Poor prognosis permanent teeth – detailed

➤ Severe caries of permanent teeth

• Severe caries of teeth in the developing dentition is a significant problem as early extractions of these teeth may not always lead to uncomplicated development.
• Ideally these teeth should be restored until an orthodontic assessment can be performed.
• In some instances, early extraction of first permanent molars at the correct time can lead to complete space closure. The presence of third molars must be confirmed prior to the extraction (Cobourne et al. 2014).

➤ Pulp or periodontal pathology

• Similar to severe caries, these teeth are often poor in prognosis and their extractions may complicate occlusal development.
• Ideally, an orthodontic assessment of the patient is required before extractions are performed.

➤ Developmental defects

• Developmental defects like molar-incisor hypomineralisation or dens invaginatus may have poor prognosis due to the severity of their condition or pulpitis (Weerheijm et al. 2014, Gallacher et al. 2016).
• Ideally, an orthodontic assessment of the patient is required before extractions are performed.

➤ A class I malocclusion with normal overbite and nil crowding

• If the child has a deep bite or severe Class II or III malocclusion, it is often best to maintain the poor prognosis tooth for as long as possible until orthodontic treatment can be initiated (Cobourne et al. 2014, Royal College of Surgeons 2006).
• Early extractions of molars in a deep bite patient will often lead to a worsening of the deep bite (Proffit et al. 2007).
• In a Class II or III patient with severe crowding, the early extractions of permanent teeth can lead to loss of space which is critical during orthodontic treatment later on (Cobourne et al. 2014).

➤ Extractions at the correct times

• Extractions of first permanent molars are best performed when the second permanent molars have < 1/3 root formation (usually at the ages of 8 to 10 years) and the confirmation of third molar development can be performed (Cobourne et al. 2014).
• Premolar extractions should be delayed until an orthodontist assessment can be performed as the spacing may be critical for orthodontic treatment.
• Balancing and compensatory extractions may be required.

➤ Severe caries of permanent teeth

• Severe caries in the full permanent dentition may require extractions of these teeth.
• Adjacent teeth drifting and opposing teeth supra-erupting are considerations which need to be assessed prior to the extractions.
• Ideally, extractions should be delayed until just prior to orthodontic treatment so that effective anchorage and space management can be performed (Cobourne et al. 2014).

➤ Pulp or periodontal pathology

• Pulp or periodontal pathology often lead to poor prognosis teeth.
• Their management is similar to the poor prognosis teeth with caries.

➤ Poor restorative longevity

• Teeth with deep or poor prognosis restorations can be a significant burden to the patient with long term likely pulpal disease.
• Their management is similar to the poor prognosis teeth with caries.

➤ Developmental defects

• Developmental defects like molar-incisor hypomineralisation or dens invaginatus may have poor prognosis due to the severity of their condition or pulpitis (Weerheijm et al. 2014, Gallacher et al. 2016).
• Their management is similar to the poor prognosis teeth with caries.