PaediatricDentistry/Orthodontics

Rebekka Nunn

Alison Murray and Jonathan Sandler

Loss of Deciduous Teeth – Is

Timing Important to the GDP?
Abstract: On a daily basis, GDPs encounter patients with prematurely lost deciduous teeth or, conversely, deciduous teeth retained well
past their accepted exfoliaton date. The timing of deciduous tooth loss impacts on many aspects of the developing occlusion. The aim of
the article is both to describe this impact and also to set out guidelines which should assist the general dental practitioner in the decision
of when to lose deciduous teeth.
Clinical Relevance: The timing of deciduous tooth loss is an important concept which, when outside the normal pattern, may have
adverse or beneficial side-effects that general dental practitioners should fully understand.
Dent Update 2011; 38: 55–64

Timing of deciduous tooth extractions has The normal eruptive sequence n The remaining deciduous teeth are
been widely discussed in the literature. exfoliated and replaced with permanent
Eruption can be defined as
Papers focusing on the indications for early successors and the second permanent
‘the biological process that follows the
extraction, the management of retained molars erupt;
formation of the dental crown and is
deciduous teeth, serial extraction and n Third molars erupt.
essentially penetration of the covering oral
balancing extractions are commonplace. This Chronology tables of the
mucosa by any part of a single tooth’.2 The
article aims to give an overview of the impact development and eruption dates of the
time of eruption of both the deciduous
of the timing of tooth loss on the developing human dentition are available. These can
and permanent dentitions occur over
occlusion and provide guidelines as to when be referred to by the practitioner when
a wide age range and are affected by
interceptive treatment is indicated. assessing patients for potential orthodontic
endocrine, genetic and dysmorphic factors.
The aim of interceptive problems (Tables 1 and 2).
Environmental factors such as ethnic origin,
orthodontics is to influence therapeutically The classic sequence of
socio-economic group, climate and fluoride
a developing/developed malocclusion in permanent tooth eruption in the upper arch
concentration can also have an effect.3
order to reduce further problems and attain is:
Variation in eruption times
a normal occlusion. The timing of deciduous n first molar, central incisor, lateral incisor,
is commonplace, however, significant
tooth extractions is an important aspect as it first premolar, canine, second premolar,
variation from the norm should be
influences the development of occlusion.1 second molar and third molar.
appreciated and investigated. Dental
Deciduous tooth extractions In the lower arch the sequence
practitioners should also be able to
may be required as part of an interceptive is:
identify patients with an unusual eruptive
approach; often the first stage of orthodontic n central incisor, first molar, lateral incisor,
sequence and take appropriate action.4
care which aims to guide the developing canine, first premolar, second premolar,
The typical sequence of eruption differs
occlusion closer to that of the ideal occlusion. second molar and third molar.
between the upper and lower arches: the
lower teeth generally erupting before their Delayed eruption of permanent
upper counterparts, with the exception of teeth can be caused by many factors but
the premolars. There are also differences retained deciduous teeth, which may or
Rebekka Nunn, Final Year Dental may not be ankylosed, are often the cause.
between the sexes, with girls’ teeth erupting
Student, Newcastle Dental School, Teeth may also show delayed eruption
in the same sequence but sometimes up to
Alison Murray, Consultant Orthodontist, due to other physical obstructions such
12–18 months earlier than boys’.
Derbyshire Royal Infirmary, PJ Sandler, as supernumary teeth, scar tissue and
Eruption of the permanent
Consultant Orthodontist, Chesterfield other soft tissue impediments. Systemic
dentition is often described as occurring in
Royal Hospital, Calow, Chesterfield, S44 conditions, such as amelogenesis
three phases:
5BL, UK. imperfecta and Down’s syndrome, have also
n First permanent molars and incisors;
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 PaediatricDentistry/Orthodontics

