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Multidisciplinary management of permanent first molar extractions

2021; Elsevier BV; Volume: 159; Issue: 5 Linguagem: Inglês

10.1016/j.ajodo.2020.09.024

1097-6752

Roy Sabri,

Dental Trauma and Treatments

•Orthodontists are treating more adult patients who have extracted and decayed first molars.•Molar uprighting after old first molar extractions vs orthodontic space closure.•Strategic extractions of compromised first molars instead of sound premolars.•Management of impacted and ankylosed first molars.•Early extraction of first permanent molars with enamel hypoplasia in young children. The first molar has been reported to be the most caries prone tooth in the permanent dentition. Orthodontists are treating more adult patients who are more likely to have missing and severely decayed first molars. This article will show the various orthodontic and restorative options for first molars that are already extracted or have to be extracted. The following clinical situations will be addressed: molar uprighting and its advantages for the future restoration vs orthodontic space closure, strategic extraction of salvable first molars, impacted molars, and early extraction of compromised permanent first molars in young children. The first molar has been reported to be the most caries prone tooth in the permanent dentition. Orthodontists are treating more adult patients who are more likely to have missing and severely decayed first molars. This article will show the various orthodontic and restorative options for first molars that are already extracted or have to be extracted. The following clinical situations will be addressed: molar uprighting and its advantages for the future restoration vs orthodontic space closure, strategic extraction of salvable first molars, impacted molars, and early extraction of compromised permanent first molars in young children. Early extraction of permanent first molars has been advocated in the literature for over a century.1Maclean S. Improved forceps & c.Am J Dent Sci. 1857; 7: 106-108PubMed Google Scholar Considered to be most prone to caries, the removal of such teeth was believed to reduce the decay incidence in the remaining teeth.2Nazir M.A. Bakhurji E. Gaffar B.O. Al-Ansari A. Al-Khalifa K.S. First permanent molar caries and its association with carious lesions in other permanent teeth.J Clin Diagn Res. 2019; 13: 36-39Google Scholar,3Halicioglu K. Toptas O. Akkas I. Celikoglu M. Permanent first molar extraction in adolescents and young adults and its effect on the development of third molar.Clin Oral Investig. 2014; 18: 1489-1494Crossref PubMed Scopus (12) Google Scholar After World War II, first molar extraction became a standard procedure. Hence, the term "extraction for prevention" was presented as a way for solving the "spread" of caries.4Wilkinson A.A. The early extraction of the first permanent molar as the best method of preserving the dentition as a whole.Dent Rec. 1944; 64: 2Google Scholar The importance of the permanent first molar in the development of the dentition and the occlusion was controversial.5Stamatis J. Orton H. The molar extraction debate.Aust Orthod J. 1994; 13: 117-121PubMed Google Scholar Edward Angle, the father of modern orthodontics, described it as the keystone of the dental arch, whereas others advocated permanent first molar extraction on a routine basis. Many studies tried to counteract the uncontrolled extraction of first molars by showing its detrimental effect on occlusion.6Salzmann J.A. Effect on occlusion of uncontrolled extraction of first permanent molars: prevention and treatment.J Am Dent Assoc. 1943; 30: 1681-1690Abstract Full Text PDF Google Scholar,7Thilander B. Skagius S. Orthodontic sequelae of extraction of permanent first molars. A longitudinal study.Rep Congr Eur Orthod Soc. 1970; : 429-442PubMed Google Scholar Despite all the preventive and prophylaxis measures available today, we still have to deal with extracted and severely decayed permanent first molars in our daily practices.1Maclean S. Improved forceps & c.Am J Dent Sci. 1857; 7: 106-108PubMed Google Scholar,8Ong D.C. Bleakley J.E. Compromised first permanent molars: an orthodontic perspective.Aust Dent J. 2010; 55 (quiz 105): 2-14Crossref PubMed Scopus (34) Google Scholar,9Yavuz I. Baydaş B. Ikbal A. Dağsuyu I.M. Ceylan I. Effects of early loss of permanent first molars on the development of third molars.Am J Orthod Dentofacial Orthop. 