THIRD MOLARS :

ITS SIGNIFICANCE IN
ORTHODONTIC
TREATMENT AND
RELAPSE
INTRODUCTION
Third molars are the teeth which are
most often missing, impacted and with
altered morphology.
Advances in dental anthropology states
that there is a reduction in the number
of teeth and size of jaws on evolutionary
basis for the past 1,00,000 years.
Third incisors ,third premolars and
fourth molars have disappeared already.
 At present human third molars often
fail to develop, which indicate that
these teeth may be on their way out.
Although there are some who advice
the early removal of the third molars ,
many strongly believe that the
retention of asymptomatic third molars
may be useful in later years as a
substitute for badly decayed teeth or
may even be useful as a transplant.
DEVELOPMENT AND
ERUPTION
There is great variation in the timing of
development, calcification, and eruption of
third molars.
Development may begin as early as 5 years or
as late as 16 years, with the peak formation
period at 8 or 9 years.
Calcification can start at age 7 years in some
children and as late as age 16 years in others.
Enamel formation is normally complete
between 12 and 18 years and root formation is
normally completed between 18 and 25 years.
 Hellman reported that the average age
of eruption was 20.5 years.
In 1962,Fanning reported average ages
of eruption of 19.8 years for females
and 20.4 years for males.
Early formation of third molars is
generally regarded as predictive of early
maturation but not always of early
eruption.
Most surveys report that more than 17%
of lower third molars become impacted.
 Lower third molars normally have
their occlusal surfaces tilted slightly
forwards and lingually during early
calcification.
As the mandible increases in
length, with bone resorption at the
inner angulation between the body
and the ascending ramus of the
mandible, the third molars become
more upright.
 In contrast, upper third molars erupt
downwards, backwards, and often
outwards.
There is, therefore, a possibility of
crossbite, but tongue pressure on
lower crowns and buccinator pressure
on upper crowns will often correct this.
If there is a lack of space, then normal
eruptive paths cannot be followed,
and crossbites can result.
ERUPTIVE PATHWAYS OF THIRD
MOLARS
Richardson investigated the development of lower third
molars between ages 10 and 15 years,using models and
four cephalometric radiographs (90 degree left lateral,
straight posteroanterior and 60 degree left and right lateral
views).
She found that the angle of the occlusal surface of the lower
third molars to the mandibular plane was 41 degree On
average she found this decreased by 11 degree by age 15.
 Successful eruption of the lower third
molar occurs by the tooth continuing
to decrease its angle to the
mandibular plane and moving
occlusally into sufficient space.
 J.B.Fayad et al in AJO 2004 determined the
relationship between the maxillary molars
sagittal inclination and the eruption of third
molars using CT scans.
In their study the sagittal inclination of
maxillary first and second molars were greater
in the subjects with erupted maxillary third
molars than in those with impacted third molars
and particularly in the younger subjects.
They concluded that the vertical position of the
first maxillary molar in the sagittal plane is a
predictor of the eruption of the adjacent third
molar; and that the sagittal inclination of the
maxillary molars increases with age which
could be the effect of a mesial drift.
 Kahl et al evaluated orthopantomograms
of 58 orthodontically treated patients with
asymptomatic impacted third molars.
In a 15 year follow up ,they observed that
some of the maxillary and mandibular
molars have rotated to a more upright
position while others had an increase in
the mesio or disto-angulation.
They found that age, period of impaction,
extent of space deficiency, developmental
stage, level of eruption and bone
conditions had no predictive values.
ASSESSMENT OF SPACE FOR THIRD
MOLARS
Shortage of space between the second
molar and the ramus has long been
identified as a major factor in the etiology
of lower third molar impaction.
Henry and Morant suggested a technique
for predicting impaction of lower third
molar using their third molar space index;
obtained by expressing the mesiodistal
width of the third molar as a percentage
