Third molars: A review

Samir E. Bishara, B.D.S., D.D.S., D.Ottho., MS.,* and

Dr. Bishara
George Andreasen, D.D.S., M.S.D.*
Iowa City, Iowa

The influence of the third molars on the alignment of the anterior dentition is controversial. There is no conclusive
evidence to indict the third molars as being the major etiologic factor in the posttreatment changes in incisor
alignment. Various aspects related to the management of thd molars are discussed, and specific situations in
which third molar extractions are contraindicated are illustrated.

Key words: Third molars, review, posttreatment changes, prediction, lower anterior crowding

T
he role of mandibular third molars in the
relapse of lower anterior crowding following the cessa-
ence of third molars and orthodontic and periodontic
problems.
tion of retention in orthodontically treated patients has
provoked much speculation in the dental literature. In THIRD MOLAR AGENESIS
Prevalence
1859 Robinson’ wrote: “The dens sapientiae is fre-
quently the immediate cause of irregularity of the teeth Third molars are the teeth that are most often con-
by the pressure exerted toward the anterior part of the genitally missing. Estimates of the percentage of per-
mouth. ” Since that time a large number of investiga- sons with one or more third molars missing range from
tors have discussed in detail the various aspects of third 9 percent to 20 percent. There are more females than
molar development and its effect on the lower arch.*-‘* males with congenital absence of third molars; a 3 : 2
The purpose of this article is to discuss some of the ratio exists, according to Richardson.14
major considerations and the present controversy sur- The average age for third molar crypt formation is 7
rounding third molars as they relate to orthodontics. It years. Its earliest occurrence was reported at 5 years
should not be viewed as an overview of all the available and its latest at 15 years.15-16
literature on the subject. According to Banks, ” it is most common for two
third molars to be missing, followed by one, four, and
THE PRESENT CONTROVERSY three. Nanda18 found the frequency to be one, two,
As recently as 1971, in a survey of more than 600 three, and four.
orthodontists and 700 oral surgeons, Laskin13 found Richardson14 indicated that if third molar formation
that 65 percent were of the opinion that third molars is delayed beyond the age of 10 years, the possibility of
sometimes produce crowding of the mandibular an- all four third molars developing is reduced by about 50
terior teeth. percent. She found no significant differences in the size
As a result of such opinions as Laskin reported, the of early- and late-developing third molars. Further-
removal versus the preservation of third molars became more, she noted that the size of the rest of the teeth did
the subject of contention in dental circles. The different not significantly differ between persons with and with-
views range between the extremes expressed in two out congenitally missing third molars.
different statements: (1) Third molars should be re-
THIRD MOLAR IMPACTIONS
moved, even on a prophylactic basis, because they
frequently are associated with future orthodontic and Dachi and Howellls examined a series of 3,874
periodontic complications as well as other patho- full-mouth radiographs. From their study, several find-
logic conditions. (2) There is no scientific evidence ings concerning impacted teeth could be noted: (1) The
of a cause-and-effect relationship between the pres- incidence of patients with at least one impacted tooth
was 16.7 percent. (2) The teeth most often impacted, in
order of frequency, were the maxillary third molars, the
From the Department of Orthodontics, University of Iowa College of Den-
mandibular third molars, the maxillary canines, and the
tishy
*Professor of Orthodontics. mandibular premolars. Of the total number of third mo-