2006; 130: 634-638Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar For patients referred by restorative dentists for migrated teeth after first molar extractions, orthodontic treatment should be aimed at facilitating the restorative process rather than correcting an existing malocclusion when it is not the patient's chief complaint. In long-standing extractions not compensated prosthetically, the edentulous space is partially closed by mesiolingual tipping of the second molar. First molar extraction in the late mixed dentition or early permanent dentition can also lead to residual spaces because of distal tipping of the premolars. Spaces can be redistributed for restorative replacement of the extracted first molar or closed orthodontically. The main advantage of space closure is that the whole treatment is finished right after completion of the orthodontic treatment without patient dependence on a permanent restoration and less treatment cost. Space closure can be difficult in atrophic extraction sites, which require remodeling of cortical bone.10Dhole P.M. Maheshwari D.O. Orthodontic space closure using simple mechanics in compromised first molar extraction spaces: case series.J Indian Orthod Soc. 2018; 52: 51-59Crossref Google Scholar Adults can have less bone apposition when moving second molars into the narrowed space of first molars extraction sites, greater likelihood of loss of alveolar bone crest height on the mesial of the second molar roots, and in some patients gingival recessions and root resorption.11Saga A.Y. Maruo I.T. Maruo H. Guariza Filho O. Camargo E.S. Tanaka O.M. Treatment of an adult with several missing teeth and atrophic old mandibular first molar extraction sites.Am J Orthod Dentofacial Orthop. 2011; 140: 869-878Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,12Thilander B. Orthodontic space closure versus implant placement in subjects with missing teeth.J Oral Rehabil. 2008; 35: 64-71Crossref PubMed Scopus (24) Google Scholar Efficient orthodontic mechanics must be used to ensure delivery of light forces and increase the interval between activations so that the tissues involved have time to recover and avoid the development of soft-tissue clefts, which have a tendency to reopen spaces.10Dhole P.M. Maheshwari D.O. Orthodontic space closure using simple mechanics in compromised first molar extraction spaces: case series.J Indian Orthod Soc. 2018; 52: 51-59Crossref Google Scholar Space closure can also be difficult in the maxillary posterior area with low sinus because tooth movement through the maxillary sinus is limited.13McGrowan D. Baxter P. James J. The Maxillary Sinus and its Dental Implications.1st ed. Wright, London, United Kingdom1993Google Scholar Pneumatization can extend to the alveolar ridge making implant placement difficult.14Park J.H. Tai K. Kanao A. Takagi M. Space closure in the maxillary posterior area through the maxillary sinus.Am J Orthod Dentofacial Orthop. 2014; 145: 95-102Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar,15Wehrbein H. Bauer W. Wessing G. Diedrich P. [The effect of the maxillary sinus floor on orthodontic tooth movement].Fortschr Kieferorthop. 1990; 51 (German): 345-351Crossref PubMed Scopus (43) Google Scholar Space closure of recent first molar extraction sites have better predictable results than ancient extraction sites. Although technically more demanding, it is sometimes advisable to extract a compromised first molar rather than a healthy premolar. Compromised permanent first molars, mostly because of enamel hypoplasia, can also be seen in young patients in the mixed dentition stage. Consideration should be given to extraction at the ideal developmental age, which corresponds to a chronological mean age of 8-10 years, to achieve spontaneous space closure with a mesial eruption of second molars.16Penchas J. Peretz B. Becker A. The dilemma of treating severely decayed first permanent molars in children: to restore or to extract.ASDC J Dent Child. 1994; 61: 199-205PubMed Google Scholar This article will describe the orthodontic and restorative approaches with common clinical situations of long-standing and recent extractions of first molars, "strategic" extraction of compromised first molars rather than healthy premolars, impacted molars, and early extraction of first permanent molars with enamel hypoplasia in young children. The main sequelae of extracted mandibular permanent first molars not replaced prosthetically are mesiolingual tipping of second and third molars and overeruption of the antagonist as seen with this 27-year-old patient (Fig 1, A and B). By uprighting the tipped molars, the tooth movement not only facilitates prosthetic rehabilitation but also enables better design, periodontal conditions, function, and stability of the restorative solution.17Roberts 3rd, W.W. Chacker F.M. Burstone C.J. A segmental approach to mandibular molar uprighting.Am J Orthod. 