Volume 8 • 2021 • Issue 6

moderate cases. “But a stainless steel crown placed at a young age will need to be replaced and there is a potential for future endodontic treatment, so a thorough informed consent discussion is necessary.” If hypomineralization is severe, restoring the tooth may not be possible and extraction might be necessary. In those situations, we want to treat as quickly as possible. Figure 1: Panoramic radiograph showing a good candidate for extraction of permanent first molars to maximize the chance of mesial migration and eruption. Note that the permanent second molars do not yet have furcation or root development. Figure 2: Molar with mild hypomineralization. Figure 3: Molar with moderate to severe hypomineralization with post-eruptive breakdown. Watch Dr. MacLellan’s full conversation on CDA Oasis: bit.ly/3BdoZ9s Dr. MacLellan says she appreciates being able to consult with an orthodontist during treatment planning who will provide orthodontic treatment later if the 7’s don’t erupt where she hopes they will. “It’s also helpful in making sure that the patient’s parents or caregivers understand clearly all of the options and their possible outcomes,” she says. When extractions are necessary, Dr. MacLellan prefers to provide treatment all at once under general anesthetic. “It isn’t that the extractions themselves are difficult; the teeth have immature apices within the bone,” she says. “But our patients are young children and we don’t want them to have a negative dental experience, because they will definitely remember it.” If hypomineralization is severe, restoring the tooth may not be possible and extraction might be necessary. “In those situations, we want to treat as quickly as possible. If we extract the permanent first molars prior to furcation development of the permanent second molars, there is a strong chance that the second molars will erupt mesially into the position of the extracted first molars,” says Dr. MacLellan. A panoramic radiograph is extremely helpful and recommended to determine the treatment plan. “With maxillary molars, if we act in time, the 7’s often erupt nicely in the place of the 6’s,” she says. “Mandibular molars don’t slide forward quite as easily and more often we see some tipping.” The crowns of a child’s first four molars may not be mineralized at the same time. “Often we see different levels of hypomineralization in each molar,” Dr. MacLellan says. “Some severe, others mild.” Consulting an orthodontist is helpful to helpmake decisions about a treatment plan if some, but not all, molars are restorable. “Do we do balancing extractions, which includes extracting the contralateral tooth? Or compensating extractions where we extract the opposing tooth?” In many cases, however, all four molars are unrestorable. 37 Issue 6 | 2021 | SupportingYour Practice