of the space available measured on
bimolar radiographs.
 If this index, exceeded a value of 120 for
a person at maturity, impaction could be
predicted.
This index decreases as the growth
continues and the space available
increases.
Ledyard, studying lateral jaw radiographs,
found that less than a 2 mm increase in
space between the lower second molar
and the ramus could be expected after
the age of 14 years and a negligible
increase after 16 years
 Ricketts claimed that if 50% of the third
molar crown lies ahead of the external
oblique ridge at maturity, there is a 50%
chance of eruption.
Schulhof in 1976 claimed that growth
prediction can estimate the adult
dimension from Xi point to the
mandibular second molar on a lateral
cephalogram taken at the age of 9 years,
with a standard error of 2.8 mm Schulhof
suggested that lower third molars could
not be classified as likely to erupt to good
occlusion if the Xi point to lower second
molar was measured less than 25mm
 Richard Olive et al in AJO 81 in a study
on dried human skulls, examined the
reproducibility of estimates of a space
width ratio (space available between
lower second molar and the ramus
divided by mesiodistal width of
mandibular third molar) on the lateral
cephalogram, rotational
tomograms(OPG), intraoral bitewings and
60 degree cephalograms.
 A template of cellulose acetate was prepared
with a right angle T drawn in line through the
tips of the most superior, anterior and
posterior cusps of the first premolar to
second molar section of buccal segment.
The template was placed over the radiograph
with the horizontal part of the T on the
occlusal plane and the vertical part touching
the most distal part of second molar crown.
 The space available (AB),the mesiodistal
width of the lower third molar(CD) and
space width ratio (AB/CD) were
computed from the digitized data.
A ratio of less than 120% will indicate a
high probability of impaction.
The rotational tomogram, intraoral
bitewing and 60 degree rotated
cephalogram were superior to the lateral
cephalogram on the basis of reliability of
results and reproducibility of radiograph
technique for estimating the space width
ratio.
 The results suggested the difficulties in
landmark location on lateral
cephalogram. Locating anterior border of
the ramus on lateral cephalogram is often
difficult, which militates against good
reproducibility of results.
It was shown that the reliability for the
lateral cephalogram technique alone was
not as good as for the other techniques.
The rotational tomograms yielded the
most accurate estimates of space width
ratio.
Intraoral bitewings yielded the next best
estimates.
IMPACTIONS
Archer defined an impacted third molar as One
which was completely or partly erupted and
positioned against another tooth,bone or soft
tissue, so that its further eruption was unlikely.
Dachi and Howell in their study found that the
incidence of patients with atleast one impacted
tooth was 16.7%.
Teeth most often impacted in order of frequency
were the maxillary third molars,mandibular third
molars,maxillary canines and mandibular
premolars.No sex differences were noted.
 Bjork and colleagues identified 3
skeletal factors that are separately
influencing third molar impaction
Reduced mandibular length,measured as
the distance from the chin point to the
condylar head.
Vertical direction of condylar growth as
indicated by the mandibular base angle.
Backward directed eruption of mandibular
dentition determined by the degree of
alveolar prognathism of lower jaw.
 Capelli in a 1991 study evaluated 60
patients who had four first premolar
extractions.
The findings from pretreatment and
posttreatment cephalograms suggested
that third molar impactions were more
likely to occur in patients with
pretreatment vertical mandibular growth.
A long ascending ramus, short
mandibular length, and greater mesial
crown inclinations of third molars, seem
to be indicative of third molar impaction.
TYPES OF IMPACTION
Richardson suggested five categories of impaction
Type A : The tooth can follow the pattern of an
ideally developing third molar, by decreasing its
angle to the mandibular plane and becoming more
upright, but the uprighting may not be enough to
allow full eruption.
 Type B : The angular
developmental position
relative to the mandibular
plane may remain unchanged

