Orthodontics

Joe Hennessy

EA Al-Awadhi, Lian O Dwyer and Rona Leith

Treatment of Ectopic First

Permanent Molar Teeth
Abstract: Ectopic eruption of the first permanent molar is a relatively common occurence in the developing dentition. A range of
treatment options are available to the clinician provided that diagnosis is made early. Non-treatment can result in premature exfoliation
of the second primary molar, space loss and impaction of the second premolar. This paper will describe the management of ectopic first
permanent molars, using clinical examples to illustrate the available treatment options.
Clinical Relevance: This paper is relevant to every general dental practitioner who treats patients in mixed dentition.
Dent Update 2012; 39: 656–661

The eruption of teeth is a complex be further differentiated into reversible Aetiology

process and can be disturbed by genetic,
cellular, molecular or tissue causes.1
Ectopic eruption describes the eruption
of a tooth into an atypical position.2
The incidence of ectopic eruption of
maxillary first molars varies between 2%
and 6%.3 It affects both sexes equally.1
It occurs 25 times more often in the
maxilla than mandible.4 The aetiology is
not completely understood. Local factors
have been suggested.5 A strong genetic
element, including a higher incidence
in patients with cleft lip and palate, has
also been reported.6,7 Ectopic eruption
is classified according to its effect on
the primary second molar tooth1 (Table
1 and Figure 1). Ectopic molars can
Joe Hennessy, BDentSci, MFD(RCSI),
Specialist Registrar in Orthodontics,
EA Al-Awadhi, BDentSci, BA, MSc,
MFD(RCSI), MOrth RCS(Eng), Consultant
Orthodontist, Lian O Dwyer, BDentSci,
MFD(RCSI), MDentSci, IMOrth
RCS(Eng), Lecturer in Orthodontics
and Rona Leith, BDentSci, MFD(RCSI),
DChDent(UDubl), Lecturer in
Paedodontics, Dublin Dental School and
Hospital, Lincoln Place, Dublin 2, Ireland.
(permanent molar spontaneously self
The aetiology of ectopic
corrects and erupts in a normal position)
molars may be considered to be
or irreversible (permanent molar remains
multifactorial. A number of authors
blocked by the primary molar). The aims
have described different predisposing
of treatment of an irreversible ectopic first
factors. A high familial tendency
molar tooth are movement of the tooth
has been noted.9 Local factors, such
distally to regain space and correction
as mesial angulation of the first
of the mesial angulation to allow normal
permanent molar, larger than average
eruption.8 Spontaneous correction can
width of the first permanent molar,
occur, but in the majority of cases this will
crowding and unfavourable shape of
have occurred before seven years of age.9
the second primary molar crown, have
This paper will describe the management
been suggested.5 Cleft lip and palate
of ectopic first permanent molars, using
patients are four times more likely to
clinical examples to illustrate the available
have an ectopic molar.10
treatment options.
Ectopic Severity Effect on primary molar
Eruption
Grade
Grade 1 Mild Limited resorption to the cementum or with minimum
dentine penetration
Grade 2 Moderate Resorption of the dentine without pulp exposure
Grade 3 Severe Resorption of the distal root leading to pulp exposure
Grade 4 Very severe Resorption that affects the mesial root of the primary
second molar
Table 1. Describes the classification of ectopically erupting first permanent molars.

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 Orthodontics

Figure 1. (a–d) The grades of resorption of the

second primary molar.
Figure 3. An ectopically erupting upper right first molar.

Figure 2. An ectopically erupting upper first

permanent molar.
Figure 4. An ectopically erupting upper left first permanent molar.

