Treatment of ectopic

eruption of the maxillary

first permanent molar A. Garrocho-Rangel,
P. Benavídez-Valadez,

in children and adolescents:

M. Á. Rosales-Berber,
A. Pozos-Guillén

A scoping review Pediatric Dentistry Postgraduate

Program, Faculty of Dentistry,
University of San Luis Potosi, Mexico

DOI 10.23804/ejpd.2022.23.02.02 e-mail: apozos@uaslp.mx

Abstract del Cojo et al., 2013; Hafiz, 2018]. In this physiological course,
multiple factors simultaneously contribute to a successful normal
Aim Ectopic eruption of the first permanent molar (EFUPM) is defined dental eruption [Bruna del Cojo et al., 2013]. The mechanism
as its local disturbed eruptive behaviour, positioning too mesially against can be disturbed by different genetic, cellular, molecular, or
the distal aspect of the second upper primary molar during the developing tissue causes [Hennessy et al., 2012]. If not synchronised, the
mixed dentition. The EFUPM prevalence is up to 6% and affects both forces acting on the developing dentition can be unfavourable
genders equally. The present study aimed to perform a scoping review for reaching a proper occlusion, and a variety of problems can
to collect the most relevant studies published in the last 30 years and arise during the tooth transitional period; one such problem
focused on the different strategies, traditional and novel, for treating is ectopic eruption (EE) [Duncan and Ashrafi 1981; Barberia-
irreversible uni- or bilateral EFUPM in children. This review also aimed to Leache et al., 2005; Yaseen et al., 2011; Ambriss et al., 2019].
make recommendations and map the gaps in this clinical topic.
The failure of permanent teeth to properly erupt is due to a
Methods An electronic and manual search was conducted in five
databases according to previously established eligibility criteria, using
range of aetiological causes, such as ectopic positioning or
different combinations of keywords, MeSH terms, and Boolean operators. abnormal orientation [Mubeen and Seehra 2018]. Ectopic first
Titles, abstracts, and full-text articles were screened and selected by upper permanent molar (EFUPM) is a relatively common local
pre-calibrated reviewers. A data charting was also accomplished for condition in which the eruption of the molar occurs under the
summarising the overview of the evidence. distal undercut of the adjacent second upper primary molar and
Results A total of 54 references were identified and 40 titles remained its impossibility to erupt to the normal occlusal plane. It was first
after removing duplicates; then, 31 potential full-text articles were described by Chapman in 1923 [Chapman, 1923]. Then, in the
carefully reviewed. Finally, 27 relevant and most informative studies 50s of the last century, Young established that EFUPM was more
were included. Most studies were case reports and/or clinical treatment frequent in boys than in girls in a significant sample [Young,
descriptions. We also found some descriptive or comparative cross- 1957]. This oral disturbance is usually diagnosed first by the
sectional or cohorts designs. No randomised clinical trials were found. paediatric dentist [Kupietzky, 2000]. Consequently, the EFUPM
Conclusions Paediatric dentists must learn to diagnose and treat this may become intraosseously impacted and stop emerging, and
condition early in order to allow the prevention of future malocclusions
causing premature resorption, and sometimes the exfoliation, of
and other clinical sequelae. Practitioners have at their disposal a variety
the second primary molar [Yaseen et al., 2011].
of corrective options available for the successful resolution of EFUPM.
The prevalence of the abnormality has been reported between
1.8% and 6%, affecting both genders equally [Kimmel et al.,
KEYWORDS Ectopic eruption; Maxillary first permanent molar; 1982; Harrison and Michal 1984; Mooney et al., 2007; Salbach et
Clinical management; Scoping review. al., 2012; Jariyapongpaiboon and Nuruzzaman 2021; Mitsuhata et
al., 2014], with a familial tendency (higher occurrence in siblings)
[Bjerklin, 1994; Helm et al., 2021] and present in numerous
Introduction syndromes [Romano et al., 2016]; also, in children exhibiting
concurrent orofacial and dental anomalies, such as cleft palate
Several aetiological factors can modify the dental arches' (with a prevalence four times higher), congenitally missing teeth,
developing process and occlusion during childhood. These supernumerary teeth, and tooth size abnormalities [Da Silva Filho
alterations may result in dentofacial abnormalities in the future et al., 1996; Mooney et al., 2007; Helm et al., 2021]. Ectopic
if they are not opportunely treated. The management sequence first permanent molars occur 25 times more often in the maxilla
includes early recognition, clinical and radiographic diagnosis, than mandible, and most of these anomalies are of bilateral
and appropriate treatment. Eruption guidance during the primary presentation [Hafiz et al., 2018; Mitsuhata et al., 2014]. The
and mixed dentitions is an integral part of comprehensive oral aetiology for EFUPM is still unclear and considered idiopathic.
health care provided by the paediatric dentistry practitioner to However, it is supposed to be determined by the involvement of
achieve a normal subsequent occlusal harmony, function, and both genetic predisposition and environmental aspects, as well
aesthetics [American Association of Pediatric Dentistry, 2020]. as molecular, cellular, or tissue reactions [Salbach et al., 2012;
Tooth eruption is a complex process consisting of the migration of Jariyapongpaiboon and Nuruzzaman, 2021]. It is considered as
the forming tooth from its intraosseous position of development a multifactorial aetiology condition and includes different local
until reaching its functional site within the dental arches [Bruna anomalies such as the second primary molar increased size or

