J Ind Orthod Soc 2005; 38:100-1 11

REVIEW Third Molars And Late Mandibular

Incisor Crowding - A Review
Sumitra, MDS
Professor,

Arundhati P.Tandur, MDS, MDO RCPS (Cl asg), MORTHRCS (Eng),

Pro fessor and Head,

Depa rtment of Orthodo nti cs a nd De ntofac ia l Orthoped ics,

KLES Inst it ute of De ntal Sc ie nces, Ba nga lore.

The role of third mo lars in ca usin g late mandibul ar in ciso r crowd ing is co ntroversi al. Various
Abstract
studi es have been co ndu cted to eva lu ate their relationshi p. The purpose of this article is to
(a) rev iew the st udi es rega rdin g the mandibul ar third mol ars an d late mandibul ar arch
crowd in g (b) fi nd out the ca use and effect re lat ion ship betwee n them (c) eva lu ate the
ju st ificat io n of prophylactic extractio n of third molars.

Keywords Late mandibul ar inciso r crowd ing, Third molars, Late mandibul ar growth, Anterior component
of force, Randomi zed co ntro l tri als, Prop hylactic extractio n of third mol ars.

Introduction arch crowd ing.8 Several studi es have been co nducted

The role of the third mol ars in late lower incisor crowd ing
is controversia l and has been debated for more than a
ce ntury. In a modern population, there is a strong
tendency for crowd ing of mandibul ar incisor teeth to
deve lop in the late tee ns and ea rl y twenties. Mild
crowd ing of the incisors tends to develop in we ll aligned
arc hes, o r it in c reases if mild crowdi ng is already
present. I Increased crowding of mandibul ar inc isors
takes place at about the time of third mola r erupti o n.
A lthough the mean age for third mo lar eruption is 20
years, mandibul ar anteri o r crowdin g co ntinu es well
beyo nd the eruption of third mo lars in both untreated
and treated individu als. 2 Even in children who initi ally
have generali zed anteri or spac ing, the teeth become
crowded as the decrease in arc h length and intercanine
w idth co ntinues fro m adolescence to middl e age. 3 It is
co nsid ered as a norm al physiological process of
matu ratio n.4, 5
Robinson (1859) stated th at irregul arit ies freq uentl y
resulted from mesia lly directed third molar pressure. 6
Broadbent (1941) was an advocate of the in signifi ca nt
ro le played by third mol ars. 7As late as 1989, Ri chardson
implicated the role of unerupted third mo lar in lower
to find ou t the assoc iation between the third mo lar and
late mandibul ar incisor crowd in g and have var ied
findings and interpretatio ns. Bishara and Andreasen
(1983),9 Ri chard son (1989),8 Vasir NS and Rob in so n RJ
(199 1),1 0 Bishara (1999) 11have reviewed this subject.
In 1971, Lask in 9 condu cted a survey of mo re than 600
Orthodontists and 700 Oral surgeons and found that 65%
were of the opinion that th e third mo lar so metim es
produce crowd ing of mandibular incisors. Two different
views ex ist regardin g the role of third mo lars in late
lower inciso r crowd ing.
1. Third mol ars should be removed o n a prophylactic
basis because th ey are frequ ently assoc iated w ith
future o rthodonti c and periodontal compl icatio ns as
well as other pathologic conditi ons.
2. Th ere is no scientific ev idence of a cause and effect
relationship between the presence of third mo lars
and o rthodonti c as well as periodontal problems.
Although there is a multifactor basis for late lower
incisor crowd ing, the third mol ars are extracted on a
pro phyl actic basis in most of the subjects to preve nt
late lower inci so r crowd ing.