Type C : The tooth can

increase its angulation to
the mandibular plane ,and
become more mesially
inclined .There is at
present no reliable way
of predicting which teeth
will follow this unfavourable
pattern,which sometimes occurs unilaterally and leads
to horizontal impaction
 Type D :The tooth can
be seen to make favourable
changes in angulation ,but
fail to erupt owing to lack
of space.These are so called
vertical impactions.

Type E :The tooth can

continue to change its
angulation beyond the ideal
occlusal position,and show
disto angular impaction
MECHANISM FOR ERUPTION AND IMPACTION

Differential root elongation might

explain differences in eruptive
behaviour among lower third molars.

Richardson offered a theoretical

explanation for favorable or
unfavorable rotational movement.
 Favorable change in angulation ,to a more
upright position ,seemed to occur in teeth
where the mesial root developed ahead of
the distal crown surface and root.
The typical root configuration showed a
mesial root which was curved in a distal
direction and was slightly longer than the
distal root.
 Unfavorable mesial tipping, leading to
horizontal impaction, seemed to occur when
the distal root became the same length, and
then longer than the mesial root.
The distal root on such teeth was seen to
appear to have a mesial
curvature.
FACTORS INFLUENCING AVAILABILITY OF
SPACE
GROWTH
Bjork et al measured the distance from
the anterior border of the ramus to the
second molar,and concluded that the
bigger the space,the better the chance of
eruption.Richardson measured an average
of 11.4 mm of growth between the age of
10 and 15 years.
 BONE RESORPTION
In 1987 Richardson examined the
creation of space for third molars in 51
subjects.
She found that increased space was
obtained from both the mesial
movement of the dentition and bone
remodeling along the anterior border of
the ramus.
On average 2 mm of posterior space
was created by bone remodeling
 SPACE RELEASED BY ATTRITION
In so-called primitive dentitions, where
considerable attrition takes place, the third molars
erupt to take up the space released.
Begg felt that lack of this attrition,due to highly
refined diets,was a mojor cause of third molar
impaction. Other authors,such as Profitt,have
questioned this hypothesis.
Early and extensive interproximal caries could
also reduce the size of erupted teeth, owing to
disappearance of proximal contacts.
SECOND MOLAR
EXTRACTION
Richardson and Richardson in AJO 93
investigated 63 patients after extraction
of lower second molars and found that all
the lower third molars erupted more or
less successfully after an average
observation period of 5.8 years.
There was considerable variation in the
time taken for eruption, ranging from 3 to
10 years and Richardson noted that it is
not possible to predict how long eruption
will take.
 Bonham Magness in JCO 86
suggests that upper third molars has a
much more predictable eruption
pattern than lower third molars.
He suggested the extraction of upper
second molars in some cases to assist
first molar positioning and increase
space for upper third molars.
 Tae-Woo Kim et al in AJO 2003
confirmed the findings of Faubion and
Kaplan that impaction of mandibular
third molars occurs about twice as
often in non-extraction patients than
in extraction patients.
The mechanism may be that premolar
extraction therapy is associated with
an increase in the amount of mesial
movement of the maxillary and
mandibular molars and an increase in
the eruption space for the third
molars.
 Cephalometric growth studies suggest 2
important mechanisms for development
of the retromolar space in the mandible;
Resorption at the anterior border of the
ascending ramus and the anterior
migration of the posterior teeth during
the functional phase of tooth eruption.
More than 60% of the patients in the
study, with a distance of 23 mm or less
from the distal of the mandibular second
molar to the Ricketts Xi point at the end
of the active treatment experienced
eruption of mandibular third molars.
 The retromolar space can increase
about 2 mm from age 15 to
adulthood.
They also showed that as many as
60% of the subjects with a distance
from the anterior border of the ramus
to the distal of second molar of 5 mm
or less experienced eruption.
These suggest that the size of third
molar eruption space associated with
a high risk of impaction might be
smaller than previously suggested
UPRIGHTING IMPACTED
MOLARS
Third molar retention may be
beneficial in many situations.
Some investigators maintain that
third molars could be used at a later
date as replacements or for
prosthetic abutments in case of loss
of first and second molars.
Third molars could also be used as
transplants
 In shallow mesio-angular impactions
Richardson used a one stage method.
A second molar tube can normally be bonded
onto the buccal aspect of a partly erupted
lower third molar, if enough enamel is visible.

It is then possible to include the tooth in full

treatment ,if other teeth are already bonded
and bracketed.
If the case is not fully banded,
then lower second or first
molars alone can be used,
with a lingual arch for support
 In deep mesio-angular impactions,a two-stage
method is used.
If it is not possible to bond onto the buccal
surface,a different technique is used which can
be delayed until 18 19 years of age, to allow
time for the tooth to improve its position.
The first stage involves bonding a second
molar tube onto the occusal surface of the
lower third molar.
 The hook is removed from the tube, before
bonding.
Lower first or second molars are banded with a
lingual arch, using first molar bands and
brackets.
A small sectional archwire, with a compressed
coil spring, is used to provide a distalizing and
uprighting force to the crown of the impacted
molars.
After some uprighting using this method, it is
normally possible to bond a tube buccally for
the second stage.
 Ike Slodov et al in AJO 89 describes
an orthodontic uprighting technique
similar to Sling shot appliance
described by Moyers and by Profitt.
Modified impaction related surgical
procedures provide easy application of
techniques to facilitate exposure of
unerupted and partially erupted third
molars and allow orthodontic
manipulation
 After surgical exposure a cleat is bonded in
center of mesial marginal ridge.
The wire portion of the appliance is fabricated
from 0.032 inch stainless steel wire and
adapted closely to the mucosa.
The mesial hook is placed 3 mm distal to the
distal portion of the third molar.
Standard soldering techniques are used to
attach the wire to the buccal (or lingual)
surface of the band. Appliance is cemented in
place and is activated with elastic modules
 By manipulation of the distal arm of the appliance
either buccally or lingually ,depending on the
desired movement,teeth can be directed or rotated
with some effectiveness.
Variation can also be accomplished
by alteration of the bond position
of the cleat.