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 DEVELOPING DENTITION AND OCCLUSION IN PAEDIATRIC DENTISTRY

atypical crown shape, delayed calcification of the permanent between 1990 and 2021 were eligible. Publications focused
molar, smaller or a more posterior position of the maxilla with on the treatment of EFUMP in which the authors explored and
respect to the cranial base, insufficient tuberosity growth, and described the different clinical strategies for the resolution of
abnormal eruptive angulation of EFUPM with the inadequate the condition in the mixed dentition stage were chosen. Studies
anterior movement of primary dentition [Kupietzky, 2000; performed in permanent dentition or adults, letters to the editor,
Mooney et al., 2007; Gonçalvez et al., 2012; Hafiz, 2018; Helm and gray literature were excluded. Reasons for exclusion after
et al., 2021]. A diagnosis of this local condition is made based on full-text reading were recorded.
combined clinical and radiographic findings. There are two types
of EFUMP: reversible or self-correcting when the ectopic molar Search strategy and screening process
unlocks and eventually comes into occlusion; and irreversible An electronic search from the period from April to July 2021
when the ectopic molar remains locked until either the premature was performed in the following four databases: PubMed,
exfoliation or extraction of the second primary molar occurs. Cochrane Library, Google Scholar, and Dentistry & Oral Sciences
One-third of EFUMP is irreversible, so interceptive orthodontic Source (EBSCO) for reviews, clinical trials, and observational
treatment must be implemented in order to redirect the eruption studies. A search strategy was conducted, employing different
path while maintaining the resorbed primary molar [Dabbagh et combinations of keywords (and synonyms), MeSH terms,
al., 2017; Kim et al., 2020]. Thus, space loss, posterior crowding, and Boolean operators. The main four key search terms were
and impaction of the upper second premolar might be prevented “children”, “ectopic eruption”, “first maxillary permanent
in the future. molar”, and “treatment”. We adapted this strategy for use in
To our knowledge, no detailed up-to-date summary of the all electronic databases. For instance, in PubMed, the following
evidence regarding the treatment of EFUPM in children is available. search algorithm was employed: "ectopics"[All Fields] OR
In this context, and considering that EFUPM is a very important "ectopic"[All Fields] OR "ectopical"[All Fields] OR "ectopically"[All
cause for malocclusions, the present scoping review intends to Fields]) AND ("erupt"[All Fields] OR "erupted"[All Fields] OR
collect those most relevant studies from the dental literature, "erupting"[All Fields] OR "eruptions"[All Fields] OR "eruptive"[All
published in the last 30 years, focused on the prevalence and Fields] OR "erupts"[All Fields] OR "tooth eruption"[MeSH Terms]
other features, and on appraising the different strategies, both OR ("tooth"[All Fields] AND "eruption"[All Fields]) OR "tooth
traditional and novel, implemented for the resolution of irreversible eruption"[All Fields] OR "eruption"[All Fields] AND (("first"[All
EFUPM. Also, this review aims to make recommendations and to Fields] OR "firsts"[All Fields]) AND ("maxilla"[MeSH Terms] OR
map the gaps in this clinical topic. "maxilla"[All Fields] OR "maxillary"[All Fields] OR "maxillaries"[All
Fields] OR "maxillaris"[All Fields]) AND ("permanent"[All Fields]
OR "permanently"[All Fields] OR "permanents"[All Fields]) AND
Methods ("molar"[MeSH Terms] OR "molar"[All Fields] OR "molars"[All
Fields] OR "molar s"[All Fields])) AND ("child"[MeSH Terms] OR
The present scoping review was carried out according to the "child"[All Fields] OR "children"[All Fields] OR "child s"[All Fields]
methodology stated by Arksey and O’Malley [2005], Levac and co- OR "children s"[All Fields] OR "childrens"[All Fields] OR "child"[All
workers [2010], and the Preferred Reporting Item for Systematic Fields]) AND (("orthodontal"[All Fields] OR "orthodontic"[All
Reviews and Meta-analysis extension for scoping reviews Fields] OR "orthodontical"[All Fields] OR "orthodontically"[All
guidelines (PRISMA-ScR) [Tricco et al., 2018] for transparent Fields] OR "orthodontics"[MeSH Terms] OR "orthodontics"[All
reporting. A scoping study comprises a further type of literature Fields]) AND ("treatment"[All Fields] OR "treated"[All Fields]
review, whose main purpose is to map relevant literature and the OR "treatments"[All Fields] OR "managing"[All Fields] OR
key concepts underpinning a clinical topic of interest. Also, the "management"[All Fields]
main sources and types of evidence available, especially when this The complete searching process was carefully carried out by
topic has not been reviewed comprehensively before. In general, two independent and pre-calibrated authors (PBV and MARB),
a scoping review consists of five steps as follows. according to the inclusion and exclusion criteria. The levels of
1. Constructing the research question. inter- and intra-observer agreement of these authors were
2. Identifying relevant studies. determined using Cohen’s kappa coefficient [Cerda et al., 2010].
3. Study selection. Any discrepancy or conflict of opinion was resolved through
4. Charting the data. discussion and consensus by consulting with the other two
5. Collating, summarising, and reporting the results. authors (AJPG and JAGR).
Nowadays, scoping reviews represent an increasingly popular
approach to reviewing dental research evidence. Scoping studies
differ from systematic reviews because authors do not assess
the quality of included studies; scoping studies also differ from
narrative literature reviews in that the scoping process requires
analytical reinterpretation of the literature [Levac et al., 2010].

Eligibility criteria
The study followed a PCC format scoping review question,
where the population (P) was “children”; concept (C) was “in
mixed dentition stage with one or two EFUPM”; and context (C)
was “clinical trials/ observational studies/ narrative review articles/
on orthodontic treatment”. Only electronic available randomised
controlled clinical trials, observational studies (cohort, case-control,
cross-sectional designs), and narrative reviews and/or clinical
case reports, written in the English language, and published FIG. 1 PRISMA flow chart for literature search.

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GARROCHO-RANGEL A. ET AL.

