THE FIRST PERMANENT MOLAR*

By W. D. N. MOORE, L.D.S., D.D.S., Chicago, Illinois

S U S T A IN E D interest in any subject N atu re’s plan fo r the function this tooth
is the best evidence o f its importance, is to perform is most interesting and
and the application o f this truth fascinating, and, when thoroughly un­
is most fitting to the topic o f our dis­ derstood, it should awaken the keenest
cussion this evening, the first perm anent
sense o f responsibility, in view o f the
m olar. I t requires some degree o f
m any considerations that are likely to
courage to prepare a paper today on a
subject th at has been so long and so be encountered if the tooth is to render
fu lly discussed as this. T h e tendency the m axim um service to its host.
o f the present day is to exploit some A ll teeth are im portant organs o f
new idea w hether or not it is fu n d a­ the hum an m outh and their conservation
m entally sound, as long as it is capable is imperative. T h e lot to which the
o f producing a th rill or furnishing first perm anent m olar is heir is in many
something o f a spectacular nature. In respects different from that o f any o f
spite o f all th at has been said o f the the other teeth. Its eruption and pres­
first perm anent m olar, much still re­ ence in the arch are so frequently un­
mains to be said if this difficult problem known to the parent or guardian of the
is to be most satisfactorily solved. T h e child, and not being under the regular
loss o f the first perm anent m olar in ­ observation o f a dentist as it should be,
troduces one of%tthe most pow erful it is frequently mistaken fo r a deciduous
forces fo r the detrim ent, and even dev­ tooth, and no attention is given it until
astation, o f the hum an mouth. serious inroads o f decay occur. U ntil
T h ere is no gainsaying the fact that the average parent is better enlightened
no other tooth in the dental arch plays initial injury to this tooth can be ex­
so im portant a role as that o f the first pected. Frequently, faulty development
perm anent m olar. E rupting am ong the o f this m olar offers a predisposing cause
earliest o f the second dentition and o f dental caries, and this liability isoften
w ithout any disturbance, as a rule, to the enhanced by an offending neighbor in
deciduous teeth or the gums, it boldly the adjacent deciduous m olar whose sur­
and definitely takes a position in the faces do not present a clean and healthy
arch, the significance o f which cannot environm ent. W ith these handicaps,
be too fu lly realized or appreciated more or less present, this tooth is born
i f a w ell developed perm anent dentition to p erform its functions in the dental
is to be m aintained. A study of arch, which are at least tw ofold, and
* R e ad b e fo re th e O d o n to g ra p h ic Society each equally im portant fo r the future
o f C h ica g o , D ec. 13, 1926. perm anent dentition.
Jo u r. A . D . A ., J u ly , 1927 1213
1214 T h e Journal o f the Am erican D ental Association
First, and naturally so, we think o f norm ally before the loss o f the decidu­
its function in mastication, and realizing ous molars, and in the proper position,
at times certain prevailing conditions the first perm anent m olar becomes the
under which it labors, the m arvel is its veritable cornerstone and central pillar
survival and endurance. I t is not un- o f the human mouth. I t is the general­
issimo o f the dental organs.
Recognizing, then, the im portant
functions and valuable service the first
perm anent m olar perform s in the
hum an mouth, we as dentists should
readily realize that its loss cannot fail
to be productive o f the most u n fo rtu ­
Fig. 1.— Loss of first permanent molar, nate results unless early treated and cor­
before and after operation; showing method rected. Its effects are so far-reaching
for correction. that it is difficult to deal fully with all
o f them here. T h e age at time o f
common, when the deciduous teeth have loss o f the m olar, the duration o f its
been lost prem aturely, to observe that absence, the m anner in which the teeth
the entire stress in the posterior part of occlude and articulate are all capable
the arches is borne by the fo u r first o f producing an endless num ber o f
perm anent m olars and practically all the conditions, each one different from the
mastication is done on these teeth. others, but all similar in their destructive
Particularly in the transition period do influence. From the very first day the
we find an extra burden placed on the m olar is lost, there at once begins a
first perm anent m olar. I t undoubtedly d riftin g and m igration o f some or all
becomes the chief organ o f mastication o f the teeth on that side o f the mouth,

Fig. 2.—Loss of first permanent molar, right and left sides.