1982; 81: 177-184Abstract Full Text PDF PubMed Scopus (47) Google Scholar The maxillary third molar had to be extracted to facilitate the alignment of the blocked out second molar. In addition, the mandibular third molar had to be extracted because it would have been without an antagonist after molar uprighting. A maxillary removable biteplane was used to enable tooth movement (Fig 1, C). The conventional uprighting spring made of a 0.019 × 0.025-in stainless steel wire was used against a segmental 0.019 × 0.025-in archwire engaged passively in canine and premolars 0.022-in brackets (Fig 1, D). This anchor unit was reinforced by a wire from canine to canine bonded on the lingual of the canines.17Roberts 3rd, W.W. Chacker F.M. Burstone C.J. A segmental approach to mandibular molar uprighting.Am J Orthod. 1982; 81: 177-184Abstract Full Text PDF PubMed Scopus (47) Google Scholar A space maintainer made of a 0.019 × 0.025-in wire was secured after tooth movement and replaced by a temporary bridge during the restorative phase (Fig 1, E). As both abutment teeth adjacent to the extraction site had large restorations, a conventional full-coverage crown bridge was indicated. This restoration allowed occlusal grinding on the second molar to compensate for the extrusion effect of the uprighting spring. This reduction of the clinical crown height yields a more favorable crown-to-root ratio.18Tuncay O.C. Biggerstaff R.H. Cutcliffe J.C. Berkowitz J. Molar uprighting with T-loop springs.J Am Dent Assoc. 1980; 100: 863-866Abstract Full Text PDF PubMed Scopus (19) Google Scholar Correction of the angular osseous defect on the mesial aspect of the second molar with better access to oral hygiene can be seen on pretreatment and posttreatment periapical radiographs (Fig 1, F and G). Molar uprighting has also favored parallel preparations with better insertion and retention of the restoration (Fig 1, H). Treatment time was 8 months. The orthodontic treatment objective was not to correct the existing Class II Division 2 malocclusion but to facilitate a restorative solution that remained functional and stable at 20 years after the treatment (Fig 1, I and J). This 32-year-old patient had a long-standing mandibular first molar extractions not replaced prosthetically. Orthodontic space closure replacing the first molar with the second molar is an attractive solution that avoids patient dependence on a permanent restoration. Light forces with increased intervals between activations are recommended in space closure, which greatly increases treatment time compared with molar uprighting for a restorative solution, especially in the mandibular arch with a greater bone density.19Roberts W.E. Huja S.S. Bone physiology, metabolism, and biomechanics in orthodontic practice.in: Graber L.W. Vanarsdall Jr., R.L. Vig K.W. Huang G.J. Orthodontics: Current Principles and Techniques. Mosby, St Louis1994: 193-257Google Scholar What needs to be considered is not the clinical crown space at the extraction site, which often appears small because of crown tipping but the root space between the second premolar and the second molar (Fig 2, A). This distance between the apices also needs to be reduced until adequate root parallelism is achieved. Optimal root position in space closure is essential for the correction of the mesial angular osseous defect, good occlusion, and stability. Despite a large extent of root movement, root resorption of the second molars was shown to be minimal in space closure.20Stepovich M.L. A clinical study on closing edentulous spaces in the mandible.Angle Orthod. 1979; 49: 227-233PubMed Google Scholar There is also a tendency for the mesial bone height of the second molar to decrease an average of 1.3 mm with space closure, but this does not compromise the periodontal support.20Stepovich M.L. A clinical study on closing edentulous spaces in the mandible.Angle Orthod. 1979; 49: 227-233PubMed Google Scholar,21Hom B.M. Turley P.K. The effects of space closure of the mandibular first molar area in adults.Am J Orthod. 1984; 85: 457-469Abstract Full Text PDF PubMed Scopus (61) Google Scholar A diagnostic setup for second molar uprighting has shown that mandibular third molars will end up without an antagonist (Fig 2, B and C). The 2 treatment alternatives were to extract third molars and upright second molars for a prosthetic replacement of the extracted first molars or to close the extraction space by bringing second and third molars forward. Even though more challenging and time consuming, orthodontic space closure was selected rather than extracting 2 sound molars to replace them with 2 implant restorations. Uprighting springs started to mesial drive the second molar roots. Tip-back bends to fully correct root position, and power chains with light forces were used for space closure (Fig 2, D). Progress periapical radiographs helped monitor root parallelism. Occlusal equilibration on the molars was necessary to compensate for mild uncontrolled extrusion. Complete space closure with adequate root