Data charting and result synthesis al., 2012; Romano et al., 2016]. In this regard, Barberia-Leache
A special tabular form for data charting was constructed et al. [2005] proposed an EFUPM classification, according to
and piloted with relevant information entries, and approved by the magnitude of the adjacent primary second molar, into four
authors’ consensus. From each selected article, the following grades as follows.
items were summarized and recorded: publication first author 1. Mild: limited resorption to cementum with minimal dentin
and year, country, study methodological design, intervention(s), penetration.
outcomes, and main findings/conclusions; in cases of observational 2. Moderate: resorption of dentin without pulp exposition.
(cross-sectional or longitudinal) studies, target population, sample 3. Severe: pulp exposure in the distal root;
size and follow-up period (e.g. cohort designs) were also taken. 4. Very severe: resorption of the mesial root.
All items were collected independently by two authors (AJPG The first two grades tend to be resolved spontaneously, but
and JAGR). the severe and very severe types do not, and present the worst
prognosis (“the more mesial the position, the greater the time
need to correct it”) [Romano et al., 2016]; however, this is not
Results a strict rule. These and other authors also mention that when a
middle or less of the marginal border of the permanent molar is
A total of 54 references were identified in the different locked, it usually self-corrects by age 7 or 8 (even up to 9) [Mooney
electronic databases, after which 40 titles remained after et al., 2007; Haznedaroğlu and Mentez 2016; Dabbaugh et al.,
removing duplicates. After the article title and abstract screening, 2017]; and that, in about 80% of cases of EFUPM, the damage
31 potential full-text articles were carefully reviewed. Finally, to the primary molar is severe or very severe [Barberia-Leache et
27 relevant and most informative studies—according to the al., 2005]. Besides, it has been mentioned that the chance of
authors’ experience (no critical appraisal was carried out)—were root resorption is higher if the molar impaction occurs below the
included in the present scoping review. The selection process was second primary molar’s cement-enamel junction [Gonçalvez et al.,
according to the PRISMA-ScR statement flowchart, as can be seen 2012]. Although treatment timing is critical and should coincide
in figure 1. On the other hand, good to very good intra- and inter- with the active phase of the first permanent molar eruption, it is
reviewer agreement levels were found for the search strategy and always advisable to closely monitor each case individually for three
screening processes, according to the kappa coefficients (0.86 to six months, mainly at ages between 7 and 8 years, looking for
and 0.92, respectively). Sixteen studies were case reports and/ delayed eruptions or asymmetry in the eruption process of one or
or clinical treatment descriptions, six descriptive or comparative more first permanent molars [Mucedero et al., 2015; Mooney et
cross-sectional designs, four cohorts, and one narrative review; al., 2007; Nagaveni et al., 2010; Hennessy et al., 2012].
no randomised clinical controlled trials were detected. Regarding In addition to causing premature exfoliation of the second
the country, most articles were conducted in Brazil, Central Asia primary molar, delayed eruption or impaction of the second
(mainly in India, Turkey, and South Korea) and Europe. Eight premolar, and space loss [Hennessy et al., 2012], EFUPM is
studies presented any type of descriptive or inferential statistical considered as a risk factor for maxillary arch constriction and
analysis (with p values). The publication dates ranged from 1992 severe transverse (e.g. lateral crossbite) and sagittal crowding
to 2021. Principal characteristics, numerical data, and findings, [Salbach et al., 2012]. Furthermore, it has been suggested
and conclusions from these articles are summarised in Tables 1 that irreversible EFUPM accompanied by severe primary molar
(1991–2000), 2 (2001–2010), and 3 (2011–2021). resorption is a potential early indicator of abnormal canine
eruption and the subsequent lateral or central incisor root
resorption. This association was found in 23.3% of the children
Discussion in the study conducted by Becktor and co-workers; the authors
concluded that these patients exhibited a biological and/or genetic
A variety of eruption disorders can occur during the transitional dysfunction of the ectoderm which troubled the development of
period in which the primary dentition is replaced by the permanent both permanent upper first molars and canines [Becktor et al.,
one, such as the abnormal eruption of permanent teeth, mainly 2005; Salbach et al., 2012]. In this same regard, Salbach and co-
upper first molars, canines, and incisors; these phenomena should workers found a significant correlation (more than 70%) between
be stressed in contemporary paediatric dentistry [Kupietzky, 2000; the disturbed eruption of the upper first permanent molar and
Nagaveni et al, 2010; Mitsuhata et al., 2014; Kim et al., 2020]. Class III malocclusions; again, irreversible EFUPM can be considered
Therefore, paediatric dentists must recognise uni- or bilateral as an early indicator of this type of malocclusion [Salbach et al.,
EFUPM in the early stages, so that they may initiate the indicated 2012]. On the other hand, retention, transmigration, and ectopic
corrective treatment at the proper time [Harrison and Michal eruption of permanent teeth in children have been associated
1984]. with odontogenic tumors (e.g. odontomas) [Marra et al., 2021].
By conducting the present scoping review, the authors A myriad of corrective techniques for treating irreversible EFUPM
pretended to identify and summarize the existing literature have been proposed. The paediatric dentist should consider four
evidence published in the last 30 years and to provide an updated main factors before choosing an orthodontic strategy [Hennessy
descriptive analysis or synthesis of those studies related to the et al., 2012]. First, the age of the patient; if a spontaneous
clinical management of EFUPM in children. correction does not occur within six months, it may be assumed
EFUPM is a painless and commonly unrecognised anomaly, an irreversible condition. Second, the status of the second primary
usually or incidentally diagnosed on the routine radiographic molar (irreversible pulpitis or increased abnormal mobility). Third,
examination in the early mixed dentition, from 6 to 7 years of the presence of the second premolar; if this tooth is missing,
age [Nagaveni et al., 2010. Nam et al., 2015; Jariyapongpaiboon it may be recommended to extract the second primary molar
and Nuruzzaman 2021]. As mentioned above, this local condition and allow the first permanent molar to erupt mesially close
is grouped as self-correcting (or “jump type”) or irreversible the resultant space. And fourth, the severity of impaction; as
impacted (or “hold type”), according to different clinical and mentioned before, grades II and IV require active treatment, and
radiographic features [Young, 1957; Kupietzky, 2000; Salbach et sometimes the extraction of the adjacent primary molar. Thus and