molars, but has also been shown to occur

Tooth Eruption Root completion
by distal drift of anterior teeth in the case
Deciduous dentition of early loss of deciduous canines where
Maxillary central Incisor 7.5 months 1.5 years teeth adjacent to extraction sites are moving
Maxillary lateral Incisor 9 months 2 years in both directions towards the extraction
space.8
Maxillary canine 18 months 3.25 years
Lower deciduous canines have,
Maxillary first molar 14 months 2.5 years in the past, been suggested for extraction to
Maxillary second molar 24 months 3 years relieve lower permanent incisor crowding.
Mandibular central incisor 6 months 1.5 years Reports have, however, shown this to cause
slight mesial drift of the buccal segments,
Mandibular lateral incisor 7 months 1.5 years
a general decrease in the arch length,
Mandibular canine 16 months 3.25 years retrusion of the incisors, an increase in
Mandibular first molar 12 months 2.25 years overbite and an increase of crowding
Mandibular second molar 20 months 3 years within the arch.9 Lower deciduous canine
5
extraction is therefore rarely recommended
Table 1. The chronology of development of the deciduous dentition.
by contemporary orthodontists.
Premature loss of the deciduous
Tooth Eruption Root completion
molars has also been shown to influence
Permanent dentition the occlusion and space within the arch.
Maxillary central incisor 7−8 years 10 years Space loss occurs more in the maxilla than
Maxillary lateral incisor 8−9 years 11 years the mandible.10 In cases where there is
little crowding, the effect of tooth loss is
Maxillary canine 11−12 years 13−15 years
minimal. However, where there is significant
Maxillary first premolar 10−11 years 12−13 years crowding, loss of the second primary molar
Maxillary second premolar 10−12 years 12−14 years leads to greater space loss than the first
Maxillary first molar 6−7 years 9−10 years primary molar. If the second primary molar
is lost prior to the eruption of the first
Maxillary second molar 12−13 years 14−16 years
permanent molar, then the entire space for
Maxillary third molar 17−21 years 18−25 years the second premolar can be completely lost.
Mandibular central incisor 6 years 9 years Generally, the later the deciduous tooth
Mandibular lateral incisor 7−8 years 10 years loss, the smaller is the overall space loss.
Extractions carried out after the age of ten
Mandibular canine 9−10 years 12−14 years
years have been shown to cause little overall
Mandibular first premolar 10−12 years 12−13 years space loss, owing to the fact that the first
Mandibular second premolar 11−12 years 13−14 years permanent molars have established their
Mandibular first molar 6−7 years 9−10 years position in the oral cavity.11
Whilst extracting a deciduous
Mandibular second molar 11−13 years 14−15 years
tooth close (within 6 months) to the
Mandibular third molar 17−21 years 18−25 years eruption time of the permanent successor
Table 2. The chronology of the development of the permanent dentition.5 will almost always hasten its appearance,
extracting a deciduous tooth very early will
have the opposite effect. It is more difficult
been implicated and delayed eruption, is likely to have some effect upon the for a permanent successor to erupt through
whatever the cause, can cause challenges developing dentition. As a general rule, the mature scarred mucosa or compact
when orthodontic treatment planning.4 there is space loss in the area with a bone which can result from early loss of a
concomitant reduction in space available deciduous predecessor.
for permanent successors. Other adverse Thought should therefore be
Early loss of deciduous teeth effects include tipping of the adjacent given to retaining deciduous teeth wherever
Early loss of deciduous molar teeth, and crowding and subsequent possible if the permanent teeth are not
teeth is mainly attributed to caries, whereas impaction of the unerupted permanent going to erupt within the next 12 months
deciduous central incisors are principally teeth.6 An increased need for orthodontic or, alternatively, to space maintenance
lost due to trauma and deciduous lateral treatment has been demonstrated in those following early loss of deciduous teeth if it
incisors and canines are lost early due to who have prematurely lost deciduous is thought that space loss might adversely
premature root resorption.1 teeth.7 Arch length is generally lost due to impact upon the development of the
Early loss of deciduous teeth mesial movement of the first permanent permanent dentition.

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 PaediatricDentistry/Orthodontics