0002-9416/83/020131+07$00.70/0 0 1983 The C. V. Mosby Co. 131

 Am. J. Orthod.
132 Bishara and Andreasen February 1983

THIRD MOLARS AND CROWDING

lars present, 29.9 percent of the maxillary third molars
Studies relating third molars to crowding
and 17.5 percent of the mandibular third molars were
impacted. Two studies are going to be reviewed since they
No sex differences were noted in the impaction of have been widely quoted in the literature as evidence of
third molars, and there was no significant predisposi- a cause-and-effect relationship between third molars
tion toward bilateral or unilateral impaction. and crowding.
Among maxillary third molars, 15 percent had Bergstrom and Jensen,23 in a study designed to de-
radiolucencies and 2.1 percent of these were diagnosed termine the extent to which third molars are responsible
as having dentigerous cysts. Thirty-seven percent of the for secondary tooth crowding, cross-sectionally exam-
mandibular third molars had radiolucencies surround- ined sixty dental students, of whom thirty had unilateral
ing their crowns, and 3.8 percent of these were diag- agenesis of the upper third molars, twenty-seven had
nosed as having dentigerous cysts. agenesis of the lower third molars, and three had one
third molar absent or lost. From plaster casts they per-
FACTORS WHICH CAN INFLUENCE THE SPACE formed left-to-right comparisons of the space condi-
AVAILABLE FOR THIRD MOLARS tions on both sides of each arch and the mesiodistal
BjSrk and colleagueszO examined 243 cases to esti- asymmetries of the lateral arch segments. They also
mate the relationship between the space available for measured midline displacement.
mandibular third molars and their impaction. They in- The results suggested that there was more crowding
dicated that, in cases of impaction, the alveolar arch in the quadrant with a third molar present than in the
space distal to the second molar is considerably reduced quadrant with a third molar missing. There was a me-
in 90 percent of the cases. sial displacement of the lateral dental segments on the
BjSrk identified three skeletal factors that are sepa- side with the third molar in the mandibular arch, but not
rately influencing third molar impaction: (1) reduced in the maxilla. They found no evidence of a correlation
mandibular length, measured as the distance from the between age and the degree of crowding or mesial tooth
chin point to the condylar head; (2) vertical direction of displacement. They indicated that the presence of a
condylar growth as indicated by the mandibular base third molar did not seem to effect the midline.
angle; and (3) backward-directed eruption of the man- Bergstrom and Jensen23 concluded that the pres-
dibular dentition determined by the degree of alveolar ence of a third molar appeared to exert some influence
prognathy of the lower jaw. on the development of the dental arch, but not to the
The rank order of the three skeletal developmen- extent that would justify either the removal of the tooth
tal factors in third molar impaction are vertical direc- germ or the extraction of the third molars other than in
tion of condylar growth, small mandibular length, and exceptional instances.
backward-directed eruption of the dentition. The com- In another study, Vego24 longitudinally examined
bination of the three skeletal factors of mandibular de- forty patients with lower third molars present and
velopment with retarded maturation of third molars ac- twenty-five patients with lower third molars congeni-
counted for 80 percent of the cases with bilateral third tally absent. None of the selected patients had under-
molar impaction. gone orthodontic treatment. Each individual arch was
Olive and Basford*l found that the ratio between the measured for the amount of crowding at two time inter-
inter-second molar width and the inter-ramal width, as vals. The first measurement was taken after eruption of
measured from posteroanterior cephalograms, is an im- the second molars at an average age of 13 years, while
portant factor in the identification of possible impaction the second measurement was taken at an average age of
of mandibular third molars. 19 years. Crowding was defined as loss of arch perime-
Bjiirkzo estimates that impaction of the mandibular ter. This is manifested either as closure of space or by
third molars may occur in every fourth or fifth adult slipping of contacts, resulting in rotation and/or ad-
male in the Scandinavian dental population. verse movement of teeth.
The prospects of estimating the risk of impaction Vego found that in all sixty-five cases the arch
from the degree of inclination of third molars at the perimeter showed a decrease from the first to the sec-
preadolescent stage does not appear to be promising, ond casts. This was expressed as an increase in the
according to Bjork.*O severity of rotated or malaligned teeth. The decrease in
On the other hand, Richardson** found that the orig- arch perimeter was less noticeable in persons without
inal angulation of the occlusal surface of the third molar lower third molars.
to the mandibular plane is significantly lower in those Vego concluded that the erupting lower third molar
persons in whom third molars have erupted early. can exert a force on the approximating teeth and indi-
Volume 83 Third molars 133
Number 2

cated that there are multiple factors involved in the

crowding of the arch.

