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In Class 11 case, with no crowding.Extraction of the first permanent molar in the lower will lead to spacing, uncontrollederuption of teeth and may compromise future orthodontic treatment. Temporise or restore ifpossible, 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 haveerupted sufficiently to be controlled orthodontically, and the extraction space can be used totreat the malocclusion

2,11. 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 beindicated

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 overjetcorrection.

[SIGN Grade C]

Class 11 case with crowding.

Consider balancing

9

extraction in the lower only if the first molar is of poor prognosis orpremolars are impacted due to early loss of deciduous molars and 8s are present12

Temporise or restore the upper and refer

2, 11. If the upper first molar is unopposed and at risk

of over-erupting and third molars are present radiographically, then extraction of the upperfirst 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 sufficientspace for overjet correction and treatment of crowding.

[SIGN Grade C]

Class 111 caseTemporise or restore and refer

2, 11

[SIGN Grade C]

IF IN DOUBT, GET PATIENT OUT OF PAIN, TRY AND MAINTAIN TEETH ANDREFER

2,9,10.

[SIGN Grade C]

References1. 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 Trans238-253.

4. Richardson A (1979). Spontaneous changes in the incisor relationship followingextraction of lower first permanent molars. Br J Orthod 685-90.

5. Abu Aihaija ES, McSheny PF and Richardson A (2000). A cephalometric study ofthe effect of extraction of lower first permanent molars. J Clin Paediatr Dent 24195-198.

6. Taylor PJS & Kerr WJS (1996). Factors associated with the standard and duration oforthodontic treatment. Br J Orthod 23: 335-341.

7. Sandler PJ, Atkinson R & Murray AM (2000). For four sixes. Am J Orthod 117:418-435.

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8. Daugaard-Jensen I (1973). Extraction of first molars in discrepancy cases. Am JOrthod 64: 115-36.

9. Crabb JJ & Rock WP (1971). Treatment planning in relation to the first permanentmolar. Br Dent J 131:396-401.

10.Penchas J et al (1994). The dilemma of treating severely decayed first permanentmolars 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 FirstPermanent Molars. Dental Update 28 304-308.

12.Plint DA (1970). The effect on the occlusion of the loss of one or more firstpermanent molar. Trans.Eur Orthod Soc 329-336.

SIGN ClassificationThe Scottish Intercollegiate Guideline Network (SIGN) classification system indicateswhether a guidelines recommendations are based on proven scientific evidence or currently

accepted good clinical practice with limited scientific evidence.

Level Type of evidenceIa Evidence obtained from meta-analysis or randomised control trials.

Ib Evidence from at least one randomised control trial.IIa Evidence obtained from at least one well-designed control study without

randomisation.IIb Evidence obtained from at least one other type of well-designed quasi-

experimental study without randomisation.

III Evidence obtained from well-designed non-experimental descriptive studies,such as comparative studies, correlation studies and case control studies.

IV Evidence from expert committee reports or opinions and/or clinical evidence

of respected authorities.

Grade RecommendationsA>(Evidence levels 1a,1b)

Requires at least one randomised controlled trial as part of thebody of literature of overall good quality and consistencyaddressing the specific recommendations

B>(Evidence levels IIa,IIb,III

Requires availability of well conducted trials but norandomised clinical trials on the topic of recommendation

C>(Evidence level IV)

Requires evidence from expert committee reports or opinionsand/or clinical experience of respected authorities. Indicates

absence of directly applicable studies of good quality.

Professor Alison Williams

Dr Roslyn McMullan

May 2004