Following activation,rapid uprighting and

distalisation will occur in 3 to 6 months in most
cases.Grinding of occlusal surface is not necessary.
When the third molars are upright,
the appliances are removed and
the third molars are banded, leveled
and aligned with the rest of the teeth.
 This procedure is contraindicated when
the molar to be uprighted has no
antagonist; is severely malformed or is
abnormally large or small, and it should
be done carefully when there is a
tendency for open bite.
Advantages are:
1. Ease of fabrication and manipulation
2. Rapid treatment
3. Little discomfort
4. No demands for patient cooperation
 Orton and Jones in JCO 87 described a simple
whip spring that is unobtrusive and fairly fast
acting with a treatment time of 4 to 12 months.
It is used for disimpacting , mild to severe
mesially impacted lower terminal molars (LTM).
LTM crown must be accessible for an edgewise
tube, preferably on a band.
Partial seating of the band on the mesial
surface is acceptable at first, which can be fully
seated as correction proceeds.
If the impacted molar has not sufficiently
erupted then surgically expose distobuccal
surface and bond an attachment.
 The whip spring is fabricated with 0.018X
0.025 wire for 0.022 slot and 0.017X0.022
wire for 0.018 slot.
A circular loop is placed mesial to the tube
to prevent posterior displacement of the
wire and to provide attachment of an elastic
module that anchors the wire in the tube.
 Wire extends mesially from the loop. A vertical
bend is placed occlusally next to the
midbuccal fissure of the anchor molar.
The wire is curved lingually to pass through
the midbuccal groove onto the occlusal
surface. It is then contoured distally to run
along the occlusal surface.
Moving the whip to the occlusal surface of the
anchor molar activates the appliance.
 The whip spring can be reactivated in
the mouth by lifting the wire away from
occlusal surface and gently squeezing
the arm of the spring between loop and
vertical bend with Tweeds loop forming
plier.
After initial adjustment at 3 to 4 weeks,
adjustments every 6 week seen to be
adequate. Overcorrection is advised.
 The force of the whip tends to extrude the
impacted molar and intrude the anchor molar.
If there is too much intrusion of anchor molar,
a new whip can be made that extends to
another anchor tooth.
The couple tends to disimpact the LTM by a
combination of distal crown tipping and
mesial root movement, resulting in root
paralleling of the molars.
 If the vertical development of the LTM
is impeded by an upper molar, then
the overerupted upper molar must be
intruded by a removable appliance
with an intrusive arm
REPLACEMENT OF THIRD
MOLARS FOR SECOND
MOLARS
During growth of maxilla ,space to accomodate
the erupting first, second, and third molars
must be created by growth in the posterior
region of the tuberosity.
The maxillary growth in this area must normally
be downward and forward to create room for
the eruption of each succeeding molar.
If growth in this region is insufficient, abnormal
eruption or lack of eruption will be the result.
 According to Malcolm.R.Chipman in AJO
1961 the third molars can be substituted for
the second molars in certain situations and
solve some of the problems of maxillary
tuberosity area.
The indications for eliminating maxillary second
molar and replacing it with third molars are
1.Maxillary third molars of fair size and shape
with the possibility of good root development
2.Small,restricted maxillary tuberosities and the
possibility of interference with distal
movement in maxillary posterior region.
3.Second molars erupted buccally.
4.Second molars decayed ,badly decalcified or
having large restorations.
5.Maxillary third molars in favourable position
and angulation relative to second molars and
maxillary tuberosity.
6.Maxillary third molars in favourable relation
to mandibular second molars.
7.Desirability of relieving the anchorage units
of an overload.
The replacement of maxillary second
molar will be considered in both Class I
and Class II malocclusions
 The contraindications for substitutions are
1.Maxillary third molars too high in the
tuberosity.
2.Maxillary third molars too low in relation to
the
second molars
3.Poor angulation in relation to second molar
and the tuberosity.
4.The possibility of third molars involving
maxillary sinus.
5.Small,odd shaped third molars or an indication
of the formation of small roots.
 There is a great variation in the time of
development of third molars, and this
together with the amount of development
in the tuberosity region, has a bearing on
the decisions to be made in the event of a
needed maxillary distal movement and a
possible replacement of the second molar
by third molar.
For this reason the dental age as evidenced
by the development of dental components,
must be given as much considerations as
chronological age.
 The shape of third molar crowns is also
considered.
Small crowns with narrow width at the
cervical margin do not lend themselves
to development of normal sized roots.
Many third molars have odd shaped
crowns with irregular cusp formations
,and, while occlusal grinding frequently
is needed, there is a limit to its use and
these teeth cannot be recommended.
 During its eruption following a second molar
extraction ,the third molar rotates or tip
mesially as it descends; the amount of
rotation being directly associated with the
degree of angulation.
The greater the degree of angulation the
greater is the amount of rotation, with the
center of rotation being based on root apex.