100

Th e purpose of thi s arti cle is to rev iew the ev idence
rega rdin g th e ro le o f third mol ars in late low er in ciso r
crowding, find out the ca use and effect relati o nshi p
betwee n them , and to eva lu ate the ju sti fica ti o n of
pro ph ylacti c ex trac tio n of third mo lars.
Changes in the mandibular arch with age
Crowding does not increase in a linear fas hio n w ith
time. M ost of the changes occur in late teens or ea rl y
twenti es. Late crowdin g is observed in both untreated
and orthodo nti ca ll y trea ted subjects.
The changes in the mandibular arch in untreated
subjects
In untrea ted arches an in crease in crowdin g betw ee n
th e ages of 12-1 3 and 17- 18 has bee n repo rted by
Si atowsky, 1974; Sakud a et. al. 19 76; M o rres et. al. 1979;
Ri c hard so n1 979; Samp so n et. aI.1 983; Brow n and
D augaard-Jensen 1951 , between 12 - 2 1 'yea rs; 9 - 19
and 22-23 yea rs by Lund stro m, 1969; 11 - 25 years by
Hum e r fe lt a nd Sl ags v o ld, 19 7 2; 12 Ri c h ard so n
1982,92,95,98,99 13 ' 1713 - 20 years by Sinclair and li ttl e,
1983 18 H elm S, Peterso n PE 1989 19 13 - 26 years, in
adulthood, 25 -45 yea rs, 6w eeks-4 5 yea rs Bi shara et al
1990,9 4,9697,2°,5,21,22Littl e RM et ai., 1990 21 Freeman
199 4, 24 H arris EF 1997,2' Bo ndev ik. 0 199 8 23 -3 4
yea rs, 26Ca rter GA, M c N amara 199 8,27 Gillil and J et. al.
200 1,28 Busc hang PH 2003,29 Tibana R et al,2004 .30
Ri chard so n (1982) 13 examined th e changes in crowdin g
during five yea rs fo llow ing erupti o n of all perm anent
teeth anterio r to the third mo lars and found a tendency
towa rd increased crowdin g.
Sincl air and Littl e (1983) I n fo und th at inciso r irregul ari ty
increased from 13-20 years and females exhibited more
incisor irregul arity th an males.
Bishara et. al. (1989,9 4,96,97)2(),5,21,22 in th e longitud in al
studi es of th e changes in th e denta l arches and dentiti o n
betwee n ea rl y childhood to adulthood , in adulthood,
25-45 years and 6wee ks to 45 yea rs and obse rved
increased late incisor crowding in both th e arches, mo re
pro noun ced changes in mandibul ar anteri o r segment.
Ri chard so n (1992) 14studi ed low er arch crowdin g in th e
young adults between 18-2 1 yea rs. She concluded that
low er arch is stabl e, regardl ess of th e third mol ar statu s
or continued mandibular growth . In 1995 , 15she noted
th at lower inciso r crow ding increased signi fica ntl y in
the three yea rs after seco nd mol ar erupti on. In1 998, 16
Sumitra et al
she examined low er inciso r crowdin g in 46 untreated
individu als in the third decade of life and fo und th at
t h e in c rease in c ro wdin g was v ery sm a ll a nd
undetectable clini ca ll y. In a stud y of lowe r arch changes
betwee n 7 to 50 yea rs (1999) 17 she noted th at lowe r
inc i so r c ro wdin g d ec rease d b etw ee n 7-1 2 yea rs,
increased betwee n 12 yea rs to 50 yea rs. Th e max imum
increase was betwee n 13-1 8 yea rs, littl e o r no change
in th e third decade and a small in crease occ urred later
in li fe.
Bo ndevik 0 (1998) 22 examined changes in c rowdin g
between 23 -34 yea rs and noti ced th at lowe r in ciso r
crowdin g in creased during th at peri od.
Ca rter GA, M c N amara et. al 23 (1998) examined 82
subj ec ts betwee n late adol esce nce and fifth o r sixth
decade of li fe . Th ey noted th e increase in crowdin g
w as the same in males and fe males . It decreased in
three percent males and seven percent females.
Bu sc hang PH et. al. (2003 ) 29 studi ed a random sampl e
of 9044 indi v idu als between 15-5 0 years of age, and
fo und th at c rowdin g in c reased m os t d urin g ea rl y
adulthood and it was not assoc iated with th e third mo lar.
Tibana et al (2004) 30 studi ed the sample of 27 individu al
with c lass I and norm al occ lu sio n. M ea n age of th e
subjects w as 21 years initi all y and 28 years at the end of
the stud y. They observed increase in incisor irregul arity.
The changes in lower incisors in orthodontically
treated patients
Lo ng-term studi es have indi ca ted th at th e seve rity of
crowding increases during ado lesce nce to adulthood
in b o th no rm a l, untr ea ted su b j ec t s and al so in
o rth o d o nti ca ll y tr ea ted p ati ent s afte r re tenti o n i s
di sco ntinu ed. Th e resul ts of lo ng-te rm lo ngitudin al
studi es have shown continuing dec rease in arch length,
w idth and increase in in cisor crowding w ith age . Th e
probl em is th e in ability to dete rmin e w heth er th ese
changes occurred primari Iy as a result of the orth odontic
th erapy o r a pa rt of th e no rm a l dev e l op m e nt a l
matu rati o nal process. Horow itz and H ixo n (1969) In
stated th at o rthodo nti c th erapy mi ght tempo rari Iy alter
th e course of th ese continuing ph ysio logica l changes
and possibly, fo r a tim e, eve n reverse them. However,
fo ll ow ing mec hanotherapy and the peri od of rete nti o n
res tr aint, th e d ev el o pm enta l m at ur ati o n p rocess
resumes. Littl e and Bi shara have no ted in th e lo ng term
studies th at low er incisor crowding co ntinu es to increase
eve n during ad ult stage.
10 1
 - )L
Fast li cht in 1970 31 observed the c h an ges in
orthodonti ca lly treated subj ects and found that crowding
increased w ith age and third molars were not related to
crowd ing.
Little et. al. , 1981,88,90,99 12,2,3.33 Unde M D et. aI.,
1983, 34 Glen G et aI., 1987, 3sAdes et aI. , 1990, 36
Freeman 1994, 24 Sadowskey 199 4 , 37 Franklin GS et.
aI., 1995 , 38 Ni eke K 1995 , 3Y Artun 1996,40 Gilliland J
et. aI., 2001, 21\ Acar A 2002 ,4 1 Freitas KM et. al. 2004,
~ 2 observed in crease in post rete nti o n crowd in g in
extract io n cases that were well treated orthodo nti ca lly.
Etiology of late lower arch crowding
The ca uses of late lower arch crowd ing in an untreated
arc h are: 43
1. Pressure from the posterior of arch
a) Physio logic mesial drift
b) The anterior compo nent of forces of occ lusio n
o n mes ially inclined teeth
c) M esial vectors of mu sc le co ntractio n
d) Presence of deve lop ing third mo lars
But these forces do not expl ain th e increase in lower
arch crowding in all subj ects.
2. Late mandibul ar growth
3. Skeletal structures and complex growt h patterns
4. Soft tissue maturation
5. Periodontal forces
6. Tooth structure/size
7. Occlusal factors
8. Connective ti ssue changes
9. Lac k of att rition 1
Theories to account for late lower arch
crowding
Three major theories have been put forward to explain
this: 1
1. Lack of attrition in the modern population:
Raymond Begg, a pioneer Australian Orthodontist noted
in his studies of Australian aborigines that malocc lu sion
was uncommon and large amount of interproximal and
occ lusal attrition occurred. Because of this he advocated
extraction of premol ar teeth in modern populatio n to
provide th e eq uivalent of attrition seen in aborigines.
H e was co nvinced that only anatomically co rrect
occl usions resulted from attrition.
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J Ind O rthod Soc 2005; 38:100- 111
Proffit points out that Begg's theory does not exp lain
the abse nce of late c rowding in modern A ustr ali an
aborigines who lack attriti on of teeth due to modern
diet. It has been observed in other population groups
that late crowding may develop eve n after the premo lars
are extracted and arc h length is red uced by modern
orthodontic treatment. Thus thi s theo ry does not exp lain
late crowdi ng.
Corrucc ini RS in 1990 44 studi ed modern A ust rali an
aborigines who were among first ge neration lac kin g
interproximal attriti o n due to modern diet. He concluded
that small jaws rather than large teeth were the cause
of tooth size arch length d iscrepa ncy.
M ockers 0 et. al. in 2004 45 investigated dental crowd ing
from the cop per age and examined the exte nt and
pattern of wear. Crowding was estimated in 43 ad ult
mandibl es using Littl e's irregul arity index. Th e remains
were found at the archaeo logica l site of Ro aix, located
in south of France. Th e sample used for the study was
43 intact mandibl es. All the mandibl es presented
crowding w ith a majo rity of minimal and mode rate
irregul arities, but in seven cases there were extreme
irregularities and two ca nine impactions. The results
are in co ntrast with the Iiteratu re that crowd i ng was
rare in prehistoric population.
2. Late mandibular growth: 1
Bjork's and Skiller's implant studies (1972,1983) exp lain
late crowding and its relationship to the growth pattern
of the mandibl e. Th e rotation of the jaw influences the
m ag nitud e of e rup tion , direct io n of er upti o n and
ultimate anteroposterior position of the inc isors.
As a re sult of in crease d growth increments in the
mandible than the maxi lla because of cephaloca udal
grad ient of growth in late teens, th e contact relationship
of m ax ill a and mandibular incisors changes. At that
time, o ne of th ese events take pl ace,
1. Po st e rior di sp la ce ment of th e m andibl e
accompanied by di stortion ofTMJ function and di sc.
2. Th e upper in cisors procline and spacing between
these teeth appears.
3. Th e lower in cisors displace lingually and become
crowded.
All the three phenomena have been reported, but the
most common eve nt is lower incisor crowding.
The path of eruption of the mandibular inci sors is upward
and forward. Th e normal internal rotati o n of the

