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Effects of Lower Third Molar Angulation and Position on Lower Arch Crowding

Article  in  International journal of orthodontics (Milwaukee, Wis.) · March 2016

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Effects of Lower Third Molar Angulation and Position on Lower Arch

Crowding

By Mimoza E. Selmani; Julijana Gjorgova; Manushaqe E. Selmani; Mirsad Shkreta; Shkelzen B. Duci

Abstract: The role of the third molars in lower arch crowding has been debated for more than a century. Objectives: The aim of this
study was to determine the relationship between lower arch crowding and the presence of angulation and position of lower third molar.
Methods and Materials: The measurements of the dental arch were made in 120 subjects aged 16 to 21 years, with average age to 18 years.
The subjects were divided into two groups: Class I normal occlusion comprised 35 male and 25 female with mean age 18, 87 years, whereas
Class I crowding comprised 27 males and 33 females with mean age 18, 5 years. The dental pantomogram (DPT) were used to calculate
the ratio of retromolar space (Ganss ratio), angulation of third molar to second molar and third molar to the base of the mandible. Results:
The results showed that measurements of Ganss ratio, third molar angulation to the base of the mandible, and third molar to second molar
inclination, was statistically significant between crowded and normal groups. Conclusion: It can be concluded that there was a strong
relationship between angulation and position of third molars and lower arch crowding.
Key words: Third molars, angulation, lower arch, crowding

ntroduction
Crowding of teeth is considered as the most
common type of malocclusion,1 which is one of
the most frequent reasons why people consult an
orthodontist, taking into account the high aesthetic demand
expressed by patients.2 Dental crowding can be simply defined
as the overlap of teeth caused by insufficient space within the
dental arch.3 Crowding may occur due to different reasons, for
example growth, decrease in dental arch length, maturation,
aging of dentition, mesial drift, soft tissue pressures, and tooth
morphology.4 According to Richardson,5 during the teenage
years, pressure from the back of the arch is an important cause
of late mandibular incisor crowding. Such pressure because
of physiologic mesial drift, the anterior component of the
force of occlusion on mesially-inclined teeth, or the presence
of a developing third molar may cause forward movement
of the buccal teeth, with shortening of the arch and increase
in crowding. A large number of researches have been aimed
to reveal influence of potential factors on the stability of
the obtained orthodontic results.6-9 Robinson10 claimed that
late lower incisor crowding is caused by the erupting third
permanent molar teeth in the lower jaw. A study of 60 dental
students with unilateral aplasia of a third permanent molar
showed less crowding on the side where the third permanent
molar was missing than on the contralateral side.11 Bjork’s
and Skiller’s12 implant studies explain late crowding and its
relationship to the growth pattern of the mandible. They had
confirmed that the changes in anteroposterior of the incisors
have a major influence on arch length changes than the molars
but found no evidence to confirm a relationship between
late lower labial segment crowding and third molar eruption.
Richardson13 conducted the Belfast third molar study that is in
support of the pressure from behind the theory. She examined
51 subjects (21 females and 29 males) with intact lower arches
and bilateral third molars present in the age group of 13 to 18
years.
Tufekci, et al14 compared the opinions of Swedish
orthodontists and American orthodontists regarding the
association between third molar eruption and dental crowding.
The results showed that both Swedish and American
orthodontists believed that lower third molars were more likely
than upper third molars to cause force (65% and 58% for
Swedish and American orthodontists, respectively) and crowding
(42% and 40%, respectively).
Some authors have tried to explain the arch crowding
through third molar position and angulation, 15 whether the
presence of third molars is capable of causing alterations in the
positioning of other teeth.
Therefore, the purpose of this study was to determine the
relationship between lower arch crowding and the presence of
angulation and position of lower third molar
Methods and Subjects
The study groups consisted of 120 subjects aged 16 to 21
years, with average age of 18 years. The sample was divided into
two groups: Class I normal occlusion comprised 35 male and
25 female with mean age 18.87 years, whereas Class I crowding
comprised 27 males and 33 females with mean age 18.5 years.
The crowded group (Figure 1) selected from patients seen in
the Department of Orthodontics, Dental University Clinical
Center, Kosovo. The inclusion criteria were: (1) presence of all
permanent teeth (including un-erupted third molars); (2) Angle
Class I molar relationships; (3) no artificial dental crowns and
no anomalies of crown morphology; and, (4) no orthodontics
treatment in maxillary and mandibular arch.

