Early Loss of E's

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Early Loss of E's
Straight Talk draws its cases and discussions from the Orthotown message boards. Written by the editorial team with the assistance of AI, each article showcases how orthodontists tackle unusual and challenging scenarios.
A 9-year-old female presented with severe mesial drift of the upper first molars after the referring dentist extracted both upper E’s to facilitate eruption of the sixes. The result was significant space loss in the upper arch and a palatally ectopic upper right canine, leaving the treating orthodontist weighing how aggressively to intervene in a young mixed dentition patient. The upper D’s remained intact and functioning as space maintainers, with the upper fours close to erupting, but accommodating the permanent canines looked like a real challenge (Figs. 1–3).

The original poster had already ruled out distalizing the sixes and was leaning toward extracting the upper right C to guide the ectopic canine, possibly placing a maxillary 2x4 with a moment on the upper right lateral. The open questions: whether to also extract the D’s, and how much intervention this case actually needed right now.
Early Loss of E's
Fig. 1
Early Loss of E's
Fig. 2
Early Loss of E's
Fig. 3

Several contributors favored getting ahead of the problem. One plan called for extracting both upper C’s and D’s and placing a 2x4 with tip-back and toe-in bends mesial to the sixes, using Australian wire for its resilience and sustained force delivery. With this degree of space loss, a single longer phase of early treatment made more sense than watching and waiting only to chase the same problems later with fewer options. If tip-back mechanics fell short, temporary anchorage devices could supplement the effort. The importance of second-order bends to manage root position on the upper twos and sixes, keeping root paths clear of the erupting canines, was also noted.

The conversation turned briefly to Australian wire itself. Those who used it regularly pointed to its advantages for 2x4 mechanics, particularly its resilience for bite opening, intrusion, and sustained force applications where stainless steel would fatigue or lose its shape. The wire was originally developed for the Begg technique, built to deliver reliable forces over longer appointment intervals.

On the other side, one Townie pushed for a more phased plan: Extract the upper right C and D’s now, take out premolars when accessible, then start comprehensive treatment once the second premolars were in. Let the developing dentition do some of the work. Avoid early fixed appliances. Treat the case as simply as possible once the permanent teeth showed up. Headgear was floated as an option for families opposed to extractions, though the compliance ask was steep.

The original poster discussed both directions with the patient’s mother. She strongly preferred the simpler, staged approach.

Cases like this put a familiar pressure on mixed dentition treatment planning. When premature primary tooth loss creates real space problems early, the clinician has to decide how much complexity to introduce in a young patient. Early mechanics and possible anchorage devices offer a shot at recovering space and guiding eruption, but they ask more of the patient and the practice. A staged extraction sequence cuts chair time and mechanical demands, but it accepts that some space management will come through removing permanent teeth rather than reclaiming what was lost.

When severe mesial drift has already compromised the upper arch in a 9-year-old, does early mechanical intervention to recover that space justify the added complexity, or does a simplified extraction sequence get to the same place with less burden on a young patient and her family? 

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