mandibl e ca rri es th e jaw upward and anteri o rl y. Th is
rotat io n alters th e erupti o n path of the m andi bul ar
in ciso rs and tend s to upri ght th e in ciso rs parti cul arl y if
excess ive rotati on is also present. Th e forwa rd intern al
rotat io n of the mandi ble is more th an th at of the max ill a;
the decrease in arch perim eter is grea ter in mand ibl e
th an in max ill a.
Th e im plant studi es have confirmed th at th e changes
in anteroposteri o r positi o n of th e incisors have major
in fluence o n arch length changes th an the mo lars.
Late inc iso r crowdin g has bee n observed in pati ents
w ith anteri or open bite and bac kwa rd rotati on of th e
mandible. In thi s situ ati o n, the rotati on of th e mandibl e
carries th e dentiti o n fo rw ard , thru stin g th e in c iso rs
aga inst th e lip. Thi s creates li ght co ntinuous so ft ti ssu e
pressure by the lip, whi ch lead s to crowdin g of th e
protruded incisors and reduces arch perim eter.
3. Pressure from third molar: 1 measured as th e subj ect w as biting o n left second mol ar
In most individu als, th e third mo lars are impac ted
because of lac k of space. Late crow ding deve lops at
about th e time of th e third mo lar erupti o n. The eruptin g
teeth produ ce pressure th at lead s to late crowdin g.
Woodside (1970) 46 postul ated th at in th e absence of
third mo lar, the dentitio n could settle di stally in response
to fo rces generated by growth changes and soft ti ssue
pressures. Th e prese nce of impacted third mo lars at th e
di stal end o f th e low er arch w ou Id prevent the posteri o r
teeth from shifting di stally, and th eir presence w ould
guarantee th at crow ding would develop. Thi s indi cates
a passi ve ro le of third mol ars in late incisor crowding.
However, late incisor crowding does occur in individu als
with congeni ta ll y mi ssing third mol ars. (Vego, Kapl an)
4 7 , 11 Thi s th eo ry does not expl ain late crowdin g, so th e
presence o f th ese teeth is not cr iti ca l for late cro w ding.
In additio n to th ese th eori es, th e anteri o r component of
occlu sa l force (ACF ) is also important in the di scussio n
of late lower arch crowdin g.
Anterior component of force
Th e primary interest surrounding ACF is because of its
possibl e rol e in causing mesial mi grati o n of teeth and
subsequent dental malali gnment. Th e axial in clinati o n
of permanent teeth is such th at the fo rces of masti cati o n
produ ce a mesi al resultant throu gh th e contact po ints
of th e teeth, th e anteri or component of fo rce. ACF is
th o ught to result fro m th e ax ial in c lin ation of th e
Sumitra et al
posteri o r teeth , w hi ch ca uses th ese teeth to tip fo rwa rd
d urin g occ lu sa l l oa din g. Thi s tippin g fo rce i s
subseq uentl y transmitted to mo re anteri o r teeth thro ugh
interp rox imal contacts. Th e tendency fo r th e teeth to
move fo rward as a resul t of occlu sa l forces va ri es greatl y
acco rd ing to th e angul ati o ns of th e teeth w ith respect
to eac h other and espec ially affec ted by the steepness
of th e occ lu sa l pl ane. 48
E.H. A ngle is cited as havin g o ri ginall y ca ll ed attenti o n
to thi s fo rce. Stall ard (1923), Newcomb (1936), W aldran
(1 94 2) suggest th at ACF co uld ca use malali gnment.
How ever, ACF was neve r measured befo re 1989.
South ard et. al. in 1989 49 deve loped an instrument to
measure AC F. Th ey developed a tension transdu ce r that
w as hooked throu gh a perforated 0.001 5-in ch stainless
stee l dental matri x strip . The matri x strip w as slipped
interprox imall y and w ithd raw n at approx imately 2 to 5
mm/sec. Fri c ti o n al res i st ance o f w ithdr awl was
with ax ial load of 20 pounds (within the range of normal
chewin g) and aga in w hen the subj ect w as not biting.
Th e di stributi o n of thi s force and its di ssipati on w ere
determined for 15 subjects. ACF was ca lcul ated from
fri cti o nal force measurements. They noted th at ACF 's
magnitude w as quite large even when generated by
fun cti onal loads. The ACF appli ed aga inst the ca nines
during a con servati ve chewin g fo rce o n th e seco nd
mo lars was 8 to 200 times greater th an th e minimal
fo rce required to produ ce tooth movement. Mu ch
higher fo rces are generated in persons with greater biting
strength . According to W einstein (1967), continuous soft
ti ssue fo rces as small as 0.0035 pounds are capable o f
movin g teeth. The ACF progressed anteri o rl y throu gh
th e interpro x im al co nt ac ts and not beyo nd o pen
co ntacts. In some subjects thi s fo rce passed beyond th e
midline and continued around the arch to th e ca nines
of the co ntralatera l side.
Southard et. al. in 199 0 50 based o n th eir experiments,
suggested th at malali gnment of mandibul ar anterior
teeth was related to the mag nitud e o f ACF and to
ti ghtn ess o f interp rox imal co nt ac ts in m andibul ar
poste ri or segment. ACF can cause dental malali gnment
in person s who c lench, brux or in any other w ay load
posteri o r teeth ax iall y for extended peri od s o f tim e.
Aca r A in 2002 conducted a study to investi gate w heth er
a relati o nship ex ists between ACF and postretentio n
crowdin g in mandibul ar inc iso rs. Th e stud y sa mpl e
co nsisted of 32 subj ects. Th e average post retention
peri od w as 3.2 years.
103