Balancing and compensating difficult to justify than balancing extractions Retained deciduous teeth
deciduous tooth extractions as it involves the removal of a healthy tooth Deciduous teeth are retained for
Balancing extractions can be from an intact arch and is therefore almost many reasons, including:
defined as ‘the extraction of a tooth from never appropriate.15 n Malposition or absence of a permanent
the other side of a dental arch from which a successor;
tooth is to be or has been either extracted or ‘Serial extraction’ n Ankylosis;
prematurely exfoliated’. Balancing extractions The ‘serial extraction’ concept n Delayed root resorption; or
are considered in order to maintain the was first suggested in 1929. This term n Supernumary teeth obstructing the path of
symmetry of the dental arch and to prevent is used to describe a sequence of three eruption.
shifting of the dental midline. phases of planned extractions, with the Whenever a retained deciduous
The idea of carrying out balanced aim of optimizing the available space tooth is observed beyond its expected period
extraction originally came from clinical in the dental arch and minimizing the of exfoliation, the clinician should ascertain
observation of centre line shift following malocclusion. It is based upon the idea that, whether the permanent successor is present
unilateral extraction and, secondly, from at the mixed dentition stage, it is possible and in a reasonable position.
the concept of ‘serial extraction’, which is for the practitioner to predict whether the The problems associated with
discussed later. It is widely observed that the natural spontaneous increase in arch size retaining deciduous teeth are that, if eruption
extraction of primary canines will cause a and inter canine width will be sufficient to of the permanent tooth is significantly
centre line shift.12 Avramaki and Stephens13 accommodate all the permanent teeth in delayed, a much more severe malocclusion
found centre line shifts to be greater in a non- correct alignment.16 Originally, the technique can result, or more complex orthodontic
balanced extraction group when compared to was proposed as a preliminary treatment treatment may be required.
a balanced extraction group. If any shift of the prior to appliance therapy and, in some If a second premolar is
centre line whatsoever is undesirable, then cases, it was thought to give acceptable congenitally missing, retaining a deciduous
balancing deciduous canine loss is probably results alone, avoiding the need for active molar will prevent attainment of optimal
worth considering. appliances.1 Class I occlusion as this tooth has a larger
Balanced extractions The extraction sequence mesio-distal width than its successor and may
theoretically encourage the drift of teeth proposed begins in the early mixed dentition prevent eruption of the first premolar. In order
to be symmetrical, however, the practice of (about 8 years of age), starting with the to achieve a perfect Class I molar relationship,
balancing extractions is itself controversial extraction of the primary canines just at the the second deciduous molar width should be
and scientific evidence for its clinical benefit, time the lateral incisors begin to erupt, to reduced by interproximal stripping. Another
sadly lacking. An alternative to balancing provide space for the anterior teeth to align limiting factor is that deciduous tooth roots
an extraction would be the use of space and to relocate potential crowding further are significantly divergent, which can prevent
maintenance to prevent undesirable drifting back in the arch. The first primary molars the adjacent teeth being moved closer than
of teeth adjacent to the site of tooth loss. are then extracted (at about 9 years) to their divergent roots allow.18
The justification for balancing encourage the eruption of the first premolars Retained deciduous teeth may
primary molar extractions is, however, much ahead of the permanent canines. The erupted become ankylosed and infra-occluded.
less clear cut. Mills 14 claimed that the effect of first premolars are then removed, in turn, Infra-occlusion is defined as ‘the cessation of
the loss of a primary molar on one side was prior to eruption of the permanent canines.17 eruption without a physical barrier or ectopic
not as important as first thought. The effects It has been suggested that the position of the tooth at some point after
of unilateral extraction of a primary molar technique should only be considered in the emergence’.18 Infra-occluded teeth remain
on the centre line are probably minimal. If a absence of any skeletal discrepancy, where stationary while the surrounding dentition
significant centre line shift occurs, however, there is a decrease in arch length, a normal and alveolus continue to develop vertically.
then a balancing extraction can be considered overbite, a Class I malocclusion and when Infra-occlusion is more common in the
but only after assessing all the other aspects all teeth in the arch are present and in good mandible than maxilla and most commonly
of the malocclusion.11 position.17 The procedure is also contra- affects the second deciduous molar.19 The
Overall, there is a lack of good indicated if a diastema is present between earlier the infra-occlusion begins, the more
scientific evidence to support balancing the central and lateral incisors, or if there is severe it can become and a clue to infra-
extractions but clinical evidence does suggest a deep bite present, as extraction of teeth occlusion is when the interproximal bone level
that balancing is necessary for primary could lead to a worsening of either of these dips down towards the ‘submerging tooth’.
canines.12 two situations. Infra-occlusion can result in the
Compensating extractions (ie The main disadvantage of serial following:
removing a tooth from the opposing arch, extraction is the need to have up to 12 n Tipping of adjacent teeth;
in addition to the tooth that is planned for otherwise healthy deciduous teeth extracted n Overeruption of opposing teeth;
extraction or has been prematurely lost) aims under anaesthetic and on several episodes. n Space loss;
to minimize occlusal interferences following This is a traumatic introduction to dentistry n Delayed eruption of permanent successors;
tooth loss. When there is no other indication with an unpredictable outcome and, in n Ectopic eruption of successors;
for tooth removal, compensating is even more contemporary practice, is rarely indicated. n Disturbed root development; and