Studies indicating a lack of correlation between

mandibular third molars and post-retention
crowding
Kaplanz5 in 1974, investigated whether mandibular
third molars have a significant influence on posttreat-
ment changes in the mandibular dental arch and spe-
cifically on anterior crowding relapse. The research ma-
terial consisted of pretreatment, posttreatment, and 10
years postretention study models and lateral cephalo-
grams of seventy-five orthodontically treated patients.
The sample was divided into three groups: The first
Fig. 1. Location of Xi point.
group consisted of thirty persons with both third molars
erupted to the occlusal plane, in good alignment buc-
colingually and of normal size and form. The second As one might expect, however, there is a dichot-
group consisted of twenty persons with bilaterally im- omy of opinion regarding both the need and the conse-
pacted third molars. All patients were candidates for quences of early enucleation. Those opposed to the
surgical removal of the third molars on the basis of procedure explain that by the age of 35 one out of five
postretention periapical radiographs. The third group Americans is wearing a full upper denture and has lost
consisted of twenty-five patients with bilateral agenesis many lower teeth as well. In addition, during adoles-
of the mandibular third molars. cence some persons develop severe dental caries which
The following variables were measured on the can result in the loss of the first or second molars.
study models: (1) arch length, (2) intermolar width, (3) Furthermore, those who oppose prophylactic extraction
intercanine width, (4) lower anterior crowding, and (5) of third molars point to the risk of complications during
lower anterior rotations. The cephalometric analysis surgery.27
included measurements of the following variables: (1) On the other side of the dichotomy are the propo-
angle of lower incisor to mandibular plane, (2) an- nents of removal of third molars on a prophylactic
teroposterior position of the lower incisor along the x basis. They believe that many young adults between
axis, (3) anteroposterior position of the lower first the ages of 18 and 22 experience problems with their
molar along the x axis, and (4) mandibular length from third molars and that at later ages pathologic changes
articulare to pogonion. often occur.** They believe that orthodontic treatment
Kaplan’s data indicated that some degree of lower is enhanced, particularly when third molar extraction
anterior crowding relapse occurred in the majority of creates space for lower incisors or when, during an-
cases. When the three groups (with third molars chorage preparation, distal movement of the first and
erupted, impacted, and congenitally missing) were second molars may be required. Such movement might
compared, however, there were no significant differ- limit the space available for the second molars and
ences in any of the parameters examined, whether pre- might result in severe impaction of the third molars.
molars were extracted or not. Kaplan concluded that Ricketts and his co-authors** further indicated that re-
the presence of third molars does not produce a greater moval of the third molar bud at the age of 7 to 10 years
degree of lower anterior crowding and/or rotational re- is surprisingly simple and relatively atraumatic. This
lapse after cessation of retention. According to Kaplan, contrasts to the difficulty of extraction of deeply im-
the theory that third molars exert pressure on the teeth pacted teeth in adults.
mesial to them could not be substantiated.
Prediction of third molar behavior
OTHER FACTORS RELATED TO THIRD MOLAR Ricketts and associates28examined 200 skulls with
EXTRACTION complete dentitions and determined the relationship of
Enucleation of third molars and their prophylactic erupted mandibular third molars to the anatomy of the
extraction ramus. They suggested the use of cephalometric head
Third molar enucleation at the age of 8 years has films, taken as early as 8 or 9 years of age, for predict-
been practiced in England since 1936 by Henry and ing the dimension, at adulthood, of the distance from
Morant .26 Xi point to the distal aspect of the second molar along
 Am. J. Orrhod.
134 Bishara and Andreasen
February 1983

Fig. 2. Patient with congenitally missing lower right second premolar. Treatment plan is to protract lower
right first molar to a Class III relationship. Note the occlusion of the second molars.