In the no n-ex t rac ti o n gro up , a stro ng co rrel at io n
betwee n ACF and irregul ari ty index was found at ca nine
p remo lar contact.
In the extract ion group, a positive co rrelatio n was found
betwee n ACF and th e irregul arity index at th e second
premo lar- first premo lar contact but no co rrelati on was
fo und at the ca nine premo lar co ntacts. Th ey conc luded
that moderate positive corre lati on ex isted between ACF
and post retentio n mandi bu lar arch crowd ing in subjects
treated w ithout extraction.
Studies relating third molars to late crowding
Be rgstro m and Jense n (196 1) 11 ca rri ed o ut a c ross
sect io nal study on 60 dental students of w hom 30 had
unil ate ral age nes is of u ppe r third m o lars, 27 had
age nesis of lower third mo lars, and had one third mo lar
absent o r lost. Th ey measured th e space conditi o ns and
mi d line disp lacement o n both sides of th e pl aster casts
of those students. Th e resu Its suggested mo re crowd i ng
in the quad rant w ith third molar prese nt th an in th e
quadrant w ith third mo lar mi ssing. M esial di spl acement
of late ral segments was found o n the side with third
mo lar in m and ibul ar arc h but not in m ax ill a. N o
correlati o n betw een age and th e degree of crowding or
mesial di spl acement was fo und. Th ey observed th at th e
unil ateral presence of thi rd mo lar did not seem to have
an effect o n th e mi d lin e. They co nc lud ed th at th e
p rese nce of third m o l ar app ea red to exe rt so m e
influence on the deve lopment of the dental arch bu t
not to the extent th at w oul d ju sti fy either the remova l
of tooth ge rm , or th e extracti on of third mo lar, other
th an in exceptional cases.
Vego (1962) 47 co ndu cted a lo ngitudinal stud y o n 40
cases w ith lower third mo lar prese nt and 27 cases w ith
co nge nital abse nce of bo th low er third m o lars, in
un t reated arc hes. Th e f irst m eas urem ent of arc h
pe rim ete r w as made after the eru pti o n of seco nd mo lar
app rox im at e l y 13 yea rs ave rage and seco nd
measurement was made at average of 19 yea rs. Th e
resu It of thi s stud y suggested th at th ere was signifi ca ntl y
greater degree of c rowding in the group w ith low er third
mo lar. H e concl uded th at th e erupting third mo lar could
exert a force o n approx im ati ng teeth. In both groups,
arc h pe rim eter loss was obse rved and so m e cases
w ithout lower third mo lar, showed an increase in severity
of rotated or malali gned teeth. Th erefo re he suggested
that there are multipl e facto rs invo lved in the crowding
of an arch.
104
J Ind O rth od Soc 2005; 38:100- 11 1
Se lmer-O lsen's stu dy (1970) 41 suggested that in peop le
w ith un ilatera l co ngenital abse nce of third mo lar, th ere
was less c rowd i ng o n that side of the arch w itho ut thi rd
mo lar th an o n the other side w ith third mo lar.
Schwa rze (1975) II in a long-term study compa red a
group of 56 pati ents w ith thi rd mo lar ge rmectom y and
49 subjects w hose third mo lars were allowed to develop.
He fou nd a signi fica nt fo rward movement of th e first
mo lars assoc iated w ith increased lower arch crowd ing
in no n-extracti o n group .
Lind qvi st and Th ilander (1982) 5 1 examined 23 boys
and 29 girls w ith impacted third mo lars o n both sides of
th e mandi b le. Th e impacted mo lar o n o ne side was
removed and the no n-extracti o n side was used as a
co ntro l. Ave rage age at the time of operati o n w as 15.5
yrs. (13 -1 9 years). Befo re th e operati on and annu all y
fo r three yea rs after th e surgery, the stud y casts and
cephalograms w ere ta ken. Th ey noted th at the space
change o n th e extracti on side was improved in relati o n
to the co ntro l side in 70 percent of cases. Th ey fo u nd a
very small benefic ial effect, 0.16mm less crowd ing in
the group w ithout third mo lars compared w ith the group
wi th th ird molars. They conc luded th at extracti o n could
be recommended in severe c rowdin g. Th e study was
not abl e to predi ct whi ch pati ents reacted favo rabl y or
unfavo rab ly to remo val of third m o lars in cases of
antic ipated crowding.
Ri chardson ME (1 989) Bconducted the Belfast third mo lar
stud y th at is in suppo rt of th e pressure from behind
theo ry. She exa mined 5 1 subj ects (22 fem ales and 29
males) wi th intact lower arches and bil atera l third mo lars
present, in the age group of 13 d 18 yea rs. Th ese cases
show ed more th an 1mm in crease in crowding on each
side. In some qu adrants, the inc rease in crowding was
4mm and onl y 16% of arches did not show inc rease in
crowd ing. M esial in c lin ati o n of th e lower ca nines is
usuall y co nsidered to be a sign th at the bu cca l segment
has moved forward . Three cases showed a distinct mesial
in c lin ati o n and in c rease in lowe r in c iso r crow din g
during th e obse rvati o n peri o d . She co nsid ered third
mo lars as o ne of th e ca uses of late low er arc h crowd ing.
Studies indicating a lack of correlation
between third molar and late crowding
Shanl ey (1962) 8 in a sm all c ross sect io nal stud y,
compared low er inc isor crowdin g and proc umbency in
three gro ups of subj ects wi t h bil aterall y imp acted,
erupted o r conge nita ll y abse nt thi rd molar. He found