Diagnosis
A thorough clinical examination
is essential in order to diagnose ectopic
first molar eruption. In children 7 years
or older, a permanent first molar crown
can often be observed clearly locked
behind a second primary molar11 (Figure
2). In most ectopic cases, the crown of the
first permanent molar is tilted mesially.12
Radiographs should be used for early
diagnosis in a 5–7 year-old child.11 A
bitewing radiograph is usually sufficient
but an orthopantomograph can be
useful in determining the presence of the
permanent teeth (Figures 3 and 4). High
positioning of the first permanent molar,
on a radiograph, intimately associated with
the distobuccal root of the second primary Figure 5. A severely resorbed upper right second primary molar.

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 Orthodontics
molar and/or a mesial inclination of the
permanent tooth, are indications of an
ectopically erupting molar tooth.11 Ectopic
eruption should also be suspected if there
is asymmetric eruption between the upper
left and right first permanent molars.
Consequences of ectopic
eruption
Ectopic eruption of a
permanent first molar can cause pain and
infection around a second primary molar.
In more severe cases, it leads to premature
exfoliation of the primary molar1 (Figure
5). The resultant mesial migration of the
first permanent molar occupies the space
of the second premolar. This results in a
decrease in arch length and can cause
delayed eruption or impaction of the
second premolar.1 For these reasons, early
intervention is advisable.
Treatment options
Most cases of ectopically
erupting permanent molars spontaneously
self-correct (50–69%).4 However, a lack
of timely intervention may result in loss
Figure 6. Upper arch space loss following the extraction of the second primary molar.
658 DentalUpdate November 2012
of the primary molars and lack of space
for eruption of the second premolar as
the permanent molar erupts mesially.1
The method of treament of an ectopically
erupting first permant molar will depend
on a number of factors:
Age of the patient;
Status of the second primary molar;
Presence of the second premolar;
Severity of impaction.
Age of the patient
Spontaneous correction usually
occurs before seven years of age.9 In
patients who are diagnosed before the age
of eight, a six-month observation period
is advisable.12 If spontaneous correction
has not occurred within this six-month
period, the tooth may be assumed to be
irreversibly impacted and some form of
active treament is required. Early diagnosis
is essential to stop root resorption of the
deciduous tooth1 (Figure 5).
Status of the second primary molar
If the primary molar is
displaying symptoms of irreversible
pulpitis or has increased mobility,
extraction may be the best option. Space
loss may occur following extraction (Figure
6). This can be prevented using a simple
removable appliance or another suitable
type of space maintainer (Figure 7).
Presence of the second premolar
The incidence of congenitally
missing second premolars was found to
be 18% in patients with cleft lip and cleft
palate.13 If the second premolar is absent,
it may be advisable to extract the primary
molar and allow the permanent molar to
erupt mesially and close the space. An
orthopantomograph may be required to
diagnose the absence or presence of the
second premolar and an assessment of
the malocclusion by a qualified specialist
would be helpful (Figure 4).
Severity of impaction
As described previously, ectopic
first molars can be given a grade from 1–4,
depending on their severity1 (Table 1 and
Figure 1). Grade 1 ectopic molars should
be observed and given the opportunity to
correct spontaneously.
Grade 2 molars require active
Figure 7. An upper removable appliance used for
space maintenance.
Figure 8. An ectopically erupting upper molar
with a button bonded to its occlusal surface.
 Orthodontics
treatment which may involve interproximal
wedging or distal tipping. Numerous
techniques have been described and these
will be discussed in more detail below.12
Grade 3 molars are generally
treated through active distal tipping of
the ectopic permanent molar. This can be
achieved by using a removable appliance
(Figures 8, 9, 10) or by placing fixed
brackets (Figures 11, 12). It may require
extraction of the primary molar.
When the ectopic eruption
is so severe that the mesial root of the
second primary molar is affected (Grade
4), extraction of the primary tooth is
advisable. Yet again, the malocclusion
Figure 9. A removable appliance engaging with
the occlusal button.
Figure 10. The upper first molar following
treatment with a removable appliance.
Figure 11. A fixed appliance being used to treat
an ectopically erupting second permanent molar.
The same technique is used when treating an
ectopically erupting first permanent molar.
660 DentalUpdate November 2012
should be fully assessed by a specialist to
determine whether space loss should be
prevented.
Examples of separation
techniques
These can be divided into
interproximal wedging and distal tipping.
A simple elastic separator, soft brass wire
or a metal Kesling separator can be used
for interproximal wedging. Distal tipping of
the ectopic first molar requires the use of a
removable or fixed orthodontic appliance.
Interproximal wedging
The separating medium should
be placed between the first permanent
molar and second primary molar.
Careful supervision of these techniques
is essential.14 Apical dislodgement of
the separator or brass wire can induce
infection and early loss of the primary
molar.12
Figure 12. The uprighted second permanent
molar.
Figure 13. An elastomeric separator being
stretched using a forceps.
Figure 14. An elastomeric separator threaded
with two pieces of dental floss.
Separator
An elastomeric separator can be
used when little movement is required and
there is minor resorption of the primary
molar. The ectopic molars can be stretched
into position by using a separator forceps
or by using two pieces of dental floss
(Figures 13, 14). This separation technique
is not routinely recommended because it
can become dislodged apically and cause
periodontal irritation. The separator may
be difficult to locate and retrieve in such
cases. It may be used by an experienced
operator provided the patient is reviewed
every two weeks (Figures 15, 16).
Kesling separator
This is an alternative to the
elastomeric separator. It may be difficult
to place, however, if the point of contact
between the permanent molar and the
primary molar is deep below the cemento-
enamel junction of the primary molar.
Brass wire
If a small amount of movement
is needed, but little of the mesial surface
of the first permanent molar is visible
clinically, a brass wire can be used. A 0.02”
or 0.025” brass wire is threaded around
the contact point between the primary
and permanent molars then twisted to
tighten the wire. The disadvantages of
this approach are that it may be necessary
to anaesthetize the soft tissue and it can
be difficult to thread the wire around the
contact point when subgingival.
Figure 15. An elastomeric separator in situ.
Figure 16. An uprighted first molar following
removal of an elastomeric separator.
 Orthodontics