the occlusal plane (Fig. 1). They indicated that the 120 percent or greater indicates a high probability of
standard error for the prediction is 2.8 mm. If the pre- impaction.
dicted distance is 30 mm. or greater, it would indicate Olive and Basford30 used lateral cephalograms, ro-
sufficient space for the third molars. On the other hand, tational tomograms, intraoral bitewing films, and 60-
if the distance is 20 mm. or less. the space is considered degree cephalograms taken on direct skull material.
inadequate. They determined the validity of these estimates when
To estimate the probability of impaction, Ricketts compared to each other as well as to direct mea-
and his colleagues used the curves developed by Tur- surements on the skulls. They also compared the rela-
ley.28, 2s According to these curves, the probability of tionship between the dimension from Xi point to the
either impaction or full eruption could be diagnosed at lower second molar and the space width ratio derived
the age of 8 or 9 years with 90 percent accuracy. from direct measurements on the skulls. They con-
Olive and Basford3’ investigated the reliability and cluded that the rotational tomogram, the intraoral
validity of various radiographic techniques used for as- bitewing film, and the 60-degree rotated cephalogram
sessing lower third molar behavior. They examined the were superior to the lateral cephalogram for estimating
reproducibility of estimates of the space width radio, the space width ratio. In their opinion, the poor repro-
which is the ratio of the distance between the lower ducibility of the lateral cephalograms was probably
second molar and the ramus divided by the mesiodistal caused by difficulties of landmark location as well as
width of the third molar. It is estimated that a ratio of the projection angle.
Volume 83
Third molars 135
Number 2

Fig. 3. Patient whose maxillary second molars were extracted. A, Before extraction. B, After extraction
of second molars. C, Two years posttreatment; maxillary third molars have not yet erupted.

Olive and Basford30 found a strong positive corre- tine” removal of the third molars as a preventive pro-
lation (r = 0.76) between the dimension from Xi point cedure be justified? (2) What are the risks and cost
to lower second molar and the space width ratio derived involved in the routine use of general anesthesia? (3)
from direct measurements. They also indicated that any What are the added costs of hospitalization, particularly
direct assessment of one variable from the other, in the in instances in which a patient has medical insurance
individual case, is of doubtful value. Olive and Basford that will pay for hospital care but not for office
concluded that, at present, prediction of impaction or treatment?
eruption based on Xi point to the lower second molar is
PATHOLOGIC CHANGES ASSOCIATED WITH
not sufficiently reliable.
THIRD MOLARS
One should realize that a correlation coefficient of
0.76, although significant at the 0.001 level of con- According to Lilly, 31 these pathologic changes can
fidence, can improve the estimate of prediction by only be divided into two categories: (1) those associated
58 percent. with erupted or partially erupted third molars (caries,
periodontitis and other inflammatory conditions, mal-
The economic factor occlusion, fractures, neuropathies, etc.) and (2) those
There are three major areas of economic concern in associated with unerupted or impacted teeth (follicular
third molar extractions: (1) Can the cost of the “rou- cysts, benign neoplastic disease such as ameloblas-
 Am. J. Orthod.
136 Bishara and Andreasen February 1983