This rotation together with the downward and
forward path of eruption ,is a major factor in
determining when the second molar
extraction may be planned.
The ideal condition calls for the descending
third molar to come into contact with the
maxillary first molar and into occlusion with
the mandibular second molar at the same
time.
 In a Class I malocclusion,the third molar
should have descended to the extent that the
occlusal surface is approximately level with
the vertical midline of second molar root and
the mesial surface of unerupted third molar is
fairly in line horizontally with the distal surface
of mandibular second molar.
Following extraction of second molar, the third
molar will then descend in a downward and
forward arc, rotating into contact and
occlusion at the same time.
If third molar is at a much higher point there is
a possibility of impaction or premature
contact. before occlusion is attained.
If it is at a lower level in relation to second
molars, it is likely to erupt into occlusion
before contact is established with first molar,
resulting in open contacts and poor
 In Class II malocclusions,the crown of
maxillary third molar is horizontally
advanced in relation to the mandibular
second molar.
In Class II cases in which second molar is to
be extracted,the most ideal location of third
molar is approximately at the junction of
crown and root of second molar.
The angulation of maxillary third molars to
the plane of occlusion and their relation to
the tuberosity must be carefully considered.
The usable angulation will range from 0 to
+30 degree.(distal tip) to occlusal plane.
 Orton-Gibbs et al in AJO 2001 described the
eruptive path of maxillary and mandibular
third molars after extraction of second molars
with the use of radiograph and assessed the
final position from study models.
They showed that the angulation of the
mandibular third molar crown long axis
showed progressive uprighting from a mean of
55 to the occlusal plane at the start of active
treatment (SAT).
Uprighting of mandibular third molars from
SAT to end of active treatment (EAT) was
limited (mean 6). However the third molars
continued to upright thereafter on average a
further 13.
 Clinically it is important to note that EAT
radiographs will not give a true picture of the
likely final mandibular third molar angulation.
Approximately 50% of the space closure
occurs by EAT. Interestingly space closure is
not a result of mesial tipping but is due to
significant horizontal translation.
The relationship of the first and the
third molar crown should be the
most important indicator of
successful outcome, not angulation
of the whole tooth.
The results confirm findings by
Dacre, and Richardson and Richardson
that the original angulation of the third
molar is not a reliable predictor of
outcome for third molar position.
 In contrast to the mandibular third
molars, the maxillary third molars
upright rapidly by 14 degree on
average from SAT to EAT.
Angular changes is minimal as the
maxillary molars settle into occlusion.
The rate of vertical change is
rapid, with almost 7 mm of
eruption occurring by the
completion of active treatment
and a further 6 mm after
active treatment
 The third molars in the study were invariably in a
position that maintains a good functional occlusion.
The periodontal health of the sample was excellent.
There was no correlation between third molar
position and the presence of gingivitis or
periodontitis.
The results showed that relief of crowding by
removal of second molar is a realistic option in
appropriate cases with mild to moderate crowding,
particularly in patients in whom third molar
impaction is predicted and in reducing the
likelihood of increasing crowding through the
teenage years
 AUTOTRANSPLANTATION OF THIRD
MOLARS
Autotransplantation of teeth has become an
accepted and reliable treatment modality in
patients with early loss of teeth or aplasia.
According to William Northway in AJO 80
autogenic tooth transplantation can give the
concept of space management a much broader
horizon.
Third molars have been frequently used for
transplantation. These teeth, which are often
extracted have served well as replacements, for
cariously destroyed first molars.
Their root development which continues into the
late teens and twenties makes these teeth suitable
for use into adulthood.
The last tooth in the arch may offer better access
for removal, and it is essential that the root not be
damaged in any way during its relocation
 The prognosis for successful transplantation is
diminished as the root apex nears closure.
Revascularisation must take place. While post
operative resorption is rarely reported, the
effective reduction in root length is minimized
by allowing adequate development prior to
transplantation.
Hale believed that the most favourable time
for transplanting was at 3 to 5 mm of root
formation.
Apfel stressed the need for delaying
transplantation until after furcation formation.
Andreasen,Baum,Peskin and Guralnick have
contented that the results will be maximized if
the operations are performed sometime
between one third and three fourth of
completion of root formation.
 Proper alveolar architecture is essential for
housing the transplant.
The recipient site should be covered with
adequate attached, keratinised tissue to allow
proper coverage or approximation to the
transplant and it should be free of chronic
inflammation.
Mesiodistal space deficiencies be eliminated
prior to the surgical procedure,either by
orthodontic means or by slicing of adjacent
teeth.
