for the shortest overall period of time (Fig. 7, G).23 Patients who display
a Class II relationship due to an anteriorly positioned maxilla may benefit from more prolonged
headgear wear.

In cases with skeletal open bite tendencies or to minimize orthopedic restraint in patients with ideal or
retruded maxillary position, a removable intraoral appliance can be used in conjunction with extraoral
high pull traction. Cetlin and Ten Hoeve24 have shown excellent results in regaining arch length using
this method. The removable appliance acts to tip the crown of the molar distally while the high-pull
headgear, directed above the center of rotation of the molar, acts to distalize the root. In anticipation of
some relapse following distalization of the molars, overcorrection is recommended with bilateral molar
symmetry the objective. Following the desired distalization, an appropriate space maintenance
appliance must be placed.

Space closure

When an erupting first permanent molar becomes locked under the distal aspect of the second
deciduous molar, space loss has already occurred. The amount of space loss increases with increased
impaction. Although the dentist's initial concen is usually one of space regaining, it is not to be assumed
that all ectopic first permanent molars should be treated by distalization. Cases with significant arch
length shortage that warrant premolar extraction might best be handled by methods other than
distalization. Dependent on the amount of arch length shortage and the amount of mesial drift of the
/6/, many options are available. Disking the distal surface of the /E/ in minimal lock cases can allow the
/6/ to erupt into position with a minimum of space loss, preserving the /E/ for space maintenance until a
final decision can be made about extraction of permanent teeth and orthodontic space closure. In other
situations extraction of /E/ can be performed followed by fixed space maintenance until a decision
about permanent tooth extractions can be made. Such cases require a thorough workup with full
orthodontic records to arrive at a proper diagnosis and treatment plan. Many factors must be
considered to make decisions about permanent tooth extractions. These factors include the amount and
location of crowding, the Angle classification, and the profile. Often these decisions must be postponed
until the eruption of the permanent incisors in order to perform an accurate arch length analysis.

Other situations that may contraindicate distalization of the /6/ are those with one or more congenitally
absent second premolars. These cases are best handled by extraction of the /E/ and by space closure as
opposed to maintenance of the /E/ or replacement with a prosthesis. The timing of extraction and the
method and management of space closure is again dependent on such things as the overall arch length
requirements, Angle classification, and profile. For example, a Class I malocclusion with a good profile
and no crowding in other parts of the arch is probably best handled by early extraction of /E/, allowing
mesial drift to occur and thus minimizing the necessity for orthodontic mechanotherapy. However, a
case with procumbent incisors, Class II malocclusion, or crowding in the anterior part of the arch might
best be handled by full banded orthodontic therapy designed to use the space provided by the missing
premolars. In these cases of maximum anchorage, preserving the distal position of the /6/ may still be
important even though /5/ are congenitally absent.

Long-term monitoring

The longevity of the resorbed second primary molar in cases that are not self-correcting is unknown.
Clinical experience indicates that many of these resorbed second primary molars remain in place until
normal exfoliation. However, there are instances in which the patient has an acute gingival swelling
resulting from previous ectopic eruption and resorption. In such instances the affected deciduous molar
must be extracted and an appropriate space maintainer placed.

Whenever possible, the space maintainer should have tooth support and a Nance palatal button. A spur
to the distal aspect of the first primary molar provides further resistance to midline deviation to the side
of early loss and prevents mesial migration of the first permanent molar.

A further problem is that of premolar eruption sequence and pathway. Distal drifting of the upper first
premolar may be observed after early loss of the second primary molar. This can occur despite an
adequate maxillary space maintainer (Fig. 8). Therefore, it is imperative that space regaining be
monitored until eruption of all succedaneous teeth. Furthermore, the second premolar is often delayed
in its eruption because of early loss of the second primary molar. This may also encourage the distal
drifting of the first premolar.

SUMMARY

In the majority of cases, the treatment of choice for ectopically erupting first permanent molars is
distalization of the molar to its normal position. The optimal treatment approach depends on a number
of factors including the clinical eruption status of /6/, the change in position of /6/, the amount of
enamel ledge of /E/ entrapping /6/, the mobility of /E/, and the presence of pain or infection. In cases in
which extraoral traction is considered, the Angle classification, skeletal pattern, and facial profile may
also be important considerations. Patients with significant arch length shortage or congenitallly absent
second premolars may best be treated by extraction of /E/ and space closure. It is important that all
aspects of the malocclusion be considered when planning the management of these teeth. Long-term
monitoring is also important following correction of the ectopic condition until eruption of all
succedaneous teeth.

Portions of this article were presented at the annual meeting of the American Academy of Pedodontics
in Scottsdale, Arizona, May 1984, by the senior author. The authors would like to thank the Word
Processing Department and the Medical Illustrations Department of the UCLA School of Dentistry for the
manuscript preparation and the illustrations, respectively.