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Article Design Aim (s) and Intervention (s) Sample size Follow-up Outcomes
Country Population
Wein-berger, Descriptive To describe the use of a fixed appliance to correct a NA NA - Advantages of this appliance:
1992, (description of bilateral EFUPM: - A transpalatal bar with an acrylic Children in mixed (1) No force is applied in the second molar. (2) Treatment
Canada an orthodontic button; distal extensions (0.036inch-wire) with soldered dentition stage. can be started unilaterally when only one molar is sufficiently
technique) hooks at their ends; bonded buttons and chain elastics. erupted.
- Elastic chains are changed every three weeks. - The (3) Only the occlusal surface of the first permanent molar
treatment active phase to achieve full correction is less needs to be bonded.
than two months. One additional month is necessary
for retention.
Hirayama, Descriptive - To describe the use of a fixed appliance to correct a NA About 6 1- If the ectopic molar is not too subgingival, the elastic
1992, USA (description of bilateral EFUPM: 71/62.3 months separator is preferred. If it is too subgingival, the metal one
an orthodontic is the first choice. - There are three sizes of metal separators:
technique) 0.018, 0.020, and 0.022 round stainless steel wire. -
Separators should be replaced sequentially by smaller ones.
Bjerklin, Prospective - To investigate the prevalence, familial tendency, 2,903 10 years Prevalence of EFUPM: 4.3 % and 21.8 (for cleft children);
1994, cohort and etiological or associated factors of EFUPM (such Children (mean age 8.3 19.8% in siblings. - Main etiological factors were (1) greater
Sweden as cleft lip/palate), and - To determine orthodontic years) with and without mesial angulation, and (2) larger width of the ectopic molar.
treatment effects, through: - Radiographic and clinical cleft lip and/or palate. - Almost all the atypically resorbed second upper primary
assessments. - Biometrics. - Histological evaluation. - - 45 children received molars remained in the dental arch until normal exfoliation.
Statistical analysis. orthodontic treatment - Orthodontic treatment (average time of 9 months) was
with cervical headgear effective for up-righting the EFUPM to good occlusion; 70%
gained sufficient space for the second premolar
Bjerklin, Prospective To evaluate the long-term effects of early orthodontic 91 Children (6.5 o 10.9 to 12.0 - Up-righting of mesially tipped EFUPM was achieved, until
1995, cohort Non- treatment 9.9 years old) with months reaching normal molar occlusion, during treatment - The
Sweden randomized irreversible EFUPM mesial angulation decreased 8-14 degrees during the follow-
clinical trial - 45 treated with cervical up period - All treatment side-effects were eliminated
traction headgear for
8 to 12 months, - 46
untreated controls
Huang, Descriptive - To introduce a clinical aid in placing a brass wire to NA NA Advantages of this technique: (1) It eliminates the need for
1995, USA (description of pass apically to the contact between the primary and Children in mixed impression and laboratory procedures. (2) It reduces the
an orthodontic permanent molars, through a pre-curved angiocatheter dentition stage. difficulty in inserting the brass wire, preventing distortions. (3)
technique) (0.020 to 0.022 gauge). Both components can be prepared easily and quickly
Gungor, Brief literature To present one case of bilateral EFUPM in which a NA Not specified Both primary second molars were extracted before
1998, Turkey review. removable appliance was used for distalization and An 8.3-year-old boy orthodontic treatment.
- Report of two up-righting.The appliance consisted of Adam´s with a - The appliance was used 24 hours a day.
clinical cases of soldered vestibular arch; and two cantilever springs (0.7 - Active treatment: 4 months.
EFUPM mm wire), which ends were mesiodistally flattened, for - A Nance arch was then placed for retention
distal movement. The ends were arched over the gum
to achieve maximum surface contact with the EFUPM
mesial surface; two 0.6 mm wires were placed to guide
and control the movement. The springs were activated
0.5-1 mm every 10 days.
Kupietzky, Brief literature To describe in detail, step-by-step, the brass wire NA Not specified The orthodontic procedure is explained in 10 single steps.
2000, Israel review technique - Brass wire (0.020 or 0.025 (it can also be prepared from
- Clinical a 0.028 coil of wire, by flattening out one end with a How
orthodontic plier).
treatment - The wire is placed between the impacted molar and the
description adjacent second primary molar. Sometimes, local anesthesia
is required.
- Wire tightening every 3-4 weeks

TABLE 1 Characteristics of the included studies (1990-2000).

according to the collected findings, some orthodontic corrective designs mentioned here. However, few systematic or clinical
procedures are economic, fast, and simple, but others are too comparative studies of treatment modalities for EFUPM and
complicated, costly, and need substantial time on the dental their effects on children have been published. According to
chair or require a lot of compliance from the patients. In general, the findings and opinions of the reviewed studies, the “ideal”
treatment modalities are classified into two types [Weinberger, orthodontic technique for EFUPM in children would have the
1992; Hennessy et al., 2012]: interproximal wedging (indicated following desirable requirements.
for minimal impactions) and distal tipping (re-establishment of • Be performed in only one visit.
the correct erupting axis) for severe impactions. Interproximal • Conservative, simple, quick, and cheap fabrication.
wedging includes brass wires, spring-type deimpactors, helical • No impressions or minimal laboratory work.
springs, bonded light wires, and Kesling or elastic separators. Also, • Adequate anchorage; the distal and extrusive movements of
the placement of preformed crowns or bands on the adjacent an EFUPM cause equal and opposite forces, resulting in likely
primary molar, acting as an inclined plane against the erupting unwanted displacements of the supporting primary molars.
EFUPM; even the distal reduction/grinding of the second primary • Preferably without band placement.
molar has been recommended [Kurol, 2002; Mooney et al., 2007; • Minimal adjustment or activation sessions.
Kim et al., 2020]. Whereas distal tipping mainly comprises space • Self-cleansing.
maintainers, regainers, or uprighting techniques. For instance, • Minimal patient cooperation; for example, in cases of using
removable Hawley-type appliances, well-anchored fixed devices extraoral appliances (e.g. cervical headgear).
with accessories (transpalatal arches, distal arms/hooks, or finger • No damage to surrounding soft tissues; for example, the Nance
springs; together with bonded lingual buttons for elastomeric appliance can produce mucosal inflammation or hyperplasia,
chains), original and modified Humphrey’s appliance, Halterman’s and sometimes pain, beneath the acrylic button.
appliance, Croll’s appliance, uni or bilateral reversed band and • In cases of unilateral appliances, it also should be safe,
loop with a distal spur, K-loops, flexible sectional nickel-titanium preventing possible detaching and ingesting/aspirating.
wires with open coil spring, cervical headgear traction [Huang et Although none of the reported treatment modalities in the
al., 1995; Bjerklin, 1994; Nam et al., 2015], and other innovative present scoping review meet all of these requirements, they

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GARROCHO-RANGEL A. ET AL.

