April 2023 Orthodontics 79

Enhanced CPD DO C

Kirandeep Nandhra Andrew Flett

Premature Deciduous
Tooth Loss: A Rare Case of
Detrimental Sequelae to
the Permanent Dentition
Abstract: Early loss of deciduous teeth can be associated with loss of space, tooth displacement, centreline disturbance, tooth impaction
and ectopia. Its inevitability, unless monitored accordingly, among patients makes it pivotal that practitioners are aware of the detrimental
effects, so they are able to consider these in the patient’s management. This report presents the case of an 18-year-old patient who
experienced tooth impaction and significant first premolar root resorption following the premature loss of deciduous second molars.
CPD/Clinical Relevance: The orthodontist should be aware of the potential for detrimental sequelae of early primary tooth loss and
subsequent tooth impaction, and ensure these are appropriately assessed and investigated in order to incorporate these into a patient’s
management plan.
Ortho Update 2023; 16: 79–81

Premature deciduous tooth loss due to caries
or trauma is prevalent among children, with
extraction of decayed teeth being the most
common reason for children aged 5–9 years in
the UK to receive a general anaesthetic.1 For
both the referring general dental practitioner
and receiving orthodontist, it is prudent to be
aware of the potential for detrimental sequelae
to the permanent dentition that may result
because of this.
Early loss of deciduous molars and canines
has been associated with an increased risk
of centreline disturbance,2 loss of space
with ensuing risk of arch crowding, tooth
displacement, impaction and ectopia.3 The
second deciduous molar is regarded as the
‘key tooth’ in the primary dentition4 because
its premature loss has been associated with
a greater reduction in leeway space than
the first deciduous molar, and is therefore
considered to have a more significant impact
on malocclusion in the permanent dentition
when not managed adequately.4–6
In cases of premature deciduous tooth
loss, an orthodontic opinion should be sought,
when appropriate, to manage and minimize
the risk of potential detrimental effects.7
Case report
A 17-year-old male patient, AH, was referred
by his general dental practitioner to the
orthodontic department at a district hospital
regarding his unerupted UR5, congenitally
absent lower 5s and ‘short roots’ incidentally
found on a peri-apical radiograph (Figure 1).
AH presented with the chief complaint of
‘spaced teeth’, and he wanted to ‘close the gaps,
and straighten his teeth’. He was a regular dental
attender, with a history of early loss of upper
deciduous second molars due to caries.
On examination, his lateral profile
view showed a mild skeletal II pattern with
competent lips at rest and an increased lower
face height. He had Class I incisors with an
average overjet and overbite, and bilateral
Class I buccal segments (Figure 2). There was
severe crowding of the upper arch (14 mm)
with some anterior midline spacing, and the
lower arch showed mild spacing of 3 mm.
His arches were otherwise well aligned. AH
had congenitally absent lower 5s, a palatally
positioned UL5 and an unerupted UR5. There
was no mobility associated with the erupted
upper premolars, and they were asymptomatic.
Intra-oral peri-apical radiographs and an
orthopantogram were taken initially (Figure 1),

