Advances in Oral and Maxillofacial Surgery 3 (2021) 100090

Contents lists available at ScienceDirect

Advances in Oral and Maxillofacial Surgery

journal homepage: www.sciencedirect.com/journal/advances-in-oral-and-maxillofacial-surgery

Distal pathologies of the second molar in the presence of the mandibular

third molar: Study by panoramic radiography
Mamadou Lamine Ndiaye a, *, Binetou Catherine Gassama b, Seydina Ousmane Niang b,
Papa Abdou Lecor c, Aminata Ndiaye a, Babacar Toure c
a
Service of Maxillodentofacial Radiology, Institute of Odontostomatology of the Faculty of Medicine, Pharmacy and Odontology of Dakar, Senegal
b
Service of Oral Surgery, Institute of Odontostomatology of the Faculty of Medicine, Pharmacy and Odontology of Dakar, Senegal
c
Service of Orofacial Physiology, Institute of Odontostomatology of the Faculty of Medicine, Pharmacy and Odontology of Dakar, Senegal

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: The aim of this study was to determine the frequency of dental caries and distal alveolysis of the
Distal pathology mandibular second molar, associated with the presence of the third molar.
Second molar Materials and methods: The study was carried out on digital panoramic X-rays of Senegalese subjects. The vari­
Third molar
ables studied were the topographical anatomy of the left mandibular third molar and the presence of caries and
alveolysis distal to the mandibular second molar. Statistical analysis was performed using the Jamovi software.
Results: A total of 386 panoramic radiographs of 201 women (52%) and 185 men (48%) were retained. The
average age was 45 ± 8 years. According to the status of the left mandibular third molar, 77.1% (n = 297) were
in normal position and 22.9% (n = 88) were enclaved. Distal alveolysis of the second molar was found in 64.5%
(n = 249) of the radiographs. Almost 50% of the second molars had caries in the presence of the enclaved third
molar (p < 0,000). Lysis of the alveolar bone distal to 37 was noted in 42.7% (n = 38) cases associated with the
enclaved third molar (p < 0,000). The prevalence of decayed second molars in the presence of the enclaved third
molar in the horizontal position was 51.5% (n = 17).
Conclusion: The presence of caries and alveolysis distal to the second molar was statistically associated with the
presence of the impacted third molar.

1. Introduction
The third molars, commonly known as wisdom teeth, are the last four
of the 32 teeth that erupt in the mouth. This is because the wisdom tooth
grows in a small anatomical space. During eruption, they are often held
back by a lack of space or by an anatomical obstacle or tumour [1,2],
making this area less accessible for cleaning by tooth brushing. If they
are enclosed or embedded, they promote the accumulation of dental
plaque, thus increasing the risk of developing infectious diseases in the
posterior molar area [3]. The presence of caries and periodontal disease
distal to the second molar is often associated with the topographic status
of the third molar [4]. They are an indication of avulsion of both the
mandibular third molar and the second molar. Thus the presence of the
third molar is a risk to the survival of the second molar on the arch.
Panoramic radiography is the first-line examination in the anatomical
exploration of the mandibular third molar region. It highlights the
topographical anatomy of the third molar and its environment, and is
the first complementary examination in the exploration of the third
molar and associated pathologies [1,5,6]. Several studies have been
conducted on the potential development of second molar pathologies
associated with third molars in different countries [7–12]. However, the
results vary according to the populations studied. Currently, there are no
data on the frequency of second molar disease associated with third
molars that are landlocked and/or included in the Senegalese popula­
tion. The aim of this work was to study the frequency of caries and distal
alveolysis of the mandibular second molar associated with the presence
of the mandibular third molar by digital panoramic radiography.
2. Material and methods
This is a descriptive transversal study of 386 panoramic radiographs,
carried out in the dento-maxillo-facial radiology department of the

* Corresponding author. Service of Maxillodentofacial Radiology, Institute of Odontostomatology of the Faculty of Medicine, Pharmacy and Odontology in Dakar,
BP 5005, Dakar, Senegal.
E-mail address: lamine7.ndiaye@ucad.edu.sn (M.L. Ndiaye).

