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References

Lucarotti PSK, Burke FJT The ultimate guide to restoration longevity in England and Wales. Part 6: molar teeth: restoration time to next intervention and to extraction of the restored tooth. Br Dent J. 2018; 225:525-536 https://doi.org/10.1038/sj.bdj.2018.754

The dilemma: Poor prognosis first molars

From Volume 18, Issue 2, May 2025 | Pages 58-59

Authors

Alison Murray

BDS, MSc, MOrth RCS(Eng), FDS RCPS(Glasg)

BDS, MSc, MOrth RCS(Eng), FDS RCPS(Glasg), Consultant Orthodontist, Royal Derby Hospital

Articles by Alison Murray

Email Alison Murray

Article

This young man was referred by his dentist who asked if we could extract the first molars as part of his orthodontic treatment because he felt that the prognosis of both lower and the upper right first molars was poor. The lower left first molar already had a peri-apical area on the mesial root and the third molars were present.

The patient was fit and well. Clinically, he had a mild skeletal II base with very slight bimaxillary retrusion and decreased lower anterior facial height, but average MMPA owing to reduced lower posterior facial height. There was minimal crowding in the lower labial segment and approximately 2 mm of crowding affecting both lower second premolars, which were slightly impacted. The upper labial segment had approximately 3 mm of crowding. The molar relationship was ½ unit Class II on the right, ¼ unit Class II on the left, and the right and left canines were ½ and ¾ unit Class II, respectively. The overjet was 4.5 mm, overbite 3 mm and centre lines were coincident. He had reasonable oral hygiene that was sufficiently good to support orthodontic treatment (Figures 1 and 2).

Figure 1. (a–d) Extra-oral views of the patient at presentation.
Figure 2. (a–e) Extra-oral views of the patient at presentation.

The panoramic radiograph revealed the presence of all permanent teeth, with adequate root length and bone levels (Figure 3). It confirmed the dentist's concerns regarding the extent of decay in the lower first molars and upper right first molar and apical changes in the lower left first molar. Cephalometric analysis indicated a more skeletal I pattern with a decreased lower facial height (Figure 4).

Figure 3. Panoramic radiograph taken at presentation.
Figure 4. (a,b) Cephalometric analysis indicated a more skeletal I pattern with a decreased lower facial height.

Would you advise extraction of all four first molars to leave the patient with an unrestored dentition?

What chance would you give the lower third molars to erupt without the need for a further course of treatment?

Knowing that root-filled molars have a poor prognosis (25% will fail within 10 years, over 50% will fail after 25 years),1 would you opt for restoration of the first molars and premolar extractions because it would be easier orthodontic treatment, and you might expect to achieve a better occlusal result? When considering the current state of dental health provision, will root treatments be easily obtained by a patient who may not be able to self-fund treatment?

What effect will extraction of first molars have on the soft tissue profile?