Lower third molar development subsequent to second

molar extraction
Margaret E. Richardson, MDentSc, D.Orth.," and Andrew Richardson b
Belfast, Northern Ireland

Development and eruption of lower third molars was examined in 63 subjects who were treated by
extraction of second molars. Changes in mesiodistal and buccolingual lower third molar angulation
were measured on 60 ~ cephalograms taken before extraction and 3 or more years later. The final
position of lower third molars was assessed on models at the end of the observation period by using
a scoring system. All lower third molars erupted in periods ranging from 3 to 10 years after
extraction. Ninety-nine percent of the third molars uprighted mesiodistally, but few became as upright
as the second molars they replaced. Model analysis showed that 96% of the lower third molars
erupted in good or acceptable positions. (AMJ ORTHODDENTOFACORTHOP1993;104:566-74.)

O n e of the main criticisms leveled at the
practice of lower second molar extraction is that the
third molars do not always erupt in ideal positions. Root
parallelism with the first molar is seldom achieved. 1.2
Nevertheless, there is a considerable volume of anec-
dotal evidence and case reports that support the view
that third molars do make satisfactory replacements for
second molars in many instances. 3-1~
Most quantitative studies to evaluate third molar
position after second molar extraction also report good
results.
Assessment of third molar position from clinical
appearance and lateral oblique radiographs by Wilson"
showed that 87% of 178 erupted lower third molars in
320 cases achieved good, very good, or excellent po-
sitions after second molar extraction. The fate of the
remaining third molars was not disclosed.
Other investigators used panoramic radiographs to
assess third molar position. Cavanaugh 12 studied 25
patients treated by extraction of second molars. He
noted that all third molars, upper and lower, erupted.
None was impacted.
Gaumond t3 reported that 86% of third molars
achieved satisfactory or very satisfactory positions in
11 cases treated by enucleation of lower second molar
tooth buds. Nine percent were imperfect and 5% were
"mediocre."
In a larger panoramic radiographic study of 140
lower third molars in 95 subjects, Goods et al.2 claimed
'Associate Specialist Orthodontist, Orthodontic Division, School of Clinical
Dentistry, Royal Victoria Hospital.
bProfessor of Orthodontics, The Queen's University of Belfast, Orthodontic
Division, School of Clinical Dentistry.
Copyright 9 1993 by the American Association of Orthodontists.
0889-5406193151.00 + 0.10 811137577
566
that only 46% had satisfactory contact relationship with
the first molar after second molar extraction.
Several investigators used study models in addition
to lateral oblique radiographs to examine third molar
relationships.
Cryer ~4 examined 66 patients from whom one or
both lower second molars were extracted. By using a
scoring system that allocated points for disimpaction of
premolars, lower anterior alignment, the need for "a
lower appliance, and the final position of the lower third
molars, he found that 35% of the results were good,
40% fair, and 25% poor.
Rindler I~ found that 77% of 118 lower third molars
erupted into good or very good positions after second
molar extraction. Only four third molars in his study
were in poor or inadequate positions.
Lawlor t6 surveyed third molar eruption after ex-
traction of 84 lower second molars. Eighty-three per-
cent of these erupted or "were about to erupt" in sat-
isfactory positions, the remaining 17% were considered
to be unsatisfactory.
Dacre ~7 reported on third" molar positions in 51 of
110 patients who bad second molars extracted. Only
lower study models were used. Acceptable or better
results were reported for 81.7% of third molars on the
left side and 65.2% on the right side, 11.3% (left) and
21.3% (right) were unacceptable, and 7% (left) and
13.5% (right) needed treatment. The fate of the third
molars in the remaining patients was not specified.
A small prospective study of 27 second molar ex-
traction cases that used standardized 45 ~ cephalometric
radiographs and study models was carried out by Hug-
gins and McBride. I Figures for the overall success rate
were not given, but gradings of excellent, good, fair,
or poor were made for contact point, occlusion, and
 American Journal of Orthodontics and Dentofacial Orthopedics
Volume 104, No. 6
axial inclination. Contact was excellent in 84%, good
in 6%, fair in 4%, and absent in 6% of the quadrants.
Occlusion was excellent in 86% and good in 14% of
the third molars. None had excellent axial inclination.
In 10% it was good, in 32% fair, and in 58% poor.
The purpose of the present investigation was to ex-
amine the course of lower third molar development and