Article Design Aim (s) and Intervention (s) Sample size Follow-up Outcomes
Country Population
Barberia- Descriptive cross- - To describe the characteristics and occurrence 509 NA EFUPM prevalence: 4.3%; it was bilaterally in 63.6 % of cases.
Leache, sectional of EFUPM and the association with the abnormal Spanish children (6-9 - 69.4% of cases self-corrected. - Mean impaction on the right
2005, Spain resorption degree of the second primary molar. years old) side: 2.91 mm; on the left side: 1.6 mm. - Spontaneous self-
Clinical oral examination.- Crown measurements correction occurred without arch length loss
in bitewing radiographs and dental casts
Mooney, Descriptive cross- - To investigate the features of EFUPM and its 48 British children (7-11 NA 50% of EFUPM children exhibited two ectopic molars. - 60.7%
2007, UK sectional associations with other dental abnormalities years old): were found to have one or more dental anomalies.
(primary molar infraocclusion, hypodontia, cleft - 28 with EFUPM - Infraocclusion and cleft lip/palate were significantly more
lip/palate, and supernumerary teeth. - 20 controls frequent in the ectopic group than in controls
Nagaveni, Clinical case report clinical case with a left EFUPM with severe NA 3 months Humphrey’s appliance usually takes 3-4 months to complete the
2010, India and description resorption of the second molar. An 8.5-year-old girl of active distalization process; it should be activated every 2-3 weeks.
of an orthodontic - A Humphrey’s appliance (S-shaped loop 0.006- treatment The end of the S wire must properly engage the pit of the
technique inch wire) is incorporated into a fixed Nance’s EFUPM; otherwise, a small shallow cavity is prepared. Before
button arch. its bonding, the clinician must evaluate for proper fit, without
- The loop wire is placed and bonded in a small occlusal interferences. After bonding, the excess cement should
occlusal preparation on the permanent molar for be removed to prevent gingival inflammation
its distalization.

TABLE 2 Characteristics of the included studies (2001-2010).

have been demonstrated to be clinically effective and safe.

Thus, the practitioner can perform a careful selection process
of the best orthodontic approach, after considering the clinical/
radiographic oral features of the case, the level of cooperation,
and the advantages and disadvantages of each strategy. Their
decision should satisfy not only the individual clinical circumstances
or potential sequelae but also the patient´s well-being [Ambriss
et al., 2019].
A representative example of EFUPM treatment is illustrated in
Figure 2. When a permanent tooth is impacted, a multidisciplinary
approach of surgery and orthodontic management is the best
mode to obtain a suitable outcome, in terms of gingival contour,
occlusal plane, and esthetics [Attardo-Parrinello et al., 2020]. So,
clinicians need to possess detailed knowledge and information
of the several issues related to EFUPM, which can help to obtain
an accurate diagnosis and to plan an effective treatment [De FIG. 2 Seven-year- 8-month old boy with the first right upper permanent molar
Mendonça et al., 2021]. Furtherly, they need to be aware of the with severe ectopic eruption, below the distal contour of the second primary
disorder through routine and periodic examinations from 5.5 years molar. There was significant reabsorption of the distal root of the primary
molar with no mobility. A 4-mm elastic separator (Ormco™) was placed
old. Once the proper diagnosis is early established, the treatment
between the molars for 5 months, with monthly replacement. After 6 months,
must be immediately initiated, when the first permanent molar it was possible to correct the ectopic position of the permanent molar, while
has its roots incompletely formed and the second permanent the primary second molar was kept in the mouth, without mobility, sensitivity,
molar is not still ready to erupt [Gutiérrez-Marín, 2021]. or pain. After a year, the permanent first molar remains in a good position and
the primary second molar is asymptomatic (reproduced with permission from
Limitations Gutiérrez-Marín N. Corrective treatment of ectopic eruption of permanent first
molars: Case report. Int J Dent Sci (ODOVTOS) 2021;23:19-26).
The present scoping review carefully followed the
recommendations stated by Arksey and O’Malley [2005] for
screening specific papers and extracting relevant data from them. more chances to limit the extent of malocclusions and to reduce
However, and as in any scoping review, a significant weakness is the possibility of further lengthy, aggressive, and complicated
that a critical methodological quality and the risk of bias of each orthodontic/orthopaedic treatment.
selected article cannot be assessed. Additionally, only clinical
case reports, narrative reviews, and observational studies were Conflict of interest
included; these methodological designs are prone to diverse bias The authors declare that they have no conflicts of interest.
and confounding. We also limited published articles to the English
language articles; so, other language relevant studies could be References
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Dent 2020;21:209-12.
› Barberia-Leache E, Suárez-Clúa MC, Saavedra-Ontiveros D. Ectopic eruption of
Paediatric dentists have at their disposal a variety of corrective the maxillary first permanent molar: Characteristics and occurrence in growing
alternatives available for the successful resolution of EFUPM. children. Angle Orthod 2005;75:610-5.
› Becktor KB, Steiniche K, Kjaer I. Association between ectopic eruption of maxillary
If EFUPM is opportunely detected and treated, there will be canines and first molars. Eur J Orthod 2005;27:186-9.