with a larger and more effective oc­ with the usual elongation o f the tooth
clusal area. B ut its function does not opposing the space. W ith this comes
end here: it m aintains the stability and the usual “ tipping” o f the teeth adjacent
integrity o f the arches in a m anner to the space a condition that proves
that no other tooth does. E rupting ruinous if long perm itted to remain.
 M uore— T h e First Perm anent M olar 1215
T h e arch becomes less in dimensions in T h e loss o f contact point o f several
all directions. T h e loss o f the first teeth, dependent in extent on the age o f
perm anent m olar before the fu ll erup­ the patient and the time space has existed,
tion o f the bicuspids will lead to a is a common sequence to the loss o f the
dropping together o f the m axilla and first perm anent molar. T here is always
mandible and result in too much over­ some loss o f the bony structure, and
bite o f the anterior teeth, in terferin g w hen pronounced inclination and elon­
w ith the contour o f the face and de- gation o f the teeth occur, an involvement

Fig. 3.— Result of delayed treatment after extraction: Above, left: right side; above,
right: left side. Postoperative treatment: Below, left: right side; below, right: left side.
tracting from the character o f the o f soft and hard tissues is usually pres­
countenance. T h e loss o f this tooth at ent; and when this condition is long al­
any age results in abnorm al occlusion. lowed to rem ain, complete loss o f the
Even when the occlusion appears to be second and third m olar has resulted.
restored by a d riftin g together o f the Im paired function is the aggravating
second bicuspid and second m olar, a cause o f this loss follow ing the m al­
model made o f the upper and lower position o f the teeth. Associated with
w ill show a faulty occlusion on the teeth that are malposed is impaired func­
lingual aspect. Invariably, there is an tion, and wherever these are to be
elongation o f a tooth or teeth opposite found a lack o f hygienics can be ex­
the space follow ing the loss o f this pected and usually prevails.
molar. I f we have a fu ll and definite per-
1216 T h e Journal o f the Am erican D ental Association
ception o f all the functions intended by tem porizing should be tolerated. T h e
N ature fo r the first perm anent m olar to idea that has prevailed in m any minds
perform , together with the m isfortune that temporary fillings should be em ­
that follow s its loss, we cannot fail to ployed in filling teeth fo r young pa­
tients is a fallacy, a contention without
be forcibly impressed w ith the impor-
any good foundation. T h ere is no place

Fig. 4.— Case presented by a young patient. Fig. 6.—Appliance used in correcting the
position of the second molar.
tance that must be attached to this tooth,
in dentistry where w ork o f a perm anent
and our responsibility fo r its w elfare nature is more clearly indicated than in
cannot be too earnestly assumed if the the treatm ent and care o f these teeth.
greatest good is our goal o f service and T h e more extensive the decay, the more
accomplishment in professional practice. imperative the dem and fo r permanency,
O u r first efforts, then, should be di­ fo r the reason that contour and contact
rected against initial injury to this tooth, are so essential to all that pertains to the
which is, and can be, best obtained by future w elfare o f the first perm anent
frequent observation and prophylaxis. m olar in the perform ance o f its fu ll
T h e importance o f this is a m atter that function. I t is not uncommon to see
large proximal fillings in these molars

Fig. 7.— Model of case shown in Figure 5,

Fig. 5.— Model of case shown in Figure 4, sition. second molar restored to correct po­
showing
after extraction.

cannot be too strongly impressed on the that are soon a fte r insertion so badly
parent’s m ind at the tim e o f the tooth’s disintegrated that a ll contact with
first appearance in the mouth. W hen adjacent teeth and contour is totally lost,
the first break in the continuity o f any a shifting o f its own position resulting,
o f its surfaces appears, no delay or as well as that of those adjacent to it.
 M oore— T h e First Permanent M olar 1217
In such cases as these, it is impossible to tem porary w ork has been only a kind­
maintain the norm al position o f the ness in disguise. T h e gold inlay has
other teeth in the arch. N o small am ount long proved its value and usefulness in
o f trouble has resulted from a lack o f operative dentistry and in no place has
it been shown to be o f greater impor­
tance than in restoring perm anently,
the first perm anent m olar, within the
tolerance o f the average young patient.
I t offers almost ideal advantages, partic­
ularly in regard to contour and contact
point, both o f which are essential in
these cases.
W h en destruction has gone beyond
Fig. 8.— Second molar in correct position. repair and the first perm anent m olar is
to be lost, it is then that the real problem
observance o f these details in first fill­
ings that have been placed in the first
perm anent molars. Pulp involvement
should be strenuously combated in con­
nection w ith these teeth.
T h e belief in the minds o f some
operators th at the cavity preparation
necessary fo r perm anent fillings in these
teeth should not be borne by the child
accounts, and rig h tfu lly so in certain
cases, fo r much o f the temporary work Fig. 10.— Finished case.
to be seen in the teeth o f young patients.
I t seems that this has often been used confronts us. Its importance in the
dental arch has been emphasized and
its loss described and it is therefore not
difficult fo r us to conclude w hat should
be done if we are to conserve the
original plan that N ature so w ell de­
signed fo r the best w elfare o f a useful
dentition. T h e greater difficulty lies in
how it can best be done. T h e first
thought should be to m aintain, as early
as possible, the space occupied by the
Fig. 9.—Appliance in position on model. first perm anent m olar, and this can best
be accomplished by the use o f a w ell-
as an excuse rather than a sound reason, made fixed bridge. I f the extraction
and we have allow ed ourselves to resort is made when the second permanent
to temporary work fo r convenience and biscuspid and second perm anent molar
sometimes economy when it was not are in position, no ordinary responsibility
truly justified. A great deal o f this rests on the operator fo r immediate
1218 T h e Journal o f the Am erican D ental Association
means fo r retaining its space, and this T h is precludes the possibility o f the
should have been fu lly planned previ­ slightest movement. But if the
ously to the operation. I t is directly adjacent teeth have already lost their
a fte r the extraction that the most rapid norm al position owing to faulty res-