toma, resorption of second molar roots and neurop- routine dental film, without a history of prior extraction,
athies) . demands more extensive radiographic examination.
Although Lilly reported on the incidence of some of The Workshop recommended that patients should
these changes in various populations around the world, be informed of potential surgical risks, including any
he stated that at the present time there are no available permanent condition that has an incidence greater than
data on the incidence of various pathologic changes 0.5 percent or any transitory condition that occurs with
associated with third molars in the United States popu- an incidence of 5 percent or more. On this basis, pa-
lation . tients should be informed about hemorrhage, pain,
swelling, alveolar osteitis, trismus, and nerve injury.
CONSENSUSDEVELOPMENTCONFERENCEON In conclusion, the Workshop identified a number of
REMOVAL OF THIRD MOLARS well-defined criteria for the renoval of third molars.
A conference dedicated to third molars was spon- Included, among others, are infection, nonrestorable
sored by the National Institute of Dental Research Nov. carious lesions, cysts, tumors, and destruction of adja-
28 to 30, 1979. Approximately 250 dentists and scien- cent teeth and bone.
tists, representing all disciplines within the profession,
What to do with asymptomatic impacted
met in an effort to reach a general agreement on when
and under what circumstances third molar extraction is third molars?
advised and to identify areas in which further research There was no consensus on the subject of removal
is needed. of asymptomatic impacted teeth with no evidence of
The conferees were divided into five workshops to pathosis, but it was agreed that the impaction or mal-
explore the following issues: the effect of third molar position of a third molar is an abnormal state and may
removal on growth and development, timing and tech- justify its removal.
nical considerations for third molar removal, periodon- The Workshop also identified several areas of in-
tal considerations, prosthodontic considerations, and, sufficient knowledge related to management of third
finally, the morbidity of third molar removal. molars and suggested that they should also be subjects
A detailed report on the areas of consensus has been of research.
published elsewhere. 32 Some of the areas of consensus Some of the areas pertaining to orthodontics are (1)
are related to orthodontic therapy and include, in part, the relation of third molar to crowding of the dentition,
the following: growth and development of tuberosity and retromolar
Crowding of lower incisors is produced by many areas, as well as the relationship of the third molars to
factors which include tooth size, tooth shape, narrow- alveolar arch and length, and (2) the optimal method
ing of the intercanine dimension, retrusion of incisors, for predicting third molar eruption.
and growth changes occurring in the adolescent stages It needs to be emphasized that what has been pre-
of development. Therefore, it was agreed that there is sented is only part of the consensus report, and we
little rationale, based on present evidence, for the ex- strongly recommend that readers familiarize them-
traction of third molars solely to minimize present or selves with the complete text.
future crowding of lower anterior teeth.
Orthodontic therapy in both maxillary and man- ORTHODONTIC CONTRAINDICATIONS FOR
dibular arches may require posterior movement of both EXTRACTION OF THIRD MOLARS
first and second molars, by either tipping or translation, From an orthodontic standpoint, clinicians should
which can result in the impaction of third molars. To attempt to persuade both the general practitioner and
avoid impacting third molars and to facilitate retrac- the oral surgeon to postpone the decision for the re-
tion, it may be deemed advisable in some cases to re- moval of third molars in patients with malocclusions
move third molars before starting retraction procedures. until the orthodontic treatment plan is completed. Of
The consensus was that impacted third molars are course, this is provided that there are no other pressing
probably not the cause of the forward relapse after indications for extractions.
posterior movement of both first and second molars. Certain situations need special attention:
The Workshop agreed that it is necessary to instruct 1. When mandibular premolars are extracted or are
the student and practitioner in recognizing the need for congenitally missing. If the orthodontic treatment plan
early removal of third molars in those instances in calls for closure of the available space in the lower arch
which extraction is definitely indicated. and a nonextraction approach in the upper arch, then
It was decided that the absence of a third molar on a the first molar relationship will become Class III. The
Volume 83 Third molars 137
Number 2