98 European Journal of Paediatric Dentistry vol. 23/2-2022

 DEVELOPING DENTITION AND OCCLUSION IN PAEDIATRIC DENTISTRY

Article Design Aim (s) and Intervention (s) Sample size Follow- Outcomes
Country Population up
Hennessy, Literature To describe the different management alternatives for EFUPM NA NA Different treatment options for EFUPM:
2012, narrative review using clinical examples (1) Interproximal wedging (brass wires).
Ireland (2) Elastomeric separators. (3) Kesling separator.* (4)
Transpalatal arch with a distal hook. (5) Variations and
modifications of fixed appliances
Salbach, Prevalence / To determine the frequency of eruption disorders in the first 8,041 Kindergarten NAs 102 children exhibited any eruption disturbance of the first
2012, Correlation cross permanent molar region- To establish the risk factors for and school children permanent molar; 88.5% of the maxillary molar was involved,
Germany sectional compromised dental development from frequency and age aged 5-9 years particularly in the bilateral form.- 72.6% presented at least
correlates one additional malocclusion (e.g. crowding and lateral
malocclusion
Thakur, Clinical case To illustrate a new simple distal tipping technique for the NA 1 year (6 Advantages of the technique:
2012, report and correction of an EFUPM - A light cure composite dimple with a An 8-year-old girl weeks (1) It does not require bands or any laboratory work.
India description of tunnel-like opening on the mesial side is bonded to the buccal of active (2) It does not need any type of activation or adjustment.
an orthodontic surface of the impacted molar - A nickel-titanium archwire treat- (3) It is a simple, quick, no injurious, and self-cleaning
technique (0.016) segment is bonded to the buccal of the first primary ment) appliance.
molar.
- The distal end of the wire is forced into the tunnel, creating
thus a “loop” that activates the wire
Gon- Clinical case - To report the ectopic eruption of an EFUPM with severe root NA 2 years The second primary molar did not exhibit any signs or
çalvez, report and resorption of the adjacent primary molar. A 9-year-old girl symptoms of pulp damage; so, it was decided to retain it until
2012, description of A twist brass wire between both molars, activated at days 0, normal exfoliation - The orthodontic technique is a low-cost
Brazil an orthodontic 15, and 30 approach and the active treatment is short (less than a month
technique. and a half in this case).
Muce- Comparative - To analyze the prevalence and distribution of EFUPM - To 1317 Children aged NA Prevalence of EFUPM: 2.5%.
dero, (and investigate the association of dental characteristics, maxillary 7-10 years, scheduled - In the experimental group:
2015, randomized) skeletal features, and tooth crowding - Five dental or skeletal for orthodontic - M-D crown widths, ATID, PTID, and dental crowding were
Italy cross-sectional parameters were measured: (1) Mesio-distal (M-D) crown width treatment: significantly greater.
design of the second upper primary molar. (2) Mesio-distal (M-D) crown - 265 as controls. - A-PML was significantly smaller.
width of the first permanent molar. (3) Maxillary and mandibular - 1052 in the - Two subjects exhibited an association with maxillary tooth
crowding. (4) Maxillary arch length (A-PML). (5) Anterior and experimental group. anomalies (agenesis and microdontia).
posterior maxillomandibular transverse skeletal relationships From these, 26 were - EFUPM can be considered as a risk factor for maxillary arch
(ATID and PTID). diagnosed with one or constriction and severe tooth crowding
two EFUPM (reversible
or irreversible)
Nam, Clinical case To report a correction of an EFUPM using a K-loop, with NA - This is a simple, comfortable, and easy technique - Through
2015, report and severe root resorption of the second primary molar.- K-loop A 7-year-old boy its two loops, the K-loop exerts light and continuous three-
South description of is a double-loop rectangular (0.016 x 0.022) TMA segment dimensional forces - Active treatment: 4 to 8 weeks
Korea an orthodontic wire - It is ligated to the banded second primary molar (with a
technique welded single tube) and then bonded to the occlusal surface
of the ectopic molar - The wire is mesially prolonged up to the
first primary molar and canine and also bonded to their buccal
surfaces for increased retention and anchorage
Hazne- Clinical case To describe the orthodontic treatment for a child with bilateral NA 6 The modified Hawley appliance is indicated in cases where:
daroğlu, report and EFUPM. An eight-year-old girl months (1) Permanent first molars are locked on the distal end of the
2016, description of - The treatment included two steps: adjacent primary molar. (2) When the patient is unwilling to
Turkey an orthodontic (1) Stripping the distal surfaces (about 2 mm) of both primary use a more complicated appliance - The appliance is safe and
technique second molars with carbide burs, under local anesthesia. easy to use but child compliance is essential.
(2) Placement of a modified Hawley appliance with C-shaped
clasps at the distal ends; these clasps were engaging the
mesiobuccal undercuts of both EFUPM and activated for
distalization
Romano, A two clinical To describe two cases of EFUPM treated with a modified Nance NA About 3 In both cases, the primary second molars could be maintained
2016, cases report and Palatal Arch placed on the primary second molars, for light distal Two children: 8.2 and months in place after treatment - The elastic chain should be changed
Brazil a description of movements and space recovery - The arch possesses a posterior 9.0-year-old every 15 days - Advantages of the appliance: (1) It can control
an orthodontic hook (a 0.7 mm wire segment soldered to the band) for elastic the distal and occlusal movements of the permanent molar.
technique chains. This wire is prolonged mesially and bonded to the buccal (2) No dependency on the patient’s cooperation. (3) It does
surfaces of the primary first molar and canine for additional not affect esthetics - Disadvantages: (1) It may hinder oral
anchorage - An orthodontic button is bonded to the occlusal hygiene
surface of the impacted molar

TABLE 3A Characteristics of the included studies (2011-2021).

› Gungor HC, Altay N. Ectopic eruption of maxillary first permanent molars:

