April 2023 Orthodontics 85

Enhanced CPD DO C

Trishna Patel Jenna Trainor, Thomas Flavell and Catherine A Brierley

Infra-occluded Primary
Molars: Diagnosis
and Management
Abstract: Infra-occluded primary molars can be challenging in terms of their surgical management and potential sequelae. The prognosis
of these teeth needs to considered allowing treatment planning for a stable long-term outcome for the patient. This article outlines
the key principles to consider following a diagnosis of an infra-occluded primary molar, and it provides a management tool to aid
decision making.
CPD/Clinical Relevance: Timely diagnosis and management of infra-occluded primary molars is vital within the overall care pathway for
these patients.
Ortho Update 2023; 16: 85–90

Infra-occlusion is when a tooth has failed
to maintain its occlusal level relative to
adjacent teeth and is therefore found
below the occlusal plane.1 In 1981, Kurol
described infra-occlusion as when the
occlusal surface of a tooth is 1 mm below
the occlusal surface of a fully erupted
adjacent tooth.2 The timely management
of infra-occluded primary teeth avoids
the need for more complex surgical
management as well as allows planning
for the resultant space. This article
highlights the key principles behind
management of such cases.
Incidence
The prevalence of infra-occluded primary
molars ranges between 1% and 39%,
with mandibular molars being much
more affected than maxillary molars.2,3
The incidence is greater the older the
patient, with infra-occlusion recorded
from the age of 3 years suggesting a
cumulative process.3 Bjerklin, however,
demonstrated that there was little
increase in infra-occlusion after the age
of 20 years, suggesting primary molars
after this age had a good long-term
prognosis.4 There also appears to be
equal frequency in males and females, as
well as the site of occurrence.
Aetiology
Ankylosis is often suggested as the
cause of the deciduous molar failing
to maintain its occlusal position.
Ankylosis occurs when the cementum
of the tooth fuses with the adjacent
alveolar bone, with resultant loss of the
periodontal ligament space.2 Biederman
described a possible genetic aetiology
whereby there is a developmental
gap in the periodontal membrane.5
This is supported by work carried out
on siblings, which showed that the
prevalence among siblings was 46%
compared with 1.3% in the control
group.6 Other theories propose excessive
pressure from mastication or possibly
trauma, as well as disturbances in
local metabolism whereby the normal
resorptive process is reversed so that
the periodontal ligament is obliterated
prior to root resorption.5 Other authors
have discussed ankylosis in primary
teeth being a transient process whereby
the tooth would ‘re-erupt’ once the
ankylosed portion of tooth had
been resorbed.7
Prior studies have demonstrated
associations between missing permanent
successors and infra-occlusion, with 17%
of cases of infra-occluded deciduous
molars associated with missing