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Figure 1: a) Class I molar relationship on crowding group;
b) Crowding of the lower arch (unerupted third molars).
Figure 2: a) Class I molar relationship on noncrowding
group; b) Noncrowding group of the lower arch (erupted
third molars).
The normal group (Figure 2) was selected from the students
in Dental University of Kosovo, and they have all permanent
teeth in both jaws (including erupted third molars) with normal
occlusion, which had not undergone orthodontic treatment.
The study was approved by the Local Research Ethics
Committee in our country, and the participants were informed
by the purpose of the study. Once participants have given their
consent, the panoramic radiograph was taken to obtain the data
of the study.
The mandibular dental arch was examined clinically, and
each subject had a panoramic radiograph taken (Figures 3, 4) All
the measurements were made by a single investigator and were
assessed at least twice. On each panoramic radiograph (Figure5),
the following parameters were traced on an acetate sheets, and
measurements were carried out by the same examiner:
1. The retromolar space to lower third molar crown width
(Ganss ratio). A- Distance between distal border of second molar
crown and anterior border of ramus measured on occlusal plane,
B- width of third molar crown. The Ganss ratio = A/B.
2. Third molar to second molar inclination (angle A).
3. Third molar angulation to the base of the mandible (angle B).
All the radiographic measurements were statistically
compared between the two groups on the right and the left
side. Differences between these measurements of the lower arch
“crowded” and “normal” (right and left side) groups were made
by Mann-Whitney U test (Z/U). Frequency and percentages
distribution of gender were calculated statistically on crowding
and normal group. Descriptive studies such as mean and
standard deviation were calculated for numerical data age. Values
less than 0.05 was considered as significant.
Results
Results related to differences in measurements of Ganss
ratio between crowded and normal groups are reported in Table
1. Values of distances A/Br in the normal group are greater than
in the crowding group; the difference for Z=-9.38 and p<0,001
46
Figure 3: Panoramic radiograph of crowding group
(unerupted) lower third molars.
Figure 4: Panoramic radiograph of noncrowding group
(erupted) lower third molars.
(p=0,000) is significant. The average value of Ganss Ratio A /
Bl in the group of subjects with normal occlusion (x = 1, 13) is
significantly higher than the average of Ganss Ratio A / B l in
the group of subjects with crowding (x = 0.61), the difference Z
= -9.34 and p <0,001 (p = 0,000) is significant.
Results related to differences in the angle of inclination
between crowded and normal group are reported in Table
2. Angle Ar and Al in the crowded group in relation to the
non-crowded group is significantly greater p<0,001 (p=0,000).
Angle of inclination Br and Bl in the non-crowded group is
significantly greater than in crowded group p<0,001 (p=0,000).
Table 3 shows the distribution of gender on crowding and
normal group. From 60 subjects, 27 (45, 00%) were male, and
33 (55, 00%) were female in crowding group. In the normal
group, 35 (58.33%) were male and 25 (41. 67%) were female.
The Pearson chi-square =0, 12 and p<0, 05 (0.69) shows that
there is no significant difference in the distribution of subjects
by gender.
Table 4 shows descriptive statistics for age. In the crowding
group, the mean age of subjects was 18.05 with a standard
deviation of ±1. 57 years, while the mean age in the normal
group was 18.87 with a standard deviation of ±1.52 years.
Subjects in the normal group are significantly older, Z=-2.75
and p<0, 01(p=0,006).
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 Table 1 - Differences of the measurements of retromolar region (Ganss ratio)
in “crowded” and “normal” clusters.

Parameters Rank Sum Rank Sum U Z p-level Valid N Valid N

Crowding Normal Crowding Normal
Ganss Ratio A/B r 1843,00 5417,00 13,00 -9,38 0,000 60 60
Ganss Ratio A/B l 1851,000 5409,000 21,00 -9,34 0,000 60 60

Table 2 - Differences between of the Angle A and Angle B/”crowded” and

“normal” clusters.