Also there should be adequate labiolingual
width on the ridge to accommodate alveolar
plates on both surfaces
SURGICAL PROCEDURE
A full thickness mucoperiosteal flap should
be employed,allowing adequate exposure
for atraumatic preparation of the recipient
site.
A very gentle handling of the soft tissue is
ensured. The socket is prepared with bone
burs and rongeurs.
Once the socket is judged to be of adequate
depth and circumference, a trial insertion of
presterilised dummy tooth can be made.
Ideally, the preparation of the recipient site
will allow insertion deep enough that the
cusp tips will be at or apical to the alveolar
crest height. This allows eruption and hence
root formation postoperatively.
 Now the transplant can be removed.
Again, adequate flaps allow exposure and
a minimum of trauma.
With gentle manipulation of surgical
instruments the dental follicle is removed
from around the crown.
The tooth is removed and transferred
immediately to the previously prepared
crypt.
It is preferable that the tooth be
manipulated only by its crown. In the
event that buccolingual width does not
allow proper placement, it can be
 This will allow preservation
of alveolar crest and the
tooth can later be
repositioned
orthodontically as desired.
Mucoperiosteal flap is
repositioned and sutures
are placed over the crown
to hold the tissues
together and tooth in its
crypt.
After a week or 10 days
sutures are removed and
direct bonded stabilization
can be employed for upto
6 weeks
 Oskar Bauss et al in AJO 2004 in
their study determined the influence
of orthodontic tooth movements on
pulpal and periodontal conditions in
transplanted immature third molars.
The indication for transplantation was
aplasia of premolars or early loss of
molars.
 In patients with horizontal atrophy of alveolar
process, with narrow alveolar ridges and
unfavourable root morphology, transplants
were placed in 45 to 90 degrees distally
rotated positions.
Derotation to a correct position in the dental
arch was performed with a couple of forces.
The initial rotational force varied between
200 to 300 grams/mm.
Mean rotation time was 12 weeks. After
complete derotation, all transplants were
integrated into a fixed appliance for leveling
and approximal space closure.
Average Orthodontic treatment time was
15.2 months.
 In vertically atrophied jaw
sections,transplants were fixed in distinct
infraocclusion (average 5.1 mm) Transplants
were leveled to the occlusal plane before
closing the approximal spaces.
Mean orthodontic treatment time was for
14.4 months.
For determining pulpal and periodontal
conditions,clinical and radiologic
examinations were carried out.
Autotransplanted third molars without
subsequent orthodontic treatment had the
best pulpal and periodontal results.
All transplants were at the developmental
stage with their open apices providing a high
chance of pulp revascularization.
 The results suggest that orthodontic
extrusion and minor lateral tooth movement
have no harmful effects on the pulpal and
periodontal condition of autotransplanted
immature third molars.
Atrophy of the alveolar process did not
affect pulpal and periodontal healing of the
transplants in the extrusion group.
A certain amount of spontaneous eruption
had occurred in most patients by the time
orthodontic treatment began.
The formation of new alveolar processes
was observed during subsequent
orthodontic treatment.
 Revascularisation started on the fourth
postoperative day with an ingrowth of new
vessels and was usually completed after 30 days,
with the entire pulp containing new vessels.In
contrast to pulpal revascularization ,first signs of
pulpal reinnervation cannot be demonstrated
until at least a month after transplantation and
are limited to the apical part of the pulp.
Even after 2 years, the restored pulpal nerves are
described as sparse, and the new axons are small
in diameter.
By postponing the onset of orthodontic treatment
to the third to sixth month after transplantation
and slower derotation of multirooted transplants
might increase the success rate.
 THIRD MOLARS AND
CROWDING
Lower arch crowding after establishment of the
permanent dentition during teenage period (post
adolescent crowding) is a common orthodontic
problem.
This late lower arch crowding is caused by pressure
from the back of the arch. Whether this pressure
results from a developing third molar, physiologic
mesial drift or the anterior component of force
derived from the forces of occlusion on mesially
inclined teeth is not clear.
There is also a school of thought holding the view
that in the absence of third molar, the dentition has
room to settle distally under anterior pressures
caused by late growth or soft tissue changes.
Thus the third molar plays, at the very least, a
passive role in the development of late lower arch
crowding
 Bishara et al evaluated the changes
in the lower incisors between 12 and
25 years of age and then re-evaluated
the same subjects at 45 years of age.
Their findings indicated that there was
an increase in the tooth size-arch
length discrepancy with age.
The average changes amounted to 2.7
mm in males and 3.5 mm in females.
These changes were attributed to a
consistent decrease in arch length that
occurred with age.
 Margaret Richardson in AJO 92
examined changes in the lower arch
crowding in young adults and showed
that between the ages of 18 and 21
years, the lower arch is stable in
terms of tooth alignment and mesial
drift, regardless of third molar status
or continuing mandibular growth.
STUDIES RELATING THIRD MOLAR TO
CROWDING
