This paper aims to update the reader on how minimally invasive (MI) techniques may be used to improve the longevity of carious or defective/compromised first permanent molars (cFPMs) in young children. Clinical and radiographic diagnosis and the prognostic factors will be discussed in view of recent studies showing that these teeth can be kept in function and have an improved prognosis as the child gets older. Clinical protocols for their care, based on the latest evidence and techniques for MI restorations, together with longevity information of possible restorative options, are described. This paper also explores the rationale behind enforced extractions and related morbidity, in order to help oral healthcare practitioners to determine the optimal management of these key elements in the dentition for the benefit of the patients.