their final positions after extraction of the adjacent sec-
ond molars.
MATERIAL AND METHOD
Twenty-sevenmale and 36 female subjects who had lower
second molars extracted were selected from a larger consec-
utive group because they attended for review until their third
9 molars had erupted. In eight cases the extraction was unilat-
eral. In 99 quadrants the opposing maxillary second molar
was also removed. The age at extraction ranged from 11 to
17 years with an average of 14 years.
Twenty-three of the subjects, who had occlusions that
they or their orthodontist considered acceptable, had second
4 on the second registering on internal mandibular structures.
molars extracted to disimpact third molars and prevent an
increase in lower arch crowding, which objectives were
achieved.'8 The remainder had some form of simple mechan-
ical treatment.
Annual examinations continued until the third molars had
erupted and no further changes in their alignment had oc-
curred. Observation periods ranged from 3 to I0 years.
Standardized 60" left and right cephalograms were taken
before extractions and at the end of the observation period
by rotating the cephalostat from the 90~ left lateral position
through 30 ~ for the left side and a further 150~ for the right.
Plaster models were made at the final examination.
Measurements
On preextraction 60~ cephalograms. The stage of lower
third molar development was classified using an adaptation
of the system devised for first molars": (1) Crypt formation,
(2) calcification of cusps, (3) calcification of half of the crown,
(4) calcification of the whole crown, (5) root formation com-
menced, (6) root formation complete, and (7) apices closed.
Mesiodistal lower third molar angulation (MDLTMA).
The angle formed between lines drawn through the occlusal
surfaces of third and first molars (Fig. 1).
Buccolbzgual lower third molar angulation (BLLTMA).
This is the linear distance between buccal and lingual cusps.
The buccolingual dimension of a lower third molar is about
8.00 to 9.00 mm. If buccal and lingual cusps are superim-
posed, the tooth is upright buccolinguallyand each millimeter
of separation represents approximately 10.0 to 12.0 ~ incli-
nation usually in a lingual direction (Fig. 1).
The space between lower second and third molars mea-
sured directly on the film at the shortest distance.
On final 60" cephalograms
Final MDLTMA (FMDLTMA). The angle measured rel-
ative to the first molar as discussed previously (Fig. 1).
The change in MDLTMA. The angle formed between lines
Richardson and Richardson 567
Fig. 1. Measurement of initial mesiodistal (A) and buccolingual
(B) lower third molar angulation, final lower third molar angu-
lation (C) and change in angulation of third (D), and first (E)
molars with a tracing of the first 60 ~cephalogram superimposed
Solid linemfirst film. Broken line--second film.
drawn through the occlusal surfaces of the third molars when
a tracing of the preextraction radiograph was superimposed
on the final radiograph registering on ifitemal mandibular
structures--the inner outline of the mandibular symphysis
and the inferior dental canal (Fig. 1). Positive values indicated
reduction in mesial inclination.
The change in mesiodistal lower first molar angulation
(MDLFMA). The angle was measured in the same way (Fig.
1). Negative values indicated distal tipping.
The change in BLLTMA. This angle was calculated as
the difference in the distance between buccal and lingual cusps
on the preextraction and final radiographs. Positive values
indicated reduction in lingual inclination.
Measurements were made by one observer on two oc-
casions. If the difference in replicate measurements exceeded
0.5 mm or 0.5 ~ a third reading was taken and the aberrant
one discarded. The mean of the two measurements was used
in calculations.
Model analysis
The final position of the third molars was assessed sub-
jectively on models taken at the end of the observation period
and was scored by awarding points on a scale from 0 to 5
for each of the five criterion: mesiodistal angulation, bue-
colingual angulation, rotation, contact with the adjacent first
molar, and occlusion. Maximum points were scored by a tooth
that was upright mesiodistally and buccolingually, with no
rotation and with ideal contact and occlusion. Assessments
were made by two observers on two occasions and the scores
totaled to a maximum of 100 points. The distribution of total
scores is shown in Fig. 2.
The first 10 sets of models were assessed twice for ob-
568 Richardson and Richardsotz American Journal of Orthodontics atut Dentofacial Orthopedics
December 1993

Numbers
50

40

30

20

10

0
100-90 89-80 79-70 69-60 59-50 49-40 39-30
Total Scores

Fig. 2. Distribution of total lower third molar scores (two observers, two occasions) derived from model
analysis.