https://doi.org/10.1016/j.adoms.2021.100090
Received 22 April 2021; Accepted 11 May 2021
Available online 21 May 2021
2667-1476/© 2021 The Author(s). Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M.L. Ndiaye et al.
Institute of Odontology and Stomatology of the Faculty of Medicine,
Pharmacy and Odontostomatology of the Cheikh Anta Diop University
of Dakar. For this study, panoramic X-rays that were judged to be of
good image quality and that included the date of taking as well as the
date of birth and sex of the patient were selected. Panoramic radio­
graphs included in this study had to show both tooth no. 37 and 38′′ All
radiographs showing motion, anatomical and metallic superimposition
artefacts that were incompatible with the reading of anatomical struc­
tures were not included. Low quality panoramic radiographs were
excluded from the study, including third molars with incomplete root
formation.
The panoramic X-rays were made by an X-ray machine from the
manufacturer (Planmeca Proline CC Panoramic X-ray, Helsinki,
Finland). The X-rays were performed by an experienced radiology
technician following the manufacturer’s protocol. The images were then
exported in DICOM (Digital imaging and communications in medicine)
format. The reading and morphometric analysis was done on a computer
screen with the free image reading software Dicom, RADIANT ®.
The radiographs were analysed by two examiners, a dental surgeon
specialised in dento-maxillo-facial radiology and a surgical thesis stu­
dent. The evaluation method was calibrated on 30 randomly selected
radiographs in order to avoid any variability between examiners.
Reproducibility was calculated by re-evaluating 15 panoramic radio­
graphs selected from the 30 radiographs over a 10-day interval. Cohen’s
kappa was calculated for the degree of inter-examiner and intra-
examiner agreement. The variables studied were the topographic anat­
omy of the left mandibular third molar (38) and the presence of infec­
tious pathology in the second molar of the same quadrant (37).
Topographical anatomy of the 38: The normal anatomical position of
the third molar, its status as an enclosed or non-enclosed molar and its
angle of inclination were the variables studied. The angle of inclination
was evaluated by measuring the angulation between the major axis of
the mandibular third molar and the major axis of the adjacent second
molar using Winter’s classification: Vertical position (10◦ to − 10◦ ),
mesioangulation (11◦ –79◦ ), disto-angulation: − 11◦ to − 79◦ , horizontal
(80◦ –100◦ ).
Pathological status of 37: caries and alveolysis distal to the second
molar was studied (Fig. 1) Caries was highlighted by the presence of a
radiolucent image on the distal face of the crown or cervical border of
the second molar in relation to the third molar. The distal alveolysis of
the second molar (Figs. 1 and 2) was objectified by the presence of a
radiolucent image to replace the lamina dura, which was initially
radiopaque.
The statistical analysis was carried out using the software Jamovi-
Stats version 1.6.11. The results for qualitative variables such as gender,
topographic anatomy of the third molar, pathological status of the
Fig. 1. Panoramic radiograph showing a distal caries in 37 and horizontal alveolysis in the presence of impacted 38 in mesioangulation.
2
Advances in Oral and Maxillofacial Surgery 3 (2021) 100090
second molar were expressed as percentage and effective and the
quantitative variables as means ± standard deviation. The Chi 2 test was
used to evaluate the association between the qualitative variables with a
significance level set at p < 0.05.
3. Results
Inter-examiner agreement was strong with a Cohen’s kappa coeffi­
cient of 0.86. Reproducibility of reviewers number 1 and 2 was almost
perfect with kappa values of 0.9 and 0.85 respectively. The sample
consisted of 201 women (52%) and 185 men (48%) with an average age
of 45 ± 8 years. The mandibular third molar was in 77.1% (n = 297) of
the cases in normal position and in 22.9% (n = 88) of the cases in the
enclaved position. The frequency of distal caries of the second molar was
33% (n = 127). Distal alveolysis of the second molar was encountered in
64.5% (n = 249) of cases (Table 1), and approximately half of the
distally decayed second molars were associated with the presence of an
enclaved third molar. The association between the topographic status of
the mandibular third molar and the presence of second molar decay was
statistically significant (p < 0.000). For 49 mesioangulated third molars,
distal caries was found in 26 s molars (Table 2). The second molars with
the third molar in the horizontal position were found in 51.5% (n = 17)
of the decayed cases. Angulation was associated with the onset of decay
in 37, with a p < 0.000 (Table 3). Alveolar lysis distal to 37 noted in
42.7% (n = 38) cases was associated with the third molar being enclosed
with p < 0.000 (Table 4). Mesioangulation was strongly associated with
alveolysis distal to 37, with p < 0.000 (Table 5) (Table 3).
4. Discussion
The presence of decay distal to the second molar was associated with
the enclaved status of the mandibular third molar. In the presence of the
enclaved third molar, the second molar was found to be decayed in
almost 50% of cases with a statistically significant difference
(p < 0.0000). Previous studies have shown that the prevalence of distal
caries of the mandibular second molar adjacent to an enclosed third
molar ranged from 6% to 55%. [9–10,12] Alhobail et al. [11] found a
prevalence of 48.6% out of 1252 M of caries of the second molar adja­
cent to an enclosed third molar examined. Angulation of the mandibular
third molar is also an aggravating factor in second molar caries. Ac­
cording to Srivastava et al. [13]. Out of 150 patients with enclaved
mandibular third molars, 37.5% had caries on the distal side of the
mandibular second molars. The incidence of caries in the presence of
enclosed and mesioangular third molars was 55%. Altan et al. [9] found
31.7% caries of the second molar in the presence of the mesioangular
third molar compared to 5% in the vertical position. In the study by
M.L. Ndiaye et al. Advances in Oral and Maxillofacial Surgery 3 (2021) 100090