Bergstrom and Jensen in 1961 examined
sixty dental students, of whom thirty had
unilateral agenesis of the upper third
molars, twenty-seven had agenesis of the
lower third molar and three had one third
molar absent or lost.
They found that there was more crowding
in the quadrant with a third molar present
than in the quadrant with a third molar
missing.
There was a mesial displacement of the
lateral dental segments on the side with
the third molar in the mandibular arch, but
not in the maxilla.
 They found no evidence of a
correlation between age and the
degree of crowding or mesial tooth
displacement.
Bergstrom and Jenson concluded that
the presence of a third molar appeared
to exert some influence on the
development of the dental arch but not
to the extent that would justify either
the removal of tooth germ or the
extraction of third molar.
 Vego in another study examined forty patients
with lower third molar present and 25 patients
with third molar congenitally absent.
Each individual arch was measured first after the
eruption of second molar at an average age of
13 years and second at an average age of 19
years.
Crowding was defined as loss of arch perimeter,
manifested as closure of space or by slipping of
contacts resulting in rotation or adverse
movement of teeth.
Vego found that all cases showed a decrease in
arch perimeter. The decrease was less
noticeable in persons without lower third molars.
Vego also indicated that there are multiple
factors involved in the crowding of the arch.
 According to Richardson in AJO 89 the Belfast
third molar study produced further evidence in
support of the pressure from behind theory.
A group of 51 subjects with intact lower arches
and bilateral third molars present were
examined at ages 13 to 18 years.
On average these cases had an increase in
lower arch crowding of slightly more than 1mm
on each side during the five-year observation
period. In some quadrants the crowding
increased by as much as 4mm.
 Molar space measured along the maxillary
horizontal as the distance between the distal
contact point of the first molar and the junction
of the ramus with the body of the mandible was
also examined.
The changes in molar space condition were
calculated by subtracting the size of second and
third molars from the measurement of molar
space.
A significant correlation between increase in
anterior crowding and initial degree of molar
crowding was found suggesting that a person
who lacks adequate space in the molar region in
early permanent dentition is likely to show an
increase in crowding anterior to first molar in
subsequent years.
 They also showed that conditions in the
molar region were only partly
responsible for increased crowding.
Mesial inclination of lower canine usually
is considered to be a sign that the buccal
segment has moved forward.
Richardson also investigated the effect
of second molar extraction on the
development of late lower arch crowding
ands found that there was a slight
decrease in crowding (-1.5mm) and a
slight distal movement of first molar (-
1.3mm).
STUDIES INDICATING LACK OF
CORRELATION BETWEEN THIRD MOLAR
AND CROWDING
Kaplan in 1974 compared pre-treatment, post-
treatment and 10year post-treatment study
models and lateral cephalograms of 75
orthodontically treated patients.
Three groups with third molars erupted,
impacted and congenitally missing were
compared. Kaplan showed that some degree of
lower anterior crowding relapse occurred in
majority of cases.
He concluded that the presence of third molars
does not produce a great degree of lower
anterior crowding or rotational relapse after
cessation of retention.
According to Kaplan the theory that third molars
exert pressure on the teeth mesial to them could
not be substantiated.
 Ades et al in AJO 1990 studied pretreatment,
posttreatment and postretention study models
and lateral cephalometric radiographs of 97
patients. The subjects were divided into those
with lower third molar erupted, impacted,
agenesis and extracted at least 10 years before.
The study showed that:
a. With time, mandibular incisor irregularity usually
increases whereas arch length and intercanine
width typically decreases
b. The persons with third molars erupted into
satisfactory function was not having a different
mandibular growth pattern than those with third
molars impacted or congenitally missing
In majority of cases some degree of mandibular
incisor crowding took place after retention,
suggesting that the recommendation for
mandibular third molar removal with the objective
of alleviating or preventing long term mandibular
incisor irregularity may not be justified.
 Lifshitz in 1982 evaluated the effect of
lower premolar extraction versus non
extraction as well as the presence or
absence of lower third molars on
mandibular incisor crowding.
He concluded that in all groups evaluated,
there was a significant increase in crowding,
but there were no significant difference
between the groups that did or did not have
premolar extractions or whether third
molars were present or missing.
 In 1981 Little et al observed that
90% of the extraction cases that were
well treated orthodontically ended up
with an unacceptable amount of lower
incisor crowding.
These studies indicate that incidence
of mandibular incisor crowding
increased during adolescence and
adulthood in untreated as well as
orthodontically treated patients after
retention is discontinued.
EXTRACTION OF THIRD
MOLARS
The third molars need to be
considered as part of overall
treatment planning, and this may
include a recommendation for
extraction.