parallelism between second premolars, second, and third molars was achieved in 15 months (Fig 2, E). A 0.0215-in twisted wire was bonded between second premolars and second molars (Fig 2, F). Space reopening and the likelihood of a long-term open contact is a common problem in first molar space closure, even with parallel roots and a twist wire. A 52-year-old patient had the mandibular first molars extracted at age 14 years, resulting in a spaced dentition (Fig 3, A-D). Orthodontic redistribution of the spaces in the first molar sites would be complex and time-consuming. Instead, as shown in the diagnostic setup, minor tooth movement of the canines and left second molar has facilitated a 3 single-tooth implants restoration in the existing spaces (Fig 3, E and F). Orthodontic treatment time was 20 months. Optimal and stable occlusion was seen in photographs taken 6 years after the treatment (Fig 3, G and H). Space closure of first molar extraction sites in the maxillary arch is usually faster and easier mechanically than in the mandibular arch because the mandible is consisted of thick cortical bone connected by coarse trabecular bone, and the molar roots are extremely wide buccolingually.19Roberts W.E. Huja S.S. Bone physiology, metabolism, and biomechanics in orthodontic practice.in: Graber L.W. Vanarsdall Jr., R.L. Vig K.W. Huang G.J. Orthodontics: Current Principles and Techniques. Mosby, St Louis1994: 193-257Google Scholar Maxillary first molar extractions may be associated with maxillary sinus pneumatization, which can hinder orthodontic tooth movement.13McGrowan D. Baxter P. James J. The Maxillary Sinus and its Dental Implications.1st ed. Wright, London, United Kingdom1993Google Scholar The maxillary sinus floor is structured with compact cortical bone formed by the alveolar process and part of the hard palate.13McGrowan D. Baxter P. James J. The Maxillary Sinus and its Dental Implications.1st ed. Wright, London, United Kingdom1993Google Scholar Light constant forces with longer adjustment intervals could effectively move teeth through the maxillary sinus wall.14Park J.H. Tai K. Kanao A. Takagi M. Space closure in the maxillary posterior area through the maxillary sinus.Am J Orthod Dentofacial Orthop. 2014; 145: 95-102Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar When the sinus floor extends more vertically in front of the tooth to be moved, more tipping will occur with teeth moving through a flat sinus base.15Wehrbein H. Bauer W. Wessing G. Diedrich P. [The effect of the maxillary sinus floor on orthodontic tooth movement].Fortschr Kieferorthop. 1990; 51 (German): 345-351Crossref PubMed Scopus (43) Google Scholar Even when optimal root parallelism cannot be achieved, it will not prevent an acceptable outcome, and pneumatization should not be a contraindication for space closure in maxillary first molar extractions.22Sun W. Xia K. Huang X. Cen X. Liu Q. Liu J. Knowledge of orthodontic tooth movement through the maxillary sinus: a systematic review.BMC Oral Health. 2018; 18: 91Crossref PubMed Scopus (11) Google Scholar This 24-year-old girl had an early maxillary first molar extraction that was to be replaced prosthetically at the end of growth. Because of insufficient space opening or lack of space maintenance, only 4 mm of edentulous space remains. Meanwhile, the third molar erupted and had no antagonist (Fig 4, A and B). There was a midline shift toward the extraction side and a tendency to an anterior edge to edge bite. She rejected a full comprehensive orthodontic treatment, which she already had in the early permanent dentition. The 2 treatment alternatives were to open additional space for single-tooth implant or close the space. An implant solution required a sinus lift surgery and extraction of a sound third molar which had no antagonist. Space closure by mesial driving second and third molars was, therefore, more appropriate. Two miniscrews allowed orthodontic space closure with minimal teeth involved and avoided relying on the canine and premolars as anchor units (Fig 4, C). An extension was soldered on the hook of the second molar band to direct the force closer to the center of rotation, favoring a bodily movement. A light continuous force was delivered by a nickel-titanium coil. The overerupted third molar was intruded and occluded with the mandibular second molar (Fig 4, D). Pneumatization of the sinus prevented optimal root parallelism, but total space closure and proper occlusion could be achieved in 9 months (Fig 4, E and F). A 0.0215-in twisted wire was bonded between the second premolar and second molar, and home care instruction with an interdental toothbrush was given to maintain a healthy periodontium on the mesial of the second molar. This 16-year-old patient had a recently extracted maxillary first molar and an unerupted