› Bjerklin K. Ectopic eruption of the maxillary first permanent molar. An Treatment options and report of two cases. J Cin Pediatr Dent 1998;22:211-6.
epidemiological, familial, aetiological and longitudinal clinical study. Swed Dent › Gutiérrez-Marín N. Corrective treatment of ectopic eruption of permanent first
J 1994;100(Suppl):1-16. molars: Case report. Int J Dent Sci (ODOVTOS) 2021;23:19-26. DOI 10.15517/
› Bruna del Cojo M, Gallardo-López NE, Mourelle-Martínez MR, De Nova-García IJDS.2020.40778
MJ. Time and sequence of eruption of permanent teeth in Spanish children. Eur J › Güven Y. Prevalence of ectopic eruption of first permanent molars in a Turkish
Paediatr Dent 2013;14:101-3. population. Eur Oral Res 2018;52:1-5.
› Cerda J, Villarroel L. Evaluation of the interobserver concordance in pediatric › Hafiz ZZ. Ectopic eruption of the maxillary first permanent molar: A review and case
research: the Kappa Coefficient. Rev Chil Pediatr 2008;79: 54-8. report. J Dent Health Oral Disord Ther 2018;9:154-8.
› Chapman MH. First upper permanent molars partially impacted against second › Harrison LM Jr, Michal BC. Treatment of ectopically erupting permanent molars.
deciduous molars. Int J Oral Surg 1923;9:339-45. Dent Clin North Am 1984;28:57-67.
› Da Silva Filho OG, De Albuquerque MV, Kurol J. Ectopic eruption of maxillary first › Haznedaroğlu E, Mentez A. A simplified method for eruption of the ectopic molars:
permanent molars in children with cleft lip. Angle Orthod 1996;66:373-80. A case report. J Dent App 2016;3:312-4.
› Dabbagh B, Sigal MJ, Tompson BD, Titley K, Andrews P. Ectopic eruption of the › Helm A, Martin-Vacas A, Molinero-Mourelle P, Caleya AM, Gallardo NE, Mourelle-
permanent maxillary first molar: Predictive factors for irreversible outcome. Pediatr Martínez MR. Ectopic eruption of maxillary first permanent molars: Preliminary
Dent 2017;39:215-8. results of prevalence and dentoskeletal characteristics in Spanish paediatric
› De Mendonça MR, Aparecido-Cuoghi O, Veloso de Linhares AP. Evaluation of the population. Children 2021;8,479-86.
mesio-distal positioning of the maxillary first permanent molar in individuals with › Hennessy J, Al-Awdhi EA, Dwyer LO, Leth R. Treatment of ectopic first permanent
ectopic eruption. Res Soc Develop 2021;10:1-6. molar teeth. Dental Update 2012;39:656-8.
› Duncan WK, Ashrafi MH. Ectopic eruption of mandibular first permanent molar. J › Hirayama K, Chow MH. Correcting ectopic first permanent molars with metal or
Am Dent Assoc 1981;102:651-4. elastic separators. Pediatr Dent 1992;14:342-4.
› Gonçalvez RA, Ardenghi-Vargas IA, Castilhos-Ruschel H. Clinical management of › Huang WJ, Childers NK. Clinical aid in placing brass wires to treat ectopically
the ectopic eruption of a maxillary first permanent molar – Case report. Stomatos erupting permanent first molars. Ped Dent 1995;17:122-3.
2012;18:16-25. › Jariyapongpaiboon S, Nuruzzaman K. Management of ectopic eruption of maxillary

European Journal of Paediatric Dentistry vol. 23/2-2022 99

GARROCHO-RANGEL A. ET AL.

Article Design Aim (s) and Intervention (s) Sample size Follow- Outcomes
Country Population up
Dabbagh, Retrospective To determine the rate of self-correction of EFUPM and 65 Children with 2 years - 45 (1%) patients self-corrected; one-third of them occurred
2017, cohort the possible clinical factors to predict an irreversible molar a radiographic at 9 years old - 18 (28%) patients increased molar impaction -
Canada impaction. - A cohort of patients treated in a private dental diagnosis of EFUPM Correlated predictive factors of irreversible ectopic eruption: (1)
office between 2000 and 2012. - The patients had no still and followed-up Increased magnitude of impaction. (2) Degree of primary molar
received any type of orthodontic treatment - Predictive factors until the outcome of resorption. (3) Severe lock. (4) Bilateral occurrence.
studied: gender, age at diagnosis, age at the outcome of the condition or for
EFUPM, unilateral or bilateral occurrence, primary occlusion a minimum of two
characteristics, primary molar occlusion, primary canine years
occlusion, and Baume arch type.
Güven, A radiographic To investigate the prevalence and features of EFUPM in a 7649 Patients NA 102 children exhibited any eruption disturbance of the first
2018, cross-sectional Turkish child sample (2010-2013). - Performed on panoramic (5-11 years old) permanent molar; 88.5% of the maxillary molar was involved,
Turkey study radiographs - Studied features: age, gender, number of EFUPM, with erupted first particularly in the bilateral form.- 72.6% presented at least one
unilateral/bilateral occurrence, resorption degree of the adjacent permanent molars additional malocclusion (e.g. crowding and lateral malocclusion
primary molar, and other dental anomalies
Hafiz, Brief literature To present a case of an irreversible, EFUPM treated with the NA 1.5 The treatment preserved the available space for the correct
2018, Saudi review - extraction of the adjacent primary molar due to significant root A 7.5-year-old girl years placement of the premolars and guided the eruption path of the
Arabia Clinical resorption and subsequent pulp involvement - A reverse band ectopic permanent molar.
orthodontic and loop space maintainer between the first primary molar and
treatment the mesial aspect of the EFUPM - The distal end of the wire is
description and forced into the tunnel, creating thus a “loop” that activates
case report. the wire
Ambriss, Clinical To describe an irreversible bilateral EFUPM with severe root NA 6 Active treatment: 6-8 weeks - The transpalatal arch can
2019, orthodontic resorption of the second primary molar - A modified Croll’s An 8-year-old boy months preserve the leeway space - Disadvantages of this appliance:
Lebanon treatment appliance was employed to perform distal tipping of both locked (1) It requires an extended chairside and laboratory time. (2)
description and molars - This is a fixed appliance banded to the first primary Good isolation for adequate button bonding can be difficult.(3)
case report molars; with distal extensions and hooks (0.036 wire), placed Frequent changes of elastics are needed
2-3 mm behind the permanent molars, for elastic chains - It
also comprises a transpalatal with an acrylic button - Two
orthodontic buttons are bonded to the mesio-occlusal surface of
both permanent molars - The elastic chains are shortened every
two weeks.
Kim, 2020, Clinical - To present a novel orthodontic approach for unlocking NA 4 Active treatment: 2 months - The appliance worked, although
South orthodontic EFUPM. - A 0.012-inch nickel-titanium wire is compressed and An 8-year-old boy months the distal of the primary molar was considerably resorbed - This
Korea/USA treatment bent gingivally before its bonding to the permanent and second technique is simple and inexpensive, exerts light continuous
description and primary molars. Also, the second primary molar is splinted to the forces, and does not require laboratory procedures - It is
case report primary first molar and canine with a bonded passive 0.0195- indicated for mild-to-moderate impactions
inch multi-stranded wire, to reinforce the anchorage