Fig. 2. Panoramic radiograph with an alveolysis of 37 in the presence of 38 impacted in mesioangulation.

Table 1 Table 5
Distribution of pathologies in the 37. Association between the angulation of the 38 and the presence of distal
Pathologies Yes n(%) No n (%) Total n (%)
alveolysis of the 37.
37 Alveolysis Total
Carie 127 (33) 259 (77) 386 (100)
Alveolysis 249 (64.5) 137 (35.5) 386-(100) No Yes

Angulation38 Mesio-angulation n 24 25 49
% 49 51 100
Table 2 Vertical n 90 214 304
Association between the status of 38 and the presence of caries on 37 % 30 70 100
Horizontal n 24 9 33
38 of position 37 carie Total % 73 27 100
Total n 138 248 386
No Yes
% 36 64 100
Normal n 214 83 297
% 72.1 27.9 100 Pearson Chi-square = 28.37, ddl = 2 p = 0.000.
Impacted n 45 44 89
% 50.6 49.4 100 Pepper et al. [10], out of 1414, only 4.2% of the mandibular second
Total n 259 127 386
% 67.1 32.9 100
molars had developed caries on their distal surfaces. This rate was
higher in the presence of an enclaved mandibular third molar. Indeed,
Pearson Chi-square = 14,32, ddl = 1, p = 0,000. carious lesions had developed on the distal surfaces of 22 out of 133
(16.5%) mandibular second molars that were adjacent to a mesioan­
gularly enclaved third molar [10r]. The work of Syed et al. showed a
Table 3
Association between angulation 38 and the presence of caries in 37.
39% prevalence of cervical caries distal to the second molar associated
with the presence of an enclosed mandibular third molar; the
37 Carie Total
mesioangulation position of the third molar was more frequent [12].
No (%) Yes (%) According to Mcardle et al. [14] distal cervical caries of the second
angulation38 Mésio-angulation n 23 26 49 molars was often a late complication of the presence of the third molar.
% 47 53 100 For Glória et al. [15] the presence of the third molar increases the
Vertical n 220 84 304 prevalence of caries on the distal surface of the second molars. However,
% 72 28 100
this risk depends on the condition of the eruption, the type of angulation
Horizontal n 16 17 33
% 48 52 100 and the contact between the third and second molars [11].
Total n 259 127 386 Alveolysis distal to the second molar was also strongly associated
% 67 33 100 with the presence of the third molar and more accentuated by its
Pearson Chi-square = 18.024, ddl = 2 p = 0.000. mesioagulation-embedded status. The presence of the third molar is a
risk factor for distal alveolysis of the mandibular second molar. This risk
is all the more important since the third molar is mesioangulation-
Table 4 locked, which could compromise the survival of the second molar on
Association between the status of 38 and the presence of the distal alveolysis of the arch. These results seem to be shared by several previous studies.
37. According to Blakey et al. [16], 25% of patients with asymptomatic
Alveolysis 37 enclosed or included third molars were associated with periodontal
No Yes Total
pathology distal to the second molar. The results of the study by Mar­
ciani et al. [8], which aimed to estimate the prevalence of perio­
Statut 38 Normal n 86 211 297
dontolysis associated with the third molar and to assess the associated
% 29 71 100
Impacted n 51 38 89 long-term risks, showed that the presence of the third molar in young
% 57.3 42.7 100 adults was significantly associated with inflammatory periodontal dis­
Total n 137 249 386 ease. The absence of symptoms associated with enclaved or embedded
% 35.5 64.5 100 third molars did not rule out the existence of periodontal disease. Ac­
Pearson Chi-square = 24.17, ddl = 2, p = 0.000. cording to Qu et al. [17] regardless of their status, the presence of the