Table I. Percentages of lower third molars at Correlation analysis of the radiographic measure-
various developmental stages at the time of ments was carried out. Significant correlations are
second molar extraction shown in Table III.
Stage ] Calcification I Percent An average of the four scores (two observers, two
occasions) for each of the lower third molar criteria
2 Cusps only 5 examined on models was calculated, and the percentage
3 Half crown 38 of teeth scoring 0 to 5 points for each criterion is shown
4 Whole crown 30
in Table IV.
5 Root begun 24
6 Root complete 3 Median values of the four scores were compared
for groups at various stages of third molar development
at extraction by using the Kruskal-Wallis analyses of
server error. Variation between observers did not exceed one variance (ANOVA) (Tables V and VI). Differences in
point for each dimension. There was complete agreement median scores for criteria with significant values in the
between observers in 70% of quadrants for mesiodistal and ANOVA were tested between pairs of developmental
buccolingual third molar angulation and in 80% for rotation, stages with Mann-Whitney 13 tests. Developmental
contact, and occlusion. stages 2 and 3 and 5 and 6 were combined because of
small numbers. Significant differences were found be-
STATISTICAL ANALYSIS AND RESULTS tween stages 4 and 5/6 for mesiodistal and buccolingual
Spearman rank correlation coefficients were cal- angulation (p < 0.05).
culated between the stage of lower third molar devel- Median scores were compared for groups with 1.00
opment at extraction (Table I) and the length of the mm or more and without space between second and
observation period (r = - 0 . 5 p < 0.001 left and third molars before extraction using Mann-Whitney 13
right). tests (Tables VII and VIII). The 5% level of significance
Means and standard deviations for the radiographic was used throughout.
measurements were calculated (Table 1I). Independent
sample t tests showed no significant sex differences for DISCUSSION
any of these measurements. Data from male and female All the third molars in this sample erupted more or
subjects were pooled. less successfully after an average observation period of
AmericanJournalof OrthodonticsandDentofacialOrthopedics Richardson and Richardson 569
Volume104,No. 6

Table II. Means, standard deviations, and ranges for measurements made on radiographs
- i i .eo I ,o I Range
Preextraction MDLTMA (degrees) Left 60 35.0 9.2 3.0 to 51.0
Right 58 39.2 9.7 14.0 to 58.0
Preextraction BLLTMA (mm) Left 60 2.1 1.1 0.0 to 4.0
Right 58 1.8 1.2 0.0 to 4.0
Preextraction space 7-8 (nun) Left 60 0.4 0.7 0.0 to 4.0
Right 58 0.5 0.9 0.0 to 4.5
FMDLTMA (degrees) Left 60 19.7 7.4 1.5 to 35.0
Right 58 22.8 7.5 4.5 to 37.0
Change MDLTMA (degrees) Left 60 17.5 10.6 -25.0 to 34.5
Right 58 18.8 11.5 0.0 to 45.0
Change BLLTMA (degrees) Left 60 1.9 1.1 0.0 to 4.0
Right 58 1.6 1.2 -0.5 to 4.0
Change MDLFMA (degrees) Left 60 -3.0 3.6 - 12.0 to 4.5
Right 58 -3.3 3.5 - 11.0 to 3.0

Table Ill. Significant correlation coefficients of measurements made on radiographs

I
PreextractionMDLTMA I FMDLTMA ClzangeMDLTMA
Left I Right I Left t Right Left I Right
Preextraetion space 7-8 XX
-0.36
XXX XXX
FMDLTMA -0.53-0.49
Change xxx xxx
MDLTMA 0.74 0.75

xx denotes significance < 0.0l.

xxx denotes significance < 0.001.