Jariya- Clinical To present a case with unilateral EFUPM and severe root NA 1 year - The elastomeric chain exerted a force of 50 g; it was
pongpai- orthodontic resorption of the adjacent molar, treated with the Halterman A 7.8-year-old boy changed every week - Active treatment: 2 weeks - A possible
boon, 2021, treatment appliance with a transpalatal arch - The transpalatal arch was disadvantage of the original unilateral Halterman appliance is
Thailand description and
cemented in the second primary molars; a distally extended wire the loss of anchorage that causes mobility of the second primary
case report. arm with a hook at the end is soldered to the buccal aspect molar; the addition of the transpalatal arch avoids this
of the band - The hook holds an elastomeric C-chain for distal
traction and tipping of the impacted molar - A metal lingual
button is bonded on the occlusal surface of the EFUPM
Gutiérrez- Clinical - To determine the prevalence of EFUPM in children. 322 Children aged NA Prevalence of EFUPM: 8.7%; bilateral presentation was
Marín, orthodontic - To evaluate the possible association with diverse dentoskeletal 6-9 years significantly more prevalent than unilateral - The highest
2021, Costa treatment characteristics. prevalence was in the 7-year-old group - Main radiographic/
Rica description and - The used digital panoramic radiographs and lateral skull cephalometric features in the ectopic group: (1) Shortened
case report. teleradiograph for Rickett’s cephalometric analysis. anterior cranial base. (2) Maxillary retroposition. (3) Distal
position of the first permanent molar regarding the pterygoid
vertical plane. (4) Decreased palatal plane. (5) Distal position of
the upper incisors
De Comparative To evaluate the mesial-distal position of the EFUPM, through 24 Children aged 6-8 NA EFUPM can occur regardless of the skeletal pattern - The control
Mendonça, cross-sectional panoramic and lateral cephalometric radiographs - Different years: group showed two significantly increased angular measurements:
2021, Brazil anatomical tracings, one linear (mm), and eight angular 12 with EFUPM 6mx to palatal plane and 6mx to infraorbital plane; also, there is
measurements were performed and then compared between 12 controls no direct relationship with the anteroposterior relationship of the
the two groups apical bases - The ectopic group exhibited a significantly reduced
mesial angulation, which represents a lack of space for the
eruption of the first permanent molar

TABLE 3B Characteristics of the included studies (2011-2021).

first molar: A case report. J Dept Med Ser 2021;46:288-92. Orthod 2015;45:190-7.
› Kim WS, Kim Y, Cho JH, Oh H, Hwang HS. Unlocking ectopically erupting permanent › Nam OH, Ahn HJ, Kim MS, Park JH. Treatment of ectopic permanent maxillary first
first molars using light wires. J Am Dent Assoc 2020;151:857-62. molar using a K-loop. J Clin Pediatr Dent 2015;39:387-91.
› Kimmel NA. Ectopic eruption of maxillary first permanent molars in different areas › Nagaveni NB, Radhika NB. Interceptive orthodontic correction of ectopically
of the United States. ASDC J Dent Child 1982;49:294-9. erupting permanent maxillary first molar. A case report. Virtual J Orthod 2010.
› Kupietzky A. Correction of ectopic eruption of permanent molars utilizing the brass Available online at: http://www.vjo.it/wp-content/uploads/2010/11/inter10.pdf.
wire technique. Pediatr Dent 2000;22:408-12. › Romano FL, Arid J, Mussolino de Quiroz A, Bezerra-Segato RA, Nelson-Filho P. A
› Kurol J. Early treatment of tooth-eruption disturbances. Am J Orthod Dentofacial modified Nance palatal arch for the treatment of ectopically erupting permanent
Orthop 2002;121:588-91. first molars. J Dent Child 2016;83:161-6.
› Levac D, Colquhoun H, O'Brien KK. Scoping studies: Advancing the methodology. › Salbach A, Schremmer B, Grabowski R, Stahl-de Castrillon F. Correlation between
Implement Sci 2010;5:69-77. frequency of ectopic disorders for first permanent molars and the occurrence of
› Marra PM, Nucci L, Itro A, Santoro R, Marra A, Perillo L, Grassia V. Prevalence malocclusions in early mixed dentition. J Orofac Orthop 2012;73:298-306.
of retained/transmigrated permanent and persistence of primary teeth associated › Thakur S, Thakur N, Gupta S. Innovative chairside for the correction of ectopically
with odontomas in young children. Eur J Paediatr Dent 2021;22:215-18. erupting permanent first molar. Dent Hypotheses 2012;3:115-7.
› Mitsuhata C, Konishi Y, Kaihara Y, Kozai K. Treatment of ectopic eruption of › Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA
permanent mandibular first molars with innovative dental appliances. Eur J Paediatr Extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern
Dent 2014;15(2 Suppl):181-3. Med 2018;169:467-73.
› Mooney GC, Morgan AG, Rodd HD, North S. Ectopic eruption of first permanent › Tripathi T, Singh N, Rai P, Khanna N. Separation and pain perception of Elastomeric,
molars: A preliminary report of presenting features and associations. Eur Arch Kesling and Kansal separators. Dental Press J Orthod 2019;24:42-8.
Paediatr Dent 2007;8:153-7. › Weinberger SJ. Correction of bilateral ectopic eruption of first permanent molars
› Mubeen S, Seehra J. Failure of eruption of first permanent molar teeth: A diagnostic using a fixed appliance. Ped Dent 1992;14:382-3.
challenge. J Orthod 2018;45:129-34. › Yaseen SM, Naik S, Uloopi KS. Ectopic eruption – A review and case report.
› Mucedero M, Rozzi M, Cardoni G, Ricchiuti MS, Cozza P. Dentoskeletal features in Contemp Clin Dent 2011;2:3-7.
individuals with ectopic eruption of the permanent maxillary first molar. Korean J › Young DH. Ectopic eruption of permanent first molar. J Dent Child. 1957;24:153-62.

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