3
M.L. Ndiaye et al.
third molar is a risk factor for the development of periodontal patho­
logical characteristics of the mandibular second molar. This conclusion
is shared by Li et al. [18] who state that this finding should be taken into
account when making clinical decisions regarding the maintenance or
extraction of third molars, particularly when these teeth were
non-functional or when their extraction did not affect function [2].
Mandibular third molar extractions appear to improve overall peri­
odontal health distal to adjacent second molars [19]. Although pro­
phylactic removal of asymptomatic third molars remains controversial,
medical decisions should be made as early as possible [17,20] The
clinical implications of these findings suggest that patients who choose
to retain their third molars should undergo periodic clinical and radio­
graphic examinations to detect disease before it becomes symptomatic
[8,20]. According to Vandeplas et al. [21] distal pathology of the second
molar associated with the presence of the third molar is common. The
enclosed status of the third molar would significantly increase the
occurrence of pathology of the mandibular second molar.
5. Conclusion
The data from this study highlight the association between the
enclosed or non-enclosed status of the mandibular third molar and the
occurrence of caries and distal alveolysis of the second molar. Pano­
ramic radiographic examination is of great value in the diagnosis and
therapeutic decision making when faced with distal caries or perio­
dontolysis distal to the second molar.
References
[1] Kaur R, Kumar Ac, Garg R, Sharma S, Rastogi T, Gupta Vv. Early prediction of
mandibular third molar eruption/impaction using linear and angular
measurements on digital panoramic radiography: a radiographic study. Indian J
Dent 2016;7(2):66–9.
[2] Br Tamba, Dia Tine S, Ba A, Gassama BC, Kounta A, et al. Difficultés d’avulsion de
la troisième molaire mandibulaire incluse: place de l’orthopantomogramme. Jomos
2015;21:127–35.
[3] Kaka L. Impacted mandibular third molar and the inferior alveolar canal in Iraqis
(a radiographical study). Iraq 2008;5(4):403.
[4] Prajapati VK, Mitra R, Vinayak KM. Pattern of mandibular third molar impaction
and its association to caries in mandibular second molar: a clinical variant. Dent
Res J 2017;14(2):137–42.
Advances in Oral and Maxillofacial Surgery 3 (2021) 100090
[5] Hashemipour MA, Tahmasbi-Arashlow M, Fahimi-Hanzaei F. Incidence of
impacted mandibular and maxillary third molars: a radiographic study in a
Southeast Iran population. Med Oral Patol Oral Cir Bucal 2013;18:e140–5.
[6] Falci SG, de Castro CR, Santos RC, de Souza Lima LD, Ramos-Jorge ML,
Botelho AM, Dos Santos CR. Association between the presence of a partially
erupted mandibular third molar and the existence of caries in the distal of the
second molars. Int J Oral Maxillofac Surg 2012;41(10):1270–4.
[7] Claudia A, Barbu HM, Adi L, Gultekin A, Reiser V, Gultekin P, Mijiritsky E.