Table IV. Percentages of all lower third molars (118) with scores of 0 to 5 for each of the various
criteria examined
Points scored
Criteria 5 I 4 [ 3 I 2 I 1 [ 0
Mesiodistal angulation 39.4 45.7 11.0 1.7 1.3 0.0
Buccolingual angulation 57.4 31.8 10.4 0.0 0.0 0.0
Rotation 63.3 26.1 8.7 1.1 0.4 0.0
Contact 27.0 34.5 19.5 3.0 2.3 11.9
Occlusion 15.0 35.4 33.5 11.0 2.8 3.2

5.8 years. There was, however, considerable variation
in the time taken for eruption ranging from 3 to 10
years. Significant negative correlations ( - 0.5) between
the stage of lower third molar development at extraction
and the length of the observation period indicate that
those third molars in the earlier stages of development
take longer to erupt, but there are exceptions so that it
is not possible to predict just how long eruption will
take.
The FMDLTMA angulation averaged 20.0 ~ (left)
and 23.0 ~ (right), with a range of 1.5 to 37.0 ~ (Table
II) indicating that lower third molars usually erupt in a
more mesially inclined position than the second molars
they replace. This is in accordance with other
reports L2'~7that root parallelism with first molars is sel-
dom achieved.
Significant correlations (Table III) between the
preextraction and the change in MDLTMA and between
the FMDLTMA and the change in MDLTMA suggest
that the steeper the angulation of the third molar before
extraction the greater will be the degree of uprighting
and those third molars that upright most will finally
570 Richardson and Riclmrdson AmericanJournal of Orthodontics and Dentofacial Orthopedics
December 1993

Table V. Kruskal-Wallis analyses of variance of median lower third molar criteria scores derived from
model analysis for groups at various stages of third molar development at the time of second molar
extraction, left side
Stage[NIMedian[Quartilel[Quartile3 I p
Mesiodistal angulation 2/3 26 4.6 3.8 5.0
4 18 4.8 4.3 4.8 0.023
5/6 16 4.0 3.8 4.3
Buccolingual angulation 2/3 26 4.8 3.8 5.0
4 18 5.0 4.5 5.0 0.025
5/6 16 4.3 3.9 4.5
Rotation 213 26 4.5 3.5 4.8
4 18 4.8 4.5 5.0 0.08
5/6 16 4.8 4.6 4.9
Contact 2/3 26 4.0 2.8 4.5
4 18 4.5 3.3 4.8 0.62
5/6 16 4.1 3.1 4.6
Occlusion 2/3 26 3.5 3.0 4.0
4 18 3.3 2.8 3.8 0.46
5/6 16 3.4 3.3 4.3

Table VI. Kruskal-Wallis analyses of variance of median lower third molar criteria scores derived from
model analysis for groups at various stages of third molar development at time of second molar extraction,
right side
S'o elNIMe ionlQuor,i'e'lQ r,"e l
Mesiodistal angulation 2/3 25 4.5 4.0 4.8
4 18 4.3 3.8 4.8 0.38
516 15 4.0 3.8 4.4
Buccolingual angulation 213 25 4.8 4.2 5.0
4 18 5.0 4.5 5.0 0.08
5/6 15 4.3 4.0 4.8
Rotation 2/3 25 4.5 4.3 5.0
4 18 5.0 4.5 5.0 0.38
5/6 15 4.8 4.5 5.0
Contact 213 25 3.8 2.9 4.3
4 18 3.8 3.3 4.5 0.86
5/6 15 3.8 3.1 4.3
Occlusion 213 25 3.8 2.9 4.1
4 18 3.5 2.5 4.0 0.89
5/6 15 3.3 2.6 4.3