Trishna Patel, MChD/BChD BSc, MFDS RCPS (Glasg), PGCert, Orthodontic Specialty Registrar 3, Derby and Sheffield. Jenna Trainor, BDS,
MFDS RCS, MClinDent (Rest Dent), FDS RCPS(Glasg), Consultant in Restorative Dentistry, Newcastle upon Tyne Hospitals NHS Foundation
Trust. Thomas Flavell, BDS (Hons), MFDS, DCT2 OMFS, Newcastle upon Tyne NHS Foundation Trust. Catherine A Brierley, BDS (Hons),
MFDS RCS, MClinDent, MOrth, FDS Orth, Orthodontic Consultant, Sheffield and Chesterfield.
email: trishnaanil.patel@nhs.net
86 Orthodontics
a b
c d
Figure 1. (a,b) Severe infra-occlusion of
LRE and ULE resulting in tipping of adjacent
teeth. (c,d) Lower centreline shift likely due
to asymmetric infra-occluded molar (LRE) and
subsequent tipping.
Figure 2. Severe infra-occlusion resulting in a
lateral open bite and tongue spreading.
permanent premolars.8,9 Hvaring et al
found that infra-occlusion was the most
important factor when considering the
prognosis of retained primary teeth
without successors.10 Exfoliation is often
delayed by approximately 6 months
in cases with a permanent successor,
although this can be unpredictable
and is sometimes significantly longer.11
Figure 3. Infra-occluded ULE and LRE with evidence of ankylosis. Vertical bony defect evident
distal to LRE.
Infra-occlusion has also been attributed
to insufficient eruption force, occlusal
trauma, infection and abnormal
tongue pressure.1,12,13
Sequelae/complications
When a tooth infra-occludes, the adjacent
teeth tip into the area with potential loss
of space for the permanent successor
(Figure 1a,b), which could also lead to
centreline shifts (Figure 1c,d). Tipping
with displacement of apices away from
the infra-occluded tooth is thought to
be related to changes in the direction
of transeptal fibres.14 Becker noted the
effect on the dental midline, showing a
deviation to the affected side.15 The effect
April 2023
Figure 4. Impaction of a UL5 as a result of
infra‑occluded ULE.
of transeptal fibres can also affect the
vertical growth of adjacent teeth, resulting
in lateral open bites or over-eruption
of opposing teeth (Figure 2).16 Over-
eruption and tipping have been shown to
spontaneously correct in some cases once
the permanent premolar erupts.1
The more severe an infra-occlusion,
the more difficult extraction becomes,
which is why the timing is important
in management. If the tooth has infra-
occluded and there has been little
resorption of the roots (Figure 3), the
teeth may require surgical removal
involving sectioning.16 This is further
complicated by the potential for
ankylosis. Surgical removal can
risk damage to adjacent teeth and
structures, such as the mental nerve,
or result in retained root fragments.17,18
Additionally, surgical removal often
involves bone removal, which can affect
future management options, such as
orthodontic tooth movement (OTM)
and implant placement.16 This is also
compounded by the observation that
infra-occluded teeth have reduced
bony development, affecting both
the ridge width and height. The
reduced alveolar bone development
can hinder OTM and can complicate
restorative intervention.13
Infra-occluded teeth can result
in food packing, reduced access for
oral hygiene measures and, therefore,
increased risk of caries and periodontal
disease for the affected teeth as well as
the adjacent teeth.18
Infra-occluded teeth may also
cause impaction or ectopic eruption
of permanent successors (Figure 4),
which can worsen an individual’s
malocclusion and can increase the
complexity of surgical and orthodontic
treatment required.5,19
April 2023
Figure 5. Mild infra-occlusion of LRE.
Classification
There are a number of classification
systems proposed in the literature to
describe infra-occluded teeth. The most
commonly recognized is that by Brearley:
 Slight: occlusal surface approximately
1 mm below the predicted occlusal
plane for that tooth (Figure 5).
 Moderate: occlusal surface
approximately level with the contact
point of one/both adjacent teeth.
 Severe: occlusal surface level with or
below the interproximal gingivae of
one or both adjacent tooth surfaces
(Figure 1a,b).20
Another commonly cited classification
system is that of Kjaer et al who used
panoramic radiographic findings to
assess the degree of infra-occlusion. The
classification ranged from ‘Group I’ to
‘Group IV’, comparing the level of infra-
occlusion to the full crown height of the
tooth, with the most severe described as
‘deeply subgingival’.21
Diagnosis
Clinically, these teeth can present with
a high percussion sound and may also
be immobile, which could indicate
ankylosis, although these indicators may
be subjective.22
Angular bony defects can be
identified on radiographs (Figure 3)
around infra-occluded teeth, although
this may spontaneously correct with
normal premolar eruption.23 Conventional
radiographs provide limited information,
and as ankylosis may only affect a
small area of the root, CBCT may be
indicated, particularly when combined
with the need for assessment prior to
surgical removal.13
Treatment options
Several factors need to be considered and
these are outlined in Figure 6.
Presence of a permanent successor
In a patient with hypodontia in the
permanent dentition, the deciduous
Presence of a
successor
Patient
cooperation
Factors to
consider
Extent of
infra‑occlusion
Existing
malocclusion
Figure 6. Factors to consider in the management of infra-occluded deciduous teeth.
tooth may not exfoliate normally and
may be retained. Consideration needs
to be given to whether treatment would
involve retaining the deciduous tooth,
with restorative input to maintain its
function and position, or loss of the
tooth and space closure. If the decision
is taken to restore the tooth into
occlusion for the short or long term, this
could be carried with direct or indirect
composite, ceramic or metal onlays, or
preformed metal crowns.13
Where there is a permanent
successor, it has been reported that
96.7% of infra-occluded primary molars
spontaneously exfoliate, although with
a delay of approximately 6 months.24
If the infra-occluded molar has not
naturally exfoliated within 6 months
of the average expected time, then
extraction of the submerged primary
tooth should be undertaken. In these
cases, the surgical risk to the unerupted
permanent successor needs to be taken
into account.
Age of the patient and timing of diagnosis
If, at the time of diagnosis, the patient
has not yet passed the pubertal growth
spurt, there is an increased chance that
Orthodontics 87
Age of the
patient
Timing of
diagnosis
Presence of
pathology
the infra-occlusion will worsen. For
those who have already experienced the
pubertal growth spurt, the rate of infra-
occlusion is reduced.10
Presence of pathology
Hvaring et al found a significant
relationship between root resorption
and infra-occlusion, although root
resorption was not considered to be
critical to prognosis.10 A tooth with
caries or an associated abscess should
be extracted; however, if the space
needs to be maintained, thought should
be given to restoring the carious tooth.25
Existing malocclusion
In cases of mild infra-occlusion, without
any obvious bony defects or ankylosis,
retaining the infra-occluded tooth for
as long as possible may be indicated
to maintain bone and space for a
prosthetic replacement where there
is no permanent successor. Therefore,
consideration of the long-term plan for
a patient is vital before any treatment
is initiated. When infra-occluded
teeth have been extracted, space
maintenance can be used in cases with a
space requirement.16,18
88 Orthodontics
Figure 7. (a) Pre-treatment and mid-treatment OPT showing good prognosis LRE and LLE. (b) Pre-operative views of LRE and LLE. (c) LRE and LLE
maintaining a good occlusal position during treatment.
Figure 8. Band and loop cemented to UL6 to
maintain space.
Extent of infra-occlusion
For severely infra-occluded teeth,
particularly in pre-pubertal patients,
extraction is indicated.25 Similarly,
moderately infra-occluded teeth in a
pre-pubertal child are likely to undergo
further infra-occlusion, and extraction
would be recommended. Conversely,
a tooth that has mild infra-occlusion,
diagnosed in a non-growing patient, is
likely to have better prognosis. Figure 7
shows retained lower deciduous
second molars with good prognosis.
Additionally, a mildly infra-occluded
tooth in a pre-pubertal patient could
benefit from regular monitoring, in
the knowledge that any further infra-
occlusion would require extraction of
the affected tooth before the pubertal
growth spurt, to reduce the risk of a
vertical bony defect developing.13
Patient cooperation
Future orthodontic treatment may
not be suitable for some patients and,
therefore, extraction at the optimal time
may be indicated. In addition, if looking
to restore an infra-occluded tooth into
function to maintain space, prevent
over-eruption and prevent tipping, a
patient needs to be able to cooperate to
enable restorative intervention.
Recommended management
Space maintenance
Space maintenance may need to be
considered when an infra-occluded
tooth has been extracted, but a space
requirement has been identified. In
some cases, it may be beneficial to use
a space maintenance device, such as a
band and loop (Figure 8).
Restorative management
The aims of restoring the occlusal
platform are to maintain contact
points, prevent tipping of adjacent
April 2023
teeth over the occlusal surface of
the infra-occluding molar, and to
maintain occlusal contact with the
opposing tooth.
Restorative options when maintaining
the tooth
The occlusal height can be increased,
and approximal contacts modified, with
the use of direct/indirect composite
addition, onlay or crown.18 There is,
however, limited evidence in the
literature for the prognosis and success
of different treatment modalities or
materials for this clinical scenario.
Considerations to take into account
include operator experience, moisture
control, surface area available to bond,
height of the restoration versus the
amount of tooth visible, pulp horn size,
pathology, previous restorations and
patient cooperation.
Tipping of adjacent teeth can
compromise the prognosis for
restoration more than the severity of the
infra-occlusion. The undercuts created
by the marginal ridges of adjacent
teeth over the occlusal surface of the
infra-occluded molar can interfere with
interproximal placement of restoration
margins and lead to voids or ledges. This
reduces cleansability, leading to food
 April 2023