no significant differences and concluded that third
molars have little influence on crowding or
procumbency of lower incisors.
Buschang P H and Shulman (2003) conducted a study
on the prevalence of lower incisors crowding in
untreated persons in the age group of 15-50 years. A
random sample ot' 9044 individuals was used. They
concluded that erupted third molars were not associated
with crowding and significant increase in crowding took
place during adulthood.
Retrospective studies
A number of studies found no correlation between third
molar and late crowding.
Kaplan in 1974 I I investigated the influence of third
molar on post treatment changes in the mandibular
anterior crowding. The study included 75 orthodontically
treated patients. The pre treatment, post treatment and
10 years post retention study models and cephalograms
were examined.
The sample was divided into three groups:
1) First group - 30 persons with both third molars erupted
to the line of occlusal plane, in good alignment
buccolingually and of normal size and form.
2) Second group - 25 persons with bilaterally impacted
third molars, candidates for surgical removal.
3) Third group - 25 patients with bilateral agenesis of
mandibular third molar.
Some degree of lower incisor crowding relapsed in the
majority of cases. The third molar groups showed no
significant increase in crowding, whether premolars
were extracted or not. He concluded that the presence
of third molar does not produce a greater degree of
lower anterior crowding and rotational relapse after
cessation of retention. According to Kaplan, the theory
that third molar exert pressure on the teeth mesial to
them could not be substantiated.
Ades AG et. ai., (1990) conducted a long-term study to
determine the relation of third molar to changes in the
mandibular dental arch. The sample for this study
consisted of four groups and subgroups. The groups
consisted of premolar extraction, non-extraction with
initial generalized spacing, non-extraction, and serial
extraction untreated subjects. The subgroups were
divided into persons who had mandibular third molars
that were either impacted, erupted into function,
Sumitra et al
congenitally absent or extracted at least ten years
before post retention records. The mean post retention
period was 13 years. (10-28 years) The mean post
retention age was 28 years 6 months. (18 years 6 months
- 39 years 4 months). They found th at mandibular incisor
irregularity increased while arch length and incisor
width decreased . The third molar subgroups revealed
no significant differences in the parameter studied. No
significant difference in mandibular growth pattern was
found in third molar subgroups. Incisor crowding was
not significant between third molar subgroups. They
concluded that the third molar removal with the
objective of alleviating or preventing mandibular incisor
irregularity might not be justified.
Nieke et. ai., (1995) 52 in their study of post retention
c rowding and incisor irregularity considered the
presence or absence of third molars, dividing the sample
of 226 cases into subgroups; bi laterally erupted,
impacted third molars, and bilateral third molars
agenesis or extraction. Lower arch crowding was found
to be influenced by the presence of third molars. In
cases with missing mandibular third molars, less amount
of relapse of crowding was seen than in any case with
impacted or erupted third molars. On the side of missing
third molars, 1.2 mm of less crowding was seen. They
concluded that the crowding was statistically significant
but clinically insignificant.
Little RM (1990,1999) examined mandibular crowding
during the post treatment phase and concluded that
mandibular crowding is a continuous phenomenon well
into the 20-40 yrs age bracket and beyond. Third molar
presence, absence, impacted or fully erupted, seemed
to have little effect on the occurrence or degree of
relapse.
Fastlicht (1970) compared the degree of crowding in
two groups-28 orthodontically treated subjects and 28
cases of teenagers and adults who did not receive
orthodontic treatment. He found that the third molars
did not correlate with observed crowding. Crowding
increased with age and increased in cases with less
intercanine width. Crowding of mandibular incisors was
more in untreated group and more noticeable in males.
Southard et. al. (1991) 53 measured the mesial force
exerted by unerupted mandibular third molars using a
technique similar to measuring the anterior component
of occlusal force. The sample consisted of 14 males
and six female patients. Their hypothesis was that the
mesial force exerted by unerupted third molar increases
105