achieve a lower angular position relative to the first
molar. There is some doubt about the validity of these
correlations since repeated measurements of the same
subject produces indices that are not completely inde-
pendent of each other, which may introduce spurious
results into the correlations. Nevertheless, the absence
of correlation between the preextraction MDLTMA and
the FMDLTMA suggests that the final angulation of the
third molar is not influenced by its original angulation.
Cryer 14 claimed the best results were found in cases
where the long axis of the lower third molar made an
angle of 30 ~ or less with the long axis of the first molar.
Huggins and McBride ~ suggested that the occlusal sur-
face of the lower third molar should be between 20 ~
and 60 ~ to the occlusal plane for satisfactory eruption.
The present findings support the conclusion by Dacre t7
that successful eruption of the third molar can occur
from a wide range of mesiodistat angulations and that
a steep MDLTMA does not necessarily preclude second
molar extraction.
The method of measuring the change in lower third
molar angulation used in the present investigation
shows lower third molars almost invariably become
more upright as they erupt after second molar extrac-
tion. In only one quadrant (0.8%) did the third molar
increase its mesial inclination. Brown 2~described a sec-
American Journal of Orthodontics and Dentofacial Orthopedics RicluTrdson and Richardson 571
volume IO4, No, 6

Table VII. Mann-Whitney LI tests of median lower third molar criteria scores derived from model analyses
between groups with and without space between second and third molars before second molar extraction,
left side
JNJMedianJOuartitelJOuartile3l P

Mesiodistal angulation Spaced 15 4.5 3.8 4.9

0.70
Unspaced 45 4.3 3.9 5,0
Buccolingual angulation Spaced 15 4.5 4.1 4,8
0.67
Unspaced 45 4,8 3,9 5.0
Rotation Spaced 15 4,5 4.0 4.8
0.06
Unspaced 45 4,8 4.4 5.0
Contact Spaced 15 3,8 2.9 4.3
0.33
Unspaced 45 4.3 3.2 4.3
Occlusion Spaced 15 3.8 3.3 4.2
0.14
Unspaced 45 3.3 2.9 3.8

Table VIII. Mann-Whitney LI tests of median lower third molar criteria scores derived from model analysis
between groups with and without space between second and third molars before second molar extraction,
right side
I lMe'i nlQuor,i'e'lQ or,i'e l
Mesiodistal angulation Spaced 12 4.3 4.0 4.8
0.50
Unspaced 46 4,3 3,8 4.5
Buccolingual angulation Spaced 12 4,6 4.3 5.0
0,94
Unspaced 46 4.8 4.0 3.0
Rotation Spaced 12 4.8 4.5 5.0 0.96
Unspaced 46 4.8 4.3 5.0
Contact Spaced 12 4.1 3.4 4.5
0.39
Unspaced 46 3.8 3.0 4.3
Occlusion Spaced 12 3.9 3.3 4.1
Unspaced 46 3.5 2.5 4.3 0.66