third molar. There was posterior crowding, which is an indication of space closure (Fig 5, A). Three bands with lingual attachments were used to correct rotations of the premolars, and the remaining first molar extraction space was closed in 5 months (Fig 5, B). The third molar erupted spontaneously right after appliance removal with optimal root parallelism and crestal bone levels (Fig 5, C and D). Extraction of the permanent first molar has been shown to have an accelerating effect on the development of the third molar, which tends to erupt earlier than the contralateral tooth.2Nazir M.A. Bakhurji E. Gaffar B.O. Al-Ansari A. Al-Khalifa K.S. First permanent molar caries and its association with carious lesions in other permanent teeth.J Clin Diagn Res. 2019; 13: 36-39Google Scholar,9Yavuz I. Baydaş B. Ikbal A. Dağsuyu I.M. Ceylan I. Effects of early loss of permanent first molars on the development of third molars.Am J Orthod Dentofacial Orthop. 2006; 130: 634-638Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar This 25-year-old patient had a similar situation with a hopeless maxillary first molar (Fig 6, A). The absence of a third molar has ruled out space closure. The patient rejected a sinus lift surgery, which was needed for an implant solution. Aligning a palatally displaced second premolar was done in 7 months and enabled an inlay–onlay restoration with minimal preparation on abutment teeth (Fig 6, B-D). This restoration has saved sound tooth structure and avoided endodontic involvement. This 35-year-old patient had a mandibular first molar extraction space that was too big for 1 implant and too small for 2 implants (Fig 7, A). Considering the standard 3.75 mm diameter implant commonly used in the posterior region, 1 single-tooth implant would end up with open embrasures and plaque accumulation, and 2 implants would be too close together and to adjacent teeth. To reduce the extraction space, the second and third molars were moved mesially. An implant placed ideally relative to the second premolar was used initially as an orthodontic anchor device and secondarily as a prosthetic abutment (Fig 7, B and C). The posttreatment radiograph shows a well-centered implant in the newly created space (Fig 7, D). Orthodontic treatment time was 7 months, and there was no space reopening 6 years after the treatment (Fig 7, E). This 13-year-old patient had an Angle Class II molar relationship with a blocked out maxillary right canine and an impacted left canine (Fig 8, A and B). The maxillary arch length discrepancy was 9 mm. Maxillary first premolar extractions would have been normally considered if the maxillary left first molar was not compromised (Fig 8, B). A full-coverage crown or an inlay–onlay restoration, endodontic treatment, and possible crown lengthening were needed to save the first molar. Rather than extracting a sound premolar and leaving a compromised first molar, the first molar was extracted instead. A Nance holding arch helped distalize second and first premolars in the extraction site, creating space for the impacted canine before fixed appliance treatment (Fig 8, C and E). Treatment time was 30 months. Posttreatment photographs show well-aligned canines and a seated Class I occlusion (Fig 8, E and F). Optimal root parallelism at the maxillary left first molar extraction site was achieved (Fig 8, G). This 12-year-old patient had a Class II Division 1 malocclusion and a deeply impacted and ankylosed mandibular first molar with curved roots (Fig 9, A and B). A corresponding bulge could be palpated at the lower border of the mandible. The second molar was impacted horizontally. Extraction of first and second molars for a 2 implants solution at a later age was unrealistic. It would leave an edentulous ridge with overeruption of the unopposed maxillary molars or patient dependence on a removable partial denture till the end of growth. The second molar was uprighted with an intermaxillary elastic hooked on a bonded bracket after surgical uncovering (Fig 9, C). A removable maxillary Hawley-type appliance with an extended arm soldered on the retention clasp was used as an anchor unit to hook the elastic at the other end (Fig 9, D). A miniscrew would have interfered with the unereupted maxillary second molar. Therefore, cooperation was essential and achieved complete repositioning of the horizontally impacted second molar in 3 months before fixed appliance treatment (Fig 9, D). A CT scan of the right mandibular region after adequate space management showed the inferior dental nerve inserted between the roots of the impacted first molar (Fig 9, E). Complete extraction of the impacted molar was ruled out to avoid nerve damage and fracture of the mandible. A partial coronectomy was done to obtain enough height for an implant (Fig 9, F and G). The implant was inserted 5 years later. Treatment time was 4 years. A panoramic and an intraoral photograph that was taken 10 years after the treatment showed the stability of the overall treatment result (Fig 9, G and H). Severely decayed permanent first molars in the mixed dentition, mostly because of enamel hypoplasia, present a dilemma for the pedodontist; should these teeth be restored with a questionable long-term prognosis or considered for early extraction?16Penchas J. Peretz B. Becker A. The dilemma of treating severely decayed first permanent molars in children: to restore or to extract.ASDC J Dent Child. 