tightness of all proximal posterior tooth contacts and
that surgical removal of third molar relieves tightness
by eliminating this force.
A 0.038mm thick stainless steel strip was slipped
between two teeth and withdrawn with a digital
transducer. The contact tightness was measured
bilaterally in twenty patients with bilaterally unerupted
mandibular third molars, in upright position,
immediately before extraction of third molar. The
patients were placed in a supine position on the operating
table and third molars were extracted unilaterally.
Immediately after unilateral third molar extraction , the
tightness of proximal contacts was measured. Contact
point tightness decreased bilaterally to the same extent.
If a significant mesial force from third molars existed,
the tightness of proximal contacts would have reduced
on the side of extraction of third molar.
They were unable to detect a mesial force exerted by
unerupted third molars. They observed that the change
of posture relieves the proximal contact tightness
dramatically. The second part of the experiment was
conducted to determine the effects of postural changes
on proximal contact tightness where no surgery has been
done. In ten subjects the mean decrease in proximal
contact tightness was noted in mandibular posterior
contacts two hours after the patient had been moved
from upright to supine position. When a steel strip is
slipped between the teeth, they will eventually separate
and tightness of contact poi nt between the teeth wi II
decrease as a result of viscoelastic relaxation of
periodontal ligament. However, This finding
demonstrated that the observed effect of posture was
not simply a result of viscoelastic relaxation of
periodontal ligament.
They concluded that if a significant third molar pressure
existed, it should have been detectable in these patients.
Its magnitude is too small to be measured by that
technique.
Richardson (1992) studied lower arch crowding in the
young adults between 18 -21 years in untreated
individuals with intact lower arches. The sample
consisted of 33 men and 32 women. The mesial drift of
first molars was measured on 60-degree cephalometric
radiographs. The mesial drift of molars was not clinically
significant in this age group. She concluded that the
lower arch is stable in terms of mesial drift and tooth
alignment, regardless of third molar status and
continuing mandibular growth.
106
J Ind Orthod Soc 2005; 38:100-111
Pirttini emi et.al. (1994) 54 evaluated the effect of
impacted third molar removal on 24 individuals in the
third decade of life. Casts were examined before and
one year after extraction of third molar. They found
slight distal drift of second molar but no significant
change in the lower incisor region.
Vander Schoot et. al. (1997) 55 examined 99 patients
before and after treatment and at least three years after
end of retention. The sample was divided into four
groups- subjects who had third molars erupted,
impacted, were extracted and congenitally missing.
No significant differences in the irregularity index were
found between the different groups. They concluded
that no relationship exists between crowding and the
presence or absence of third molars.
Harradine et. al. (1998) 56 conducted a prospective
randomized control study to evaluate the effect of
extraction of third molars on the late lower arch
crowd i ng. 164 subjects participated in the study
following completion of orthodontic treatment. The
number of patients who returned for follow- up was 77.
They randomized 44 of these patients to have third
molars removed. There was no evidence of responder
bias. A ll the patients had third molars with the proposed
path o f eruption through the adjacent second molar.
No treatment in the lower arch or only premolar
extraction was carried out. No statistically and
clinically significant decrease in crowding (1.3mm) was
observed in the third molar extraction group. They
concluded that the removal of third molar to reduce or
prevent late crowding could not be justified.
AI Balkhi et. al. (2004) 57 carried out a post orthodontic
treatment pilot study in the age group of 14-19 years to
evaluate the role of different third molar conditions on
recrowding of lower anterior teeth in the absence of
tight interproximal contacts. Proximal stripping was
done to relieve the tightness of interproximal contacts
between the lower incisors. The cases were followed
up for one year. The results of this pilot study did not
show correlation between different thi rd molars
conditions and lower incisor crowding.
Discussion
Bergstrom and Jensen's study (1961) suggested a positive
role of the third molars in late crowding.
Vego (1962) noted that the erupting third molars could
exert a force on the adjacent teeth. He observed late
crowding in subjects with congenitally missing molars.