ond molar extraction case in which the left lower third
molar tipped mesially and impacted horizontally while
the right one erupted. Lawlor t6 reported that 15% of
third molars in his study tipped mesially. Whitney and
Sinclair 21 found an average mesial tipping of lower third
molars of 1.2 ~ in 30 subjects who were treated by ex-
traction of second molars. Staggers 22 claimed average
increases in lower third molar mesial inclination of 6.9 ~
(left) and 5.6 ~ (fight) in 22 second molar extraction
cases. None of these studies give a true measure of
lower tl~ird molar angular changes since the measure-
ments are related to the lower first molar. The present
study shows a tendency for the lower first molar to tip
distally after second molar extraction (Table II), which
would give the impression of an increase in mesial
inclination of the third molar. In subjects who do not
have lower second molars extracted, the percentage of
lower third molars that increase their mesial inclination,
as they develop, to become mesioangularly or horizon-
tally impacted is 12%. 23 The incidence of third molars
increasing their mesial inclination in the present inves-
tigation (0.8%) suggests that extraction of second mo-
lars actually reduces this tendency.
Many lower third molars were tilted lingually to
some extent before extraction. Most uprighted in this
dimension during the observation period (Table II) sug-
gesting that lingual inclination is not a contraindication
to second molar extraction.
The negative correlation between the FMDLTMA
and the space between second and third molars, al-
though it reached the level of significance only on the
left side ( - 0 . 3 6 ) (Table III), suggests that the presence
of such a space is associated with a lower FMDLTMA.
This is at odds with the observation by Lawlor ~6 that
in 13 of 14 quadrants where the third molar position
after second molar extraction was judged to be poor, a
space was present between the second and third molars
before extraction. The presence of a space between
second and third molars is a common feature in the
early stages of third molar development. 24 It usually
closes as the third molar develops and should not be
construed as a sign that there will be room for the third
5"/2 Richardson and Richardson
Fig. 3. Right and left 60~ cephalograms before, A and B, and 5 years after, C and D, second molar
extraction and models, E, showing lower third molars that scored maximum (100) points on model
analysis.
molar to erupt. 25 Absence of significant differences in
median lower third molar scores derived from model
analysis between groups with third molars develop-
mentally spaced or unspaced from second molars
(Tables VII and VIII) reinforces the radiographic sug-
gestion that the presence of spacing between second
and third molars is not a contraindication to second
molar extraction.
The total scores for the final position of lower third
molars on models (Fig. 2) indicates that, in this material
96% of third molars make good or acceptable replace-
ments for second molars. In 4% of the quadrants the
result was unsatisfactory.
Fig. 3 shows a case that scored maximum points
for third molar position. Fig. 4 shows the poorest result
that scored 36 points (left) and 41 (right). The left lower
third molar in this subject was the only one in the study
to tip mesially.
Mesiodistal lower third molar angulation judged on
models scored the maximum 5 points in 39% quadrants
and 4 points in 46% quadrants indicating a slight mesial
inclination. Only 3% of third molars had a score of 2
or less suggesting severe mesial tipping (Table IV).
Only 10% of third molars scored 3 for buccolingual
inclination, and none had a lower score for this di-
mension. The majority were upright buccolingually or
had only a very slight lingual tilt (Table IV). This com-
plements the radiologic finding that there is a strong
tendency for third molars to upright buccolingually so
American Journal of Orthodontics and Dentt(acial Orthopedics
December 1993
p,
J,
that lingual inclination is not a contraindication to sec-
ond molar extraction.
The majority of lower third molars, 63%, scored
maximum points for rotation. A few (26%) had a mild
degree of rotation with a score of 4. Only 9% of third
molars scored 3, and 1% scored 2, indicating marked
or very marked rotation either mesiolingually or me-
siobuccally (Table IV). So that, although a small per-
centage of lower third molars may erupt in rotated po-
sitions, rotation does not present a problem in the ma-
jority of cases. Huggins and McBride I claimed that
lower third molar rotation could be detected radiograph-
ically as a crenelated appearance of 3 or 4 cusps along
the upper margin. Examination of radiographs of those
third molars scoring 3 or less for rotation suggested that
radiographic detection of rotation was insufficiently ac-
curate to regard it as a contraindication to second molar
extraction.
Contact with the lower first molar was scored at 5
for 27% and 4 for 35%. Twenty percent of third molars
scored 3 for contact indicating an acceptable but not
very good relationship with the first molar. Seventeen
percent had poor contacts scoring 2 or less (Table IV).
This included 12% where no score was recorded be-
cause a space remained between the first and the third
molars. In terms of dental and periodontal health such
a space may be preferable to a poor contact. These