1994; 61: 199-205PubMed Google Scholar The conditions favoring early extraction of permanent first molars are (1) poor tooth quality, (2) presence of second and third molars, (3) posterior crowding with third molars reasonably positioned, (4) patient willing to pursue long-term follow-up and future fixed appliance treatment, and (5) open bite tendency.23Sabri R. L'extraction précoce des quatre premières molaires permanentes : à propos d'un cas.Rev Orthop Dento Faciale. 1996; 30: 407-415Crossref Google Scholar,24Sandler P.J. Atkinson R. Murray A.M. For four sixes.Am J Orthod Dentofacial Orthop. 2000; 117: 418-434Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Conversely, severe arch length discrepancy and protrusion are contraindications for early extraction of first molars. Spontaneous space closure with the mesial eruption and drift of the second molars will not allow the use of the extraction space to relieve crowding or protrusion. In such patients, extraction of compromised first molars should be delayed until the full eruption of the second molars. Space maintainers such as the lingual arch and Nance appliance will maintain the needed extraction space until fixed appliance treatment in the early permanent dentition. This 9-year-old patient had enamel hypoplasia on 3 out of 4 permanent first molars. All third molars were present with signs of posterior crowding (Fig 10, A). Spontaneous early exfoliation of the maxillary and mandibular right primary canines was an early sign of arch length deficiency. The pedodontist questioned the feasibility of early extraction of these compromised first molars as part of a future orthodontic treatment, which was needed anyway. There was a full Class II molar relationship with an overjet of 11 mm. The appearance of calcification of the interradicular bifurcation of the second molar, as can be seen on the panoramic radiograph, is used as a suitable time for extracting the first molar (Fig 10, A).25Demirjian A. Goldstein H. Tanner J.M. A new system of dental age assessment.Hum Biol. 1973; 45: 211-227PubMed Google Scholar, 26Jälevik B. Möller M. Evaluation of spontaneous space closure and development of permanent dentition after extraction of hypomineralized permanent first molars.Int J Paediatr Dent. 2007; 17: 328-335Crossref PubMed Scopus (64) Google Scholar, 27Teo T.K. Ashley P.F. Derrick D. Lower first permanent molars: developing better predictors of spontaneous space closure.Eur J Orthod. 2016; 38: 90-95Crossref PubMed Scopus (19) Google Scholar This corresponds to a chronological age of 9-10 years. One year after the first molar extractions, the second molars erupted mesially with a good axial inclination (Fig 10, B). The mandibular left deciduous second molar was still retained, and the underlying successor mesially inclined. Third molars had completed crown calcification. There was a spontaneous space closure in the maxillary arch with the mesiopalatal rotation of the second molars in the first molar extraction site, unlike the mandibular arch, where some residual spaces remained. All canines erupted fully with a good overall arch alignment (Fig 10, C-F). Fixed orthodontic treatment was initiated at the age of 11 years for 30 months. A good Class I intercuspation with a normal overbite and overjet and long-term stability can be seen in intraoral photographs taken 25 years after the treatment (Fig 10, G-J). Careful management and timely extraction of the compromised permanent first molars simplified later orthodontic mechanotherapy and saved this young child from teeth with a questionable long-term prognosis. Extracted and decayed permanent first molars are still prevalent. Significantly compromised first molars have a great potential to enter a restorative cycle, eventually ending with extraction. Tooth migrations after nonreplaced molar extractions complicate restorative treatment. Orthodontic treatment is also more extended and requires great control of mechanics with first molar extractions. This article has shown how a well-coordinated multidisciplinary approach can facilitate the orthodontic and/or restorative treatment of extracted permanent first molars and achieve rewarding outcomes.