Fig. 11.— Results of early loss of the lower first permanent molar.
movement o f the adjacent teeth is made, torations, this is not necessary; fo r their
particularly if the occlusion is such as correction o f position should first be
to favor their m igration. Unless con­ obtained. M ore often than otherwise,
siderable movem ent o f these adjacent these cases come to us a considerable
teeth has taken place previously to ex­ time a fte r this m olar has been lost, and
traction, and this is common, owing to with various conditions of derangem ent
cavities or faulty restorations o f the o f the teeth already established; all o f
first perm anent m olar, it is good practice

Fig. 12.— Results of early loss of the

lower first permanent molar. Fig. 13.-—Results of loss of the upper first
permanent molar.
to construct the bridge, or at least its
greater part, before the first perm anent which adds to the complexity o f the
m olar is extracted, and place it in posi­ task.
tion alm ost imm ediately on extraction. “ T ipping” o f the teeth on one or both
 M oore— T h e First Permanent M olar 1219
sides o f the space is a condition not to ular aspect o f the subject comes within
be overlooked w hether it has happened the field o f the orthodontist. I look
before or a fte r extraction. Before any w ith much interest fo r his enlighten­
replacement is considered, particularly m ent on this side o f the subject.
in the younger class o f patients, their W hile the treatm ent follow ing the
contact with adjacent teeth and their loss o f the first perm anent m olar in the
proper occlusion w ith opposing teeth young patient may extend over a con­
should be reestablished. I n addition to siderable period o f time, i f properly car­
this, bridging inclined teeth fo r these ried out through its entire procedure it
patients is employing teeth to bear an can supply intense interest and a grati­
extra strain at a disadvantage, and w ill, fication to both patient and operator
when done, prove a detrim ent to them. that is most genuine in character.
T h e more vertical position is the one T his is particularly so w hen compared
most suitable and toleran t to the sur- w ith cases o f long standing in the

Fig. 14.— Results of loss of the upper first permanent molar.

rounding tissues o f a tooth. T h erefo re, m ouths o f patients who are somewhat
it is only a logical conclusion th at those advanced in years and where correction
teeth whose positions have in any way o f position o f the teeth is not to be
been changed by reason o f the loss o f considered. In these cases, the move­
the first perm anent m olar should, pre­ m ent o f bicuspids and molars toward
viously to the use o f a bridge fo r service each other has been so m arked that their
and m aintenance o f its space, be placed surfaces often are w ithin a m illim eter
in a norm al position in the arch, even or tw o o f contact. In m any mouths,
if this is not, strictly speaking, a correct this is a most aggravating condition, and
position. even w hen no cavities or fillings are
T h e methods to be used fo r moving present in the teeth, the only correction
these teeth into norm al position, and can be an operative one, preferably made
the age lim it advisable fo r such pro­ by the use o f the gold inlay in one or
cedure, as w ell as m any other particulars both teeth.
incident to this operation, can be much Probably the most discouraging
more ably covered by D r. Lourie in his condition that we are called on to treat
discussion o f this paper, since this partic- is that in m iddle-aged patients in which
1220 T h e Journal o f the Am erican D ental A ssociation
the bicuspids, and particularly the second m olar that there must be several differ­
and third molars, have not moved so ent methods employed if all conditions
much bodily but “ tipped” extensively, are to be successfully cared for. T h e
w ith a marked elongation o f the upper technical detail is m itself a sufficient
first m olar, and w ith a history o f pain topic fo r an evening and one which
in masticating. T h e second and third could better be treated from a clinical
molars may be slightly loosened and no standpoint. I should, however, feel
cavities or fillings present. W h a t we disappointed if I could not at this time
accomplished in the younger patient by express my appreciation fo r the help
correcting the position can be only par­ and cooperation I have received from
tially gained by operative methods in re­ the orthodontic branch of our profession
storing occlusion by preparing cavities and D r. Lourie in particular. F o r sev­
on the proximal and occlusal surfaces eral years, I have been deeply interested