Rank Sum Rank Sum Valid N Valid N

Parametar U Z p-level
Crowding Normal Crowding Normal
Figure 5: Panoramic radiographic Angle A r 5310,00 1950,00 120,00 8,82 0,000 60 60
measurements. A: Distance between Angle A l 5250,00 2010,00 180,00 8,50 0,000 60 60
distal border of second molar crown
Angle B r 2731,00 4529,00 901,00 -4,72 0,000 60 60
and anterior border of ramus measured
on occlusal plane, B: width of third molar Angle B l 2495,00 4765,00 665,00 -5,96 0,000 60 60
crown. The Ganss ratio= A/B. Angle A:
Third molar to second molar inclination. Table 3 - Frequency and percentage distribution of gender
Angle B: Third molar angulation to the
base of the mandible.(31). Crowding group Normal group
Gender Frequency Percent Frequency Percent
Male 27 45,00 35 58,33
Discussion Female 33 55,00 25 41,67
Lower arch crowding that develops after finalization of the
Total 60 100,00 60 100,00
permanent dentition during the teenage period as well as post
orthodontic treatment relapse is a common clinical problem
faced by many orthodontists. Mandibular third molars have Table 4 - Age statistics
attracted the interest of the orthodontic professionals, not
only because of their position and eruptive pattern but also Age in Years
because of their possible role in the development of late incisor Crowding group Normal group
crowding.16,17 Many studies have been conducted to determine Number of subjects 60 60
relationship between dental crowding and gender dimorphism.18,
Mean Age 18,05 18,87
19
According to Rūta et al,20 dental crowding is more frequent
in females because males had significantly longer and wider Std. Deviation 1,57 1,52
dental arch dimensions than females. Males generally showed
higher values in all arch dimensions, but the differences were not
statistically significant in comparison to females.19 Frequency
and percentage distribution by gender in our study were more tendencies for crowding in the mandibular anterior teeth were
in female subjects than in male for crowding group, while in expressed in groups with third molars present than in groups
the normal group, the percentage and frequency were greater with these teeth missing, supporting the concept of an anterior
in male subjects than female; however, there was no statistically component of force.
significant differences between males and females for the Third molars generally erupt between 16 and 24 years of
crowding and the normal group. Numerous research studies age, and the position of the mandibular third molar changes
have been conducted to determine the effect of third molars on during the eruption and development period.26, 27 If space is
lower incisor crowding.21-23 insufficient, they can cause complications such as difficulties
Lindauer et al 24 reported significant differences between during their eruption, lower arch crowding, inflammatory
the opinions of American orthodontists and those of oral and processes, and temporomandibular joint dysfunction.28-30
maxillofacial surgeons regarding the role of erupting third Angulation of the third molar and the available space in the
molars in causing crowding of anterior teeth. More surgeons third molar region reportedly affect the possibility of third molar
than orthodontists generally believed that erupting third molars eruption.31,32 A large number of studies have measured third
produce an anterior component of force and cause crowding of molar angulation and space on panoramic radiographs33-35 and
the anterior dentition; thus they were more likely to recommend have shown that panoramic radiograph are a reliable indicator in
prophylactic removal of third molars to prevent such problems. evaluating third molar angulations 36,37. Thus, we decided to use
Sidlauskas and Trakiniene 25 evaluated the correlation panoramic radiographs to determine the angulation and position
between third molar presence and lower incisor crowding in of third molars. Niedzielska et al31 concluded that based on the
91 subjects. They reported that although differences between measurement of the ratio, third molar angulation to the base of
the groups were not statistically significant, a greater number of the mandible, and third molar to second molar inclination, it is

IJO  VOL. 27  NO. 1  SPRING 2016 47

possible to predict lower third molar position in the dental arch
and make an early decision concerning its removal or retention.
Thus, in the present study, the angle between third molars
and the mandibular plane is smaller in the crowding group
than in the normal group with significant differences while the
angle of third molar to second molar inclination is higher in
the crowding group than in the normal group with significant
differences. Through this data, the third molars in the crowding
group were inclined mesially, and we expect that they will have
the upright position of the eruption, and this shows it possible
to exert mesial force in the teeth of the lower arch.
Ades et al.38 conducted a long term study to determine
the relationship between the third molars and changes in lower
dental arch parameters. They concluded that the third molar
removal to decrease or prevent incisor crowding might not
be justified. Similarly, Hasegawa, et al.39 found no significant
correlation between the angulation of the lower third molar and
the angulation of the other teeth in the lateral segment. Findings
in our study show that there were statistically significant
differences between lower arch crowding and third molar
angulation and position. Niedzielska 15 suggested that, when a
sufficient space is available for the eruption of the third molars,
the tooth assumes a normal position in the dental arch and does
not cause displacement of the other teeth; conversely, when the
space is deficient, third molars may aggravate dental crowding.
Zachrisson40 reported that a mesially-directed force is an
important cause of increased mandibular incisor crowding
in early teenagers and young adults and that the presence of
a developing mandibular third molar with insufficient space
could be a cause of late mandibular arch crowding. This is
in agreement with our study because at this age, we have
an insufficient retromolar space since values of Ganss ratio
were smaller in the crowding group when compared with the
normal group, with significant differences, and this could
be a contributing factor for lower arch crowding. All these
measurements can be useful in providing information regarding
future development of lower arch crowding. The early prediction
of third molar eruption will be a great help and relief during
orthodontics treatment planning and results in a timely decision
for third molar removal.
Conclusion
The results of the present study have shown substantial
evidence to assert that third molars are a contributing factor for
lower arch crowding. Therefore, it can be concluded that there
was a strong relationship between angulation and position of
third molars and lower arch crowding
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