The timing of extractions requires an

understanding of the various
techniques available.
EXTRACTION BEFORE TREATMENT
It is not common practice for third molar
teeth to be enucleated before
orthodontic treatment of adolescents.
Orthodontists are normally reluctant to
make surgical extractions a prerequisite
of providing treatment.
They may feel that ramus growth and
lower third molar eruptive pattern
cannot be predicted, and take the view
that the third molars may erupt
eventually.
 Those in favour of enucleation believe that
many young adults between the age of 18
and 22 years experience problems with their
third molars and that at later ages,
pathologic changes often occur.
Ricketts et al indicated that removal of the
third molar bud at the age of 7 to 10 years is
surprisingly simple and relatively atraumatic.
Schulhof recommended that enucleation
should be considered for any lower third
molars which, after careful diagnosis, had a
greater than 50% chance of impaction.
Enucleation is not, however, a generally
accepted procedure. Later caries experience,
space conditiond, and the effect of
orthodontic treatment are unknown at this
early age.
LATERAL TREPANATION

At about age 12 years ,the need for third

molar extraction may be more obvious.
Conventional surgical removal of the
calcified crowns, at this age is difficult.
The tooth rolls in its crypt with
considerable trauma to the adjacent
tissues.
There is also a risk of gingival
damage,with a pocket formation to the
distal of the lower second molars due to
the U shaped incision involved.
 Henry recommended a deep lateral
approach ,calling it Lateral
trepanation for third molars in an
early stage of partial development.
Burgess et al and Henry
recommended lateral trepanation as
an easier technique, with less
complications and more rapid healing.
EXTRACTION DURING TREATMENT

If orthodontic treatment includes

orthognathic surgery to one or both
jaws, and third molars also require
extractions, surgeons prefer to do it at
the same operation.
However, some prefer to remove lower
third molars 6 months before
orthognathic surgery,so that bone
healing can occur in the surgical site.
EXTRACTION AFTER ORTHODONTIC
TREATMENT
Extraction of third molar after orthodontic
treatment with a view to prevention of relapse
should seldom be necessary.
Lindquist and Thilander in 1982 attempted to
determine the effect of the prophylactic removal
of mandibular third molars on the lower incisors.
They extracted a third molar on one side at an
average age of 15.5 years and left the third
molar on the other side as a control.
They measured study casts and cephalograms
on these patients 3 years postoperatively.
They evaluated numerous parameters but were
unable to predict which patient would benefit
from such a procedure as both sides essentially
had similar changes.
 Southard et al in 1991 measured
proximal contact tightness between
the mandibular teeth in cases with
bilateral unerupted third molars.
The measurements were taken before
and after the unilateral removal of one
third molar.
They found that surgical removal of
third molar did not have a significant
effect on contact tightness.
 Pirttiniemi et al in 1994 evaluated the
effect of removal of impacted third molars
on 24 individuals in their third decade of
life.
Dental casts were evaluated before and
after one year after extractions.
They found that the extractions allowed for
slight distal drift of the second molar but
had no significant change in the lower
anterior area.
From the available data it can be
concluded that third molars do not play a
significant, quantifiable role in mandibular
anterior crowding.
 Two consensus conferences were dedicated to the
management of third molars ,one sponsored by the
National institute of Dental Research in 1979 and the
other by the American Association of Oral and
Maxillofacial Surgery in 1993. Points of the
concensus which were important to Orthodontics
were:
1. Crowding of the lower incisors is a multifactorial
phenomenon that involves a decrease in arch length,
tooth size, shape and relationship, narrowing of the
intercanine dimension, retrusion of the incisors, and
growth changes occurring in adolescence.
Therefore, it was agreed that there is little rationale
based on the available evidence for the extraction of
third molars solely to minimize present or future
crowding of the lower anterior teeth.
If adequate room is available for third molar
eruption, every effort should be made to bring these
teeth into functional occlusion.
2. Orthodontic therapy, in both maxillary and
mandibular arches, may require posterior
movement of both first and second molars
by either tipping or translation, which can
result in the impaction of third molars.
To avoid impacting third molars and to
facilitate retraction, it may be deemed
advisable in some cases to remove third
molars before starting retraction procedures.
3. There is no evidence to suggest that a third
molar is needed for the development of the
basal skeletal components of the maxilla
and mandible.
4.There was agreement that postoperative pain,
swelling, infection, and other possible
consequences of surgery are minimized when
surgery is performed in patients who are
dentally young, as judged by the third molar
roots being about two thirds developed.
As a result, it is important to instruct the
clinician in recognizing the benefit of early
removal of third molars in those cases in which
extraction is definitely indicated.
5. Although there are orthodontic reasons for the
early removal of third molars, the consensus
was that enucleation of third molar buds based
on measurements obtained at age 7 to 9 years
is not acceptable.
This is because the present predictive
techniques for third molar eruption or impaction
are not highly reliable and should be used with
caution.
6.Patients should be informed of
potential surgical risks including any
permanent condition that has an
incidence greater than 0.5% or any
transitory condition that occurs with
an incidence of 5% or more.
On this basis, patients should
be informed about hemorrhage, pain,
swelling, alveolar osteitis, trismus,
and nerve injury.
 Bonding techniques allow placement of fixed
lower retainer which allows stabilization of
lower incisors, while awaiting further
development of third molars.
Bonding techniques also allow uprighting of
some third molars.
Thus the case for wait and see with third
molars is stronger than it was, and the case for
extractions has become weaker.
Kahl et al who carried out a long term
radiographic follow up of asymptomatic
impacted third molars recommend every 2
year radiographic review of former orthodontic
patients.