10. Shanley, L. S.: The influence of mandibular third molars on

maxillary second molar will have little or no occlusal
mandibular anterior teeth, M.S. thesis, Washington University,
contact with the opposing tooth, that is, the mandibular
St. Louis, MO., 1960.
second molars (Fig. 2). The preservation and proper 11. Sheneman, J. R.: Third molar teeth and their effect upon the
alignment of the mandiublar third molars will allow lower anterior teeth: A survey of forty-nine orthodontic cases 5
them to interdigitate with the maxillary second molars. years after band removal, M.S.D. thesis, St. Louis University,
2. When the orthodontic treatment plan calls for St. Louis, MO., 1968.
12. Stemm, R. M.: The influence of the third molar on the position
extraction of first or second permanent molars, particu-
of the remaining teeth in the mandibular dental arch, M.S.D.
larly in nongrowing persons with Class II malocclu- thesis, University of Nebraska, Lincoln, Neb., 1961.
sions or open-bite tendencies. 13. Laskin, D. M. Evaluation of the third molar problem, J. Am.
3. When first or second molars have been extracted Dent. Assoc. 82: 824, 1971.
because of extensive caries and periapical involvement. 14 Richardson, M.: Late third molar genesis: Its significance in
orthodontic treatment, Angle Grthod. 50: 121-128, 1980.
In any situation in which extraction of first or second
15. Barnett, D. P.: Late development of a lower third molar-A
permanent molars is considered, it is important to case report, Br. J. Orthod. 3: 111-112, 1976.
evaluate the size and morphology of the unerupted third 16 Gam, S. M., Lewis, A. B., and Bonne, B.: Third molar forma-
molars by taking periapical radiographs before the ex- tion and its developmental course, Angle Orthod. 32: 270-279,
tractions are recommended. One has to recognize that 1962.
17. Banks, H. V.: Incidence of third molar development, Angle
the presence of a normally developing third molar does
Orthod. 4: 223-233, 1934.
not automatically mean that the tooth will erupt into the 18. Nanda, R. S.: Agenesis of the third molar in man, AM. J. OR-
line of occlusion (Fig. 3). THOD. 40: 698-706, 1954.
19. Dachi, S. F., and Howell, F. V.: A survey of 3,874 routine
CONCLUSIONS full-mouth radiographs. II. A study of impacted teeth, Oral
Surg. 14: 11651169, 1961.
The influence of the third molars on the alignment
20. Bjork, A., et al.: Mandibular growth and third molar impaction,
of the anterior dentition is still controversial. There is Acta Odontol. Stand. 14: 231-272, 1956.
no conclusive evidence to indict the third molars as 21. Olive, R., and Basford, K.: Transverse dentoskeletal relation-
being the major etiologic factor in the posttreatment ships and third molar impaction, Angle Orthod. 51: 41-47,
changes in incisor alignment. 1981.
22. Richardson, M. E.: Some aspects of lower third molar eruption,
Various aspects related to the management of third
Angle Grthod. 44: 141-145, 1974.
molars have been discussed and specific situations in 23. Bergstrom, K., and Jensen, R.: Responsibility of the third molar
which third molar extraction is contraindicated have for secondary crowding, Sven. Tandlak. Tidskr. 54: 11 l-124,
been illustrated. 1961.
24. Vego, L.: A longitudinal study of mandibular arch perimeter,
REFERENCES Angle Grthod. 32: 187-192, 1962.
1. Robinson, J.: The causes of irregularities of teeth, Dent. Rev., 25. Kaplan, R. G.: Mandibular third molars and postretention
p. 268, 1859. (In Weinberger, B. W.: Orthodontics: An histori- crowding, AM. J. ORTHOD. 66: 441-430, 1974.
cal review of its origin and evoluation, St. Louis, 1926, The 26. Henry, C. B., and Morant, G. M.: A preliminary study of the
C. V. Mosby Company, vol. 1, p. 325. eruption of mandibular third molar teeth in man based on mea-
2. Bjiirk, A., and Skieller, V.: Facial development and tooth erup- surement obtained from radiographs with special reference to the
tion, AM. J. ORTHOD. 62: 339, 1972. problem of predicting cases of ultimate impaction of the tooth,
3. Broadbent, B. H.: The influence of the third molars on the Biometrika 28: 378-427, 1936.
alignment of the teeth, AM. J. ORTHOD. ORAL SLJRG. 29: 312, 27. Friedman, J. W.: The case for preservation of third molars, J.
1943. Calif. Dent. Assoc. 5: 50-56, 1977.
4. Dewey, M.: Third molars in relation to malocclusion, INT. J. 28. Ricketts, R. M., et al.: Third molar enucleation: Diagnosis and
ORTHOD. 3: 529, 1917. technique, J. Calif. Dent. Assoc. 4: 52-57, 1976.
5. Fastlicht, J.: Crowding of mandibular incisors, AM. J. ORTHOD. 29. Data-Bits, profiles from Rocky Mountain Dental Systems, No.
58: 1.56-163, 1970. 4, Denver, 1975, Rocky Mountain Orthodontics.
6. Hixon, E.: Cephalometrics: A perspective, Angle Orthod. 42: 30 Olive, R., and Basford, K.: Reliability and validity of lower
200, 1972. third molar space-assessment techniques, AM. J. ORTHOD. 7%
7. Moore, A. W.: In Hopkins, S. C.: Inadequacy of mandibular 45-53, 1981.
anchorage, AM. J. ORTHOD. 46: 440, 1960. 31. Lilly, G.: Pathologic processes associated with third molars,
8. Nance, H.: Limitations of orthodontic treatment. Part II, AM. J. paper read at the Consensus Conference on Third Molars,
ORTHOD. 33: 253, 1947. November, 1979; personal communication.
9. Schwarze, C. W.: The influence of third molar germectomia-A 32. Judd, W. V.: Consensus Development Conference at the Na-
comparative long term study, Abstr. Third International Grth- tional Institutes of Health, Indian Health Service Dental News-
odontic Congress, London, 1973. letter 18: 63-80, 1980.