Relationship between third mandibular molar angulation and distal cervical caries
in the second molar. J Craniofac Surg 2018;29(8):2267–71.
[8] Marciani RD. Is there pathology associated with asymptomatic third molars? J Oral
Maxillofac Surg 2012;70:S15–9.
[9] Altan A, Akbulut N. Does the angulation of an impacted mandibular third molar
affect the prevalence of preoperative pathoses? J Dent 2019;20(1):48–52.
[10] Pepper T, Grimshaw P, Konarzewski T, Combes J. Retrospective analysis of the
prevalence and incidence of caries in the distal surface of mandibular second
molars in British military personnel. Br J Oral Maxillofac Surg 2017;55(2):160–3.
[11] AlHobail SQ, Baseer MA, Ingle NA, Assery MK, AlSanea JA, AlMugeiren OM.
Evaluation distal caries of the second molars in the presence of third molars among
Saudi patients. J Int Soc Prev Community Dent 2019;30; 9(5):505–12.
[12] Syed KB, Alshahrani FS, Alabsi WS, Alqahtani ZA, Hameed MS, Mustafa AB,
Alam T. Prevalence of distal caries in mandibular second molar due to impacted
third molar. J Clin Diagn Res 2017;11(3):ZC28–30.
[13] Srivastava N, Shetty A, Goswami RD, Apparaju V, Bagga V, Kale S. Incidence of
distal caries in mandibular second molars due to impacted third molars:
nonintervention strategy of asymptomatic third molars causes harm? A
retrospective study. Int J Appl Basic Med Res 2017;7(1):15–9.
[14] McArdle LW, McDonald F, Jones J. Distal cervical caries in the mandibular second
molar: an indication for the prophylactic removal of third molar teeth? Update. Br
J Oral Maxillofac Surg 2014;52(2):185–9.
[15] Glória JCR, Martins CC, Armond ACV, Galvão EL, Dos Santos CRR, Falci SGM.
Third molar and their relationship with caries on the distal surface of second
molar: a meta-analysis. J Maxillofac Oral Surg 2018;17(2):129–41.
[16] Blakey GH, Marciani RD, Haug RH, Phillips C, Offenbacher S, Pabla T, White Jr RP.
Periodontal pathology associated with asymptomatic third molars. J Oral
Maxillofac Surg 2002;60(11):1227–33.
[17] Qu HL, Tian BM, Li K, Zhou LN, Li ZB, Chen FM. Effect of asymptomatic visible
third molars on periodontal health of adjacent second molars: a cross-sectional
study. J Oral Maxillofac Surg 2017;75(10):2048–57.
[18] Li ZB, Qu HL, Zhou LN, Tian BM, Chen FM. Influence of non-impacted third molars
on pathologies of adjacent second molars: a retrospective study. J Periodontol
2017;88(5):450–6.
[19] Passarelli PC, Lajolo C, Pasquantonio G, D’Amato G, Docimo R, Verdugo F,
D’Addona A. Influence of mandibular third molar surgical extraction on the
periodontal status of adjacent second molars. J Periodontol 2019;90(8):847–55.
[20] Sun LJ, Qu HL, Tian Y, Bi CS, Zhang SY, Chen FM. Impacts of non-impacted third
molar removal on the periodontal condition of adjacent second molars. Oral Dis
2020;26(5):1010–9.
[21] Vandeplas C, Vranckx M, Hekner D, Politis C, Jacobs R. Does retaining third molars
result in the development of pathology over time? A systematic review. J Oral
Maxillofac Surg 2020;78(11):1892–908.