Therefore, he suggested that there were multiple factors
involved in the crowding of lower arch.
Woodside DG (1970) postulated that in the absence of
third molar, there is distal settling of the whole
mandibular dentition during the growth period and the
presence of third molar would prevent distal settling.
Schulhof RJ (1970)511 compared Vego and Kaplan 's work.
According to him , if different statistical tests were
applied in Kaplan ' s study, their findings would support
Vego's conclusions. He reached at a conclusion that
the third molars were a factor in late incisor crowding.
Ricketts RM et. al. (1976) 9 stated that removal of the
third molar bud at the age of seven to ten years is
surprisingly simple and relatively atraumatic.
Lindqvist and Thailander (1982) were in favor of the
opinion that the third molars cause late crowding in
some individuals.
Richardson ME (1989) conducted the Belfast third molar
study that is in support of the pressure from behind
theory. She examined 51 subjects (22 females and 29
males) with intact lower arches and bilateral third molars
present, in the age group of 13 and 18 years. These
cases showed more than 1mm increase in crowding on
each side. In some quadrants, the increase in crowding
was 4mm and only 16% of arches did not show increased
crowding. Mesial inclination of the lower canines is
usually considered to be a sign that the buccal segment
has moved forward. Three cases showed a distinct mesial
inclination and increased lower incisor crowding during
the observation period. She considered third molars as
one of the causes of late lower arch crowding.
Richardson ME (1990)59studied the effects of removing
second molars on late lower crowding and observed a
slight distal shift of second molars and decrease in lower
incisor crowding.
Richardson ME (1996)observed greater increase in third
molar space, forward movement of the second molar
and increase in interincisal angle in the group with
crowding than the non-crowding group between the ages
of 12.5 and 15.5 years.
Vasir NS, Robinson RJ (1991) reviewed the role of third
molars in late incisor crowding and noted that it
indicates a small but statistically significant relationship.
Graber (1970) 46 opined that the third molars do not
cause crowding and its role has been misunderstood in
Sumitra et al
orthodontics. But terminal horizontal growth and
disturbances in musculature can cause crowding if there
is no room.
Bramante MA (1990) 60 concluded that the vast bulk of
evidence indicates insi gnificant rol e of third molars in
late crowding.
According to Sampson WJ (1995) 6 1 it is illogical to
assume a single cause as the simple observation if
crowding belies the complexity of possible interacting
factors.
Sinclair JH (1996) 62 concluded that carrying out a
procedure that has a significant risk of morbidity without
good reason is unacceptable. We need to reconsider
our whole approach to third molar removal.
Vego's study (1962) showed a slight increase in
crowding of 0.8 mm in the group with the third molars
present.
Fastlitch's study (1970) that included an untreated
control group suggested that the third molars do not
cause late crowding.
Schwarze (1975) 56 observed a decrease in crowding of
1.5 mm on the side of prophylactic germectomy of third
molar. The extractions were not randomized in this study.
Lindqvist and Thilander's (1982) study showed a
beneficial effect of 0.16mm less crowding on the side
of extraction of the third molars.
Little RM (1990,1999) observed that the absence or
presence of third molars seemed to have little influence
on the occurrence of late crowding in untreated
individuals, and the degree of relapse of crowding in
orthodontica"y treated persons.
Southard et al (1991) were unable to measure the
mesial force exerted by third molars using a technique
similar to measuring anterior component of force. They
concluded that it was too sma" in magnitude to be
detected by that technique. It indicates that pressure
from back of the arch is not significantly influenced by
third molar extraction.
Richardson (1992) reported that the forward mesial
movement of first molar was not related to third molar
status in 18-21 years age group.
Nieke et. al. (1995) reported less relapse of crowding
(1.2 mm) on the side with third molars missing. This
was statistically significant but clinically insignificant.
107