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 PaediatricDentistry/Orthodontics

given to the patient’s age, condition of the

deciduous molar, patient preference for
treatment and the occlusion. It is always
wise to send patients with a developing
malocclusion for orthodontic opinion prior to
carrying out any extractions.24
A general overview of treatment
options for retained deciduous teeth is:
1. Permanent successor present and close to
eruption:
n Extract deciduous tooth if not mobile and
not about to exfoliate.
2. Permanent tooth 12 months from
erupting:
n Slight submergence – review in 6 months;
n Moderate submergence – restore occlusal
surface, eg with composite or stainless steel
crowns and review in 6 months;
Figure 1. OPT radiograph of the patient on first presentation.
n Severe submergence – extract (careful
surgical procedure required) and consider
space maintainer.
n If there is no sign of root resorption, 6 3. Permanent successor absent:
months after normal exfoliation of the same n Extract early to achieve complete
tooth on the opposite side of the arch, with spontaneous space closure ( more likely in
no overriding reason to keep the retained maxilla);
deciduous tooth; n Extract as part of overall orthodontic
n There is severe tipping of adjacent teeth treatment plan;
and the need to regain space; n Consider space maintenance;
n Other reasons such as caries or abscess n Leave into adulthood if not infra-occluded
Figure 2. Single tooth space maintainer in place. making patient aware of guarded prognosis
formation.
The generally held view is and need for restoration and probable
that normal resorption and exfoliation of prosthodontic replacement at a later date.23
deciduous teeth depends on the presence Cases to illustrate clinical
n A more complicated extraction.20 problems with deciduous teeth and the
of permanent successors. The rate of root
It is therefore wise at least to solutions follow.
resorption in deciduous teeth without
consider extracting any infra-occluded tooth
successors is often slowed and these teeth
as soon as the phenomenon is noticed,
are often retained into adulthood, however,
but bear in mind the work of Bjerklin and
spontaneous root resorption does occur in
Case 1: Single tooth space
Bennett21 demonstrating that a significant
some of these teeth. Studies have shown that
maintainer
proportion of retained second deciduous A 13-year-old patient attended the
a considerable number of primary molars can
molars can last the patients into their 50s. clinic with retained upper deciduous canines
remain in the arch unaltered up to 15 years
If infra-occluded or ankylosed and a retained lower left second deciduous
after their expected exfoliation time, when
teeth are to be extracted, the loss of alveolar molar. The upper right canine was palpable
there is agenesis of their successors. The
bone should be kept to a minimum as this can but the upper left canine was not. The lower
retention of these teeth may be acceptable
complicate further restorative or orthodontic right second deciduous molar had been lost 9
as a semi-permanent solution, but further
treatment. Extraction should therefore be months earlier and the second premolar had
follow-up studies are still needed to ascertain
carried out when infra-occlusion is first erupted to a good position (Figure 1).
whether this could serve as a life-long
diagnosed, allowing the alveolar bone after The radiograph gave an indication
option.22
extraction to grow with the adjacent teeth, of the upper left canine being in a slightly
A deciduous molar with a
resulting in a less severe bone defect.18 more palatal position than the upper right
permanent successor should be expected
There are some other situations canine as its crown size was magnified
to exfoliate within 6 months of its opposite
where retained deciduous teeth should be compared to the palpable canine. Also, the
number. Therefore any deciduous tooth
considered for extraction: lower left second premolar appeared to be in
that is 6 months past its normal exfoliation
n The permanent successor is not erupting or an ectopic position and erupting towards the
date should be extracted.23 An ankylosed
is erupting into an ectopic position; root of the lower left first molar. No resorption
deciduous tooth without a permanent
n When the deciduous tooth is preventing of the roots of the deciduous molar was
successor is less likely to exfoliate
eruption of the adjacent teeth; evident.
spontaneously and so thought should be
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 PaediatricDentistry/Orthodontics

Treatment recommended at
this stage was removal of the remaining
deciduous teeth to encourage the
permanent successors to erupt into a more
favourable position. Because the lower left
second premolar was probably 12 months
from eruption, it was decided to maintain
the space between the lower first premolar
and first molar.
A unilateral space maintainer
was duly constructed and fitted (Figure 2).
This involved selecting an orthodontic band
for the first molar and taking an alginate
impression over the top and sending this
to the laboratory. A 1.0 mm stainless steel
Figure 3. OPT radiograph after 12 months of space maintenance. wire was fashioned to engage the disto-
occlusal surface of the lower first premolar
to prevent space closure and mesial
movement or tipping of the first molar after
the deciduous second molar is extracted.
A check radiograph taken 12
months later shows that, following the
deciduous tooth extractions and provision
of a space maintainer, all three permanent
teeth have assumed a more normal path of
eruption (Figure 3).