figures are considerably better than the 46% satisfactory
contact relationships claimed by Gooris et al.'- from
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 104, No. 6
Fig. 4. Right and left 60 ~ cephalograms before, A and B, and 5 years after, C and D, second m01~
extraction and models, E, showing lower third molars that scored 36 points on left and 41 pointS,On
right on model analysis.
subjective evaluation of panoral radiographs. As sug-
gested by these authors, a more "accurate description
of tooth position in all planes of space" is possible by
examination of study models.
Occlusion was probably the poorest feature of those
examined. Only 50% scored 4 or 5 points indicating
good or very good occlusion. In 35% of the quadrants
occlusion was just acceptable with a score of 3, and
16% had poor occlusion scoring 2 or less (Table IV).
Poor occlusal relations included cusp-to-cusp contacts
and crossbites. No vertical discrepancies associated
with differential timing of eruption were found.
The subjects in this investigation were examined
annually, and it was interesting to note that third molars
did not always erupt directly into optimal positions.
Considerable improvement in angulation, space clo-
sure, and occlusion commonly occurred after the tooth
appeared in the oral cavity.
Analysis of median lower third molar scores be-
tween groups at different stages of third molar devel-
opment suggests that the timing of second molar ex-
traction is of little importance to the final third molar
position. The ANOVA revealed significant differences,
on the left side, for mesiodistal and buccolingual an-
gulation (Tables V and VI). Comparison of pairs of
developmental stages for these dimensions showed sig-
nificant differences between stages 4 and 5/6 that might
imply that later second molar extraction produced
Richardson allURe.hard, on 573
poorer results but since the differences betw.e~a stages
2/3 and 4/5 were not significant, this calal~0t ~I~ con-
sidered of much clinical importance.
Gaumond ~3recommended enucleatio~u0~tlle~;r,eond
molar tooth bud "as soon as the presell~ ~ ~t non-
ectopic and sound third molar germ was~r
by radiography." Cryer ~4 and Dacre ~7 a d v t ~ 0tlaat the
third molar crown should be fully formed I~llI~Uot for-
mation not yet begun. Lawlor t6 suggested~ til~ lack of
third molar root formation at the time of scmal~tlmolar
extraction could lead to a poor result. The ~ n t find-
ings suggest that the timing of second molar exgraetion
has little effect on the final third molar position. If o n e
of the objects is to treat or prevent lower arch crowding,
early extraction is advisable.
In his editorial, inaptly entitled "Let's take axational
look at permanent second molar extraction," Haas :6
strongly condemned the practice analogizing it to the
substitution of a beaten up Mini (a small British-made
car) for a new Mercedes. Few orthodontists would
dream of substituting third molars for second molars in
an ideal occlusion, but such occlusions do not usually
present for treatment.
Most of the lower third molars in this study erupted
into positions that were rated as adequate though im-
perfect. These results, together with those of other
workers ~.3-~7 lead to the conclusion that extraction of
second molars is a viable clinical option in mild or
574 Richardson and Richardson
m o d e r a t e arch length discrepancy cases w h e r e third m o -
lar impaction is inevitable and deterioration in tooth
alignment likely. ~8'27 T h e small numbers o f impactions
that do o c c u r are usually mild in d e g r e e , such as those
illustrated by L a w l o r t6 and G o o d s et al. 2 and in Fig. 4
and can be aligned by one o f the methods described in
the literature. 28':9
CONCLUSIONS
1. N o r m a l sized l o w e r third molars m a k e adequate
replacements for second molars in the m a j o r i t y
o f cases.
2. The mesiodistal angulation o f a l o w e r third m o -
lar b e f o r e second m o l a r extraction does not ap-
p e a r to influence its final position. L o w e r third
molars can upright and erupt f r o m a w i d e variety
o f m e s i o a n g u l a r positions.
3. T h e t e n d e n c y for s o m e l o w e r third molars to tip
m e s i a l l y and b e c o m e m o r e m e s i o a n g u l a r l y im-
pacted appears to be reduced by extraction o f
second molars.
4. L o w e r third molars tend to upright in the buc-
colingual d i m e n s i o n after second m o l a r extrac-
tion. Lingual inclination o f a third m o l a r does
not appear to be a contraindication to second
m o l a r extraction.
5. Presence o f a space b e t w e e n a d e v e l o p i n g third
m o l a r and the adjacent second m o l a r does not
s e e m to be a contraindieation to second m o l a r
extraction.
6. T h e timing o f l o w e r second m o l a r extraction in
terms o f third m o l a r d e v e l o p m e n t is not critical,
but third molars in earlier stages o f d e v e l o p m e n t
at extraction are likely to take l o n g e r to erupt.
We are very grateful to Dr. Chris Patterson for advice on
statistical procedures and to Mrs. J. Nicholl, Mrs. M. Boe,
Mrs. S. Sloane, and Mrs. S. Meehan for preparation of the
illustrations and tables.
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Reprint requests to:
Dr. Margaret Richardson
Orthodontic Division
School of Clinical Dentistry
Royal Victoria Hospital
Grosvenor Rd.
Belfast BT12 6BA
Northern Ireland