Figure 9. Recommended management.

Orthodontics 89
90 Orthodontics
packing, caries or loss of the restoration.
Interproximal reduction of adjacent
teeth can facilitate restoration, but
there are risks for sensitivity and pulpal
inflammation. As the degree of infra-
occlusion becomes more severe, there
is less tooth available for bonding, and
the greater height of restorative material
may also reduce prognosis.
Restorative options when extraction
is necessary
If infra-occlusion is rapid, or tipping
of adjacent teeth makes maintaining
oral hygiene and restoring the tooth
impossible, then extraction may be
required, although the option of a dental
implant may be limited if infra-occlusion
or surgical extraction have led to
reduced horizontal or vertical availability
of alveolar bone.
Resin-bonded or conventional
bridgework may be feasible, but might
require preparation of the adjacent
tooth if tipping has occurred, to remove
undercuts and optimise connector
length. Orthodontic treatment can help
to optimise the space for restoration.
The flowchart in Figure 9 provides
some guidance.
Conclusion
Considering all the relevant factors
allows for optimal treatment planning
and can aid in preventing future
complications that can impact on
restorative treatment options. The
management of infra-occluded
teeth is often multidisciplinary in
nature, involving the general dental
practitioner, restorative and oral
surgery colleagues.
Within the care pathway, orthodontic
assessment is vital to fully assess the
space requirement that plays a key role
in the overall management.
Early identification and accurate
diagnosis of patients with infra-occluded
primary molars is imperative for the
timely and optimal management of these
cases, particularly for those who can
present with further complicating factors.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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