Fig. IS.— Results of loss of the lower first permanent molars.

o f the molars and so shaping inlays that in this subject, and the help and interest
occlusion is corrected w ith a more up­ given me by D r. Lourie has strength­
right position given to the natural ened my convictions o f its importance
crowns. T h e n , by assembling these in ­ and stim ulated my determination to treat
lays, which w ill greatly stabilize the tw o the cases along the lines I have here
m olars as w ell as serve as an abutm ent endeavored to indicate. I wish to ex­
to carry a substitute fo r the lost m olar, press my appreciation to the program
a reinforcem ent is gained that is o f committee fo r enlisting his support to­
m uch value. T h e second bicuspid night on this subject fo r I feel certain
treated in a m anner sim ilar to the molars that the greatest good can only come
w ill supply the anterior abutm ent. T h e where a close cooperation o f all the
upper first m olar should be shortened branches o f our profession prevails.
and inlayed. Cases o f this kind have DISCUSSION
been made com fortable and serviceable
What im­
Lloyd. S. L o u rie, C hicago, III.:
to the patient fo r m any years.
portance do you place upon the loss of the
So m any and varied are the conditions first permanent molar in young children, and
follow ing the loss o f the first perm anent what should be done in such cases? Dr.
 M oore— T h e First Perm anent M olar 1221
Moore has answered the first question so ably tioners might practice successfully here if only
that I shall simply indorse his statements and they did their best as early as possible. Pend­
show a few cases illustrating the damage re­ ing the eruption of the second permanent
sulting from early loss of this tooth. Cases molar, little can be done except to maintain
1 (Fig. l l ) and 2 (Fig. 12) show results of the positions of the other erupted teeth; but
early loss of lower first permanent molars, at that time, a decision should be made be­
while Cases 3 (Fig. 13) and 4 (courtesy of tween closing or opening the space previously
Dr. J. W. Ford) (Fig. 14) show results occupied by the lost tooth. Certainly, the
of the loss of upper first permanent molars. adjoining teeth must not be allowed to drift
In Case 1, there was at least 50 per cent without supervision, for they usually require
reduction in masticating efficiency on the side assistance one way or the other if malocclu­
where the tooth was lost. In Cases 3 and 4, sion and facial deformity are to be avoided.
the spaces have more nearly closed, but with Various things must be considered in making
considerable malocclusion and just as much this decision. The difficulty of the proposed
as or greater facial deformity than in Cases tooth movement under the two plans must be
1 and 2, in which lower molars were lost. estimated, and in this, attention should be
Cases 5 and 6 (Fig. 15) show different re­ given to the distance the teeth would have to
sults after loss of the lower first permanent be moved, the character of the alveolar
molars. Possibly in Case 5, the loss occurred process and the amount of tipping or root in­
earlier, before the bicuspids were in occlusion, clination, it being easier, of course, to move
allowing them to drift toward the space as the crown than the root, to improve the axis
well as the second permanent molar, while of the tooth for occlusal strain. Radiograms
in Case 6, only the second molar moved. I would, of course, help here. Orthodontic
agree with Dr. Moore that if the loss occurs opinion seems to be against extensive bodily
after the eruption of the second permanent movement of molars, and probably, in most
molar, the best procedure, in most cases, is to cases, greater good will result from prosthetic
place a fixed bridge as soon as possible, and than from orthodontic treatment, though or­
if delay should seem advisable, a space re­ thodontic assistance may often make possible
tainer should be used. The space retainer better prosthetic work, as explained by Dr.
should also prevent the overeruption of the Moore. Plate and spring appliances such as
tooth in the opposing arch, and probably a he has described seem particularly suited to
plate would best fulfil all requirements. If these cases, combining as they do space reten­
the first permanent molar has been lost before tion and the means for improving tooth
the eruption of the second, a more difficult positions, preparatory to prosthetic restora­
problem is presented. This problem may be tions. It does not seem advisable nor is there
prosthetic or orthodontic or both, and must time to discuss extensive orthodontic correc­
first be considered by the general practitioner tion. That is often out of the question be­
who first has the opportunity of seeing the. cause of limitations of the patient’s time or
great majority of these cases. The specialist finances. It must be remembered, too, that
seldom sees them until after the time for do­ ideal results are not to be expected by any
ing the greatest good has passed. The correc­ plan of handling these cases; consequently,
tion, which all orthodontists can accomplish, is conservatism should be a controlling influence
but “a drop in a bucket” compared to the pre­ in efforts to give the patient the greatest
ventive orthodontia which the general practi­ benefits in a practical way.