Th ere is onl y one prospective randomi zed co ntrol tri al
regar din g th e third mo lars and late lo w er in c iso r
crowd in g. In H arradin e's rand omi zed c lini ca l tri al,
(1998) ext raction of third mo lar produ ced a max imum
benefit of 1.3 mm . Thi s was co nsidered as statisti ca ll y
and c lini ca ll y in signifi ca nt.
Busc hang PH and Shulman (2003) concl uded th at th e
eru pted third molars w ere not assoc iated w ith increased
mandibul ar crowdin g in untrea ted individu als.
Late crowding has bee n reported in ind ividu als with
mi ss in g third mol ars. It c lea rl y indi ca tes th at oth er
etio logic fac tors are more important th an third mo lars.
Th e impl ant studi es have confirmed th at the changes
in anteroposteri or positi on of th e inc iso rs have major
influence on arch length changes th an th e mo lars. I
Th e latest evid ence suggests th at th e third mo lars do
not have a signifi ca nt rol e in th e development o f late
mandibul ar arch crowding and should not be extracted
to prevent late lower arch crowding.
Limitations of various studies
Si mil ar studi es show di ssimil ar results pa rti cul arl y w hen
obse rving cases of third mo lar ex tracti o n or agenesis.
They may di ffe r geneti ca ll y in tooth size and arch length
and th e subj ects ca nnot be matched in all aspects.
In Schwa rz's study of prophyl acti c ge rm ectomy, th e
bas is fo r ex trac ti o n was not desc ribed . He did not
randomi ze extracti on of third mo lars.
Ni eke et al fo und c lini ca ll y in signi fica nt increase in
post retenti on crow ding (1.2 mm). Th e ex tracti on and
non-ex tracti o n groups we re unmatched. Th e mi ssing
third mo lars we re th e resul t of age nes is rath er th an
extracti o n and th e groups we re not matched.
It is d iffic ul t to compare th e changes in lowe r arch
ali g nm ent in untr ea t ed arc h es w ith t hose o f
ort hodo ntica ll y treated arches. Th e fac to rs re lated to
treat m ent and relapse tend ency ca n in flu ence th e
amoun t of crowd ing obse rved. Th e facto rs contributing
to post retention crowding are:
(a) Arc h w idth red uct io n fo ll ow in g in c rease during
trea tm ent
(b) Th e amount and d irecti on of tooth movement
(c) Th e interin c isa l angle
(d) Th e relati onship of th e inc iso rs to th e soft ti ssues at
the end of th e treatment
108
J Ind O rthod Soc 2005; 38: 100- 11 1
(e) Periodontal degenerati on
(f) Th e natu ra l relapse tendency.
Th e meth ods of measuring th e changes in th e amount
of crowdin g also di ffer in th ese studi es.
Diffe rent age groups fo und in th ese studi es make it
di fficult to compare th e results.
Untrea ted contro l groups we re not included in most of
th e post retentio n studi es.
Consensus development conference report on
removal of third molars
N ation al In stitute of Dental Resea rc h in 1979 and
Ameri can Associati on of Oral and Maxillofacial Surgery
in 1993 sponsored it. Some of the points of consensus
we re: I I
1. Crowdin g of th e low er incisors is a multifac tori al
phenomenon th at invo lves a decrease in arch length ,
tooth si ze, sh ape and relati o nship , nar row in g of
interca nine dimensio n, retru sion of inc isors, and
grow th changes occurring in adolescence. Therefore,
it w as agreed th at th ere is littl e rati onale based o n
th e ava il abl e evid ence for th e extrac ti o n of third
mo lars sol ely to minimize present or future crowding
of th e lowe r inciso rs. If adequ ate room is avail abl e
fo r third mol ar erupti on, every effo rt should be made
to bring th ese teeth into function al occlu sio n.
2. Orth o donti c th e rapy, in b o th m ax i ll ary and
mandibul ar arches, may require posteri or movement
of both fi rst and second mo lars by either ti ppi ng or
translati on, w hi ch ca n result in impacti on of third
mo lars. To avi od imp ac tin g third mo lars and to
fac ilitate retracti on, it may be deemed advisabl e in
some cases to remove thi rd mo lars before sta rti ng
retracti on procedure.
3. Althou gh th ere are orth odonti c reaso ns fo r th e ea rl y
removal of third mo lars, th e co nse nsus was th at
enucl eation of third mo lar bud s at seve n to nine
yea rs of age is not acceptabl e. Thi s is beca use the
present predictive techniques for third mo lar eru ption
or impacti on are not hi ghl y reli abl e and shoul d be
used with ca uti on.
Current trends for third molar extractions
Th e third mol ars are routinely removed for th ree reasons:
1. All impacted third mo lars are potenti all y pathogeni c
therefore prophyl act ic re moval should be done to
elimin ate th e ri sk.

2. The prese nce of third molar can cause late inc isor
crowding.
3. Removal during adolescence and young adulthood
reduces the risk of operative and postoperative
compli cations in older patients.
Nieke et. al. (1994) 11 evaluated orthopantomograms of
58 orthodontically treated patients with asymptomatic
impacted third molars. In a 15-year follow-up, they could
not find the predictive value of age, period of impaction,
extent of space deficiency, developmental stage, level
of eruption, and bone co nditions. They suggested that
third molars should be periodically eva lu ated.
Song et. al. (1997,2000) 6 3. 64 carried out systematic
reviews of literature on third molars and concluded that
there is no reliable research evidence to support
prophylactic removal of disease free impacted third
molars. They concluded that there is little justification
for the removal of pathology- free impacted third mol ars.
Kruger et. ai., (2001) 65 observed complete eruption of
some radiographically apparent impacted third molars
(other than horizontal impactions) between 18-26 years,
and the low incidence of pathosis assoc iated with
impacted third molars.
According to Pasqualin, Erniami et. ai., (2002) 66 the
current trend for third molar extraction is a more
co nservative clinical approach rather than an
aggressive extraction poli cy.
The evidence suggests that the most appropriate
treatment for asymptomatic, pathology-free impacted
third molars in young adults is observation instead of
prophylactic removal.
Recommendations for future research
The studies that include untreated individuals provide
a better insight to the cause and effect relationship of
third molars and late mandibular incisor crowding th an
the post retention studies.
1. Although data from observational studies is useful ,
well designed randomized control tri als should be
co nducted in untreated subjects to compare the
effect of prophylactic removal of impacted third
molars with deliberate retention , on late lower
incisor crowding.
2. Randomized control trials should be conducted to
evaluate late lower incisor crowding in orthodontically
treated subjects with the inclusion of an untreated
control group.
Sumitra et al
Conclusions
1. Long-term studies in untreated individu als do not
suggest evidence of a cause and effect relationship
between third molars and late mandibular in cisor
crowding.
2. Asymptomatic and pathology-free third molars
shou Id not be extracted to prev ent late lower
crowd ing in untreated individuals.
3. The asymptomati c and pathology-free third molars
should not be extracted to prevent post retention
crowding.
Communications
Dr. Sumitra, MDS
Professor
Dept. of Orthodonti cs and Dentofacial Orthopedics,
KLES Institute of Dental sciences, Bangalore.
E-mail: sumayjr@yahoo.com
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