Distal tipping of the ectopic first molar
Transpalatal arch with a distal hook
If resorption of the primary
molar is severe and the permanent molar
has moved significantly, distal movement
of the permanent molar is required. The
clinician can fabricate a transpalatal
arch (TPA) on the primary molars with
a cantilever arm extending from the
appliance distally. An elastomeric band or
spring can then be hooked from the end
of the cantilever arm to a button which
has been bonded on to the permanent
molar to initiate distal movement of the
ectopic molar (Figure 8).
Fixed appliance
Again, a TPA is placed on
the primary molars to stabilize these
teeth and a bracket is placed on the
buccal surface of the permanent molar.
A flexible sectional nickel titanium wire
is used to upright the molar (Figures 11,
12).
Relapse
After the first permanent
molar is repositioned, relapse may often
occur.12 The simplest way to prevent this
is to place a molar band with a distal
extension on to the occlusal surface of
the second primary molar.12 The patient
is checked every 6–8 weeks and the band
is not removed until after the permanent
molar has erupted sufficiently to prevent
relapse.12 If the second primary molar
is extracted, a Nance or palatal arch
appliance can be used on the corrected
molar to maintain its position.
Conclusion
The incidence of ectopically
erupting permanent molars is relatively
common. Dentists need to be aware of
the potential sequelae of this condition
and the available treatment options.
Early diagnosis and treatment can save
the patient, and his/her parents, time
and future expense.
Acknowlegments
We would like to thank The
Angle Orthodontist for permitting us to
publish Figure 1.
References
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Clua M, Saavedra-Ontiveros
D. Ectopic eruption of the
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11. Harrison LM, Michael BC. Treatment
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12. Pinkham JR. Paediatric Dentistry:
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13. Shapira Y, Lubit E, Kuftinec MM.
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Pediatr Dent 2000; 22(5): 408–412.

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