Case 2: Timely extractions of

deciduous and permanent
teeth
A 12-year-old girl presented
with congenital absence of lower second
premolars and retained lower second
deciduous molars which had drifted
mesially following removal of the deciduous
first molars. This is sometimes a helpful
strategy in cases with congenital absence
of lower second premolars, to help with
Figure 4. Composite of Case 2. spontaneous space closure in the lower
arch. These deciduous molars, however,
were now preventing the eruption of
the lower first premolars. In the upper
arch, the upper left second premolar was
congenitally absent and there was marked
crowding of the upper right quadrant
(Figure 4).
Careful examination of the
radiograph revealed a very slight shortage
of space in the upper left quadrant to allow
the upper canine to erupt fully and a much
more severe space deficit in the upper left
quadrant (Figure 5).
A decision was made not only
to extract the lower deciduous second
molars to allow the premolars to erupt
Figure 5. OPT radiograph of mixed dentition situation in Case 2.
and also the lower molars to drift forwards
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 PaediatricDentistry/Orthodontics

Case 3: Late presentation with

retained deciduous teeth
A 17-year-old patient presented
with retained deciduous canines which were
severely worn occlusally and unaesthetic. He
also had a retained upper left first deciduous
molar which had deflected the upper left first
premolar buccally to some degree. The upper
first molar had drifted mesially to occupy a
half unit Class II position but the occlusion
was otherwise good (Figure 7).
The radiograph reveals two
normal canine teeth in a vertical position
above the deciduous canines (Figure 8). The
crowns of both of the canines appear slightly
larger than normal, however, they were
palpable buccally. Had the two deciduous
canines been removed at the correct time,
ie at 13 years of age, then the upper canines
would almost certainly have erupted into a
normal position. If the patient had needed any
remedial orthodontic treatment, it could have
Figure 6. Spontaneous correction of the malocclusion following timely extractions. been provided at the same time as his peer
group was undergoing brace treatment.

Case 4: ‘Watch and wait’

approach is generally unhelpful
A 13-year-old girl presented in
the late mixed dentition with three second
deciduous molars retained. The OPT revealed
congenital absence of the lower right second
premolar and the other two second premolars
were potentially in a reasonable position,
although the lower left second premolar
was mesially tipped. (Figure 9). The overlying
malocclusion was Class 1 with no skeletal
discrepancy in the antero-posterior, vertical or
transverse dimension.
The lower right second deciduous
molar had not been extracted and appeared
to be submerging significantly and this would
probably get worse over the next few years.
The lower left second premolar could not
erupt as the deciduous tooth’s distal root
was not resorbing. Resorption of the roots
of the upper right second molar was almost
complete, indeed, the crown was showing
Figure 7. Case 3 at 17 years of age. Upper deciduous canines still in place.
signs of internal resorption therefore loss of
this tooth should be imminent. Appropriate
treatment at this stage was therefore
extraction of the remaining second deciduous
spontaneously, but also to extract the upper space closure, but will also provide the small molars.
left deciduous second molar and the first amount of space required in the upper The patient returned after a
premolar on the right. Extracting the upper left quadrant to allow the canine and first year, having visited her GDP who stated to
left deciduous molar will not only allow the premolar to adopt an almost perfect position her he would rather ‘watch and wait’ rather
first molar to drift mesially to get spontaneous within the arch (Figure 6). than actively extract the teeth. A second OPT
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 PaediatricDentistry/Orthodontics

Figure 8. OPT of Case 3 showing canines in a normal position.

Figure 9. Case 4 on presentation, 3 retained deciduous second molars.

Figure 11. (a, b, c) A 21-year-old student who

had been advised that the deciduous teeth will
eventually drop out

Figure 12. Complex orthodontics required to sort

Figure 10. Case 4 after a further period of ‘watch and wait’, 2 retained deciduous second molars still in
out this difficult malocclusion.
place.

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 PaediatricDentistry/Orthodontics

(Figure 10) revealed that the submergence n Balancing deciduous molars to prevent Guide to Orthodontics. SI: British
had, indeed, deteriorated and there was centre line shifts is almost never appropriate. Orthodontic Society, 1998.
little sign of eruption of the lower left n Compensating extractions are almost 12. Ball IA. Balancing the extraction of
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now completed their active orthodontic n Serial extraction of teeth is an outdated Dent 1993; 3: 179–185.
treatment and she had still not started her approach. 13. Avramaki E, Stephens CD. The effect of
treatment. n If in any doubt about extractions, always balanced and unbalanced extraction of
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