Kirandeep Nandhra, BDS (Hons), MFDS RCS (Ed). Dental Core Trainee; Andrew Flett, BDS, FDS (Orth), RCS Eng, MOrth RCS (Eng),
MClinDent (Orth), MJDF RCS (Eng), Consultant Orthodontist; Nottingham University Hospitals NHS Trust.
email: knandhra94@gmail.com
80 Orthodontics
a a
b c
Figure 1. (a–c) Pre-operative peri-apical and orthopantogram radiographs demonstrating almost total
obliteration of UL4 and UR4 roots, and blunting of UL5 root.
which suggested possible root damage of the
UL4 and UR4 associated with the impacted
upper second premolars.
To accurately assess the root damage,
a CBCT scan (Figure 3) was taken of the
maxillary premolar regions, which revealed the
following. UR5 was palatally impacted with a
distal tilt, and its root length was measured
at 11.5mm. UR4 had almost total palatal and
approximately 50% buccal root resorption. The
fully erupted and palatally positioned UL5 had
a blunted root at the apex, with an 8.5-mm
measured total root length. Its eruption path
had caused almost complete obliteration of
the palatal root of the UL4, and considerable
resorption to the buccal root (Figure 3b).
AH was fully informed of the findings, and
warned of the risk of loss or damage to the
upper 4s and UL5 due to the root resorption.
The following options were discussed
regarding his ongoing management:
 Extract UL5 and UR5 only, with no
orthodontic treatment;
 Extract UL5 and UR5 only, with fixed
April 2023
Figure 2. (a,b) Pre-operative intra-oral
clinical photographs.
b
orthodontic appliances to align
the arches;
 Extract UR4 and UL4 with closed exposure
of UR5 and fixed orthodontic appliances,
with a view to align the UR5 and UL5.
Figure 3. (a,b) Pre-operative CBCT scans
After an in-depth discussion of these
including 3D reconstruction of left maxilla.
options, AH decided on the third option to
extract UR4 and UL4 with closed exposure
of UR5 and fixed orthodontic appliances.
 Fixed appliances to align upper 5s, close
Provided the UR5 aligned, this was deemed
the lower arch spacing, and retain Class I
to have the best long-term prognosis for the
incisor and buccal segment relationships
patient’s dentition owing to the significant
 Finishing and retention.
resorption of both upper first premolars.
AH was consented for the following AH commenced treatment with extraction
of UR4 and UL4, and closed exposure with a
treatment plan:
gold chain on UR5. Orthodontic treatment
 Oral hygiene to an exemplary standard; began with a TPA on maxillary 6s 2 weeks after
 Extraction of UR4, UL4, closed exposure surgery to prevent mesial drift of the upper
and gold chain bonding of the UR5; first molars until UR5 was aligned. An upper
 Fit of transpalatal arch (TPA) on fixed appliance was also bonded (American
maxillary 6s to provide horizontal Orthodontic mini master series, MBT
anchorage, preventing mesial drift and prescription, GAC, USA) with 0.016’’ nickel–
space loss until alignment of UR5 and UL5 titanium wire (Neosentalloy, GAC, USA) and a
was achieved quick ligature on UL5 (Figure 4). He progressed
April 2023
a Conclusion
b are left in situ without regular assessment
Figure 4. Application of TPA and bond-up.
c
Figure 5. Eruption of UR5 with distal powerchain
to UR6.
to an 0.016’’ nickel–titanium piggy-back wire
placed in the gold chain to apply traction on
the UR5 with an 0.016” stainless steel archwire
to hold arch form.
The UR5 was moved mesially using a
closed power chain attached to the existing
gold chain links with a stainless steel ligature,
and connected from UR4 to UL4 to gain the
necessary traction. Following eruption and
mesial movement of UR5, an orthodontic
button was placed with a distal power chain
to the UR6 to begin to fully align and derotate
the tooth into the arch (Figure 5). This
provided good movement and repositioning
of the tooth into the line of the arch.
After 15 months of treatment, a lower
0.016’’ nickel–titanium fixed appliance
(Neosentalloy, GAC) was bonded with a band
around the LR6. Once progression had been
made to posted 19/25 stainless steel wires
in both arches, any residual spacing was
closed using closing coils. All appliances were
debonded with a final result of Class I incisors
and almost perfect Class I buccal segments
(Figure 6). The patient was delighted with the
outcome, with minimal dentistry required in
the long term.
AH presented with a treatment
requirement owing to unfortunate and rare
consequences of his premature deciduous
molar loss. This was likely to have been
associated with a reduction in maxillary
arch length and subsequent impaction
and displacement2 of his UR5 and UL5. The
average maxillary premolar root length is
13–14mm. On his initial CBCT imaging, the
UR4 had approximately 6 mm of buccal and
2 mm of palatal root remaining, and UL4 had
4–6 mm of buccal and 2 mm of palatal root
Figure 6. (a–c) Debond intra-oral
clinical photographs.
remaining. It was felt the root resorption of
the UL4 and UR4 gave these teeth a poorer
long-term prognosis than the displaced and
impacted second premolars, thus warranting
their extraction.
Discussion
This is a useful learning case for the
orthodontist when encountering impacted 5s.
Here, appropriate clinical assessment and
investigation revealed the unfortunate
consequence of AH’s premature deciduous
tooth loss, enabling its appropriate
management. It demonstrates the use of
orthodontics to correct the detrimental
sequelae of early primary tooth loss, negating
the need for placement of dental prostheses.
AH completed his 2-year combined surgical
and orthodontic treatment satisfied with the
result, while keeping his long-term financial
impact low.
From the author’s critical perspective
of treatment outcome, AH does not have a
perfect interdigitated Class I buccal segment
on the left side. We decided to accept this
marginal discrepancy as his treatment was
completed during the COVID-19 pandemic,
when additional hospital appointments, for
marginal health benefit, were not appropriate.
Orthodontics 81
Early primary tooth loss can have long-
term detrimental effects on a patient, and
it is indicated that these patients have an
increased orthodontic need.4 This case
highlights what can occur if impacted teeth
or a long-term plan. While uncommon, AH’s
case shows the rare effect of upper second
premolar impactions causing significant root
resorption of the upper first premolars. Here,
the detrimental sequelae led to significant
costs for the patient and health service in
terms of time and financial impact.
The case of AH demonstrates how
to orthodontically correct the unwanted
sequelae of early tooth loss, and highlights the
importance of appropriate assessment and
investigation of the orthodontic patient with
impacted 5s following premature deciduous
tooth loss.
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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